HomeMy WebLinkAbout0026 SPYGLASS HILL ROAD - Health 26 SPYGLASS HILL ROAD,BARNSTABL
A 355002.003
i
r
4 �
V
�.' _ o c d: w u,� .-. �- - � ,:. �;::. ..-. � _� _,tea. . .p •. ' - � .. q.., ..
r
�s
Commonwealth of Massachusetts
Title 5 official Inspection Form z
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
lug
26 Spy Glass Hill Road, Cummaquid - M -355 P-002-003
Property Address
Alfred &Joyce Sancho
Owner Owner's Name
information is P.O. Box 411, Cummaquid MA 02637y March 26 2013
required for every � •
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. General Information
on the computer, "
use only the tab 1. Inspector:
key to move your
cursor-do not TroyWilliams
use the return
key. Name of Inspector
Troy Williams Septic Inspections
Company Name {
19 Hummel Drive
Company Address
South Dennis MA "' 02660
Cityrrown State "Zip Code
(508) 385- 1300 " S1682
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 16.000).The system: '
® Passes, 0 Conditionally Passes ❑ Fails.
❑ Needs Further Evaluation by the Local,Approving Authority"
Uj March 26, 2013.
In ''ector's Signature r Date ,
-Jactw6 i.
13 system inspector shall submit a copy of this inspection reporfto the Approving Authority (Board
of ; ealth or DEP)within 30 days of completing this inspection. If the system is a shared system or
. ca has a-5design flow of 10,000 gpd or greater, the inspector and the system owner'shall submit the
t re 'ck'to the appropriate regional office of the DEP. The original should be sent to the system owner
A Wpies sent to the buyer, if applicable, and the approving authority.
Thi sport 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.
t5ins-11/10 r Tide 5 Official Inspection F`r :J.bsurface Sewage Dispos I System-Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
26 Spy Glass Hill Road,Cummaguid M-355 P-002-003
Property Address
Alfred&Joyce Sancho
Owner Owner's Name 4
information is required for every Box umma4 p O. B 411, C uid MA 02637_; March 26, 2013
page. Cityfrown - State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:. ', a
® 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:
s -
System meets minimum standards set by Massachusetts DEP at the time of inspection only.This
inspection is not a guarantee or warranty on the future working conditions of leaching, pipes,
components or the future structural integrity of said components and only represents conditions found
at the time of inspection only.
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health,:will pass.
Check the box for"yes","no"or"not determined".(Y, N,,ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old' or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available:
❑ Y V = ❑ N ❑ ND(Explain below): .
N/A
e Ax
_ l
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 2 of 17
Commonwealth of Massachusetts
W Title 5 official Inspection Form
C
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 26 Spy Glass Hill Road, Cummaquid M'-355. P-002-003
Property Address
Alfred &Joyce Sancho
Owner Owner s Name
information is required for every P.O. Box 411, Cummaquid MA 02637 March 26, 2013
page. Cityrfown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ 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):
N/A
O,
❑ 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):
N/A
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form'.
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
26 Spy Glass Hill Road, Cummaquid M-355 P-002-003
Property Address
Alfred &Joyce Sancho
Owner Owner's Name
information is p O. Box 411 Cummaquid MA 02637 March 26'2013
required for every � ,
page. Cityrrown State Zip Code' Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well"*.
Method used to determine distance:
This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
N/A
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
El ® 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 Y2 day flow
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
26 Spy Glass Hill Road, Cummaquid M-355 P-002-003
Property Address
Alfred &Joyce Sancho
Owner Owner's Name
information is required for every p O. Box 411 Cummaquid MA 02637 March 26, 2013
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes - No
El ® 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 as I urface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- -
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure '
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D. .
Yes No
❑ ❑, the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
El ❑ the system is located in a nitrogen sensitive area (interim Wellhead Protection
Area-IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department. .
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
I
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 26 Spy Glass Hill Road, Cummaquid M -355 P-002-003
Property Address
Alfred &Joyce Sancho
Owner Owner's Name
information is required for every Box ummaq p O. B 411, C uid MA 02637 March 26, 2013
page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on: '
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 5 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 gpd
t5ins•11,10 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
26 Spy Glass Hill Road, Cummaquid �M -355 P-002-003
Property Address
Alfred &Joyce Sancho
Owner Owner's Name t
information is P.O.
required for every Box 411, Cummaquid" MA 02637 i March 26, 2013
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents:
Does residence have a garbage grinder? w® Yes ❑ No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ° ® Yes ❑ No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d 12=153,000 gals.''
g ( Y 9 (gp.)) 11=152,000 gals.
Detail:
Sump pump? K c 1 ❑. Yes ® No
Last date of occupancy: occupied
Date
Commercial/Industrial Flow Conditions: f a.
Type of Establishment: N/A
• N/A •.
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.): N/A'
Grease trap present? _ ❑ Yes ❑ No
Industrial waste holding tank present? ' ❑ Yes ❑ No
�I Non-sanitarywaste discharged to the Title 5 system?9 Y _ ❑ ..Yes ❑ No�'w
Water meter readings, if available: N/A ,
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form ,
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 26 Spy Glass Hill Road, Cummaquid M=355 P-002-003
Property Address
Alfred &Joyce Sancho
Owner Owner's Name
information is required for every P.O. Box 411, Cummaquid MA 02637 March 26 2013
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: N/A
y Date
Other(describe below):
General Information
Pumping Records: '
Source of information: Last pumped July 2012 per info from owner.
