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Home My WebLink About0110 SALT ROCK ROAD - Health 110 Salt Rock Road, Barnstjable A=316-006 1 i r Commonwealth.&Massachusetts 00(p �- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form.- Not for Voluntary Assessments 110 Salt Rock Road Property Address Barbara Garran Trust ti Owner Owner's Name information is required for every Barnstable MA 02630 9/6/2019' page. City/Town State Zip Code Date of Inspection . Inspection results must be submitted on this form. Inspection forms,may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information /Z/a bw on the computer, use only the tab James Ford key to move your Name of Inspector cursor-do not Ford Septic Services, LLC use the return Company Name key. P.O. Box 49 rae Company Address Osterville MA 02655 City/Town State Zip Code � 508-862-9400 S 12482 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 9/8/2019 Inspe�'s Signature Date Thetem inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under.the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 c Commonwealth of Massachusetts ,, Title 5 Official Inspection Form I o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 0 110 Salt Rock Road of Property Address Barbara Garran Trust Owner Owner's Name:: information is required for every Barnstable MA 02630 9/6/2019 page. CitylTown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 c� Commonwealth of Massachusetts Title 5 Official Inspection Form '- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments V!% 110 Salt Rock Road Property Address Barbara Garran Trust Owner Owner's Name information is required for every Barnstable MA 02630 9/6/2019 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. "System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts �v ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c � 110 Salt Rock Road Property Address Barbara Garran Trust Owner Owner's Name information is Barnstable MA 02630 9/6/2019 required for every i page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS.is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of.the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp,doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 f Commonwealth of Massachusetts �m Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments e !% 110 Salt Rock Road V Property Address Barbara Garran Trust Owner Owner's Name information is required for every Barnstable MA 02630 9/6/2019 page. CityTTown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion:of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no.acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section CA. Yes No ❑ ® the system is within 400 feet of a surface drinking water supply ❑ ® the system is within 200 feet of a tributary to a surface drinking water supply ❑ ® the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,�V 110 Salt Rock Road Property Address Barbara Garran Trust Owner Owner's Name information is required for every Barnstable MA '02630 9/6/2019 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner 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? ® El available 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. ® 0 Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts �n Iti Title 5 Official Inspection Form JSubsurface Sewage Disposal System Form -Not for Voluntary Assessments 110 Salt Rock Road Property Address Barbara Garran Trust Owner Owner's Name information is required for every Barnstable MA 02630 9/6/2019 page. Cityfrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: unknown Sump pump? ❑ Yes ® No Last date of occupancy: currently Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u- 110 Salt Rock Road Property Address Barbara Garran Trust Owner Owner's Name information is required for every Barnstable MA 02630 9/6/2019 page. Cityrrown 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: Pumped 10 years ago Source of information: Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1000 gallons How was quantity pumped determined? Reason for pumping: maintenance t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 110 Salt Rock Road Property Address Barbara Garran Trust Owner Owner's Name information is Barnstable MA 02630 9/6/2019 required for every _ page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information. A leach field was added 8/13/97 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 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.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form < Subsurface Sewage Disposal System Form - Not for Voluntary Assessments !% 110 Salt Rock Road Property Address Barbara Garran Trust Owner Owner's Name information is required for every Barnstable MA 02630 9/6/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 16"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. H-10 Sludge depth: 10 Distance from top of sludge to bottom of outlet tee or baffle 14 Scum thickness 3 Distance from top of scum to top of outlet tee or baffle 5 Distance from bottom of scum to bottom of outlet tee or baffle 13 How were dimensions determined? measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tees were present. There was no sign of leakage. The tank is under the deck and only the outlet cover was accessable. The tank was pumped after the inspection. