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HomeMy WebLinkAbout0104 MAUSHOP AVE - Health 104 MAUSHOP AVENUE Barnstable _ A= 299 -081 �p. 6 N � u ° j1 T la 6 I e, o Commonwealth of Massachusetts a679-OgI Title 5 official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments p Barnstable ✓ M -299 P-81 104 Mausho Avenue, _ Property Address Aj John & Susan Ehret ' Owner Owner's Name ? information is required for every P.O. Box 757, Barnstable MA 02630 April 2 2019 r"s page. City/Town State Zip Code Date of Inspection C,, 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 614 13to on the computer, Troy Williams use only the tab y — —_ key to move your Name of Inspector cursor-do not Troy Williams Septic Inspections _ use the return Company Name key. _19 Hummel Drive Company Address South Dennis ___ MA_ 02660 City/Town State Zip Code (508) 385- 1300 _ _ SI682 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. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails J April 2, 2019 Inspector's Signature Date. The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system 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 c Commonwealth of Massachusetts Title 5 Official Inspection Foram Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 104 Maushop Avenue, Barnstable M -299 P-81 Property Address John & Susan Ehret Owner Owner's Name information is required for every P.O. Box 757, Barnstable MA 02630 April 2, 2019 - page. Citylrown 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: System meets minimum standards set by Massachusetts DEP at the time of inspection only.This inspection is not a guarantee or warranty on the future working conditions of leaching, pipes, components or the future structural integrity of said components and only represents conditions found at the time of inspection only. System is 43 years old. 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 f A. Commonwealth of Massachusetts �a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 104 Maushop Avenue, Barnstable M -299 P-81 Property Address John& Susan Ehret Owner Owner's Name information is p O. Box 757 Barnstable MA 02630 April 2, 2019 required for every � —_—.— _ page. Citylrown 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.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 e_\ Commonwealth of Massachusetts �a--=,p Title 5 Official Inspection Form 1a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments -� 104 Maushop Avenue Barnstable _ M -299 P-81 Property Address John & Susan Ehret Owner Owners Name information is required for every P.O. Box 757, Barnstable MA 02630 April 2, 2019 — --- — page. Cityrrown 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, Y 9 p 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: F 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.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 104 Maushop Avenue, Barnstable M -299 P-81 _ Property Address John & Susan Ehret Owner Owner's Name information is required for every P.O. Box 757, Barnstable MA 02630 April 2, 2019 — -- page. City/Town 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 1/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. El ® 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 l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 ` a N Commonwealth of Massachusetts Title 5 Official Inspection Form <➢' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 104 Maushop Avenue, Barnstable _ _ M_299 P -81 Property Address John & Susan Ehret Owner Owner's Name — ---- ----- ----- ---- information is required for every P.O. Box 757, Barnstable MA 02630 April 2, 2019 - 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 P9 Y 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 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 104 Maushop Avenue, Barnstable _ M -299 P-81 Property Address John & Susan Ehret Owner Owner's Name information is p O. Box 757, Barnstable MA_ 026_30 Aril 2, 2019 required for every _ P _ page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 2--- Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 gpd Description: Number of current residents: 0 - 1 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: N/A Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage 18=26,000 gals. 9 ( Y 9 (gPd)) 17=_29_,000 gals._ Detail: Sump pump? ❑ Yes ® No Last date of occupancy: occasional use Date t5insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 ' w Commonwealth of Massachusetts -- -=, Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 104 Maushop Avenue, Barnstable — _—_ _ M_299 P-81 Property Address John & Susan Ehret Owner Owner's Name ----- -- -— - --�information is P.O. Box 757, Barnstable MA 02630 Aril 2 2019 required for every �.. �_.__.__- page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: NIA Design flow(based on 310 CMR 15.203): N/A Gaiions per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): N/A Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: N/A Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: N/A Last date of occupancy/use: N/A Date Other(describe below): N/A 3. Pumping Records: Source of information: No pumping info. 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.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 f Commonwealth of Massachusetts :. Title 5 Official Inspection Form to Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 104 Maushop Avenue, Barnstable _ M -299 P-81 Property Address John & Susan Ehret Owner Owner's Name information is required for every p O. Box 757, Barnstable__ ___ MA_ 02630__ April 2, 2019 _ _ _ page. City/Town T 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): no d-box Approximate age of all components, date installed (if known) and source of information: Tank & leaching were installed on 8/24/76 per as-built. Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 18"feet _-- --------- Material of construction: ® cast iron ❑ 40 PVC sch 20 pvc ® other(explain): - Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Lines were found clear at the time of inspection. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 104 Maushop Avenue, Barnstable M -299 P-81 Property Address John & Susan Ehret Owner Owner's Name— -------------- ------ --- ------information is P.O. Box 757, Barnstable MA 02630 Aril 2 2019 required for every _ .