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
ElOther(describe):
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
26 Spy Glass Hill Road, Cummaguid M-355 P-002-003
Property Address
Alfred &Joyce Sancho
Owner Owner's Name
information is required for every P.O. Box 411, Cummaq uid MA 02637 March 26, 2013
_
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date,installed,(if known) and source of information:
Tank, d-box and leaching were installed on 12/14/94 per compliance. "
Were sewage odors detected when arriving at the site? - ❑ Yes ® No
Building Sewer(locate on site plan):
18"+
Depth below grade: feet
Material of construction: `
❑ cast iron ®40 PVC _ ❑ other(explain):
Distance from private water supply well or suction line. N/A
feet•
Comments(on condition of joints, venting, evidence of leakage, etc.):
Flushed lines and found clear at the time of inspection.
Septic Tank(locate on site plan):
30"with riser to grade o-
Depth below grade: feet
Material of construction:
® concrete El 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
6'X10.5'X6' 1500 gallon
Dimensions:
Sludge depth:
4"
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
}
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 26 S Glass Hill Road Cumma uid M-355 P-002-003
s• ,PY q
Property Address
Alfred &Joyce Sancho
Owner Owner's Name
information is
P.O. Box 411 Cumma uid MA 02637 March 26, 2 1
required for eve � 4 0 3
4 every
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
2,8„
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness none
Distance from top of scum to top of outlet tee or baffle
b 6"
Distance from bottom of scum to bottom of outlet tee or baffle
14"
How were dimensions determined? probe/measured
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pvc inlet and outlet tees were found present and in working order. No evidence.of leakage or damage
was found. Tank was not in need of pumping at this time.
Grease Trap(locate on site plan):
Depth below grade: N/A
feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
N/A
Dimensions: N/A
Scum thickness N/A
Distance from top of scum to top of outlet tee or baffle N/A
Distance from bottom of scum to bottom of outlet tee or baffle N/A
Date of last pumping: N/ADate
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
M
Commonwealth of Massachusetts -
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
'< 26 Spy Glass Hill Road, Cummaquid M-355 'P-002-003-
Property Address _
Alfred &Joyce Sancho
Owner Owner's Name information is P.O. Box 411 Cummaquid " MA 02637 March 26 2013
required for every
page.. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of.leakage, etc.):
N/A
°
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
N/A
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
N/A
Dimensions: N/A
r .
aci N/A
Capacity:ty: gallons F .
Design Flow: N/Agallons per day '
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑, No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
N/A
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins°11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form'
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 26 Spy Glass Hill Road, Cummaquid M -355 P-002-003
Property Address
Alfred &Joyce Sancho
Owner Owner's Name
information is required for every P.O. Box 41 ummaq,1, C uid MA 02637 March 26, 2013
page. CityTrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert level
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D-box was found level and in working order with equal distribution to outlet lines. No evidence of solid
carry-over or backup in the past were found at the time of inspection. D-box down 4.0'.
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
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 official -inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
a 26 Spy Glass Hill Road, Cummaquid M -355 P-002-003
Property Address
Alfred &Joyce Sancho +
Owner Owner's Name
information is
required for every P.O. Box 411,.Cummaquid MA 02637 March 26, 2013
page. Cityfrown State 'Zip Code Date of Inspection
D. System Information (cont.) } ,
r - .b
Type: -
❑ leaching pits number:
❑ leaching chambers number:
® leaching galleries' number: 6 galleys with
stone
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number: ,
innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of
vegetation, etc.):
Galleys were found with a low water level present. Checked stone and found dry and clean. No
evidence of hydraulic failure or problems in the past were found at the time of inspection.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration . N/A _
Depth-top of liquid to inlet invert N/A
- N/A
Depth of solids layer'" ,
Depth of scum layer .
Dimensions of cesspool
N/A . -
Materials of construction N/A µ
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 174 ^
Commonwealth of Massachusetts
Title 5 official Inspection Form'
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
26 Spy Glass Hill Road, Cummaguid M-355 P-002-003
Property Address
Alfred &Joyce Sancho
Owner Owner's Name
information is q
required for every P.O. Box 411, Cumma uid MA 02637 March 26, 2013
page. Cityrrown State Zip Code. Date of Inspection
D. System Information (cont.)
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
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Foam
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
w 26 Spy Glass Hill Road, Cummaquid M -355 P-002-003
Property Address
Alfred &Joyce Sancho
Owner Owner's Name
information is P:O. Box 411 C
required for every ummaquid MA 02637 March 26, 2013
page. City/Town State Zip Code "Date of Inspection
D. System Information (cont.) v
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
6 C_
- (D O
S
L = `l�
•
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 26 Spy Glass Hill Road, Cummaquid M - 355 P-002-003
Property Address
Alfred &Joyce Sancho
Owner Owner's Name
information is P.O. Box 411 Cummaquid MA 02637 March 26 2013
required for every >
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
❑ Surface water .
