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HomeMy WebLinkAbout0031 DORAL ROAD - Health 31 Doral Road :Barnstable A= 349- 039 I I 1 I ISMEAD No.2-153LBE UPC 12034 mmcad.com - ludo In 48A ,Pcl;� Olc 17) JO © `� o lcIe,P �- �r Z �.j1{�0 3r� �/Q l� � 5 C 0,45; �Us � 1 �_'F; o�,`W`^�;�f� � """� ��,f F' `S� �A •' y .s.• ry�,.�4 � - � - �A 7 W'• 'w,? l'- •'r*V� �� eIG.Y •' *.i '' f..1 r{W�"`� ` �' f+ ) L s " -_ .[; UAA r f ..y�`fi) .Y� �+.��n} e�'A __ •f��yf'��-.,n /�yi ,p ss„ei�l,•'<� .� 0 v 4 "� � t g �, •1f ~ yy "� Q 'V5 V,!y!'j4 i $!# it _ Q. C , c a y 0 �a + t , n v" is + ' S, tea. - .a S�R• .x v' f - n♦ ♦III d .1 ,, •Ys -_ ' ----------------- r e. t {� , ^ rY •*9 �.#'� �¢.. �"1..• "`�' »„"f 1 � ' *�� g�. ♦ � ,y. it 5 �•_- b R � 0 `�aY w � v �':'"� � 1 �.. .!� ,� +.•'a ^- �.+• •�. . ti f a of{C3t�tj 1=LC�G� PChN. . ;� .rr v�tr. cawitgLl�aIIr•' r r - � .. ..h LD Uwt to - l rou.lnrm T � - - �_ — U •I .KI tL11EN - �� .�� �I r� _� I i. Y � ,7cztCY.. — zc t e'cte.ncn a=s ) I I I I i . (��nt 1tly7I 1 I 4scgst•.. .. 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City/Town State •Zip Code Date of lnspectlon Inspection results must be submitted on this form.Inspection forms may not be altered in any, r. . .way.ti important:u ms A General Information filling out forms a .. . =,- on the computer,use only the tab 1. (n'spec6` key to move your cursor-do not 'D{on G Dugan ' use the return' Name'of Inspector `key-Dugan Construction Company Name I� 41S43 Main,St: ' Company Address f Brewster MA 02631 • M/ City/Town State Zip Code 5,08-896-9390 60 Telephone Number License:Number s B Certification } { certify that 1 have personally inspected the sewage disposal system at this address and that the information reported below is true,,accurate 8nd.complete as;of the time of the inspection.The Jnspection WAS peiformed based on my tmirling'and experience in the proper function and maintenance of on site sewage,disoosal sy4erfis:i am a DEP approved system inspector pursuant to Section 15 340.of { Title'5(310 CMR 15.000).The.system:' Passes ❑ Condi Tonally Passes Fails Needs Further Evaluation by fhe Local'Approving Authority L 3/C) Inspectors Signature Date . The system inspector shall submk:a copy of this inspection report to the Approving Authority(Board 'g ) _, 0 gpd or greater,-•the rns ector and the s stem owner sutimit theor of Health or DEP within 30 days-of'com completing this ms dron. If the system has a design of:10 000 p y ;'.'report to the appropnate regional office of the DER The original,should be sent to the system owner and copies.sent to the:bu er,if a ' Y pplicable,and approving authority. "This report only describes.conditions-•at the time of inspection and under the.conditions of use Bit that time.-This"ins ection does not address°-how the system will perform in the future under the same or different condrtions`of.use, �n 210 21 Doraf Rd Cummaquid(31)•03l08 Title 5'Offieial Inspection Form:Su Sewage D'is, I'S)sfem•Page t of 15 [ h Commonwealth of Massachusetts Title 6 ® coal Ifispectoon Form o Subsurface Sewage Disposal System Form Not for Voluntary Assessments 21 D(bral Rd. Property Address Estate of Fred Hastings c!o Terry&Marilyn Traver, 31 Wildflower Dr. Westerly RI 02891 Owner Owner's Name information is Cumma uid MA 02673 1/13/09 required for every q page. Cityrr?wn State 'Zip Code Date of Inspection B. Certification (cunt.) Inspection Summary: Check A,B,C,D or E/almys complete all of Section D i 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: B)- System Conditionally Passes: One or more system components as described in the`Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes, no or not determined(Y, N,ND)in the❑for the following statements. If"not determined,"please explain. 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 exfiftration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. : *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: El Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed 21 Doral Rd Cummagi id(31)-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts Title 5 ®ffcoai -Inspection Foru Subsurface Sewage Disposal System Fonm-Not for Voluntary Assessments' 21 Doral Rd. Property Address Estate of Fred Hastings clo Terry&Marilyn Traver 31 Wildflower Dr. Westerly Rl 02891 Owner Ownef s Name information is required for every Cummaquid MA' 02673 1/13/09 page. Cityrrown State Zip Code Date of Inspection B. Certification (cunt.) B) System Conditionally Passes(cont.): ❑ distribution box is leveled or replaced ND Explain: El The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines-in accordance with 310 CMR 15.303(1)(b)that the system.is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any) 4„ z tilic health,determines that the system is functioning in a manner that protects the pu 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. 