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Home My WebLink About0076 AUGUSTA NATIONAL DR - Health ,6 Augusta-National Dr;Uv Barnstable P 355 013 i I i i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 76 Augusta National Property Address Bill Robinson Owner Owner's Name information is q required for Cumma uid Ma. 02637 5/29/2009 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms the computer, r,use 1. Inspector: only the tab key to move your Robert Paolini cursor-do not Name of Inspector use the return key. Capewide Enterprises,LLC. Company Name t� P.O.Box 763 Company Address ' Centerville Ma. 02632 nun City/Town State Zip Code (508)428-4028 S14454 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 5/29/2009 Ins ec is ig ure 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. L-4 b!16 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1�oW f Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form Not for Voluntary Assessments ;M s 76 Augusta National Property Address Bill Robinson Owner Owner's Name information is q required for Cumma uid Ma. 02637 5/29/2009 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The septic system is in porper working order at the present time. r 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•09/08 Title 5 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 °M 76 Augusta National Property Address Bill Robinson Owner Owner's Name information is q required for Cumma uid Ma. 02637 5/29/2009 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M s 76 Augusta National Property Address Bill Robinson Owner Owner's Name information is q required for Cumma uid Ma. 02637 5/29/2009 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6"below invert or available volume is less than %day flow ` t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts L Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 76 Augusta National Property Address Bill Robinson Owner Owner's Name information is q required for Cumma uid Ma. 02637 5/29/2009 . every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 1 0,000g pd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 r Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M s 76 Augusta National Property Address Bill Robinson Owner Owner's Name information is q required for Cumma uid Ma. 02637 5/29/2009 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 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 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 76 Augusta National Property Address Bill Robinson Owner Owner's Name information is q required for Cumma uid Ma. 02637 5/29/2009 every page. City/Town State Zip Code Date of Inspection D. System Information Description: The septic system consists of a 1000gallon septic tank,distribution box and two 500 gallon drywells. Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ® Yes ❑ No Water meter readings, if available last 2 ears usage d 2007:54,000 g ( y g (gP ))' 2008:51,000 Detail: 2007:147gpd 2008:140gpd Sump pump? ❑ Yes ® No Last date of occupancy: 5/29/2009Date 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 76 Augusta National Property Address Bill Robinson Owner Owner's Name information is required for quid uid Ma. 02637 5/29/2009 _ every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Capewide Enterprises,LLC. Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1000 gallons How was quantity pumped determined? Measured Reason for pumping: Maintenance Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no)(if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments s 76 Augusta National Property Address Bill Robinson Owner Owner's Name information is q required for Cumma uid Ma. 02637 5/29/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 2001 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 2' Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line. 10+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of Ieakage.System vented through the house vents. Septic Tank (locate on site plan): 2' Depth below grade: 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: 0 t5:ns•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 76 Augusta National Property Address Bill Robinson Owner Owner's Name information is q required for Cumma uid Ma. 02637 5/29/2009 every 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 NA Scum thickness 0 Distance from top of scum to top of outlet tee or baffle NA Distance from bottom of scum to bottom of outlet tee or baffleNA How were dimensions determined? Pumped at inspection Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump septic tank every two years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears to be structurally sound. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 76 Augusta National Property Address Bill Robinson Owner Owner's Name information is q required for Cumma uid Ma. 02637 5/29/2009 every page. City/Town State Zip Code Date of Inspection D. System Information cont. Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank-must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 76 Augusta National Property Address Bill Robinson Owner Owner's Name information is q required for Cumma uid Ma. 02637 5/29/2009 . 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): Depth of liquid level above outlet invert No 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.): Box is Ievel.Box has one outlet Iateral.No evidence of solids carryover.No evidence of leakage into or out of box. 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: ,Sins•09/08 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 76 Augusta National Property Address Bill Robinson Owner Owner's Name information is q required for Cumma uid Ma. 02637 5/29/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2 ❑ 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.): No signs of hydraulic failure.Chambers were dry at time of inspection.Stain line observed 13" below invert. 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 Gins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 76 Augusta National Property Address Bill Robinson Owner Owner's Name information is q required for Cumma uid Ma. 02637 5/29/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 76 Augusta National Property Address Bill Robinson Owner Owner's Name information is q required for Cumma uid Ma. 02637 5/29/2009 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal sy4tem, 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 777 ran z� 3s 14 o I i t5ins•09/08 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 ;M 76 Augusta National Property Address Bill Robinson Owner Owner's Name information is q required for Cumma uid Ma. 02637 5/29/2009 every page. City/Town 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: Bottom of drywells 35' feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health-explain: As-Built Card ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: USED:USGS Observation Well Data.USED:Technical Bulletin 92-0001 plate#2 annual ranges of groundwater elevations. Before filing this Inspection Report, please see Report Completeness Checklist on next page. :Sins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 76 Augusta National Property Address Bill Robinson Owner Owner's Name information is q required for Cumma uid Ma. 02637 5/29/2009 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 17 of 17 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION RECEIVED PARCEL SEP 0 12004 TOWN OF BARNSTABLE TITLE 5 HEALTH DEPT. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: J Owner's Name: Owner's Address, Date of Inspection: Name of Inspector: eas print 6 Company Name: r •r �� Mailing Address: �6LOt�S Telephone Number: 52 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 approved system inspector pursuant to Section 15340 of Title 5(310 C training and experience in the proper nction and maintenance of on site sewage disposal systems.I am a fu DEP MR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: --- —�-'RO r/ 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. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/152000 page I Page 2 of 11 OFFICIAL INSPECTION FORD—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE I NSPOSAt SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner: �E Date of Inspection:_" 71 * _ Inspection Summary: Check A,I1,C,D or E/ALWAYS complete all of Section D A. System Passes: rI 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" need to be replaced or repaired.The system,upon completion of the replacement or repair,as approv y the Board.of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the foil g statements.If"not determined"please explain. The septic tank is metal and over 20 years old*or septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration o failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank approved by the Board of Health. *A metal septic tank will pass inspection if it is y sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old' available. ND explain: Observation of sewage bac r break out or High static water level in the distribution box due to broken or obstructed pipe(s)or due to a bro settled or uneven distribution box.System will pass inspection if(with, approval of Board of Health}: broken pipe(s)amend obstruakm iszemoved distribution boat is knreled or replaced ND explain: The sy in required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass' n if(with approval of the Board of Health): broken pipes}are replaced obstruction is removed ND explain: 2 Page 3 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: /�r ✓ 7� to f.41f C—co r Owner ellp Date of Inspection: C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to termine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance . 310 CMR 15.303(l)(b)that the system is not functioning in a manner which will protect public th,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 ve fed wetland or a salt marsh 2. System will fail unless the Board of Heal (and Public Water Supplier,if any)determines that the system is functioning in a manner that pro is the public health,safety and environment: _ The system has a septic tank an soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to surface water supply. — The system has a septic and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a sep ' tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a tic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply ell**.Method used to determine distance **This system p s if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and vo file organic compounds indicates that the well is free from pollution from that facility and the presence ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure crit a are triggered.A copy of the analysis must be attached to this form. 3. O er: 3 Page 4 of I 1 ' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SERFAGE DOSAE SYSTEM INSPECTION FORM PART.A- CERTIFICATION'(continued) Property Andress: L v , r Owner: . Date of Inspection: — D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No b Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or Bonding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool — Liquid depth in cesspool is less than 6"below invert or available volume is less than'/z day flow J Required pumping more than 4 times in the last year NOT due to clogged or obstructed pq*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'.within a Zone I of a public well. _ Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or 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 taboratory,for toMm bacteria and volatile organic.compounds indicates that the well is free from-pollutiou 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 r are triggered.A copy of the analysis must be attached to this form.] A%V (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system usust serve-a fa '' with a design flow of 10,000 gpd to 15,000 gpd- You must indicate either"yes"or"no"to each of the wing (The following criteria apply to large systems in on to the criteria above) yes no — _ the system is within 4W feet a surface drinking water supply — the system is within 2 feet of a tributary to a surface drinking water supply the system is Ioc in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a p lic water supply well If you have answe "yes"to any question in Section E the system is considered a significant threat,or answered C yes"in Seccio above the large system has failed The owner or operator of any large system considered a. significant under Section E or failed under Section D shall upgrade the system in accordance with 3l0 CMR 15.304. a system owner should contact the appropriate regional office of the Department. 4 PW5of1I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address- ' pe _,Z Owner:_ / Date of Inspection: Check if the following have been done.You must indicate"yes"or`no"as to each of the following: Yes No Pumping information was provided by the owner,occupant,or Board of Health — ' Were any of the system components pumped out in the previous two weeks? — Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined?(If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? _ Were all system components,excluding the SAS,located on site? j _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no _ Existing information.For example,a plan at the Board of Health_ iA _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CUR 15.302(3)(b)) 5 Page 6 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 4(4cw r( we Owner: Date of Inspection: OW CONDITIONS RESIDENTIAL Number of bedrooms(design): .3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 33 O Number of current residents: 2 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): Wa [if yes separate inspection required] Laundry system inspected(yes or no):00 Seasonal use:(yes or no): No Water meter readings,if available(last 2 years usage(gpd)): OIL �a � J 305� Sump pump(yes or no):(0 l Last date of occupancy: Gdrt+� COMMERCIAIANDUSTRIAL Type of establishment: Design flow(based on 310 CM I5. apd Basis of design flow(seats/perso ft,etc.): Grease trap present(yes or no _ Industrial waste holding present(yes or no):_ Non-sanitary waste dis ged to the Title 5 system(yes or no):_ Water meter reading if available: Last date of occ Ile OTHER(de nbe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no): A7p If yes,volume pumped:____gallons—How was quantity pumped determined`' Reason for pumping: TYPE OF SYSTEM IX Septic tank,distribution box,soil absorption system Single cesspool r Overflow cesspool Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank —Attach a copy of the DEP approval —Other(describe): . Approximate age of all components da tnstalle (if known}and source of information: Were sewage odors detected when arriving at the site(yes or no):NO 6 Page 7ofil OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: 5�,� sayt C. w� Date of Inspection: '1 a S BUILDING SEWER(locate on site plan) . Depth below grade: _ Materials of construction:_cast iron A'40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: Of (locate on site plan) Depth below grade:_moo Material of construction: ar concrete_metal_fiberglass polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of certificate) Dimensions: 1000 4061 Sludge depth: a Distance from top of sludge to bottom of outlet tee or baffle: TO Scum thickness: �, a Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: y How were dimensions determined:(s g y 1-.