❑ Check cellar g
❑ Shallow wells
Estimated depth to high ground water: 20"0'+
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
® Accessed USGS'database-explain:
AIW 247 Zone C 23.6' 3.9'adjustment
You must describe how you established the high ground water elevation:
USGS map for Barnstable shows groundwater estimated at over 20'. Hand augered 4' below bottom`
of leaching with no water found at a depth of 14.0'. Groundwater adjustment at the time of inspection
was 3.9'. Bottom of leaching at 10.0'was found not to be located in the high groundwater elevation at
the time of inspection.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 '
I
J
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .
26 Spy Glass Hill Road, Cummaquid M- 355 `P-002-003
Property Address
Alfred &Joyce Sancho
Owner Owner's Name
information is every
P O. Box 411
required for eve , Cummaquid MA 02637 March 26, 2013
page. Citylrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed
® System information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
k
t5ins•11I10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
,t
CG`,I�10'��'�E:1ITH OF 1IASSA''HL'SETT5 I
EIXEICUTIYE OFFICE OF E`VIRON'NIENTAI, -VE- IRS
I __ DEPARTMENT OF EN-VTROofMENTAL PROTECTION i
ONE XIN'FER S'?'RFET. BOSTON NIA 02108 1617t292.5500
W'ILLIAM F. WELD � ,R1,DY COX-7
Governor Secretary
ARGEO PAUL CELLUCCI DAVID B. STRUF:S
Lt, Governor Comrtusaeoner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
r
PART A �
CERTIFICATION
i�G,(� S r0o�
Property Address: v G 0.55 (A t�� Address of Owner: eik F<>� tIli differeritiDate of Inspection:Name of Inspector:I am a DEP appr ved system inspec t x pursuant to Section 15.310 of TiUc 5 l31(1 C,�1R 15.000U Compam Name: .r si_ �:�,eaLri `U\S C[�iCS�S Mailing Address: 9Telephone Numher: ✓sT 9 8
CERTIFICATION STATEMENTr `
I certify that I have personally inspected the se.+,;e dlspos,:: system at this aooress and that the information retorted be.loxvps,true, accurate".-,and complete as of the time of Inspection. Tr:e mspecnon•�.-a, performed based on my training and experience in the p oper It nctaor"q anal®o
maintenance of on-site sewage disposal systems. The sv�wrn
r/Passes `
_ N(IPO< rhf- Lr,i.;i Annrovule Autnunt`: "
— Fails
Inspector's Signature: `�_ Date:
The System Inspector shall submit a copy of this Inspec7lon report to the Approving Authority within thirty (30) days of.r mpleting 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, Q, C, or D:
�27
ES:
ot found any information ,vr:Ch indicates that the syst^m violates any of the failure Criteria as'defined in 310 -MR 15.303.
Any failure criteria not evaluated are indicated bc�i'Iow.
COMMENTS: _ _--. -- --
fc';
BI SYSTEM CONDITIONALLY PASSES:
One or more system components os descrihed In the "Conditional Pass,, se ncri' red to be replaced or repaired. The system, upon
completion of the replacement or repair, as approved by t.�e Boa dip--Health, will pass.
Indicate yes, no, or not determined (Y, N, or ND!. Describe bas,�s'bt determination In all instances. If "not determined", explain why not.
y The septic tank is metal, unie.ss the owc:e�'or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) Inolc;woe„th5t tide tank was installed within twenty (20) years prior to the date of the Insoection; or
the septic tank, whether or rk<metal, Is cracked, structurallti unsound, shows substantial infiltration or exfiltration, or tank
f;ulure is imminent. T 'vstem will pass Inspection if the existing septic tank Is replaced with a coniorming septic tanx
as approved by theB<rtrrr tit Hv,tlth
d r r
9(revined 04/25/97) Page 1 o`_ 10
I I
w Printed In Recvded Paler
_ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A j
. . CERTIFICATION tcontinuedt
'1
Property Address: d(v S
Owner: �e f l t tti tJ
Date of Inspection:
B) SYSTEM CONDITIONALLY PASSES tcontinuedt
x is
ue to broken or
_ sery
Sewage backup or breakout or high }t�r'wen�distrjer �but on boti' The systb in the in the len,l �Ullo�sscinspuct on ii mith approvtat�oe he
prpe(s) or due to a broken, settled or u
Board of Health). Describe observations:
broken Dipets) are replaced
obstruction is rernoveci ,% I
distribution box is lew'�'d or replaced
The system required pumping re than four times a year due to broken or obstructed pipets). The system will pass
with approval
the Board of Health): -
inspection if 1 I p
broke pipe(s) are replaced
o' ruction is removed
C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation lry the Board of Health r rder to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINE HATFTHE SYSTEM NOT FUNCTIONING IN A MANNER
W P1:Ft U' tit Al TN :.�(� �AFFT`r ���. :• r-- ,
_ Cesspool or privy is within 50 feet of a sunac ater M
_ Cesspool or privy is within 70 feet of a bor ring vegetated wetland or a sail marsh.
WILL FAIL UNLESS THE BOARD OF �6LFH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
2) SYSTEM PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
THE SYSTEM IS FUNCTIONING IN A MAN
THAT
ENVIRONMENT:
The system has a septic to and soli absorption system (SIBS) and the SAS is within 10 feet to a surface water supply or
tributary to a surface wa r suppiY p y I well.
