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HomeMy WebLinkAbout0243 MIDPINE RD - Health A243 Midpine Road, Ber:a table qi e 1 ° L r Commonwealth of_Massachusetts Title 5 Official In pection Form Subsurface Sewa9e Disposal System Form-Not for Voluntary Assessments y 243 MIDPINE RD. , i� Property Address LINDA.CARLSON-DUNPNY o Owner wnor's Name Information is CUMMAQUIO required for every MA 02675 page. City/Town State ZIp Code. ,Date of.Inspection: Inspection results most be submitted on this form. Inspection forms;may not;be tittered In any. way.Please see completenesschecklist atthe end of the form. Important:When A. Ins ector Information: co filling form p Stir IL`Q& on the computer, use only the tab Douglas Brown key to move your Name of Inspector cursor-do not Cape Cod Septic Services Inc. use the return key. Company Name 350 Main St. _ U Company Address West Yarmouth MA 0267.3 CitylTown State• Zip Code: 508-775-2825 SI4297 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);'l 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 performedbased proper function on my training,and experience in the and maintenance of on-site sewage disposal systems.After`conducting this inspection 1 have determined that the system: • 1, Passes 2.. [1 Conditionally:'Passes 3. ❑ Needs:Further Evaluation by the Local Approving Authority 4• ❑ Fails Ins iP/a'tf 1% or'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 comple#ing 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 tote appropriate regional office of the DEP The original form should be sent to the system owner and copies sent to the buyer; f applicable, and the'approving authority: Please note; This report onlydescribels conditions at the tlme of inspection:and under the conditions of use at that time.This Inspection does not address low the. yetem`-will perform In the future under the same or different conditions of use: 15insp.doo•rev.7/28J2618 Title 5 Official inspection Form:Subsu face Sewage Dispoeat System r Pap 'll ofAs r Commonwealth of,Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r/ 243 MIDPINE RD __.o _ rop _.... - __..__.......... pperty,Address LINDA CARLSON-DUNPHY Owner -- -.~ _...._ _.._ _ .. _ Owner's Name _.._ Information ie CUMMAQUID MA 02675 : 10-1-2019 required for every ;,... ..:_ �. �.....___. page, Gity/Town' State Zip code 'Date of Inspection C. Inspection Summary Inspection Summary: Complete.1, 2, 3,.or 5 and all of 4 and 6. 1j System Passes- 1 have.not found any information which indicates that any of the failure criteria described in 310 CUR 15.303 or in 310 CMR 15,304 exist.Any failure criteria not evaluated are indicated below. Comments: SYSTEM IS IN WORKING CONDITION. 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 over20 years old"or the septic tank(whether inetal'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'lndicafing that the tank is less than 20 years old is available: ❑ 'Y ❑ N ❑ ND(Explain below): l6insp doc",r,rev,7126/2018; Title S.Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of I8 usetts Commonwealth.of Massach LL - Title 5 Official Inspection .,Form ~ W Subsurface Sewage,Disosai S stem F p y orm"-Not for'Voluntary Assessments, 243 MIDPINE RD. - Property Address ..... LINDA CARLSON-DUNPHY Owner _........ - 'Owner's Name information is CUMMAQUID required for every ..._.. MA. 02&75 10-1 2019, _ —. page. Cltyrrown state Zip Code Date of Inspection .. C. Inspection Summary (cont) 2) System Conditionally Passes-(cont.): 0 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): p p O p 0 Y ❑ N ..0. ND'.(.Explain:_below) 0 broken i e s are replaced obstruction is removed (] ,Y N [] ND.(Explain`below): distribution box is.leveled'.or replaced n: Y E1 N []' ND(ExplaiWbelow) r The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass it}spection if(with approval of the Board of Health): [❑ broken pipes)are replaced [T Y N C] 'ND(Explain below.): [] obstruction,is removed D .Y El N ND(Explain below); 3) Further Evaluation is'Requlred.by the:'Board of Health- El. 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 M0 GMR 15.303(1)(b)that the system is not functioning in`a manner which will protect public health, safety and'the environment: t5inap.doc,rev.712612018 Title 5 Official Inspection Form:subsurface'Sewage Disposal System Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 243 MIDPINE RD. Property Address LINDA CARLSON-DUNPHY Owner Owners Name Information is CUMMAQUID MA 02675. 10 1 2019 required for every _ �� �:..�� ...._ _�.._._____ _......._.�.... _. page. City/Town State Zip Code Date of Inspection C. Inspection Summary (coat.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or,a salt marsh b. System will fail unless the Board of Health:(and Public Water Supplier, if any) determines:that the system is functioning in a manner that protects the public health, safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply ortributary to a surfacewater: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 welly*. Method used to determine distance: k`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: a. Other: 4) System Failure,'Criteria Applicable to All Systems: You must indicate"Yes.".or."No"to each of the following for all Inspections: Yes No Backup of sewage into facility or system component due to overloaded or clogged-SAS or cesspool O Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5lnsp.doe+rev.7/26/2018 Title 5:ofticial Inspection Poeer Subsurface Sewage Disposal System-Page 4 of IS Commonwealth of Massachusetts ro Tithe .5 official In spectron Form Subsurface'Sewage;:Disposal System.Form-Not for Voluntary Assessments 243 MIDPINE.RD Property Address LINDA CARLSON-DUNPHY Owner Owner's Name information is CUMMAQUID h' -� State 02675' 10-1-2019, required.for every _ MA . page. Ci rroWn Zip Code Date of;inspection C. mma Inspection S'u. -p ry (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 orcesspool ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less than' day flow. ❑ Z Required pumping more than 4 times in the last year NOT due.to clogged or obstructed pipe(s),Number of timespurnped: 13 El Any portion of the SAS, cesspool or privy.is below highground water.elevation.: ❑ Any°portion of cesspool or privy is within 100.feet of a surface water supply or tributary to surface watersupply 0 ® Any portion 6fa cesspool or privy:s.within a Zone 1 of a public:vvater supply well.. N 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 400 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 collform 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 trigger6&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 god- 10,000 gpd: The system fails.1'have determined thaf.one or.more:of the above failure criteria exist as describetl'in 310 CMR 15303, thereforethesystem fails. The system owner should contact the 3oard of_Health to determine'what will be necessary to correct thefailure. 5) Large Systems: To be considered a large.system the system must serve a facility with a' design flow o I0,000 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 i6 Section CA. Yes No 13 El the system is within 400 feet of a urface drinking water supply ❑ the system is within 200 feet of a ributary to a surface;drinking`wateraup'I ❑ o the system is,located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone:ll of a;public`water supply well t8insp:doc•rev.7/26/2018 Title 5 Official:inspection Forin:Subsurface Sewage Disposel System;Page S of 18 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-:.Not for Voluntary Assessments. .243 MIDPINE RD. Property Address LINDA CARLSON-DUNPHY Owner Owner's Name: ......_. ....... ... __—._ __..... _ _: _ Is requiretifore CUMMAQUID MA 02675 10-1-2019 required for every ..-....... _. — page. CityFrown State. Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes,'to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section,CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed Under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office.of the Department. 6. You must indicate"yes."or"no"for each of the following for all Inspections: Yes No Pumping information was provided by the owner, occupant, or Board of Health Were'any-:of the system components pumped out in the previous two weeks? Has the system received normal flows in the previous two week period? Have large volumes of water been''introduced to the system recently or as part of this inspection? Were,as built plans of the system obtained and examined?(If they were not available note as N/A) Z ❑ Was the facility or dwelling inspected for signs of sewage back up? S ❑ Was the site inspected for signs of break out? Z ❑ Were all system components, excluding the SAS, located on site? Z ❑ 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)] t5lnsp.doc rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•,Page 6 of 18 Commonwealth of Massachusetts - -P Title 5 Official Inspection Form Subsurface.Sewage,Disposal System Form=-Not for Voluntary Assessments 243-MIDPINE RD. Property Address LINDA CARLSON-DUNPHY Owner Owner's Name information is CUMMAQUID MA 02675 required for every 10-1-2019 page, Cityfrown state Zip Code Date of inspearion D. System. Information 1. Residential Flow Conditions: Number of bedrooms(design): 3 Number:of bedrooms(actual); 3 DESIGN.fioW.based on.31.0 CMR 15.203(for example: 110 gpd x#of.:bedrooms); 330 Description: Number of current residents: Does residence have a garbage grinder? El Yes..® No: Does residence have a,watertreatment°unit? 0 Yes.®' No If yes,discharges to: Is'laundry on a separate sewage.system? (In'clude laundry system:inspection information in this report`.) 0 Yes No: Laundry system inspected? ❑ Yes '®: Nil: Seasonal.use? Yes ® No'. Water meter readings, if available last 2 ears usage 2017 202 GPD 9 ( Y 9 (9pd))' 2018 191 GPD Detail: _ Sump pump? ❑ Yes ® No Last date of occupancy:: CURRENT *n doc•rev.7/26/2018 � Title 5 OttEcial Inspeotion Foim°Subsurfaoa,$ewage Disposal System-Page_?0!18 Commonwealth of Massachusetts -;@ Title 5 Official Inspection Form Subsurface Sewage DisposalSystem Form-Not for Voluntary Assessments 243 MIDPINE RD. , Property Address LINDA CARLSON!DUNPHY Owner Owner's Narne � - Information is CUMMAQUID MA 02675 10-1-2019 required for every - - _ _...._.. page. City/Town State .Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): -- ---- Gallons per day,(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes,discharges to: - Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste;discharged'to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: - Last date of occupancy/use: - - Date Other(describe below); 3. Pumping Records: Source of information: NO RECORD Was system pumped as part of the inspection? ❑ Yes 0 No If yes, volume pumped, - .gallons How.was quantity pumped determined? — --- Reason for pumping: ........ t5insp.doc rev.712 612 01 8 Title 5 official Inspection Forth:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts -_ Title 5 Official Inspection Form — Ri Subsurface Sewage Disposal System Form-Not for Voluntary Assessments" 243 MIDPINE RD. —._.. _,. Property Address LINDA CARLSON-DUNPHY`. Owner -- Owner's.Name information is required for every .:._CUMMAQUID MA 02675 10-1.-2019,,_ _.- page. Clty/Town State Zip Code Date ofinspection D. System Information (coat.) 4. Type of System z Septic.tank, distribution box, soil,absorption.System E Single cesspool ❑ Overflow:cesspool 0 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 contmdt(to'be obtained,from system owner)and a copyof latest inspection of the I/A system by system'operator under;contract Tight tank.Attach:a°copy of the DEP approval. Q Other,(describe): f I Approximate age of all components;.date installed (if known)and source of information: 19.89:PER BOH RECORDS Were sewage odors detected when.arr'ivng:at;th.e site? M" Yes No 5. Building Sewer(locate on site plan): ` Depth below grade` Material ofconstruction: cast iron ❑4t) PVC El other(explain): Distance from private water,supply well or suction line; +10 feet Comments(on condition of joints, venting, evidence of leakage, etc j LINE CHECKED BY SEWER CAMERA ANDMASFOUND TO BE CLEAN, PROPERLY PITCHED WITH NO;SIGN OF ROOT.INTRUSION: t5insp.doo a rev.7126=18 Title,5 OM6121 lnspWW Form;Sbbsurface Sewage Digposal Sysfem•Page 9 of 18: Commonwealth of Massachusetts F Title 5 official Inspection Form - Subsurfacet Sewage,Disposal System Form Not for Voluntary Assessments v" 243 MIDPINE RD.. - Property.Address .. _...... LINDA CARLSOWDU.NPHY _.. ..owner .Owner's Marne information Is e CUMMAQUID MA 02675 10-1-2019 required for every _- _ _ _ _ page. City/Town . _ . State Zip Code Date of Inspection D. System, information (cont.)_ 6. :Septic Tank(locate on site plan): Depth below grade: g feet Material of construction: concrete ❑ metal ❑fiberglass ❑ polyethylene El other(explain) If tank is metal, list age: years _Is age confirmed by a Certificate of Compliance?{attach a.copy of.certificate) ❑ Yes Z No Dimensions: 1000 GALLON--- 5° Sludge depth; w. Distance from top of sludge to bottom of outlet tee or baffle —- - ---- 3" - Scum thickness -- Distance from top of scum to top of outlet tee or baffle ---- --- Distance from bottom of scum to bottorn,of outlet tee or baffle -- - ............--- --- How were dimensions determined? MEASURED Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): TANK IS STRUCTULLY SOUND:TEE'$IN PLACE lSlneg:doo-rev.7/28/2016 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 .official Inspection-form —. Subsurface Sewage_Disposal System Form-Not"for Voluntary Assessments lr 243 MID,PINE RD; Property Address LINDA CARLSON-DUNPHY: ._ __._ Owner ame information is CUMMAQUID required for every . state MA 02675 10-1=2010 page. CltylTown State Zip Code:. Date.ofanspection D.,$ystelrn Information (cont,) 7. Grease Trap(locate on site.plan): Depth below grader feet _. Material of construction: El concrete E metal F fiberglass []-polyethylene ❑other(explain): Dimensions; Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of-outlet tee or baffle Date of last pumping: —.. .. _..__._... Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structum[integrity;- liquid levels as related to outlet invert;evidence of leakage, etc.,) 8. Tight or.Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: concrete ❑ metal ❑fiberglass- El polyethylene ❑other(explain)- Dimensions: .,_.: Capacity: _ gallons Design flow: gallons per day t5insp.doc•rev,7/2612019 Title 5 Official Inspection Porm3subsWace Sewage Disposal System•'Page 11 of 18 Commonwealth of Massachusetts =. Title 5 Official Inspection Form t Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 243 MIDPINE RD. _ . Property Addre§s ..... LINDA CARLSON-DUNPHY Owner Owner's Name information.is CUMMAQUID MA 02675 10-1-2019 required for every _ __._._.._� __. __ _..__�....... page: CityfTown State Zip Code. Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: -- Alarm in working order: ❑ Yes ❑ No Date of last pumping Date Comments(condition of alarm>and float,switches., etc.): *Attach copy of current.pumping contract(required). Is copy attached? ❑ Yes ❑ No 9: Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert - 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.): SYSTEM DOES NOT HAVE A'.DISTRIBUTION BOX. TANK HAS 2 OUTLETS t5insp;doc-rov.012612018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal system-Pago 12 of 1e f Commonwealth of Massachusetts -, Title 5 Official ,Inspection Form Subsurface Sewage Disposal System Form..Not for Voluntary Assessments: 243 MIDPI.NE RD. Property Address LINDA CARLSON-DUNPHY Owner m _ :.....,. -Ownees Name' _ information is required for every CUMMAQUID _ MA _ 02675 .. 