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HomeMy WebLinkAbout0037 MAUSHOP AVE - Health 37 Idaushop Avenue, Cum maquid A=298-097 r i ai i t �q e I� Commonwealth of Massachusetts P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 37 Maushop Ave. " Property Address Smedberg Owner / information is Owner's Name ✓ " required for every Barnstable MA 02630 3/18/21 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. A. Inspector Information Sl*lsaq} Frank Nunes III Name of Inspector saa Company Name Box 841 Company Address East Falmouth MA 02536 City/Town State Zip Code 508.272.6433 13010 Telephone Number License Number B. Certification I certify that: 1 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. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 3/18/21 Inspector's rignature 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts (P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,. 37 Maushop Ave. Property Address Smedberg Owner information is Owner's Name required for every Barnstable MA 02630 3/18/21 page. City/Town 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: ® 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: 2) 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): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 37 Maushop Ave. Property Address Smedberg Owner information is Owner's Name required for every Barnstable MA 02630 3/18/21 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 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): ❑ 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): 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form ° Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 37 Maushop Ave. Property Address Smedberg Owner information is Owner's Name required for every Barnstable MA 02630 3/18/21 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 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. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts (o Title 5 Official Inspection Fora r. _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 37 Maushop Ave. Property Address Smedberg Owner information is Owner's Name required for every Barnstable MA 02630 3/18/21 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® 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 Y2 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 1 of a public water supply 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 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 ❑ ❑ 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 I , Commonwealth of Massachusetts �n rP Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 37 Maushop Ave. Property Address Smedberg Owner information is Owner's Name required for every Barnstable MA 02630 3/18/21 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 ® ❑ 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)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts �. re Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 37 Maushop Ave. Property Address Smedberg Owner information is Owner's Name required for every Barnstable MA 02630 3/18/21 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: 3 bedroom permit on file at BOH Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: occupied Date t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,.% 37 Maushop Ave. Property Address Smedberg Owner information is Owner's Name required for every Barnstable MA 02630 3/18/21 page. City/Town 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): 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 Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Pumped 2018 per owner 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.7/26/2018 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 37 Maushop Ave. Property Address Smedberg Owner information is Owners Name required for every Barnstable MA 02630 3/18/21 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 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 ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: Original septic tank from 1979, 1996 repair they added a new leach pit Were sewage odors detected when arriving at the site? ❑ Yes ❑ No 5. Building Sewer(locate on site plan): Depth below grade: 4'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.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 L Commonwealth of Massachusetts Ip Title 5 Official Inspection iForm Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �e 37 Maushop Ave. Property Address Smedberg Owner information is Owner's Name required for every Barnstable MA 02630 3/18/21 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 3'6"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) H-10 tank appears to be structurally sound, inlet cover to grade with a steel cover, outlet cover is under sidewalk pavers and inaccessible If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000g Sludge depth: 811 Distance from top of sludge to bottom of outlet tee or baffle '12 Scum thickness 6" Distance from top of scum to top of outlet tee or baffle >2" Distance from bottom of scum to bottom of outlet tee or baffle >2„ How were dimensions determined? measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping suggested every 3yrs to prolong the life of the system, scum and sludge measurements taken at inlet t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts i? Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 37 Maushop Ave. Property Address Smedberg Owner information is Owner's Name required for every Barnstable MA 02630 3/18/21 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. 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 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 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 i Commonwealth of Massachusetts ► Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 37 Maushop Ave. Property Address Smedberg Owner information is Owner's Name required for every Barnstable MA 02630 3/18/21 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last um in p p g: Date Comments (condition of alarm and float switches, etc.): *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 0" Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box was video inspected and appears to be structurally sound, it is 4' below grade, probing gives no indication of a raised cover t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts �o Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 37 Maushop Ave. Property Address Smedberg Owner information is Owner's Name required for every Barnstable MA 02630 3/18/21 page. City/Town 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.): * 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: ® leaching pits number: 2 ❑ 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 37 Maushop Ave. Property Address Smedberg Owner information is Owner's Name required for every Barnstable MA 02630 3/18/21 page. Cityrrown 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.): The old pit is in hydraulic failure, it is 4' below grade with a steel cover to grade, the"new" pit from 1996 is damp at this time, it is 7' below grade, stain line about 1/2 way up the sidewall, sidewall is clean above the stain line, no indication of past hydraulic failure, cover raised to 12"of grade I 12. 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 I� r Commonwealth of Massachusetts (P Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 37 Maushop Ave. Property Address Smedberg Owner information is Owner's Name required for every Barnstable MA 02630 3/18/21 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts �a (P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 37 Maushop Ave. Property Address Smedberg Owner information is Owner's Name required for every Barnstable MA 02630 3/18/21 page. Cityrrown State Zip Code Date of Inspection 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 r_ 4 �� w 71 �lfl pCT c L c_ � q b t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 37 Maushop Ave. Property Address Smedberg Owner information is Owner's Name required for every Barnstable MA 02630 3/18/21 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water 4 ® Check cellar i ❑ Shallow wells Estimated depth to high ground water: >20'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: 4' seperation per 1996 compliance ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: TOPO mapping shows the site at 80'msl and nearby surface water at 27'msl You must describe how you established the high ground water elevation: See above Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 i Commonwealth of Massachusetts ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 37 Maushop Ave. Property Address Smedberg Owner information is Owner's Name required for every Barnstable MA 02630 3/18/21 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® 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 c t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION _ TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSIVMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Addres :. / R�CE��E Owner's Name: fl Owner's Address: .0. Date of Inspection: J 30 12101�2 �� 00� Tpw U` D 6 2001. Name of Ins ect r:, lea a rint NFo Tti DEp rAe�F P P ) T Company Name. Mailing Address: 0 Telephone Number: S( R�-'7'7/. !2,39 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete..as of the time of the inspection. The inspection.was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: . V Passes Conditionally Passes Needs.F rther Evaluation by the Local Approving Authority. ,s Inspector's Signature: Date: 4aZ77��� 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 