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HomeMy WebLinkAbout0172 MIDPINE RD - Health I. �. .. . • , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments rri 0 172 Midpine Drive Property Address 4 Carol Davis ' Owner Owner's Name m.t :a Information is Quid ✓ ' I %-D required for every Cumma �A'R�. MA 02637 8-15-17 page. City/Town State Zip Code Date of Inspection 0 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 A. General Information filling out forms Sl:;tr � a 7-Lf'T on the computer, %������SµrOFtuhpp�y use only the tab 1. Inspector: .�'��a'`` 1 key to move your cursor-do not g; N James D.Sears �, .1AMES m is keY the return Name of Inspector :y 5 Capewide Enterprises * + %y o'er �rra—Q AF ,y Company Name � ���' .� a 153 Commercial StreetNSPEG����� Company Address ter. Mashpee MA 02649 City/Town State Zip Code 508-477-8877 S 1623 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system Inspector pursuant to Section 15.340 of Title 5(310 CMR 16.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 8-15-17 spector'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 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. t5in%doc•rev.8116 Title 5 official Inspection Form:Subsurface Seviage Disposal System•Page/of 17 �o VS I, abed xezI dH 69:£1, L 60Z L I, 5nV Commonwealth of Massachusetts Title 5 Official Inspection Form "s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 172 Midpine Drive Property Address Carol Davis Owner Owner's Name information is required for every Cummaguid MA 02637 8-18-17 page. Clty/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check.A,B,C,D or E J always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The system is a 1000 Gal. Tank D Box and pit. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins.dw•rev.6115 Title 5 Orficlel Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Z abed YPJ dH 65:£6 L 60Z L 6 5riv Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 172 Midpine Drive Property Address Carol Davis Owner Owner's Name information is required for every Cummaguid MA 02637 B-18-17 page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ 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); ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ NO (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ NO (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ NO (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 ❑ NO (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ NO (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 16.343(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 t5lns.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 £ a6ed xe:1 dH 69:£6 L 60Z L l, find Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Foam-Not for Voluntary Assessments 172 Midpine Drive Property Address Carol Davis Owner Owners Name information is required for every Cummaguid MA 02637 8-16-17 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. . ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well, ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: *"This system passes if the well water analysis, performed at a DEP certified laboratory, for 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. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in is less than 6" below invert or available volume is less than Yi day flow PiT t6ins.doc-rev.6116 Title 5 official Inspection form:Subsurface Sewage Disposal Systeir.•Page 4 of 17 abed ue� dH 69:£1, L 60Z L 1. 6n`d r Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 172 Midpine Drive Property Address Carol Davis Owner Owner's Name information is required for every Cummaguid MA 02637 8-18-17 page. City/Town State Zip Code Date of Inspection B. Certification (cunt.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria Indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-, 10,000g pd. ® The system fails.I have determined that one or more of the above failure criteria exist as described in 31C CMR 15.303, therefore the system fails. The system owner should contact the Board of Health-to determine what will be necessary to correct the failure. , E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins.doo-rev.6116 Title 5 Offidal Inspection Form:Subsurface SeAsge Disposal System-Pape 5 or 17 5 a5ed xez! dH 69:£6 L I,OZ L I• 6ny Commonwealth of Massachusetts 3 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form •Not for Voluntary Assessments 172 Midpine Drive Property Address Carol Davis Owner Owner's Name information is required for every Cummaquid MA 02637 8-18-17 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes"or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms). 