HomeMy WebLinkAbout0161 CAP'N LIJAH'S ROAD - Health 161 Cap'n Ujah's.. Road
Centerville P
192170,
No. 4210 1/3 ORA
Pendaflex'
100/
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS .
OqjDEPARTMENT OF ENVIRONMENTAL
MAP �-- � AUG 2 4 2004
PARCEL ``� 0
TOWN OF BARNSTABLE
1.0 �� HEALTH DEPT.
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 161 Capt Lijahs Road
Centerville
Owner's Name: Barbara S i mmong
Owner's Address: 130 Forest "Hi 1-1 s -Road
Fo
Date of Inspection: "Lc
Name of inspector:(please print) W i 11 i am F_ •Rob i nson Sr.
Company Name: William E. Robinson Septic Service
Mailing Address: P O Box 1 089
Centerville, MA
Telephone Number:_(508) 775-8776
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP
approved system inspector pursuant to Sect"on 15.340 of Title 5(310 CMR 15.000). The system:
asses
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
L � I
Inspector's Sigriature: Date: 0 0
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.
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 I l�
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 161 Capt Lil ahs Road
Centerville
Owner: Bar m ons
Date of Inspection: t- D
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System asses:
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. stem Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaire .The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer es,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please
explain.
e septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound exhibits substantial infiltration or exftltration or tank failure is imminent.System will pass inspection if the
existingis replaced w'
p with a complying septic tank as approved by the Board of Health.
•A me septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicati g that the tank is less than 20 years old is available.
ND cx ain:
Observation of sewage backup or break out or high static water level in the distribution box due to-broken or
obstru ed pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with
appro al of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
explain:
The system required pumping more than 4 times a year due to broken or obsu�ted pipe(s).The system will
pass ' spection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is rzmovW
ND ex ain:
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 161 Capt Lij ahs Road
Centerville
Owner:
Date of Inspection: . —O
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 fail g to protect public health,safety or the environment.
I. yytem will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
stem 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
;.x
2. Sy tem 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
sur ace 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 frotil a
rivate 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 Gee 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 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 161 Capt. Lii ahs Road
Centerville
Owner: Barbara Simmoils
Date of Inspection: �d
D. System Failure Criteria applicable to all systems:
Y 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 I00,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 uatcr
supply well with no acceptable water quality analysis.(This system passes if(lie 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.]
(Yes/No)The system fails.1 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. arge Systems:
To a considered a large system the system must serve a facility with a design now of 10,000 gpd to 15,000
hp
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 11 of a public water supply well
If you ave answered"yes"to any question in Section E the system is considered a significant threat,or answered
"ycs"i Section D above the large system has famed.The owner or operator of arty large system considered a
signifi ant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.30 .The system owner should contact the appropriate regional office of the Department.
4
Page 5 of II
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 161 Capt Li-jahs Road
Centerville
Owner: Barbare, simmoris
Date of Inspection:.
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?
t/ 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?
V 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
te
mai
nnance 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 ClAR 15.302(3)(b)J
_
5
Page 6 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 161 Ca t Li ' ahs Road y
Centerville
Owner. Barbara Simmons
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):. Number of bedrooms(actual):,
DESIGN flow based on 310 CMRj 5.203(for example: 110 gpd x#of bedrooms):
Number of current residents:
Does residence have a garbag grinder(yes or no): u
Is laundry on a separate sewage system(yes or no):; a [if yes separate inspection required]
Laundry system inspected(yes or no): v
Seasonal use:(yes or no)� 0
Water meter readings,if available(last 2 years usage(gpd)): 2003 — 54, 000
Sump pump(yes or no):-L v 2002 — 56, 000
Last date of occupancy:
CO/(describe):
CIA USTRIAL
Typablis ent:
Desw(b don 310 CMR 15.203): gpd
Bassi ow(seats/persons/sgft,etc.):
Gre p sent(yes or no):_
Ind ste holding tank present(yes or no):_
Nonwaste discharged to the Title 5 system(yes or no):_
Waer readings,if available:
Lasof
f occupancy/use:
OTdescribe):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part of the inspection(yes or no): /0v-c.�
If yes,volume pumped:_gallons-=How was quantity pumped determined?
