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HomeMy WebLinkAbout0141 INDIAN HILL ROAD - Health 141 INDIAN HILL ROAD Bamstable A= 318 -041 r _ l P =x Commonwealth of Massachusetts 318 oyl ii Title 5 Official Inspection Form F' Subsurface Sewage Disposal System Form- Not for Voluntary Assessments stir 141 Indian Hill Rd. r Property Address - WYLAN,BARBARA TR �s Owner Owner's Name information is Barnstable MA 02630 2/23/20 P.? required for every page. City/Town State Zip Code Date of Inspection c r; Inspection results must be submitted on this form. Inspection\forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When ~' filling out forms A. Inspector Information 64 j4f319 on the computer, use only the tab Robert Paolini key to move your Name of Inspector cursor-do not Robert.Paolini use the return key. Company Name a 67 Tanbark-Rd. Company Address Marstons Mills MA 02648 � - City/Town. , State Zip Code (508)280-9499 S14454 Telephone Number. License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5(310 CMR 15.000); 1 have,personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® 'Passes 2. ❑ Conditionally Passes 3. El Needs Further Evaluation by the Local Approving Authority 4. 0 Fails �. 2/23/20 Inspect is Signatu Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or-DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd'or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ` Please note: This report only describes conditions at the time of inspection and under the - conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/28/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System(Form -Not for Voluntary Assessments J/ 141 Indian Hill Rd. Property Address WYLAN,BARBARA TR Owner Owner's Name information is Barnstable MA 02630 ` 2/23/20 required for every page Cityrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1., 2,3,'or 5 and all of 4 and 6. 1) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. t: Comments: 2) System Conditionally Passes: ❑- One or more system components as described in the"Conditional Pass" section need to be The system, u on completion of the replacement or repair,.as approved by ed or repaired. T replaced pP 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 ind icating that the tank is less than 20 years old is available. p g ❑ Y .❑ N ❑ ND (Explain below): - ' y -Page 2 of 18 t5insp.doc-rev.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 141 Indian Hill Rd. Property Address WYLAN,BARBARA TR Owner Owner's Name ` information is required for every Barnstable MA 02630 2/23/20 , page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cunt.) 2) System Conditionally Passes(cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of'sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ - obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): i ❑ 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 ElY ❑ N ❑ ND (Explain.below): 3) ._Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if ' the system is failing to protect public health; safety or the environment., a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the'environment: - t5insp.doc•rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 T c Commonwealth of Massachusetts �= Title 5 Official Inspection Form M1 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments I .141 Indian Hill Rd. . Property Address WYLAN,BARBARA TR Owner Owner's Name information is Barnstable MA 02630 2/23/20 required for every page. City(rown State tipCode Date of Inspection ' C. Inspection Summary (cunt.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool orprivy is'within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier,if any) determines that the system is functioning in a manner that protects the.public health, safety and environment: ❑ The system has'a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. 0 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. stem has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or ❑ The s p Y - more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen g is equal to or less than 5 ppm, provided that no other failure criteria.are triggered. A copy of the analysis must be attached to this form. c. Other: i 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following fore inspections: Yes No ❑ ® Backup of-sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection -Form ; - I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 141 Indian Hill Rd. V Property Address W WYLAN,BARBARA TR Owner Owner's Name information is Barnstable MA 02630 2/23/20 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) = . 