330 t5ins.doe-rev.6/16 Title 6 ofra:iel Inspealon form:Subsurface Sewage Disposal System•Page 6 of 11 9 a5ed Xe� dH 00:V 6 L 60Z L 6 find Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 172 Midpine Drive Property Address Carol Davis Owner Owner's Name informrequire for is Cummaguid MA 02637 B-18-17 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: The system is a 1000 Gal. Tank D Box and pit. Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No 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 ears usage d 2015-67,000Gais 9 { y 9 (9p ))' 2016-69,000Gal's Detail: Sump pump? ❑ Yes ® No Last date of occupancy: NA Date CommerciaUlndustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seatslpersonslscI t., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: 15inadoc-rev.6116 Title 5 Official Inspectlor Form:Subsurface Sowage Disposal System•Page 7 of 17 L a5ed xeJ did 00:t I. L 60Z L 6 6nV Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t 172 Midpine Drive Property Address Carol Davis Owner Owner's Name information is required for every Cummaquid MA 02637 8-18-17 page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank,distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins.doc•rev.6116 Title 5 Df al tnspectlon Form Subsurface Sewage Disposal System•Pape 6 of 17 9 abed xed dH 00:V 1, L 60Z L 1. 6rTV Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 172 Midpine Drive Property Address Carol Davis Owner Owner's Name information is required for every Cummaguid MA 02637 8-18-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1977 Permit #77- 624 8-2017 New D Box. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2, feet Material of construction: ❑ cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Pipeing is 4" PVC SCH -20 &SCH -40. Septic Tank(locate on site plan): Depth below grade: 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 Gal. Precast H-10 ` Sludge depth: 2" 15ins.doe rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 6 abed xeJ dH 60:b 6 L 60Z L 6 6ny Commonwealth of Massachusetts kowlTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 172 Midpine Drive Property Address Carol Davis Owner Owner's Name information is required for every Cummaguid MA 02637 8-18-17 page. Cltyrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 28 Scum thickness 0" Distance from top of scum to top of outlet tee or baffle 8' Distance from bottom of scum to-bottom of outlet tee or baffle 18 How were dimensions determined? Asbuilt-Tape Sludge Judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): ' Tank at working level. Tank and cover's at1'below grade. Inlet baffle, outlet tee . No sign of leakage or overloading. 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 tFiins.doc•rev.&16 Title 5 Orficial Inspection Form Subsurface Sewage Disposal System•Page 10 of 17 p 6 abed xe:1 dH 10:17 l, L 60Z L l, find Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 172 Midpine Drive Property Address Carol Davis Owner Owner's Name information is Cummaquid MA 02637 8-18-17 required for every page Cityn own State Zip Code Date of Inspection D. System Information (cunt.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑concrete ❑metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.). II *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 15lns.doc•rev.6116 Title 5 official Inspection form:Suhseace Sewage Disposal System•Page 11 of 17 I i, abed xezI dH Zt l, L 60Z L I• bn`d Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments dY 172 Midpine Drive Property Address Carol Davis Owner Owner's Name information is required for every Cummaquid MA 02637 8-18-17 page. Citylrown State Zip Code Date of Inspection D. System Information (cost.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 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.): D Box is 26"below grade wlone line out. Box is New 8-2017. 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. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc-rev.6116 T tie S official inspection Form:Subsurface Sewage Disposal System-Page 12 of V Z 6 abed YPJ dH 60:t 6 L 1.02 L l• 6nV Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 172 Midpine Drive Property Address Carol Davis Owner Owner's Name information is required for every Cummaquid MA 02637 8-18-17 page. Cltyrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is a precast pit. Pit at 2' below grade w/cover at 14". Pit dry w/stain line at 2' 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 151na.doc•rev.fin 6 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 El, @tied xed dH Wtp l, L 602 L l, 6n'd Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Savage Disposal System Form - Not for Voluntary Assessments 172 Midpine Drive . Property Address Carol Davis Owner Owner's Name information is required for every Cummaguid MA 02637 8-18-17 page. City/Town State Zip Code Date of Inspection D. System Information (cant.