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Home My WebLink About0035 WINGFOOT DRIVE - Health rBamstable _ ; Commonwealth of Massachusetts 3� / Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 35 Wingfoot Drive t Property Address , Jeff and Connie Shaw Owner Owner's Name r information is Ma 02637 3/10/2021umma uid r� required for every C q �� page. Cityrrown State Zip Code Date of Inspection f . r Inspection results must,be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. Inspector Information ;1 filling out forms p , S'�• � St3�� on the computer, r } , use only the tab Patrick McDowell-,.,"_" key to move your Name of Inspector J cursor- not PKM CONTRACTORS INC keY y the return urn Company Name k 1110 313 HOKUM ROCK-ROAD/PO BOX 775 16 Company Address EAST DENNIS MA 02641 Cityrrown State Zip Code ` 51 508-385-5993 S1 13023 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 stem: 1. asses 2. ❑ Conditionally Passes 3. ❑ Needs Further Ev ation by the ocal Approvi g Authority 4. ❑ F s 3 In ectol's Signature Date The system inspector shall submit a co 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 Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 35 Wingfoot Drive Property Address Jeff and Connie Shaw Owner Owner's Name information is required for every Cummaquid Ma 02637 3/10/2021 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. r 1) 7em Passes 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. N 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 35 Wingfoot Drive V� Property Address Jeff and Connie Shaw Owner Owner's Name information is q required for every Cumma uid Ma 02637 3/10/2021 page. CitylTown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): El 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 obstructedpipe(s).The Y q P P 9 Y 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 35 Wingfoot Drive Property Address Jeff and Connie Shaw Owner Owner's Name information is q required for every Cumma uid Ma 02637 3/10/2021 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, 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 ❑ P/ 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 Commonwealth of Massachusetts Title 5 Official Inspection Form c , I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 35 Wingfoot Drive Property Address Jeff and Connie Shaw Owner Owner's Name information is required for every Cummaq uid Ma 02637 3/10/2021 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ M/ 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 ❑ 19 Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ [1� Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ E/ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ E� 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.] E E' The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ d 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`fires"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 11 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .� 35 Wingfoot Drive Property Address Jeff and Connie Shaw Owner Owner's Name information is required for every Cummaq uid Ma 02637 3/10/2021 page. Cityrrown 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 [✓1 ❑ 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? ❑ d 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? R ❑ 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? M ❑ 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: [f ❑ Existing information. For example, a plan at the Board of Health. ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 35 Wingfoot Drive Property Address Jeff and Connie Shaw Owner Owner's Name information is q required for every Cumma uid Ma 02637 3/10/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual). DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Description: 4 A 4 40 c�k Number of current residents: Does residence have a garbage grinder? ❑ Yes B No Does residence have a water treatment unit? ❑ Yes e No If yes, discharges to: Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes Z/ No information in this report.) Laundry system inspected? ❑ Yes El/No Seasonal use? ❑ Yes H/No Water meter readings, if available(last 2 years usage (gpd)): Detail: 9 GSC�v v ..vl f? `7 oc>v Sump pump? ❑ Yes No Last date of occupancy: Date t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 11 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t 35 Wingfoot Drive Property Address Jeff and Connie Shaw Owner Owner's Name information is q required for every Cumma uid Ma 02637 3/10/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) M 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t 35 Wingfoot Drive Property Address Jeff and Connie Shaw Owner Owner's Name information is 4 required for every Cumma uid Ma 02637 3/10/2021 page. Cityfrown 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: Were sewage odors detected when arriving at the site? ❑ Yes E240 5. Building Sewer(locate on site plan): Depth below grade: -'Z feet Material of construction: [Zcast iron Q/40 PVC ❑ other(explain): t Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): 6 i ov. (��. /K tt f V V I L 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 �o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 35 Wingfoot Drive Property Address Jeff and Connie Shaw Owner Owner's Name information is q required for every Cumma uid Ma 02637 3/10/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 1 Depth below grade: 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: Sludge depth: d Distance from top of sludge to bottom of outlet tee or baffle rr Scum thickness r Distance from top of scum to top of outlet tee or baffle y Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? � Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): G�'1 QV 2`t� t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 35 Wingfoot Drive Property Address Jeff and Connie Shaw Owner Owner's Name information is q required for every Cumma uid Ma 02637 3/10/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Iti(4 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date 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): 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 Commonwealth of Massachusetts P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .; 35 Wingfoot Drive Property Address Jeff and Connie Shaw Owner Owner's Name information is q required for every Cumma uid Ma 02637 3/10/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes. ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): 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 t �a 35 Wingfoot Drive •J Property Address Jeff and Connie Shaw Owner Owner's Name information is q required for every Cumma uid Ma 02637 3/10/2021 page. Cityfrown 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.): " 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: 5Q leaching pits number: G ' ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 35 Wingfoot Drive Property Address Jeff and Connie Shaw Owner Owner's Name information is q required for every Cumma uid Ma 02637 3/10/2021 page. CitylTown 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.): NJ V f�► '� v I 41j /•CJL QI^J aV f I-C4 c /1/ 12. Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 lok Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �o u 35 Wingfoot Drive Property Address Jeff and Connie Shaw Owner Owner's Name information is q required for every Cumma uid Ma 02637 3/10/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 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 35 Wingfoot Drive Property Address Jeff and Connie Shaw Owner Owner's Name information is 4 required for every Cumma uid Ma 02637 3/10/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ nd-sketch in the area below Ln drawing attached separately v t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form t �o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 35 Wingfoot Drive t,- Property Address Jeff and Connie Shaw Owner Owner's Name information is q required for every Cumma uid Ma 02637 3/10/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: Check Slope ❑ Surface water Check cellar ❑ Shallow wells Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: Obtained from system design plans on record If checked, date of design plan reviewed: 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) [v]� Accessed USGS database-explain: You must describe how you established the high ground water elevation: Vv �� t' ►�Cti i 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 Commonwealth of Massachusetts Title 5 Official Inspection Form IIa Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4' 35 Wingfoot Drive Property Address Jeff and Connie Shaw Owner Owner's Name information is 4 required for every Cumma uid Ma 02637 3/10/2021 page. Cityfrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: [IA. Inspector Information: Complete all fields in this section. Ud 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 Inspectlon Form:Subsurface Sewage Disposal System•Page 18 of 18 9 . ,aw yyw....mr+aww.r.vreur✓".au:.vu� � 1 N� y in✓ t 6y ko k cl • � OCt� ,ems. � '� Li �� 11 9e1 U i d co ®It poop 0 o kq r� L ACME®SHOREY PRECAST CONCRETE"PRDDUC'TS Carver-Harwich MAILING: P.O.BOX 374 a N.Falmouth, DNA 02556 voice PHONE(508)'548-9607 FAX(5o8)548.1664 TOLL PPEE:1-800-560-9949 Imoice Num : 2 9891 Invoice Date: Jul 15, -2020 Sold To: Ship To: lag` C C Cons truction r. 11 Can to r Court KA ? Plymouth, NA . 02360 Requested Time r Time Out Time In Sales Order# uteri Customer ID _ Customer PO Payment Terms � CCCONST Net 30 Days f Sales Rom,ID Shi .,2n Method Shi Date - Shea ! - ..F Due Date i CUSr PICKED UP 7/15/20 i ` 8/19/20 Item Description -� Unit Price 3 Extension i 1. DBF315H H-10 DP3 RISER 15" 57.Q0 57.00 1.On, RlBX12H H-10 18" X 12" RISER R18 54.00 54.00 € 1. }624H B-10 18" X 24" RISER i 68.00 68.001 I -, p4 CT - . 1 61 i $ -2 ® Ho- ice p I have examined the products delivered for any damage.- Our company will accept them as they are,with the signing of this slip. Notice maximum time Subtotal 179.00 30 mins-$100.00 per hour after 30 mins. 1 yr limited warranty on concrete products. SalesTax11.19 TIwice Az 1mnt 190.19 AUTHORIZED SIGNATURE: Credit Applied By the signing of this invoice,the agent for the above named company,gives TOTAL Acme Precast the authority to collect amount(s)due and-makes the above named 190'19 company responsible for any balance of invoice,including all collection costs, court and attorney fees,if necessary. Acme-Sborey is not responsible-for any damages incurred by our d equipment to property or dtvelling after truck leaves State or Town pavements. WIND RIVER ENVIRONMENTAL; I IV��CFi Wind River Environmental LLC. M rlborLizo uDr Suite 1000 52Customer Number: 1134203 Marlborough MA 01752 Questions: 978.841.5080 BILL TO Ate. ` ,�T JOB SITE Joe C.C.Construction * ?Meet d'w6,�tlrtarnidtAa Accounts Payable ,. ,C�i,, ,35 mg of Ave mow ; PO Box 1493 Cummaquid MA 02637 South Dennis,MA 02660 S Service Date: 15-Jul-2020 Invoice Number: 4673023 Order Number: 0217078877 P.O.Number: Invoice Date: 17-Jul-2020 Order Date: 06-Jul-2020 99antity Service Tvnse Amount hX 1.00 Service Call $185.00 $0.00 1.00 Fuel/Energy Recovery $13.88 $0.00 SAVE TIME AND'GO PAPERLESS WITH OUR NEW ONLINE E-BILLINGI _t[ With Wind River Bill Pay,you can be notified by email when a new invoice has posted.You can search,sort,view,download and pay your invoices through a �3 secure customer portal Use the link below and your enrollment code to get startedl 'PLEASE UPDATE YOUR FILES TO REFLECT OUR NEW REMIT TO ADDRESS' Subtotal Non Subtotal Taxed` Tax 4 Subtotal Adjustment Payments Payment Terms Amount Due Tax r $198.88 $0.00 $0.00 $198.88 $0.00 Due on Receipt $198.88 1QVIEVYAHOPAY.C1HtNIE,GQ%O _ http:/hvrenvironmental.bilitrust.com MSI~CHEk�tii4lLtM1COpE ' „ ;RTRKQWKLV .. Please detach here and return the bottom portion with your payment. From: Customer# Order Number Invoice Number Invoice Date Amount Due C.C.Construction Accounts Payable 1134203 0217078877 4673023 17-Jul-2020 $198.88 PO Box 1493 We accept the following credit cards within 30 days of the invoice data. Wind River Environmental will appear on South Dennis,MA 02660 your credit card statement for this transaction. For quueesilons please visit www.wrenvironmentai.com/policies Remit To: Wind River Environmental LLC. P.O.Box 22074 New York,NY 10087-2074 _ 22074 000004673023 '000001134203 0000019888 6 TOWN OF BARNSTABLE LOCATION W :""r °' V"n SEWAGE # VILLAGE A ,;c "" ASSESSOR'S MAP & LOT /14 INSTALLER'S NAME&PHONE NO. C . t- ^' `r' �- ►t; - "� Y SEPTIC TANK CAPACITY 1 6 o G G y LEACHING FACILITY: (type) l r � 6:r. (size) NO. OF BEDROOMS �I BUILDER OR OWNER PERMITDATE: 3 I a 3 )f)S COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility rJO E.- 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 leaching facility) -Soo +t ' Feet Furnished by e• l=f `B Lt Q 9cL c G TOWN OF BARNSTABLE LOCATION V)R v SEWAGE # q S-17 2 rl VILLAGE '1A R ASSESSOR'S MAP &,LOT `15 Q'l INSTALLER'S NAME&PHONE NO. 4 o a S�' !�,�• G' `02 8`� SEPTIC TANK CAPACITY LEACHING FACILrrY: (type) 1 b e o (PA(- f i m (size) NO.OF BEDROOMS W th BUILDER OR OWNER T C A-1-4 C® rv"'t m S O A W PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility /Vo(A �'Tr✓t- Feet J g Y Private Water Supply Well and Leaching Facility (If any wells exist j on site or within.200 feet of leaching facility) No Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) .SAA d 6 n - Feet Furnished by C L-4 A k 6 co 6 � C 't' R � Oct � o VD J r3 - r - sow —_r ASSESSORS MAPNO° PARCEL NO: �� No. (�.. ..._ FEB Mz) ......... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH TOWN OF BARNSTABLE r d XpVtirFataoaa for Di-aipwi al Work, Toaatitrnrtaon ramit Application is hereby made for a Permit to Construct (�) or Repair ( ) an Individual Sewage Disposal System at: Add or o. ..............CO..,V.:; _0..f --- y ................ .. ....................... N. Z✓..i. nstaller N „' Address U Type of Building C• o w ST g Size Lot___�.�S��Sq. feet �t Dwelling—No. of Bedrooms------------- ..__.._..______.__...___Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of.Building ----."-.-"_________________. No. of persons--"-_--"_--_---___-__..._--- Showers ( ) — Cafeteria ( ) Q' Other fixtures ..-."-"-.-."-_-----"----------- --- - W Design Flow................_,...................gallons per per day. Total daily dow_._.._........ _--. ._-........_....._.___gallons,,, G4 Septic Tank—Liquid capacity/��.galIons Length---I) ---_-_ Width..Y%7.__ ---------------- Depth. Disposal Trench— No. .................... Width__._I.............. Total Length.-.__-___._-i------ Total leaching area....................sq. ft. Seepage Pit No.-."-."-I............ Diameter------ Depth below inlet---- Total leaching area..................sq. ft. Z Other Distribution box O) - Dosing tank ) M,C" M _.gWG 8 Percolation Test Results Performed b _ _. W--- 0- •-- ----------- Date----�t.13.......... .......... a ..... _ _----_.-.. 44 Test Pit No. 2.'G..�---minutes per inch Depth of Test. Pit----}_- ..i........ Depth to ground water---A1.1A........ a /�•----------------------------- ............................. .... ••-•------•---- Description of Soil ( .I.. a �� "7-------W -r�1 } � L x x ••-•••-•-•------- ----------------------------------------------------"_-"------------------------------------------------------------------------------------------------------------------------------ U Nature of Repairs or Alterations—Answer when applicable-------------------------------------------..................................................... -----------------------------------------------------------•--------...-••-•-....--••-•......-••-•• -- . ........... ---------------------------"----......