4) System Failure Criteria Applicable to All Systems: (cont.) - Yes No 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. ❑ ® Any portion of a cesspool or privy is within a Zone t of a public water supply well. k ❑ ® 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 otherfailure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.,303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 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 CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ ' the system is within 200 feet of a tributary to a surface drinking water supply ' El ❑ 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 �YFfn.�OC•iOY.7l28f2018 Tdto 6 gHwiai tewpedia•.Gn...r.n_`—=__Cmy.000 Diapwwb G,ab...•D:ps G wF+fa - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 141 Indian Hill Rd. Property Address WYLAN,BARBARA TR Owner Owner's Name information is 'Barnstable MA 02630 2/23/20 required for every page: City/Town State Zip Code Date of Inspection C. Inspection Summary .(cont.) If you have answered"yes" to any question in Section C.5 the system is considered a significant threat, or answered"yes" to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. -You must indicate"yes"or"no"for each of the following for all inspections: Yes - No 4 ® ❑ 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? O ® 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 i available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, - dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of.subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS),on the site has been determined based on: ❑ ® Existing information. For example, a plan at the Board of Health. Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage_Disposal System•Page 6 of 18 c Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary.Assessments 141 Indian Hill Rd. Property Address WYLAN,BARBARA TR Owner Owner's Name information is required for every Barnstable MA 02630 2/23/20 page. Cityfrown State Zip Code Date of Inspection .D. System Information 1. Residential flow Conditions: 3 Number of bedrooms(actual): : 1 Number of bedrooms (design): _ ) DESIGN flow based on 310 CMR 15.203(for-example: 110 gpd x#of bedrooms): 330 Description: T 0 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Does'residence have a water treatment unit? [I Yes ® No If yes, discharges to: Is laundry on a separate sewage system?(Include laundry system inspection p Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No I Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No NA Last date of occupancy: Date 1 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Ford Subsurface Sewage Disposal System.Form -Not for Voluntary Assessments 141 Indian Hill Rd. Property Address WYLAN,BARBARA TR Owner Owner's Name information is required for every Barnstable MA 02630 2/23/20 page. Cityfrown r State -.Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): g Gallons per day(gpd) Basis of design,flow(seats/persons/sq.ft.,•etc.): Grease trap present? ❑ Yes ❑ 'No Water treatment unit'present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No 4 . Water meter readings, if available: ' F Last date of occupancy/use: Date Other(describe below): i I r I 3. Pumping Records: Source of information: w . Was system pumped as part of the inspection? ❑ Yes) ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.M612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments, 141 Indian Hill Rd: Property Address WYLAN,BARBARA TR Owner Owner's Name information is Barnstable 'MA 02630 2/23/20 required for every page.- City/Town State Zip Code Date of Inspection D. System Information.(cost.) 4. 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 i ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ ' Yes ® No 5. Building Sewer(locate on site plan): 3' Depth below grade: feet Material of construction: ❑ cast iron 9140 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight. No evidence of leakage.System vented'through house vents. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 r Commonwealth of.Massachusetts' y Title 5 Official Inspection'. Form ISubsurface Sewage Disposal System Form -Not for Voluntary Assessments 141 Indian Hill Rd. Property Address WYLAN,BARBARA TR Owner Owner's Name information is required for every Barnstable MA 02630 2/23/20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont) 6. Septic Tank(locate on site plan): 3' Depth below grade: - feet Material of construction: ® concrete metal ❑.fiberglass ❑ polyethylene ❑ other(explain) o If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No 1000 GI. Dimensions: 3" Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 44' Scum thickness 7- Distance.from top of scum`to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle j Measured How were dimensions determined? 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 every two years.lnlet and outlet tees in place.No signs of leakage. t5insp.doc•rev.726t2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 usetts'Commonwealth of Massach Title 5 Official Inspection Forte Y Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 141 Indian Hill Rd. Property Address WYLAN,BARBARA TR. Owner Owner's Name information is required for every Barnstable MA 02630 2/23/20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. .Grease Trap(locate on site plan): Depth below grader feet , Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: e sions: Scum thickness Distance from top of scum to top of outlet the or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑"fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day• t5insp.doc•rev.7/26/2018 We 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 i Commonwealth of Massachusetts p Title 5 Official Inspection Form } Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 141 Indian Hill Rd. Property Address WYLAN,BARBARA TR Owner Owner's Name ' information is required for every Barnstable MA 02630 2/23/20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) 6 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.): i r . *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. 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 level.Box has one outlet laterals with equal distribution.No signs of leakage. t5insp.doc•rev.7/26/2018 Tale 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments u 141 Indian Hill Rd. Property Address WYLAN,BARBARA TR Owner Owner's Name information is required for every Barnstable MA 02630 2/23/20 page. Cityrrown State Zip Code Date of Inspection D. System Information .(cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ -No*. Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): r � I� 66 * If,pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: • Type: 6'x6' 2' stone ® 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: ' t5insp.doc-rev.7126I2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official . lnspectio.n Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 141 Indian Hill Rd. Property Address &. WYLAN,BARBARA T'R Owner Owner's Name information is required for every Barnstable MA 02630 2/23/20 ' page. City/Town State Zip Code Date of Inspection D. System Information (cont.) ` 11. Soil Absorption System(SAS) (cont.) Comments(note condition of soil; signs of hydraulic failure, level'of ponding, damp soil, condition of vegetation, etc.): Sandy soil.No signs of hydraulic failure.Pits were dry at time of inspection. f - 12. Cesspools(cesspool must be pumped`as part of inspection) (locate on site plan): f 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.): d ` l t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 141 Indian Hill Rd. u - Property Address o WYLAN,BARBARA TR Owner Owner's Name information is Barnstable MA 02630 2/23/20 required for every page. Cityrrown State Zip,Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): i Title 5 official Inspection Form:Subsurface Sewage Disposal System•page 15 of 18 t5insp.doc•rev.7/26/2018 Commonwealth of Massachusetts " Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-,Not for Voluntary Assessments 141 Indian Hill Rd. Property Address WYLAN,BARBARA TR Owner Owner's Name information is Barnstable MA 02630 2/23/20 required for every State Zip Code Date of Inspection page. city/Town D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet: Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below -❑ drawing attached separately Commonwealth of Massachusetts Title 5 Official Inspection Form - i Subsurface Sewage Disposal System Form Not for Voluntary Assessments u 141 Indian Hill Rd. Property Address WYLAN,BARBARA TR Owner Owner's Name ' information is required for every Barnstable MA 02630 2/23/20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) . 