21 Doral Rd Cummaquid(31)•0308 Title 5 Official Inspection Form:Subsurface S&Awle Disposal System•Page 3 of 15 Commonwealth of Massachusetts Toile 5 Official o n4pectoon Foy Subsurface Sewage Disposal System Form-Not for Voluntary Assessments uv.�, 21 Doral Rd. Property Address Estate of Fred Hastings clo Terry&Marilyn Traver 31 Wildflower Dr. Westerly RI 02891 Owner Owner's Name information is required for every: q Cumma uid MA 02673 1113/09 page. City/Town State Zip Code Date of Inspection B. Certification,(cont.)� C) Further Evaluation is Required by the Board of Health(cunt.): 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 El ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool El ® 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 ❑ ® 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. 21Doral Rd Cummaquid(31)•03108 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 4 of 15 . Commonwealth of.'Massachusetts . Title 5 ffiCA l I t S peC ��0 F ­ .p rM Subsurface Sewage Disposal System'Form'-Not for.Voluntary Assessments 21 Doral'Rd. Property Address Estate of Fred.Hastings� cto Terry&Marilyn Traver 31-Wildflower Dr. �Westerly RI 62691 Owner ,Owmer s Name information is required for.every Cummaguid ... . MA 02673 1/13/09 page. City/Town State Zip Code Date of Inspection. _ B. Certification (cunt) D) .System"Failure Criteria Applicable to All Systems(cunt,):.. Yes No ❑ ® Any portion of a cesspool or privy is within a'Zone 1 of a.publicwell. 6 ® Any portion of a cesspool or privy is^within 50 feet of a private water supply well. El 0 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 acxeptable water qualify analysis. [This 4 system passes if the well water analysis,'performed at;a DEP certified r lab6ratory,1br-fecal conform bacteria indicates absent and the presence of ammonia'nitrogen and nitrate nitrogemis equal to or less than5 ppm, =F provided that no other failure criteria are triggered.A copy of the`analysis and chain of custody must pe attached to this form.] The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd: The system fails:.)have determined that one or more of the above failure criteria exist as described in 310 CMR t5.303,therefore the system fails.The , system owner should contact the'Board of Heafthto 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 15 006 9pd. For large,systems,you must indicate either"yes"orn on 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`:ndrogen sensitive:area'(Interim Wellhead Protection El El Area IVOA)l or a mapped Zone II of a public water supply well If you haveanswered°yes""to any question in Section E the system is considered a significant threat, or answered"yes"in Section D above the large system has4ailed-,'The owner or�operator of any large system considered-a sign cant thieat`undecSectionE or failed u"rider Se` on snail upgrade the system in accordance with,310 CMR 15-304,The system.owner should contact the appropriate regional office of-the D.epar#ment> 21 Doral Rd Cumma uid 31 WIN Title 5 OfficialIns g Dispose System•Page 5 of 15 q� ( )' pectori t=orm;Subsurface Sewa e I t Commonwealth of`Massachusetts Title 5 O,fri-cia'l Qnsp C$i®n Form _ •Subsurface Sewage Disposal System Form-Not,for Voluntary Assessments � 21 Dl ral Rd. Property Address Estate`of Fred Hastings clo•Terry&Mddlyn'Traver 31 Wildflower Dr. _Westedy R102891 Owner Owner`s Name _ information is Cumma uid MA 02673 1/13/09 required for every. q -• page. City/Town State Zip Code Date of-Inspection t , C. Checklist Check if.the following have.been.done.You must�indicate ayes'or ano"as to each of the following Yes No ® ❑ Pumping information-was provided by the-owner, occupant,or Board of Health Ell 'Were�any of the system components pumped out in the previousawo:weeks? ❑ :Has the system received normal flows in the previous two week periods " Have large volumes of water:been:introduced to the system recently or as part of ❑ this inspection? Were as built:plans oft h e system obtained:and examined!