Reason for pumping:
TYPYeOF 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/Altemative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
_Tigbt tank Attach a copy of the DEP approval
_Other(describe):
Approximate age of all components,date installed(if known)and source of information:
RIe�—�L1
Were sewage odors detected when arriving at the site(yes or no):�e 1
6
f
Page 7 of 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPO
SAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 161 Capt Liiahs Road
Centerville
Owner:Barbara Simmons
Date oflnspectlon:
BUILDING SEWER(local n site plan)
Depth below grade:
Materials of constructi :_cast iron _40 PVC—other(explain):
Distance from priva water supply well or suction line:
Comments(on co ition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: z/locate on
_( site plan)
Depth below grade: ) D
Material of construction: ✓concrete metal fiberglass
other(explain) — — g —polyethylene
If tank is metal list age:_ Is age confirmed-by a Certificate of Compliance(yes or no):—(attach a copy of
certificate) d
.Dimensions: [, a. 6 Cl
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: 3 �sL
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or fff—e—:--
How were dimensions determined:- d P`. (i
Comments(on pumping recommendations,inlet and outlet tee or baffle conditicn,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
GREASE TRAP:—(locate on site plan)
Depth below grade:_
Material of construction: oncrete—metal fiberglass_polyethylene_other
(explain): _
Dimensions:
Scum thickness:
Distance from top ors m.to top of outlet tee or.baffle:
Distance from botto of scum to bottom of outlet tee or baffle:
Date of last pumpin
Comments(on pu ping reconunendations,inlet and outlet tee or baffle conditio:t,structural integrity,liquid levels
as related to ouile invert,evidence of leakage,etc.).
I
7
Page S of 11.
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Properly Address: 161 Capt Lij ahs Road
r'entirui I I P
Owner: arans
Date of Inspection: — , _6
TIGHT or HOLDING T K: (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: allons
Design Flow: allons/day
Alarm present(yes or o):
Alarm level: Alarm in working order(yes or no):
Date of last pumpin .
Comments(conditi n of alarm and float switches,etc.):
DISTRIBUTION BOX: t✓ if resent must be o ened locate on site a
( p P )( s plan)
Depth of liquid level above outlet invert:
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.): Q
PUMP CHAMBER: (locate on site plan)
i
Pumps in workin rder(yes or no):
Alarms in worki g order(yes or no):
Comments(no condition of pump chamber,condition of pumps and appurtenances,etc.):
8
Page 9 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 161 Capt Lij ahs Road
Centerville
Owner: Barbara Simmons
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS): �(locate on site plan,ezcavation'not required)
If SAS not located explain why:
Type
leaffing,pits,number:_
leaching chambers,number:
- leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/altemative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.): _
CESSPOOLS: (cesspo/stumped as part of inspection)(locate on site plan)
Number and configuration:
Depth—top of liquid to isle invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspo
Materials of cons tion:
Indication of gro dwater inflow(yes or no):
Comments(no condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: /ction:
e plan)
Materials of co
Dimensions:
Depth of soli s:
Comments 9note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
Page 10 of l l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 161 Capt Lij ahs Road
Centerville
Owner: Barbara Simmons
Date of Inspection: —G—6�-z
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.
-----------------
10
I�
.Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 161 Capt Lii ahs Road
Centerville
Owner. Barbara Simpons
Date.of Inspection:
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water D 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)
C ecked with local Board of Health-explain:
ecked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
12
S ® 8
11
I
\ COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
b
DEPARTMENT OF ENVIRONMENTAL PROTECTION
v�y
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Add reslsb1 Cap' n Lijahs Rd.