{cl Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as re�l'a{le_d_to outlet invert,evidence of leakage,etc.): a _ ` K(R. S J Niles GREASE TRAP: (locate on site plan) } I Depth below grade:_ Material of construction:`concrete me fiberglass__polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum top of outlet tee or baffle: • Distance from bottom scum to bottom of outlet tee or baffle: Date of last pump' , Comments(on mping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to et invert,evidence of leakage,etc.): 7 Page 8 of l l OFFICIAL INSPECTION FOOD—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 7 Owner: Date of Inspection: TIGHT or FOLDING TANK: (tank must be pumped at ' e of inspection)(locate on site plan) Depth below grade: Material of construction: concrete �Talfiberglass_polyethylene other(explain): Dimensions: Capacity: allons Design Flow: allonslday Alarm present(yes or Alarm level: Alarm in working order(yes or no): Date of last p mg:_ Comments ndition of alarm and float switches,etc.): DISTRIBUTION BOX: SC (if present must be opened)(locate on site plan.) Depth of liquid level above outlet invert:-U-6" Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage int or out of box,etc.): L 1t.6 2 T f vytQj! PUMP CHAMBER: locate on siteplan) Pumps in working order(yes or no) Alarms in working order(yes or n _ Comments(note condition o chamber,condition of pumps and appurtenances,etc.): I . 8 - Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address• p� �r, Owner: Sk, Date of Inspection: SOIL ABSORPTION SYSTEM(SAS):_4(locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number._ 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.): is I CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet inv . Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construct" n: Indication of group ater inflow(yes or no): Comments(note ndition 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 soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 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: 6 v a.0,44 fowj 7)r -r Owner: Date of Inspection- 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 wells within 100 feet.locate where public water supply enters the building. r CPO , f �n IL Page 11 of 11 OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 7 6 Owner- Date of Inspection: SITE EXAM Slope tQS Surface water 00 Check cellar VS Shallow wells &10 Estimated depth to ground water o feet PIease indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you e9ablished the high round ater ele atio II -i 914, 4 m AN I PAN NIA N� TOWN OF BARNSTABLE LOCATIO UGQ -Fjq UTO VILLAGE ASSESSOR'S MAIP NE 62 SEPTIC TANk LEACHING FACILITY (typo A)'57i6c 4 - 7)( yz NO OF S: 19 V E L x7E OR�-PUBLIC,; PRIVA 7777 BUILDER OR OWNER DATETERMXT1mu .2 ATE' C ., PLl.ANCEI9,SUtD: VARIANCE GRANTED: Yes No —- ---------- 14. �n ... .............. TOWN OF BARNSTABLE L ATION��O �u606P Kv4_/Ql ,VL-1>21VC SEWAGE VILLAGE CLMS"1 A Ovrc1 ASSESSOR'S MAP INSTALLER'S NAME & PHONE NO. A & B CANCO 775-6264 -SEPTIC TANK CAPACITY /QL 0 qw/ LEACHING FACILITY:(type)�� 0,t*q_Ae✓S (size) �'7-c wC NO. OF BEDROOMS ^� PRIVATE WELL OR PUBLIC WATER1�. BUILDER OR OWNER MAM S446H"9140 •t DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED• VARIANCE GRANTED: Yes No ,,,, w M � O 1 N Q r, q U UST N TiuN /lw 7 Fee .i THE COMMONWEALTH OF MASSACHUSETTS Entere in mputer. Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS Zippiicatiou for Otoozar *rztem Comaructiou Vermtt Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.76 qv y yr iCt. 4�r a Own is Name,Address and Tel.No. id A (SkZt-1 an Assessor's Map/Parcel 15 s-^ D 1-3 6 A��S'� od Installer's Name,AddrA,&d&ICANW V/' Designer's Name,Address and Tel.No. 350 Main Street Aa Yarr—.uth, MA 02673 Type of Building: Dwelling No.of Bedrooms 13 Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Iterations(Answer when applicable) .L/)S f4 ( O X 1-t) G�L_ Nr S .S'�oYt 6 Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of tlt . Signe Date 4,ch d I Application Approved by Date Application Disapprove o the following reaso Permit No. ` Date Issued 1,64 S 'Fee U THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: V Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 3paprtcation for Oi!5ponl *p5tem Congtruction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 4 t ,)N A I Owner's Name,Address and Tel.No. Assessor's Map/Parcel I� 5— -- 01 1��Yl SA-ee Installer's Name,Address,and Tq�t 8 CANCO Designer's Name,Address and Tel.No. �350 Main Street W. Yarmouth- Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil 1 Nature of Repairs or Alterations(Answer when applicable) Ins fA (� ( !1 O X �o S��h Date last inspected: Agreement: �J The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of exalt . ' Signe l A Date (.o / f Application Approved by Date Application Disapprove or the following reaso s S 4 Permit No. ' Date Issued —-------`-- ------- — --- L---- -__ THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired(—TIJpgraded( ) Abandoned( )by G^/�.