_ The system has a sept tank and soil absorption s stem and the SAS is within a Zone I of a public water supplyter supply
The So
nd
system has a s' tic tank and soil absorptink and Soil on system and the SAS is le(�m and the SAS is sstthan 10 in 50 tfeet of abut 50 fee private t or more from a
_ The system has optic to
waters I well, unless a wall water analysis for coliiorm bacteria and volaen anda prate nipo-tennis qualeto or
P
rivate pp Y ammonia nitro
the well is fr e from pollution from that far_ility and the presence oil pprooximationgnot valid).
less than ppm. Method used to determine distance
3) OTHER
Pug" 1 of 10
i(revised 04/25/97) i
I
{
f
SUBSURFACE SL%vACE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Propertv Address:
Owner: feCr kq v o
Date of Inspection: Li
DI SYSTEM FAILS:
You must indicate either "Yes" or "!gin' as to each of the following:
I have determined that the system violates one or more of the following failure criteria as del 10 CM 15.303. The basis
for this determination is ideritiileci below. The Board of Health/beed de mine \rnat will be necessary to correct
the failure.
Yes Nit
_ Backup of sewage into iac l ty or s•vsti'm compor'ent t clogged SAS or cesspool.
Discharge ar pond ng of eiiluent to ;ne surface of thers due to an overloaded or clogged SAS or
cesspool.
o !et �nven due to in overloaded or clogged SAS or cesspool.
Static liquid level in the distribution box above
_ Liquid depth in cesspool is less than 0- beellw irnert or a\aiiable volume: is less than 1;2 day flow.
re than a times n the last rear NOT due to clocgea or obstructed pioetst.
_ Required pumping n^o
Number of time, pumped
_ S\strm, cescprol or pri\v is below the hntl•� groundwater elevatiun.
any portion of the Soil Absort on
_ -\ny ponion of a cessl:,00' or privv is within 100 feet of a surface water supply or tributary to a surface water supply.
,nv portion cf a cis ool or p: :} G
j Any portion of a :esspool or privy is \vithin 50 feet of a private water supply well.
A
vate
er
with no
Any portion f a cesspool or privy is ICSS tt'an 1 flit tc' analvbut rzedeto than
be acceptable, attach from
copy oft wel lit\�ater .inlalvs s for
acceptable titer quality analysis. li the well has .ice
and nitrate nitrogen.
coliform acteria, volatile organic compounds, ammonia nitrogen
El LARGE SYSTEM FAILS:
You must indicate either "Yes" or "No" s to e each
of thn additionfollowing:
go th criteria above:
The following criteria apply g
with a design flow of 10,0 gpd or greater (Large System) and the system is a significant threat to
The system serves a facility
ment becau one or more of the following conditions exist.
public health and safety and the environ
Yes No
_ the system is within 400 feet of surface drinking water supply
_ the system is within 200 f t of a tributary to a surface drinking water supply
_ the system is located a nitrogrn sensitive area (Interim Wellhead Protection Area - JWPA) or a mapped Zone II of a
public water suppl well)
ter
The owner or operator, of any sue . iern sh;iI! I) the system and ionlaly into ofi offull ice the Departmentmpliance tfo hfurther information.
treatment program
requirements of 314 CN1R 5 00 nd 6.00. Nlcase consult the local r( c
I
Page 3 of 10
1(revisod 04/15/97)
1 ,
SUBSURFACE Sf:WAGE DISPOSAL SYSTE'si INSPECTION FORti1 l
PART B
CHECKLIST
Property A4r('\CIr%0
ess: �b
Owner:
Date of Inspection:
i
Check if the following have been done: You f.ufS( uxifcatc ruher 'Yes" or 'No' as ui each of the following:
Yes/ No I .
AO" _ Pumping information was provided hv the owner, occupant, or Board of Health.
None of the system components have been pumped for at least two weeks and the system has been receiving normal
flow rates during that perind, Large volumes of water have not been introduced into the system recer,tiv or
as part of this inspection.
;s built plans have been obtained and examined. Note if they are not available with NIA.
The facility or d,velling was inspected for signs of sewage rack-up.
The system does not receive non-sanitary or industrjal waste flow
The site was inspected for s;gns of orehout
(/ All system components, excluding the Soil Absorption Svsti:mt have been located on the s1te, r /
/ yrCktrie r �TrpSc ys
D4,i,se�<aftr_-�"avtk`�r'�ins1
!!!/// _ T�.2 �c:�2"�aynK F'1av+1hL�.� uJCs-�,��nc.;vc'�"Ccy��9�^_. �a ,.. .C•�h tk•s'i�c.`.;, p-C
/ bJ111CS Uf tee , mal('f lAl Of LUn�lf Cliv diillen�iuil�, ue'pih U; ;ICILiiii, iepth Uf sludge, dep,h it scum.
/ The size and location of-the Soil Absorption Svstem on the site has been determined based on:
ddd _ i h facility owner (and occupants. if different from o vrier) were provided with information on the proper maintenance o'
/ Sub Surface Disposal System.
Existing information. Ex, Plan at B.O.H.