6/15/2000 page 1 i Page 2 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE'SEWAGE DISPOSAL SYSTEM INSPECTION FORM PA ' T A CERTIFICA ION(continued) Property Address: 7. Owner: Date of Inspection: Ins ection Summary: Check A B C D or E%ALWA S comp let.e all of Sectiori D p y p A. (System Passes: V I have not found any information which indicates`;hat any of the failure criteria described in 310 CMR , 15.303 or in 310"CMR 15.304 exist.Any failure criteria nbt evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in tl e"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the'replacemeni or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y N,ND)in the or the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old* or. he septic tank(whether metal or not)is structurally unsound,-exhibits substantial infiltration or exfiltration ortank-failure is imminent. System will pass inspection if the existing tank:is replaced with a`complying septic tank as: pproved by the Board of Health. *A metal septic tank will pass inspection.if it is structural ly sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old.is available. ND explain: Observation of sewage backup or break out or hiol 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 rel laced obstruction is remoy d distribution box is le eled or-replaced ND explain: 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):.I broken pipe(s)are replaced obstruction.is remove ND explain: 2 f Page 3 of 1'1 OFFICIAL INSPECTION FORM.- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE:DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION,:(continued) Property Address: 2 —� Owner w. Date of Inspection:. /J a J6/ 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. I. 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.wiii protect public:health,safety and the environment: Cesspool or privy is within 50 feet of a surface water. Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public.Water.Supplier, if any)determines that the system is.functioning in a.manner that protects the.public health,safety and environment: i 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 I 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 1.00,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 and volatile organic compounds indicates that the well is free from pollution from that facility.and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5.ppm,provided that no other failure criteria are triggered.:A•copy of the analysis must be.attached to this form: 3. Other: 3. Page 4 of l l OFFICIAL.INSPECTION FORM NOT FOR VOLUNTARY'ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: A 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 NV Backup of sewage into facility or system component due to overloaded or`clogged SAS or-cesspool i/ 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 ''/z day flow Required pumping more than 4 times"in the last year NOT due to clogged or obstructed pipe(s).Number' lof 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. i 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,.provided that no other failure criteria are triggered:A copy of the analysis'must beattached to this form.] (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'Sy'stems: To be considered a.large:system.the'system must serve a facility with a-design flow of 10,000 gpd to 15,000 gPd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no 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. 4 f Page 5 of 1.1 OFFICIAL INSPECTION FORM.-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION"FORM PART B 'CHECKLIST Property Address: d ,4 Owner: _ Date of Inspection: Cam,/�1-3/1)., Check if the following have been done.You must indicate"yes"or"no"as to each of the following; Yes N . • Pumping.information'was provided by the owner,occupant,'or.Board of Health.,. ere.any of the system components pumped out in the previous two weeks? <' , I _ Has the system received normal flows in the previous two week period? — Nave 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) , __Z Was the facility.or dwelling inspected for.signs of sewage backup v 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 bused on;. Yes o );.fisting 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(3)(b)] 5 Page 6 of l l OFFICIAL;INSPECTION•FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION-.r,oRM PARY C SYSTEM INFORMATION Property Address: al �G Owner• L . Date of Inspection: FLOW CONDITIONS RE,ESIDENTIAL t, Number of bedrooms(design):� Number of bedrooms(actual): DESIGN flow based=on`310 CMR 15.203 (for example: 11:0*gpd x#of bedrooms): Number of current residents: Z Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system (yes or no [if yes separate inspection required] Laundry system inspected(yes or no),.,.,�W Seasonal use:(yes or