(if they were not, available note as N%A) ® ❑ Was the facility or dwelling inspected'for signs of sewage backup? ® ❑ Was the site inspected for'signs of break out? L, 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 ofthe'baffles or tees,material of,constructioni' -dimensions;depth of liquid;depth ofsludge.and depth of scum? r ® ❑ 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: z ® ❑ Exi sting'information_For example,a plan at the Eoard:of Health. ® ElDetermined in the field(lushy of the failure criteria related to Part"C is at:issue approximation of distance is unacceptable)[310 CMR 15.302(5)] 21 Doral Rd Cummaquid(31)-03M Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts Title's Official Inspection Forte Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 21 Doral Rd. Property Address Estate of Fred Hastings clo Teny&Marilyn Traver 31 Wildflower Dr. ' Westerly RI 02891 Owner Owner's Name information is Cummaquid MA 02673 1/13/09 required for every ' page. City/Town State Zip Code Date of Inspection D. System.information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 gpd Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[tf yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available ast 2 ears usage 07 40;000 gal 9 0 Y 9 (gpd)} 08 22,000 gal Sump pump? ❑ .Yes ® No 9/08 Last,date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): 21 Doral Rd Cummaquid(n•fJ= Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 7 of 15 Commonwealth of Massachusetts Toile 5 Official Inspection Forte Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 21 Doral Rd: Property Address Estate of Fred Hastings s c%Terry&Marilyn Traver 31 Wildflower Dr. Westerly RI 02891 Owner Owner's Name information is Cumma uid MA 02673 1/13/09 required for every q page. Cityfrown State Zip Code Date of inspection D. System Information (cont.) General Information Pumping Records: Source of information: pumped: unknown 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) (f 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 VA system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components,date installed (if known)and source.of information: installed 1977 and new leach pit'added 4/27/89 20 years old Were sewage odors detected when arriving at the site? ❑ Yes 0 No 21 Doral Rd Cummaquid(31)•03M Title 5 OfficW Inspection Fonn:Subsurface Sewage Disp l System•Page 8 of 15 Commonwealth of Massachusetts Title 5 '®ffidal Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ww 21 Doral Rd. Property Address Estate of Fred Hastings . c/o Terry$Marilyn Traver 31 Wildflower Dr. Westerly RI 02891 Owner Owner's Name information is Cumma uid MA 02673 1/13/09 required for every 4 page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Building Sewer(locate on site plan): 5' Depth below grade: feet Material of construction: 0 cast iron' ®40 PVC ❑ other(explain): Distance from private water supply well or suction line; feet Comments(on condition of joints,venting, evidence of leakage, etc.): Joints are tight,venting is at the roof, no signs of leakage. Septic Tank(locate on site plan): Depth below grade: 4'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: 1,000 gal. 2" Sludge depth: " # Distance from top of sludge to bottom.of outlet tee or baffle Z8 Scum thickness 511 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? by tape and rod 21 Doral Rd Cummaquid(31)•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth.of.Massachusetts Title 5 Oaa8 asjecu® For Subsurface Sewage Disposal System f6mm Not for Voluntary,Assessments M 21 Doral Rd. Property Address Estate of Fred Hastings` c/o Terry&Ma T rilyn raver '31 Wildflower Dr. Westerly RI 02891 Owner Owner's Name information is Cumma uid MA 02673° 1/13109 required for every q page. City/Town State Zip Code Date of Inspection D. System Information`(corio, Comments(on pumping recommendations,inlet and outlet tee or,baffle condition,structural.integrity, -.liquid levels as related to outlet invert,evidence of.leakage; etc): Pumping is not needed atdthis time.Tank and'tees in good condition pno'slgn of leakage., s - W. Grease Trap(locate on"site plan): Depth below grade: feet Material of constru ction f 'O concrete 'O metal 0 iberglass O polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle n Distance