__:__..___.._..___.._ page. Clty/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: 7'with riser to 1' feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallon Sludge depth: 4"2' 8" -- — — Distance from top of sludge to bottom of outlet tee or baffle ------ -- 1 Scum thickness ---- Distance from top of scum to top of outlet tee or baffle 6" ------ ------ Distance from bottom of scum to bottom of outlet tee or baffle 15" — — How were dimensions determined? probe/measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet and outlet tees were found present and in working order. No evidence of leakage or damage was found. Pumping at this time is recommended. No evidence of backup in the past was present at the time of inspection. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 104 Maushop Avenue, Barnstable _—_ �_--- _ _ M -299 P-81 — Property Address John & Susan Ehret - Owner Owner's Name ---- ----------- -- -- information is required for every P.O. Box 757, Barnstable _ _ MA_ 02630 April 2_2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: N/A —- ---- -- —, _-- feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: N/A ----------- --- Scum thickness N/A Distance from top of scum to top of outlet tee or baffle N/A_ Distance from bottom of scum to bottom of outlet tee or baffle N/A Date of last pumping: N/A 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.): N/A 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: N/A Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: N/A ----- - - Capacity: N/A gailons--------------------------- Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts =, Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c, f< 104 Mausho Avenue, Barnstable M -299 P -81 _ p Property Address John_& Susan Ehret Owner Owner's Name -------- --------------------- — --- information is P.O. Box 757 Barnstable MA 02630 April 2, 2019 _ required for every — ----------------...----....-------- --------- page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank (cont.) Alarm present: ❑ Yes ❑ No Alarm level: N/A-- --- ------- Alarm in working order: ❑ Yes ❑ No Date of last pumping: N/A -- Date Comments (condition of alarm and float switches, etc.): N/A *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert N/A— --- - ------------ 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.): No d-box installed per as-built and past inspection information. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments . 104 Maushop Avenue, Barnstable _— _ ` _M -299 P -81 Property Address John & Susan Ehret Owner Owners Name — - -------------------- --- ---- --- information is required for every P.O. Box 757, Barnstable MA_ 02630 April 2, 2019 _ _ __ - - 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.): N/A " 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: 1 -6'X6' pit with2' of stone ❑ 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 c Commonwealth of Massachusetts -, Title 5 Official Inspection Form w Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r 104 Maushop Avenue, Barnstable —_M_299 _ P -81 Property Address John_& Susan Ehret Owner Owner's Name ----------------------------------- --- -- require tion is p O Box 757 Barnstable MA 02630 Aril 2, 2019 required for every ._......•__ .___.___.�_ page. Clty/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.): Soil was sandy and rocky. Leach pit was found with 6" of water present at the time of inspection. No evidence of hydraulic failure or problems in the past were found at the time of inspection. System meets minimum standards set by Massachusetts DEP at the time of inspection only.This inspection is not a guarantee or warranty on the future working conditions of leaching, pipes, components or the future structural integrity of said components and only represents conditions found at the time of inspection only. System is 43 years old. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration N/A Depth—top of liquid to inlet invert N/A ---- ---- Depth of solids layer N/A Depth of scum layer N/A_ Dimensions of cesspool N/A--------- Materials of construction N/A Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/A 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 104 Maushop Avenue, Barnstable _—_—_ __ -M -299 P-81 Property Address John & Susan Ehret Owner Owner's Name -- ------------------------------- ---- ----- information is required for every P.O.p O. Box 757 Barnstable _ ____ MA_ 02630 April 2�2019 _ _ __— page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: N/A _ — __--_---------------- Dimensions N/A.------- ----------...--- ------- - Depth of solids N/A ------ -- -- =---------------- Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/A t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 c Commonwealth of Massachusetts = _- Title 5 Official Inspection Form l Subsurface Sewage Disposal System Form - Not for Voluntary Assessments � ........... r 104 Maushop Avenue, Barnstable M -299 P -81 Property Address John & Susan Ehret Owner ---------------------------------------------------- Owner's Name information is P.O. Box 757, Barnstable MA_ 02630 April 2 2019 required for every --- ------------------------ --- P ----- — page. City/Town 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 _ �ur AI I I �D✓Lt� 33 01 3 = © 0 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts �- Title 5 Official Inspection Form is Subsurface Sewage Disposal System Form - Not for Voluntary Assessments P Y V � 104 Maushop Avenue, Barnstable_ — — _ _ _ _M -299 P-81 Property Address — John & Susan Ehret Owner Owner's Name ---------------�.------------------------------------ information is P.O. Box 757 Barnstable MA_ 02630 _April 2, 2019 required for every ___ _ —_—.___._ _ ___ _ _ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 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: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: AIW 247 Zone B 21.8' 1.1' adjustment You must describe how you established the high ground water elevation: Soil was sandy. USGS maps show water at over 25' and also visual drop in grade is over 20'. Groundwater adjustment in area at the time of inspection was 1.1'. Bottom of leaching at 14.5 was found not to be located in the high groundwater elevation at the time of inspection. 