Centerville
Owner's Name:1 arbara Simmons
Owner's Address: 5 Park I-@--.
Date of Inspection: - L®
Name of Inspector: (please print) jai 1 1 jam R_ _ Robinson Sr.
Company Name: William E. Robinson Septic Service
Mailing Address: P O Box 1089
Centerville, MA
Telephone Number: (5 0 8 ) 7 7 5-8 7 7 6
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Sec ' n 15.340 of Title 5(310 CMR 15.000). The system:
asses
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: /d Date: no
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of HeaRh 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
**** conditions of use at that
This report only describes conditions at the time of inspection and under the
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 l l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 1 61 Cap' n Lij ahs Rd_
Centerville
Owner: Simmons
Date of Inspection:
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. Sys m Passes:
7I 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:
/Z Wit.✓ 1`,� �
System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
re ired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Ans er yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please
expla' .
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unso d,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the
existin tank is replaced with a complying septic tank as approved by the Board of Health.
•A me 1 septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicati g that the tank is less than 20 years old is available.
ND exp in:
bservation of sewage backup or break out or high static water level in the distribution box due to broken or
obstruct pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with
approva of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND exp ain:
e system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass ' pection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
N explain:
I
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 161 Cap'n Lij ahs Rd.
Centerville
Owner: Simmons
Date of Inspection: :F-a
C. rther Evaluation is Required by the Board of Health:
onditions exist which require further evaluation by the Board of Health in order to determine if the system
is failin to protect public health,safety or the environment.
1. stem will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
s stem 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
sy em 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
ivate water supply well".Method used to determine distance
* This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
cteria and volatile organic compounds indicates that the well is free from pollution from that facility and
t e presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
ilure criteria are triggered.A copy of the analysis must be attached to this form.
3. Other:
3
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 161 Cap' n Lij ahs Rd.
Centerville
Owner: Simmons
Date of Inspection: 0
System Failure Criteria applicable to all systems:.
Yo 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
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.]
(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. Lar a Systems:
To be c sidered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
Spd-
You mu t indicate either"yes"or"no"to each of the following:
(The fol owing criteria apply to large systems in addition to the criteria above)
yes n
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 yo have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes Section D above the large system has fait .The owner or operator of arty large system considered a
signifi ant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.30 .The system owner should contact the appropriate regional office of the Department.
4
r
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:1 61 Cap' n Lij ahG Rd.
Centerville
Owner: Simmons
Date of Inspection: '7 -e";L5-
Check if the following have been done You must indicate`yes"or"no"as to each of the following:
Yes o
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?
t� 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?
_V_ 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 15302(3)(b)]
5
Page 6ofII
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 161 Cap' n Lij ahs Rd.
Centerville
Owner: Simmons
Date of Inspection: "6
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):
Number of current residents: yr
Does residence have a garbage grinder(yes or no):�0
Is laundry on a separate sewage system(yes or no): f&d (if yes separate inspection required)
Laundry system inspected(yes or no):A-0
Seasonal use: (yes or no):
Water meter readings, if a ailable(last 2 years usage(gpd)): 2000 68,000 gal.
Sump pumpes or no): 1999 53, 000 gal.
Last date of occupancy: �F—X-C"-4
CO ERCIAL/INDUSTRIAL
Type o establishment:
Design ow(based on 310 CMR 15.203): gpd
Basis o design flow(seats/persons/sgft,etc.):
Greas trap present(yes or no):
Indus ial waste holding tank present(yes or no):
Non- anitary waste discharged to the Title 5 system(yes or no):_
Wa r meter readings,if available:
LaSi date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: 1A
Was system pumped as part of the inspection(yes or no): Z.,v
If yes,volume pumped:_gallons--How was quantity pumped determined?
