HomeMy WebLinkAbout0104 ANSEL HOWLAND ROAD - Health 104 Ansel Howland Road
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Centerville
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SMEAD
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Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
•'°p 104 Ansel Howland Road
Property Address
Jeffrey J. Corey
Owner Owner's Name
information is required for every Centerville MA 02632 October 5, 2012
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not David D. Coughanowr, R.S.
use the return key. Name of Inspector
Eco-Tech Environmental
Company Name
43 Triangle Circle
Company Address
Sandwich MA 02563
City/Town State Zip Code
508 364-0894 1328
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
M
CM Needs Further Evaluation by the Local Approving Authority
�- sac
cc October 5, 2012
C�
t�i. _ In is Signature Date
T �- stem inspector shall submit a copy of this inspection report to the Approving Authority(Board
C14 of 7RpIth or DEP)within 30 days of completing this inspection. If the system is a shared system or
N h 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 should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****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.
�C ID 0/1
t5ins•11/10 Title 5 Official Inspect n Form:Subsurface Sewage Disposal System-Page 1 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
104 Ansel Howland Road
Property Address
Jeffrey J. Corey
Owner Owner's Name
information is required for every Centerville MA 02632 October 5 2012
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 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:
Inspector's Note==> The septic system described herein is deemed to pass this Real Estate Transfer
Inspection if it does not meet any of the failure criteria enumerated in Section D on pages 4-5. The
scope of this inspection is limited to health and environmental compliance and the septic system has
been evaluated according to the conditions observed on the day it was inspected. No estimate or
guarantee of system longevity is made or implied by a passing determination.
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass,
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of' }
Health. -s
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate b
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 104 Ansel Howland Road
Property Address
Jeffrey J. Corey
Owner Owner's Name
information is required for every Centerville MA 02632 October 5, 2012
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ 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):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
l5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
u W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
104 Ansel Howland Road
Property Address
Jeffrey J. Corey
Owner Owner's Name
information is required for every Centerville MA 02632 October 5, 2012
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/z day flow
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
;M 104 Ansel Howland Road
Property Address
Jeffrey J. Corey
Owner Owner's Name
information is required for every Centerville MA 02632 October 5 2012
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® 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 well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
104 Ansel Howland Road
M
Property Address
Jeffrey J. Corey
Owner Owner's Name
information is required for every Centerville MA 02632 October 5 2012
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 104 Ansel Howland Road
Property Address
Jeffrey J. Corey
Owner Owner's Name
information is Centerville MA 02632 October 5 2012
required for every ,
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 1
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)): 52 gpd
Detail:
2010, 2011 and first half of 2012
Sump pump? ❑ Yes ® No
Last date of occupancy: current
Date
Commerciallindustrial 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
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
I o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 104 Ansel Howland Road
Property Address
Jeffrey J. Corey
Owner Owner's Name
information is required for every Centerville MA 02632 October 5 2012
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use:
Date
Other(describe below):
General Information
Pumping Records:
Source of information:
owner
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
104 Ansel Howland Road
Property Address
Jeffrey J. Corey
Owner Owner's Name
information is required for every Centerville MA 02632 October 5, 2012
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
Age: 27+ years. Certificate of compliance for new system was issued 9/24/1985 (Permit#85-793 at
Health Dept).
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 2
feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Sewer line appears structurally sound with no evidence of leakage or backup into dwelling.
Septic Tank(locate on site plan):
Depth below grade: 1
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:
8.5 x 5 x 6- 1000 gallon tank
Sludge depth: 3 in
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
c
^M 104 Ansel Howland Road
Property Address
p Y
Jeffrey J. Corey
Owner Owner's Name
information is required for every Centerville MA 02632 October 5, 2012
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle 31 in
Scum thickness trace
Distance from top of scum to top of outlet tee or baffle 10 in
Distance from bottom of scum to bottom of outlet tee or baffle 14 in
How were dimensions determined? Design plan
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pumping is not required at this time. Maintenance pumping is recommended in 2-4 years. Tank and
tees appear structurally sound and functioning as intended.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
104 Ansel Howland Road
Property Address
Jeffrey J. Corey
Owner Owner's Name
information is Centerville MA 02632 October 5 2012
required for every ,
page. CityrTown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
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
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
l
Commonwealth of Massachusetts
4 W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�^M 104 Ansel Howland Road
Property Address
Jeffrey J. Corey
Owner Owner's Name
information is required for every Centerville MA 02632 October 5 2012
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert at outlet invert
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D-box appears structurally sound with no evidence of leakage in or out. Some solids in sump.
