HomeMy WebLinkAbout0162 COUNTRY CLUB DRIVE - Health 162 COUNTRY CLUB DRIVE,BARNSTABLE
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Commonwealth of Massachusetts F
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Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments F
M r� 162 Country Club Drive;.Curimmaquid,
Property Address. ..
Evelyn Obbard
Owner Owner's Name `
information is required for every P.O. Box 314, Cummaquid ., MA 02637 November 20, 2008
.
page. Cityr town State Zip Code . ;:Date of Inspection
Yl
Inspection results must be submitted on this form. Inspection forms-may not be,altered in any
.way,
Important:when A. General information
filling out forms
on the computer,
use only the tab r �
key to move your 1. .Inspector. O, 1 .� Y .
cursor-do not Troy Williams
use the return Name of Inspector '
key.
Troy Williams'Se tip c Inspections
re6 Company Name :, t
19 Hummel DriveAZ
Company Address
South Dennis :' •, MA 3 �`: 02660
City/Town State Zip Code
(508) 385-.1300 S1682
Telephone Number License Number `
B. Certification= t :
r.
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 Secti66.15.340 of
Title 5(310 CMR 15.000). The'system
® Basses „ .
Conditionally Passes, ;�❑ Fails`
❑ Needs Further Evaluation,by Local c ocal Approving Authority '
y
November 201 2008,
Inspector's SignatuP6 Date
The system inspectorshall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing.;this.inspection'. If the system is a shared system or .
has a design flow of 10,000 gpd or greater, the inspector and the system owner shaltsubmit the `
report to the appropriate regional,office of the DEP:The original should be sent to the system, owner;
and copies sent to the buyer, if applicable, and the approving authority.
***,'`'This report only describes Condition's 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 tinder
the same or different conditions of use
n x I ZA U�
S J
162 Country Club Drive,Cummaquid•03/08 . :. ',Ttle 5 Official Inspection Form:Subsur q-.Sewage pisposal System r_Page 1 of 15
G
Commonwealth of Massachusetts
Title 5 Official inspection For'
Subsurface Sewage Disposal System Form-Not for Voluntary Assessmenfs.
-
162 Country Club.Drive;Cummaquid '.
^M
Property Address
Evelyn Obbard
Owner Owners Name
information is p O. Box 314, Cumma uid MA',' 02637 November 20,'2008
required for every q ~
page. CityTrown State Zip Code Date of Inspection
B. Certification (cost:)
Inspection Summary:Check A,B,C,D or E%alwayscomplete all of Section D.
A) System Passes: ,
® have not found an information which Indic y ates that any of the failure criteria.described I, :
in 310 CMR 15.303 or in'310.CMR.15.304 exist. Any failure criteria not evaluated are
indicated below. . -
Comments:
System meets minimum standards set by Mass DEP at the time of-inspection only. This inspection is
not a guarantee.or warranty on the future.working conditions of leaching pipes or components.
c
B) System Conditionally Passes:
yOne or more system components as.described in the"Conditional Pass" section need to be . a
replaced or repaired..The system, upon completion`of the replacement or repair, as approved by.
the Board of Health,.will pass.
-Answer yes,no or not determined (Y, N, ND) in the 0 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 Complian
ce indicating that the tank is less than.20 years old is available:
ND Explain; .
N/A t
❑ Observation of sewage backup orbreak out or high`static water'level in the distribution box due
to broken or obstructed pipe(s)or due to`abroken, settled or uneven distribution box: System will
pass inspection if(with approval of Board of Health):
broken pipe(s)are replaced k
❑ obstruction is removed
162 County Club Drive,Cummaquid•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•.Page 2 of 15>
•
Commonwealth of Massachusetts
Title 5 Official. Inspection' Form'
Subsurface.Sewage Disposal System Form -Not for Voluntary Assessments
162 Country Club Drive, Cummaguid < +
Property Address
Evelyn Obbard
Owner Owners Name
information is p O. Box 314, Cumma uid MA 02637 November 20,-2008
required for every 4
page. City/Town State' Zip Code Date of Inspection
B. Certification '(cont.)
B) System Conditionally Passes(cont.):
distribution box-is leveled or replaced
ND Explain:
N/A
❑ The system-required pumping more than 4.times a year due to broken..or o6stru9ted_'0ipe(s). The
system will.pass inspection if(with approval of the Board of Health)
El broken pipe(s)are replaced
❑ obstruction is removed _-
ND Explain:
N/A
C) FurtherEvaluation is Required liythe Board of Health:
s.
tJ
❑ 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 envirorment. b,
1. System,will pass unless Board of Health determines m 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 wlthiri`50 feet of a surface water
i.
;❑ Cesspool or privy is within 50 feet of.a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health and Public Water Supplier,if any)
determines that the system,is functioning m a manner that protects the public Health,
safety and'environment:
El The system tas 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 aseptic 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 SAA Is within'50 feet of a private water
supply well.
162 Country Club Drive,Cummaquid-03108 Title 5 Official Inspect&form.Subsurface Sewage Disposal System-Page gof 15,,
,
Commonwealth of Massachusetts _
Title 5 Official' Inspection .dorm
Subsurface Sewage Disposal System Form -Not for.Voluntary.Assessments'
y 162 Country Club Drive, Cummaquid'
Property Address
Evelyn Obbard
Owner
Owner's Name o
information is
P.O. Box 314, Cumma uid MA _ 02637 'November 20, 2008p .
required for every q '
page. City/Town State', Zip Code Date of Inspection
B. Certification (cont.)
C) Further Evaluation is Required by the Board of,Health (cont.): . -
❑ 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**.x 2*
Method used to determine distance: N/A
**This system,passes if the well.water analysis, performed at a DEP certified laboratory, for 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. A t.
N/A ;
D). System Failure Criteria Applicable to'All Systems:
You mu indicate "Yes, or"No"to each of the following.for all inspections;
Yes . No
T r Backup of sewage into facility or system component.due to overloaded or
ti '• ® ' clogged SAS or cesspool
r ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an:overloaded;orclogged,.SAS:or cesspoolEl
Static liquid{level`in the distribution box above outlet-invert due to_an overloaded
r;..
® _ or clogged SAS or cesspool.., ,;'
0 ® Liquid depth in cesspool is less than 6" below invert or available volume is less.
than'/2 day flow
® Required pumping OT`more than 4 times in the last yea' N due to clogged or '
obstructed pipe(s):'Number of times pumped.
-0 Any portion of the SAS, cesspool or privy is below high ground water elevation.
r ,® _•. Any portion of cesspool or pnvy.is within 100 feet of a surface water supply or
tributary to a surface water supply.'
162 Country Club Drive,Cummaqwd•03108 Tale 5 Official Inspection Form:Subsurface Sewage'Disposal System•Page 4'of 15
•
rr
• y
Commonwealth of Massachusetts`
Title 5 Official Insp ection� Fora
Subsurface Sewage-Disposal System form-Not for Voluntary Assessments
162 Country Club Drive, Cumma 'uid
Property Address
P
Evelyn Obbard
Owner Owner's Name
information is
required for every P.O. Box 314, Cummaquid MA 02637 November20, 2008
page; City/Town State Zip Code Date of Inspection ,
B. Certification (cont.)`
. A�
D) System Failure Criteria Applicable to.All Systems (cont.): ,
A
Yes No a
0 ®- Any portion of a cesspool or privy is within a Zone 1 of a public well.-
Any portion of acesspool:or privy is within 50.feet of a private water supply well
0 Any portion`of a cesspool.&privy is less than 100 feet but greater.than 50 feet
from a private water supply weit with no acceptable water quality analysis. [This
System passes if the well water analysis, performed at a DER certified
laboratory,°forfecaI 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.
Q The.system fails. I have determined that one or more of the above failure
criteria exist as described-in'310 CMR 15.30.3, 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 Seetorr D.
Yes- No
❑ ': the system is within 4,00 feet of a.surface drinking,wate(supply
® the system is within 200 feet of a tributary to`a.surface drinking water.supply
0 ® - the system is located In a nitrogen sensitive area (Interim Wellhead Protection
" Area":_IUVPA)or a mapped Zoneal 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 a ny 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
regionaf office of the Department:
>. 162 Country Club Drive,Cummaquid r 0XQ8 Title 5 official Inspection Form:Subsurface,Sewage Disposal System•.Page 5 of 15
Commonwealth of Massachusetts
Title 5 Official ins ection Form
Subsurface Sewage Disposal.System:Form Not for Voluntary Assessments
162 Country Club Drive, Cummaquid
Property Address
Evelyn Obbard
Owner Owner's Name
information every um q
tion i
required for e P.O. Box 314, Cma uid MA 02637 November 26, 2608.
page. Cityfrown '` ':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?
El
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) ;
f
®- ❑ Was the facility or dwelling inspected for signs of sewage backup?
® ❑ Was the site inspected for signs of breakout?
® ❑ 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?;
�r The size and location of the Soil Absorption System (SAS)_on the site has R
beian,determinled based on:. _
® ❑ Existing Information. For example,a plan at the Board of Health.
Q Determined in the ,field if any of the failure criteria related to'Pa,t C is at issue
approximation'of distance is unacceptabie)[310`CMR 15.302(5)]
. t .