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 - Z. Commonwealth of Massachusetts M -= _=,� Title 5 Official Inspection Form �`Vto Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �,,, 104 Maushop Avenue, Barnstable M -299 P-81 ` � Property Address John & Susan Ehret Owner Owner's Name ----------�------------- — information is required for every P.O. Box 757, Barnstable MA _ 02630 April 2, 2019 —.- -----------------_-------____..____._-- 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 i McKean,;Thomas From: McKean, Thomas Sent: Wednesday, March 27, 2019 10:11 AM To: 'Amanda Kundel' Subject: RE: 104 Maushop Barnstable Village We printed:out a map of this particular area showing the WO district delineation. If you would like a copy, please let us know and will mail it to you. From: McKean, Thomas On Behalf Of Health Sent: Wednesday, March 27, 2019 10:05 AM To: 'Amanda Kundel' Subject: RE: 104 Maushop Barnstable Village Good Morning, The existing septic system is located within the Well Protection (WP) District on the one-half acre parcel; therefore the dwelling is currently limited to two (2) bedrooms maximum. In order to expand,the old septic system would have to be removed and a new septic system would have to be constructed outside of the well protection district. From: Amanda Kundel [mailto:akundel@kinlingrover.com] Sent: Tuesday, March 26, 2019 12:46 PM To: Health Subject: 104 Maushop Barnstable Village Hi. Hoping you can offer some insight on this property. It is my understanding that the system is designed for 2 bedrooms and it is a tank&pits. My clients who are purchasing it are wondering if future expansion is possible to your knowledge (any restrictions in this area- GP, wetlands, etc.)? Thank you, Amanda Swift Kundel Kinlin Grover Real Estate P.O. Box 156 3221 Main Street ; Barnstable, MA 02630 508-360-7364 Mobile 508-362-9001 Fax Licensed in,Massachusetts Broker#009521133 r } 1 Flynn, Judith To: akundel@kinlingrover.com Cc: McKean,Thomas Subject: 104 Mau shop Ave, Barnstable Amanda... I 'm faxing you a scan of the property showing the property (104 Maushop, Ave). This scan shows you that the property frontage where the original two(2)bedroom septic is located in the Water Pollution area(shaded),and therefore restricted: The back of the property is not restricted; If there is any additional construction the larger septic system will have to be relocated to the back of the property. Please feel free to call me if you have any further questions. lTud't� 508 862 4681 1 h Commonwealth of Massachusetts. = Title Official Inspection Form ° Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 104 Maushop Avenue,'Barnstable Property Address Susan Ehret. Owner Owners Name information is p O. Box 757, Barnstable MA 02630 • Jul 10, 2009 required for every y 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; �- Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector. COPY key to move your cursor-do not Troy Williams use the return Name of Inspector key. TroYWilliams Septic Inspections ray Company Name 19 Hummel Drive Company Address e Br� South Dennis MA_ 02660 , _ City/Town State Zip Code 5508�385-1300 S1682 Telephone Number License Number B. Certification 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 CIMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving:Authority June 10, 2009 _ Inspector's 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 is a shared system or has a design flow of 101000 gpd or greater, the inspector and the,system owner shall submit the report to the.appropriate regional office of the DER The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t Oiall'age 104 ausho Avenue B r table•03/08 M a ns TfUe 5 Official Ins ecdon Form: ubP S surface ewa a Dis o al S s 1 of 15 P 8 P Y E , I� is Commonwealth of Massachusetts —Y -Title 5 Official . lnspection' Form Subsurface Sewage•Disposal System Form -Not for Voluntary Assessments 104 Maushop Avenue, Barnstable Property Address Susan Eh_ret Owner Owner's Name --- — — —information is P.O. Box 757, Barnstable• MA 02630. Jul 1012009 required for every _ — _�-- page. City/Town State Zip Code Date of Inspection i r B. Certification (cont.) Inspection Summary: Check A:B;C,D,or E/always complete all of Section D A) .System Passes: ® I have not found'any.information which indicates that any of.the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.30.4 exist. Any failure criteria not evaluated are indicated below: Comments: System meets minimum standards set by Mass DEP at the time of inspection only. This inspection is not.a guarantee or warranty on the future working conditions of leaching, pipes or components. System is 33 years old _ 4 _ _ B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board.of Health; will pass. Answeryes,no or not determined,(Y, N, ND) in the [Ifor 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. x A metal septic tank will pass inspection if it is structurally sound, not,leaking and if a.Certificate.- of Compliance indicating that the tank is less than 20 years.old is available:. - ND Explain: N/A ❑ Observation of sewage backup or breakout 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): r ❑ broken.pipe(s) are replaced ❑ obstruction is removed 104 Mausliop Avenue,Barnstable-03108 Title 5 Official inspection Form:Subsurface Sewage Disposal System.Page 2 of 15 Commonwealth of(Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments ,M y 104 Maushop Avenue, Barnstable Property Address: -- - ------- --- Susan Ehret Owner Owners Name information is required for every P.O. Box 757, Barnstable MA' 02630` July 10, 2009 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont:) B) System Conditionally Passes (cont.): ❑ distribution box is'leveled or replaced .: ND Explain: N/A ❑ The system required pumping more than 4 time_ s a year due to broken or obstructed pipe(s). The system will pass inspection if(with'approvai of the Board of Health): ❑ -broken pipe(s) are replaced ❑ obstruction is removed ND Explain:. N/A < C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board.of Health in order to determine if the system is failing to protect public health; safety or,the environment: 1. System will pass unless Board of Health determines in accordance with 310 CMR' 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: , ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh w. 2. System will fail unless the Board of Health (and,Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system hasa 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._ El 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. 