-lJGU at i, vwim has X96 constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit 'ojated Installer Designer The issuance of this ,ermit shall not be construed as a guarantee that the ys ill function as deign/ed. Date -� Inspec or _ _ --.s -- ------- -- ---------------- ----Fee CJ NA I THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS lwf 5potal *potem Construction Permit Permission is hereby granted to Co struct( )Repair( pgrade( )Ah�andon( ) System located at 7 (/ v,I / �f,u W /] G 4 rY� v✓l and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Constructio must I com eted within three years of the date of this pe it. / C Date: Approved by U 1/6/99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WIT'HOUT DESIGNED PLANS) I, J J1 cctAc�, . , hereby certify that the application for disposal works construction permit signed by me dated & ( 0 ( , concerning the property located at 7& / u c.,s (, It 4 k).iA4 J a Cuwrti meets all of the following criteria: ' This faded system is connected to a residential dwelling only. There are no commercial or business s associated with the dwelling. • The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. /7ere are no wetlands within 100 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system There is no increase in flow and/or change in use proposed There are no variances requested or needed. • The bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when pplicable] • If the S.A.S.will be located with 250 feet of any vegetated wetlands,the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: co Q A) Top of Ground Surface Elevation(using GIS information) JC ) • U B) G.W.ElevationQY- +the MAX. High G.W.Adjustment. �•� = c� DIFFERENCE BETWEEN A and B 3 SIGNED : J L\ DATE: [Please Sketch proposed plan of system on back]. NOTICE Based upon the above information,a repair permit will be issued for bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system plans. q:health folder:cert .2i /. s No a� 3 Fx$....It.9.............. THE COMMONWEALTH F MASSACHUSETTS BOAR® HEALTH -------------_-OF...... ....... - ---.---..-.-..-----.-.---------- t ApplirFattlau for UaiqvniiFal Wjarkg Tamitrurtaau Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( Vfan Individual Sewage Disposal System at: ` catio -Address r ..�itl✓c�.� �� . • ..... -1 L.. :........... .y�=- �•--- ............ _.................. ---- - ---•-- Installer Address Type of Building �-� Size Lot............................Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) PL4Other—Type of- Building No. of persons............................ Showers — Cafeteria PL'' Other fixtures .................................. W Design Flow.......... f—......................gallons per person per day. Total daily flow....... ......................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width•_.__.............. Total Length.................... Total leaching area....................sq. ft. Seepage Pit No-------l'----------- Diameter-------- -------- Depth below inlet.............. Total leaching area-4�,Pe_Y...sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Q+' •-••-•-----•----------------•--•--••----••---------•----•••••-•--•----•--------••-----•••----•-_............................................................. 0 Description of Soil.....................................................................................................----------------------------------------------------.............. x V •-••-----•-• -------------•-•---•-.... W •-•-•--------------------------•-•-----••--•-------------•------------•••••-•----------••---•••-•----------•------.._.._...------.. -------------------- -- -- ------- - ------ --------- U Nat re of epairs or Iterations—A er whe3i�ap�licable____ ®J' ..__ �`1..._�___.. N � ry ----------------------•--•--•- ol- /I---- aY �-' Y' Y�.__�.*_ Y"N...45�------••............................................................................................. Agreement: The undersigned agrees to install the aforedescri d ndividual Sewa e Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Co Ire un i n ur a es not to place the system in operation until a Certificate of Compliance has ee > oard h /Ze., `�S>gned_ .. --------------•------------•••-- v Application Approved By............. '=/Q...�=-•------•---•-----------------------------------•-- ....................Date.............. Date Application Disapproved for the following reasons------------------------------------------ ----------------------------------------------------------------••---- _......-•--------••----------•-•-•---•--••••-•--•---•---••---••••----•-•----------•-....