no); Water meter readings, if available(last 2 years usage(gpd)): Sump pump(yes or no Last date of occupancy: . COMMERCINUINDUSTRIAL-/X411_ Type of establishment: Design flow(based on 310 CMR.15.203): gpd ' Basis of design flow(seats/persons/sgft,efe;): „ Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system'(yes or no):— Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system.pumped as part of the inspection(yes.or no): If yes,volume pumped;, .gallons--How was q ity pumped determined? Reason'for.pumping: TYP SYSTEM eptic tank,distribution box,soil absorption system Single cesspool _Overflow cesspool _:Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach'a copy'of the DEP.approval Other'(describe): (Zroximate age of 11 components,.d a installed(if kno n)an source of i formation: j/0hz& LU-4UZZ&(A'PIAS,-X ® C;7 4QV)71_ 0 Were sewage odors-detected when arriving.at the site(yes or no) "_/ _��� ' 6 f Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE-SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address Owner Date of Inspection:—SO4/a-Azo J BUILDING SEWER(locate on site plan) —: Depth below grade: Materials of construction:_cast iron. 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: �ocate on ite plan) Depth below or C o,GGeP p � 8 Material of construction: 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: S"S' k k Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: 3 5- . Scum thickness: Distance ftomtufp of scum to top of outlet`tee or baffle: -- Distance from bottom of scum to bottom of outlet tee or baffle'.. How were dimensions determined:� .e�tol.�i? Comments(on pumping recommen ations, Inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): r GREASE TRA ocate on site plan) j . . t Depth below grade:_ 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: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels 1 as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL`INSPECTION FORM-NOT FOR VOLUNTARYASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM -PART C SYSTEM'INFOk.'MATION(continued) Property Address•.� Owner:.( Y. Date of Inspection: ( 725 �!Zo 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/day Alarm present(yes or no): Alarm level: Alarm in working.order(yes or no): Date of last pumping: Comments(condition of alarm and float switches, etc;): DISTRIBUTION BOX:--V'(if present must be opened)(locate,on�siitee plan) Depth of liquid level above outlet invert: f Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of al-age into or out of box, tc. , PUMP CHAMBER ocate on site,plan) Pumps in working order'.(yes or no): . Alarms in working order(yes or no):. Comments(note condition of pump chamber, condition of pumps and appurtenances,etc.): 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: Owner Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan.,excavation not required) If SAS not located explain why: Type ' I aching 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, ii CESSPOOI�S�b `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 or no): Commenfs(note condition of soil,.signs of hydraulic failure, level of ponding, condition of vegetation,etc.):, PRI -(tpcate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level ofponding,condition of vegetation,etc.) 9 Page 10 of 11 OFFICIAL INSPECTION FORM 'NOT,FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISP SAL SYSTEM INSPECTION'FORM P `RT C SYSTEM INFOI ATION(continued) Property Address: —7i /,4 Owner Date of Inspection: �13 40 1 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system includir g ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.Locate wl ere public water supply enters the building. 0 a Qoj 10 Page I I of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner Date of Inspection: 6 ,%p/ SITE EXAM Slope Surface water Check cellar. Shallow wells Estimated depth to ground water 2,/ feet Please indicate(check)all methods used to determine the high groundwater 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) V/Accessed USGS database=explain: You must describe how you established,the high ground water elevation: or 11 TOWN OF BARNSTABLE LO AI-ION . '� U 5 L" SEWAGE #901 7 VILLAGE 2(912r)5 -PU le ASSESSOR'S MAP & LOT Yk- ,097 ATALLER'S NAME&PHONE NO. Z P hancom beer avei 3:�I c— SEPTIC TANK CAPACITY %S-00 LEACHING FACILITY: (type)Z }�/ (size) 1000 NO. OF BEDROOMS BAR OWNER PERMIT DATE: OMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 7'1l • �4 Kv \ 3r ` �S 4 f No. :* Fee Ov THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS 01ppYication for nizpaal *pgtem Con5truction Permit Application is hereby made for a Permit to Construct( )or RepairXX n On-site Sewage Disposal System at: Location Address or Lot No.37 Maushop Ave Owner's Name,Address and Tel.No. 508— Cummaquid,Mass. 02637 Thomas Harris 37 Maushop Avenue