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 110 Salt Rock Road Y u- Property Address Barbara Garran Trust Owner Owner's Name information is required for every Barnstable MA 02630 9/6/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): N/a Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): N/a Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 I� cam, Commonwealth of Massachusetts �v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments !% 110 Salt Rock Road u— Property Address Barbara Garran Trust Owner Owner's Name information is required for every Barnstable MA 02630 9/6/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information 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.): N/a *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): N/a t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 110 Salt Rock Road Property Address Barbara Garran Trust Owner Owner's Name information is Barnstable MA 02630 9/6/2019 required for every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): N/a * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 2 - 1000 gal. ® leaching chambers number: 6- infiltrators ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev,7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 c� Commonwealth of Massachusetts Title 5 Official Inspection Form I, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments V � 110 Salt Rock Road Property Address Barbara Garran Trust Owner Owner's Name information is required for every Barnstable MA 02630 9/6/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The infiltrators were clean and dry.There was no sign of failure. A camera was used 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration n/a Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts IF Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 110 Salt Rock Road Property Address Barbara Garran Trust Owner Owner's Name information is required for every Barnstable MA 02630 9/6/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.j 13. Privy (locate on site plan): Materials of construction: N/a Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 • , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments `.............c, �,!% 110 Salt Rock Road V� Property Address Barbara Garran Trust Owner Owner's Name information is Barnstable MA 02630 9/6/2019 required for every page. CitylTown 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 . � I O O a Ilo Ay 3 3 311 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Diu 110 Salt Rock Road Property Address Barbara Garran Trust Owner Owner's Name information is required for every Barnstable MA 02630 9/6/2019 page.e. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ® Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 30 +/ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with.local Board of Health -explain: Topo and water contours map. ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: see above Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 c� Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments « !% 110 Salt Rock Road Property Address Barbara Garran Trust Owner Owner's Name information is required for every Barnstable MA 02630 9/6/2019 page. Cityfrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or.attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 TOWN OF,,BAR��NSTABLE S4 G� y elrJ LOCATION SEWAGE n .S' S4 ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. 1�U 5��+' �✓ �Cy SEPTIC TANK CAPACITY �[ J LEACHING FACILITY: (type) 6 1Gt�t7�/ ►"`�'��Z (size) NO.OF BEDROOMS `/ BUILDER O OWNER hilt 1,CS ; PERMITDATE: 6 I1 7 COMPLIANCE DATE: r�' I.3 — 17 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 Q7 Edge of Wetland and-*Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by . o 1a3 t33 t Commonwealth of Massachusetts Executive Office of Enviromnental Affairs Dept. of Environmental Protection One winter Street,Boston,Ma. 02108 .John Grad D.E.P. Title V Septic h>spector P.O. Box 2119 Teaticket, MA 02536 WILLIAM F.WELD (508)564 13 (�. t f Governor ARGEO PAUL CELLUCCI Lt.Governor a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR a r PART A CERTIFICATION 3 1997 Property Address: 110 Saft Rock Rd.Barnstable Address of Owner: r01v1V0F8AgNST Date of Inspection;7129/97 (if different) HEAL THpEpTAB(E Name of Inspector:John Graci Jeff Jones I am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000) A 1 Company Name,Address and Telephone Number: y E CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: _ Passes This inspection is based on criteria defined in Title V _ Conditlona P sses code 310 CMR 15.303.My findings are of how the system is _ Needs Fu h valuation B the Local A rovin Authorit perrorminq at the time of the inspection.My inspection does Y PP 9 Y not imply any warranty or guarantee of the longevity of the X Fails septic system and any of its components useful life. Inspector's Signature: f Date: 8/11197 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. 