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.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
104 Ansel Howland Road
Property Address
Jeffrey J. Corey
Owner Owner's Name
information is required for every Centerville MA 02632 October 5, 2012
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Soils above leaching pit appear unsaturated. No evidence of surface ponding, breakout, lush
vegetation, or other evidence of hydraulic failure was observed. An observation hole was dug into
leaching pit stone and no effluent contact staining was observed in the stone or overlying soils. No
standing effluent was observed to a depth of 2 feet below the top of the peastone layer.
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
l5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
104 Ansel Howland Road
Property Address
Jeffrey J. Corey
Owner Owner's Name
information is required for every Centerville MA 02632 October 5 2012
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
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.):
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Officiaal .lnsp,ecton Form
Subsurface Sewage,Disposal.Systeni.Form---N'ot.for Voluntary Assessments
104 Ansel Howland Road
Property_Address
Jeffrey J. Corey
Owner Owner's-.Name
information is Centerville MA 02632 October 5',:2fl12
required=for every
page. city/rown State Zip Codez Date of Inspection
D. System Information (cont.)
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 1`00 feet. Locate
Where public water supply enters the building Check one of the.boxes below:
hand-sketch in the area below
El drawing attached separately
LE INCH
1T
t prN K
-
W
AAJ�C- L 40W r �
15ins•11110
Title 5 Official lnspocti6n Form:Subsurface Sewago Disposal System -Page 15 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
104 Ansel Howland Road
Property Address
Jeffrey J. Corey
Owner Owner's Name
information is required for every Centerville MA 02632 October 5 2012
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 15+
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: 9/10/1985
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:
Barnstable GIS Department records
You must describe how you established the high ground water elevation:
Approved design plan on file with the Board of Health shows bottom of system to be 4 feet above the
bottom of a witnessed test pit in which no groundwater was encountered. Town of Barnstable GIS
Department records indicate that the property is over 15 feet above groundwater table.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
104 Ansel Howland Road
Property Address
Jeffrey J. Corey
Owner Owner's Name
information is required for every Centerville MA 02632 October 5, 2012
page. Citylrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
Commonwealth of,Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 7 ,,
104 Ansell Howland Road, Centerville MA 02632 4:5715 Vr...
Property Address
James Rourke
Owner Owner's Name
information is required for 53 Knollwod Drive, Waltham MA 02345 July 1, 2008 ,
every page. Cltyfrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.
Imp
Men mg out
M filling A. General Information
When fil
forms on the
computer,use 1. Inspector:
only the tab key
to move your Patrick M. O'Connell
cursor-do not Name of Inspector
use the return
key. Septic Inspection Services Co.
Company Name i
VQ189 Cammett Road
Company Address j a
Marstons Mills MA t}2648
ream Cltyrrown _..:
State .; Zip Code
�.„ 508.-428-1779 SI 12855 r-
Telephone Number `` ' License Number 1
- -i~
B. Certification c-- r--
a rn.
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
2 July 1, 2008
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 is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the 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 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.
LOB-173ourke.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M �l 104 Ansell Howland Road, Centerville MA 02632
Property Address
James Rourke
Owner Owner's Name
information is y 53 Knollwod Drive, Waltham MA 02345 Jul 1 2008
required for ,
every page. City/town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
.__ -A) -System Passes:
® 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:
Tank scheduled for pumping following inspection, leaching pit was empty at time of inspection with a
high stain line indicating pit had not been more than half full.
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Answer yes, no or not determined (Y, N, ND) in the ❑ 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.