Determined in the field (if any of the failure criteria relited to Pirt C is at issue, approximation of distance is
unacceptable) tI5.302(3)(b)J
1(revioed 04/25/97) Page 4 of 10
SUBSURFACE St'tiVAGE DISPOSAL SYSTEM INSPECHON FORM
PART C
SYSTEM INFORMATION
Property Address: 'Wo 5 G("s �{�` 0
t Owner: Fer fci V-0
f Date of Inspection: � I(�[�
1p FLOWN CONDITIONS
RESIDENTIAL:
Design flow: ,.lI/bedroom for ti.A.5.
Number of bedrooms:
Number of current resrdents:�
Garbage grinder Ives or no):_,Ve,5
Laundry connected to system (yes or noi.`�
Sez ^^:al use ryes or no):-P—L-1
9 ao
i
Water meter readings, if available (last 1-0 (?) year u-•age
Sump Pump (yes or no): �
I
Last date of occupant}:A
COMMERCIAI-,INDUSTRIAL:
Type of establishment: -
:
Ues(Rn flow: gallons/day
Grease trap present: (yes or no)_
Industnai Waste Holding Tank present: ryes or no)
Non-sanitary waste discharged to the Title: S s ern: '%es or not_
\water meter readings, if available:
l,.st alz a Sr::o'c C,o
OTHER: (Describe)
Last date of occupancy
GENERAL INFORMATION
PUMPING R,CORDS and source SOf intorrna ion,
System pumped as pan of inspection: lyes or not_
If yes, volume pumped: G�Ilons
Reason for pumping:
TYPE OF 'STEM
Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
_ Privy
Shared d system (yes or no) (if yes, attach prevu)us inspection records, if any)
I/A Technology etc. Copy of up to date contract'
Other -----
AP
PROXIMATE AGE of all cofnponenis, date'(n5talleel (if known) and source of information: r
Sewage odors detected when arming at the >t fy of not
•
Pogo s of 10
6 (=wiaod 09/25/97)
' SUBSURFACE SEwAGC DISPOSAL SYSTEM INSPECTION FORM
PART C d
4 SYSTEM INFORMATION (continued)
Property Ad ress: �� 5��1Gr�s, VA
owner:
Date of Inspection: n
BUILDING SEWER:
(Locate on site plan)
Depth below grade: i
Material of construction: _ cast iron "C — u-mer (eNplain)
Distance from or,
water sups well or suction line
Diameter t
Comments: (condition o' ints, veming, evidence of leakage, etc.)
TAN___1
SEPTIC _
(locate on site plan) '
dl ,
Depth below gradc:
Material otconstruction: concrete _'llwal _E l;cre,a>s �pok'e•(hvlene ,_oiherexplain)
If tank is n etal, list age Is rite connrn,ed Iw (-enu:cate of Com:)l ante _ (YesiNrr
Dimensions: `1 it'�
11
Sludee depth: b J S�(
Scum thickness: rr
Distance from top of scum to top of outlet tee or baffle:_ I'It
Distance frorn bottom of stun, to bottom of outlethee ur baffl(!:
How dimensions were determined: -&Aka/t cy
Comments:
(recommendation for pumping, conditio of inlet and outlet tees or baffles, depth of liquid level in relation to utlet in srt�`,tructural�� r
k L t A L'm`vl e
i tegrity, evidence of leakag , etc.) �S VvA
re t v�
GREASE TRAP /
4
(Locate on site plan)
.i
Depth below grade: X,
Material of construcion: concrete fi�tal _Fiberglass _Polyr'thylenc_other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to p of outlet tee or baffle: -
Distance from bottom of scu to bottom of outlet tee or baffle:
Date of last {pumping: _
Comments: %,
(recommendation for mping, condition of inlet and outlet tees or bartles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of lleakarc, etc.) -- _
r
9 Raga 6 of 10
(revised 03/25/97)
y r
- OL 7a L eEo,� lL6/Sr..'►0 pva�no�l 1
f
-- I;r •,..L .;.;un%1ti ' ;,c'l" , ,ii; ,:. r,rL'_u;� 'r•Nlun•y-, d'und Jo ai0ul
,.,pio ,luryu),n ul Sw�e1b
� -_-----Irr,1 ui 1,1 .i.lpjO dui i,c.•n w sdwnd
(I eld al s uo a1rD01)
i J
dwnd
ta 'x09 Jo Inc :c owl .ar. e;ll to ;nyulslp j(.:v aluu)
.`ilUO JWO,
,I:•O(pC j;)%�1j (,Irl',II 1O yl(",nl:
(ul"Id 011N uD OICY)l'
�;:x02 �.ou-,s;alslc
,,, iil: .I .•�. li oll :)u!P uur'.r Iu U( 'o0l I'li�.,' :0 U0111DUC),
s'Uau,Wo-,
.. 1iuldll)n(1 jr,nnJ,ll IU aIec
i
,1•, � J�1()1() .,I,II�I:'.'.\ I.:I 1:;.;i'I' --- _.— �.I:\�11 liJ1C
i
JII"':-.�.,�.,i l','i� ,lU ill',.1� �'�i'�tf� ---' �I•I�!.:._.._._ .II�;1)IlU liO�;.�n1:'R,� IU
It.l 'Ir: is IIl) Iill'.):11
II' I :.l �I:i. ...I I11{1 it '�lll,l _.—.._ :.,I'I\'� 1 `.�I'vi(1 Il_)F I ))�� A.1;711
IN\,r
t\'2iC)I \C)I I:?ld�\I l\ Ilti tC IVY.),ICI(I 1')`. 1 )VIA !,,!! 1, '
IL
�i,bStl';-:IAU Si:\SAG[ DISPOS%L S)SICIM 1�SPICII( I ogm
P-\RT C
SYSTEM 1`FOR,NAATION (continuedi
z Property A(:::,ess:
0%8 ner: r%4 wry
Date of In,,pection: q
SOIL ABSORPTION SYS`M (S,\S):—
locate on 5i!e plan, it p(7ssibie, f"(11 "(1, hol 111'r, he. :w:m 1XIIIII(I'd i)v non.in(ru�ivc metho(.J;i
1;not c1erminE-cj to be present. CxPlam:
Type:
leaching pits, number:_
leaching chambers, number:_
leaching galleries, number
a-hing trenches, number,lcnanh: Q le-)
'eaching fields, number, dimensions:
overflow cesspool, number_
.0ernative system: _
Name o: Technoiogy:
Comments:
Inoi ond I i!ion of soil, signs of hvdjuhc failure levei ci L)ond.inp, cond I in of vegeui ion.
