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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
570 Bay Lane
Property Address
Wainwright
Owner Owner's Name
information is required for every Centerville MA 02632 08/01/10
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
I
on the computer, 3ni
I �'
use only the tab 1. Inspector: ` (�
key to move your
cursor-do not Michael Kellett
use the return Name of Inspector
key.
Aardvark Environmental Inspections
my Company Name
P.O. Box 896
Company Address
+� East Dennis MA 02641
Cityrrown State Zip Code
508-385-7608 S1 3742
Telephone Number License Number
o —9
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B. Certification
C z
c� o
I certify that I have personally inspected the sewage disposal system at this address and thiat the 3
information reported below is true, accurate and complete as of the time of the inspection.rMe insepection
was performed based on my training and experience in the proper function and maintenancej of 0 site
sewage disposal systems. I am a DEP approved system inspector pursuant to SectiorE:0.3¢7—of
Title 5(310 CMR 15.000).The system: N v
C0
® Passes ❑ Conditionally Passes El Fails ^' rn
W
❑ Needs Further Evaluation by the Local Approving Authority
r� 08/04/10
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.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
570 Bay Lane
Property Address
Wainwright
Owner Owner's Name
information is required for every Centerville MA 02632 08/01/10
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:
B) System Conditionally Passes:
❑ one or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
570 Bay Lane
Property Address
Wainwright
Owner Owner's Name
information is required for every Centerville MA 02632 08/01/10
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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
y� 570 Bay Lane
Property Address
Wainwright
Owner Owner's Name
information is required for every Centerville MA 02632 08/01/10
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 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 Y2 day flow
Commonwealth of Massachusetts
Oro Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
570 Bay Lane
Property Address
Wainwright
Owner Owner's Name
information is required for every Centerville MA 02632 08/01/10
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.
Commonwealth of Massachusetts
l Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
570 Bay Lane
Property Address
Wainwright
Owner Owner's Name
requir atone Centerville MA 02632 08/01/10
required for every
page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
330
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):
Commonwealth of Massachusetts .
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
'< 570 Bay Lane
Property Address
Wainwright
Owner Owner's Name
information is required for every Centerville MA 02632 08/01/10
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
Seasonaluse? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: current
Date
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:
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
y 570 Bay Lane
Property Address
Wainwright
Owner Owner's Name
information is required for every Centerville MA 02632 08/01/10
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:
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):
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
570 Bay Lane
Property Address
Wainwright
Owner Owner's Name
information is required for every Centerville MA 02632 08/01/10
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
20 years
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 2.1
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: 1.5
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: 1000 gal
Sludge depth:
3"
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
570 Bay Lane
Property Address
Wainwright
Owner Owner's Name
information is required for every Centerville MA 02632 08/01/10
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
29"
Scum thickness
2"
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
16"
How were dimensions determined? measured
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
The tank was sound and tight with tees in place and liquid at outlet invert.
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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
570 Bay Lane
Property Address
Wainwright
Owner Owner's Name
information is required for every Centerville MA 02632 08/01/10
page. Citylrown 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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
570 Bay Lane
Property Address
Wainwright
Owner Owner's Name
information is required for every Centerville MA 02632 08/01/10
page. CityrFown 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 Even
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.):
The box was level and tight with no sign of carryover.
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:
Commonwealth of Massachusetts
upTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
570 Bay Lane
Property Address
Wainwright
Owner Owner's Name
information is required for every Centerville MA 02632 08/01/10
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.):
This system has 6'x6' precast pit surrounded by two feet of stone. There was no sign of ponding or
failure in the stones.
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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
y< 570 Bay Lane
Property Address
Wainwright
Owner Owner's Name
information is required for every Centerville MA 02632 08/01/10
page. Citylrown 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.):
CommonweaNh of Massachusetts
Title 5 Official inspection Form
Subsurfaee Sewage Disposal System Form-Not for Voluntary Assessments
570 Bay Lane
Property Address
Wainwright
Owner Owner's Name
information is Centerville MA 02632 -08/01/10
required for every —
P89e• City/Town State Zip Code Date of Inspection
D.-System Information (cunt.)