ND Explain:
❑ 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
❑ obstruction is removed
08-173 Rourke.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15
Commonwealth of Massachusetts
ERSERM
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
104 Ansell Howland Road, Centerville MA 02632
Property Address
James Rourke
Owner Owner's Name
information is required for 53 Knollwod Drive, Waltham MA 02345 July 1, 2008
every page. Citylrown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ . distribution box is.leveled or replaced.
ND Explain:
❑ 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
❑ obstruction is removed
ND Explain:
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
08-173 Rourke.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15
r
Commonwealth of Massachusetts
4 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
104 Ansell Howland Road, Centerville MA 02632
Property Address
James Rourke
Owner Owner's Name
information is y 53 Knollwod Drive, Waltham MA 02345 Jul 1 2008
required for ,
every page. Cityrrown 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**.
Method used to determine distance:
**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:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No" to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than_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.
08-173 Rourke.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
104 Ansell Howland Road, Centerville MA 02632
Property Address
James Rourke
Owner Owner's Name
information is 53 Knollwod Drive, Waltham MA 02345 Jul
required for y 1 2008
every page. City/Town State Zip Code Date of Inspection
B. Certification cont.
D) System Failure Criteria Applicable to All Systems (cont.):
Yes No
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply
well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory, for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of he follvoiing, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
if you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
08-173 Rourke.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15
Commonwealth of Massachusetts
uTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
104 Ansell Howland Road, Centerville MA 02632
Property Address
James Rourke
Owner Owner's Name
information is y 53 Knollwod Drive, Waltham MA 02345 Jul 1 2008
required for ,
every page. Citylrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes"or"no" as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
❑ ® Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
❑ ® Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
❑ ® Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation.of distance is unacceptable) [310 CMR 15.302(5)]
L08-173ourke.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M ' 104 Ansell Howland Road, Centerville MA 02632
Property Address
James Rourke
Owner Owner's Name
information is required for 53 Knollwod Drive, Waltham MA 02345 July 1, 2008
every page. City/Town State Zip Code Date of Inspection
D. System Information
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): 330
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?(if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage 68,000 gal. _
9 ( Y 9 (gpd)): 93 gpd.
Sump pump? ❑ Yes ® No
Last date of occupancy: November 2007Date
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
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe):
08-173 Rourke.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15
r
Commonwealth of Massachusetts
NO Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
104 Ansell Howland Road, Centerville MA 02632
Property Address
James Rourke
Owner Owner's Name
information is required for 53 Knollwod Drive, Waltham MA 02345 July 1, 2008
every page. City/town State Zip Code Date of Inspection
D. System Information (cont.)
General Information
Pumping Records:
Source of information: None
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
1985
Were sewage odors detected when arriving at the site? ❑ Yes ® No
08-173 Rourke.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
104 Ansell Howland Road, Centerville MA 02632
Property Address
James Rourke
Owner Owner's Name
information is y 53 Knollwod Drive, Waltham MA 02345 Jul 1 2008
required for ,
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan):
1'
Depth below grade: feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade: 1
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:
8.5' long x 5.2'wide- 1000 gal.
Sludge depth:
4"
Distance from,top of sludge to bottom of outlet tee or baffle
26"
Scum thickness 3-1
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
10"
How were dimensions determined? Measured
08-173 Rourke.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
104 Ansell Howland Road, Centerville MA 02632
Property Address
James Rourke
Owner Owner's Name
information is Y required for 53 Knollwod Drive, Waltham MA 02345 Jul 1, 2008
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Liquid level was found at bottom of outlet invert, tees are intact and clear.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
08-173 Rourke.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
104 Ansell Howland Road, Centerville MA 02632
Property Address
James Rourke
Owner Owner's Name
information is 53 Knollwod Drive, Waltham MA 02345 Jul 1, 2008
required for y
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Tight or Holding Tank(cont.)
Dimensions: —
Capacity: gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*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 On
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.):
No solids or high stains present.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
08-173 Rourke.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
104 Ansell Howland Road, Centerville MA 02632
Property Address
James Rourke
Owner Owner's Name
information is required for 53 Knollwod Drive, Waltham MA 02345 July 1, 2008
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
® leaching pits number: One 6x6 pit.