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc,): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc,): 15ins.doc-rev.6116 Title 5Official Inspection Form:Subsurface Sewage Dieposal System•Page 140117 b L abed xed dH Wt i, L 60Z L l, find Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 172 Midpine Drive Property Address Carol Davis Owner Owners Name information is required for every Cummaguid MA 02637 8-18-17 page, City/rown State Zip Code Date of Inspection D. System Information (cunt.) 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 A 'v fro K 1 1 Arl •� y� o A-y= 3?f 8 Vr +1's' t5ins.doc•rev.S/IS Title 5 01'Wal h5pection Form:Subsurface Sewage Disposal System-Page 15 or 17 56 a6ed xed dH WK LW L6 6rrtf i, • Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 172 Midpine Drive Property Address Carol Davis Owner Owner's Name informrequired is Cummaquid MA 02637 8-18-17 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells N d 11'+ Estimated depth tofh'igh ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Cbtained from system design plans on record If checked, date of design plan reviewed, 5-20-77 Date ❑ Cbserved site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain; ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: T.H.on Design plan 11'+ no G.W.. Bottom of pit at 6' below grade. Bottom of pit at 5'above T.H. Depth. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t6it S.doG•reo.6f1t3 Title S O fidal Inspeetlon Form:Subsurface Sewage Disposal System•Page 16 or t) g l, @lied xed dH Wt,6 L ME L 6 finy r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form •Not for Voluntary Assessments 172 Midpine Drive Property Address Carol Davis Owner Owner's Name requiretifoon e Cummaquid MA 02637 8-18-17 required for every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file tSins.dac•rev.6116 Title 5 Official Inspection Form.Subsurface Sewage Disposal System-Page 17 of 17 Li, abed xed dH £O ,6 L 60Z L I, find 7 TOWN OF BARNSTABLE LOCATION / SEWAGE# `ILLAGE 1InZ22294 Li p U ASSESSO ' MAP & LOT 3 616 1 NAME&PHONE NO. � �©9�e�i Grz!' e— SEPTIC TANK CAPACITY ) LEACHING FACILITY: (type) /mod/s �a J (size) '7'JX S—� NO.OF BEDROOMS BUILDER O PERMITDATE: COMPLIANCE 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 eachi``n�fac' ) 1,4� Feet . Furnished by /O b % � 1(C g/) / �-- �:,4RAC� � �� �� ��� . 0 q �, . �, i� i 1 �e�� 9" � li v �� No. V Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Zipplitation for MispoBal 6pstrm ConstrULtion 3pPrmit Application for a Permit to Construct( ) Repair(� Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No. 1'7;7, k e7)4D1 AJ E P10 Owner's Name,Address,and Tel.No. Assessor's Map/Parcel 35(o d(3 �A�h� (a Mf0_ &)r AAZ 4jAAJ oT Installer's Name,Address,and Te.No. 58!R—"7—8:FZ'7 Designer's Na Address,and Tel.No. G4Q .J 6ct)E ENTCkBQJ56S 01Q I"3 4- k#J S'— MA,- ',06C Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building !DL` T��� No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) -T"574u, LJEW H —f0 Q`GoY L8LIN 5 -71 JS7JGt,[. 06vi T€ 0110 D CC'1' Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health Signed Date , 1+ Application Approved by IA t Date Application Disapproved by Date for the following reasons Permit No. p2 _ Date Issued �� f -+", f�'^. I f' '..L� .-a,� . .+-.:._�'J�.... r,r iatw r•...,,_. ... .. .!- .+1- -•w_ .. _ �, .w ' r � r /n�I No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: �--� PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes application for Disposal 6pstem Construction permit Application for a Permit to Construct( ) Repair()� Upgrade( ) Abandon( ) ❑Complete System X Individual Components Location Address or Lot No. 17;k M(N A!AJ F5 AD Owner's Name,Address,and Tel.No. � t3/Eiz1�/ ESr'ET.& 0,F NtAP-SI gl,eLtlCucc.. Assessor's Map/Parcel 35Gp o t:3 ('t Pl wis w> Installer's Name,Address,and Te.No. '0g"'�{' 7�-B 8"t'7 Designer's Nan}e,Address,arid Tel.No. G 4Q9w 1 N5 E+N-r6k?4j zC l A /53 40&40c6,kuA(_ S''r MolKW SG: Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building M f D&%1T(41,. No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) .rNS-r c(,, u eu.) H•-to D-C_3o y (­�t Z}( k js&% �lUST1K.L /J >tlr-W_�/ TECZ O fj OCR Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal sysiem in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Healt Signed n Date Application Approved by !A,` t Date Application Disapproved by ! Date for the following reasons fCJ Permit No. G .� Date Issued 1 f rt--� THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance - THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(A,) Upgraded( ) Abandoned at !3AW, has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No..