from.bottom of scum to bottom of outlet tee:or baffle s Date of last pumping: g. Date Comments(on pumping.recommendations, rniet and outtettee or baffle.condition,,structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): Tight or Holding Tan,W(tank must be pumped at time of inspection){locate on site plan) Depth below grade: Material of construction: . O concrete O metal O fiberglass O polyethylene O other(explain): 21 Ddral Rd CummagWd(31)•03108 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 10 of 15 g .Commonwealth:of Massachusetts itle s -Qfffida' InipOction Form Subsurface Sewage.Disposal System.Form-Not for Voluntary-Assessments N 21 Doral Rd. Property Address Estate of Fred Hastings Go-Terry 8t Marilyn Traver 31_Wildflower Dr. Westerly Rl 02891 Owner Owner's Name. information is required for every -Cummaquid RM.. 02073 . 1/13/09 ' page. citylTow n' n State ZIP GodeF Date of Inspectio D. Systernrinforrnation (cunt.) Tight or Holding Tank(cunt:) Dimensions: Capacity: ;^ gallons r Design Flow: gallons per day, Alarm present. : .Q Yes . �0 No Alarm level,- - Alami-in Worlang order ❑ Yes ❑.'No Date of last um in : P P 9 Date. Comments(condition of alarm and floatswitches,etc:): *Attach copy of current pumping contrail(required) Is.copy attached? ❑ Yes No . 3 N. Distribution Box(if present must bef opened).(locate on slte`plan) ' Depth of liquid level above outlet inved Comments(note if,box is level and distribution to,outlets equal,,any evidence ofsolids carryover, any evidence of leakage into or out of box,etc:): D=box was found level and.distribution is equal.No sign of.carryover or leakage.'. Pump Chamber Pocate on site plan).- Pumps in working order. El Yes` ;.E] No Alarms in working order Yes. No 21 Doral Rd Cummaquid(31)-03101 Title 5 Official Ir"ion`kwm:Subsurface Sam a Disposal System-Page 11 of 15 ` Commonwealth of Massachusetts Title 5 Official ,Inspection ,Forte Subsurface Sewage Disposal System Form Not for Voluntary Assessments' w, 21 Doral Rd. Property Address Estate of Fred Hastings c%Terry A Marilyn Traver 31 Wildflower Dr., Westerly R1,02891 Owner Owner's Name information is required for every Cummaquid MA 02673, 1/13/09 page. City/Town State Zip Code Date of Inspection D. System Information=(cont:) Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): 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.): 21 Doral Rd Cummaquid(31)•03= Tole Official Inspection Form:Subsurface Sewage Disposal System.-Page 13 of 15 Commonwealth of Massachusetts Toile 5 Official Inspection Forte Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M 21 DO:ral Rd. Property Address Estate of Fred Hastings c/o Terry&Marilyn Traver 31 Wildflower Dr. Westerly RI 02891 Owner Owner's Name information is Cumma uid MA 02673 1/13/09 required for every q page. Cityrrown. State Zip Code Date of Inspection D. System Information (cunt.) 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: Type: ® leaching pits number two 6'x 6'pits w/stone ❑ leaching chambers numbed 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.): pit#1 found with 30"of liquid in if; no signs of staining, no signs of failure 21 Doral Rd Cummaquid(31)•03108 Title 5 Official Inspeclion Form:Subsudace Swvage Dsposal Sysftn-Page 12 of 15 F Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Forrn Not for Voluntary Assessments 21 Doral Rd. Properly Address Estate of Fred Hastings clo Terry 8 Marilyn Traver 31 Wildflower Dr. Westerly RI 02891 Owner Owner's Name information is required for every umq Cma uid MA 02673 1/13109 page. Cityrrown State Tip Code Date of Inspection D. System Information (cunt.) Y 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. A- ( - o A 63 A _F. - 79 � � b �QV 51� I ~rL 2 - S l� d' �7 [3 W A 7N G E w O 3 / ' 1- W b L irk 21 Doral Rd Cummaquid(31)•03MB Title 5 Official Inspection Forth:subsurface Sewage Disposal System•Page 14 of 15 Y i Commonwealth of Massachusetts Title 5 Offic' is nsDec!6ii Forte Subsurface Sewage Disposal System Form-Not for Voluntary Assessments a 21 Dora[Rd. 'Property.Address.. , Estate"of Fred Hastings �� do Terry. 