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: I have not found any information which indicates that the system violates any of the failure criteria defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,passes inspection. Indicate yes, no,or not determined(Y, N,or ND). Describe basis of determination in all instances. If "not determined", explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal, is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04n7/97) One Winter Street 9 Boston,Massachusetts 02108 . FAX(617)556-1049 0 Telephone(617)292-5500 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 110 Salt Rock Rd.Barnstable Owner: Jeff Jones Date of Inspection:7/29/97 Sewaae backup or.breakout.or hiah.static water level observed.in.the distrihution box is due to a broken. or obstructed pipe(s)or due to 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 leveled or replaced —The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed Cl 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 the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 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 IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface of water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presense of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method usedto determine distance (approximation not valid) 3)Other Dj SYSTEM FAILS: You must Indicate either"Yes"or"No"as to each of the following: X I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No -X— Backup of sewage in facility or"system component due to an overloaded or clogged SAS or cesspool. X_ Discharge or ponding Of effluent to the surface of the ground or surface waters due to an overloaded or clogged cesspool. X — SAS is in hydraulic failure. (revised 04/27/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 110 Sale Rock Rd.Barnstable Owner: Jeff Jones Date of Inspection:7/29/97 D] SYSTEM FAILS(continued) Yes No X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6"below invert or available volume is less than 112 day flow. x Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Numbers of times pumped X Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. —X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. _X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no - — acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: 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: _ The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No x the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply _ X 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) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04127/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: 110 Saft Rock Rd.Barnstable Owner: Jeff Jones Date of Inspection:729/97 Check if the following have been done:YOU must indicate either"Yes"or"No"as to each of the following: _C.._ — Pumping information was requested of the owner,occupant, and Board of Health. X None of the system components have been pumped for at least two weeks and the 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. X As built plans have been obtained and examined. Note if they are not available with N/A. X — The facility or dwelling was inspected for signs of sewage back-up. X — The system does not receive non-sanitary or industrial waste flow. — The site was inspected for signs of breakout. X _ All system components,excluding the Soil Absorption System,have been located on the site. X 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. X _ 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 Systens. X Existing information. Ex. Plan at B.O.H. x Determined in the field(if any failure criteria related to Part C is at issue, approximation of distance is unacceptable)]15.302(3)(b)] (revised 0427/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 110 Sale Rock Rd.Barnstable Owner: Jeff Jones Date of Inspection:7129/97 FLOW CONDITIONS RESIDENTIAL Design flow: 330 g.p.d./bedroom for S.A.S. Number of bedrooms: 3 Number of current residents:5 Garbage grinder(yes or no): No Laundry connected to system(yes or no): Yes w Seasonal use(yes or no): No Water meter readings,if available:(last two(2)year usage(gpd): n/a Sump Pump(yes or no): No Last date of occupancy: n/a COMMERCIAL/INDUSTRIAL: Type of establishment: n/a Design flow:0 gallons/day Grease trap present:(yes or no) No Industrial Waste Holding Tank present: (yes or no) No Non-sanitary waste discharged to the Title 5 system: (yes'or no) No Water meter readings,if available: No Last date of occupancy: n/a F OTHER: (Describe) n/a Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System was last pumped 1.5 years ago. System pumped as part of inspection:(yes or no)No If yes,volume pumped: 0 gallons , Reason for pumping: n/a TYPE OF SYSTEM X Septic tank/distribution box/soil absorptions system Single cesspool Overflow cesspool Privy Shared system(yes or no) ( if yes, attach previous inspection records,if any) I/A Technology etc. Copy of up to date contract? Other: APPROXIMATE AGE of all components,date installed(if known)and source information: 25 years with upgrade installed in 1991 Sewage odors detected when arriving a1 the site: (yes or no) No (revised 