162 Country Club Dnve',Cummaquidi 03108 Title 5 Official Inspection Form Subsurface Sewage Disposal System•,Page 6 of 15.
Commonwealth of Massachusetts
Title 5 Official Inspection Fo-rm'-
Subsurface Sewage Disposal System Form Not for Voluntary Assessments ti
M 't 162 Country Club Drive,'Cummaquid.
Property Address
Evelyn Obbard
Owner Owner s Name ,
information is k
4
required for every
P.O. Box 314, Cumma uid MA 02637 November 20, 2008
,
page. City/Town r' ,.State Zip Code Date of Inspection,
D. System Information
Residential.Flow Conditions.`
3.,. = 3
Number of bedrooms (design): Number of bedrooms(actual):
r DESIGN flow based on�310 CMR 15.203 (for example: 110 god x#yof bedrooms): 330 god
Number of current residents:.,. p 1,
Does residence have a ysarba
9 a ender?9 9 ❑ Yes ®. No
Is laundry on:a separate'sewage system?[if yes separate inspection required] ❑ Yes ®.< No-
Laundry system inspected? f. : . . �:; r:.: Z Yes ❑ No
Seasonal use? , El -Yes No
w
Water meter readings, if available(last 2 years-usage(gpd)); 07=55,000gals "
08=48,000gals
Sump pump? - ❑ -Yes, ® No
Last.date of occupancy: '
Occupied
Date
Commercial/Industrial Flow Conditions. , 1
-
Type of Establishment: ^
NA
Design flow(based on 310 CMR.15 203): Gallons per day(gpd)
Basis of design flow(seats/persons/saft etc.): N/A
Grease trap present?
❑ Yes M No
Industrial waste holding tank present? Yes ® No
Non-sanitary waste discharged to the Title 5 system., ❑ ayes No
Water meter readings, if available:
N/A
Last date of occupancy/use:"
Date
Other(describe).
N/A
162 Country Club Drive,Cummaquid•03%08 ' Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15
Y_
Commonwealth of Massachusetts
01 Title 5 Official InspectionForm*
Subsurface Sewage Disposal System form -Not for Voluntary Assessments
,•.�' 162 Country Club Drive, Cummaquid i fi
Property Address
Evelyn Obbard
Owner Owner's Name
information is q
required for every P.O. Box 314, Cumma uid MA 02637 Noyember.20, 2008.
page. City/Town ry S.tate Zip Code Date of Inspection
D. System Information (cont.)-
General Information
Pumping Records:. `
Source of information: Pumped on 8/2/04 per owner.
Was system pumped as part of the inspection? ❑ Yes ® No,
If yes, volume pumped: N/A
gallons. ,
How was quantity pumped determined? • 'N/A
N/A
Reason for pumping.
Type of System:i_
® Septic tank, distribution box, soil absorption system
El Single cesspool
Overflow cesspool
Privy
Shared system:(yes or rib) (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)gand a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach`a copy of the DEP approval.
El Other(describe)-
Approximate age of all_components, date installed (if known) and source of information: :
Tank was installed on 12/16/77. Leaching was installed on 8/31/92 per"compliance. .
Were sewage odors detected when arriving at site? ❑ Yes No
.162 Country Club Drive,Cummaquid•03/08 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 -
Commonwealth of Massachusetts
= Title 5 Offiicial Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
¢,
M 162 Country Club Drive; Cummaquid
s. Property Address _z
Evelyn Obbard
Owner Owner's Name
information is required for every P.O. Box 314, Cummaq uid MA " 02637 November`20, 2008
page. City/Town State. Zip.Code Date,of Inspection '
D.,System information (cont.)
Building Sewer(locate on site plan):.
18"+
Depth below grade: feet
Material of construction:
❑cast iron 40 PVC ❑ other (explain):
a.
Distance from private wafer supply well"or suction liner N/A
t feet
Comments(on'condition.of joints, venting evidence of leakage, etc.):
Flushed lines and,found:clear'at the time of inspection. 4.
Septic Tank(locate on site plan):
Depth below grade: 20"
feet
Material of construction: .
® concrete ❑ metal ❑ fiberglass,. ❑ polyethylene ❑ other(explain),
4 - °
-If tank is metal, list age: N/A
years
Is age confirmed by a Certificate of'Compliance? (attach a copy of certificate) ❑ Yes"❑ No
-----------------.------.------------ ----- -.�_ --------------- ------------- ------- ---------- -- ------ -----
5'-X 9'X 6'' 1000 gallon
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle Z8„
•
Scum thickness none
Distance from"top of scum to top of outlet tee or baffle 6''
Distance from,bottom of scum to bottom of outlet tee.or baffle 14
How were dimensions determined? Probe Measured
162 Country Club Drive,Cummaquid•03l08§ Title 5 Official Inspeclion*Form:Subsurface Sewage Disposal$ysfern a Page 9 of 16
• F.. -
Commonwealth of Massachustyetts
u
Title 5 Official jh',5pe" -c- tion" Form
Subsurface Sewage.Disposal System Form- Not Yor Voluntary Assessments,
ti 162 Country Club Drive, Cummaquid..,',
Property Address ,
Evelyn Obbard
Owner Owner's Name ,
information is a -
required for every P.O. Box 314,-Cummaquid MA ' 02637 'November 20;:2008
Cit State!Town. .: �• Zip '� Date of In
page. Y .. , p.Code ' Inspection ,
4 P.
D. System Information (cont.) ;
j Comments (on pumping recommendations, inlet and outlet tee or baffle conditionstructural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.): 5'
Concrete inlet and outlet tee's were present.Outlet tee was coroding but present.No evidence of.
leakage or damage was found. Tank was not in need of pumping at".this time
r
4
Grease Trap(locate on site pla . x
_ n): -
Depth below grade; y N/A
feet
41
Material of construction.`
El concrete ❑metal ❑;fiberglass ❑ polyethylene ❑ other.(explain)
E Dimensions: '. .. N/A
:, 9
Scum thickness b ,, ' N/A
Distance from top of scum to top of outlet tee or baffle
.. f•�
Distance from bottom of scum to,bottom.of outlet tee'or baffle.;
Date of last pumping N/A
4, Date
,Comments(on pumping'recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outletinvert, evidence of leakage;etc.).. `
Tight or Holding Tank(tank must be pumped at time of Inspection).(locate'on site plan):
Depth,belowjgrade: < £ N%A
Material of construction,.-
El ` . , •
concrete' ❑ metal • '❑fiberglass ❑ polyethylene ❑ Other(kplaln):
"N/A ,
162 Country Clup Drive,Cummaquid•03108 ,A; _. Title 5 Official Inspection Form;.Subsurface_Sewage Disposal System Page j0 of 15
Commonwealth of Massachusetts W
Title 5 Official , Inspection ion Fom ,
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
162 Country Club Drive, Cummaquid
Property Address
Evelyn Obbard
Owner Owner's Name.
information is
required for every . P.O. Box.314, Cummaquid MA, 02637 November 20, 2008
page. •Cityrr9wn State Zip Code.' Date of Inspection
D. System Information (cont.)
Tight or Holding Tank(cont.)
Dimensions: MA
Capacity. .' N/A
gallons,
N/A'
Design Flow:
.;.
gallons per day
Alarm present , ❑ 'Yes'. E;No
Alarm level: . N/A Alarm in working order: 0 "Yes Ej :No
Date of last pumping N/A` �.
Date
Comments(condition of alarm and float-switches, etc:):
N/A
Attach copy of current pumping contract(required). Is copy attached? '`Yes ❑ No
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', an evidence of solids car over, an
( q . y.. a.:ry y
evidence of leakage into or out of box, etc.):
No d-box on'asbuilt and none found present.
Pump Chamber(locate on site plan):
Pumps'in.working order: Q Yes 0 No
'Alarms in working order: D ,Yes` ❑ No
162 Country Club Drive,Cummaquid-03108, Title 5 Official Inspection Form:Subsurface Sawa ge Disposal System•Page 11 of 15`
4
Commonwealth of Massachusetts:
s Title 5 Official Inspection Form'%
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M V y 162 Country Club Drive. Cummaquid' r
Property Address .. ,
Evelyn Obbard
Owner Owners Name " a
information is p O. Box 314, Cumrria uid MA 62637 Noyember20, 2008.
_ required for every 4 -
page. CitylTown State Zip Code ;Date of In
D. System Information (cont.)
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-wh`y;
N/A c" r.
Type`
1-6'x6 pit
® leaching pits number: w/2'stone
❑ leaching chambers ., number:
EY leaching galleries .` number:
El
leaching trenches number, length—
El
leaching fieldsy number, dimensions.