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
ab �6
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
570 Bay Lane
Property Address
Wainwright
Owner Owner's Name
information is required for every Centerville MA 02632 08/01/10
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: 20.0
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
® Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
USGS maps show an elevation of over 20.0 feet
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
570 Bay Lane
Property Address
Wainwright
Owner Owner's Name
information is required for every Centerville MA 02632 08/01/10
page. Cityrrown 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
• COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
LIV
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 570 Bav Lane
Centerville, MA 02632
Owner's Name: Nancy Wainwright
Owner's Address: 28 Tobey Brook / l -/_0�70
Pittsford.NY 14534
Date of.Inspection: June.7. 2007
Name of Inspector: (Please Print) James M. Ford
Company Name: James M.Ford
Mailing Address: P.O.Box 49
- Osterville.MA 02655-0049
Telephone Number: (508) 862-9400
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 performedEbased oti_my
training and experience in the proper function and maintenance of on site sewage disposal systems. rI am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: s
✓ Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Auth rity i
Fit •• i
W r--
o M
Inspector's Signature: Date: June 14 200
The system inspector shall subm' 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.
Notes and Comments
**"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.
Title 5 Inspection Form 6/15/2000 page 1
• Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 570 Bay Lane
Centerville, MA
Owner: Nancy Wainwright
Date of Inspection: June 7, 2007
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:
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
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:
2
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 570 Bay Lane
Centerville, MA
Owner: Nancy Wainwright
Date of Inspection: June 7, 2007
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.
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 and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of armnonia 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:
3
r
Page 4 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 570 Be Lane
Centerville, MA
Owner: Nancy Wainwrikht
Date of Inspection: June 7, 2007
D. System Failure Criteria applicable to all systems:
You must indicate either"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
✓ 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 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,provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.)
No (Yes/No)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 System:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd•
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
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.
4
I
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 570 Be Lane
Centerville, MA
Owner: Nancy Wainwright
Date of Inspection: June 7, 2007
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:
Yes No
✓ _ 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(3)(b)].
5
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 570 Bay Lane
Centerville, MA
Owner: Nancy Wainwright
Date of Inspection: June 7, 2007
FLOW CONDITIONS
RESIDENTIAL
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 or no): n/a
Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required]
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings, if available(last 2 years usage(gpd)): Unavailable
Sump Pump(yes or no): No
Last date of occupancy: Unknown
COMMERCIALANDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): Qpd
Basis of design flow(seats/persons/sqft,etc.):
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/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: Never pumped-per owner
Was system pumped as part of the inspection(yes or no): 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:
Date of installation unknown
Were sewage odors detected when arriving at the site(yes or no): No
6
Page 7 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 570 Bay Lane
Centerville, MA
Owner: Nancy Wainwright
Date of Inspection: June 7, 2007
BUILDING SEWER(locate on site plan) .
Depth below grade:
Materials of construction: _cast iron _40 PVC other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: 16"
Material of construction: ✓ concrete _metal _fiberglass polyethylene
_other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1000 ,ap L
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 30"
Scum thickness: I"
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: Measuring stick
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.).
Cement tees were present. The liquid level was even with the outlet invert.. There did not appear to be any signs of leakage.
GREASE TRAP: None (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(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
7
Page 8 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 570 Bay Lane
Centerville, MA
Owner: Nancy Wainwriirht
Date of Inspection: June 7, 2007
TIGHT or HOLDING TANK: None (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/day
Alarm present(yes or no):
Alarm level: Alann in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: --
Conunents(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.):
The D-box was level. No solids were present.
PUMP CHAMBER: None (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.):
8
•
Page 9 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPEC
TION FO
RM
PART C
SYSTEM INFORMATION(continued)
Property Address: 570 Bay Lane
Centerville, MA
Owner: Nancy Wainwright
Date of Inspection: June 7, 2007
SOIL ABSORPTION SYSTEM(SAS): ✓ (Iocate on site plan,excavation not required)
If SAS not located explain why:
Type
✓ leaching pits,number: 1 -6'x 671000 gal.)