104 Maushop Avenue,Barnstable•03/08 - : - Title 5 Official Inspection Form:Subsurface Sewage Disposal Syslem•Page 3 of 15 . Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 104 Maushop Avenue, Barnstable Property Address -— — ------- Su_san Ehret Owner Owner's Name --- ---- -- ---- -- ----- -. --------- -- - ---- — require tion ie P.O. Box 7_57, Barnstable i _ MA , 02630 Jul 10, 2009 , required for eve --__ page. City/Town State Zip Code Date of.lnspeption B. Certification (cont:) .ti. C) Further Evaluation is Required by the Board,of Health (cont.): ❑ 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 i ne distance: N/A - This asses system if the well water y panalysis, performed at a DEP.certified laboratory, for coUform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: N/A .. D) System Failure Criteria Applicable to All Systems: You must indicate ":Yes" or"No"to each of the following for all inspections: Yes No . . Backup of sewage into,facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding'of effluent to the surface of the ground.or surface waters due to an overloaded or clogged SAS or cesspool ® Static liquid level in the distribution box above outlet invert due to an overloaded or.clogged SAS or cesspool ® Liquid depth to cesspool is less than 6" below invert or available volume is less than /2 day flow ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed'pipe(s). Number of times pumped: - 0 ® Any portion of.the SAS, cesspool or privy is below high ground water elevation. ® %Any portion of cesspool or privy is within 1.00 feet:of.a surface water supply or ' tributary to a surface water supply. 104 Maushop Avenue,Barnstable•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts Title 5 Official InspectionForm Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 104 Maushop Avenue, Barnstable_ Property Address. Susan Ehret Owner Owner's Name --- — _ information is P.O: Box 757, Barnstable MA 02630 Jul 10, 2006 required for every y page. City/Town State Zip Code Date of Inspection B. Certification (cont;) D) System Failure Criteria Applicable to All Systems(cont.); Yes No ® Any portion of a cesspool or privy is within alone 1 of.a p,ublic.well. El ® Any portion of a.cesspool or privy is within 50 feet of.a private water supply well. ❑ ® Any portion,of a cesspool or privy is less than 100 feet.but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered..A copy of the analysis and chain of custody must be attached to this form.] The system is a cesspool serving a.facility with:a design flow of 2000gpd- ❑ ® 10,000gpd. The system fails. I have determined that one or more of the above failure ❑ ® criteria exist as described in 310 CMR 1.5.303, therefore the system fails..The system owner should contact the Board of Health_to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system.the system must serve'a facility with a design flow of 10,000 gpd to 15,000 gpd.. For large systems, you must indicate either"yes"_or"no"to each of the following,,;in addition to the questions in Section D. . a. Yes. No ❑ M 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. 104 Maushop Avenue,Barnstable•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts r Title 5 Official Inspection Form 0 Subsurface Sewage Disposal.System Form -Not for Voluntary Assessments. w„ 104 Maushop Avenue, Barnstable _ 9 Property Address Susan E_hret Owner Owner's Name --- _.—..—-------------- --- information is required for every P.O. Box 757, Barnstable MA 02630 Jul 1y 0, 2009' requ -- — -- page City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You,must indicate"yes" or"no" as to each-of the following: Yes No ® ❑ Pumping information was provided by the:owner, occupant, or Board of Health . ❑ ® Were any of the system components pumped out in the previous two weeks? Q ® Has the system received normal flows in the previous two week.period? El ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® Were as built plans of the systemµ obtained and examined? (If they were not El available note as N/A)<., M ❑ 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 tan 1'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 inttie field (if any of the failure criteria related to Part C is at issue El approximation of distance is'unacceptable) [310 CMR 15. 302(5)), • 104 Maushop Avenue,Barnstable•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form; Subsurface Sewage Disposal System Form Not for Voluntary Assessments 104 Maushop Avenue,Barnstable Property Address Susan Ehret Owner Owner's Name information is p O. Box 757, Barnstable MA 02630 Jul 10,2009' required for every — — -- -- --Y-- page. City(Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms(design): 2 — Number of bedrooms (actual)., 2 DESIGN flow based on 310 CMR 15-203 (for example: 110 gpd x#of bedrooms): . 220 gpd Number of current residents: 0-2 — Does residence have a garbage grinder? ❑ Y. ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected?. ® Yes ❑. No Seasonal use? ❑ Yes M No Water meter readings, if available (last 2 years usage (gpd)): 08=34,000gals 07=48,000 ag Is Sump pump? ❑. Yes .M No Last date of occupancy: Occasional use -Date Commercial/industrial Flow Conditions: Type of Establishment: N/A N/A Design flow(based on 310 CMR.15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): :N/A Grease trap present? ❑. Yes ® No Industrial waste holding tank present? ❑ Yes '® No 'Non-sanitary waste discharged to the Title 5 system? ❑ Yes '® .No Water meter readings, if available: N/A Last date of occupancy/use N/A --------- Date Other(describe): NIA -- -- --- - 104 Maushop Avenue,Barnstable•03108 Title 5 Official,Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 i r Commonwealth of Massachusetts 10 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments ,N 104 Maushop Avenue, Barnstable —, Property Address Susan Ehret Owner Owner's Name information is P.O. Box 757, Barnstable MA_ 02630 July 10,2009 required for every -. -- page. CitylTown State Zip Code Date of Inspection D. System_Information (cont.) General Information Pumping Records: Last dumped in 1995 per info obtained. - Source of information: -- — — -- — Was system pumped as part of the inspection? ❑ Yes ® No f N/AT ------ --If yes, volume pumped: . gallons t N/A How was quantity pumped determined? ------ - N/A -- Reason for pumping: — Type of System: ® Septic tank, distribution box., soil absorption system q ❑ Single cesspool ' ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no).