El
overflowcesspogl ; �: number:
qs
❑ innovative/alternative system
T e/name.of'technology..,
yP. . _ _
.y
Comments (notecondition of soil; signs of hydraulic failure level of ponding, damp soil condition-of
vegetation, etc.):
,Leach it was found with 4 of water resent with a visible stain line approx. 6 i v
P. P ,. , . . higher. No evidence of
hydraulic failure or problems in the past were found at the-time of inspection. ,
162 Country Club Drive,Cummaquid 03/08 4 Tide 5 Official Inspection Form:Subsurface'Se,aZe Disposal System Page 12 of 15'
s
Commonwealth of Massachusetts
Title 5 Official Inspecti®n dorm
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
rw ,
162 Country Club Drive, Cummaquid r r
Property Address -
Evelyn Obbard x
Owner Owners Name
information is
required for every P.O:Box 314,'Cummaquid A'M 02637 November'20, 2008 ,
page. City/Town State Zip Code -,Date of Inspection "
D. System Information`(cont.)
Cesspools (cesspool must be pumpedas part`of inspection);(tocate`on site plan);
Number and configuration N/A
Depth top:of liquid to inlet invert N/A
-
Depth of solids layer ry N/A
}
N/A
Depth of scum layer
Dimensions of cesspool ; +
y N/A
N/A
:Materials of construction
Indication of groundwater inflow Q Yes No `
Comments (note condition;of soil, signs of hydraulic failure, level of.ponding` condition ofveaetation,,'-
etc.)-
N/A
r_
Privy,(locate on site plan)::
. Materialsof Construction: Q N/A
N/A
Dimensions F
e .
Depth of solids N/A
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.) ,
N/A2.
"
' c
162 Country Club Drive,Cummequid 03/08 Y Ttlle 5 OffiGal Inspection Form Subsurface Sewage Disposal System Page 13 of 15
.. ,
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Noffor Voluntary.Assessments;
.J' 162 Country Club Drive,.Cummaguid. "
M
Property Address
Evelyn Obbard
Owner Owner's Name
information is
x MA P.O. Bo 314 Cumma ruid 02637 ov m
required for eve q
'^ N e ber 20 2008
page. City/Town State Zip Code Date of Inspection
D. System Infor + at on"m � cont.
Sketch Of Sew a e,Dis osal"S stem: Provide a'sketch of he ` w ' ` i t sewage e d s osal s stem includin ties.
to at least two permanent reference landmarks or benchmark`s."Locate all wel S wittii,
P ( n 1 t)0 feet.
Locate where public water supply enters the building.
r
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. I ,
L r
P
7 .
r
•
`p.
r ;
- _ - -1
162 Country Club Drive;Cummaquid•03108 r, TRW 5 official in
s'pedion Form:Subsurface Sewage Disposal System Page.14 of 15
Commonwealth of Massachusetts
Title 5 .Official Insxpection Form
Subsurface Sewage Disposal System+Form -Not for Voluntary Assessments
162 Country Club Drive, Cummaguid` _
Property Address
_Evelyn Obbard
Owner Owners Name
information is RO. Box'314, Urnma uid MA 02637 November 20,"2008 4
required for every q
page. Cityrrown State Zip Code Date of Inspection
D. System Information.(cont ) rb
Site Exam:
•® Check Slope '
Surface water '
Check cellar.
❑ .Shallow wells'
Estimated depth to high ground water. 19.3'.
:" feet.
Please indicate all methods.used to determine the high ground water elevation
„"0 Obtained from.system design plans on record
If checked, date of design'plan reviewed pate
,.
® 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.
A1W247 Zone B• .''24.8" 4.1' adjustment
You must describe how you established,the high ground Ovate[elevation:
Soil was`'sand-'sandy., groundwater
_ y . g undwater map and elevations showed groundwater'to,be 23.4'below 7.' -
grade. Groundwater adjustment in area at the'time of inspection was 4 1' Bottom of leaching-at 9.8'
Was found not to be located inane high groundwater elevation at the#ime ofinspection.
,en L'r, t
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162 Country Club Drive,Cummaquid•03/08 Title 5,01fi teal Inspection Form:Subsurface Sewage Disposal System Page 15 of 15
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Corrmmonweafth of Massachusetts �� {
. Executive Office of. Envimnmental Affairs
. r Wiliam F.Weld ' ;j
Trudy
y EOEA +.g t' S .a m' 0-�1 4T
£ David B.Struhs ,� h rf
t1?a{ ; oomminioner
# `try fa SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION,FORM
; 1 PART A „ ,`r
r : t CERTIFICATION '�° :Ms , .
3
s Property Address: �(p Cpul�fr-1 �� a�m _Address of Owner.
` Date of In
spection• 9-a3-76 (If'.different)
n t >�
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Name of:1nspector. Q �`.� vir
µ company_Name, Address anAe4lephone Number, , .'
i CERTIFICATION STATEMENT
I.certify that I have personally inspecte�``the sewage disposal system at this address and that the information reported belo.H fs true;accurate
and complete as of the time.of inspection. The inspection was performed based on my training and experience fn the proper function and ,
maintenance,of on site sewage disposal systems. The system; i t .t
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COndltlOnailly PdSSES y ,x{t a. v'af trw M9afl s ey y
n r,°{ t Needs.Further Evaluation By the.Local Approving Authority,.,
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� R'The System Inspector shall submit a copy of this inspection report to the'Approving Authority w.ithrn thirty`(30)'days of completing this R '
gins ctionslf'the s<stem;is a shared's°stem or-ha deli n. flow of 10;000 or realer, the"ins ector and the3s stem oner shall submftt�
pet ) ) 8 gPd g P Y 7 �� � n= " Zx
:4he report.19 the appropriate-regional.office of°t he.;Department of Em,ironmental.Protection,,
,� ss The original should be sent to;ne system oti+ner and copies sent to the buyer; if applicable and'the approving au:ho it
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INSPECTION SUMMARY.
s 4�`` .¢3 S� �.1 )}yea }{."�.^ l L;.Jtj4t 1s 4a.4 i ,. "-`` as tit. fl #+ ai #.F �,.�Tt i t ak ryja t�C..�r, e F2-sd�.FZ! .`•'n,5i
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3x{ r ': •:�;Ihavenot found an nformation„whichindicates that system violates anyHof the�failure criteria as defined m..:310 CMR 15 303�" 3 t '
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g t �" Y., r a' x`Any failure criteria not evaluated are indicated below. }
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" B] SYSTEM CONDITIONALLY PASSES s a
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�s '�3$�,;Y `I si,�rr i,€ r*r, w:#-,# .91�,tgea. ., f., E +,:: # •i�:i)i4 5 �'""^"} 4'l ;t�F R r!" x s.tit�.a:.'"�e'ti'bx �aFy'"„ 'K "-
/ 7 ;Orieor more system components need to be replaced:or.repaired, The system;upon completioniof�theeplacement orfrPair;:
f �� "S' i .1 i t >t•*'' 4k " y. 32t € s$``r �� 4 z_p n
' passes inspection
nay s r k
,lndiwte;Yes, no,,or not:determine d (Y, N',or ND).';Describe basis of determination m all instances If snot determined ,rexplam why not)
g� The'septic tank is metal;cracked, structurally. unsotind,'shows'substantial infiltration'or„exfiltration, oi,tank failii`feiss
�� M.,
"%fist , a =imminent:YaThe system,wil) passin5pection ifthe.existing septic tank is replaced with;;a,conforfrrng septic tank asp' a
;g approved by the Board of Health. xi5 j
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Winter Street o' Boston,Massachusetts 02108 a FAX(617)556-1049 0 Telephone(617)292 5500 r a
W'FS";�sr �`'` '`• '. �'y` �p '� f
Primed on Recycled Paper
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM` 6 } ` ' , } {
PART A k a
s u x
CERTIFICATION (continued)
Property Address:
'Owner.
= Date of Inspection_
6]SYSTEM CONDITIONALLY PASSES (continued)
r .
Sewage backup or breakout or high static water level observed in the distribution box is due to'broken or'obstructed
r pipe(s)'or due to a broken,`settled or uneven distribution box. The system will pass"inspection if(with approval of the-_M i
, a n Board of Health)
broken pipes)are replaced
obstruction is removed
distribution box is levelled or replaced
_ -' .., � � � S+k.''nix.#g,V6*F�� .•� i 1?p4 x^�v'��S'�?$. .2��Fa,3 t
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_ The system'required'pumping more than four times a year due to broken or obstructed pipe(s)r The system wtllfpass 3 � E
Y` F inspection if(with.approval of the Board of Health):
broken.pipe(s)are replaced
F� t Mid. +` tea`• '� -: 7 r c
t obstruction,is removed
yafi 1 7„V7 yby't Fy 5 a ,t ef i:d 4 'f tLPxFs ys3 hJ act r .;tct i
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av,uar .t ^�� f '" dt t*,.t.s �' :�. .G. .."'• :s_.', 4z "-e + rg tit,•xa a .a t25 �rr i r '� y4 v+v a 5`3 ,34.,-a.at t
s `{1,:FURTHER EVALUATION IS REQUIRED BYTHE BOARD OF HEALTH �4k' �t~ r
, r Conditions exist which require further evaluation by the Board•of Health into order determine if the system is fatlmg to protect:the ,
public health, safety:and the-environment.