04/27/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 110 Satt Rock Rd.Bamstable Owner: Jeff Jones Date of Inspection:729/97 SEPTIC TANK: X (locate on site plan) Depth below grade: 5' Material of construction:X concreate_metal_FRP_Polyethylene_other(explain) If tank is metal, list age 25 . Is age confirmed by Certificate of Compliance No (Yes/No) Dimensions: L B'6•H 5'7'W 4'10' Sludge depth:V Distance from top of sludge to bottom of outlet tee or baffle: 26" Scum thickness:2" Distance from top of scum to top of outlet tee or baffle:6" Distance form bottom of scum to bottom of outlet tee or baffle: 16" How dimensions were determined: measured 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.) Septic tank and all components are structurally sound.Recommend pumping septic system every two years for maintenance. GREASE TRAP:_ (locate on site plan) Depth below grade: n/a Material of construction: _concrete_metal_FRP_Polyethylene—other(explain) Dimensions: n1a Scum thickness:nla Distance from top of scum to top of outlet tee or baffle:n/a Distance from bottom of scum to bottom of outlet tee or baffle: n!a Date of last pumping,va 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.) n/a BUILDING SEWER: (Locate on site plan) . Depth below grade: 16• Material of construction: cast iron X 40 PVC_other(explain) Distance from private water supply well or suction line Town Diameter: 4' yvainments:(conditions of joints,venting, evidence of leakage,etc:) (revised 0427197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C b SYSTEM INFORMATION(continued) Property Address: 110 Sale Rock Rd.Barnstable Owner: Jeff Jones Date of Inspection:7/29/97 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: We Material of construction:_concrete_metal_FRP_Polyethylene_other(explain) Dimensions: n/a Capacity: n/a gallons Design flow: n/a gallons/day Alarm level:_rva Alarm In working order?_Yes_No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches,etc.) n/a DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: rya Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box etc.) n/a PUMP CHAMBER: (locate on site plan) " Pumps in working order.(yes or no)No v Alarms in working order(yes or no)_Yes Comments: (note condition of pump chamber,condition of pumps and appurtenances, etc.) n/a (revised 04/27/97) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 110 Salt Rock Rd.Barnstable Owner: Jeff Jones Date of Inspection:7/29197 SOIL ABSORPTION SYSTEM(SAS):X (locate on site plan,if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: n/a Type leaching pits, number: 2-1,000 gallon leach pit leaching chambers,number:n/a leaching galleries, number: n/a leaching trenches,number, length: n/a leaching fields, number, dimensions:n/a overflow cesspool, number:n/a Alternate system:_n1a Name of Technology:_n/a Comments:(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) The leach pits are past the effective depth of leaching.The sas is in hydraulic failure. CESSPOOLS:_ (locate on site plan) Number and configuration: n1a Depth-top of liquid to inlet invert: n1a Depth of solids layer: n/a Depth of scum layer: n1a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater: n/a inflow(cesspool must be pumped as part of inspection) n/a Comments:(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) n/a PRIVY:_ - (locate on site plan) Materials of construction: n/a Dimensions: n/a ` Depth of solids: n/a Comments:(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.) n/a (revised 04/27/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 110 Salt Rock Rd.Barnstable Owner: Jerf Jones Dale of Inspection: 7/29/97 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) ISM sQ G AC (revised 04/27/97) page ! of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 110 Salt Rock Rd.Barnstable Owner: Jeff Jones Date of Inspection: 7rz9/97 Depth to Groundwater 12+ Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site IAbutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers x Use USGS Data Describe in your own words how you established the High Groundwater Elevation. (MUST be completed) USGS Maps and Charts (revised 04/27/97) page 10 of 10 TOWN OF BARNSTABLE LOCATIGPitjb S41-1 4 t29 SEWAGE # 7' 413 VILLAGE 'S�'`� 1 ASSESSOR'S MAP & LOT L4 ` M& ,/� INSTALLER'S NAME&PHONE NO. 1 mod: �� SEPTIC TANK CAPACITY 1&oJ LEACHING FACILITY: (type) k"�" (size) NO.OF BEDROOMS BUILDER O!O"ER h 1 r LJb -U 1 y-s PERMTTDATE: 9? COMPLIANCE DATE: ' Q — 9 7 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 leachii g",1facility,). Feet Furnished by W O No. •- j' Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS Zipprtcation for Digaal *p!tem Con!5truction Permit Application for a Permit to Construct( )Repair( )Upgrade( VyAbandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 110 St,1--T epL Owner's Name,Address and Tell.No. Assessor's Map/Parcel I, ��` Installer's Name,Address,and Tel.No. 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 LNy gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank CV-0 Type of S.A.S. c� C�t-Tr�Z-re f7f Description of Soil Nature of Repairs or Alterations(Answer when applicable) j 1tih i LT e7.