(if.ye.s, 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 1/A system by system operator undercontract ❑ Tight tank.`Attach a copy of the.DEP approval: ® Other(describe); . i No d-box Approximate age of all components, date installed (if known) and source of information! Tank& leaching were installed on 8/24/76 per as-built. e Were sewage odors detected when arriving at the site? ❑ Yes ® No 104 Maushop Avenue,Barnstable•03/08 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -.Not for Voluntary Assessments ,.' 104 Mausho_p Avenue, Barnstable_ Property Address Ehr Susan et Owner - -- - - - Owner's Name information is every required for eve P.O. Box 757, Barnstable MA 02630 July 10, 2009 4 — -- State Zip Code f l i /Town Date o Inspection on Ct p P page. City frown System Information (cont) Building Sewer.(locate on site plan): Depth below grade: 18t -- feet 1 Material of construction: ® cast iron ❑40 PVC ® other(explain):. r. Distance from private water supply well or,suction line: N/A feet Comments(on condition of joints, venting, evidence of leakage, etc.): Flushed lines and found clear at the time of inspection: . Septic Tank(locate on site plan): Depth below grade: T with riser to 1' _ feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: N/A years Is age confirmed.by a Certificate of Compliance? (attach a,copy of certificate) ❑ Yes ❑ No Dimensions: 5'X 9'X 6' 1000 gallon 8., Sludge depth: _ Distance from top of sludge to bottom of outlet or baffle 2,4 — — Scum thickness 1"to thin Layer 6" Distance from top of scum to top of outlet tee or baffle — 14 Distance from bottom'of scum to bottom of outlet tee or.baffle How were dimensions determined? Probe Measured, 104 Maushop Avenue,Barnstable•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts ` Title 5 Official Inspection Form ` - t_ Subsurface Sewage Disposal System Form Not for Voluntary Assessments 104 Maushop Avenue, Barnstable. Property Address --- -- — Susan Ehret Owner Owner's Name --- -- --- information is R.O. Box 757, Barnstable MA' 02630 Jul 10, 2009 required for every —y page. CityfFown , State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Concrete inlet and outlet tee's were present. No evidence of leakage or damage was found. Pumping of tank would be recommended at this time.No evidence of backup in the past was present at the time of inspection. Grease Trap (locate on site plan): Depth below grade: N/A feet Material of construction: ❑concrete ❑ metal Q fiberglass ❑ polyethylene ❑ other(explain): N/A Dimension N/A s Scum thickness N/A _ = Distance from top of scum to top of outlet tee or baffle N/A Distance from bottom of scum to bottom of outlet tee or baffle N/A Date of last pumping: N/A 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.): N/A 3 Tight or Holding Tank (tank must be pumped at time of inspection).(locate on site plan): . N/ADepth below grade: ' LL ' Material of construction: ❑ concrete El metal 0 fiberglass El polyethylene ❑ other(explain): N/A . 104 Maushop Avenue,Barnstable 03/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts Title 5 Official !Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 104 Maushop Avenue, Barnstable Property Address — _Susan Ehret - Owner Owner's Name information is P O: Box 757, Barnstable MA 02630 July 10, 200.9 required for every. - — — ----- State Zip Code Date of Inspection page Cityrrown D. System Information(cont.) Tight or Holding Tank(cons.) N/A Dimensions: N/A. ---- Capacity: gallons-------------- "� N/A Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: N/A Alarm in working order: ❑ Yes ❑ No N/A Date of last pumping: Date ----- Comments (condition of alarm and float switches, etc,): N/A Attach copy of current,pumping contract(required).is copy attached. ❑_Yes ❑ No Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert -- 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.): No d-box installed per as-built and past inspection information. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in„working order: ❑ Yes ❑ No 104 Mausl iop Avenue,Barnstable•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Fora " Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 104 Maushop Avenue, Barnstable _ Property Address -- Susan Eh_ret er _ ------ --- Owner Own 's Name information is - MA 02630 July 10 2009 7 Barnstable _ required for every DO. Box 75_, _ - - Zip Code Date of Inspection page. City/Town State D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): N/A — Soil Absorption System (SAS) (locate Aon site plan, excavation not required): If SAS not located, explain why: N/A - Type: 1-6'x6'pit ® leaching pits number-.. w/2'stone ❑ leaching chambers number. — ❑ leaching galleries number: leaching trenches number, length: -- ❑. leaching fields number, dimensions: ❑+ overflow,cesspool number: ❑ innovative/alternative system Type/name of technology: • Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil condition of vegetation, etc.): .Soil was sandy and rocky. Leach pit was found with 1' of water present with a history of water level being approx. 