15. Site Exam: ® Check Slope , ® Surface water V` Check cellar ❑ Shallow wells Estimated depth to high ground water: 15 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: pate ® Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health-explain: ' As-Built j ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS,database-explain: • z t You must describe how you established the high ground water elevation: Used USGS observation well data.Used technical bulletin 92-0001 r Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 a Commonwealth of Massachusetts F Title 5 Official lnspection Form �- I Subsurface Sewage Disposal System Form-Not for Voluntary Assessments -u 141 Indian Hill Rd. Property Address WYLAN,BARBARA TR Owner Owner's Name information is Barnstable MA 02630 2/23/20 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist PP Complete all applicable sections of this form inclusive of: p ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed& Dated and 1, 2,`3, or 4 checked • C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4(Failure Criteria)and 6(Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included J �i�•.�$_=m:sWaa9a � ���ilRI LOCATION ,f SEWAGE PEOMIT q0. VILLAGE INSTALLER'S N.AC1E Si ADDR.ESS f L. i 0,U I L DE R OR OW W Ell :.'rsi DAT "E PERC.lIT ISSUED DATE C 0 M P L I A N C E ISSUED 1 i a l Av 'Q. 1 �I?v 005 �. v N(RD9 -2-,L> ...J.Q THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .............OF....... 'V / .......................... Appliration for UWpaaa1 10ork.6 Tnntrnrtinn Vamit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: � � Ah". A?7 �9 e p � �Z ..........�/ ...........................................°`7�`J--•-��......•---... -----•------............................ ................................................. Location-Address or Lot No. �' oGi3 �. s- 6ciCt�i � /7 ...............4 f - ........................... ----- -------------- ------ :.: ........._..........._................ Owner Address Installer Address < Type of Building ' Size Lot_ . _� -------Sq. feet Dwelling—No. of Bedrooms.......... .............................Expansion Attic ( ) Garbage Grinder ( ) P4 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) PaOther fixtures .......................................................... ----------------------- ---------------------------------------•"----------•--------------- Design Flow.._...._.._.-a........................gallons per person per day. Total daily flow ......... .__.....____........._gallons. WSeptic Tank—Liquid capacity/.,5._o9.ga11ons Length_%f?.� . Width---0_ Diameter________________ Depth.. .__. x Disposal Trench—No. .................... Width_-.---___---____-___ Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------- ---_-_-__-_ Diameter.....�A.j627 Depth below inlet....kl _.. Total leaching area...U�._._sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results 2V�- Performed by.__�...................... _1..G__.._. Date_.__..�___.:....._.._�___.____.... ,aa Test Pit No. l c minutes per inch Depth of Nest Pit-----Z'744 __. Depth to ground water________________________ Test Pit No. 2................minutes per inch Depth of Test Pit....A ig...... Depth to ground water........................ a -�-"--`•�-•-----------'-,------i-�-•----:-••----....---•••-•--•-•--•--....-------•? --------------...-•------•.....-•••-----•-----•.... O Description of Soil----© _ A-7 �S`1,13--So/� ........................ TD4,? 'e._ - - -•••----• . �....A_....T...�..s.. U ............ ............................................................. ............... ---------------------------------------------------------------------------------------------------"---------------------.:.-------•-•------------------•----•-•------------------------.........-•---- U Nature"of Repairs or Alterations—Answer when applicable._-............................................................................................. Agreement: The undersigned .agrees to install the afore d Individu ewa a Disposaes ystem in accordance with p r1T� 5 of the State S ry ode he j lgn - rtl era not to place the system in the provision of l: . operation until a Certificate of Compliance ha y t o i S' ed -tl r�r ------ ---------•-------- ...... - Date �- Application Approved By................... ,+ .../��%` .......................U L B'v__. _ - Date Application Disapproved for the following reasons---------------------------------------------------------------------------------------......................... -----------------------------------------•-------------------------------......