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.):
The pit was dry and clean. There did not appear to be any signs offailure A video camera was used for the inspection
CESSPOOLS: None (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 or no):
Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.):
PRIVY: None (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.):
9
r -
•
Page 10 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 570 Bay Lane
Centerville, MA
Owner: Nancy Wainwright
Date of Inspection: June 7, 2007
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.
Q
PrOA-r
3 O
a
. � C
.3 a-7 y3.
10
.' Page I 1 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 570 Bay Lane
Centerville, AV
Owner: Nancy Wainwright
Date of Inspection: June 7. 2007
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 20+/- feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
✓ Checked with local Board of Health-explain: Topographic and water contours maps
Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Using Barnstable topographic and water contours maps the neaps were showing approximately 20'+1-to ground water at this
site.
This report has been prepared only for the septic system and components described herein. This septic system has been
inspected and passed as of the date of inspection. This report is not a.warranty or guarantee that the system will
function properly in the future. There have been no warranties or guarantees, either expressed, written or implied,
relating to the septic system, the inspection, this report and/or any components of the septic system which have not
been located and inspected.
I1
TOWN OF BARNSTABLE
)CATION S� l a'��I /An 4- SEWAGE#
VILLAGE (3exr(y-I(L ASSESSOR'S MAP&PARCEL
INSTALLERS NAME&PHONE NO.
SEPTIC TANK CAPACITY GW
LEACHING FACILITY.(type) (size)
NO.OF BEDROOMS 3
OWNER Gv/JM wr,/4�
PERMIT DATE: COMPLIANCE DATE:
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 f I'lity) Feet
FURNISHED BY AX1 l,u� J • r
c
�QA-r.
A
3 p
a �
I3 G
r i� a6
a �8 3q
3 a-r ys
�z `Z
D AT E : 7121103
PROPERTY ADDRESS: 570_ Bat/_ ----------
Lane- RECIB
--Cente2v_��Pel /�ae._------ AUG 2 3 2003
02632 TOWN OF BARNSTABLE
------------------------
HEALTH DEPT.
On the above date, I inspected the septic system at the above address.
Tnis system consists of the following:
MAP
1. 7- 1500 ga.P.Pon ae/2tic tank. PARCEL ®�
2. 1-l�.iat2.i 9ut.ion &oz. L01' Tj
3. 1- 1000 ga.P2on /22ecaZt .Peach.ing 12 ii— ,�-
Based on my inspection, I certify the following conditions:
4. 7h.i,6 .ins a t.it.Pe �.i.ve .se/2tie .3y4eem. (78 Code)
5. The 6e/2t.ic hyhtem .iz .in /2/to/2e/z woak.ing o/Ldea at the /22ezent time.
6. Oa,6te wate2 is 48" ge.Pow the, .inveat /2.i.l2e o," the .Perishing
SIGNATUR
Name - J_- P_-Macomber-Jr
COmpany : �gtph pJ_M��4mtZtzr d_ Son, Inc ,
address : @Qx _rzt�----------- `
- - -('exue:YLLLp.,_ Ja _QZ-632-0066
�none : __508- 775_ 3 ) 38 --------
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
JOSEPH P. MACOMBER & SON, INC.
Tanks•Cesspools•Leachflelds
Pumped & Installed
Town Sewer Connections
P.0 Box 66 Centerville. MA 02632.0066
775.3338 775.6412
COMMONWEALTH OF MASSACHUSETTS
= EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
i
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 570 Bay Lane
Cent eay.c e, Na,6.3.
Owner's NameNancy Wainwaigh.t
Owner's Address: Same
Date of Inspection: 7121103
Name of Inspector: (please print) ao,3e12h P. Nacomge2 Ia.
Company Name:_ J. %. Macom e.,c 9 on nc.
Mailing Address: Box 66
Cen.teay.i.2.Pe, Nazz. 02632
Telephone Number: 5 0 8-7 7 5- 3 3 3 8
CERTIFICATION STATEMENT
I certify that 1 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
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date:
The system inspector shal mit 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.
Notes and Comments
****This report only describes conditions at the time of Inspection and under the conditionsof 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.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 570 Bay Lane
en e2v.c e, 77.6.