10-1-2019 page. City/Town State Zip=Code Date of<Inspecdion 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'.appurtenanees, etc:): *If pumps:_or alarms are not in working order;:system is=a conditional pass.. 11. .Soil Absorption System(SAS) (locate on site plan; excavation not required): if SAS notlocated, explain:why: i Type, leaching pits number: 2 leaching chambers number: El leaching galleries number. , ❑ leaching trenches number, length: ❑ Teaching fields number, dimensions: overflow cesspool number: ❑ innovative/alternative system= Type/name of technology: l5insp.d6c-rev,7/28/2018 Title Official Inspection Form:Subsuriace.Sewage;Disposal Syetem•Pegs 13,of to Commonwealth of Massachusetts -fl? Title 5 Official Inspection Form Subsurface.Sewage Disposal System Form-Not for Voluntary Assessments r` 243 MIDP.INE RD. Property Address LINDA CARLSON-DUNPHY Owner Owner's Name requiration Is. fore CUMMAQUID MA 02675 10-1-2019 required for every: .._ __ - � page. CityRown 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.): 2 1000'GALLON PITS WITH STONE, MINIMAL LIQUID. 12. Cesspools (cesspool must be,.pumped as part of inspection)(locate on site plan): Number and configuration — - --- Depth-top of liquid to inlet invert ....... -- Depth of solids layer --- - --.--.-- Depth of scum layer --- - ---- Dimensions of cesspool Materials of construction ----- ..... Indication of;groundwater inflow ❑ Yes ❑ No Comments(note condition of soil,signs of hydraulic.failure, level of ponding, condition of vegetation, 15insp:doc rev.7126l2018. Title 5 Official Inspection Form;Subsurface Sewage Dlsposal,System•Page 14 of 18 Commonwealth of Massachusetts A= Title 5 Official Inspection :Form , Subsurface Sewage Disposal System.form-Not'for Voluntary Assessments 243 MIDPINE RD._, .Property Address LINDA CARLSON.DUNPHY'. . Owner Owner's Name Information is CUMMAQUID' required for every _ MA 62675. 10 1 r2df9 Y State. Zip Co de: Date of Inspection page; Gtt page. M System:information (cont) 13. Privy(locate on.site plan): Materials of construction: Dimensions Depth of solids -_ Comments(note condition of soil, signs of hydraulic failure; level of ponding; condition of vegetation, etc.): f t5insp.doc-rev.7126=18 Title 5.0f icial Inspection Form::Subsurface.Sewago Disposal Syafem-Page 1$of 18 Commonwealth of Massachusetts Title 5 Official 1nsDection Form Subsurface Sewage Disposal,System Form-Not for Voluntary Assessments 243 MIDPINE RD. Property Address LINDA CARLSON-DUNPHY Owner Owner's Name required foon r every CUMMAQUID required for eve MA 02675 10-1-2019 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 t.! ' I it 9 x . boob G-- 1 , tfinsp.doc•rev.'7126=18 Title 6.0fricial Inspection Form:Subsurface Sewage Disposal System•Page i6 of is Commonwealth of Massachusetts Title 5 Official Inspection Form , ' Subsurface Sewage Disposal System Form-Not.for VoluntaryAssessments 243 MIDPINE RD. Property.Address .. LINDA CARLSON-DUNPHY Owner . Owner's Name information is required for every CUMMAQUID _ MA. 0875. 10-1-2019, page. Cttyrrown State' Zip Code' _ Date of Inspection .D. System Information.(cont.) 15. Site Exam: Z Check Slope 0 ,Surface water Check cellar Shallow wells Estimated depth to high ground water:; BELOW 22' 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(?butting property/observation hole within.1i50 feet.of SAS) (� Checked,with local-Board of Health_-explain:. ❑ Checked.with local excavators.installers-(attachAocumentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation PER BOH' Before filing this Inspection Report, please see.Report Completeness Checklist on next page. t5insp,doc-.rev.712612018 Disposal System; Page 17 of 18 Title s OKcial In tion.Farm:$ubsurface Sewage Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 243 MIDPINE RD. Property Address LINDA CARLSON-DUNPHY Owner Owner's Name information ie regtared for every CUMMAQUID MA _ 02675 10-1.2019 _,.� _ page. City/Town 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 Q.'inspection Summary: 1,2, 3, or 5,coinpleted as appropriate. 4(Failure Criteria)and 6 (Checklist)completed ® D. System Information: For8: 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 ;5lrisp,doc rev:7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 104 Jr 1 i(D - TOWN.QF 7_ARNSTABLE � LOCATION�4� tE��►�� SEWAGE# y VILLAG ASSESSOR'S MAP &LOT 3Wq—p20 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY �/ 6 � l } LEACHING FACILITY: (type) (size) NO.OF BEDROOMS_ BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE:ZZ? Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility 11 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 an Leaching Facili (If any wetlands exist within 300 feet f leachin f i Feet Furnished by � � \ ILI . ry ILO CATION P SEWAGE Pr2 a ! No. TL cE . P s INS7ALLER'S M A M E A D► DR'ESS Q U l L 013 OR OWN EN �—, — DATE PERMIT ISSUED DAT E C 0 M 7 L I A N C E I S S U E 0 L44'1 p Fr►^-L i �1- �/ Fee /CJJ .� / 67 . No. 'L THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTAB.LE, MASSACHUSETTS Yes 01ppYicatton for �Digpoga.Y *pgtem (ron%tructtorl der Application for a Permit to Construct O Repair(/pgrade O Abandon O 0 Complete System Individual Components Location Address or Lot No.,�-?y3 4- Owner's Name,Address,and Tel.No. P Assessor's Map/Parcel Q-- G+Dr/�' �- Installer's Name,Address,and Tel.No. Ol'4042qj' j 7 Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building 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 appli able) pn a C/ io .La4,G ieo �Or 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 BoaW o Health. Signed/ o Date Application Approved by Date Application Disapproved by: Date for the following reasons Permit No. Date Issued L ——----——————————————————————— — — ————————-- J ` IL No. �� 1q�p Fee THE-COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION.- TOWN OF BARNSTABLE, MASSACHUSETTS Zipplication forigogaY *pgtetn Contruction dePt Application for a Permit to Construct Repair �U Upgrade( Abandon a 1 pp. O p ( pg O 3 Abandon( System r Individual Components Location Address or Lot No.�y3 ��/p' Owner's Name,Address,and Tel.No.CQHaO--) r� Assessor'sMap/Parcel -17% O �`05'2Qd --)Yb7 1/4'�✓14.11 Installer's Name,Address,and Tel.Nol / 4,4,4 . C00 Designer's Name,Address and Tel.No. n ��6 6ti11i �• >h,ll , Type of Building: Dwelling No.of Bedrooms, Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title f Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) ,o O!-e 0d `'' %*'>' i f� S-� l,C /0 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 BoaW of Health. t Signe i� a Date Application Approved by J Date Application Disapproved by: Date for the following reasons 1 Permit No. Date Issued _ _- ----- ------ —=-------- THE COMMONWEALTH OF MASSACHUSETTS �( BARNSTABLE, MASSACHUSETTS (Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed Repaired �' U raded g P/ Y ( ) P ( ) Pg ( ) � Abandoned( )by�yi at �� /� /, 00 r7�d9li �/ has been c nstructed in accordance with the provisions of Title //5 and the for Disposal System Construction Permit No. �� dated Installer / B✓/1l�OJ�/ C a�� L Designer #bedrooms V Approved d sig flow g d The issuance of this pe ' sh 11 of onstrue as a guarantee that the system w, fu ction�as esig ed.. �' Date Inspector /. ---No. -----�--_e-.../ ----------------- -- Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS Xigpogar *pgtem Cott. druction permit Permission is hereby granted to Con trurrct ( ) Repair ( Upgrade ( ) Abandon ( ) System located at C""ex fZ&, CJ- and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title S and the following local provisions or special conditions. Provided: Construction mu be co leted within three years of the date of this it. Date Approved by. r yF > i ' r o-, O� Alb `� _ ._•„fit,- � . Nt * .