Reason for pumping:
TYP OF SYSTEM
OF
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 sourcp of information:
9-Z3-r> 1 ',&4:�7-yv SA -5 46
Were sewage odors detected when arriving at the site(yes or no)-ho
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: 161 Cap'n Lij ahs Rd.
en ervi e
Owner: Simmons
Date of Inspection:
B LDING SEWER(locate on site plan)
Depth elow grade:
Materi is of construction:_cast iron._40 PVC_other(explain):
Distan from private water supply well or suction line:
Co nts(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: 1,�(locate 2%11,
site plan)
L
Depth below grade: )
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) ", z '
Dimensions: 3-e `r g
Sludge depth: O „
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: O L
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of utlet tee or baffle: IL1
How were dimensions determined: 0 �i�� G o u z'fa 'l
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of.leakage,etc.): r i��
as
G
l6 � � l Tom :./_ >�� I'
GR)1aated
E TRAP:_(locate on site plan)
Delow grade:_
Maof construction: concrete metal fiberglass_polyethylene_other
(ex — —metal
ons:
Scckness:
Di from top of scum to top of outlet tee or baffle:
Di from bottom of scum to bottom of outlet tee or baffle:
Daast pumping:
Cots(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as to outlet invert,evidence of leakage,etc.):
7
Page 8 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS L
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 161 Cap' n Lii ahs Rd.
Centerville
Owner: Simmons
Date of Inspection: '7"�'.f
TIG I or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth b ow grade:
Material f construction: concrete metal fiberglass polyethylene other(explain):
Dimensi s:
Capacit}: gallons
Design F w: gallons/day
Alarm pr sent(yes or no):
Alarm le el: Alarm in working order(yes or no):
Date of st pumping:
Comm is(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: l/, (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
PUMP C MBER: (locate on site plan)
Pumps in orking order(yes or no):
Alarms in orking order(yes or no):
Commen (note condition of pump chamber,condition of pumps and appurtenances,etc.):
8
f
Page 9ofll
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 161 Cap' n Lij ahs Rd.
Centerville
Owner: S immonS
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Type
��eaching pits,number:_
✓ 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.):
Al, 0 n LZ czi<l'-G LL 6'
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth—top of liquid to inlet in 1 .
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.):
PR (locate on site plan)
Mat ials of construction:
Dim nsions:
Dep of solids:
Co ents(note condition,of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:161 Cap' n Lij ahs Rd.
en ervi e
Owner: Simmons
Date of Inspection:
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.
fa wl
I/ t
Y 9 S
LJ
.a
10
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 161 Cap in Li ' ahs Rd.
Centerville
Owner: Simmons
Date of Inspection: S�o
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water S 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: J' 6 � tom �".*;f
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
M'
1
ry
11
I�M
o
4:
4"Vklr�-- -
TOWN OF BARNStkBLE
L-QCA uo,0. 5 ` ad SEWAGE # 6
VILLAGE
ASSESSOR'S MAP &LOT 192 170
INSTALLER'S NAME&PHONE NO.
&)b t n, 0"I
SEPTIC TANK CAPACITY /00 0
LEACHING FACILITY: (type) er'-J (size)
x
NO. OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: 1,
COMPLIANCE DATE.
Separ
ation.Dist.ance Between the:
Maximbrn Adjusted Groundwater Table to the Bottom of Leaching Facility. Feet
Private Water SupplyWel
l and Leaching Facihty;*
(If any wells"exist
On site within 2 Feet'
e or,v
00 feet of le hi ng facility)
Edge of Wetland and Leaching Facibty(If any:wetlands exist
in t1i facility)With
qe of ea:c, ng aci ty) .Feet
FuFurnishede'd b:y.
Syr gyu
...........
C NO
cvt
C-1
0
( c�
No. 7 ( -3 ti L Fee 5 0
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
ZIpprication for Migoal *pgtem Construction Vertu
Application for a Permit to Construct( )Repair( X)Upgrade( )Abandon( ) O Complete System ❑Individual Components
Location Address or Lot No. Owner's Name,Address and Tel.No.