Owner:Nancu Ida.inwa.igh.t
Date of Inspection: 7/21/0 3
Inspection Summary: Check A,B,C,D or E/ALWAYS-complete all of Section D
A. Syst m Passes
_,O 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:
7ho_ .4�12.tir- hu,stem iz .in /2/co12e2 wo2king oacle2 a.t
fh0 nn 0 AD ni Y •MP_
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.
.(V10 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:
,V-6 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
distribution box is leveled or replaced
ND explain:
/t 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:
2
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:5 70 Bay Lane
erz e2vi e, a-6,3.
Owner: Nancy Nainw2.iy
Date of Inspection: 7121103
C. Further Evaluation is Required by the Board of Health:
A6 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:
,VP Cesspool or privy is within 50 feet of a surface water
4.0 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:
&L!5.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.
416 The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
,16�2 The system has a septic tank and SAS and the SAS is less than 10,0(eet but 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 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, provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other-
3
Page 4 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 570 z3aq Lane
en t e/LV ems.
Owner:Nancy Oa�inwzigha
Date of Inspection: 7121103
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
i/ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
2esspool 7 Cq
,Liquid depth in oo spool is less than 6" elow 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
V
imes pumped Q.
_ portion of the SAS,cesspool or privy is below high ground water elevation.
�y portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
,water supply.
f1 /arty portion of a cesspool or privy is within a Zone 1 of a public well.
�y 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 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, provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
VC) (Yes/No)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.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no /
Z 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
ythe 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.
4
Page 5 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 570 Bay Lane
Cen.te,cviii Nazi.
Owner: Nancy &raz—n--w—A7—CVzit
Date of Inspection: 7777703
Check if the following have been done. You must indicate' s"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 ?
e/ Have large volumes of water been introduced to the system recently or as pan of this inspection ?
Were as built plans of the system obtained and examined? (jr 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 ?
J _ Were all system components,/eluding the SAS, located on site ?
4z_ 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 ?
2— Was the facility owner(and occupants if different from owner)provided with information on the
maintenance of subsurface sewage disposal systems ? proper
The size and location of the Soil Absorption System (SAS)on the site has been determined based on:
Yes no
Existing information. For example, a plan at the Board of Health.
Determined in the field(if any of the failure criteria related to Pan C is
Issue approximation of distance is unacceptable)(310 CMR 15.302 3
5
I
Page 6 of I 1
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:570 Bay Lane
Owner: Nanru Uriinb,a 'ghi
Date of Inspection: 7/.;)9/h 3
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): ` Number of bedrooms(actual):
DESIGN flow based on 310 CMR 5.203 (for example: 110 gpd x N of bedrooms): 'T//a = of�,d
Number of current residents:(,lN,
Does residence have a garbage grinder(yes or no):y8
Is laundry on a separate sewage system'Ives or no):• 6 (if yes separate inspection required)
Laundry system inspected(yes or no): ?��S
Seasonal use: (yes or no):,LES
Water meter readings, if available(last 2 years usage(gpd)): 2001—5 0, 000 ga—f-eonz 13 6. 9 9 qPD
Sump pump(yes or no):A-0 2002-39, 000 gai-eon.6=106. 85 9PD
Last date of occupancy:/?2e-se1Z
COMMERCIAUINDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): d
Basis of design flow(seats/persons/sgft,etc.): r/z
Grease trap present(yes or no): XA
Industrial waste holding tank present(yes or no):AM
Non-sanitary waste discharged to the Title 5 system(yes or no): 4¢ )
Water meter readings, if available: 10h
Last date of occupancy/use: Aj
OTHER(describe): AM
GENERAL INFORMATION
Pumping Records
Source of information: �Z
Was system pumped as pan of the inspection(yes or no):
If yes, volume pumped:_gallons -- How was quantity pumped determined? "41'4
Reason for pumping:
TYP,1` OF SYSTEM
OF
tank,distribution box, soil absorption system
,(&Single cesspool w
Overflow cesspool
Privy
42�Shared system(yes or no)(if yes, attach previous inspection records, if any)
1)6lnnovative/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
Ab Other(describe):
AP roxi ate age al components,date installed(if known)and source of information:
X Tr �6V
Were sewage odors detected when arriving at the site (yes or no),e,1r,),
6
Page 7 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 570 Day Lane
Cente,zy.ii.Qe, Na,6,3.