8t'Marilyn Traver.:31�Wldflower Dr. "Westerly RI 02891 Owner. Owner's Name information ie Cumina uid MA 02673 111W09 ' required for every - q , page. City/Town _ State. Zip Code Date of Inspection - . ® System.Information (cont) Site Exam: s ❑t-Check Slope El Surface water Check.cellar - - 0:Shallow-wells �' Estimated depth to high ground water. feet Please indicate all methods used to determine the high groundwater elevation: ❑ Obtained from system design plans on record' t If checked,date of design plan reviewed: Date "µ# Observed.site(abutting property/observation.hole within 150.feet of SAS) El Checked with local Board.ofHealth-explain: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database.-explain: You must describe how you established the high groundwater elevation:: By U.S.G.S.atlas :H A-692 ;>F separation. 21 Doral Rd Cummaquid(31)•03lOB Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 � o . I TOWN OF IiARNSTABLL � �le LOCATION IZ/ SEWAGE # G VILLAGE ASSESSOR'S MAP 6z LOTell INSTALLER'S NAME & PHONE NO. he eiy7/3QR str C TANK CAPACITY LEACHING FACILITY:(rype)__ / (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: _ DATE. COMPLIANCE ISSUED__ VARIANCE-GRANTED: Yes—' W - Na_ V i / '.�/ �. � � es�' .s�; i r s � � / '� �� � �� � � ro ��� � � � � Q� q4� jl` ` ; � I„. q\ Fmc...... .....2II...fJ.D THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH Tawn- ------------------OF.......Barn.s.t;^abL.e------------......------------..........---------- ApplirFativaa for M-4pug al Wurku Cfuaastra tivaa,prrutit Application is hereby made for a Permit to Construct ( ) or Repair (XX) an Individual Sewage Disposal System at: _____________31 Dora1 Road Location.Address or Lot No. ............. ................................................ ..............................................a.................................................... Owner Address a -•-----------J-P...1�Is� Q�oolZ_x...sI!._........................................ •....---------•-•---••--••••••-----....----------------•••----•-••---------------..._...........-- Installer Address UType of Building Size Lot............................S q. feet Dwelling x-xNo. of Bedrooms................3..........................Expansion Attic ( ) Garbage Grinder ( ) Other—Type T e of Building ......_..... No. of persons............................ Showers a YP g ---------------- P ( ) — Cafeteria ( ) Q' Other fixtures -----------------•-•--•---•--•-- . W Design Flow............................................gallons per person per day. Total daily flow..................:.........................gallons. WSeptic Tarik—Liquid capacity............gallons Length................ Width................ Diameter________-___--_ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. ' Seepage Pit No--------------------- Diameter...._............... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.................... ..................................................... Date........................................ . aTest Pit No. i................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-------_................. a •---••••--------------------•---•-•--•••--•----------•-----•---•--------•---._.....---------.....---......................................................... 0 Description of Soil---...................................................................................................................................................................... Ux •--_------••----- nd... -----------------------------------------•---------•-- W U Nature of Repairs or Alterations—Answer when applicable---------1,1.0_00--- a-1-1ari •... •----------•---•-••.......................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TiT I.;a. p 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 health. Signe ZIe ._. ....................... 4 Date Application Approved By................Cj ----------�-�L9 n... . . --._....--•-----••--•-----------•--- Date Application Disapproved for the following reasons----------------•------------•--------------------------------------------------•----------------------------•. --•--------------------------•-•-...-----••----...••----•--------------•......•--------••---•------•---•-I--....--••••-••••--•-•-----------••------•------•-•••-------•--•----•------•--••-•----••-•----- ate Permit No...... ®----------------•---_.... Issued.................................J''......D at------- �F ;i .............................. _ THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH �1%4 I' ?T.i - ........--- . OF.......Ira.r.nss.tr'bl,a----------------- -----•--••---••---.