161 MCag' 1} Li ahs Rd. , Centerville Barbara Simmons
Assessor's ap arce
- / O 5 Park Ln. , E Walpole, MA
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Wm. E. Robinson Septic Service
P O Box 1089, Centerville
Type of Building:
Dwelling No.of Bedrooms 2 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil Sand
Nature of Repairs or Alterations(Answer when applicable) Title-5 leach system consis—
ting of a D—box and 2 precast, concrete leach chambers with
stone all around.
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by t ' Bo of Health.
Signed Date
Application Approved by Date 6- #- zoo i
Application Disapproved for the following reaso s
Permit No. 2,6'0 (, 3`11— Date Issued t7
No. ---.3 t t Z Fee$5 0
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE,, MASSACHUSETTS
Application for Mi5paar *pgtem Congtruction Permit
Application for a Permit to Construct( )Repair( X)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. Owner's l ftAddress and Tel.No.
161, MCa�p't� Lij ahs Rd. , Centerville Barbara Simm ons` ' i > 14.
Assessor s apfParce /n Z — d
7 5 Park Ln. , E Walpole MA
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Wm. E. Robinson Septic Service
P 0 Box 1089, Centerville
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title wi
Size of Septic Tank Type of S.A.S.
'k. .�✓'`vf A,` p'7
Description of Soil Sand
Nature of Repairs or Alterations(Answer when applicable) Title-5 leach system consis-
ting ,or a D-box and 2 precast, concrete leach chambers with
stone all around.
Date last inspected:
t
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
" in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by tj]'&Bo d of Health.
Signed Date
Application Approved b Date �i- ZW
Application Disapproved for the following reaso s
i
Permit No. Zdt? 3 4 Z- Date Issued
THE COMMONWEALTH OF MASSACHUSETTS D-A X
Simmons BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired(X )Upgraded( )
Abandoned( )by Wm. E. Robinson Septic Service
at 1 61 Cap'n Lij ahs Rd. , Centerville has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No.&V(-30 dated i( /
Installer Wm. E. Robinson Sr. Designer
The issuance of this pegrut shalk not be construed as a guarantee that the syst 11 function esigned
Date 2 310 Inspector
---------------------------------------
No. 7,f / - 3q Z- Fee$5 0
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE,, MASSACHUSETTS
Simmons &5pooal *pgtem Construction Permit
Permission is hereby granted to Construct( )Repair(X )Upgrade( )Abandon( )
System located at 161 Ca 'n Lijahs Rd. , Centerville
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Constructi n st be completed within three years of the date of this ermit.
Date: y 9 Approved by,
ut►As -
t
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only. -
CERTIFICATION OF SKETCH AND APPLICATION FOR A DLSPOSAL
WORKS CONSTRIICTION PERMrr{WrfHOUT DESCGNED PLANS)
William E. Robinson.S> y Certify thu the application fir disposal works
consuue Lion permit sigped.by me dated �1� d / ,.oncming the
prope" located at 161 Cap' n Lij ahs Rd. , Centerville meets all ofthe
Mowing criteria:
• The failed system is 10
a rewhntial dwellutg only. There are no coaumercial or business
uses associated Wirth the t
The soil is classified as 1 and Ow percolation rate is 1es Um or equal to 5 mimua per inch.
