HomeMy WebLinkAbout0425 AMES WAY - Health 425 Ames Way, Centerville
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UPC 12534
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Commonwealth of Massachusetts /-Q-DD/-066
I9 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
425 Ames Way
t-e
Property Address
Stephen Twomey
Owner owners Namer
information is �
required for every Centerville +�page. City/Town MA 02632 5/31/2019 2:'
State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. Inspector Information
fillip out forms 614r
on the computer, O
use only the tab Paul C. Martin
key to move your Name of Inspector
cursor- not Cape Cod Septic Services Inc.
keY y the return
urn Company Name
350 Main St.
rab Company Address
West Yarmouth MA 02673
City/Town State Zip Code
508-775-2825 S15016
Telephone Number License Number A�
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection.was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
6/6/2019
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of 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.cloc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface sewage Disposal System•Page 1 of 18
Commonwealth of Massachusetts
s 19 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
V 425 Ames Way
Property Address
Stephen Twomey
Owner Owners Name
information is
required for every Centerville MA 02632 5/31/2019
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.
1) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
System is in working condition.
2) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and 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
F Title 5 Official Inspection Form
I' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�U-
425 Ames Way
Property Address
Stephen Twomey
Owner Owner's Name
information is
required for every Centerville MA 02632 5/31/2019
page. Cityrrown State Zip Code Date of inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with.Board of Health approval if
Pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
is Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
L
425 Ames Way
Property Address
Stephen Twomey
Owner Owners Name
information is
required for every Centerville MA 02632 5/31/2019
page. City/Town
State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
425 Ames Way
Property Address
Stephen Twomey
Owner Owners Name
information is
required for every Centerville MA 02632 5/31/2019
page. Cityrrown
State Zip Code Date of Inspection
C. Inspection Summary (Cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 5 of 18
Commonwealth of Massachusetts
IF Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
425 Ames Way
Property Address
Stephen Twomey
Owner Owner's Name
information is
required for every Centerville MA 02632 5/31/2019
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes"to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes" or"no"for each of the following for all inspections:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided.with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
1
Commonwealth of Massachusetts
Title 5 Official Inspection Form
r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
425 Ames Way
rroperty Address
Stephen Twomey
Owner owners Name
information is
required for every Centerville MA 02632 5/31/2019
page. Ciry/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 110x3=
Description:
330gpd -
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ❑ No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection
information in this report.) ❑ Yes ® No
Laundry system inspected? ® Yes ❑ No
Seasonal use?
❑ Yes ® No
Water meter readings, if available (last 2 years usage(gpd)): 2017=151gpd
Detail:
2018=121gpd
--
Sump pump?
❑ Yes ® No
Last date of occupancy: Current
Date
t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
ip Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
425 Ames Way
Property Address
Stephen Twomey
Owner Owners Name
information is
required for every Centerville MA 02632 5/31/2019
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present?
❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? El Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use:
Date
Other(describe below):
3. Pumping Records:
Source of information: No Records
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 Form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
- (F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
425 Ames Way
Property Address
Stephen Twomey
Owner information is Owner's Name
required for every Centerville MA 02632 5/31/2019
page. Citylrown 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:
Est. 20
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade:
15"
feet
Material of construction:
❑cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: +10'
feet
Comments (on condition of joints,venting, evidence of leakage, etc.):
Line checked with sewer camera and found to be clean, properly pitched with no sign of root
intrusion.
t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18
Commonwealth of Massachusetts
p Title 5 Official Inspection Form
is Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
425 Ames Wa
Property Address
Stephen Twomey
Owner Owner's Name
information is
required for every Centerville MA 02632 5/31/2019
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 7"
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: 1500Gal
Sludge depth: 2-3"
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness 3-5"
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined? Estimated'
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
1500Gal tank in good structural condition. PVC tees in place. Tank at normal operating level. Covers
5" below grade.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
425 Ames Way
Property Address
Stephen Twomey
Owner Owner's Name
information is
required for every Centerville MA 02632 5/31/2019
page. City/Town
State Zip Code Daespection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade:
feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass 9 ❑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 El polyethylene
iEl other(explain):
I
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
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
s 425 Ames Way
Property Address
Stephen Twomey
Owner Owner's Name
information is
required for every Centerville MA 02632 5/31/2019
page. City/Town
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 Oil
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.):
H-10 DB-6 with 1 line in and 5 lines out in good condition. Box is clean and level with minimal solids
carryover. No sign of overloading or hydrailic failure. Cover 6" Below grade.