----_--_- ti Allp irFa#iun for Disposal Works Tour rnr#iun Vrrmit � Application is hereby made for a Permit to Construct ( ) or Repair (XX) an Individual Sewage DisposalI System at: ad Ora! Roz .......-•- --------•-_. Location-Address or Lot No. ............. -•--------------------------------------•------- -•-------•-••-••------....----------•---••-••----.....----...............................•---•••-- TT �y ry�g ` y Owner Address W _______t._e .._......Sl�st r 3e..!.C:.a. ............................... a - Installer Address UType of Building Size Lot............................Sq. feet Dwelling's No. of Bedrooms............... ..........................Expansion Attic ( ) Garbage Grinder ( ) aal Other—Type of Building ............................ No. of persons--..___-_-__-__"___--_--___ Showers ( ) — Cafeteria ( ) < Other fixtures -------------------------------- W Design'-Flow............................................gallons per person per day. Total daily flow............................................gallons. 9 Septic Tank—Liquid capacity------------gallons Length---------------- Width................ Diameter................ Depth................ Disposal Trench—No. .................... Width-------------------- Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..........1_......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........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water_.__-____-.__-_---.____. R+' --------------------"---.....__...------------------------•"-------•"--•----........--..............--•----------•""--------------------....--.•..-- 0 Description of Soil........................................................................................................................................................................ V —a.Y ----------------------•------------------•-------.....-------------•.............._ W ---------------------------------------------------------------------------------------------------------------------------------------------------.................................................. UNature of Repairs or Alterations—Answer when applicable---------1--^-—0-00-__ -a_11 n ; t_±.:....................................... ......................................................:................................................................................................................................................ Agreement: The undersigned agrees to install the afore_described Individual Sewage Disposal System in accordance with the provisions of TIIL- i of the State-Sanitary Code f T_he undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board-of.-health. Signed ".'., 1 IX ;¢ ..................... _..._,� r 1_7/a 2..---•- �! _ wtAPPa � lication Approved BY .......... Date Application Disapproved for the foll&wing reasons:----------"----------------------"-----------------. ......................................................... ........_..._ .:- Date C Permit No.......91,=---/*,n------------------------- Issued-...------;�=...---------------------•------••----------- ' THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH - ............. � :..:..................OF..........:Pc3C�1ste1..blC?........................................... �rrtif irFate of Tomplianrr } THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired, Xy) by-----J.P----- ---------•--•---------•"--•--........-""-------------------------------------•---•--•-•--......-----.........--•--------------------.....------. Installer at.........' ..__e`� _C .. S? �a.. tw �xttl- ----------------------tall-- ' has been installed in accordance with the provisions of TI T%.E 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No--------490'eX___Z.67.C1_...........r3 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 WWi' ' .... OF.......... NO ................................ ...---•-.... ..� ..�� t ` . FEE........................ Disposal Morks Tontr ion �rmit Permission is hereby granted......J.-_'_i«I C O;IS���r Jr. --••--.------•-------------------------•--------------------- ........ ...... to Con truct ( ) or Repair F) an Individual Sewage Disposal--System at No- 1 Doral Roar": Cumm .gui :� -------------------------•----------------------- ------------------------•---•----•---•.---------------------------------•--------------•------------•----------•-----............