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FUNCT
;
1) ,SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM'IS NOT` IONING IN
` A MANNER
WHICH WILL PROTECT THE;PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT a ; w aYsF '
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-fi r :.��„� .". ^tA y i v� 4 }^te r• „' ` a.,. ,�" t } �
� Cesspool or privy is within 50 feet of a surface'water
71
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Any
Cesspool or privy'is within50 feet of a bordering vegetatedtla.wend or,a salt"marsh
�'^��`�i� � � r' !rr : ->s •'a, f r' t't`a � + .�;; �'v'r r t''r..� i txi` .S3t a '',{ s > �:`�; t s ;�iK � ,x>'r� ��� '�'"'��z.= ��e,, g'�•��'. ,�,;� � ��•
� � ,•:.l�as '� r.il:3}.t�(`kp.„.._7. .,r..•,s,. i�.: a._#�.5 E..,,ilr<, .�,}i3..�...,N`�„_�V°..,..�"!z{ .��,e ! r ,.;�'.4 �?ti ,A'a.5 �...,,�'�.,. ;-r ):�yC7 zi�,,i#a�+pF�I � .,f3, �:cn,.�"r- -�!�`[:n.�a��`�'+.`'-
.° ctt: IF:.APPROPRIATEYMETERMINESaTHATd�s� z
2) SYSTEM WLLL'FAWUNLESS.THE BOARD Gf HEALTH (AN,D. PUBLIC WATER SUPPLIER,
THE SYSTEM IS FUNCTIONING IN A MANNER,THAT PROTECT THE PUBLIyCfiHEALTH AND SAFETY ANDtTHE t� tk ,i4 � ;
L c44' �n h e "l:.. r I r is„4t5 �t i•;:�i6 .. S. . } t.•t '!J'!, +'a+`h�. 4::§,ks S y;1.� 'r 31"rh` r ' :tq{Fnk�� ' t{^ s t+.C +.4'�+ lr.t
r< %. EN IROtiA1E'�T ,' � ,: tti:„r ft 1 � w ,'' r
A 3 t d pt r
+x. r the cvctern hay a sepuc.tank ano soli ausorpuun system anu is wilhui t0� fbEi w a �u�o.� wa,C�`s�pplt or .trib,,,art t0 a5� v y
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t t r f r +i�`MU x
surface water"supply. K {
_ � -� ..'.: �.' .� F'r y, ti.�`' '�'ai:: � .gas � �-
.r> Y; Y;The'system ha aseptic tool and soil absorption system and is within'a Zone. I of a public water supplyzwell ` Yy :
f r '� "The systemhas aseptic•tank and soil absorption system and'is within 50'feet of a private water supply,well ssa ;�,,
``The system'has a'sepUc tan{ and soil absorption system and is less
-than 100 feet but.50 feet or morefrom a'prtvate3water ;
., v
ppI) well,"unless a well,.water:anal •sis for coliform bacteria and-volatile'organic compounds`mdicates thafthetwell ts�
�, y.. t4 free from'Pollution 9f' m that facility,and the presence of ammonia nitrogen-and nitrate nitrogen is equal to or less than 5 ,
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}"D 'SYSTEM FAILS w s �, fy §r"i
,if,
I�have determined that the system,wiolates .one or more of the following failure criteria as definedn,310 CMR'15 303The hosts,'"
z
`,forrthWde'termination,-Widenttfied'below a The Board of Health should be contacted to determine what wt I necessary,to correctft
7t�eythe fallUre . . r$ t nay Ja{ryS T y s €a8 $�vY '
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' y-::*� �, Backup of'sewage}into facility or•system,;componenuclue to:an overloaded.or clogged SAS ortCessPool"'i7,t r,���n. `
..;'fi .A',. t F t,. + 6 F .
%�St voh;a d ° ;4:? s F y ass aS e t}
,3 -IN:.. S ....t.,;�,;�.#� ... ..� . .. 'r,..�. w.�.k!+st
,;.Y:- ding,' ` %,. ..
Discharge or ponding of effluenf to the surface of the ground or surfacetwates dute=to an overloadedor;clogged SAS o t
.� a .cesspool
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{g88,� (q(qq(q,,, dj"` .x t.° 'i•" * s '.k�'s' �,t gd Vill.�t � rv.tgyy^;��j-ka.���C'. F`.i, %i", Y ''',e �?i j' 'ae�'7v,. T'°neM o %s t'M!`^�'x'l„r>g`�`;} e ��;,,;•.r� .0 k.`` ,e„ f'�..
WS
r ,Nd Y�r,Wy�,yB'rt , _ K %..4 qY a , .. d ,� h k> v4'F{g a k45�A,j i Ord �c,t-•�1,�"°.t. '`.e.+7 a xx pp,�.
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s SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
: PART A M.
' t CERTIFICATION'(continued) r
CD v�:i vy cl Jb a w&
` Property Address: - +
ti
Owner:, /�,rs POO 2
Date of Inspecti(6.- w .
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D) SYSTEM FAILS(continued):
Static.liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or,'cesspool; `�
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a x
Liquid depth,in cess spool is.less than6"below invert available volume is less.than 1/2.da flow '"��
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ti a� Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). � `�r` n
Number of times pumped
Any portion of the Soil Absorption System, cesspool or privy is below the high:groundwater elevation Ms ;
J Any portion of a cesspool'or privy is within 100 feet of a surface water supply or tributary to a surface water supply
§ � xa .
w � t� z r 1
o <;
' , r Any portion of a cesspool or privy is within a Zone I of a public well. £
Any portion of a cesspool or,privy,is within 50 feet of a private water supply rwell.
'Ins ;
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Any portion of a cesspool or privy is less than 100:feet but greater than 50 feet from a private watery supply�we11 withIf
£no �
acceptable water quality analysis. if the well has.been analyzed to be acceptable, attach copy of�well water analysis�o `
t, coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate-nitrogen.-.,
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�" El LARGE,SYSTEM FAILS:
ask
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s �; The following criteria appl} io large systems in addition to the criteria above' r, v�W2 ,
'Px�y the design flo++.of system is 10,000 gpd or"greater Marge System) and the system is a sigmficantAthreat to'public health and safety '
ar�tand,the environment be one or,more of the following conditions;..exist
r
*. the system is within 400 feet of a surf.ace drinking water-supply z ` � � � � W.
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ys w' j A ,. :'',__ - ° fi w. 3•i ' r ¢ -^c Yam.
Yr ; ; ." ,the system is,within 200 feet of.a tributary to a surface drinking water supply �;�'A.x� � f� � 4"�k
' '�'t,d .i q3t r��. �•« Y ` «� .Y t g " ,� ;s'k`o �i r�t� ���� ,�xw,7 r i
the syste
� m is located, in a nitrogen sensitive area (Interim Wellhead Protectwn:Area (IWPA) or,a"mapped^Zone II of ati
?sT�" .s+ ».: public water supply well _
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f� 'b'.A``Z4�'��.t.11i`t,t�t"a�`✓^'t= a D :r� a:r+ .4 ?;�*� .2 �''� .r a+� 'A' C +#�txy'�a '=� ti�' .^.�, _.. �i���,ti,�'.�k,. {�," !
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The owner or operator.of any such system sha11 bring the system and facility into full compliance.with the'groundwater treatment program y, 0,
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requirements of 314 CMR'S 00 and 6 00 Please consult the local regional office of the Department for further information.,.,
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
•t . PART.B _
F' .CHECKLIST 3 ' h '• ..;
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tin .Property Address: 60 U11X"`� G�J 0"Or
tr, Owner: / '��r n�U✓. '
x Date-of Inspection. t. :, x
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`'S 4 ..'+1' t Ih`
Check if the following have been done:` � , �� r
gyp=r, a1 Pumping information was requested_of the owner, occupant, and Board of H I _ a`• x ' `tea
Health th. s r l
. ,
None of the system components.have been pumped for at least two weeks and the,system has'been recervingtnor al'flow rates {,�•; dyring that period: Large volumes of water have not been introduced'into the system recently or as part of this inspection `
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As/built plans have been obtained and examined: Note if they are not available with'N/A
A �TThe
Th fa 'lity or dwelling was.inspected:for signs of sewage back up system does not receive non-sanitary or industrial waste flow
��a a....� f a,..-. / . 6 N - t A�+� ,js«*•wriJ� k^' �,f"a=s_' � t�`,.'f
Th!p site was inspected for signs of breakout.
_N' ��, _AII system components,.excluding the Soil.Absorption System, have;been locatsite.,,,_:'_'
ed on the
A' A
` he septic tank manholes were uncovered;,opened,"and the rnter►or of,the septic tank.was inspected for condition of baffles or
` tee , material of construction',:.dimensions, depth of liquid, depth of sludge,'depth of scum
e `=c ,
'42, `r The size f�o 'and location of the Soil Absorption System on the'site has been determined based on existing;information or'-*'
�� a r o x i m a t e d by non intrusive methods. '" jr ,
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f .. `• : ;'twit *' 1T i a'� ' 3Tk
�k ,The;facil�,� c, ..,e. ,� ,' occupants, if differen from o++,ner? were provided with information on the proper ma,ntenance of Sub r f r Surface Disposal System v
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SUBSURFACE;SEWAGE DISPOSAL SYSTEM INSPECTION`FORM ��� rV r
PART C_ 4 K + 1 3 ,
I�[�.