--2i✓L 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 t to place the system in operation until a Certifi- cate of Compliance has be this Board a t-. " Signed Date Application Approved by Date.... Application Disapproved for the follYving reasons Permit No. ?7— Date Issued 3 No. — ` Fee 1 r= THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 0 pprication for 3tgpossar 6pgtem Construction j3ermit Application for a Permit to Construct( )Repair( )Upgrade( Abandon( ) ❑Complete System El Individual Components Location Address or Lot No. I '(� SaFT 6L RJP Owner's Name,Address and Tel.No. Assessor's Map/Parcel 3 _b0� Installer's Name, . ss,.and Tel.No. Designer's Name,Address and Tel.No. F9�-r�1!S�rt x S✓L I`� Type of Building: �/ Dwelling No.of Bedrooms T Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( Other Fixtures Design Flow gallons per day. Calculated daily flow �y gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank `—""Si Type of S.A.S. rLT k�of Description of Soil M _j S IA V4�) 4 Nature of Repairs or Alterations(Answe when applicable) -:z--µ-c 1 LT-,,r-t/rl S (�v �{ S 1 LIB U Iti.Si wr_r --- Date last inspected: Agreement: 1 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 to place the system in operation until a Certifi- cate of Compliance has is Board all . e� Signed A Date OQ-/J Application Approved by Date 8 " Application Disapproved for the/fo'1•lowing reasons"` r E:Z yr. ir .._ Permit No. e-4 ' ' jf Date Issued' - t ----------- i�—pr THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS ` 1 Certificate of Compliance THIS IS TO C at tAe On-sa wage Disposal System Constructed( )Repaired ( ) Upgraded( Abandoned( )by 6L -r - A— at 1`D S r4��' ou 13V42w5�� has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. Y 7• L// dated Installer Designer The issuance of this perrwt shall not be construed as a guarantee that the syst will function as de�si-gne Date e f / Inspector iefi c 12. ---"--�—/ --------------------------------- No. J / Fee �I U THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Owf 6possar *pgtem Con5tructiou Vermtt Permission is hereby granted to Construct( air 44,�,�pgrade( )Abandon( ) System located at 0 5 � LYL l�p and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date: Approved by :Vt) a NOTICE: This Form is to be used for the Repair of Failed Septic Systems Only CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PEItNll"I' (IVI'I'IIOU'I' DESIGNED PLANS) !1 1, (� hereby certify that the application for disposal works construction permit signed by me dated —J C7 `� . concerning the property located at /10 .5►91 ��- � �� meets all of the following criteria: a There are no wetlands within 300 feet of the proposed septic system a There are no private wells within 150 feet of the proposed septic system The observed groundwater table is 14 feet or greater below the bottom of the leaching facility a There is no increase in flow and/or change in use proposed a There are no variances requested or needed. - SIGNED: DATE: S 0—� 7 LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER IAttach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted). r E� _ '/ / I �\ C ' � /i /ram �� O ' ,i� u w 1 i f L'O C'A-'T ION EW A G E PERMIT NO.. / "A 77 VILLAGE INSTALLER'S NAME & ADDRESS 71 B UI'LDE R OR WRER so DATE PERMIT ISSUED DATE COMPLIANCE ISSUED -12 _.�� 0_ e � -t �fl •ti r No........�e............. Fps. .................. THE COMMONWEALTH OF MASSACHUSETTS BOARD 9 E HEALTH . App iration for Disposal Works Tonstrnriiun Prrmit Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at: ........ ............................................ ---•--......-----.---.--..........----•.. » � oca. Lot No. -Address .......... ................................... ..caner Address e-. .. --•-•----•-•------------------•-••- ---------------- m�.Cli.dr!l!L. �:.a..... -�_................ Install Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms--..____ ... ........................Expansion Attic ( ) Garbage Grinder ( ) Other—Type woo a ype of Building ____________________________ No. of persons_......��........... Showers (�— Cafeteria ( ) Otherfixtures --------------• -•--•-------•--•-----------------•-•..••••---------•-••------•-------•--- -•---•-----•----•----.........------------------. W Design Flow..........��....................gallons per person per day. Total daily flow.............._.............................gallons. W Septic Tank—Liquid capacity............gallons 'LengthDiameter-----C_'��epth_... _. �- . ---------------- Width----->---------- 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........................................ Test 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-.-_•.-____--_------___- x -------------------------------------------------------------------------------------------------•••......................................................... 0 Description of Soil........................................................................................................................................................................ U -•----------------------•--•--------•--.....----•----•------•---.....•.•....-----...