�6 f dated Installer (2-49cyim 6IVT€ 4j5eS Designer #bedrooms Approved design flow gpd The issuance of this permit shauynot be construed as a guarantee that the syste ,will-funct_'i`onn adsdesigned. Date Inspector, ) �_ - - - -------- ---- a'O� � o --------- --------•--------------------------------------------------------- --- ��---- No. 7" Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Disposal 61-p-stem Construction Permit Permission is hereby granted to Construct( ) Repair(X) Upgrade( ) Abandon( ) System located at ' !e �� (� k y A D 5 � and as described in the above Application for Disposal System-Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. `o Date L ~— Approved by x Tom' CO1MVILONWELTI.I OF M.ASSACHUSETTS'. 7��S'% /is' EXECUTIVE OFFICE OF ENVIRONMENTAL AFI:AIRS ' DEPARTMENT OF ENVIRONMENTAL PROTECTION s sue•` TITLE 5 t_ OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: `� R �--#L Owner's Name: Owner's Address: Date of Inspection: Name of Inspector:(please print) Company Name: ✓aPlc Mailing Address Telephone Number. �O$OoZ6�(I CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the4fiformation reported below is true,accurate and complete as of the time of the inspection.The inspection was performed:based on my ge disposal systerrii I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 training and experience in the proper function and maintenance of on site sewaCMR 15.000). The sys'tem: --�V Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: S C)j 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 authority. approving 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 6lIS/2000 page 1 Page 2 of;1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL-SYSTEM INSPECTION FORM PART A CERTMCATION(continued) Property Address: �.uwlwtAt4ut` Owner: y. Date of Inspection: Inspection Summary: Check A B C,D or E I ALWAYS complete all of Section D A. System Passes: K 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: 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 th,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statern If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic unsound P ep (whether metal or not)is structurally >exhibits substantial infiltration or exfihtration or tank is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank as" ed by the Board of Health- *A metal septic tank will pass inspection if it is stru sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is av ' le. ND explain: Observation of sewage backup or out or bigh static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, ed or uneven distribution box.System will pass inspection if(with approval of Board of Health): broken pipes)are.rgAwed obshvctkm is Temoved disu%uticni box is keeled or replaced ND explain: The system equired pumping more than 4 times a year due to broken or obstructed i s .The s pass inspection i with approval of the Board of Health): y p p� ) �nli broken pipe(s)are replaced obstruction is removed ND explain: 2 I Page 3 of I 1 I OFFICIAL, INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTSSUBSU FACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address- � Owner: Date of Inspection: C- Further Evacuation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order t determ is failing to protect public health,safety or the environment. ine if the system I• System will pass unless Board of Health determines in accordance with 0 CMR 25-303(Ixb)that the system is not functioning in a manner which will protect public health afety 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 w and or a salt marsh 2. System will fail unless the Board of Health(and Pu sc Water Supplier,if any)determines that System is functioning in a manner that protects the p is health,safety and environment: the _ The system has a septic tank and soil absorp on system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface w r supply. — The system has a septic tank and SAS d the SAS is within a Zone 1 of a public water supply. — The system has a septic tank and S S and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**.Met d used to determine distance "*This system passes if the w crater analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organi compounds indicates that the well is free from pollution from that facility and the presence of ammonia ttrogen and nitrate nitrogen is equal to or less than 5 failure criteria are triaa ed_A copy of the analysis must be attached to this formpm�provided that no other 3• Other: 3 i Page 4 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY A.SSESSM[ENTS SUBSURFACE SEWAGE DTSPOSAL SMEM INSPECTION FORM PART.:A CERTIFICATION{continued) Property Address: 17 v Owner: Q y0ta Date of Inspection: 711 1 p,>_ D. System Failure Criteria applicable to all systems: You must indicate`yes"or"no"to each of the following for all inspections: Yes No K Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _ Liquid depth in cesspool is less than 6"below invert or available volume is less than%day flow Required pumping more than 4 times in the last year LOT 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 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 qualify analysis.