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
i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
l;
425 Ames Way
Property Address
Stephen Twomey
Owner Owner's Name
information is
required for every Centerville MA 02632 5/31/2019
page. Cityrrown 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:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length: —
® leaching fields number, dimensions: 1-5 Lines
❑ 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
Commonwealth of Massachusetts
11F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,. 425 Ames Wa
Property Address
Stephen Twomey
Owner Owners Name
information is
required for every Centerville MA 02632 5/31/2019
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
1-Leach field with perforated pipe and stone. No standing effluent in lines during inspection. Lines
were clean , soil was probed with no sign of overloading or hydraulic failure.
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
Commonwealth of Massachusetts
z Title 5 Official Inspection Form
is Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
425 Ames Way
Property Address
Stephen Twomey
Owner Owner's Name
information is
required for every Centerville MA 02632 5/31/2019
page. Citylrown
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
lip Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
425 Ames Way
Property Address
Stephen Twomey
Owner Owners Name
information is
required for every Centerville MA 02632 5/31/2019
page. Cit ,T own
State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
❑ hand-sketch in the area below
® drawing attached separately
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18
Commonwealth of Massachusetts
,p Title 5 Official Inspection Form
It Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
425 Ames way
Property Address
Stephen Twomey
Owner Owner's Name
information is
required for every Centerville MA 02632 5/31/2019
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: +10'
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed:
Date
® Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Hand auger did not encounter water at 10'. Max bottom of leaching is 4'.
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
P Title 5 Official Inspection Form
Subsurface Sewage Form-Not for Voluntary e Disposal S Assessments
425 Ames Wa
Property Address
Stephen Twomey
Owner Owner's Name
information is
required for every Centerville MA 02632 5/31/2019
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria)and 6 (Checklist)completed
® D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18
Y � _
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4N.\ COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL 21
DEPARTMENT OF ENVIRONMENTA ECTION i,t#
01E )A INTER STREET. BOSTON. h1.4 02108 61 _•SOU �
ae ✓ T
�� rA`�j�
TRUDY COXE
W'ILLIAM F.WELD
Govemo: 444 M Secretan
ARGEO P.aUL CELLUCCI AVID B.STRUHS
Lt.Govemor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIO b Commissioner
PART A d�
CERTIFICATION
Property Address: 425 AMES WAY CENTERVILLE Address of Owner: PO BOX 309 CENTERVILLE MA 02632
Date of Inspection: DECEMBER 30,1997 (if different)
Name of Inspector: JAMES A ORPHANOS
I am a DEP approved inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)
Company Name: CERTIFIED INSPECTION ASSOCIATES
Mailing Address: 47 CAMERON ROAD NORTH FALMOUTH,MA. 02556
Telephone Number. [S,QM)564-5653
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete
as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site
sewage disposal systems. The system:
X Passes
Conditionally Passes
_ Needs Further Evaluation B�y�the
eLLocal Approving Authority
_ Fails
Inspector's Signature: Date: DECEMBER 30,1997
The system Inspe or shall' bmit a copy of this inspecti n report to the Approving Authority within(30)days of completing this inspection. If the system is a
shared system or as a de gn flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office
of the Departmen f Envir nmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and the
approving authority.
INSPECTION SUMMARY: Check A, B, C, or D:
Aj SYSTEM PASSES:
X I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure
criteria not evaluated are indicated below.
COMMENTS:
B) SYSTEM CONDITIONALLY PASSES:
_ One or more system components as described in the"Conditional Pass"section need to be repaired or replaced. The system,upon
completion of the replacement or repair,as approved by the Board of Health will pass.
Indicate yes,no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance
(attached)indicating that the tank was installed within twenty(20)years prior to the date of inspection;or the septic tank,whether or
anot metal,is cracked structurally unsound,shows substantial infiltration or exfittrabon,or tank failure is imminent. The system will
` { pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health.