There are no w edands 100 feet of the proposed sapnc kvwcm —
There air no private within 150 fact of the proposed septic:s}stenc
f,
There is no in Dow andfor chanF in use proposed
• There ac+e no uegnested or needed
• The boumn of prnI "Ibichm bality will W_be located less than five fm abaft the
ma dinutn groundwater table elevation:[Adjust the gtamdwater table using the Frimptor
method w apficable►
If the S_ will be located with 250 Suet of any'venetatcd w�the bottom of the pmposed
biting will mkt be located less than fauteett t 141 fen above the ma:,anwm adjusted
table elevation,
Pit a oottaplae rite fouw#iw
Al Top of Ground Surhm Elevatign(usieg cls infottmation) � �--
81 G.W.Elevation; �_+the mAX. tfigh G.W.Adjt>smta=
DIFFERENCE BETWEEN A and 8 —
SIGNED: DATE:
[Skewh proposed plan of sysem on bw#
tF tun tip Lcn
I,t
} TOWN OF BARNSTABLEN
LOr A'?"iORT A] G�;C���,S Rc� SEWAGE #
VILLAGE CS4 4- ASSESSOR'S MAP & LOT 91 Z /70
INSTALLER'S NAME&PHONE NO. 't''- �b[ d� 17 s'2-7
SEPTIC TANK CAPACITY /00 0
LEACHING FACILITY: (type) �v[/I�'Y)���,� (size) y S
NO.OF BEDROOMS 3 �SX z Z 47—
13UILDER OR OWNER M M OA 5
PERMIT DATE:_ —0 l COMPLIANCE DATE- —7'9`3"6
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—
Fr�ry � C °0
Est
ell
3c•
o
i
u
7�
R.6
p.
e
/(al 6 'n t j ash`s 'r�, Getz-fit
neqVI r76
C
No....,... .......�� o Faic....,1. ....................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
r10 Aplifiration -for lhgiogal Workii Cnomarurtton Prrutit
Application is hereby'made for a Permit to Construct ( <or Repair ( ) an Individual Sewage Disposal
t1ut System t: '
---------••-. ••--• ....._.... .n- ,--- ---------- -------------------- -------------------------- ---- 5
Location- d"A dr or Lot No.
/ O Address
.............................•-•----•-------
..
Installer Address
Type of Building Size Lo / l f_-Sq. feet
1 Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic (.t/)�Y" Garbage Grinder
aOther—Type of Building ,,C' Alt No. of persons...._-------e! �......--•_.__ Showers ( ) — Cafeteria ( )
Otherfixtures --- ------ •--------•-----------------------•-- -----------------------•------------=--•---•---•------
W Design Flow...........�`'4 .......................gallons per person per day. Total daily flow........®v__-____-.-------..gallons.
WSeptic Tank—Liquid capacity f otgallons Length................ Width................ Diameter_........----- Depth................
xDisposal Trench—No. .................... Width--------_----------- Total Length.................... Total leaching area------------.-------sq. ft.
Seepage Pit No...... ,/--------- Diameter.___0_%�9.e--- Depth below inlet________ _ _________ Total leaching area..----..---..-_--sq. ft..
Z Other Distribution box Dosing tank ( ) al, � ;Z 4'`7 6
aPercolation Test Results Performed by----- ---------------------------------------------------•------•------••- Date--------- ------------------------
.1 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 w er------------------------
®.... _ < -- -•-•• -----------------•-----------
�.
Descr' ton of *o` �..� i �X + Pa4 �
x
W ------------- - r
Nature of Repairs or Alterations—Ans'
U P wer when applicable.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article \I of the State Sanitary Code—The er igned further a r place the system in
operation until a Certificate of Compliance has been issue t oard of �h.
Signe
Date
Application Approved By.-..-. . -- -•. •-- ... ® -y-A9 7�
Date
Application Disapproved for the following reasons------------------------------- -----------------------•--------.-------.----.----._---------.------------_-----
----•-•-•--•----•-----••---------•-•--•-•-•---------------------•--------------------•••------•----••-------------------------•----••-------------------------•----------------------.---------- --•---
/ Date
Permit No. �/- Issued. --f..........................
Date
Zf
FEs .............
THE COMMONWEALTH OF MASSACHUSETTS ^'
I' BOAR® OF HEALTH
t ... .. .. ..-_.OF ...�- ,��................................-_.
phr a#ion .fur M-4ponal Works -C ustrnrtton Prrutil
APPkfion is,herebY-made for a Permit',to Construct -or, Repair, an Individual Sewage Disposal'hc
system t
j
!ei 4 9 l 4 i / t
}; Location ddr_ or Lot No.