11" below inlet invert on-past inspection from 1998. No evidence of hydraulic failure or rp oblems in the ap st were found at the time of inspection_Home has had occasional use since 98. Title 5 Official Inspection Form Subswface Sewage Disposal System-Page 12 of 15 104 Maushop Avenue,Barnstable 03108 Commonwealth of Massachusetts Title 5 Official. inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 104 Maushop Avenue, Barnstable Property Address Susan Ehret Owner Owner's Name information is P.O. Box 757, Barnstable MA 02630 .. July 10 2009, required for every City/Town State Zip Code Date oflnspection page. D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate.on site plan) N/A. _ Number and configuration N/A Depth—top of liquid to inlet invert N/A Depth of solids layer N/A Depth of scum layer N/A Dimensions of cesspool N/A Materials of construction K , Indication of groundwater inflow ❑ Yes ® No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc-): NIA Privy (locate on site plan): N/A Materials of construction` N/A Dimensions -- -- N/A Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/A, Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 104 Maushop Avenue,Barnstable•03/08 ,. s Commonwealth of Massachusetts Title 5 Official Inspection Formr Subsurface Sewage Disposal System Form -Not for Voluntary Assessments '< 104 Maushoop Avenue, Barnstable Property Address A, Susan Ehret _---__ -__-- Owner Owner's Name information is P.O. Box 757, Barnstable MA 02630 July 10� 2009 required for every State Zip Code Date of-inspection page Cityrrown D. System Information,(cont.) Sketch Of Sewage Disposal System: Provide,a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks: Locate all wells within 100 feet. Locate where public water supply enters the building. Z : IL y : t r3 = 3' L UL-1 6 urface Sewage Disposal System ge 14 of 15 104 Maushop Avenue,Barnstable•03/08 Title 5'Official Inspection'Form:Subs ;Pa Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 104 Maushop Avenue, Barnstable Property Address Susan Ehret — Owner Owner's Name information is P.O. Box 757, Barnstable , . MA 02630 July 10 2009 required for every — page. City/Town State Zip Code Date of Inspection D. System Information. (cont.), Site Exam.- Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells 20V Estimated depth to high ground water: 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: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database -explain: AIW 247 Zone B 22.9' 2.2' adiustment a You must describe how you established the high ground water elevation: Soil was sandy. USGS maps show water at over 25' and also visual drop in grade is over 20'. Groundwater adjustment in area at the time of inspection was 2.2'. Bottom of leaching at 14.5'was found not to be located in the high groundwater elevation at the time of inspection. 104 Maushop Avenue,Barnstable•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 b TROY WILLIAMS L`'} SEPTIC INSPECTIONS Certified by MA Department of Environmental Protection (508) 385-1300 19 Hummel Drive South Dennis, MA•02660 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTEC `ION' U ONE HINTER STREET. BOSTON, MA 02108 617.292.5500 s WILLIA GovemoM F.WELD �� �� TRUDY COXES Governor - Secrcury ARGEO PAUL CELLUCCI � �lTya�s� 15`��C1a B.STRUHS Lt.Govcmor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM f ��F Comm4sioricr PART A CERTIFICATION / S r Property Address: Address of Owner: Date of Inspection: /cf Of differen0 Name of Inspector: 4roy Williams 16 am a DEP approved system inspector pursuant to Section 15.340 of Title S (310 CMR 1S.000) Company Name: Troy .Williams Septic Inspections J b Mailing Address: 19 Hummel Drive , South DPnniS , MA 02660 Telephone Number: �l 5 0 8T3 8 5-13 0 0 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 inspection: The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: ,Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails cc Inspector's Signature: Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, 8, C, or D: Al SYSTEM PASSES: _j/ I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: BI SYSTEM CONDITIONALLY PASSES: IV 119 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. Indicate yes,no,or not determined (Y, N,or ND). Describe basis of determination in all instances. If'not determined', explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty(20)years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound,shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health (r.vl..d 04/25/97) P.q. 1 or 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) 104 Maushop Avenue,Barnstable,MA Property Address: Ada M. Brueggeman Owner: September 4, 1998 Date of Inspection: B) SYSTEM CONDITIONALLY PASSES (continued) /Vt/'9 Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced — The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEAL TH: /Y 4 Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within So 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, ll`APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: — The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis 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 S ppm. Method used to determine distance (approximation not valid). 3) OTHER SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 104 Maushop Avenue,Barnstable,MA Owner: Ada M. Brueggenum Date of Inspection: September 4, 1998 D) SYSTEM FAILS: N You must indicate ei;,.er "Yes" or "No" as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. _ Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within too feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. _ Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: NI-19 You must indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet o(`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 11 of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST 104 Maushop Avenue,Barnstable,MA Property Address: Ada M.Brueggeman Owner: September 4, 1998 Date of Inspection: Check if the following have been done: You must indicate either "Yes" or"No" as to each of the following: Yes No _ Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates . during that period. Large volumes of water have not been introduced into the system recently or // as part of this inspection. S!/ _ As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. JL . _ The system does not receive non-sanitary or industrial waste flow. _J / _ The site was inspected for signs of breakout. �C _ All system components, excluding the Soil Absorption System, have been located on the site. _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material-of construction, dimensions, depth of liquid, depth of sludge, depth of scum. V1 The size and location of the Soil Absorption System on the site has been determined based on: The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. Existing information. Ex. Plan at B.O.H. JL _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) 115.302(3)(b)] (revised 04/7S/911 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION 104 Maushop Avenue,Barnstable,MA Property address: Ada M. Brueggeman Owner: Date of Inspection: September 4, 1998 RESIDENTIAL: FLOW CONDITIONS Design flow: !