('This system passes if the well water.analysis, performed at a DEP certified laboratory,for ealilbrm bacteria and volatile organic.comp�ds indicates that the well is free from-pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equat 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.] (Y es/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure: E. Large Systems: To be considered a large system the system most se a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or ,no,,to each tlse following (The following criteria apply to large syste in addition to the criteria above) yes no — _ the system is within 400 t of a surface drinking water supply _ — the system is wi ' 00 feet of a tributary to a surface drinking water supply _ — the system is ted in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of public water supply well Ifyou have answ ed"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Secti D above the large system has failed.The owner or operator of any Iarge system considered a. f significant eat under Section E or failed under Section D shall upgrade the system in accordance with 310 CIVIlZ 15.304.The system owner should contact the appropriate regional office of the Department. I A r Page 5 of 11 OFFICIAL INSPECTION FORNj—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM[ PART B CHECKLIST Property Address: k Owner: Date of inspection: 0 Check if the foIlowin have been done.You must indicate"yes"or"no"as to each of the following: Yes No d�C s .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 2 Ni 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 g depth of scum? i Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no — Existing information.For example,a plan at the Board of Health. _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CUR 15.302(3)(b)j 5 Page 6 of I I OFFICL4,L INSPECTIONF�R� — TARY ® ASSESSMENTS SEWAGE DISPOSAL STEM INSPECTION ON FORM PART C SYSTEM INFORMATION Property Address 0 C, �r` Owner: Date of Inspection: 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): 33(� Number of current residents:-&a_ Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no): Nt7 [if yes separate inspection required] Laundry system inspected(yes or no): Nb Seasonal use:(yes or no): NV Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no):A/o Last date of occupancy: p r COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203):_ opd Basis of design flow(seats/persons/sgft,etc . Grease trap present(yes or no):_ Industrial waste holding tank Ares (yes or no): Non-sanitary waste discharge the Title 5 system(yes or no): Water meter readings,if av 'able: East date of occupancy/ e: OTHER(descriw/__::�: GENERAL INFORMATION Pumping Records Q p� Source of information: 10/5a/I y bl �>�o�9s� lvas4u( Y 0! +?0.K Was system pumped as part of the inspection(yes or no):-gyp If yes,volume pumped:"gallons—How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM OC 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) Tight tank ____Attach a copy of the DEP approval —Other(describe): Approximate age of all components,date installed(if known)and source of information: _t Were sewage odors detected when arriving at the site(yes or no): #0 6 I Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURIFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 'Owner: V VA Date of Inspection: BUILDING SEWER(locate on site plan) . Depth below grade: y N_ Materials of construction: cast iron _p 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- LY (locate on site plan) Depth below grade: /5-It 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:- Sludge depth. a Distance from top of slujge to bottom of outlet tee or baffle: o?8 a 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 affle: How were dimensions determined: �Yf y red Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related t outlet invert,evidence of leakage,etc.): teas GREASE TRAP:_(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 outlet tee or baffle: Distance from bottom of scum bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping r ommendations,inlet and outlet tee or baffle condition, structural integrity,liquid levels as related to outlet rove evidence of leakage,etc.): 7 Page S of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISI'®SA]L SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: t p Owner: Date of inspection: TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete m fiberglass_`polyethylene other(explain): Dimensions: Capacity: ns Design Flow: ns/day Alarm presen Alarm level: n order Date of last p�7n�dii g (yes or no): Comments(ct switches,etc.): DISTRIBUTION BOX: 3( (if present must be o e pen d)(locate on site plan) Depth of liquid level above outlet invert:ANN,, 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.): / r t y rW l o JPrI• PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or Alarms in working order(ye no): Comments(note conditio f pump chamber,condition of pumps and appurtenances,etc): . 