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. SYSTEM INFORMATION , ,s ', 4 ,--
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Property A�,1,ress: 5 t +
y Owner. .''1'I'IdS+' Ovi✓ ,, ,„ Yx
Y i�
�7
Oate of Inspection: ", �° .
q t af`
y FLOW CONDITIONS '. - .,�, ,4 ,.. `. ,
'fir .RESIDENTIAL•
r.A - - ' K�x a °Z
Z Design flow:__gallons `_ ,v 3 ` , l
.Number of bedrooms: h r _- *I'1 _,.I
Number of current residents: * { y `
>r tx! Sri 'fir" k ' tcik ,A#K f�i J6 k ,§.,.€°'.i
f k-,Garbage grinder(yes or no): 5' "%A "—` t;,,y�-,Wt
Laundry.corinected to syst�rt? (yes or no): �c r f [' �� �{. 3 r °
Seasonal use(yes or no): .. ' x ,'4"*� i
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''.Water meter readings, if available: T r A r j
- - r _ *,� a x#�3� '.. `rF,j r Sr i,t+ v s. J'
j " Last date of occupancy:, ; f f,,�L T,-T--9�� :� ,
- .. -, P' Xr,.�
.^✓ s.. l f t� ,} c k (�^ ` }d^j '44"+inf"i �S,�i
rCOMMERCIAUINDUSTRIAL r.
�+� k ;
. Type of establishment.
4 o'. t, '
,Design flow Rallons/day jq{' ,ts) i 7 °€.ur 4 t6 5Bk e�r ` �g r r t
Grease trap present (yes.or no) , j;xk +
Industrial Waste Holding Tank present (yes or no) � t; � -� -
I 'Non sanitary waste;.discharged to the Trtle 5 system: (yes or no) r ¢
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,a.-_ -`
Water<meter readings, if available: � l J �, , � Y'ice
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Last date of occupancy ,,A2j sx 'i g .'
:, yam,
'' l.r r <7N,. + r rt e . sa Tr +, ��§ a tIIIi
OTHER L(pesciibe)' F « ;
Last date of occupanq: `I ` , - _ ""--1 _.i
��,+.n ,''vr x wmy. �a9.4'I v+ "*'."+ai;'�7,t•-+gY�J �"'' - S..S q w r' .,�'r�.q dJ�yrv''4�"._ k s r' 11' ", -.!
j: GENERAL'INFO RMATION x ,�s.xg r. -, F` ss x% € •i'
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PUMPING'RECORDS and source:of information:: �'{00 '-�;f1 {`,,fg x r „�_� ,
A� 4
n
�'�-"� 1/L J ✓vim. , ' $ * r v# r a
4 kti niv a Jy-,. S 1, .: t. ''7 ..., ,"'"��>,e �a4Nt L��"` ;:'
t a<� f'1d� .G ` a i l
rfr System pumped as pan of rnspection (yes or no)_ �� - 3 � :
f&« ,. If•yes,'volume primped �, `,
r �,N x gallons � � ti .
11..3i( 4P b `ti �„ •� at. 4� Y aJ a^ M{ Y+•yi>t , 4�'
" '£ +r' ,ReaS0 r pumping }E .x ate"` fir+. S --, , i.i r"�r� +,'h?q�e- ara 15x 3 da ,ya`,�. igaV.k-kL
Imp -e` �r it w ., y.Y'..
TYPE,OSTEM -, :.; o r, 4 kr F ��
V Septic tank/distribution box/soil absorption system " `.
x
..,�;.x.. , ,fi, p 4,.ra§� 3} m sa,` - ?`la�,�;r�.it r5t a'S* ^# •.C'�.,q"pi' �§ `rt»hJa,�k�, ,#, ,-'.,
Single cesspool .. e � >.
a
OV21fIOW^Ce55 OOl '; i�> r b .., °� #r -- 1,-4fe'k '.,-
v .PrIW :r I - 4v x yZ ra" ra f *f i
��.:. '7 „s.t v - c a�'.' �` „y tyF �+Yx._ }i r�•>ah.`r "r"f'+F r-',
--; I •.Shared.system`(yes or no); (if yes,"attach,previous Inspection records, if any) r` ti' � .< �� .1 �,��,
Y�i„y �— a .. *d may. aM*' `4 fie. .'., v F,,rF "kw,,�_i
ice_ Other(ezplam) qp, �� ?��f.i
�t
p: '`'tar ;,*#^'I 1�$ A'a$ s , t < r -.' t rp P �w k "xa- . , ? k t,i .� A µ s�`°}.�,,,.s, .. ex4`4!
Ta'j sd ayn-Ate '^�.r r r _' 4 a,� 1.1 ? it`�' W ;:SY/ -'#� ,{t�"". yt, ':i k 7K f.i.' ��.Cm
sE3 N.?. f" w..,`x CM I.x'xr fi .:4 , _ .. /t! ('�' ^n.4Y..�.£.;.., +r *r . w. ri's'� -t
APPROXIMATE AGE'of all components, date installed (if known)and source of Information, 7 4�` , :
ai J x.¢,a.to �' *s - - 1.. r -r f 1' T.*'•. a J•'*i' a' i
S 7*' fi` ,h,.°¢ .1 ' {.•ea ark#k
'g2.f `Ue'�-E° y 's ii �'`{t F g t".f' g �. :"- ° tt_;.0 *a+,� {- `� a� 's4 R j,rrr &.-,,� ,:I
t ub3'x £a s` z,+ '� xe " �, Y++# asa+ k�#'`:1r '
Sewage odors detected when arriving at the site: (yes or no) {
yY kx'' 3'"z.vyii f k.�s ::y 4 '�,.:,4aY r i r rC * ' +fik.',v+Ysu s'+ +a7,�v.'T'�e'�7'- ,'• Y�j$W An`.
yM1: r' "V'r ,•� -.r s -r;^-i a f f : i `, Ae't r ^' ! I •ik ,F44,—", r,. `a`� ,2{ c c.. 11 1..`£de s'_i
+ w r' `6 2* f •r a C � i :' "�C'u�,1 r«x,n'Sr`at f',At, 'n. 4 a r
tTOVS80d t8/15/95I ' J ? q hxy t rt1€b .2QK c* :!
(,' ,Y 4 ;..xls.a.• xy: "* rI "�'`,j,- i .fs `,sy.,r:
it #za•y '.'Y. ss"', ;��k y - .. -k, .:;,,•r h``{K,140'. > n y'.`.,-—.
- x 1 ,.A "M
..
�.r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued).''
Property A ress: / 9
Owner: OU f
Date of Inspection: _��_ f rig y 'F r h
afire ; sr ,
A f sw. • � .: �'_ *t < I�93 Fu Y.x
SEPTIC TANK- > � 'r :
(locate on site plan)
Depth below,grade:L._ s ;,_ ,
Material of construction: concrete metal _FRP_other(explain)
_ { h S
71'3H
Dimensionst „
t Sludge depth:�3�' �t .: ~
1' Distance from top of sludge to bottom of outlet tee or baffle: n '
S Scum thickness:_,_ p t E
r� • -Distance from top of scum to top,of.outlet tee or baffle: / �(`
Distance from bottom of scum to bottom of outlet tee or baffler I f
comments:
(recommendation for.pumping, condition of inlet and outlet tees or baffles, depth'of liquid level,in relati n to outlet invert structuralr` �
;_gintegrity, evidence of leakage, etc.) �1't/�kF C�
7Y' < ze
Yri 5 )'
'}�yi,'�}* $w S �'f, M«.n.:Ir. .. �+:::,�.•.. ....�.� -. .. ,. +. ;,fT'. .dfl 'if S&r'� r+M tiIT,} "a
GREASE TRAP: �s. ��� _
r � .
k (locate on site Ian) F ((
rr• a ns;,,.s ,.,. ,P <
�,1 FDepth below.grade
y� Material of construction, concrete:_metal—FRP—other(explain). � �'p
;rDimensions:
;Scum thickness: r tir
"Distance from top of scum'to top of outlet tee or baffle: � � a`tF i
' 'Distance from bottom 09 !turn t-hottorr•ot-outlet tee or bather
w x-Comments
)E* � ,y. '
�, ?? (recommendation for pumping;condition of inlet and outlet tees or baffles,,depth of liquid level m relation tououtletmvert;,st ructural ,
' tntegnty,evidence of leakage, etc ►
'"}567�,-sal ` a;s"F-'�rsi•e 34 gat } $�#,'€z,*_.� ;q
� 'CYSLY•X"4r �'4 4 Y s r� x a.«n r ,rd
"„:ti'z.7 i r r`^°yw .r 'y, .,, '` s x + d k ' �.' „t to•�mp ,.34
' +'4 'xyr .'" `"""R%
a��`�
� ,,.�t �f Est dw[��yy�,'Y r' - pf ?^ � a,t t Y y� A t,�_2 'SK'��� A•5 e rt i�x K�`7
{6 M'
z��••••
r>FNg'M u},T'`•-r' .: ?;F"n<4' y' x? �,.. z..- Kxf'r..;
yr �',n' sM• " s ... - ;'ram, r - ., 7 a•�y--' a-+..,w,.'N 4... { ,y,r, Ys77....*..