Owner: Nancu Va.in2.ight
Date of Inspection:7/2 1/0 3
BUILDING SEWER(locate on site plan)
Depth below grade:
0
Materials of construction: Ata cast von _40 PVC Adother(explain): ,yA
Distance from private water supply well or suction line: // ' t
Comments(on condition of joints, venting, evidence of leakage, etc.):
_Zo.i al,A ris <�/Z2p z yht. No evidence o,,' .Peaka ge. The 6 y,3t em ie vented
th.,couyh the �2-oo� ven ,6.
SEPTIC TANK: 1/ (locate on site plan)
d
Depth below grade: 1� /
Material of construction: concrete.l>Gmetal 1!!EJfiberglass,f Lpolyethylene
,f 0other(explain)
If tank is metal list age: &) Is age confirmed by a Certificate of Compliance(yes or no),16(attach a copy of
certificate) _
Dimensions: 114 .YO.w 5-9dnu/ii
Sludge dept
Distance from top of sludge to bottom of outlet tee or baffle:,4--
Scum thickness: _
Distance from top of scum to top of outlet tee or baffle:
-L �t--
Distance from bottom of scum to bottom of outlet tee or bade [
How were dimensions determined: / J4SU2��^J
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of.leakage, etc.):
1)ump the ,3e t.ic tank even 2-3 eat.6. Iniet 9 outiet tee.6 ate .in
zrp 7he tank 1,6 3tauctu zaiiy .6ound and hhowz no evidence o
ieaka ye. Liquid .Peve.l. at the out r?et .invent .iz 51"
GREASE TRAP (locate on site plan)
Depth below grade: AM
Material of construction:oconcrete,eAmetalt)Yfiberglass�olyethylene,40other
(explain): 04
Dimensions: AM
Scum thickness: ./)A
Distance from top of scum to top of outlet tee or baffle: 4 4
Distance from bottom of scum to bottom of outlet tee or baffle: _
Date of last pumping: A�4
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage, etc.):
42ea.6e t2aI2 i,3 not /12eeent.
7
Page 8 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 570 l3ay Lane
Z nt e2 v.c e, ill a,6,3.
Owner: Nancy
Date of Inspection:
TIGHT or HOLDING TAN]{ wed (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: 4
Material of construction: concrete&_metal,�i fiberglass d h,:.polyethylene V other(explain):
AA
Dimensions:
Capacity: alions
Design Flow: alions/day
Alarm present(yes or no):
Alarm level: 4W Alarm in working order(yes or no): 461
Date of last pumping:_A),4
Comments(condition of alarm and float switches, etc.):
Tioht oa hoid ing tank.6 ate no pAezenf.
DISTRIBUTION BOX: Y (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: ,a
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.):
Diet2.igul-ion &ox ha.6 one iate2a.P. No evidence o� zo id.6 eaazy
ouea. No evidence oZ ieakage -into o2 out o e ox.
PUMP CHAMBERAJo.00-(locate on site plan)
Pumps in working order(yes or no): 41.4
Alarms in working order(yes or no):-ZY
Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.):
Pump cham&ea .i.6 noi pAezent.
8
i
Page 9 of 1 1
OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 570 L3ay Lane
Cente/tv.if-I.Te, 77azz.
Owner: Nancy Oainwltighi-
Date of Inspection: 7121103
SOIL ABSORPTION SYSTEM (SAS): 71 (locate on site plan,excavation not required)
1- 1000 gaiion R/zecazt -Reaching /:.it.
If SAS not located explain why:
Located: See Rage 10
T pe
leaching pits,number:
leaching chambers,number: d
leaching galleries,number:_1)
leaching trenches,number, length:
leaching fields,number,dimensions:
overflow cesspool, number: �� �
innovative �
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.):
Loam .nand to goney medium nand to ?P-ine zand, No z.igns o/ hydzaaiie
,&a.iigae oa Ronding baste watea .iz 48" geeow e inve2 pt/2e
Soii.3 ate d/zy. Vegetation 1.6 noama e.