(revised 4126197) Page 1 of 10
DEP on the World Wide Web http:/AYww.magnet.state.ma.us/dep
Cj Printed on Recycied Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 425 AMES WAY p A.
Owner: BARBARA SCHRADER'
Date of Inspection: -DECEMBER So_1997e
A ` �0E
B]SYSTEM CONDITIONAL ASSES,.(conti
IrYv�• nued)
_ Sewage backup breakout or:high static water level observed in the distribution box is due to broken or obstructed pipe(s)or due to a
broken;settled or uneven disVibution box. The system will pass inspection(with approval of the Board of Health).
Describe otis'e atioh7�0V
broken pipe(s)are replaced
_ obstruction is removed
distribution box is leveled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection(with the approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
c]FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,
safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH
WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)DETERMINES THAT THE
SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet to a surface water
supply or tributary to a surface water supply.
_ The system has a septic tank and soil absorption system and the SAS is within a Zone 1 of a public water supply well.
_ The system has a septic tank and soil absorption system and the SAS is within 50'of a private water supply well.
_ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is
free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 PPM. Method
used to determine distance (approximation not valid)
3) OTHER
(revised 4/25/97) Page 2 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 425 AMES WAY
Owner: BARBARA SCHRADER `�
Date of Inspection: DECEMBER 30 1997
D]SYSTEM FAILS:
You must indicate either'yes"or"no"as to each of the following:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303.The basis for this
determination is outlined below. The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
Backup of sewage into the facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or the surface waters due to an overloaded or clogged SAS or cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day.flow. +
4 Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone 1 of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with
no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform
;T'It.,i T „,bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen.
E)LARGE SYSTEM FAILS:
You must indicate either"Yes"or"No"as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public
Yes No
The system is within 400 feet of a surface drinking water supply.
The system is within 200 feet of a tributary to a surface drinking water supply.
The system is located in a nitrogen sensitive area [Interim Wellhead Protection Area-(IWPA)or a mapped Zone II of a
public water supply well.)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of
314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
Pa e3of10
(revised 4125197) g
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 425 AMES WAY
Owner: BARBARA SCHRADER
Data of Inspection: DEUMBER 30 1997
Check if the following have been done: You must indicate either"Yes"or"No"as to each of the following:
Yes No
X _ Pumping information was requested of the owner,occupant,and Board of Health.
X _ None of the system components have been pumped for at least two weeks and the system has been receiving normal
flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
X' — As built plans have been obtained and examined. Note if they are not available with N/A.
X _ The facility or dwelling was inspected for signs of sewage back-up.
X — The system does not receive non-sanitary or industrial waste flow.
X _ The site was inspected for signs of breakout.
X _ All system components,excluding the Soil Absorption System,have been located on the site.
_ The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,
material of construction,dimensions,depth of liquid,depth of sludge,depth-of-scum.
X _ The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub-Surface
Disposal System.
The size and location of the Soil Absorption System on the site has been determined based on:
Existing information. Far.Plan at B.O.H.
X _ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)
15.302(3)(b)]
AS-BUILT SKETCH SHOWS FIELD AT 79 FROM LEFT HOUSE CORNER AND 89-FROM RIGHT RO TO CORNER
AR OF YARD PARTIALLY BELOW
AT THE RIGHT REAR OF THE
LOT LOOKING FM FRONT REAR FIELD SURVEY INDICATES THAT FIELD 1a LOCATED IN LEFT
AN ABOVE GROUND SWIMMING POOL.
(revised 4/26/97) Page 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 425 AMES WAY
Owner: BARBARA SCHRADER
Date of Inspection: DECEMBER 30,1997
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 110 g.p.d./bedroom for S.A.S.
Number of bedrooms: 3
Number of current residents: 3
Garbage grinder(yes or no): NO
Laundry connected to system (yes or no): YES
Seasonal use(yes or no): NO
Water meter readings,if available(last(2)year usage(gpd): 1995 IS 119,000 GALLONS: 1996 IS 88.000 GALLONS AND FIRST 6 MONTHS OF 1998
IS 32,000 GALLONS.