--•---------•-•---•------------•---•---•--•-••-••--•---•---•-•-----•-----------------------------•--••-•---••---••-•----- _ Date PermitNo..............-.,........................... Issued..................................................... Date �Y7 F�$ C3....... ............. .- THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH 01AIne. ...... �/ AIST/97.34<.......................... . O F............. ApplirFatiou for Uiipuiiaal Workii Tonstrurtion ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: T //� ///"G Adz J c/i L> �O 7- .3 3 3 i9 ................_....._.............---.........-------•-•----•--•------•--•------• ------------------...........-------------•----------•------------•------------.._......... Location-Address or.Lot No. --- --- - ----- ------------------- Address -....._... e V O .................. /--•-----.. - ----•--•------------ % ,-1 +1 -----• .........................................•• ...... Installer Address Z p 7U Type of Building Size Lot.._--./7____________________Sq. feet Dwelling—No. of Bedrooms___.___._...................................Expansion Attic ( ) Garbage Grinder ( ) `4 Other—Type of Building No. of persons............................ Showers — Cafeteria P� YP g P ( ) ( ) a Other fixtures ------------------------------------------------------ W Design Flow............*.`�_3_______________________gallons per person per day. Total daily flow-----------? Q-....................gallons. WSeptic Tank—Liquid capacity gallons Length ev_.!�:T.. Width__- .rr_ Diameter................ Depth.3_ T.... x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No----------_--------- Diameter..... Depth below inlet__._G.E ... Total leaching area...L�7-_--_sq. ft. Other Distribution box ( ) Dosing tank ( ) Z �-s G'. ". _ Date__TvA/G' Percolation Test Resul performed by__.i �'_____________________��.R4f_._......... aTest Pit No. I....___� _minutes per inch Depth of Test Depth to ground water........ ............ (i Test Pit No. 2................minutes per inch Depth of Test Pit____0G8_---__ Depth to ground water........................ . .......... w ---------- ------------•----•------------------•------•------4...........-�-•----- O Description of Soil----�_ � �SG. `7A/c ID�7✓SG •Si ----- -- -•-------•------•-----•-•----------------------------------------------------------------------------__ -•----- jZ � 2.1 U .............................................. -------------•------------••----------------------------------•--- W ----------------------------------------------------------------•--•-------------------••--------------------------- .......•-•---------------•----•-•-----------•--••-•.....---•--••-•-•-•••--...------ UNature of Repairs or Alterations—Answer when applicable--.............................................................................................. ...............................-........................................................................................................................................................................ Agreement: The undersigned agrees to install theme re scribe Indi lah' ispo�es stem in accordance with C1T�'1 the provisions of 7 5 of the State San ry he ig lace the system in operation until a Certificate of Compliance h ee issued by th bo of hea h. 1 Application Approved B ........t �� Date Application Disapproved for the following reasons-............................................................................................................. Date PermitNo...................:.........•----=--•-••----------_.. Issued....................................................... Date. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �1 ..OF......... Trdifir atr of f ompli aurr P" THIS IS �, . ndivi�t�l Se P *aW4 n constructed ( ) or Repaired ( ) bY>-•-•••.._...-••.•--- ------ ---------•----• --•••-...----------- --•-- -- --------------••......••••------...----....................._......- A /1 Installer AAA A/ L � .•.. has been installed in accordance with the provisions of >f,3(e State Sanitary Code as described in the application for Disposal Works Construction Permit No. __-__ -............. .......... dated_.............................................. THE ISSUANCE OF THIS CERTIFICATE SMALL NOVSE CONSTRUE® AS A GUARANTEE THAT THE ,SYSTEM WILL FUNCTION SATISFACTORY. DATE----•-----,..ZIL(31.91................................... Inspector.