CESSPOOLSltj►E�cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: D
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer: yw
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.):
t^vh,�nooP.s alze not 2/te.6ent
PRIVY4,j"(1ocate on site plan)
Materials of construction:
Dimensions:
Depth of solids: �/y}
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.):
�niuy i�, nnf /�Rp/,Onf_
9
Page 10 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:570 Bay Lane
Owoer.Nancy a.cnw/zig ,
Date of lospeetioo:7 21/03
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 ioo feet. Locate where publlc,vater supply enters the building.
/ 3' / \ ,
e `
O o
- S 76 6 /4y L �
10
19/2003 11 :45 FAX (6002/004
1 V w L`i Vr AAl<i�J 1 N►aLL
1
LOCATION S?O Blo.A � h SEWAGE M
VUTAG� � � -U 1 l�, ASSESSOR'S MAP& LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY �O
LEACKING FACQM: (type) t 1 (size) L k
NO,OF BEDROOMS
BUILDER OR OWNER 0
—4% ATE: w,l"].lCts;t COMPLIANCE DATE:
Separation Distance Between the: I
Maximum Adjusted Groundwater Table to the ` et
Private Walter 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 N 1� . Feet
within 300 feet of leaching facility)
i Furbished by .�
I
i,t,►`11
"Page 11 of II
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 570 Bay Lane
en e2v.e e,
Owner: Nancy
Date of Inspection: 7121103
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water M feet
s
Please indicate (check)all methods used to determine the high ground water elevation:
y�S Obtained from system design plans on record- If checked date of design 7127103
Y 8n P gn plan reviewed:
q f S Observed site(abutting property/observation hole within 150 feet of SAS)
qES Checked with local Board of Health-explain: .4.6 &u.i2t ca zd
y�Checked with local excavators, installers-(attach documentation)
qfS Accessed USGSdatabase-explainht.t/2:Ili-own. &a2n.6.ta&-Pe. ma, uz.
You must describe how you established the high ground water elevation:
LLzed: Gahaetu & N iiiea Model. 12116194 G2ound wa.tea eeevai_ionz move '3ea .Peve2.
11,6ed: USGS;0&,seavat.ion weig data. tune 1992
1Lhed: lLSgS:7echnica4 &uiie.tin 92-000- 1 71.Pa.te #2 Rnnuai 2ange,3 o.J gaound
watp2 aP a .4_40a t_
1up Of rouna
Leaching /I
Pit `. . :eet
Groundwater: Feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method
Therefore, the vertical separation distance between the bolt
of the leaching pit and the adjusted groundwater table is �
feet.
11
` •IT•+1T -nll'1T TT� .'RTIRf•I.T.R TnRiTT.ITI t•.1rI1'I.►fTRR.IR11fTAL .TTITTT T{--..�. r-...
'I'UHN OP Ba2n"ta_M WARD OF IIEALTII
0 SUBSURFACE SEHAGF DISPOSAL SYSTEM INSPECTION FORM - PART D - CERTIFICATION I+
•••T!1 R'•.•:'.-T.1I►��TTI.TI R1w'...11I1 T'1R 1fTIiR"RTTT-t7 T'7 V.T.'�>RR}r•�f.�.�.�RnR\ �1. •.A
-TYPE OR PRINT CI.EAALY-
PROPERTY INSPECTED
STREET ADDRESS 570 Bay Lane Cente2vi22e, l'la�si. ,
ASSESSORS MAP, BLOCK AND PARCEL # 187-070
OWNER' s NAME Nancy Ua.inwaight
PART D - CERTIFICATION
NAME OF INSPECTOR Joseph P.Macomber Jr.
COMPANY NAME J P Macomber & Son InC:`
COMPANY ADDRESS Box 66 Centerville Mass. 02632
Street Town or City State 91P
COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX ( 508 ) 790 -1 578
R
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at
this address and that the information reported is true , accurate , and
omplete as of the time of .inspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems ,
� Illi�ll,
Check one :
1�
J� System PASSED
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
healLh or the environment as. 46fined in 310 CMR 15 . 303 , Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form ,
System FAILED*
The inspection which I have con acted has found that the system fails to
protect the public health and the environment in accordance 'with Title
6 , 3.10 CMR 15 , 303, and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form ,
Inspector Signature Date
ne copy of this ce t.ification must be provided to the OWNER, the BUYER
( Where applicable ) and the BOARD OF HEAL1'II.