Sump Pump(yes or no) NO
Last date of occupancy: THE HOME IS CURRENTLY OCCUPIED
COMMERCIAL/INDUSTRIAL: N/A
Type of establishment:
Design flow:_9allons/day
Grease trap present: (yes or no)
Industrial Waste Holding Tank present:(yes or no):
Non-sanitary waste discharged to the Title 5 system: (yes or no)
Water meter readings,if available:
Last date of occupancy
OTHER: (Describe) M
Last date of occupancy: y -
GENERAL INFORMATION
PUMPING RECORDS and source of information:
THE SEPTIC TANK WAS PUMPED IN DECEMBER OF 1996 ACCORDING TO THE OWNER
System pumped as part of inspection: (yes or no) NO
If yes,volume pumped: gallons
Reason for pumping:
TYPE OF SYSTEM
Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
_ Privy
Shared system(yes or no) (if yes,attach previous inspection records,if any)
Other(explain)
APPROXIMATE AGE of all components,date installed(if known)and source of information:
11/24/92 ACCORDING TO CERTIFICATE OF COMPLIANCE#92 15 ON FILE AT THE BOARD OF HEALTH
Sewage odors detected when arriving at the site: (yes or no) NO.
(revised 4/25/97) Page 5 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 425 AMES WAY
Owner: BARBARA SCHRADER
Date of Inspection. DECEMBER S0.1997
BUILDING SEWER: �l
(Locate on site plan)
Depth below grade:
Material of construction: cast iron 40 PVC _ other (explain)
Distance from private water supply well or suction line
Diameter
Comments: (condition of joints,venting,evidence of leakage,etc.)
SEPTIC TANK:
Qocate on site plan)
Depth below grade: 4"
Material of construction: X concrete metal Fiberglass Polyethylene other(explain)
if tank is metal,fist age confirmed by certificate of Compliance (Yes/No)
Dimensions: 5'WIDE X 10'LONG X 4'DEEP (EFFECTIVE)
Sludge depth: 1"
Distance from top of sludge to bottom of outlet tee or baffle: ,'}r
Scum thickness: 0"
Distance from top of scum to top of outlet tee or baffle: $"
Distance from bottom of scum to bottom of outlet tee or baffle: 14"
How dimensions were determined: TAPE MEASURE.
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural Integrity,evidence of
leakage,etc.)
THE LIQUID LEVEL IS 48"AND THE TANK APPEARED VERY CLEAN A PLASTIC INLET AND CONCRETE OUTLET TEE ARE PRESENT AND IN
SATISFACTORY CONDITION THERE ARE NO ADVERSE INDICATORS AND NO RECOMMENDATIONS
GREASE TRAP: N/A
(locate on site plan)
Depth below grade:
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:
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of
leakage,etc.)
(revised 4126/97 Page 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 425 AMES WAY
Owner: BARBARA SCHRADER
Date of Inspection: DECEMBER 30.1997
TIGHT OR HOLDING TANK: N/A (Tank must be pumped prior to,or 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/day
Alarm level: Alarm in working order Yes: _NO
Date of previous pumping:
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
DISTRIBUTION BOX: X_
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) THE D-BOX COULD NOT BE
LOCATED AT THE TIME OF THE INSPECTION. IT APPEARS THAT IT IS LOCATED BELOW AN ABOVE GROUND POOL AND THEREFORE THE
LOCATION IN THE SKETCH IS APPROXIMATED.
PUMP CHAMBER: NIA
(locate on site plan)
Pumps in working order: (yes or no)
Alarms in working order:(Yes or No)
Comments:
(note condition of pump chamber,condition of pumps and appurtenances,etc.)
(revised 4126197) Page 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 425 AMES WAY
Owner. BARBARA SCHRADER
Date of Inspection: DECEMBER 80 1997
SOIL ABSORPTION SYSTEM(SAS): X
(locate on site plan,if possible;excavation not required,but may be approximated by non—intrusive methods)
If not determined to be present,explain:
Type:
leaching pits,number:
X leaching chambers,number: FOUR
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
Alternative system:
Name of Technology:
Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.