(''Y �A�'�. fir_ � !7� �• it E't�, ��. Y a• COMMONWEALTH OF MASSACHUSETTS = ExECUTnT OFFICE OF ENVIRONTMENTAL AFFAIRS rtl DEPARTMENT OF ENVIRONMENTAL PROTECTION s 4 . TITLE 5 OFFICIAL, INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: Owner's Name-40. b-�nOwner's Addres rm v /- /� Date of Inspection: Name of inspector: please print) �6 Ae, , an Name: CDCom Company rC ✓r r �f, �vi S�ct4JN T Mailing Address: -77 x t' Telephone Number: : �o L`3 CERTIFICATION STATEMENT 27. I certify that I have personally inspected the sewage disposal system at'this address and that the inf rmation:ftported4 below is true; accurate and complete as of the time of the inspection. The inspection was performed based on my hi training and experience in the proper function and maintenance of on site sewage disposal systems. am a ljRP rri approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The syste : Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: D 6 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable;and the approving authority. Notes and Comments re iS rto +�e a>2 � du' �`E oe wd o �"`�-`4^klc_, elrf Ys a. 're 4O-@4-/eGh 4�,4 -t`rS+ at.46( 5 e cot 14. f"t v�o 4--e'e t 5 t k&kaej �fu,t� � �t- r� ',�s-� -�G w Irk re �e� i w�C, This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address flow the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM :NOT FOR VOLUNTARY ASSESSMENTS �I SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART A CERTMCATION (continued) Property Address: Owner: VIA Date of Inspection: 6 /fit Inspection Summary: Check A,B,C,D or E/ALWAYS mplete all of Section D A. System Passes: I have not found any information whi indicates that any of the failure criteria described in 310 CMR . 15.303 or in 310 CMR 15.304 exist.Any ilure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. in the for ollowing statements.If"not determined"please Answer yes,no or not determined(Y;N,ND) explain. The septic tank is metal and over 20 years oI or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfil ion or tank failure is imminent.System will pass inspection if the existing tank is replaced with a complying sep ` tank as approved by the Board of Health. *A metal septic tank will pass inspection if' is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 ye old is available. ND explain: Observation of sewage b ckup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a oken,settled or uneven distribution box.System will pass inspection if(with. approval of Board of Healt broken pipe(s)are.replaced obstruction isxr moved distribution'box is leveled or replaced-. ND explain: . The stem required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass insp tion if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of t i - - -- OFFICIAL. INSPEC g ION FORM- NOT FOR VOLUNTARY ASSESSMENTSSU�SLTRFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:_ 00Y,f 41 � C�1 Owner' C0.vo•%'DV% ex Date of Inspection: p7 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: — Cesspool or privy is within 50 feet of a surface water — Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)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 I of a public water supply. — The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but SO feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at i DEP certified laboratory, for coiifortn bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm; provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: jr t ` -.o u-f Orr 4ew - `c oif r-y U C-0 le- co Ksolp rd u (, �rr2 `6 t'(' t �-� S C V 3 Page 4 of l l OFFICIAL INSPECTION FONT—NO'T°FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM s PART>A- CERTIFICA>cION(continued) Property Address: S� ♦ �/'�c.`'� p Owner: ",^Vao Date of Inspection: D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no'to each of the following for all inspections: Yes 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 cesspool is less than 6"below invert or available volume is less than'/z day flow o Required pumping more than 4 tunes 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. AAny 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. 0 Any portion of a cesspool or privy is less than f00 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 caliform bacteria and volatile organic.compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is.equal.to or less than 5.ppm,provided that no other:.failure criteria are triggered.A copy of the analysis must be attached to this form.] (Yes/No)The system fails.I have determined_ that one or more of the above failure criteria exist as M described in 310 CR 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 faci ith a design floes of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no'to each of the fo g: (The following criteria apply to large systems in.add` 'on to the criteria above) yes no _ the system is within 400 feet of a ace drinking water supply _ — the system is within 200 feet o a tributary to a surface drinking water supply _ — the system is located in a • ogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water upply well If you have answered"yes"to y question in Section E the system is considered a significant threat,or answered "yes"in Section D above the ge system has failed. The owner or operator of any large system considered a. significant threat under Sect* n 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. t. d , Page 5ofII OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL, SYSTEM INSPECTION FORM PART B Q CHECKLIST , Property Address: ��3 t� U It C u yk diLA Owner: C c n^bh Date of Inspections 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 Dl� 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 NIA) 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 mith information on the proper mintcnance 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 CMR 15.302(3)(b)) l 5 Page 6 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL, SYSTEM INSPECTION FORM PAIN C SYSTEM INFORMATION Property Address: Owner: C'4l V, Bate of Inspection: v FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):__S Number of bedrooms(actual): _ DESIGN flow based on 310 CMR 15.203 (for example: 110 Td x#of bedrooms): ,530 Number of current residents: D Does residence have a garbage grinder(yes or no): PS Is laundry on a separate sewage system(yes or no): AC [if yes separate inspection required] Laundry system inspected(yes or no): a Seasonal use: (yes or no):_a Water meter readings, if available(Iast 2 years usage(gpd)): Sump pump(yes or no):JjJ6 Last date of occupancy: ra/e,6/per COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203). gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present es or no): Non-sanitary waste discharged t e Title 5 system(yes or no):_ Water meter readings,if ava' le: Last date of occupancy/ OTHER(desert GENERAL:INFORMATION Pumping Records , Source of information: Was system pumped as part of the inspection(yes or no):— If yes,volume pumped:_gallons-- How was 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) —Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no): IWO 6 • Page 7 of l 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE; DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 0 3 !� % JD/ Owner: e-G-� Date of Inspection: L22 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction:`cast iron t(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: (Iocate on site plan) Depth below grade: y Material of construction:4 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: t,70,5a Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: . 