"�;�"
,��.-'.
� .sw
Hai- aA ra ,,,ft fit' ia,�.v+r{��nr•w a rta,F..v f a �•r f
K
`_*" ,r'r`":a"F ..U.4 a yr s it
�� ,c? �tst j-
¢
_ (revised s
Wxt
39 ,�'.t, I i ,r,:, �.,:sya-f,2•-y `3s7 �F ur .l
,a�'a.•.J i� �. 2 J1 a ... t e x-r„�.'��,3y.sic.,-.•�,5 �� � _ Wig '--...i
y;4^4 Sz • 4 ';f" .k �4sMr r m n �..- r
y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION,FORM-
� 1
PART C
SYSTEM INFORMATION (continued), . 'T W, `-A
d
' Property Address �d-
�.Ovtti.T ice( G4 V U ' �rv-� C VIAwt -
• . Date of:lnspection: o/ I �.��.��i�
;TIGHT OR HOLDING TANK: -M-404t
(locate'on site plan)
DepthTbelow grade , ;
r b' onstruction: _ oncretemetal _ RP_othe (exlai'Materna n)
Ea4
r� Dimensions:
rr r ,CapaGty:' gallons-
' -,Design flow: gallons/dad x
Ald m�level
"(condnbon of inlet tee, condition of alarm and float switches,.etc.) # 4in
et, _ - .' - - :fw-er x �^l+• "+s :.r vs•t .Py',�
Sk
f�I DISTRIBUTION BOX:J�
• C '" A ,li
(locate on site plan) ;. _ ;
a ,t 34 � �F3,
} y LY y � �i nw: -..'* t„ .c,,r+:. t 1.av-tzi,.y+# .Cs ,�.
Depth of liquid level above.outlet invert s
p'j ;
Et Y I 'j t
y c`tngte d level and d(striburie,i r ryuai, e%;Jencf of solid: carr�oier, 61dence of leakage into or out of boa
� -.*•.�� 'i u } >r .,,,a, x�., r �..Y .� K r...w'w- fl��C' .g+ �k ,. .,.- xc.-n,_ es ;
50
WLOR� ';:.yr a -?a'i ,.t ( . ita`rF? a +�� t°r �,;{;rix 'r 'aa<<t't lt "� `s ::l'Yi"}i� '�+# '? a° ,, s•"ra F'`,r`Phrr�a7 �'«, '�4a� <sz`�" 2'r..
s c4 a -P,te':�<: $ •p 1 c ffi.z�+ nsr>fi z-is
PUA�P CHAMBER sd.se *-..�.. .'�#r r -w k �';yC, •F'.'}.{5_-h e'Y ' pry,a
(locate on site plan)
-, °., ,mot t • sh.,.v. ,o,.,. .:+, ry-� a y3 T�.¢a.:,'.�a•�a tL a r "mas,we': .a sY.zY,.fk i
sY'" w row , a,av +s'.i. an•..a 'r•.+•.>„•,. ...r` s a t `ti S.. - .fi'S F
:. �
Pumps in orking order.(yes or,no �_ �*� t r � �" ''w
A r ,ems r,� h r' ;,. , s e+• z +g-'' �
c 7a
Comments° t ., { r r .+a
....: Ya+ ' !_F .� § ,, rn. �,'� O y 4E 4,7af+ ,k'tx3a
'(note conditnon"of,pump;chamber,condition of pumps and appurtenances,;etc) - AV!
«'
*. •� 1•*:'
��,.�! �IS%.r ¢.. � Fb, • 1 S. Y 'Y � F k � :k Y CRmn J'^'•'�J� >���J�rS� a..:
s§J „Ytk-x 6 t i,Ps'..., ... .. s '. •'r -':: K �Tw yy. ro C9 ...:°r'.E:"14
:,n r° b:e f; ., a h 4 Yr •*'>•t +v«skad xak=V^':}s ,,n s^; +, x a g3' r r, ,rsz.4 r r t .tea Mw^ 1
1•% },s t 'S� a :,fi 'r` ; `' .•
,�a? ,",,, r,..>. ,.+w• :r2"�N•M• ,�«� x+s a s �F A•,,.+ i a a x +� `e
f.R-
x xra
s'.�1�.�Ts y ': ±• #t�' z + n1d''a+S ciY'....5,+ 'x�'r
y tTOv18ldi 6�15�95) 7<i {� ^ `; t �
'��� 6 ra(t;^�;d` - �d ,.#", 4 '��n � � �s -a/�a +�, � �• yet
$k-y�. 2d�,,i.ak yM1" � 4Y `' f• R r � r`�'��G� � e t.�h- ��,� .A.�,r.+' Y.
� � ��e„''�,-:� ' z •�' � a �' ��tY +.t s e',k��v^'���i x is,y/ �� 3y r
k Xti=r r � _ - 'ems 3 ��k •'�t ��x 3 r��,+� rya �:i5 �tr�.�
t. SUBSURFACE SEWAGE DISPOSAL"SYSTEM INSPECTION FORM"
PART'C
SYSTEM INFORMATION'(continued) - 4
a
Prope dresss:: ��- �Ot•i d-f .C��Ir� t-. C�-✓h , 4 '.,¢ x i
Owner re (
Date of_Inspedion:�—a�-��,
f SOIL ABSORPTION SYSTEM (SAS): roximated by non intrusive
methods)s # ' ` ` s • ,
(locate on site plan, if possible; excavation not required, but may be app
If not determined to be present, explain:
t"a
Y T
*� ..-�".. -tr* - r"' �• �,� j ,tee; .-,,w..., �.h*.�*��.��r '�,y^S-�p - j
` Type:
" * leaching pits, numb-—
leaching chambers, number._ ? I
leaching galleries, number: t 't r
_ leaching trenches, number,length: rt
4a
teaching fields, number, imensions x
y ' w
r
ABC„:.' overflow cesspool, number:. s=E ,4 , ;
���*� .. -- a - '.;�. "1+�✓si - 'E a
�1} ,Comments: (note condition of soil, signs of hydraulic
failAe, lever of ponding,°condition of vegetation etc)
�J 1✓y l U Y C
OO W1li� SF:
A .
Jf I
;w ....�.Kw. kcti -,st
_ z,•.. ;
CESSPOOLS- , �
s
F x `(locate on site plan)
Yr� Number and configuration:
x° Depth-top of-liquid to inlet.invert: y' i
$'Depth of solids layer.
� 2 z sK
`Depth of scum layer-
Dimensions
Dimensions of cesspool , ��,
Materials:of-construction, rk
s 3�'u fira s[. .t tl� ..i °€= J, "a ,� 1:ra} u•-,Y
indlcation•of grounds+atc::
mflow (cesspool:must be pumped as past"of inspection) r +
XAr
;,; i »"v , 's +.• .•."` 1 rA ., ', "sv,'
`£�-s,� 7 i.,.. ?,. .. . : ��- a �^`
VON , Comments:. (note condition of soil sign of h draulic:failure, level of ponding,condition of vegetation, etc)'
r n 14
}4w z f r qq"
����
, }'te
PRIVY ,.:.I
* �M
}��, (locate on site plan) '1 '
y1k ^• f ::>pL yu, ry1h *41 c�,fx3 c/a ,��, t�`a�`b,.'..�I"q`�S�•" �t.,� C,'.4��, �"+ �•
kaa "�i'"' ' rx a.�, f k Y 3 fs h ,
s a .s Dimensions
' uction"Matenals,'of constr " »` EvaF sy, ,++ s� e ,•F� �
Ai n .xiMb'..-. .n/..},;pAaf-y as 'S'...
�t pepth of sol tds �=._� ;>�. < ^ ",:,. n w.,,.. t
w&
s < aComments (note conddion of soil, signs`of hydraulic failure level'of pondVmg, condition of vegetation, etc.)"
;
tx�.a'��+`y ��',<v aa�7K..c "�ah. k-. >M:��.,...=.r s .a •e s (r v� ��� �`.` d "'�3', '"'+s�+'-' ��a'##��+c.`,+�4=.�
ax
"iktvr air i sad j ?
I� r. n���SqH - - � �-•. i "�.x v 4Y'.�,y' 'ix� a +a � �i°„c£•�t^�..
€.��s z 4Y�3�,� l , .. • q '"'� : � _� G•�� es�'�� ��r., � H�Y���'�_,th s���,
+#y g` + a ' '' t 5 � f'E x• L t -+y 'a57nz,
t,
* (revised"8/15f95) ' �< x �; te ��
�St+x �,r, ti .�: - it .s• �y ���� �u•.. •� X+, �1 $��a�'4.