8 Page 9 of I l OFFICUL INSPECTION FOR —NOT FOR VOLUNTARY ASSESSMENTS SUBSU1kFACK SE*AGE DISPOSAL SYSTEM INSPECTION FORME PART C SYSTEM INFORMATION(continued) Property Address. Mi < P Owner: Date of Inspection: O SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type _Teaching pits,number leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): w s� Ltat IZ x1t "few— 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 laver: Depth of scum layer: Dimensions of cesspool: Materials of constru n: Indication of gro water inflow(yes or no): Comments(not condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note c dition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)-. �I 9 Page 10 of 11 .OFFICE,INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: L Date of Inspection SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. a5 6b 33 6� 3� 61 I Page 1 I of l l OFFICIAL,INSPECTION FORM—NOT FOR `IOvI.,�NTARKY ASSESSMENTS SUBSPACE SEWAGE DISPOSAL SYSTEM INSPECTION I.ORx'�JE PART C SYSTEM INFORMATION(continued) Property Address: Owner: , Date of Inspection: SITE EXAM Slope NU- Sur-face water NO Check cellar Vps Shallow wells 00 Estimated depth to ground waterfeet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Checked with local Board of Health-explain: Observed site(abutting Property/observation hole within 150 feet of SAS) Checked with local excavators,installers-(attach documentation)C Accessed USGS database-explain: You mast describe how ou established the high ground water elevation: u s � c f r , 1I No....... �3 MdTHE COMMONWEALTH Ts BOARD OF HEALTH AppIirtt#iort -for Dbipwia1 �rk� (�vtt.Strttsttntt Pumit Application is hereby'made for a Permit to Construct ( k1l"Or Repair ( ) an Individual Sewage Disposal System at:Z j!S <r2�/?A-IF—n- 104,1 ->E C��dG.....yyZ���fsSlDid/a�d---Qf2/�IG'� .........-•--•--- ...-•------------------------ �®........................ ."r-- --------••---------- ✓SC/4G.!- I+oc "`+ )sr liC:� /. ^� or Lot No. T Owne j� Address T �/�'�W��•�--dress.......................................... U Type of Building �- � - 3 I g Ize Lo _._. .� ----Sq. feet Dwelling—No. of Bedrooi _____________________________Expansion Attic (A40 Garbage Grinder (A1 0 aOther—Type of Building__________ ___________ No. of persons-----7-�--___-.-.-- Showers Cafeteria t, 7Vj --- Other fixtures --•--------•-•- -• 1 = Design Flow----------------��.......___.._...._gallons per pet-son per day. Total daily ow-_____---..__ gallons. W -- g" P P P ,,� Y• -��4-------- -------- WSeptic Tank—Liquid capacit/A!.'.O_gallons Length_.-.�_____- Width._ ...... Diameter----- --- ------ Depth..__ __._._.. x Disposal Trench—No.--------- -------- Width__.._....`-------- Total Length------_......... Total leaching area.......-----------sq. ft. � Seepage Pit No.-__---�_-_____--- Diameter___ `F�..._�____ Depth below inlet_............. Total leaching area.3, -----sq. ft. Z Other Distribution box (tell Dosin tank ) Percolation Test Results Performed by. ._._._ Qs .® � -•__ Date____..- _ /Zd ,-7 �f7 � Test Pit No. ___minutes per inch Depth of Test Pit....�,���_----- Depth to ground water...... 8��. (S, Test Pit No. 2......=......minutes per inch Depth of Test Pit._______..'-........ Depth to ground water....e QvPV •O ---•----•-•------------------ --------------•----------•-------------- - O Description of Soil__�- z z= q, .. © •. d -- -- ��.�_ 6� '�._f � W U Nature of Repairs or Alterations—Answer w -- when applicable._.-__-•�-- --�---------------•-----•----------._._._----._......___._-_.----.... ---------------------- ---------------•--------- ----------- ----------------------------------------------------------------------- -- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article YI of the State Sanitary Code—The undersi ed further agrees not to place the system in operation until a Certificate of Compliance has b ,jtdsued by of he Signed- - ------------• ---- - --- ----6 s---./ � .. / ------------- Date ApplicationApproved By------------------------------------------ -••---••--.--.•-------. ........................ Application Disapproved for the following reasons--------------------------------------------------------------------------------•------------Da .te --------------------------------------------•---------------------------------------------- ---------------------------------------------- / Date Permit No..................................