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 obale: How were dimensions determined: *1`(j(, Comments(on pumping recommendati ns, inlet and outlet tee or baffle condition;structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): oe GREASE TRAP:_(locate on sjte plan) Depth below grade: Material of construction:_concrete_metal tberglass_polyethylene`other (explain): Dimensions: Scum thickness: Distance from top of/ommendations, let tee or baffle: Distance from bottomm of outlet tee or baffle: Date of last pumping Comments(on pumpons, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet roeakage,etc.): 7 Page 8 of 1 l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL. SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:..� Owner: Ca wn6v� Date of Inspection: 4 TIGHT or HOLDING TANK- (tank must be pumped time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete me fiberglass_polyethylene other(explain): Dimensions: Capacity: lions Design Flow: gallons/day Alarm present(yes or no Alarm level: larm in working order(yes or no): Date of last pump b: Comments(co rtion of alarm and float switches,etc.): 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.}: PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no) Alarms in working order(yes o o): Comments(note condition pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of I l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT'S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C (SYSTEM INFORMATION(continued) Property Address: a7� M- Xs t': %-� Owner: ca.—FVW1 Date of Inspection: _G�^�a 7 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type am� leaching pits,number:v2 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 podding, damp soil, condition of vegetation, etc.): yte3 A 4 � vl��.�' 1tic1 b e CESSPOOLS: (cesspoo�must be pumped as part of' ction)(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 in w(yes or no): Comments(note conditio of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): I PRTVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil igns of hydraulic failure,level of ponding,condition of vegetation, etc.): 9 A Page 10 of 11 OFFICIAL INSPECTION FORM-1 NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORD i PART C SYSTEM INFORMATION(continued) Property Address: Owner: C t%eto h 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. o - l �f q3 ` Page 11 of I I . OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection:_ '1�I/i-10 7 _ SITE EXAM Slope Surface water Check cellar Shallow wells VB Estimated depth to ground water Vb`-feet 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: 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) De. Accessed USGS database-explain: You must describe how you established the high ground water elevation: s f 11 eo �PVJ_ PN Q' i!M* t�® DATE : 9/23/97 PROPERTY ADDRESS: 243 -oM` d`—Pli�ne*.Dr-A-,v.e Cummaq.uid,Mass. 02637 On the above date, 1 Inspected the septic system at the -above address. This system consists of the following: 1 . 1 -1000 gallon septic tank. 2 . 2-1000 gallon precast leaching pits. Based bn my InRc,ectlon, I certify the following conditions: 1 . Thi'S is a title five septic system: .( '78Code ) 2 . The--septic system is in proper working order at the present time: - SIGNATURE: I , Name J P Macomber Jr_ - ------- Company:_J , P_Macomber &- Son-_Inc ,. Address -1- __Centqrvi1LeLMass__02b32 ' Phone: 5Ga__Z7-S_3338------- . I THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY 'go .�OSEPH P. MACOMBER & SON, INC. lT 1 /GF® Tanks-C*%4poo1s-LerchfIelds W & l Town SewerCon Connections P.O. Box 66' Centerville, MA 02632.0066 'o 775-3338 775-6412 L 9 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE HINTER STREET, BOSTON, MA 02108 617-292.5500 WILL1A'A F.WELD TRUDY COaT Govcmor Sccrcw ARGEO PAUL CELLUCCI DAVID B.STRUFt Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissionc PART A &4w e k4 CERTIFICATION Property Address: 243 €vl'ld—Pine—Lai7e­­iCummaquid MAAddress of Owner: Date of Inspection: 9/18/9 7 (If different) Name of Inspector: Joseph Pjdacomber Jr. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: J.P.Macomber & Son Inc. Mailing Address: Box 66 Centerville,Mass. 02632 Telephone Number: 508-775-3338 CERTIFICATION STATEMENT I cenify 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 - I Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: /, Date: ti The System Inspector Sall 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, B, C, Or D: A) SYSTEM PASSES: 1 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: If 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. ,40 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 ex-filtration, 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. (ravirred 04/25/97) Page 1 of 10 DEP on the World Wide Web: hrtp://www.magnet state.ma.usldep Printed on Recycied Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:243 Mid Pine Drive Cummaquid Ma Owner: William Morges Date of Inspection: 9/1 7/9 7 B) SYSTEM CONDITIONALLY PASSES (continued) V&V, Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstruc ed 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 (our 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 I N I RE BY THE BOARD OF HEALTH: CJ FURTHER EVALUATION S REQUIRED O Q i Conditions exist which require funher evaluation by the Board of Health in order to determine if the system is fading to proten 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: L(pl Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM 15 FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: �Jp 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 (or 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 ()4 _ (approximation not valid). 3) OTHER �. AM )revised 04/25/97) Page 2 of 10 J SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:243 Mid Pine Drive Cummaquid Ma Owner: William Morges Date of Inspection: 9/1 7/97 D) SYSTEM FAILS: 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 bass 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 el Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool y Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. _/p4P1-- Static liquid level in the distribution box above outlet inven due to an overloaded or clogged SAS or cess000� Liquid depth in Qocspae is•less than 6" below invert or available volume is less than 112 day floe Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s1 Number of times pumped _. -e/ Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation J/ Any portion of a 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. 41 Any ponion of a cesspool or privy is within 50 feet of a private water supply well. Any ponion 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, artach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. EJ LARGE SYSTEM FAILS: 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: I 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 �A the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area - IWPA) or a mapped Zone if 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 funher information (r•vis•d 04/7S/97) P•9• ) of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:243 Mid Pine Drive Cummaquid Ma Owner: William Morges Date of Inspection: 9/1 7/9 7 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes NO r— ", _ Pumping information was provided by th caner 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. _ As built plans have been obtained and examined. Note if they are not available with N/A. l The facility or dwelling was inspected for signs of sewage back-up. ZThe system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. _ All system components,!Fkluding 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. 