---------------------•---------------------------------------•-••--•-------- -•----•-----------•---•-••----._.._.._ W U Nature of Repairs or Alter tlons—Ans when_a applicable .Lce`....._ p PP r-- -------- ------....•----•....h� .�_! :1-'.`d.�s0...... . .................. .d..0.C----- --. �.Z f1fv �/�-��=----- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by t4bopaf health. Signed.. .........•--r ----- --------••-•.............. 7- 1 -- '. Date . Application Approved By............ ,, =� �� L 1 L. !............... �'./1�........ ... --------- ---- -- Date Application Disapproved for the following,reasons:................................................................................................................ --........................................•--------------.......----.....------------•--...------------•--•-------•---...-••--•------•---••---------• ----•`----••-•-••----•---------••-----••---•-•- 9 7^ Date PermitNo......................................................... Issued---. -• ---------------•--......-------------------- Date �g of '1 a.e No...... ..AC_K... Flcs. "........_............ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH. IVI OF........ .---- ... ..................•••......... Alrpliration for �i u �a1. 3 nxk C� n rnr iun rrini# Application is hereby made for a Permit to Construct ( ') or Repair -(JP ( 'an Individual Sewage.Disposal Systgn at: :..•....... ............ "" �'..A.._ ��.i...... ..._ .................................... .....rAM .........................................'a Location-Address . or Lot No. - = ............................................ - -•-.....-:..------...........--•- rL f}�(-ner Tart /A�ddrress .._.. __._ ._L'^_....... - ;.f._�......... ........' ___" Z _. ................. Insta r ,:� Address Type of Building "Y q. Size Lot-------•------•-------------S feet: U Dwelling—No. of Bedroom' s------- .. .................:.......Expansion,Attic ( ). Garbage Grinder ( ) Q pa,, Other—Type of Building _._ ...... No. of persons.....__-__..___•____ Showers (IQ - Cafeteria ( ) a Other fixtures .--•-••............•..........•- WDesign Flow......... _:...........................gallons per person per day. Total daily flow............................................gallons WSeptic Tank—Liquid capacity_________._.gallons Length________________ Width._.__.__._.__.._ Diameter____-Cf' Depth..Ar.Ff.. 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........................................ Test Pit No. 1................minutes per inch Depth�i'of Test Pit.................... Depth to ground water_._________._.___.._.__. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ G4 . .................................................•-•----•••--...-•-•-----•-•.... ----...---....-- Descriptionof Soil ..........................r . ' .---------------•----------------------•••-••-•••........... ........................ U .............•-•-=••••••-•......-••••-•••--•••-••-•---••-----•----••-=......•-------------•--......-----------------------------------------------------------------------------------...........---••••• W •••---•--•------------------•------•....••••--•••••---•---------•--•-••-•--•----••••••••••••----•-•• •• UNature of Re airs or Altetiat�ons Arl applicable 1� ►Sj/" �:._.......... .. , t+'� ,- l"'_Ld -•-••• .............40.0_12....� `.t__". � ------------ ............ Agreement: The undersigned agrees to install the aforedescribed Ind idual Sewage Disposal System in accordance with the provisions cf T IT?.;:;. 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by lao d of health. s Signe ...................... / r 7 7 .. . • ` Date Application Approved By....... - _.. ._. ._,....:._.:...... /-- -- .... :X...... Date Application Disapproved forthe following reasons:......................... .__._....._.. ---..._....••-•-•••••••••-•--••-•--••••••••••••••-••--•••-•-••-•--•••••••-••...............•••-••..................----- --- ----....................................................-.................. Date :Permit No........................................................a Issued_..........L......... ....... .................. Date T.HE'COMMONWEALTH OF MASSACHUSETTS : BOARD OF HEALTH �' W�:`........OF..............00k . ............... ............................ ... (9pdif iratr of Tompliatta TH S IS TO CERT Fh t the Individual Sewage Disposal System constructed ( ) or Repaired F E ` C by •-•---•---------------------- has been installed in accordance with the provisions of -„the State Sanitary Code as`escri in the application for Disposal Works Construction Permit N ... y THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION,SATISFACTORY. DATE... ..1`.3........................:........................ Inspector ------------- ----------.---.---.------•---•---------.--.---- R. THE COMMONWEALTH OF MASSACHUSETTS BOARD HEALTLj e ' .... OF......... . .......... No.......... FEE ............. arkg All nr inn Vprrmit Permission i hereby grant d._ d&7; z ----- to Constr c ( o Repair In ld ever is s st9rri at No.... r ................_. street as shown on the application for Disposal Works Construction- Pep No.. . � . j Dated I- 7--- M Board of Health DATE--- -?t/ ...... 7. FORM 1255 HOBBS & WARREN. INC.,'PUBLISHERS - _