--•••--------•-•---••---•--•----•--••--•-------•-•-•-•-•------------------•••--------•-•----------•--••-•-•----- Date PermitNo...........:............................................. Issued....................................................... Date • t. 3•ate r, �` INo..................... F�$.... ��-`...... t THE COMMONWEALTH OF MASSACHUSETTS BOARD ....... HEALTH ..............OF...... I�J. . -- . Appliratioo for BW.Voiiai Forks Tomitrurfioo ranfit Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at: A ..... ......... X2. d.KC.7�.......... ................ Address-----..... ....................ow.--- '-•.... ------- ----..._--•--- �� _ f�_rr!E20._. . ....... .......-- ...... 14 Installer Address PQ Type of Building tl Size Lot............................Sq. feet U Dwelling No. of Bedrooms.............................. _._..Ex Expansion Attic a g— --•------ p ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures •-----------••------------------------•----•---•-------••-----•'•--•-----'•-•••-----....-••••-••--•--•-----'-'-••-'--•-••••'"-'......"•--""---•-- W Design Flow...... �✓ .....................gallons per person per day. Total daily flow......4; 0 ............. 1:4 Septic Tank—Liquid capacity............gallons Length................ Width................. Diameter................ Depth................ W Disposal Trench—No..................... Width... ........_...... Total Length.................... Total leaching area------- sq. ft. Seepage Pit No......../----------- Diameter........ -..... Depth below inlet......_-�......... Total leaching area��lP�.l___.sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 1-4 rX, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a' ............................................................................................................................................................ 0 Description of Soil........................................................................................................................................................................ W V -------------------------- --------- •---------------- •--------------------------------------------------- ------------------- ---------- -- -- - -- ---- W -'--••-•-•-•-- -- --------------------------••-•----••-•-•----•--•--•--------------•-••'--••-'••-•----'---------•--------.. ---- U Nature of Repairs or lterations—A wer whelr ap licable____.4,��-..--- .....--- p Agreement: ✓. The undersigned agrees to install the aforedescribe`d ndividual Sewa e Disposal System in accordance with the provisions of TIT 5 of the State Sanitary Code'— .he and sign ur 1 -Zees not to place the ystem in operation until a Certificate of Compliance has bee i card o he Signed_ ...... --- y�3 Date Application Approved By............... ��1.........----- •---•----'----------------------------"- ........................................ Date Application Disapproved for the following reasons---------------•-----------------'--•--------------- ............................................................ --•------------------------------------------•------------------------------.-.------------------------------------------------------------------------------------------ Date PermitNo......,-................................................ Issued......................................................... Date THE COMMONWEALTH OF MASSACHUSETTS k BOARD OF HEALTH ..........................................OF............................................................................ tT rtifiratr of Tomphaurr THIS IS T,.PSE.RT� , That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by--------------_- .--•----'----................. r. -------- ---- --------- •----------------- Install at .................... ------•----•...... --•--'------•--------'-"-------••'••......-•---•.... has been installed in accordance with the provisions of TIT Hof ':Plie,>Ite Sanitary Code as described(in the application for Disposal Works Construction Permit No......................................... dated_...._--.___._-_-..--____---............. _... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE......................................................•'-"-'---------'--.......... Inspector...............•----------------•"-------------•----....•............_........--'-' THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 2.��!..........................................OF........-----.......... No......................... FEE........................ Disposal t:knot iort Errant Permissionis hereby granted-------'•---•---------'-•--'.•......•------------------'---------•------------'--------------'-••f----------... -----------.----------- to Construct ( ),�5 Repair �anIndu is ds Sysat No..--••-'-•'•-'--•••-•' .........•-"--'- ......... ...............-•"'-------------......-----"•-••'•. --•---•--'••--•-•--•'••----•'•-'---'•-•-•'-'•--........ Street as shown on the application for Disposal Works Construction Permit Dated.......................................... �a Board of Health DATE ................................................. FORM 1255 HOBBS & WARREN. INC., PUBLISHERS L0CAION SEWAGE PERMIT NO. LAGE 3S�- 6 /3 INSTA LLER'S NAME A ADDRESS U I L 6 OR 0 ER DATE PERMIT ISSUED �� DATE COMPLIANCE ISSUED � �� .. f — F�o,�f �� <--T—