Cummagid,Mass. Installer's Name,Address,and Tel.No. 5 0 8—77 5—3 3 3 8 Designer's Name,Address and Tel.No. J.P.Macomber & Son Inc. R.J. 01Hearn,Inc,RLS,RS 0 638 Box 66 Centerville,Mass. 02632 191 Main Street West Dennis,Mass. Type of Building: Dwelling XXXNo.of Bedrooms 3 Garbage Grinder(no) Other Type of Building RES l No.of Persons 2 Showers( ) Cafeteria( ) Other Fixtures Design Flow 330 gallons gallons per day. Calculated daily flow_ 2x1 1 0-22n gallons. Plan Date 4./1 /78 Number of sheets Revision Date 9/12 96 Title Description of Soil L o&my—��:A aclay to medium G a n r3 Nature of Repairs or Alterations(Answer when applicable) Adding an additional 1000 gallon leaching pit to an existing 1000 gallon tank distribution box and a n r3 /F t p].t Date last inspected:Q/1 Cl,1 a 6 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 issue by this BoarjA of alt Signed Date 9/121/96 Application Approved by Application Disapproved for the following reasons Permit No. Date Issued 9 / y—,pe THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired/replacecl(XX)on by J s P.Manomhar & Son 'Tn n. for Tb oma s He rris as A, R-niiA 'Rn-r-nSt8'h1e ..MQSS , has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 96 `y dated Use of this system is conditioned on compliance with the provision forth below: No. 96 / _ Fee$ 40.00 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS 30i5po.5al *p4tem Con5tructfon Permit Permission is hereby granted to J.P.Macomber & Son Imne to construct( )repair ZkXlIan On-site Sewage System located at 37 Maushot_� Avenue Barnstable.Mass. 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. All construction must be completed within two years of the date below. Date: Approved by h .00 v No. 9 -t"` S .�n n`.e -� Fee $ 4 0 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS" application for Migozal *pgteut Con.5truction 30ermit Application is hereby made,for a Permit to Construct( )or Repairy�(i XXnn On-site Sewage Disposal System at: Location Address or Lot No. 37 Maushop Ave Owner's Name,Address and Tel.No. 50$m` � Cummaquid,Mass. 02637 Thomas Harris 37 Maushop Avenue .0,ummaga?d,Mass. Installer's Name,Address,and Tel.No.. 5 0 8--77 xj—3 3 3 8 Designer's Name,Address and Tel.No. J.P.Macomber & Son Inc. R.J. O'Hearn,Inc/RLS,RS f 0 638 j Box 66 Centerville,Mass. 02632 191 Main Street West Dennis,Mass. Type of Building: Dwelling XXXNo.of Bedrooms 3 Garbage Grinder(no) Other Type of Building RES No.of Persons 2 Showers( ) Cafeteria-(" ) Other Fixtures Design Flow 330 gallons gallons per day. Calculated daily flow 2x1 1 Q=220 gallons. Plan Date G/1/78 Number of sheets Revision Date a!12/96 Title' Description of Soil Loamy paid clay to medium sand N tore of Repairs or Alterations(Answer when applicable) Adding an additional 1000 gallon Teaching pit to an existing 1000 gallon tank distribution .box and and rt nit, —� Date last inspected: 9,110,196 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- caafe of Compliance has been issue y this Boardof ealt �# Signed d /J w Date 4112/06 Application Approved by'\ l Application Disapproved for the following reasons r Permit No. ,w ` 7 7 Date Issued �� �� CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PLRMI'I' (WITHOUT DESIGNED PLANS) I, Joseph P. Macomber Jr n li,�rtby certify that the application for disposal works construction perntit signed by me dated 9 12` .96 , concerning the property located at 37 Maushop Avenue Barnsta b7 e ,mass meets all of the following criteria: • There are no wetlands within 300 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system • The observed groundwater table is A feet or greater below the bottom of the leaching facility • There is no increase in flow and/or cliange in use proposed • There are no variances requested or needed. SIGNED ' i DATE: 9/12/96 LICE SEPTIC SYS"r1.:11M11NS"TALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system. Also if the licensed installer posesses..a certified plot plan, this plan should be sbmitted]. r ',,j.4� {i ,rt�t�G _•j{'t/♦1r7 i 94 L , � ..4 ... �' ` ° .. L I , 40wm avow GiN 6 - f 44e 4L QL � t 1 o << ErgCN/M6 ri y C �'/' • Aci ? � 1 OivV '� ' 1P.1hE5 CY C'ii:ARIJ f ! JP,Mr"S v O R'APN C. 'Sf , ;Cs1;,.,i f LEGEND EXIS1•ING ;,SPOT .ELEVATIONS O,A EXISTING.,: ,CONTOuk — 0-. — = -y✓ FINISHED- SPOT 5LEVATIONS FIN I SHED ':<_:c.oNTouR o --- PROPOSED PLOT PLAN, APPROVE-DI BOARD OF HEALTH MASS. . C„T E - I I CFRT,IFY THAT ' THE PROPOS I f) R t/ 01Hc:Af?lV 11VC F?L a,. Rs_..._ UILDING SHOWN ''ON 'THIS ' PLAN' 191 M41N ST. (RTE. 26 ) ",FORMS ` TO THE. ZONING Lg ', + VY`EST DC.'NNIS., fA.455 , _. ;J 1 A E . GIS.I ERE LAND .�LRVE'I I'•.O.f1.__._ ___ ; sHE C. OF L 0-C'A T"I0N S A G E PERMIT 910. 14r� 3 -7,� VItLLAGE INSTA LLER'S NAME A ADDRESS 0 UILDER 0{ Ill DATE PERMIT ISSUED DATE COMPLIANCE ISSUED t ` r, J -3,.3 ' � 0 � o-ty ��cu THE COMMONWEALTH40.5-M.