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leaching pit was found empty with a high stain line indicating pit had never been more than half full.
08-173 Rourke.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
'< 104 Ansell Howland Road, Centerville MA 02632
Property Address
James Rourke
Owner Owner's Name
information is
required for 53 Knoliwod Drive, Waltham MA 02345 July 1, 2008
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
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.):
Privy (locate on site plan):
Materials of construction:
Dimensions —
Depth of solids
Commends (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
L08-173Rourke.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
104 Ansell Howland Road, Centerville MA 02632
Property Address
James Rourke
Owner Owner's Nan,,-
information is required for 53 Knollwod Drive, Waltham MA 02345 July 1, 2008
.._—
every page. City/Town State Zip Code Date of Inspection
D. Systern Information (cont.)
Sketch Of Sewage Disposal System: Provide a sketch 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.
58 35
55 27
, / / „
%
r / r / / / /I%
\ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \
Water
Service
Ansell Howland Road
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
104 Ansell Howland Road, Centerville MA 02632
Property Address
James Rourke
Owner Owner's Nam:
Information is required for 53 Knollwod Drive, Waltham MA 02345 July 1, 2008
-
every page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Er:am:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to ground water: 15
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:
USGS topo map and town GIS.
You must describe how you established the high ground water elevation:
Town groundwater contour map shows water at el. 35 and topo map shows property at el. 50.
08-173 Rourke.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15
I
i
Town of Barnstable
F THE
" Regulatory Services
saxxsrns�e Thomas F. Geiler,Director
9� r Public Health Division
ptED MA'S A
Thomas McKean,Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
REGARDING SEPTIC INSPECTIONS BY PRIVATE CONTRACTORS
DISCLAIMER
This septic system inspection report was completed by a private inspector who is certified by
the State of Massachusetts, Department of Environmental Protection.
Although the Town of Barnstable Health Division received the original or copy of the report;
this Division does not warranty the functionality of the septic system in the future nor does
this Division agree with any technical observations and interpretations contained within this
report.
In addition, by receiving this report the Town of Barnstable Health Division does not
automatically approve the number of bedrooms listed within this report. The actual number
of bedrooms approved at a particular property would be listed on the "Disposal Works
Construction Permit".
If you should have any questions regarding this report, please contact the certified Septic
System Inspector who conducted the inspection.
QASEPTIC\Disclaimer Private Septic lnspections.DOC
`TOWN OF BARNS BLE
LOCATION &A Anse d Adev�,0mj' \`8 SEWAGE#
VILLAGE C2 viNq r.ASSESSOR'S MAP&PARCEL
FRS NAME&PRONE NO.
SEPTIC TANK CAPACITY 1600 �
LEACHING FACILITY:(type)��I' (size) QJ
NO.OF BEDROOMS
OWNER �afte.S
PERMIT DATE: C E DATE:-;4;,�P, -71 t los
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the 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
FURNISHED BY
,
i
358 5
55 27
I
I
I
i
Water
Service
.s.. A_..,,....d.!:iol..'►�ncA.!e.rnrl'_�.n�'el�.___—_----""" -- —._..
� )
No. �: .. Fps......��.�...................
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® 9F HEALTH
----------- --.....OF.............................. ....... ...............................
Apptiration for Uispooa1 Works Tom5trnrtion ranfit
Application is hereby made four a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
system .. . ...... !..GI.............. - ------ ------- - ------ ----------------------------------------
3�
Loca' n-Address or Lot No.
...... .. .......... ... ..... .................................................. .................. -- ----------------
-.......
...............
Q^pjer Address
a ----- -- - ------------
Installer Address
d Type of Building -- Size feet
Dwelling—No. of Bedrooms........ ..............................Expansion Attic ( ) Garbage Grinder (/)v6
Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria
a' Othe fixtur
W Design Flow......................_______-------------gallons per person per day. Total daily flow..........3..... Ions.
WSeptic Tank—Liquid capacityt§!!7.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........................................
a . 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........................