-•-•- Street ��• as shown on the application for Disposal Works Construction Permit No..41 :f-l ' Dated.......................................... ................................ ...................................................... (J .DATE................... =--�-•��-............................... Board of Health FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS i � CYq 7 - No.. •. � FIc$..... e` THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Appliratiun for Disposal Works Tonstrurtiun frrmit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal em at: �- ... _ : ... .............1 ....._ Ab.. & ..---.......-----•..-----.................---•---------------------'---•--.............---.....--- toion-Address or Lot No..........•------- Owner Address ........•. ... .. ---------•-- c �.._.... Installer -54 0 p'r Address Type of Building 0 Size Lot............................Sq. feet aDwelling—No. of Bedrooms........ ' ...........................Expansion Attic (Vof` Garbage Grinder Other—Type of Building ............................. No. of persons............................ Showers ( ) — Cafeteria ( ) Other.fiXtures ------. ----------•--•--- ---•--------•-- W esign Flow......... _ -•--- -gallons per person p day. Total da•ly ow..... .......................gallons. W �Septic Tank—Liquid ca.pacity.i gallons Length._.......... Width....__._.... Diameter______________ Depth................ x i Dsposal Trench—No. .................... Width__ ............ Total Length......._........... Total leaching area------- ____sq. ft. PC Seepage Pit No.........'---------- Diameter........ ........ Depth below inlet...._ ........ Total leaching area_ ___sq. ft. Z L*Other Distribution box ( ) Dosing tank ( ) Q 8Percolation Test Results Performed by Date Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water----------_........ _.__. fs,(� Test Pit No. 2................minutes per inch Depth of Test Pit..........•.__...... Depth to ground water........................ ----------------- Ah Descrl ion of Soil ' _.►.._. -....... �_®.3, ._...I� '. \ .+ cs -........................................................._ .. " V V.. U Nature of Repairs or Alterations—Answer when applicable__________________ G___._L.1. ;1� .... l�' s�_�a-� � o).......---------------•----------------------------------------•--•................----------------------------•------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal,System in accordance with the provisions of TI'I1Z- 5 of the State Sanitary Code—The undersigned further agrees not to+place th system in eration until a Certificate of Compliance has en issued b the board.of Health. q� i Date pplication Approved By......... �i .. :.. -----------------------•• -------- , --------71- D 3_* Application Disapproved for the following reasons:------•-------------•--•---•--------•---------------------------------------------•---•-•-•-•.ate.--....•....- W - ..................................................................................................................................................................... Date pPermit No....................................................... Issued-----------............................................ Date If h No................. .... FE$...... ............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH --------------oF......-. . - Allp irFatiun for Disposal Works Tongtrurtion runfit Application is hereby made for a Permit to Construct (1�' or, Repair ( ) an Individual Sewage Disposal SVem at .......................... --- -. --------------•------........._..._•---•- .. "A it.AAL. - e o ation-Address ", rr or Lot No. i!'„•• _ _ _._.^.. _._.. .....................'.......... Owner ,� Address a ... . -_ '�' - ...JF.. .. ;.e..R................................ Installer Address dType of Building Size Lot____________________________Sq. feet Ex ansion Att>c Garbage Grinder a Dwelling—No. of Bedrooms____. _________________ p ( ' g ( j Pk Other'=Type of'Building ............................ No. of persons.......................... Showers ( ) — Cafeteria ( ) a' Oth ures,,.------.................................................... d W Design Flow.......t•-4............. gallons per person p r day. Total daily flow_.____°" .......................gallons. WSeptic Tank—Liquid capacity L► gallons Length...... `...... Width_.. -_--____ Diameter_______________ Depth................ x Disposal Trench—N _____________________ Width__ ------- Total Length..._..