'Ll 0 - Cie o k � %W ("'-. -q) CC _nc W\ Akf Ct-V�A PN_
vvcl
CE'SSPOOLS:
ilocate on site plan)
Number and coniiguration
Depth-top of liuuid to in1vt invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow (cesspool must by umped as part of inspection)
Comments:
(note condition of y/,/I signs of hydraulic failure, k-vt,l 017 ponding, condition of vegetation, etc.)
PRIVY:
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids:
Cor-nments:
(note condition of soil, sit'ns of atilic f,oIijrt,. level of pondung, conji:ion of vegetation, etc.)
1(rovined 04/25/97) Pacy. 8 of 10
St.BSI RFA([ SMAGE DISPOSAL S)SILM INSPECTION FOR1111
PART C
d SYSTEM INFORMATION (continued)
Property address: b k G�55
Owner: f— fir-o 1
Date of Inspection:
SKETCH Of SEWAGE DISPOSAL SYSTEM:
include ties to at least two permancm wwrences landmarks or oenchmarKs
nc:ue aii wells �Nitnm 100' (t-m.ite nuunc water suppw CC'Mes into house)
1(zaviamd 01/75/97) Page 9 of 10
" SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR,.%1
PART C
SYSTEM INTOFd1NIATION (continued)
t Q Q
Pr®party Address: g ` Gr S' �� �� t✓
Owner:' Ir<`C't�r-0
Date of Inspection:
Depth to Groundwater Feet
Please indicate all the methods used to determine High Groundwater Elevation: r
Obtained from Design Plans on record
.r•
Observation of Site (Abutting property, observation hole, basement sump etc.) R y
Determine it from local conditions
i
Check with local Board of health
• ,r I
Check FEMA Maps
w i
Check pumping records . Y :,
Check local excavators. installers ;r"
Use USGS Data
Describe in your own words how you es;ab;ished the Hipl; Grecndxa:cr E!e:anon._;�4ust be comaleted)
A4 siaa
Naf) iF E47
co II ss
So(0 V\ k W vSet
a
a (,e.ig3ed tunsm)
tup to of to
• r"
6/7/2021 ShowAsbuilt(1700x28 o) _
TOWN O AARNSTABLE
LOCATION2'ESPY GLASS HILL ROAD L�.'.�' SEWAGE y
VILLAGE CUMMAQUID
ASSESSOR'S MAP&LOT
INSTALLER'S NAME&PHONE NO ELLIS BROTHERS CONST. CO. 362-6237
SEPTIC TANK CAPACITY_ Sm u
LEACFIING FACILITY:(rype) 6yf` .C-y (size)_ X L
NO.OF BEDROOMS PRIVATE WELL OR PUBLIC WATER Pu tiles
BUILDER O OWNER (ZA{..PNrp�py(�-N6
DATE PERMIT ISSUED:__
DATE COMPLLANCE ISSUED:
VARIANCE GRANTED: Yes No
31
SPY GLASS LIe« 24 ,
https://itsgldb.town.barnstable.ma.us:8431/Home/ShowAsbuilt?mp=355002003&sq=1 1/1
r TOWN O BARNSTABLE
<LOCATION 26 SPY GLASS HILL ROAD 'fir' SEWAGE# QL- 6 �.,F
CUMMAQU I D
VILLAGE ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO ELLIS BROTHERS CONST. CO. 362-6237
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) (size) X
NO. OF BEDROOMS2 PRIVATE WELL OR PUBLIC WATER
BUILDER O OWNER R�rLPK
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No �"
YL00T
_ o r
0
a
S5 ,)Ja
_ k
}
k
SAY moss Nfc�24 , -
No ASSESSOR;.MAP NO-
PELTHE COMMONWEALTHOO-r MASSACHUSETTS
BOARD OF HEALTH
T� N ..........OF...... NS'T�J. .................................