�V tt.P.d./bedroom for S.A.S. Number of bedrooms: oZ Number of current residents: Garbage grinder (yes or no): Vb Laundry connected to system (yes or no):-!j�G-S Seasonal use (yes or no):_o Water meter readings, if available (last two (2)year usage•(gpo): _�'7-`/� _ 4/,q S S i/ „� s 6 -S)_ yZ� .U') Sump Pump (yes or no): IV41 Last date of occupancy: O e %.,p I COMMERCIAUINDUSTRIAL• Type of establishment: Design flow: ¢allons/day 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: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: PyH Ac.� 3V✓3 G^ 9 Ca J•e 6— 1.fD o !!. .�t..� �'D��, O[.��')4✓ System pumped as pan of inspection. (yes or no)_,,*I/V If yes, volume pumped: gallons Reason for pumping: TYPE 9'F SYSTEM Septic tan soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AG of all components date installed (if known) and source of information: t 5•� ►j t �t 4? Sewage odors detected when arriving at the.site: (yes or no) No SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 104 Maushop Avenue,Barnstable,MA Owner: Ada M.Brueggeman Date of Inspection: SWember 4, 1998 BUILDING SEWER: IV (Locate on site plan) Depth below grade: Material of construction: cast iron _ 40 PVC —other (explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK:, (locate on site plan) i Depth below grade: 7 Material of construction: _,(/concrete _metal _Fiberglass _Polyethylene —other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No) Dimensions:_ �S r r q 'Jr 6 / Sludge depth:_ ?�• T Distance from top of sludge to bottom of outlet tee or baffle: (A Scum thickness: ,'. Distance from top of scum toZp of outlet tee or baffle: r' Distance from bottom of scum to bottom of outlet tee or—baffle:-- 117" How dimensions were determined: .�1 s • b ;fit-. Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) / ` w c.t {a,,., J` � /�,,, ,,� �',�C .�r��� Als 0 C'"riJ c 7y� 2icti / f/L..a — Q — /.0 ✓: S�c1.J(�-. �• f i i 1/ 4 / 6. J CA GREASE TRAP:-6�A (locate on site plan) 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: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,evidence of leakage, etc.) l..v/..A nd f—/et, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 104 Maushop Avenue,Barnstable,MA Owner: Ada M. Brueggeman Date of Inspection: September 4, 1998 TIGHT OR HOLDING TANK:N119(Tank must be pumped prior to, or 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 level: Alarm in working order_Yes;_ No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: //9 (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)_ Nd r � .� .►.�r r �� ,�<.� u �— 6.�' 1 .f a .. L,�w.t o ..��,�,. PUMP CHAMBER:,,I//9 (locate 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.) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 104 Maushop Avenue,Barnstable,MA Owner: Ada M.Brueggeman Date of Inspection:September 4, 1998 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number._�2t! l� XG C �.•<< 1, T i �- w i a S e leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc..) V rat ..- � ✓��( T J Hn-t c� .L v C t c . v. .•�•� L v 1�-. S 7 S 4 c�' G, �lG�✓c.h C lL 'a9 4.�-y�y,,.-. �.� c�7�� i. CESSPOOLS: /,� 9 y s (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(cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: (locate on site plan) Materials of construction: Dimensionsi Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (r.vf..d 04/2s/07) vag. a of 10 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 104 Maushop Avenue,Barnstable,MA Owner: Ada M. Brueggeman Date of Inspection: September 4, 1998 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) y3 T w t (revi..a 04/25/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART C SYSTEM INFORMATION (continued) Property Address: 104 Maushop Avenue,Barnstable,MA Owner: Ada M.Brueggeman Date of Inspection: September 4, 1998 Depth to Groundwater Feet adjusted high groundwater level Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation. Must be completed) IL 'e J c- t'. (r—i..d 04/25/97) o..._ ,,. _. ... .1 w p —01 No THE COMMONWEALTH OF MASSACHUSETTS 4 , p BOARD F HEALTH a (7) O ..........OF.... .... . .................... Appliration -for Uhip iat Workii Tonstrurtinn Prrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at --........--� ----.-----�--.....--- -p � i P Loc 'on ddress or Lot No. __ , � O�y�er -'�ddre�s °'::--.----•----�?� �� .��-------------------•--•--- ---•--•---------------------........... p----- :­ InstallerJq lddress Type of BuildIng� Size Lot_. . q f t V Dwelling—No. of Bedroom -_--_.-_-__--Expansion Attic (r) Garbage Grinder ( ) Other—Type of Building _ r1 :.__.. No. of persons.........q.............. Showers (l ) — Cafeteria ( ) Q' Other fixtures - e-i- ..... 6 I.. y .................•-•--------------------•-•-•------- W Design Flow........ --_ _ --. ._gallons per person pe day. Total daily flow----------- ----------------gallons. WSeptic Tank iquid capacity. gallons Length...... ....... Width_ Diameter---------------- Depth______.__... x Disposal Trench—No. .................... Width-------------------- Total Length-------------------- Total leaching area-._ ------__.--___--sq. ft. Seepage Pit No_____________________ Diameter.................... Depth below inlet............ Total leaching area-------.----------sq. ft. z Other Distribution box ( ) Dosing tank ( )�—40—;r(a p Percolation Test Results Performed bY-------------------------------------------------------------------------- Date............... ----------------------- aTest Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water._.-_--_--._-._-.--._. fiq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water--.--.-.-__-__-----_-... P' •------------- ---- Descri tion of Soil----- �_____ 1...-„, tf' s3 _ - ------------ ----- --- .