THE SOIL IS DRY AND NO INDICATION OF HYDRAULIC FAILURE IRE IS EVIDENT 9/18/91 PLAN BY YANKEE SURVEY MARSTONS MILLS
SHOWS 18 X 28 X 0 8 FIELD BUT NOTE ON PLAN SAYS REMMED 11121/92 4 INFILTRATION BASINS 2'OF STONE THE LEFT REAR
AREA OF THE YARD WAS PROBED AND GRAVEL PACK WAS FOUND PRESENT AT C IN THE LOCATION SHOWN IN THE SKETCH
CESSPOOLS: NA
(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(cesspool must be pumped as part of inspection)
Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
PRIVY: NA
(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.)
(revised 4125/97) Page 8 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 425 AMES WAY
Owner: BARBARA SCHRADER
Date of Inspection: DECEMBER 30.1997 - ;.,,•
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (locate where public water supply comes into house)
425 AM q WAY
IWATER SERVICE
21 31'
82'
POOL
APPROXIMATE LOCATION OF SAS
NOT TO SCALE
(revised 4125197) Page 9 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 425 AMES WAY
Owner: BARBARA SCH ADER
Date of Inspection: DECEMBER 30 1997
Depth to Groundwater 17.68 feet
Please indicate all methods used to determine High Groundwater Elevation:
Obtained from Design plans on record
_ CX Observation of Site (Abutting property,observation hole, basement sump etc.
Determine it from local conditions.
Check with lo
cal Board of Health
Check FEMA Maps
Check pumping records
Check local excavators installers
Use USGS Data
Describe in your own words how you established the High Groundwater Elevation. (fit be completed)
DESIGN PLAN SHOWS TEST PIT AT 11 0'"NO WATER" AND G DE ELEVATION AT 66 5'WHILE THE ELEVATION OF THE SMALL POND
LOCATED ACROSS THE STREET IS 38 82
(revised 4125/97) Page 10 of 10
No. 0.�
.h•�� (Q THE COMMONWEALTH OF MASSACHUSETTS
r APPRo! W BOARD OF HEALTH
Barnsttlpll C T BARNSTABLE
.. . - . OF.......................................
V utt#i> lar 15ispaial Works Tonstrudinn Prrmit
Application is hereby made fgra�mit to Construct ( X) or Repair ( ), an Individual Sewage Disposal
System at: �
LOT 13 AMES WAY CENTERVILLE
••..............___--__...--••-•---•............-------........---......_•---..._....--_..... ......................-.......................
- N-...........................................
Location-Address or Lot o.
...
RICHARD SCHRADER
...- ......___. .............• ..
•-•--------•._................ ......... . ..................._._.. .......
.._.._.. -- - -------•----
Owner Address
............
Installer Address
Type of Building Size Lot___43, 561 Sq. feet
Dwelling X No. of Bedrooms.-3..................... ..._._.___Expansiori Attic (X ) Garbage Grinder (NO)
P4 Other—Type of Building ..US................. No. of persons____________________________ Showers ( ) — Cafeteria ( )
a' Other fixtures ..........-....-......................................................................................................................................
W Design Flow......110..............................gallons per person per day. Total daily flow....330•...............................gallons.
94 W Septic Tank X-Liquid capacity1000-gallons Length$.-6___.___ Width.5-6_...... Diameter________________ Depth 5.............
x Disposal TrenchX-No.1................. Width_....18......... Total Length.___25..._...... Total leaching area_450 sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
`"' Percolation Test Results Performed by---UPPER CAPE ENGINEERING Date..... �2.7/91................
�.7 -
Test Pit No. 1_______ ......minutes per inch Depth of Test Pit....11.......... Depth to ground water.....NO
fi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a ---••- --------------------•---.........--••--.............._•-•---••_-•.........................................................
0 Description of Soil.......... v -1 .......1/! !/SUB....
x 1 ' -11 ' MEDIUM SAND
U ___ ____________MEDIUM -----......
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 TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee�Idl..bof h It .Signed . ........... ............. •_ ._
Application Approved By...l --.-�f ��: . ............. ......_ / Date
8 1�1,� =
Dat
Application Disapproved for the following reasons________________________________________ _......................_.........................................