Appliration for Disposal Worka Toustrurtion Prrmit
Application is hereby made for a Permit to Construct ( ) or Repair (. ) an Individual Sewage Disposal
System at:
��^^ ��±ocation Address or Lot No.
......................'.. � /'N�f�% E CO
Owner Address
W
1 nstal i er Address
Q Type of Building Size Lot..z�.���.....Sq. feet
Dwelling—No. of Bedrooms.......... .............................Expansion Attic ( ) Garbage Grinder (9e)
Other—T e of Building No. of persons............................ Showers — Cafeteria
aOther fixtures .................................4----------------••------------------------•--------------------.--------------•---.---------.-------.----.---------
Q
W Design Flow.............'s�..............._....___.gallons per person per day. Total daily flow__._...................................................gallons.
tx Septic Tank—Liquid capacity!r;?..gallons Length%a.'�H_-.. Width..spa".. Diameter................ Depth..5.'�'�
Disposal Trench—:�?o. ..._..Z.___._.... Width.... . ......... Total Length...../`.�...... Total leaching area._s:V........sq. ft.
Seepage Pit No--_----------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed b .5 a --- ::.. �� ... Date.... �:.2'7 1"47
Y 'y t-------•--------
,`�a Test Pit No. 1...5;Z.-_.minutes per inch Depth of Test Pit... Depth to ground water........
00,
(i Test Pit No. 2....4.Z...minutes per inch Depth of Test Pit...e- ......... Depth to ground water........................
P'
0 Description of'S61'..B_` 3n«_i4t4161>40A `1-....f' tSvC -S��e. -76"- 7 ......�✓�S......r,..
UIg/i.; .._4 ..6 .../2QC_ s 7�."_/�s� �i�'D...`s4 o IAIIW sue' �3
UNature of Repairs or Alterations—Answer when applicable.............................................................. .................................
------------------------------------------------------•----•-•----..........................-•----•----- -•-- •----------•--•••-.....-•-••.....•••--••--•----•-•-•----•-----••--•-•-•-••--•---•-'-•--
Agreement:
The undersigned agrees to install the aforedes i ed I ividual Sewage Disposal System in accordance with
the provisions of T of the State Sanitary ode—— e under d further agre s not to place the system in
operation until a Certificate of Compliance has d by the d of health.
` Signed-------------------------- = ---- . ..................... ................................
Application Approved By.._ /�� ?a. .... _:: - �'
i
. Date
Application Disapproved for the following reasons--=--------------------------------•-•--• ......--------------••-•---------------•---•----......-------'---•-
..-------•-----------•-----------------------------------------------------------------------------------
/\ Date
Permit No.......:._.. -`._... ............ Issued....
No......................... FEE..........................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Appltration for Disposal Warks Tianotrurtion rruttt
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
-•- _ .. _. .---��-= - --•----- ........... ---------•----------------------- - �} -- • - ...................
Location-Address or Lot No.
Owner Address
W
Installer Address f
Type of Building Size Lot....Z:_:':`_:. :.°.......Sq. feet
U Dwelling No. of Bedrooms............:?_.._.._ .....Ex anion Attic
g— .............. p ( ) Garbage Grinder (5r)
Other—Type of Building No. of persons............................ Showers
� yP g -------------•------•---•-•• P ( )--- Cafeteria (---->-
Otherfixtures ..................................----•--•-••---•...••---••-••......•-----•-•-•-----•---•---•-----•...........-•-_-
Design Flow................::........................gallons per person per day. Total daily flow.___.___.___................................gallons.
W
W Disposal Trench Liquid ca acrt _____ .gallons Length.<z.:' _-_. Width.._.: ._�'f Diameter................ Depth.......... ._.
x
Septic P z. .Width......3.......... Total Length........�Y_...... 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...........? �-:f'.::.�......._..:..jCr t t �/ Date___ ! ..........'__ �' .
Test Pit No. 1..... per inch Depth of Test Pit.... �_'_.._. Depth to ground water___________.....,__,...________
Test Pit No. 2..... :...=_•.minutes per inch Depth of Test Pit.... t.`.....--. Depth to ground water....... ...........
... •••••-s•---••-••-•..............-•-•••..................................................
-•- •------•--...
p Description of Soil //. ; c . v . =?h _ 7Z .. X /'
. .... .-•-------- ......---- - ...-•------
JZ ` /� 4, /-e V. '/=U l r := ` ....: • ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
W
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
------------------------------------------------------------------------..................... ......•- ----------------------•---•------------•-------------------------------••••••••-•.....
Agreement:
The undersigned agrees to install the aforedesc ' ed In vidual Sewage Disposal System in accordance with
the provisions of TITL% 5 of the State Sanitary e— T undersi further agrees not to place the system in
operation until a Certificate of Compliance has b by the b d of health.
Signed......................... -✓is�...._. ......
. .......... ............Da..e..............
Dat
ApplicationApproved By•---•••-••••-•-••-•-•-----•-•••......•-••-•-•--••-••......••--•-----•--•-•...............•.-•_... .•-•-•-••-•---•------•-•----.........---
Date
Application Disapproved for the following reasons:----------•-----------------•-----------------------------------------------•--•----------------..............
......................................................-.................................................................................................................................................