Q+' -------------------------------------------------------------------------------------------------------------------------------------------------------------
ODescription of Soil................................-....................................................................-------------------------•----------------------------------------
x
U -----------------------------------•------------------------------------------------..__....------......--------------------------•-•-•--•--------•---•-------------•-----------------•---••------------
W ----------------------------------------------------------------•-------------------•-----------------------------------------------------------•---------------------------------------------------_...
UNature of Repairs or Alterations—Answer when applicable................................................................................................
----•---•-----------------------------------------------•--•--------------------------._....._-•_...--------------•----------------------------------------•-•--------------------------................
Agre ent-
T e undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
e p ovisi i of T11, 5 the State Sanitary Code—The undersigned further agrees not to place the system in
op do n fic f Compliance has beenis§ued by the b and of health.
�j
Signed--- . --- .................................... -•-- .....s....I y .
A ' roved B !6� — --._.. ----D
ca n At 1 PP y-------------.—.
Date
plication Disapproved for the following reasons------------------------------------------•-------------------------------------------........................
.................................................•---------------•--------...---......-----•--------......---._..__...._..-------------- -------------------•------------------------------•-------....
Permit No._.__ �-- _�� Issued_____________________________
------------------ ....._..ate
Date
-------------
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.t'�- LOCATION # - SEWAGE PERMIT NO.
85 A 773
VILLAGE
60 ta -Ile
INSTALLER'S NAME&ADDRESS
�Q�L�,v. �i,G(.�A �r�. Uhl'•
BUILDER OR OWNER
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED /
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THECOMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Appliration for Disposal Works Tonstrur$ion ami$
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
• " o Lot N
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i Location Address ' .�'"r .
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Owner Address
{ ........................................E tA. E'er 71.E j ...... .................•.............
Installer Address
Type of Building Size Lot` {__f_.`�`....._Sq. feet
�-, Dwelling—No.I of Bedrooms-----------7�1................................Expansion Attic ( ) Garbage Grinder
Other—Type of Building ••••----__.--- No. of ersons............................ Showers
Design Flo Other
_______g............... p ( ) Cafeteria (;f){t
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Other fixtures
ign w........ P' ._ gallons per person per day:"Total daily flow-_-_-__-- ._...ga gallons.
w -- .....•. 11
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.......................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water...........::___._.._...
----•--•------------------------------•-•------------ •-•-•-......•... -----._.... --•-•-----•------••-•--••----.---•-
D Description of Soil.............................................................................------ -------�
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VNature of Repairs or Alterations—Answer when applicable.______________________________•................................................................
--------------------.......------------------------•------•-•-----••-----------••---•--••----•-•--------.....---------------------------------------------------------------------------•--•---.....•-_.
Agr ent:
e undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
e visi r o 51 1 the State Sanitary Code—,.The undersigned further agrees not to place the system in
op do un i e the of Compliance has been issued'by the board of health. -
A . is on Approved B n e
Date'
PPlieation Disapproved for the following reasons:................................................................................................................
,:;:r.,;
Date
PermitNo. .. __�_1 --`---------------- Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS -
BOARD OF HEALTH
OF.......................................
5 (Ir ifirtt$r of Tautplianre
THIS.IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired ( )
by .. = .a'rm .
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at
has been installed in accordance with the provisions of TIT 1F 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No. -. _-_' ' "°` ............ dated. .._-_ _ _...__.__...
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY
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DATE........... - Inspector...... _ `�� ••-• .. .. . v t
•---...•-• --•• ---••-... --•---
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.,THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF 'HEALTH
OF....................................
............
.... ......... FEE a
Did osa arks Tonstrur$iot
� n a1nt$
�, en-& --
Permission is hereby granted. ....................... . = n
to Construct ( ) or Repair (/ ) a Ind vlduaI Se, Dyspo a1 S stem fa d
at No.. �"' t ` d?
Street - - ,
as shown o+t.hepplication for Disposal Works Constru tTo.___ e ___.` '�
j;.. � ........_
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_ _________ ____._ .___
V 4 Board of He it
DATE---•-• .... .._. f
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FORM 1255 A. M. SULKIN, INC., BOSTON.
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