W / DWSW— T c Address...
���--
Installer Address
U Type of Building Size Lot," 4 ..Sq. feet
Dwelling-�No. of Bedrooms.___ --_____________________________-__-Expansion Attic (.�/�" Garbage Grinder
p, Other—Type of Building .� ,�i-<lj_ No. or persons------------ Showers ( — Cafeteria
�� . ) )
d , Other fixtures ------------•----------------••------------=------................................................. -------------------------------
.
Design Flow------->;_: "`K2.......................gallons per person per day. Total daily flow._.._____r ................................galloxls,
9 . Septic Tank—Liquid capacity lt�*tgallons Length _If:__________ Width.................Diameter........-------- Depth-- ---
Disposal Trench—No_____________________ Width-------------------- Total Length-----------......... Total leaching area:-___-_-____- __ -.sq. ft.
Seepage Pit No------0/......... Diameter____, 0___ Depth below i et_______ ______ __ Total leaching area------- ----------sq. ft. _
Z Other Distribution box ( Dosing tank ( ) 0 ..- � , `'�� `"'74
Percolation Test Results Performed by-_.__- -_ -.__. ..................
Date_._ __..___-_-._
f
Test Pit No. 1----------------minutes per inch Depth of "Pest Pit-------------------- Depth to ground water ..........
k (� Test P>t No: 2................minutes per inch Depth of Test Pit.................... Depth to round w r__......_______-____ --
-------------
al +.
f O Descri -;L.'_j- ---------&- -..
�on of �o �` - "s 1 2 :� 4,- _
x
Y r
1 .'! n Y
��Zw
e'er - ;
------
S
U Nature of Repairs�or:`Alterations— pp Answer when alicable._-____..___-_. --:_ x
t
-
.
`Agreement
The undersigned lgrees to install the aforedescribed Individual Sewage hisp qs4ill System in iaccordahce with ; ri
,the provisions of Article \I Xof the State Sanitary Code The e�gned`further a ges=riot-tee place the,system'in '
1 •operation until a Certificate-of Compliance has been issued the-i5'oard of
ti r F ,
II
n
D /
Application Approved" BYif t to
tY f
• �"' z Dafe e
Application'Disapproved for the following reasons:
.--- -- - -
1 r
J ......f........ .......................---------------......................
______._______.__._________..____.________�_._. __... _
4 .g Date
Permit No...._ �` Issued: . " z
' d Date: ` r
THE COMMONWEALTH OF MASSACHUSETTS
e
� a BOARD OF HEAL-TH
err#if ir�a#r of Bunt Iitanrr
THIS I,�TO CERTIFY, ghat the Ind>vldual Sewage Disposal System constructed (i77j^o Repaired
by ...................................... ----- -----
Installer�' -
.� - '
has been installed in accordance with.the provislons of Art' I f The State Sanitary Coe as describeA m the
application for Disposal'Works Construction Permit No.-_:_ 1.- ___ dated-_-__ ...��-___%�' �......
THE ISSUANCE.OF THIS CERTIFICATVSHALL NOT BE CONSTRUED AS A IGUARANtEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY: 7:
4 f t' '
DATE..........24`�r . ,<E€ f ., , _: Inspector
THE COMMONWEALTH OF MASSACHUSETTSAL
p r"
y/ BOARD OF HEALTH
? `�-��
OF_-. - ✓-
No.------- ;., � _ � FEE
_• ...............
Bispnrtt1 Workli Quidrurfivit Vrfnift
Permi��
ssion is hereby "granted �s' s_ .c �"
to Construct ( ,4,efRepair ( ) an Individual Sew-� Disposal. System
at No...... z^--------'-r---------.............._< , 4 X' =7 --•- -- �i
r 47- 2?