-,!,��SSACHUSETTS BOARD OF HEALTH Application is hereby made for a Permit to.Construct or Repair an Individual Sewage Disposal System at: ion-Address or Lot Installer Address 9 Septic tank/L Z Other Distribution box Dosing tank ( A /;-;t- Percolation Test Resul Performed by..=------ Zta ---------- ------------ ----------------------------------------------------------- -X� The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TL I I= 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b sued by t�e boa oVea Date Date ---_-'----'---_-__----__--__—'-______'--------'_---__---__-----'--.-'-'___'---'_-__''--__- 7 ~.� P�zo� ' - ' Date ~ _ No THE COMMONWEALTH-0V MAZSACHUSETTS BOARD OF HEALTH ...........................................OF.............................. ........... - ....... .........._.........._.._. Appliration for Disposal Works Tomitrurtion ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at :.....!.2 Vq d%Rr.................... ....... #.. r Lot •--•------....... ..... .....---- Location Address o No. j Owner Address pq Address Installer VType of Building Size Lot,3..S,_o e.v------.-Sq. feet Dwelling�No. of Bedrooms._-----3.............`...........•__..._..Expansion Attic (J")s Garbage Grinder (y 6 S aOther—Type of Building _.__...==.............. No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures -----••--------------------------------•---•----•-----......--•--•......•..... W Design Flow.............:. ........._._......_.gallons per person per day. Total daily flow..... gallons. WSeptic Tank Liquid capacity/.e,fj�.gallons Length................ Width................ Diameter................ Depth................ x Disposal Treftch—No..................... Width.................... Total Length.................... Total leaching area•-__--------•------sq. ft. Seepage Pit N,o......./........... Diameter...._..._...... Depth below inlet..... Total leaching area... ,/...sq. ft: Z Other Distribution box ( ) Dosing tank '-' Percolation Test Results Performed b C52 l -_ Date...__..:: :.= :......__. Test Pit No. I.D._......minutes per inch De o Test Pit.................... Depth to ground water................._-_-__. I 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ i M1 :: ---..._.. __ O Description of Soil....L-•---.." - �f�` a. / _ j ,, - s r ._..�'77 ... ............. � tom-----•- /•� •_ - /�• rf-----•� W r �J �.. � x � -----•------- U Nature of Repairs or Alterations when applicable------------------------------------------------------------------------------------------------ ----------------------------•--•----------------....------.......---------.....-----.....---••---------...•..------------............................................................................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of 1-p of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee ssued by the board of lea)th. � /f Signed....._..-•-•-�b.,�. ,f-....�...... ,- o C• .. ; /Z LJ�/7 C7 . ' ....-•-------... ---------------------- •--- Date .._...._... 1=> Application Approved By...............'- PPP...•-•--• '- .................. ----- Yn¢ Application Disapproved for the following reasons:........................................................................................ ale.......•----- --......-•----•-----------------------------------------------•.....-----.......-•---........----....-•----...------------------...---- ---------...---------------------------------------------------- Date PermitNo......................................................... Issued_........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .............77: ......OF................ Tatifiratr o Bunt lt�anrr THIS IS TO CERTIF , That the Individual Sewage Disposal System constructed ( 4-Sr Repaired ( ) by.--------41..... --/....... ................... ................. Installer at---•- envin's - T ?: - mac !;..---------=---•------------ --•------... --------------------------------- has be `talled'in'accor�danc tl provisions o IT r' j of The State Sanitary Code as described in the application for Disposal Works Construction Permit No...._ dated__.... Co THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CO STRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. , DATE...........� ------------------------- Inspector............ .............................. .z�R_�--------- .... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH N � D` z� ...... .........................OF......:.. FEE---c � . _ ................................ -�,�•�•ra�'... .. Dispaasat Works %onstrudion rruti# Permission is hereby granted........... ----- ........---•---•----. to Construct ( ) Repair. ( )"find ��ages at No.. = ' a ----Z as shown o t e application for i�al �°rks ConstructionOfrmit No._~................ 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