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. _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [I5.302(3)(b)) (revised 04/25/97) Page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:243 Mid Pine Drive Cummaquid Ma Owner: William Morges Date of Inspection: 9 17 97 FLOW CONDITIONS RESIDENTIAL: Design flow: 2YO g p.d./bedroom for S.A.S. Number of bedrooms: Number of current residents. . Garbage grinder (yes or no.):__&Q Laundry connected to system (yes or no): BLS Seasonal use (yes or no): 43 Water meter readings, if available (last two (2) year usage (gpd): TS`1— Sump Pump (yes or no):lee) Last date of occupancy: COMMERCIAUINDUSTRIAL• Type of establishment: 'tof Design flow: >A gallons/day Grease trap present: (yes or no)�� Industrial Waste Holding Tank present: (yes or no)149 Non-sanitary waste discharged to the Title 5 system: (yes or no) 1�- Water meter readings, if available:.Ul4Z Last date of occupancy: N/¢ OTHER: (Describe) "of- Last date of occupancy: 61 GENERAL INFORMATION PUMPING WORDS and Source f informatio System 6umped as pan of inspection: (yes or no) s If yes, volume pumped: IZ906 gallons J Reason for pumping: TY�EOSYSTEM Septic tank/ oil 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 /fJJg AP—PROXIMATE AP-PROXIMATE ACE of all comp nents, to installed (if known) and so rce of information: ao;,pUrl,� Sewage odors detected when arriving at the site: (yes or no) l7 (revised 04/25/97) Pa9. 5 of 10 f, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address243 Mid Pine Drive Cummaquid Ma Owner: William Morges Date of Inspection: 9/1 7/9 7 BUILDING SEWER: (Locate on site plan) Depth below grade: dT/ Material of construction: st it _ 40 PVC _ other (expla n) _ 70 74��� T Distance fro privaiLtwater supply well or suction line Diameter -?,_ Comments: (condition of joints, venting� evidence of leakage, etc.) t,,;'y7-5 R�r 7, /�7' AA 0.//V,at0.u,M- O 6&4T: c�v SEPTIC TANK:�(f��9 �'S (locate on site plan) l Depth below grade: 4e Material of construction: concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list ageVA Is age confirmed by Cenificate of ComplianceAW (Yes/No) Dimensions: Sludge depth: —T Distance from top of sludge to bonom of outlet tee or baffle:_ Scum thickness 41 _ Distance from top of scum to top of outlet tee or baffle: Distance from bonom of scum to bonom of outlet tee or baffle.e How dimensions were determined: , 9 1,,AJ 7lQQ� Comments trecommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural iniegri),, evidence of leakage, etc.) P c T I GREASE TRAP:AL*V-` (locate on site plan) Depth below grade:-&�& Material of con struct ion 4- concrete,(&6metaI4,AgFiberglass,(LAPoIyethyleneA//jother(explain) ,VA ' Dimensions: Scum thickness. Distance from top of scum to top of outlet tee or baffleaz�� Distance from bonom of scum to bonom of outlet tee or baffle:,AZA Date of last pumping: >41W 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.) ` I (r•v1••d 01/75/97) P•g• 6 of 10 l lb SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 243 Mid Pine Drive Cummaquid Ma Owner: William Morges Date of Inspection: 9/1 7/9 7 TIGHT OR HOLDING TANK:AW(Tank must be pumped prior to, or at time, of inspection) (locate on site plan) Depth below grade:ti/4 Material of construct ion;al4concretoVAmetalv4Fiberglass,�JAPolyethylene.-V, other(explain) A14 ti�p Dimensions: ,/>1,0 Capacity: AW gallons Design flow: gallons/day Alarm level: Alarm in working order 41hYes;41 Na Date of previous pumping: 4//�f Comments. (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX-&*1e— (locate on site plan) Depth of liquid level above outlet invert: A14/� Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) PUMP CHAMBER:4�We— (locate on site plan) Pumps in working order: (Yes or No)� Alarms in working order (Yes or No).4jf} Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 04/25/97) P.90 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 243 Mid Pine Drive Cummaquid Ma Owner: William Morges Date of Inspection: 9/1 7/9 7 SOIL ABSORPTION SYSTEM (SAS):c2��Q�N ;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:, leaching chambers, numbec-0 leaching galleries, number: leaching trenches, number,length:� leaching fields, number, dimensions: overflow cesspool, number:Q Alternative system: WA Name of Technology: ZIA ICI Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) i CESSPOOLS: (locate on site plan) Number and configuration,:djfg r Depth-top of liquid to inlet invert: Depth of solids layer: , za Depth of scum layer: /1J. Dimensions of cesspool: Materials of construction: AIX Indication of groundwater: /y inflow (cesspool must be pumped as pan of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: (locate on site plan) I Materials of construction: Dimensions: /L Depth of solids: 14,10 Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 04/25/97) Page 8 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 243 Mid Pine Drive Cummaq uid Ma Owner: William Morges Date of Inspection: 9/1 7/9 7 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) I \ � f \ / i i9 BSI n, (uvix6d 04/25/97) Page 9 01 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Properly Address: 24.3 Mid Pine Drive Cummaquid Ma Owner: William Morges Date of Inspection: 9/17/97 Depth to Groundwater Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abuning property, observation hole, basement sump etc.) Determine it from local conditions Check �.jth local Board of health Check FEMA "taps Chec' umping records Check local excavators, installers Use ('SCS Data Describe n your ow, words how you Pctablished the High Groundwater Elevation. (Must be comol-1-1' Cape Cod' ' , Water Tble Contours and Public Water Supply Wellhead Protection Areas September 1995 Cape Cod Commissiom Map a (r.vi..d 04/25/97) Page 10 of 10 t.......—n ,-r—,-.-.ram.-nr.r m nr-...-rn,.+r R:•n.•+-.�.r:++r+.n.n.rmv nrm�.m m-.�-v.rr-o m-r-r�.�—,_ _ ._ TOWN OF Barnstable WARD OF HEALTH SWISUNPACF SF.KA(;F, I)ISfOSAL SYSTEM IN911FCTION FORM - PART D - CF1Cr1F1CAT10,,; —TYPE OR PRINT CLEARLY— PROPERTY INSPECTED STREET ADDRESS 243 Mid Pine Drive Cummaquid,Mass . ASSESSORS MAP , BLOCK AND PARCEL # OWNER' S NAME William MOrges ®s PART D - CERTIFICATION NAME OF INSPECTOR Joseph P. Macomber Jr . COMPANY NAME Joseph P. Macomber & •ffon , Inc . COMPANY ADDRESS Box 66 Centerville , Ma . 02632-0066 5 t r 9 e t Town or Clty St,t• t;? COMPANY TELEPHONE (508 1 775 -3338 FAX ( 508 ) 790 -1 578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system n � this nddress and that the information reported is true , accurate , and complete as of the time of .inspection . The inspection was performed and an;: recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance o �site sewage disposal systems . Check one : XXXXXXXXXXX)Syste6 PASSED The inspection Iyhich I have conducted has not found any information which indicates that the system fails to adequately protect public hea1Lh or Lhe environment as defined in 310 CMR 15 . 303 , Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section: of this form . System FAILEU The inspection which I hAve con ilcted has found that the system fails to Protect the public health and the environment in accordance with Titie 5 , 3l0 CMR 15 . 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . .Inspector Signature Date 9/23/97 Cne copy of this c t.ification must be provided to the OWNER , the BUYER ( -here applicable ) and the DOARD OF I(EAL111 . • If the inspection FAILED , the owner or operator shall upgrade the eyate^ ir.hin one year oC the date of the inspection , unless allowed or requires: h otherwise as provided in 310 CMR 16 . 