--A& -----.----------------•-----------•---------------•---___-__-- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .....r```' OF ............................:..............................................••--.... 0 FEE.__.... . 'Dist1�a�-- lRga� r1�I ,at rr , ,arc Al 4A� Permissio Hereby granted ---------- ------------------------------------------------------------ •---------------•. ....... to Construct or Repair,� I dividu 1 Sewage Disposal System at No. G. Z'a i ��oN V A n//ce.r 2�• CvM MJ �. �-•--------------••--•----•-------...................•---------.........•••--...-•--.-•------------••---•-----•-------•-------•----•-•-•-----•-••--•--•-•••--••--••...............-- Street as shown on the application for Disposal Works Constructioi if No..................... Dated.......................................... ../'y: r/ ✓ -- ------------- -- -------•-... _ oard of Health DATE--------------------------------•-•--.............._.:-----•------'-------••--• `� FORM 1255 HOBBS & WARREN. INC., PUBLISHERS Z- -5,A04re .3 r ,I loT 3,5 1 I a 113.Z4 v ak Ab^mil; [ '0, �' A [s9vi sr LoT''r,3 Z q Plr Cor � �33 29976 n, P 1 „e 32�9 t N 00 40 'WipE- EYA7,o�vS BAs6D O.v �SSv�'7E� CERTIFIED PLOT PLAN KELL Y CU1.MAQU D, MASS. 02637 LOCATION SCALE . A��- . . . . . DATE ��c.? !980 PLAN REFERENCE 33,09 Epp � ,.- T-CIO/A�►! /��GG �'ST�'7�S �� • :; -EY e� 1 qp,V v Ar. Bk- 134 I CERTIFY THAT THE ... ..... . . . . SHOWN ON THIS PLAN IS LO UND AS SHOWN HEREON AN MS TO THE SETBACK REOUI N T yTOWN OF WHEN CONSTRUCTED. DATE . . . . . . . . . . .. ' PETITIONER: C'o'vCoiz.�� /"JOSS ' REGISTERED LAND SURVEYOR i 51vezT Z o f Z .51* 5 v�. TOP OF FOUNDATION CONCRETE COVER CONCRETE COVERS 4"CAST IRON PIPE (OR 12"MAX. � m "'�"'�• • 4"ORANGEBURG(OR EQUIV.) 12"MAX. EQUIV.)- MIN. PIPE-� MIN. LEACH' PITCH 1/4"PER. PITCH 1/4..PER.FT PIT o,o PRECAST -� LEACH I N G o' NVERT a a EL.. 3.. INVERT INVERT e w e; PIT OR SEPTIC TANK INVERT DIST. EOUIV. INVERT BOX ASQ�' GAL. INVERT INVERT u va a: :.�: 3/4"TO I1/2 w w � EL4/:oo a 0: WASHED w STONE �8'---►�+-6'D IA.. DI PROR LE OF GROUND WATER TABLE SEWAGE DISPOSAL SYSTEM NO SCALE RNs' SOIL LOG WITNESSED BY DATE BOARD OF HEALTH TEST HOLE I TEST HOLE 2 Tf+(?tis)s. E, �E?� /?E- . ENGINEER ELEV. .4-7 00 . ELEV. .43.70 �7�w.ga t.ACctua'/ .P,L.S. DESIGN DATA s„r�.say c. Pic 014-y NUMBER OF BEDROOMS 3G SAD �4 TOTAL ESTIMATED FLOW , 3 3o GALLONS/DAY BOTTOM LEACHING AREA . . . . . . . . SO.FT. /PIT --- °Z SIDE LEACHING AREA SQ.FT./ PIT SA+vD GARBAGE DISPOSAL Na^!L. .(50% AREA INCREASE) Ssr,.a 7.67,o� TOTAL LEACHING AREA . . . . .. . . SQ.F.T PERCOLATION RATE l3S '4'!+.�a��. MIN/INCH LEACHING AREA PER PERCOLATION RATEZ. SQ.FT. -Nc -.WATER ENCOUNTERED - ---- - - - NUMBER OF LEACHING PITS 1P./T.1V/TJV TJNo F2T APPROVED . . . . . . . . . . . BOARD OF-HEALTH DATE . . . . . THOMAS E.KELLEY CO. AGENT OR INSPECTOR ENGINEERS-SURVEYOR 346 LONG POND DRIVE SOUTH YARMOUTH,MASS, ,(t1 OFMgS 0.9064 THO �vT!`.32� 33A . . . . o Y 24260 O ti �STE PETITIONER w E �0NAL� � Z �D 919.-Oyt Fxs...s. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ��.. ........ ...OF....... 71V!Js/ 7-34- ............................ Appliration for Biionsal lUorkV Tomtrurtiun rranit Application is hereby'made for a Permit to Construct ( ) or Repair ( ) an:Individual Sewage Disposal System at: e M/ �., C L �i7 �z-s7�y�1 ,j s� �1�7' ,31. _3_3 ....... ..-... tio- o Location-Address -� Owner W ..__ �............ ..:.....:...::. 9.k1 » / Address 7✓ry __-•-•• _-•-•-----________......___..._.0 5 nstaller S Address d Size Lot:._.:Type of Building Z _.__Z /v------- q. feet_ _. Dwelling—No. of Bedrooms._.__.____-�_______________________________Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a+ Other fixtures ----------------------------•-•. W Design Flow............ .....................gallons per person per day. Total daily flow........... 3c..................................gallons. WSeptic Tank-Liquid capacity�3�E'.galloris Length_%�t.!=r__ Width _ Diameter..._ Depth 3 ��.... x Disposal Trench—No. .................... Width. ............ Total Length..................... Total leaching area.. _.._.______sq. ft. Seepage Pit No........Z---------- Diameter.__?!. ./ Depth below inlet.... !:'... Total leaching area... .....sq. ft. Z Other Distribution box ( ) Dosing tank ( ) / a Percolation Test Resultsperformed.bY---�f`.....-•-•----- -- ------ : „ ........ Date r 4 Test Pit No. 1__. utes per inch Depth of Test Pit----- ___ Depth to ground water________ ____________ Test Pit No. 2................minutes per inch Depth of Test Pit____/C:8 j._. Depth to ground water.................... ..................................................................................................... O Description of Soil -= '�••0 S.- _Jc.. � �� ti 3 Z" �.�c� d �- ��1-�►--�? •. -•-- U ..... ---•••• -----•- W •-•--------------------- --------------------------••------•--•----•----•-•----------•..-•••--......----•-.•-----------......••------••-•----•------••---•-----------------••....................... U Nature of Repairs or Alterations—Answer when applicable............................................................................................... -------------------------------------------------------------=--------------------------•--._...-•------•-•-----......---------------------------------....-----------....----•-•---•----------_...•-•-• Agreement: The undersigned agrees to install the afore d Individu ewa e Disposal ystem in accordance with T=' the provisions of 5 of the State S ry ode he er lgn rther a snot to place the system in 20 operation until a Certificate of Compliance ha y t .� - -- _ -;� G / _Date - Application Approved By--••-•-••••------ ' /�,+ /' ............................... ........................................ Date Application Disapproved for the following reasons:................................................................................................................. •-----......•-••--•-----•----•--•••••-••-.._..--••---•------••-•-•••----------•---••••••--•--•••-----••--..............................................••............................................... Date r PermitNo......................................................... Issued-...................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ....OF.................=....................................................... ................................ TrrfifirFa#r of TompliFaatrr THIS is � > Tndivio.41 Se_Vg0,LA** ,P40V constructed or Repaired ( ) P by:............ ... --__........... ----•-------------.------------------------•----------------......._........-----.....------......_........-.--------- Installer ��TJ :3� �► 3 / Mira A, /3�i�e- !1 a, c v/W In.,l j� at ----------------------•-•---........-----••------•-•--_-----------•----------•-••----- ----•-----------------•-•-----•--•-------•---•--•--........__....---... ..................... has been installed in accordance with the provisions of r IT�e State Sanitary Code as described in the application for Disposal Works Construction Permit NJ r- ----•-,j'-'--•------••••.. dated................... ................._..___. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT-BE CONSTRUED AS A GUARANTEE THAT'THE SYSTEM WILL FUNCTION SATISFACTORY. DATE............ ..................•....----- ---- Inspector.... i --___-•----------------•-----•------------•---------•-----•--- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH xr d O F................................ . 0--%� ........ .............................. 8c� .nor FEE........................ Rolm � nni r A �,,�w Permissiohereby granted.....................................................--...---•--•---•-•-•..........._. .......-•-.........-----._._...----•----- to Construct or R,.ee�pp air n.I dividu 1 Sewage Disposal S stem at No............................................................. rUr��c e r 12 0.: C i.,I" ••-----...----•---•--.....--•-•---••-•-• --• ••••-•••----•--------••-•----••-•--••...••-_----_._ . Street as shown on the application for Disposal Works Constructio mit No..................... Dated........................................... c� ./� ---•------------- .......... 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F ry pp � 1 19800 O, ; 1f _ - • _ /2$50 ^ N 4 1 f O .V Sdy92 y 9j0/1. 67.99 M ti .r' Y l 1 ff 69.00 ANNC S.CL1vTON S• `S88•3',S•/O'1Y - Nta:0 ��'.N60642 � I I .. ' • 2 A. 'V86.36%O F. �9�6 � s k; • 11 23A•. - 'tn '�9y �/88.6030 Es h��ry9. 24A 9 V--� /Q 8 I I • p , • I 6 22990 m P g 25 f' D A L n 27770 * 26A $ 16800 0;l f 1� • %oN � tio$ DO'TIf ON BARN ST4BLE-CAPS-COD-;MASS. SHOWING QEV15I0N5 A..RENUMBERING.,LOTS N OROP6gTY OF 1 �y ANNE S. CLO FToN. Shis Plan does not roquiro �� 0 - tha approval 02 fne IIoard 0€Survoy i BARNSTABLE Scales ll E 80 fed•- January. s7.22,19 ^^GYSTRY OF DEEDS Ey. KELLoGG - Cwr�. ENarNE6R ` APR 3-1957 OBTERV f L L E 1 RECORDED BOARD FSuRVEYIjas OF Ott 1