--•-••---•----•••-... Issued. _W �d Date t/ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ....... Applirati.on -for 'iipmat Works Towitrurtinu PPrutit Application is hereby`made for a Permit to Construct ( ior Repair ( ) an Individual Sewage Disposal System at ""� .....i2....... �._ .s.. ice --------------- x or i��. ---`-! 5• -r ti" �r Y t--- ...... Lot No. Owne / Address Q Type of Building ✓ nstalle ,,4 Size Lt�e o U Sq. feet �-, Dwelling—No. of Bedroom _ ______ ________________Expansion Attic (• ,fO Garbage Grinder (/S aOther—Type of Building � No. of persons......... ------ Showers Cafeteria ( Q Other fixtures ............ ------•---------•-•----- W Design Flow................. ..............gallons per person per.,,day. -_ er�day. Total dailly�flow....._.. '..-. -----------------ga�loil R: Septic Tank—Liquid capacity/OOP gallons Length__ ..._"'____. Width ..'$_. .".. Diameter-----"'0-._____ Depth......•_._. Disposal Trench—No.................. Width........"" _---- Total Length....... .. Total leaching area... ""` _ sq. ft. Seepage Pit No--------Z---------`Diameter....�_11_k�---- Depth below inlet-------- ...... Total leaching area___33e. --------sq. it. Z Other Distribution box ( Dosin k ) ~" Percolation Test Results Performed by. •' .- ------- ----- •-�`���. _-_a ,,_____ .. Date-_---.-f � �Test Pit No. 1 .____mmutes per inchT �inch Depth of Test Prt.__ �.__. Depth to ground water....------_'---.--.----- 40 (s, Test Pit No. 2.......�_----minutes per inch Depth of Test Pit..........�y_.... Depth to ground water_-.- ®v'� O --•-- - -- Descri ----------- Description of Soil C3� ' t` C3 ��� . ��-//;V_'�'' �'" s S'4oI/o P er :� ----- ------ �i i/ �, W x ------ ------ --- 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 \I of the State Sanitafy Code— The undersigAd further agrees not to place the system in operation until a Certificate of Compliance'has be rued by b" rd of he ► Signed ------- / Date ApplicationApproved BY -----------------------•--------------•-.......;- ------------------------ -•---•------------------- Date Application Disapproved for the following reasons:.:---•---------•--•-------•-----------•-----------------------•-------------•--------•-----------•------•------- ................•-••------•-.....•-•------•-•----•------------•--• -----_-- 44 Date Permit No.--........................................ Issued........ �!........... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ... ........OF........ .�+ ......................................................` ertifira#r 6f f I'llut litturr s, THIS IS TO CE I•IFY, That the In ividual Sewa „Disposal System constructed (Xor Repaired ( ) by I f �+�,� �y ,t` --- atl�-� _ ° 1 �`.'."�" � f�'`' /�f /�i�hf r✓4 ;� 4Y C°-S'J'/` � , f�✓L-- has been installed i"n,accordarce with the provisions of Art' I of The. State Sanitary Code as described in the application for Disposal Works Construction Permit No----- ----�__ ------_. dated.................. '--��................ THE ISSUANCE OF=THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL F NCTIOY SATIS CTORY. DATE---------------- -----------------7•-•-------•--•--••-•--•-•-•••-• Inspector:__== -=------------------------------- w THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No......... � 7 M+ FEE..:.:................... . �i��n�,�tt1 �rk�. � t�tr k.�rti�att �rrZattt Permission is hereby granted_.. ..__._..____ I! --- ------ ---------------- to Construct. ( or�e�air an Individual Sewage Disp sal S m at No +4/•�7 - �.............�`aa _G?✓�'• .. 'J e ,+ >ryt,, j. 2"�a4� aopC�' o-/ , /e/ , Street p as shown on the application'for Disposal Works Construction Perm o Dated l a _ Board of Health DATE...............�-.�"7 7 FORM 1255 HOBBS.& WARREN. INC.. PUBLISHERS - 91 /7 7 9_?r �010 g } o G q Q \ � 16, l� lean y �4,451 4 44 QV 4//jet c,�" '` , � •. '. /y 3 4.. (/ ' ,es ��o B�_ avfL T 7•pP e.Vo A,/. rr" J^� �� G7� oc/�/S CEO C-�•�CAO�• - •o p: p'E'we ScN yo S!''�Yc .ScN yo �' 1 /.ti�laF.e7' °`y: �'. �' 6.�aLGo,✓s /N4142T /N'Olet 60t ��1�'�T '.Q []•�= 3/!�l % ��/„� S.EPT/c-7_.A9Av1c o o: X2 PB •'p• is G,4,E'Q,pG.s /C�' ---� � •'�_i` _G' ALE A' d`o /G � a� A�O�OSB�• A.// ST�A ScAL�� ....� ,Q4�9O/Eo0/vl.S 330 CAG 1�•9� / -7-,oe T/o/ .,, L /9 ct� ,p v�'� o srvA L o,e/7� 70 A/l//mac'o�/1?E�/r'AL ("o O� 7 TL �� /< 'r T'i,� �p t �•.f" t ! < 71E:-S"T S CTE PL AN SHOWING PROPOSED CONSTRUCTMNj. F O R . A P P ROVE D SCALE : / G A T E: i . `c �' BOARD OF H E. A L T `.' r , R E F E R E N C E : 6,0 / � ,� a�' r�.�� .�`.�,. . ���v ' '�,r 1 !�3 � '� DATE A G E N T 4,16E I>/ s,r.r'�.,1�>��i/ �'"! � ./VC.e• , CMS ASSOCIATES , INC . func ; REGISTERED ENGINEERS L LAND SURVEYORS Xx 0 MID -CAPE OFFICE BUILDING - 1265 ROUTE 28 . �5�0ltAl.��`v,. . • . ' SOUTH YARM OUTH, ' MASS. 02664 r