.*,��xa?m��ax 'y t i,' - - t Ar'.. ��,� +c..+.. •`C����� FS t
3y`a.� y s: • x t � A.�':y � �fi'"` F".' € ,y ,kM-may.,:,'�.9L2F°�,.�,. ,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART Cx4xa
SYSTEM INFORMATION (continued) "` ;F �;;'•
P I n16/ ��ur\/�v� L' Wb AJ�1� v..R,C,V h�.�t
� "Pro a Address: 6 x ,
'Owner. '.IM.J'S. �pv.� .. . ����„r •.' �,
d Date of Inspection: .h
\
SKETCH OF SEWAGE DISPOSAL.SYSTEM: '
T include ties to at least two permanent references landmarks`or benchmarks
t locate all wells within 100' '
L ry
�K 3
777
.y
3/r
4 Sam
,rm� l
N £
K2+
HE,
x+ i .i f yO r
�j r :i
# 4
'n �. ..-.
f5W'i
t
r
tnzy� gy
Jz'
{ a \ f
rr X +sue ti �
fM�"�r.,*�5',�g��t' �p-'�" �+a r�Yr��'t-'s�`.. 't.^��-�3_��
V ,'"��C;a., ^i 5$'t�u, r r. r !'B-.4,•!., $j, y x a 3,.�< '�L yr�F 'c ;q 'f"
yr r,E - Ott c� ri
rat �r'xi a•c -.L' ,z,y" v '+rt-
DEPTH TO,GROUNDWATER 4 '\`��� �;�"ye`��,"�'s'1k•;Rk
`Depth to g►oundwater feet
method of determination or"approximation
� riJr.r '` ya.; � s f /• " r � 5• J*�a".'r" � �_h.�.t�•'.!�`e�„`g�"",� f. +" 5���
t •. >_,.. _`:. .... .. :. .. _ ° "' .:.:. ,. .t "L _ � ,:rtF't�,}ems.�'
�{ n,t�� k' � :_ , �." •a 1�{ ..s ash• -�"���'�'� �`3 }�.,.� .�c����
-(ZQV�BQd 3 6�is 951 9 * ar "..�, �,td• *^3 r ' ''!- x xtfi- F� f_ f
s�!�, t sc�a"� r ru. ,� t +. " §e s s r -, •hx�'�` jwr ; ,o-. ,. +t i rn- y�+.T p�, a5 x'�d;
ems :
TOWN OF BARNSTABLE
LOCATION '� �. � �"j(�:./ ClQb SEWAGE a
VILLAGE ��VUlrlllYe'�U�1 ASSESSOR'S MAP & LOT 61,2
INSTALLER'S NAME & PHONE NO. �
SEPTIC TANK CAPACITY 95—;�j!;:rps,,�
LEACHING FACILITY:(type) � �^ 06 (size) w f
NO. OF BEDROOMS3 PRIVATE WELL OR UBL1C WAT.' R
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED: �t - 'Z
VARIANCE GRANTED: Yes No
r 4
rj,`
��� jell
cal DSO
Fss. .�..�..............
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH APPROVED
TOWN OF BA R N STA B LE 8ar bt m erve ion Department
Appliration for DhipwiFal Workii Tome
gign6d Date
Application is hereby made for a Permit to Construct ( ) or Repair ( L�- n Individual Sewage Disposal
System at:
�......L cation-Address or Lot No.
Owner Addres
Installer Address
Type of Building Size Lot............................Sq. feet
�. Dwelling—No. of Bedrooms......................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
d . Other fixtures --------------- ---------------
w Design Flow....... .._ .....................gallons per person per day. Total daily flow........�3��b......................gallons.
W Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter__-_-_-----------------
Depth................
x Disposal Trench—No..................... Width_._.. ....... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No.....j-------------- Diameter----L0......... Depth below inlet... _.......... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
�14 Test Pit No. 2................minutes per inch Depth of.Test Pit---:................ Depth to ground water........................
R'+ -----------------------------------------------------------•---......-----------•----••-----••_..............................................................
ODescription of Soil........................................................................................................................................................................
x
w
U Nature of Re�irs or Alterations—Answer when applicable-__ _ .......d_ ...1.�q !�._ � ........
---------------w ` ..e ms....
---------------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Corn e has be iss//ued b the and of health.
` Z� `Signed .. -- --------------------- -------�---p'V----
Date
Application Approved BY ✓ J -------- -- ................................................................... Date
Application Disapproved for the following reasons: .....................-------------------------------------------_------_--------...................................................
..--..._.--. .........................-------------------'----------......---------------................---...----............_:.--------.....-----....-------------- -'--------.. ........................................
Date
PermitNo- -------------------------------------------------------------------- Issued ........------------........ ------. --------...-----------
Date
�C-C (
Fizz.... .o.........
! THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE _
Appliration for 11ii utial lard Can t trnr n erntt �- a
Application is hereby made for a Permit to Construct ( ) or Repair ( L)--an Individual Sewage Disposal
System at: r� '
(� Cov v\.-c�i G tab 0V Ot
Location-Address or Lot No. t
..................... ........s_. .........•------...-••-••-•-•---..__...--•--•-• ...........-----•--S}n!.........................................
�\
Owner _ - /-� Address r -
nl
...............v.._A. ._.. �._..__.__.__.._................ .......-.--._�_.__.-----------......._�:.-....._..__._........._._........................_._..._.
Installer V i' Address
Q Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms___-_�____________---------------------Expansion Attic ( ) Garb geGrinder ( )
aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
QOther fixtures ........---•----- -------•-----------------------------------------------------
W Design Flow____.__?-___....................gallons per person per day. Total'daily flow-----_�•�3 .......................gallons.
W Septic Tank—Liquid capacity------------gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No_ ____________________ Width.................... Total Length.................... Total leaching area....................sq. ft.
�r
� Seepage Pit No.....I.............. Diameter....�.�..c...... Depth below inlet... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
~I Percolation Test Results Performed by---------------------------------•----------------------•---•------------ Date........................................
1.4
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
rzq Test Pit No. 2................minutes per inch Depth of.Test Pit.................... Depth to ground-,water........................
ODescription of Soil...............................................................................--------------------••---------•- - ''�
V
W ---------------------------------------------------------------------------------------•--------------------------------------------------...-------•---------
U Nature of Repairs or Alterations—Answer when applicable____�__w _`l 0_��_______t_..��v_._C. -G ��{ !�! � ___-
t _ , l --
------------- 5`l-i�ti '-------`�` ------- �1y v 7 "1
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the,
system in operation until a Certificate of Cor�2pliagce has been issued by.the board of health.
Signed t"'
U--'--------... Daze
Application Approved By -- w..... ---- ......--5.- lv- .2
Application Disapproved for the following reasons- ------------------- :......
.-.._---�---= ------------- -
--------------------------- --- -------....--...----------- -- -- .....----- ----- ------------------ ------ ..-...---- ------------. -'"-�- ----------
Dare
Permit No. ,f/Esui5d' ! %� �''� . .. ----
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
CeT`ttftettte of C11IImytiance
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
by-------------...................................
-, I C_............................................. ------ ----------------------------
s alter �
at ------------------ ---------------------} a Cn.ti.r.L -.V•f...G vl' .... J v C ..' . ` �J -
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. ................................................ dated ................................................
THE ISSUA�4q,,OF THIS CERTIFICATE SHALL NOT'BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTTIO14 SATISFACTORY.
DATE---------------------------- A
J
- Ins
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
- ,,
No.... FEE___r�.o.........--
lRisposal Worse Tonstrnrtion rrnttt
Permission is hereby granted._.__.___._ ' __.(:bAe`r.O_._-<{'l�_._Y_L.___.__
•----------------------------------•........................
to Construct ( ) or Repair ( ) an Individual Sewage Disposal System
at No. t.(1? Ord_?2 C�,VK u'11 Cl L�lD
-------- ---------•-----•--------•-•-__
Street �'
as shown on the application for Disposal Works Construction Permit No.__1a7 Dated..........................................
---------------------------------------------------
C �
DATE................... -�)..-•--------•--•-------------•-•--- Board of HealthV
FORM 36508 HOBBS&WARREN.INC..PUBLISHERS
77 ,
LOC&T-ION 5EW C4E. PERMIT M-O..
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ASSESSORS MAP
tARCFI N0:
--IN-STQLLER-S-1J-dNlE-�-A-D.DRE.SS _—
DATE APE-Rt A T 1.55UED--._�.-.1st'a-7
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LOC_AT_ION-_ __ ___ __ _/_pS�EWA,C,E PERMIT_UO.
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13.U.Ll._O_ER-S-t�l_A1.�lE_�_ADDRE.SS
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No.................
....... ...................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF -E , TH
----------- OF.... .............. ..... . ...... .....
-- ----- -------------
Appliration for Disposal Works Toustrurtion ramit
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at:
# q '7
............................................ ....... ............................................... .............................
r Locati,A,-Addr-, or Lot No.
No
. ........ ............... ...................................................
0 er Address
..........
.................. - -------------------
a........... ..... ......I......................................... ..............................
Installer Address
U
Type of Building— 3 Size Lot............................Sq. feet
( V?
Dwelling ENo. of Bedrooms............................................Expansion Attic (71)* Garbage Grinder
PL4 Other—Type of Building ............................ No. of persons............................ Showers Cafeteria
Otherfixtures ......................................................................................................3.3.....................................
Design Flow________...57.-S.....................gallons per person per day. Total daily flow...................0.....................gallons.
r4 Septic Tankf��Liquid capacity//21.V..gallons . Length................ Width__.__,_._._.___. Diameter....._...___._._: Depth___._.__.___....