_.._
........................................................p_...... .-.......___.__.........____......._.___._.___..___.._..____....___......___... ._._ ___.......____._ ...._....._
__ __
Date
Permit No......� �.,�r------------------ Issued....._____-! _ ����3
-•-- --._... Date
!' TOWN OF BARNSTABLE �c
LOCATION yZ Sr /ahv�S Gr `� SEWAGE #
VILLAGE C6h!'y"h Wl VL c ASSESSOR'S MAP & LOT /fin-on 1'0!�
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY 4�� 6 C.
LEACHING FACILITY: (type) //v f• t5 dl431 hr S (size) U N X P—VW l3
NO. OF BEDROOMS�� `
BUILDER OR OWNER
PERM T'DATE: fid A 2� COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge.of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet J Furnished by .0&PpAr-V1 - inrt,-
r _ _
p
� � � �
�- �� � � J
� � � � � _ �
f .
n
� � �
�.
_ _,
Ot'
_1 r.
OF BARNSTABLEe op ItIA#I9a—
LOCATION SEWAGE #
VILLAGE_ ASSESSOR'S MAP & LOT/b-oo/- 0o5"
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) (size),/
NO. OF BEDROOMS � PRIVATE WELL OR< BLIC WATER
BUILDER OR OWNER <S-cmz --4Lq-
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No J
r
nl
_L
qy �e
9
�9
t
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......-. --.. ...................•.....OF......................................---.........--.........---..........................
Applira#ion for Dispoa tl Works Tonstnution Frrnti#
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
................___.-__........................................................._........... ......................-.......................
•..........................................
Location-Address or Lot No:
......................__........................................................................ ..........------............................ ........ -•- -.............
Owner Address
a •-•------------------------------------------•-------...---...---...------------------------.-•-- ..................................................................................................
Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—Type T e of Building No. of persons............................ Showers
C4 YP g ---------------•-------•-•-• P ( ) — Cafeteria ( )
a' Other fixtures -----------------•-----.....----•--•-----•-•-- -------------------------
---------------------
W Design Flow............................................gallons per person per day. Total daily flow............-.------
--......................gallons.
WSeptic Tank—Liquid'capacity............gallons Length........_...... Width................ Diameter--.----------.-- Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter.............--..... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
� Percolation Test Results Performed bY.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit..................... Depth to ground water.....................--.
f14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P ---------- -----------------------------------------------•---..........._......------------------..........................................................
0 Description of Soil........................................................................................................................................................................
W
U .....................••....•••............•••-•----•------••••••------•------•---•••---...............•------•••----••-------••-----•-•......•••••-•-•-.........:.........------•--...-•-•.....-•---••-
W
--- -----------------_-- -----------------------------------------------------------......---...------------•--------•------------•------------------------•---••-------............_....._.._......
M. 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 undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed.............................•..........----•-••....-•--------••._.....----•--•......_ ...... ---•--............__...
.�� Date
Application Approved By... . �_' r=- .%_'..
Date
Application Disapproved for the following reasons-......................................../.................................................................
..................••.._....---•-•------..........---•---•--•-.................••----------....__---••----.......•------•-----•-•-----••••••-•-•-•--•••••..................••••--•••••.........-•-...-----
Date
Permit No.........._.
... -. Issued_........./.-"14a.��:3
Date—
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF.....................................................................................
Trdifiratr of Toutpliunrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
bY----------------------------------------------------------------------------------------------- ---.----------------------------------------------------------•--------------••---•------------
Installer
at.....................................................................................................................................................................................................
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No---- -.�?-.. ..- __.._.... dated-- -^-�f`..-®-
A
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFA TORY.
DATE..........................7...
-` ..... ----- Inspector............... ------�............................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....O F.....................................................................................
No. x.:.f- FEE........................
Disposal Works Tonutrnrtion rrntit 1.40 �r
Permissionis hereby granted..............................................................................................................................................
to Construct ( ) or Repair ( ) an Individual Sewage Disposal System
atNo...............................................................................................................................................................................................
Street
as shown on the application for Disposal Works Construction Permit No' %....... _._ Dated-----------------;........_._-.� ... `
---------------------------------------------------------------•.....--------.....--••--......----------
Board of Health
DATE................................................................................
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