Street „
Q
as shown on the applica'
,for Disposal Works Construction rt No- �_J___ Dated-- _ r' �J- -
6.f
• Board of Heal
DATE_ + th
FORM 1255 HOBBS &'WARREN. INC.. PUBLISHERSt �' "
F
rsT l "C n evwov
5Lt� �� �
0 M,� T a AIJ n
O 28M1� TA.+K
4 v) W
r R_4sEnYt
FodNOg7.air ZO I, '3 G
40'�:
1 - - ---- r c M D
S2AVc-I-
L.G T
N U G+JN i 7-Z:Tom_
T/-,/1-; i- 7;Ftc E•X S;-1,,JS,
1y) 7/01,J
TG'r✓<J,t/ Lvi}T / - �S °J%! �L ✓r/ A /✓(> CGNi-�J3P 9 t /,%tr'
f//-tlLA% %-jL.�. -�:.J�� r� r;:_�" tea'/[�. -T��C-n,'/i.i��,... ��r�s ,• •� � .�-,,L �._
M/A.1 A4C//t/!
3 U/LD//vG S ETE3AC� �EC�U/,��ME•t./T:5 D�a ;:-� �� �r:�� �.��..�% .�T��
P2o,a0 5EZ7 �
I
-3 B ED f20oMS � �
SEP T/(= 5 y5 TEM CpN.S T2 UG T/ON
SHALL CO1VFo.2M TO MASS . C7 -SIC
N FLOW 30G GALl17Ay
E N e//,2 o/vM E/v r�L GOOD. Ti TL� ]� L L-A A C�-/ 2,4 TE �NO TOL✓N OF 3A�.�J.ST-4ALE M/A/ ///ti/C/-/
TOP OF A/EALT,y GUl-A 7-/0NS P20IC:�'06 F-V L EAC14 Al EA 2 70 �
FD L/A/0A770A/
MANHOLE Ca✓E,� To E)cTE/./Z> -To /MPE,,2✓/OUS coVEQ
W/ Ts-I/n/ /' OF F//�//5�/L�17 GIZi4�7� TO 'a/ZE V&A,/T
F20M /NF/L Ti2A T/it/F `
n
co S 'O 7n./E
I � � I--.A-
1 1 �
4"CAsr/�,v —-�-— I BOX 2/
— :; 3..A4/A/
Q!� ~
/y/N7007-
SU�I - n� w1�-3..--�-- ,�"D!A 16P r 4' wA. /O,L L-q C/-/ _
P/ N FA-Ow L,NE —W.--
M/N Di TCH
�4" /O"M/N /¢• �4 �iDoT �- Miw hi rC fi P/T j'� �2 D/A.
Y /0 0 U Mihl /,�./�ooT A WA S HEO
ron/E
GALLO&I /A/VEET `� 6 ' 0� <-lLL
/NVE.QT CA PA G/ T Y ,4l2 OuN0
SE,oT/G TA N� S '>77-OA4 OF
CWA 7G/2 TG/ ,Y T) n/✓E�t/
/NI/E2T fj�oca/Su�SSp/t � p/T'�/
INVE2T �� GA,28AGE G.e/N�l-P `-'`f C.
Z
LOCAT10/l1 ✓/LGE. N1A .Jr /� 761.. '.G %L; _:1r /� / /✓;�'.fli.'A v�
/�EFE2Bn/CE /CC
Z 7 4 / oq JE;:, S, SE D T/G TA&//C� 4C>/S T',e/BUT/ON BOX
C5 OCJTL-E.Ts) A/VD P/T
GEC AGE G O, _ TO BE OF QE//�/F02CED GO.vG,rzETE
C01-/C,2ETE Sr,2E,vGTt,/ 3000 P.s/ M/A/.
20000 ,.
y N-/O LOA DING
D,2/VE-WAY A/O T TO BE LOCATE D
OVEj 5YSTEM Un/4-E55 44�-. 00
IDES/G^/ LOADI,vG /S USED.
ip
C
DATE 14E4L77-/ AGF_.c/T
Q PP�oOV.4Z-