� 5' / x Ud -' r- 4t � eay' cf G c� -�'�1 ------------- W ------------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------- V Nature of,Repairs or Alterations—Answer when applicable------------------------------•-----___-.-.._--___.__--------_--_-___---_..._-___-.---._-_..._ ----------------------------••-•-.------------------------.-•-..---.--------------------------.--•.--------------------•---------..-.-.-----.-------.--.----------•.-.-•-•----- ----------------.------ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance ha been issued by the board of healt Signe `. -- .----•<......... •. Date Application Approved BY .... r 1 Z-4G- .................Z , FDat --------------- Application67 Disapproved for the following reasons: ----- ---- ---------------------------------------------------------------------------------------------------------•---------------------------------------------------------------------------------------------- Date PermitNo......................................................... Issued........................................................ Date 2, 2,- FElic ........._­ .... ............ THE COMMONWEALTH OF MASSACHUSETTS BOARD F HEALTH Ig ............. !P,a4.................. Appliration -for 43hipatial Worko Tonotrurtion Vanift Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: .................... ........Ps.." ................. ---a-'al-P........................... . .........9.......... ..... Lot No Loc dress A o, ------------------------- X................ ............."6/&.0�_S.......................... .................................I...........Add,eo...................................................... Installer Address Type of Buildingy-,r-O' Size Lot Y7_ ...t.�et U Dwelling�f_No. of Bedrooms Garbage Grinder ( ) --------------------------------------Expansion Attic (�J) Other—T Type of Building A -t4!;n ..... No. of persons""________.. ----- Showers Cafeteria ( ) y I ----------4--------- Otherfixtures --------I ...... -------I I---------------------------------------------------------------------------------------- Design Flow fl gallons per person per day. Total dail W............. ................gallons. 9 Septic Tank .____ capacity ...." gallons Length------6------ Width_ ---------- Diameter_____..._-""____ Depth__----------_- Disposal Trench—No_ -------------------- Width_-_____________-__-- Total Length__.___.._..._.____.. Total leaching area....................sq. f t. Seepage Pit No..................... Diameter_.___.__...____._._. Depth below inlet_.._...________..___ Total leaching area------------------sq. f t. Z Other Distribution box ( ) Dosing tank ( )6 - / - 76 - , aPercolation Test Results Performed by--------- ................................................................ Date____------------------_----------------. Test Pit No. L.--------------minutes per inch Depth of Test Pit_"_____.__.__._..___ Depth.'to ground water-..----------------_--- fZ4 Test Pit No. 2----------------minutes per inch Depth of Test Pit_-______...____.__._ Depth to ground water__-_-"_"___--_"_____"__- ..............7..................................................... - - --- --- ----- 0 Descri tion of Soil-------- ------- S-4--t------_-- -------------------------------------------------------------------------------- 1_Z4-__,------------ U ----------------------------------- --------------------------------------...........................011------------------------------------------------------------------------------------ --------- U Nature of Repairs or Alterations—Answer when applicable------------------------------------------------------------------------------- ---------------- ---------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------- -------........ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance ha been issued by the board of healt k4 V SSi .....; ............ , .................. igne ........... ... .. ------------------------ --- ................................ Date "7----2_2 Application Approved By_""_--_.. . ..... ..... --------------- - ------- .-7­&------- Date Application Disapproved for the following reasons:............................. ........ .................................................................... ........................................................................................................I----------------------------------------------------------------------------------------------- Date PermitNo......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD ,HEALT� .. .............0 F........ .. 4 ........ ...................... TIVS (1:11'rrfifirate of TOmpliaurr constructed SKIS TO CERTIF)Y, That the Individual Sewage Disposal System or Repaired T— by.-=.V eR_......... ---------------------------------*-----------------------*----------------- at_... .. . -----------------*--------- ---------------------------------------------........ ..... ........!Z...... has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.---.3...Z_Z................... dated_._"_?--X5_Z:.-_77.,C............ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. ... .. ..............DATE. ------77��... Inspector.... ........ ....... ....... . ..................... THE COMMONWEALTH OF MASS&ACHTTS BOARD 09 HEALTH ............. 6�..�. ... ......of...... No......................... FEE. .)............. .......... ..Permission is hereby ranted------ --- ---- ----- -- --—----- ----------------------------------------- to Constr or p q/ Individu Sewage isposa] Sys atNo.. ..../-Y- ,.72-------- _- -- ...... 4. . ----------------------------------------------------- Street 12 as shown on the application for Disposal Works Construction Per N -------------/Dated___,?.................................. ,.,/......................... DATE............................. -------------------------------------------------- Board of Health FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS w 4 i y � ' Sly �t:• ,�! { =�UNT..lq.r�J!J 4.7 ! ; J J q`t f•�! '�.�jN �.�f 1 � ' _ _� .may` �f•.�_ ,•'`.•� (✓,,... �.� _ A .S/LG flE✓____-- FfT L180✓E POAD PL a r OL. A A/ L OCA r/ON ;_;�.s S C A G&_ ; =' —DA 7 7 GE I HEREBY C:7T/FY TNA T 7A.1E EXiST- a p '^ /NG FOU1/DA T/ON LOC,4 T/aN /S G29.eeE 45-=SAI0WAI AA/D rY/TN THE SU/LD/NG SETh3.4Ctk-PfgUiP�MF�c? Qom. c:44j5 3CTZ t/E Yoe C,2o U/6" d 7',a Y4.02 9 W144OW 67 Y.Q2MOU7i/77M07 M.4.