___.......... Total leaching area....................sq. ft. Seepage Pit N•o._______ _.._. Diameter _._..#t Depth below inlet____. ! Total leachin area s it. P ----•- P' g q Z Other Distribution box ( ) Dosing tank 0-4 Percolation Test Results Performed by-------------------------- -•---------------------------•--•-------- Date........................................ a4 Test Pit No.•1________________minutes per inch Depth of Test Pit_:________:_________ Depth to ground water------------------------ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water......................... B i'...................................9 -e�ction of D x / VA UNature of Repairs or Alterations{ Answer w) applicable------- --- ! ,- - -------------------------------------------------- --1- - - `s Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System,in accordance with the provisions of TITTIE 5 of the State Sanitary Code—The undersigned further agrees not td,place th system in operation until a Certificate of Compliance ha en issued b the board of lealth. 4� S> - 3 --•• D �. .. : ate OF Application Approved By...... f -•--•-- --• ;---------------•-----•• _.. --`-- '-- - Date Application Disapproved for the following reasons:......................:............................................................._--------------------.------_ -•...............:...•---.....-•-----...-----._.....-----._........_..-•---- --.....---.....-----------.._...------=-=----=--------------------------------------------::-------- ----------- Date • PermitNo............................ -------------------•.___. Issued_.........................................................- Date i_ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF H�EA o�.... .. .._-------------------- ... . Trtifiratr of Toutpliattrr TH IS T C TIFY, at the. lividVal wage Disposal System constructed ( ' -or Repaired ( ) �! .. r M stal �[n ler /�'rJ -at..__..._. - _. - ----- - ----... has been installed in accordance with the provisions of T 5 of The State Sanitary Co e as described in the ------------•--• dated_ -- ;_ _--------•-•--• application for Disposal Works Construction Permit No. '�.__-_��� �' THE ISSUANCE OF THIS CERTIFICATE SHALL MOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE...... ....�� b �---•--•--•-----_..... Inspector............... ... -----• -•-------- ....................... THE COMMONWEALTH OF MASSACHUSETTS rQ, BOARD . OF HEALT, ..........OF.. .fir ................... No........................ FEE.. ............ �iu�rou 1 ` •�ku1--ol. n rPermission is hereby granted'--- . •-•-•-•. - -� - y----------------- to Con ct r, fir ( ) anndwidual. wage D• p al Systems Street as shown on the application for'Disposal Works Construction Per No Dated_._'"a_ k 72._______.._. . 1/ PP and Bo Health" DATE._ _ . "�FORM` 1255 HOBBS'& WARREN, INC., PUBLISHERS T_ - - - - ---- 14u 1 Lt>tAG sew (Z - Aq V i OAS'- -)22,u4- - �� ---� ----vim - -- -- L AWN F, -R os � �' ; 1 � � � I t f � i � ► � i ► I i ► } t _ i I ► � I I � I l . } I I � � • 1 {{ � t 1 aG�O'>7 Gd4�ER 2:d' 6�6" 4 6-c" s•a" a b" 2.'S' G�-O' s.lo' 2.O- t 9" 100to � Q N o -7lN tG O 4 N ' ticcGC S: 2c t Hp F ll lEVEt_c<4.UWE tWEE .. - Cwr r NtIY....GQb15T'ELUcZlflN •... � �.. � - -N 2.i' 3-a, b-l0" 3.8- '1-8'- ''�-8' ¢.Q"- '.A%- ccxm Ajurr i .. cnaTaEpTts� _. txlsTiW5.1'h_nitUd. I L.-, ,r 'l-,}.J •� _ 3 T � It ERts't,u(; SjtYu4e - '7 6TEIt.MJ-IkocbMc . F7�E EXISTtN�j Vt•,:tti5C2oc�P••� y. :c ErtsTra,S pp�� - i N.' 7 MOST VtL)LTIC V OE WX 5 t70�/.^6 R At3t�lTW t.i�ilI.TEE�`CLO_N 5_ Mr.11o. ....w....r o.�a.� Bruce Devlin .,-cute.-- clZPra DmignO 774-23"773 31 �oa^�KaAr> 1 K Y 2.Cr .,.s � ,• C-G- S 1" 3 t-r '2.5 C'.O- S.10 .2.0' , < ,.t '9"'a� trr lr r - .. n' �S}nr.:' . 's,._ ].. _ 4 „ .` x6. s '° •9. ..•: �.. : a.A` t.� .,�.- _ ... ;M 4 •G'•. � �:`♦ _� �b , , r , ,y • •... � xd..\ •- .. - ... k...aygw _ - .. ,Df . •tea - �# ,, t - - I o �.r , • 1n or i N .'a M14tl _ 4 _ 1• �n 1L •.. - _ •. - f.. -, ;z - - Y \v,Lnpa�, -'cl ..qyr aar F T. a a A +'N i -- r -<, - .�, .. i.- •• yj _. -,. 'LEVCL CCU.UWE - + : _ - s. - •r e - , z�a CN t low P . . s r- , _ F , � : r i .... .mot: -. •.. , _ .- - - - - ire \vaPl1.CG I '—f3P,.O.,L• h"°VL - - e ., - ♦' � .- 1 , ". ". • r.^ ._ ,- r -. _ rap\v - • _ s +. b t•IXR E / II •n,e5 • T u • F ..f �F f' f, : _ K.E�LIC,ed. -I .. 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