* If the inspection FAILED, the owner or*"hoper•ator shall upgrade
he aYste
within one year of the date of the inspection, unless allowed ortrequiredm
otherwise as provided in 3.10 CMR 15 . 306 .
partd .doc
SEWAGE INSPECTIONS
LOCATION 570 PaU fono DATE 7121103
V:L.LAGECent�.�tviLe9- Ncz,s,t_ ASSESSOR'S MAP & LOT 187-070
.INSPECTOg_ao'SeRh %, t'acom&e2 a/2,
SEPTIC TANK CAPACr Y11500 1-Box
LEACHING FACILITY: (type) 1-LP- 1000 (size) 1500 yaiion s
NO.'OF BEDROOMS 3
BUILDER OR OWNER Nancy Va.inw2 igh._
y
.OWNER MAILING ADDRESS
-Same
o =.,
� r
i
y�
i
�9, � �
��
i %�� �� ��
_ =;
S76 r3 �ay L- �
TOWN OF BARNSTABLE
Loc- TIONq' S?6 �l_M LN3, SEWAGE #
VILLAGE ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) l (size) (n k to
NO.OF BEDROOMS
BUILDER OR OWNER y � .
— DATE:rf�_T1 COMPLIANCE DATE:
Separation Distance Between the: e I
Maximum Adjusted Groundwater Table to the > Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) 4X Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by ILLI�29C,cn
z
G.
db
�2 dot e�1i
No.0.2!S_5�...... Fes$_ .j.............
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
TOWN...... ...............OF........BARNSTABLE
Appliration for U44pasal Works Tnntitrnrtiun ami#
Application is hereby made for a Permit'to Construct (X ) or Repair ( ) an Individual Sewage Disposal
System at:
........LOT 2z BaY...i-:anea...CentervilIe..-Ma5h.........
.... .........
Location.Address or Lot No.
......... ............... ,.._._...61_9_.Main__Str�et_ �n.t.�xuil.Le-,---i.---_•---..:..----
Owner Address
W ✓oNN AA4 To 040 FAc MovTi/ �PoAe, MARSi 0 0 IoYllt
a •..................••--•-•••• ----------•• --••••.....---.....•-•••••----•••••-•---•----•--
Installer Address
d Type of Building Size Lot__26,A7..7.............Sq. feet
Dwelling—No. of Bedrooms.....three (3)___________ __Expansion Attic ( ) Garbage Grinder ( )
P-4 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
04 Other•fixtures ..--••-----•-•---•--•--•------ --
w Design Flow....425.................................gallons per person per day. Total daily flow-----a3a................................gallons.
WSeptic Tank—Liquid capacity_-!s QQ_allons 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..2W.........sq. ft.
Z Other Distribution box (X ) Dosing tank ( )
'-' Percolation Test Results Performed by.....Alan-_W,..... Qne.s...................................... Date..May...7-,--.L9a2............
aTest Pit No. 1....2..........minutes per inch Depth of Test Pit...12...feet. Depth to ground water---18---feet-•.--.
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water---____----:------_-_-_.
------------------------------------•---•-------•--•-------.........--•-------------•-......----.............................................................0 Description of Soil......co_arse sandy gravel, medium-_sand___________________ ....................................................
x
w
..................-............................................................................................................................................------...................---..............
V 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 iITIZ 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.
Si ned__ 11� <� `" ` `' -----------------S e_rir..P
�� - to
Application Approved B _.__._ _
PP PP Y �
Date
Application Disapproved or the following reasons-............................................... -------------------------•--•--••••-•-••-•-----�
---------------------------------------------------------------------------•-----•------.....------------._.....__.._.....-----------------•------------------------------------. :------------
Date
PermitNo......................................................... Issued-.......................................................
Date
e
l'
f
Fxa.. ........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN.........................OF........BMSTABLE ..-- --------------------------------•••---.............