Disposal Trench—No_ ____________________ Width_.____..__._ Total Length.__._____._ ...... Total leaching area....................sq. f t.
Seepage Pit Noi.-I.............. Diameter_.. ....... .... Depth below inlet.______............ TAal leaching area.,YUT,:�!1q; ft.
Z Other Distribution box Dosing tank ) —d - — 9 77,
Percolation Test Results Performed by........... ...... ....................... Date..... .....
Test Pit No. -----minutes per inch Depth of Test Pit_,__,_. ............. Depth to ground water.____.._..,.,______,_...
44 Test Pit No. 2................minutes per inch Depth of Test Pit___.._._________.__. Depth to ground water.._.___.._.____..____...
9 .................4............................. ;.......... ........
t-�-X- --------------7.............. ------
----------- ... ......
0 Description of Soil....e.::n
U .........................................7...............................................................................................................................................................
--------------------------------------------:....................................................................... ................................................................................
U Nature of Repairs or Alterations—Answer when applicable------------------------------ .....................................................------
....................................................................................................................................................................................................
Agreement:
. The undersigned agrees to install the aforedescribed Individual Sewage Disposal System. in accordance,with
the provisions of'I"I'LPIE 1 5 of the State Sanitary. Code—The undersiffed further agrees not to place the system in
operation. until a Certificate.of Compliance has been issu y th of health
SignDate.............. .......................................W...... ............ ..
Application Approved By....... ... ------- ------------------------- .....
Date
Application Disapproved for the following reasons:..............................................................................................................
....................................................................................................................................................................................I...................
Date
PermitNo.--- ....•-•------•---•-------•-•----•-•--------------- Issued.......................................................
Date
. ..S'Y"rl�'c� a _.t � :?r��t e :.'�n1. �.a� ,.3�r�l.,:{7x :� »4 �n?$''�k'y.�`��.:- \ y �s.,,{:�, k �.`�.•;"'� "i .:",l�y�.�`.��� -Y.:�.y- .
No.........» _ . _ "Fxs . `.. ........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF E TH
> -- .. ... OF... ...................................
. • x
' Appliratiun for Disposal Works Tonstrur#ion Frrmit
Application is hereby made.for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal"
System at:
•- Locati n-Address or Lot No.
._... .�».. .... ......... ................ .....................................________..............................._
O Address
t -•-----------------•----•-----------•-••----_____----------------•---•---------
$ Installer Address
Type of Buildin Size Lot----------------------------Sq. t
Uy` ._.__Ex anion Attic Garbage Grinder �.
. � Dwelling=.No:.:°�Bedrooms-------------•---•--•------------------ P g (
aOther—Typeq#:3Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
Other fixtures -------------------------- ................................
Design Flow______ .."I. -_____ gallons per person per day. Total daily flow................... gal
W -- ------------gallons.
. W Septic Tank Liquid capacity�P�'�'__gallons Length................ Width................ Diameter................ Depth................
Disposal Trench—.No
Io _______._ _ ._ Width _ , .._ Total Length......... Total leaching area_____ ______s�9. ft.
Seepage Pit No_ ____ ___________ Diametc _..__ epth below inlet . ......_. T 1 leaching area_ �aa�q. ft.
Z Other Distribution box Dosing tank ( ) �(� - .2� /9 7`7
'-' Percolation Test Results Performed by______._._ jp�_ _._ '. .__..___..._ Date..... ? " '
Test Pit No.'1 ' ____.minutes per inch Depth of Test Pit _________________ Depth to ground water __..._.._
(_, Test Pit No. 2................minutes per, inch Depth of Test Pit.......:......._____ Depth to ground water..........................
O Description of Soil.... tF_ .......... .
V ---------------------------------•---•-----=---- =•----•--------------
W _.
;;:
U Nature of Repairs or Alterations=Answer when applicable.................................................................._______________________________
Agreement:
The undersigned agrees✓to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITIE 5 of the State Sanitary Code—The undersi ed further agrees not to place the system in
operation until a Certificate Compliance has been iss th" of health.
Sig -- - -------- -- "• ---•- ................................
Date
Application Approved By...... �==., -----,- - - �� -- ........................ � --- +��--" �-�--•-�-r�-'�--
Date
Application Disapproved for the following reasons------------- -- . --------------------------•-------------------------------------------------•-•----
.............................................................Y_...._____...._._._.__.___..___._._..__.....__._
i.. _
,Date
PermitNo......................................................... Issued_.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O . HEALTH
...........................................
(9rdifiratr of Tomplianp
THIS S TO C TI 'Y, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by........ ---•_--- - ---------••-------••---
In taller
at .......
has been=installed in accordance wi. the provisions of 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit N 7______1 ___ ____________ dated__..- _ .___ .............
t .
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE...--. ... ... Inspector Ron?". _ --------
j ,; .. ;
�- '
.. 1� tII�. /fit'. to C°� t•��� -,,Q o �..
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
&77
........OF......... .......................................
�tso �trk '° o irn rrnt #
A __ ' ! t.
Permissio ereby granted --- . ---•-- ----------....... ......... ....................... -----
to Construe or Repair In ivld Sewa ispod}y�yst,
at No:. _ _....
Street '+
as shown on the application for"Disposal Works Construction Per• • o. __ /:/__ 1_____ t d...I/�-X _
/ �x " Board of Health »
DATEfib' d.
FORM 1255 HOBBS & WARREN, ,INC.. PUBLISHERS -
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CERTIFIED_ . PLOT. PLAN
LOCATION
EDWARD E. KELLEY SCALE . . "30 DATE . . . . . .
CUM AAQUID, MASS..02637 PLAN REFERENCE QE iN� Lo r " 4-7
S Iokl v o v ,q .`?Z4.
OF 6f /2E�9LT�/ TQciS J A�vO QE�'D QD ED
EELLEY H
No 26100 O
� l 1 CERTIFY THAT THE ..
�C1STE� ,0� c E GROUND
SHOWN ON THIS PLAN IS "
�Aro SU10 ` AS SHOWN HEREON � NFORMS TO THE
SETBACK RE THE TOWN OF
. . . . . . . . . . . . . . . WHEN CONSTRUCTED.
/yes Mgccoty Mo,esE DATE
C/o WiG</RH E• SNEatH,9A T7z
PETITIONER: /,geyouTF/pazT, /yq s$,
REGISTERED LAND SURVEYOR
S//6-67- Z o F Z Sf/eZ-r3
EL. So.00'
TOP OF_FOUNGATION
CONCRETE COVER
CONCRETE COVERS
0 0 4' CAST IRON 12"MAX. f
12"MAX. m"�j
° PIPE ) .— 4°ORANGEBURG(OR EQUIV.)
o ITCH ) - MIN. PIPE- MIN. LEACH
PITCH I/4"PER.FT PITCH 1/4"PER.FT.
PIT PRECAST
o INVERT o a LEACHING
° EL• ,`F3• INVERT INVERT o . o PIT OR
c'. SEPTIC TANK DIST.•
w
EL..-9-As.. . EL¢ 73 >= EQUIV;
o INVERT /Cqo BOX — ' ,►
GAL. INVERT INVERT �j°~ °' :.�., 3/4°TO I I/2
o WASHED
EL.. .
/O'
w STONE
6'D IA.DIA
PROFILE OF GROUND WATER TABLE
SEWAGE DISPOSAL SYSTEM
NO SCALE .
SOIL LOG WITNESSED BY :
DATE /977.. TIME.-!!:!ti A.ti: /�FIuL_ !Ivee/,?
�! BOARD OF HEALTH
TEST HOLE I TEST HOLE 2 ENGINEER,
E L E V. .-44:I". . E L E V. .4$.30
WooACOFH WbbcLoAry .,
8.. 8 DESIGN DATA
SuB-SbiL SuC3Soi L
NUMBER OF BEDROOMS 3, ,
30
TOTAL ESTIMATED FLOW 33o GALLONS./DAY
BOTTOM'LEACHI NG AREA //3:/o ..SQ.FT. /PIT
I ile�,�y SIDE LEACHING 'AREA SQ.FT./ PIT
SAni p
GARBAGE DISPOSAL /NoPev . .(50 % AREA INCREASE)
SA,v p
TOTAL LEACHING. AREA 33/cZ9 SQ.FT
PERCOLATION RATE <ess ?x'A^? 2 MIN/INCH
LEACHING AREA PER PERCOLATION 'RATE SQ.FT.
.:`—WATER ENCOUNTERED '
NUMBER OF LEACHING PITS. . . . 1 .
APPROVED . . . . . . . . . : . BOARD OF HEALTH � Mug. . . . . . . . .
DATE .
AGENT OR INSPECTOR
OFlyys
ZoT'� .47
Co�.vr�y clue Deg vim. . . e
U L
THOMAS E.KELLEY CO. No.24260 N
i`125: i lAL CoG�/ ENGINEERS—SURVEYORS
�/o I✓iGL/AM �: �N�x�/�Nv Te. 346 LONG POND DRIVE 9o�F G/SAL
PETITIONER 80VT-1i YARMOUTH,MASS.
•9.2 My vT/•/1�o,e�
. . . . . 02664