305 . Partd . dos Sic w y� b r THE COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF ENVIRONAENTAL PROTECTION BE IT KNOWN THAT Joseph P. Macomber, Jr. Has satisfied the Department's qualifications as required and is hereby authorized to use the title CERTIFIED TITLE S SYSTEM INSPECTOR as provided in 310 CMR 15 .340 and Section 13 of Chapter 21A of the General Laws . Issued by The Department of Environmental Protection. Junc 8. IW5 Acting Dircctor of the t ion of Witcr Pollution Control i s TOWN OF BARNSTABLE LOrATIOPt 3 y4,�� Z9 AI,. XeZ cv/AA,+4SPRWAGE #_ F7- /�3�— VILLAGE. ASSESSOR'S MAP & LOT 4 . INSTALLER'S NAME & PHONE NO. leg SEPTIC Sa,✓ ?7.5' 3 3 �� SEPTIC TANK CAPACITY r LEACHING FACILITY:(type) (size) /, o aD Y NO. OF BEDROOMS 3 PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER �f DATE PERMIT ISSUED: DATE COLIPLIANCE ISSUED: 3-5/ VARIANCE GRANTED: Yes `� No �'- — a 1 \��� � ��, I �o� � ��. � N, w_' � �5 � . , �3 � �� �, �, 9 � Y r Fims.. .._. .Q.:.QO THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH Town................OF...............B a r n s t.a b l e.......................................... ApplirFation for Dhipoii al Works Tomitrnrtinn Pumit Application is hereby made for a Permit to Construct ( ) or Repair JXgk an Individual Sewage Disposal System at: ^243 Mid Pine Road Cummaquid ... ---.. ..•-- ....••-- ----.....•----••-••---•---••-•.................•-•---•---•--•-----..........---•-•-------••-----•- Location-Address or Lot No. ................. Merges.------------................ --•----•----------........---•--......----•----------•--........------•---.........-------•------- Owner Address a ..................J.,.F..Xacj.mhes...Jr........................................ •--•--•-•-------------....----•-•. Installer Address Type of Building Size Lot............................Sq. feet U Dwelling--X No. of Bedrooms............3..............................Expansion Attic ( ) Garbage Grinder ( ) `4 Other—T e of Building No. of persons............................ Showers — Cafeteria P4Other fixtures .._......_•---- -•-•-•--......••-•-••-•••••`••-••-•...•--•-•-•-•••••......---•--•-•---. ............................................................. W Design Flow............................................gallons per person per day. Total daily flow.;..........................................gallons..... WSeptic Tank—Liquid capacity............gallons Length...:............ Width................ Diameter---------------- Depth................ x Disposal Trench—No..................... Width'................... Total Length.................... Total leaching area___••_•_.•-__•------sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date......................................... aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water_---__--________-.-_---. (i, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground`water..-__________-_-----_..- a •---•-•-••-••--•••--•--••---•--••-•-•-••-•----•-----•..................................•--•-••---•--.......-••---..... --------------- .----------------- 0 Description of Soil........................................................................................................................................................................ v nd •-•••-•••-••-•••-•-----••-••••----••--•.....---••-••••-•-•••---••••-•-••-••--•••..Sa ------------------------------•----•----------------------------------------------------••--••--......•--•- W ------------------------------------------------------------------------------------------------------------------------------------------------------------------=----------------------------••---•--- V Nature of Repairs or Alterations—Answer when applicable............................................................................................... ...........................-.................................................................1_-1000.--ga-llon-..leaching••.pit......------------....••--•.--•- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TTT`.E:• of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be n issued.by/]thee oard of t ealth. Signed. ! y. •-••--••-•--• ..-- ..................... 3Z 3 8 ate Application Approved By........ ... ........... . ... ..... -----•-•-•- . ......... --••--•••- te Application Disapproved for the following reasons-------------•--------------••-----•--------------------•--------------------•--•------------------••-••--•--••-- --------------•----•........•----•--- --------------••--•-••••----- •-•--•----••-•••-•----•-•--.................................. Date PermitNo.-.-� -•-•-•-----•........•-•----------------- Issued....................................................... D_te 5 No..l ..�, L_. / Fps.. 1 _2 11 THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ` ApplirFa#iou for Mipoli ai 10orkii Tomitratrtiou Punfit Application is hereby made for a Permit to Construct ( ) or KepairX an Individual Sewage Disposal System at: ....... ,'43, tt ;t. Pine Rand Cummmac �a..._ ...................................................... ----•-•------•-------•-•••----•---••••......_..--•--------•---•-•------.....--•--•----------•••--- Location-Address or Lot No. ................. :.....W 1.11 2.C1ZL..M47 ESP ----•-•-------------------•--- .................................................................................................. Owner Address ........................................••----------.......-•----•--.....------••---............ Installer Address UType of Building Size Lot............................Sq. feet �., Dwelling-X No. of Bedrooms.............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures --------------------------------------------------------•--••------------•----•-•---------•------•--•••------•-•-..........---•-•-••----•••-•--- W Design Flow............................................gallons per person per day. Total daily flow-------:....................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter---__-__-____- Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.. Seepage Pit No---------_--------- Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) . ►-' Percolation Test Results Performed by.......................................................................... Date........................................ a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water_-:_--.---___-__---_--_. 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water_--___-..-_-•--_--__..__ ��.• ODescription of Soil....................................................................................................................................................................r x Sand� —7 VW -------------------------------------------------------------------------------------------------------------------------------------------------------------------•---; ' ; Nature of Repairs or Alterations—Answer when applicable n f" - , 1. Agreement:The undersigned agrees to install the,.�afo.ed ed Individual '$ewage Dis'pd-sal System in accordance with the provisions of'T`:12 5 of the Stag ba` y nitar .Code_14FA'undersig e riot fur' r reel oi to place the system in operation until a Certificate of Compliance has been issued by the board of ealth. r--1 Signedr/r Application Approved-Bye._.....�.. ( - �} � Date Application Disapproved f or the following reasons:--•---••-------•----•--•---•---•----••-•----••--•...--•-•-----•...-•------•---•--•------•---•--------•--.-•--.Date _.._ _.rJ_`�Permit No..... � ------------------------------- Issued_..........................................--------•---- �•� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Toi,,r n Barnstable ........................................OF..........I.............I............................................................ V �ra�ifiratr of ToutpliFaatrr THIS IS TO CERT1,FY,--That the Individual Sewage Disposal System constructed ( ) or Repairedil ') Y........... .... --------------------•----------------•------.--------------------••-------------------•-- �?-s3 1�T�CI. PkT1 I ,ld �'.1,'ir�Ma,, 2Ea Installer at -`n---------- --•-------•--------•-----•--------•--------•----•--•--------•-•---- has been installed in accordance with ttie provislos of T Of T Ss+�Sallnitary Code as described in the application for Disposal Works Construction Pel;mfh►: / „ ti, dd�ted_.. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT'SE C NSTRUE® AS)k 66ARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. '" •�.►""`'�`� DATE--------------------------.'�.'..<<.7._......._...... Inspector =.. 1............................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH I'O'tJ�3 OF : .,. ..s NO.. ... ........ FEE!....-•-—--•- 0...• Disposal Worko TwOnotratrtiou Vanfit Permission is hereby granted 3 P maco bear jr. ..................... ------•--------------------- to Const T cS ( ) or Repair F ) an Individual Sewage Disposal System at No. 2a Pi.t1 iZn �? f.�.>�+s11, tYlzi�' ---•-----------•------ ---------------------------------------......._.......- Street / as shown on the applicati for isposal Works Construction Per o. _ __...... ate�. ...........1...... .. .. ...............= Board of Health DATE--.......................°••--- -• --•-.............................. �. FORM 1255 HOBBS "& WARREN. INC.. PUBLISHERS No.---- ........ F$$...,, . ................... THE COMMONWEALTH OF MASSACHUSETTS OH BOARD OF HEALTH Application for Diapagal 10orko Toro rurthin Vamit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Systemat............ / :../.� ......... ... ..... L. .......:... .............................................................IT - T.s� z v'Location-.dd(! s or Lo o, — ......... y�.C24 .11 . r............................. .........s _T vner dd. � —...................... ��i, C� lf ' ..... ............................. . ........ cd..:.... . Installer Address U Type of Building Size Lot.... feet ., Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( } �a Other—Type T e of Building No. of persons..................:......... Showers — YP g ----•-----------•---••------ P (---->-------Cafeteria ( ) Otherfixtures ............------------------------------------------..--------------•-----•-----.....-----•-----------•--••- ------ W Design Flow.......,_0...........................gallons per person per day. Total daily flow......._...-3�a.------._.............gallons. WSeptic Tank—Liquid capacity..�©odgallons 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 ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water----___.-_-___-_-__-_-.. w Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water__-___-_-_-__--------_-- P?4 .-----•------•-----•----••-----••--••-•..................•---•-•••••••-------••-•-•---•.......-•----......................................................... 0 Description of Soil.......................................................................................................----------_---- ............................................... Z ---------------------------------------------------------------------- S01L.c �!_.. .�_:... 3 f --- 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 has beea* ed by t b of h lthSignedf....�� . -7% / Ye ApplicationApproved BY.......................................................................... .......------ Date Application Disapproved for the following reasons-------------------------------------•-------------------....--------------•--.....---•----•-••---•-••........... .. . ...........•-•-----••-•--•-----•-- -----•--•-•-----•••-•-•-------•-----•---•---•--••---........ Date PermitNo..........7.3..................................... Issued....................................................... Date THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGIIVAL (S) I A , m / �C(�J IL DATA No.....:,_..f:_ ._____._ 1t Flan..... : ................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH me Appli-rativu for i p a-4al Workii Cn.niarn,ruan Vantit Application is hereby made for a Permit to Construct ( ) or Repair,( } an Individual Sewage Disposal,,, System at: ........... :..:..............�.4..:` r�e4"yf£...E ...... _.. r *.... ........ ............. ....... Location Address or Lot No a fn� ..... ?�.' if- .,s.; rr f., aFh" T . {"'.^"_. bra'f'/ ✓,�. ........... nei > .................. ........ t , rt ddresf `�.... .:.. ss " ...... E # . . .� . ' c• . �°� •y�-r v d... ..f... q Installer X Address Q Type of Building Size Lot-----y:: :,. a....Sq. feet U Dwelling—No, of Bedrooms________ ....................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type T e of Building p.. YP g ---------------------=------ No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures .............. :._ gallons. W Design Flow_-__..-.a?__�*_ ............................gallons per person per day. Total daily flow............ __....g WSeptic Tank—Liquid capacity.._: _ ' `gallons Length________________ Width................ Diameter................ Depth................ Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No---_---------------- Diameter_................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed bv---------- ----------•------•--------------------- ------• Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ fi Test Pit No. 2................minutes per inch Depth.of Test Pit.................... Depth to ground water........................ a' ------------•---------------------•------•-•-------•-----•-•-•--._.......---••---•------•-•----•---•......................................................... 0 Description of Soil---------------------------------------------------------------------------------------------------------•-----...------------------------------------------------•-•-- ....... •----•-•-•--••--•-•••. r • F / UNature 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 has been yed by tP17 b��d of health. / � x .r �� Signed - ,f-�c ''x'mr7 Yt xr r^a * rd�tl,/xr, :._ _ .. Date Application Approved BY..................................................... .... : -- ./-- Date Application Disapproved for the following reasons:---------------------------------------------------------------------------------------.......................... l _________________________________________________________________________________________________________._-_._._..______.__.__.___..__..__.............._..__.__._._.__._..._.......................... Date Permit No. -:...,.. .-•---•---.......-•-••••-••-.......... Issued- ...... t -- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH f,...f .............OF....... 4, ............................... J Trrfifiratr of To p1iam THIS TO °, CERT FY, 'the Individual Sewage Disposal System constructed ( or Repaired ( ) by .�........ ` - •c a1;',.r............................. ------------------------••-----...-----------------•-----------•--................------.....-- � a:nstalier --- ---:--- has been installed in accordance with the provisions of'Article XI of The State Sanitary Code as clescribed in the application for Disposal Works Construction Permit No.....!:11`__ei--_--_---•--_.-.-__--_:_.. dated...... ............ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT RE CONSTRUE® AS A GUARANTEE WHAT THE SYSTEM WI �L F CTIO SATISFACTORY. DATE.........- _ ................................ Inspector_._.._ C .. THE COMMONWEALTH OF MASSACHUSETTS c' BOARD OF HEALTH s c' ................................... ..:!f 1 `r NO . 3...:.`. FEE.......:............... i .rk lei? r wit rrunt Permission is hereby gran'ted....... f= d1 ��0 = Y .. ... ...... ............ to Construct ( ) or Repair ( ) an Individual Sewage Disposal System ? atNo ....: ........ •- `......-•-....... . Z...... ............................... ..................... :........................... 4 Street F as.shotivn on the application for Disposal Worlcs COn.iiiuctian r rinif "o. ..... Dated....... ;11... . ...' r ................. t3uard of Real th DATE...... !:, • --- • ------------------------------------- FORM 1255 HOBS&a-..WARREN, 1NC., PUFLISHERS - - - -