----...---------•-••-••-•......----..--•-•- Agreement: The undersigned agrees to install the aforedes ibed dividual Sewage is osal System in accord nce with the provisions of TITLE 5 of the State Environm d rther agrees rs t 6kcp t Q system in operation until a Certificate of Complia e a of ealth. o Signed ..-. - ----- --------------- -------._. ...----- i--- -------- / ---------- --- ------------- Date Application.Approved By ..... ....... / V Date ...._ Application Disapproved for the following reafonf: ------------------------------------------------------------------------------------------------------------.............. ------...._--------------------------------------------------------------------------.....------..._-----.:.------------------------------------------------------------------------------- ................................ Dare Permit No. --------1....s.. ..-) a � Issued Dare 71 rFic .-• ................ 4 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Applira#iou .fur Biispwi al Worbi Towitrnr#iun Frrutiff , Application is hereby made for a Permit to Construct (<) or Repair ( ) an Individual Sewage Disposal System at: ... #3 �N� Dl�1' 1 .:__ lJ�►'l�n ( �i_I s�� f�_------------------- .....................o. pp ddr5' " ........................ or ..............co&� ora --- .. 'S----............. Nt Z�fl-�L " Address r Clistaller ` •-^^�""'r,� J Address Type of Building I Size Lot___.5. ._1Sq. feet U., Dwelling—No. of Bedrooms________________ -------------------.--Expansion Attic ( ) Garbage Grinder ( ) a * Other—Type of Building ............................ No. of persons____-___.___-.-..-.---__-. Showers ( ) — Cafeteria ( ) Other fixtures -------------------------------------- -------------------- --- W Design Flow................ .. ------------------- per pe I day. Total daily�fow_.____._.__... ..._ ._.____.._......._-- t lons.,, WSeptic Tank—Liquid capacity[-50.0galIons Length___ __ _________ Width_.&-�' _ D .>au�Eer____...._.-_-__-- Depth-*_.-..&P. x Disposal Trench—No. .................... Width__ .r....._.._.._._ Total Length-----.____..1_..... Total leaching area..................... ft. Seepage Pit No----____!............ Diameter------i1.-_--.-- Depth below mlet___..r---•--_-_-- Total leaching area..................sq. ft. Z Other Distribution box (Y.) Dosing tank6_ �D. M'6 G(j w—t-W& `-' Percolation Test Results Performed b ,�Y�- --- ----------- Date--- Y--,;? Test Pit No. 1 14-____minutes per inch Depth of Test Pit-----t__ _ -------- Depth to ground water-. r- ----..... ... G14 Test Pit No. 2_'�..11.____mmutes per inch Depth of Test Pit-----J.. ----------- Depth to ground water...-NIA....... O .Description of Soil------.M .•-- -C(�... �'1��. �� W� �� L� x - ---------------------------- --------------------------------------------------------------------------------------------------------------------------------------.----- `----------------- ' U Nature of Repairs or Alterations—Answer when applicable---------------.------------------------------------------------:...........: ................ ---------------------------------------------------------------------------------------------------% -----...------------------------------------------------------------ ...�_ . Agreement. �t ' The undersigned agrees to install the afore.'des if bed ' dividual Sewage is osal System in accordance with the provisions of TITLE 5 of the State Environm nt-a1"C. de/,, Tho unde ned further agrees nat tolgiac Y49 system in operation until a Certificate of Compiia c a e• s • by-the-b a• of health. 1 Slgned .. ---- -- -. .... � - -- ` Dace Application.Approved BY ---- l-t/�..... ..... ---- --- --- .3— Application Disapproved for the following reason.r: .................................................................... - ----------------------- �. I?ace Permit No. .......:.,/) -s - Issued -----------------------3 - --- -� Dace --o m--— —._.---------------. ---a-------<..��. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Certificate of Compliance THIS IS TO CE TIFY,That the Individual Sewage Disposal System constructed ( >�) or Repaired ( ) by -I-1- - .1' .c.�C... r� =------------------------------ ----------------- at ---------3--5---- 1'J1 �i t�Q -.. .c--C1 � � --------------------- --------------------------------------------------- F'` has been installed in accordance with the provisions 6f TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. 2--r-X__7......... dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE........ ..... ....'. -5......./g........ ... ........ .......... Inspector .... - -----------------------------------------_r--------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 9 ' � TOWN OF BARNSTABLE No..........:�..-----. FEE---Z...D.....D......... Ropouttl Workii �unu#rra/r#U,an ernti# Permission is hereby granted......... -j__0_ --•_--- ` `' '----...................................................... to Construct or Repair ( ) an Individual Sewage Dis osal System - s atNo..-•-•-•.3.�..._...1 !_.J_ i,.l �t�i,_,��_� . --- --- -- -------------------------------------- Street n as shown on the application for Disposal Works Construction Permit No._ __S'.j�2-J .�)/ated___/_: .-�`�� .!. .n..-�...--.. �� Board of Health DATE J •....-•--...---••-•--... FORM 36508 HOBBS R WARREN,INC.,PUBLISHERS 4 bIN►NG K'17 - �. gam- py LIJ� NG r - 0M Gv M M�-Qvl D1 M A . sus - � 96 _ � � 3 � Ao�e�-p (0 � VI) N 1 bC 1-01 OF .01 l J V ' - v�tr � �� 2`1 2 J 02-19-1999 05:OOPM FROM TO 15087906304 P.01 le.�C C . CONSTRUCTION INC . 957_72� -N a'L" PO Box 238 176 Underpasss Rd . �'LMEN Qrr' UMMKMal, Brewster, MA 02631 DATE d BNo. (508)896-2879 /i9/9Q Fax : (508)896-8130 ATTENTION Eq TO r J `~ RE: ffea ha X : 7 F 0 - 63o 8 . PAGES INCLUDING COVER GENTLEMEN WE ARE SENDING YOU G Attached O Under separate cover via the following Items: O Shop drawings 0 Prints O Plana O Samples 0 Specifications O Copy of letter O Change order O copies DATE NO. DESCRIPTION THESE ARE TRANSMITTED as checked below O For approval O Approved as submitted Q Resubmit copies for approval O For your use O Approved as noted O Submit Copes for distribution O As requested 0 Returned for corrections ❑ Return owrected prints O For review and comment O O FOR BIDS DUE „19 O PRINTS RETURNED AFTER LOAN TO US REMARKS I ' COPY TO SIGNED �Q V If nn rl.l c•.nn urw-n• �..•,.r ol.,+rr nnrNv .ram n•n..�n 02-19-1999 05:00PM FROM TO 15087906304 P.02 1 IW Fr rift jwn l t ♦ 1 i 4 � 1 i i S I II �v� 00 4} t)�� TOTAL P.02 I O - �•rone I wl P1- A55r' ' S , ►�dF 349 PGL , -14 3C n hook lobo PG, 16, 8 GiN�s < �MiN1lN Gltir4 � j A'Nn {4N� ,. UG o Nv w.Ifn- H- 1,O T 1 O C, LD Vli IN 5 t S -T P N. �+ fir, y.reu� ► �y.' � �� - �� T. !9; \ y `.' %p07� GN►MwtN A5 Nrr«5SeaH q2 8 �nr ti 1 5 NIMN�tf As NE�GSSAR / To WIT4►N 12^ rim, 60 i P,"A ` � �� TO W I fH/N 12" FIN, 6leAV l or rovf4r TIoo SIN• G12. -- yFIN ��. ��L. /00100 �8,0 �4 `/N // / 1 52t Ir 4r'� ,�0 �_ �` p„ �g-1'/1vJas1-tEo STot MAX. *lb& & 4" 5G N�D ON 9� a'Z E`EN` :�� - - J - - 17 .00 / 5 t F ��1.. �K�►.e�, ';• ® (9 o INS'Bg 561 l aw c ITN Ir►v, 9G,¢D B�e,. ® 0 0 � E C';Ti•.,(_ ELF_--b, Tbl r, - _. _ raN1L• _ o�s� -%psU- I C)Q ItJv.El. a :: a m ® m Q p 0 a o 0 P #IF 00 m + !Nn_ else - orb, o O ` rr I ,► t w �ii I1 LEACHING PIT S � o , 5oT, -r,H. SI , 5 �-1 5T5 .DES 1 N s -r N d GAQ13AG1: Of 1!5'0 5A1 D�51�N t2 ow ; 4 g,R. CD 1 /D (vAZ• /n��-f = �4U GAt �► o I z 40 ' 5�p T!G TA N>K : �41� �a�, x �5p � d q a, IJ � N � 1 N �� \ N Co 1 ti L. OF U5G- l SDO 61AC. TANK �1 LF 1 M A IN ST�'� � 'r ASz � p Jt_��/tD g \ 7 owN \NaT12 y e3 O UTµ 1A A�FZW \ G,`-4 1✓A A., ,�NCAVIL villa t-j5 A c -f I M G rA U(- I T&1 0 (o L21 A. p I r h/I -r" S TONE p p tit 72',x 4T x 0,F3 S )27 8 S T 4, I.E TOTAL = 479, 7 GAS. PfzOVI Div S 'EW P C�� 4� �SPOSPtr 5�-15T EM01 AT JACfS Lot- Iq2 -1Iw I FooT >]IZ\ VC— _+. F O C ON S T,a N C E S H V\/ � a11' <' K.e,►A cCA L S ; A5 NOTFv DA7'�;nnav�N 22 1gg5