Appliration for Viupouttl Works Tonstrurtion "unfit
Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal
System at:
...... .............•..----------......------........----........--•---------------....-•-------....-----
Location-Address or Lot No.
..........SUM"
._#..5.�.1v�a. ............ .....6.19..X&iri.-Stteat;...Cemeru 11P_,:..M&........--•---..
Owner Address
W Jo,*,1( AAtTo O[.D FA,4 INC UT,Y ROAD MARSTONt /W/ZZS
'a ............................ ...................
..._..._.._...... --------.----------•-•-----------------•-- -•-------------•-----------•--••------ -a---------------•••-•...• -----------•—q'•--••--
� Installer Address
Type of Building Size Lot..?A,[ 7.............S feet
�-, Dwelling—No. of Bedrooms...._three (3) Ex Expansion Attic
a p ( ) Garbage Grinder ( )
Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria
Other fixtures
w Design Flow.....4-25.....................__________gallons per person per day. Total daily flow.....3,3Q...................
............gallons.
WSeptic Tank—Liquid capacity.:1.a 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..2,Q ........ ft.
Z Other Distribution box ( X) Dosing tank ( )
Percolation Test Results Performed by.....Alan_W. Jonge......................
,-1 -•---------•--- Date._h1_Ay-.7.,••-1982.......
---
,� Test Pit No. 1....2.........minutes per inch Depth of Test Pit -12__ft@A Depth to ground water...l8-_feet----
44 Test Pit No. 2................minutes per inch Depth of Test Pit........'_........... Depth to ground water........................
a
..............................................................................
0 Description of Soil.......coerse sandy..graye.l_j..medium sand
x
U -•-••••-•••-•--••------••••••••••-••--••••••••--...••••••••••-•••••••-•-••••••••••-•-••-••••••••----••...•--••-•--•-•-•-•••----•••••----•-••-•--•••••---•----•••-•-••-•-•••-•••-••...-•••--......-•••--.
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 been issu d by the board of
health.
Signed ` y = :_:.=-�!� ----1-_'�-------- Septe b_ r....... 1982
Application Approved By eur. ; Date
�-------------- /to..............................
Application Disapproved f r e following reasons:...........................
..............................•••.........•....••......••••.... ......•.....--
-•-•----------------------------------------•--------------------------•-------------------------•-------••••••--••••-•-••••-••-••-•--- ••-•••-•-••--•-••-••---••-•••---••-•--•-•--••---•-•••-......----
Date
PermitNo......................................................... Issued-.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HKAL H
4 ....es^........................OF
...... ... .................................................
Tbrrtifiratr of Toutpliunrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( Vf or Repaired ( )
by.....'r,�t" 1�'_. . .le't .-•-----•---•----------------•-•---------------•---------------------•---..............-------•------......---------•----•------•--•----•-------...--........
4 yd't Installer
at....�A.!r••........-----�-----1. d-(---A"eV..--------•---- eA--74f_ e yU-t, =
has been installed in 'accordance with the provisions of TITLE 5 of The State Sanitary Cos described in the
application for Disposal Works Construction Permit No-----' `e►? f:?.............. d-ated.oA#1?, *.. M"._.._....._.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED A GUARANTEE THAT THE
CTION SATISFACTORY.
DATE
�WaATE. l F ..........................-------•---------------- Inspector..... _.._ ....-•••-.....-••••-••••••-•-...,-••••........._...........--•-.•••--
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF H BT
No.__......`.!... °� FEE...w. �
Disposal or n ion prutit
r
Permission is herebyranted..._ a( '';.t_•.-
g e. ki�
...................... ...................._.........................
to Construct ( ror Repair ) an Indiv al'`Sewage Disposal
at No...-- Ce
Street
as shown on the application for Disposal Works Construction Permit No.. 2__:5..�7_ Dated.. .!�:__.r��...'...'
-----------------------------•-••-----------------------------------------------••••..••...............DATE _
Board of Health
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS
.LOCATION' ' SEWAGE PERMIT NO.
VILLAGE
IkSTA LLER'S N� ME & ADDRESS
® UILDER O!1 OWNER
DATE. PERMIT ISSUED
DAT E C 0 M P L I A N C E ISSUED L2/�f
M3Or
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