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........................ ................................................
(1rrtifiratr of Tootphattrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (r-,-y or Repaired ( )
by....................................................................................................................................................................................................
Installer
at......................................................................................................................................................................................................
has been installed in accordance with the provisions of TITIE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No......................................... dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
......OF.. ......................
No......................... FEE........................
Disposal Works Tottotrurttiott rrutif
Permissionis hereby granted..............................................................................................................................................
to Construct ( 4 or Repair ( ) an Individual Sewage Disposal System
at No
....................................
Street
as shown on the application for Disposal Works Construction Permit No..................... Dated..........................................
r ------------------------------------••---•---.--
Board of Health
------------•-------
DATE ::. 1 - -----•-------
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
i
75,
TCP OF =OUNGATiC j
Po
, i .�OR S�EDULE 4J — �l; 1 4.,SCH=D'JLE 4 J ter» ..� �T�� _ - _• <� >-� _ ,- 1
1; ' 'P.V. - , ,^rE td. I O TY_ P.V. ' (ONLY) 12"MIN LEACHING GALLEY (3 ) REO.
~
�y 'i r1-CH 1/4'?=R..i. PIPE MIN.
?ITCy�I/4'r'�? 1/8"- 1/2" WASHED STONEN
21
1 v -----z
n p
-RT "LJ !1� '� �j[ ot�no4 QLn3nacLi ononn noaoo 4
�, �, I l AD0g0 RL7 X3OD WPt,cO np U 0 0
L =L...4.:... IrivERT INVERT Or30 aCD cgaon onnaa 0nt700
�o v SEPTIC TANK - / DIST. onngc� gppbt, 0nn00 bnnn0
G�.38 J O -tG2.7 000Qo oanUoo cinnn❑ aoQno
/ :• INV�R� G1L, ( INVE.z S X
l 00004 0b Op ❑93W U Gp 000
/ t 3 CI000 ❑ OoaO f:IOII n r3gvnq �` /
cZ.94 I I INV_;T -- -- S
.Lt .44 3/4"- 11/2" WASHED
Zo STONE
Gus MfPP S HLC /" Ztsov ' Is ',I� /S i I` / --r'I - �c -- �Z ' -- --- e.,t<;.., •kt'
I
f L� C G
•• I, GROUND WATER TABLE
SOIL LOG SEN�'AGE DISPOSAL SYSTEM E�1 TYPICAL CROSS SECTION
Ate, i7, �f*4 V,E /o-o� .+•�, `o s ALA LEACHING GALLEY
-EST rJ`_c 2 NO SCALE
Ev. �� 3�? . DESIGN DATA '
�2 -..
12 CAI N 3/4"-l y2G �
woAL frr i.w n NU�dEE.R __- S � WASHED �
STON E
Ley- s>i 3- 30" T , L_
v ��O
w c- C]DD ¢ .
�^* 42 Etcl,Bo 36T,vM L_.J=:•ti3 ? /ZB.o .. SG.FT./�o�� � onnon
s�►uo o F„vc vn..� i .,.rcn WASHED ,n Q o Cl n
LAr2ct t Sc.,ei G� G o
cr0E L=aCN!NG AR=� ��/• �G PEk STONE 3 g%
72 ' Lm�cce R++:4r� �Ery Ay�q n cl o o n
c2,IS Q C 3 Gam?°AvE D!SPGS:,L �` . . . . .�`0°� i`' R= -- ono 0 0
S. o Y a AREA tC, _. _�)
y, -y �- f� I iyw eLr TOTAL LE-CHINS A.R WSJ/. �
W.rv+ Lv"v ?ERC0L AT!CD =.:.'E&5SVlAbv rWO 'rER. 'NCH
L"ACNfNG A:IEA PER PERCOL.^TIGN RATE ... SO.?T ;'i?D.
pe,>}?oGRCUND r4.; LE I
— --- — — — — CC .S8_3*. AP?ROVED . . . . . . . . . . . . .. ER :.?
ws�7 5C/L✓Tc /- BOARD CF n=.L i
. ..WATER ENCOUNTERED _
D"�T
WlT ESSED BY : AGENT OR INSPEC vR „�;�- ; OF r��s
!c% D(r .v _
ti
,, I v --- A �� 4°DL✓!3e< EDWARD
. . ENGItiEE.R i'' I LEY I
coG L �1-u r r,i_ r.•,
o I Tip f \ _ rK �7
k
7 j —. __ r/ 0L n T` 'N s¢r fiFC1°TES
10' i° ( l f' 1 s� rET'TICNER �•1L LR �� I
Sax
C 7z ' W �3, '
� w
-- > I N — _ - 70
y _ �EK1C<I 111:�7v�'H 1
73
71
- 72 ---- ----
741 7S ' 7.
74'
i
i:.: /` ,.. �f f`�' --' ���._.-�/`../'_ ���✓jC�. � �,� �..ate.
i
eV a t/L-`r-tom"' '� /4 i�`�'•� � ',��G G� /�S h�o rg y
I
t
i��/�f ; �C-f� -• f'C/-��, �_ _� a� '�S"L ��G�:, `�=-`' ,q•��;7 �.�►.+>'le',c:� _ _, ,,.. 4r� �