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Commonwealth of Massachtusetts /(tig oc�3- C)oI
lR Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
L � 16 Carrie Lees Way
Property Address
Owner Costa
information is Owner's Name
required for Centerville V Ma 02632 4-21-21
every 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: A. Inspector Information
When filling out N
forms on the
computer, use Douglas A Brown
only the tab key Name of Inspector
to move your D.A.Brown Inc
cursor-do not Company Name
use the return
key. P.o Box 145
Company Address
r Centerville Ma 02632
City/Town State Zip Code
508-420-4534 S14297
iarmn Telephone Number License Number
B. Certification
I certify that: I am a DEP approved sy:ctem inspector in full compliance with Section 15.340 of Title
5(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
s
--- 4-21-21
pet ignature Date
The system inspector shall submit a ropy of this inspection report to the Approving Authority (Board
of Health or DEP) within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time. This inspection does not address how the system will perform
in the future under the same or diffr'rent conditions of use.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
R
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal Systern Form - Not for Voluntary Assessments
16 Carrie Lees Way
Property Address
Owner Costa
information is Owner's Name
required for Centerville Ma 02632 4-21-21
every page. CityTTown State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
9) 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 C'NIR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
System met or exceeded all passing requirements at time of inspection. This report can not predict
the future performance under the same or increased usage. System appears to be original from 1978
2) System Conditionally Passes:
❑ One or more system componem's as described in the "Conditional Pass" section need to be
replaced or repaired. The systern, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Cheek the box for eyes", �'no" or"not determined" (Y, N, ND) for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
Commonwealth of Massachusetts
►-0 Title 5 Official Inspection Form
I' Subsurface Sewage Disposal Systern Form - Not for Voluntary Assessments
� t � 16 Carrie Lees Way
Property Address
Owner Costa _
information is Owner's Name
required for Centerville Ma 02632 4-21-21
every page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cant.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
3) Further Evaluation is Required by the Hoard of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Hoard of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
l/i� Title 5 Official Inclhection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
16 Carrie Lees V1!a_y
Property Address
Owner Costa
information is Owner's Name
required for Centerville Ma 02632 4-21-21
every page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cola.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the :Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tan;<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 tan((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.
1-1 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 supple well".
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No" to each of the following for all inspections:
Yes No
❑ E Bac'Kup of sewage into facility or system component due to overloaded or
clogged SAS oi-cesspool
❑ Discharge or pending of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
l� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�- 16 Carrie Lees Way
Property Address
Owner Costa
information is Owner's Name
required for Centerville Ma 02632 4-21-21
every page. CityFrown State Zip Code Date of Inspection
C. Inspection Summary (coat)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid leval in the distribution box above outlet invert due to an overloaded
or clogged SAE; or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1/2 day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
E) 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 passer 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 F cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to ccrrect the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the
questions in Section CA.
Yes No
❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
El ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA) o a mapped Zone II of a public water supply well
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
r h Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
16 ie Car. Lees 1/\/a
r
Property Address
Owner Costa-- — — —_— --
information is Owner's Name
required for Centerville _ Ma 02632 4-21-21
every page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cost.)
If you have answered "yes" to any question in Section C.5 the system is considered a significant
threat, or answered "yes" to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate "yes" or"no"for each of the following for all inspections:
Yes No
❑ 0 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)
ZJ ❑ Was the facility or dwelling inspected for signs of sewage back up?
Z ❑ Was the site inspected for signs of break out?
® Were all system :omponents, excluding the SAS, located on site?
N ❑ Were the septic lank 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?
❑ N Was the facility owner(and occupants if different from owner) provided with
information on th= proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
❑ ® Existing information. For example, a plan at the Board of Health.
Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
J
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
16 Carrie tees\./\'ay__
Property Address
Owner Cosh _
information is Owner's Name
required for Centerville Ma 02632 4-21-21
every page. City/Town State Zip Code Date of Inspection
De System Information
1. Residential Flow Conditions:
Nurnber 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
Description:
A 1000 gallon septic tank-Distribution box-and leach pit were found on site.
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ❑ No
Does residence have a water treatment unit? ❑ Yes ❑ No
If yes, discharges to:
Is laundry on a separate sewage sys.:em? (Include laundry system inspection ❑ Yes ❑ No
information in this report.)
Laundry system inspected? ❑ Yes ❑ No
Seasonaluse? ❑ Yes ❑ No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
House is vacant
Sump pump? El Yes ❑ No
Last date of occupancy:
Date
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
C Commonwealth of Massachuse-tts
,T Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
16 Carrie Lees�l�fay
Property Address
Owner Costa
information is Owner's Name
required for Centerville Ma 02632 4-21-21
every page. CitylTown State Zip Code Date of Inspection
D. System Information (coot.)
2. Cornmercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.:203):
Gallons per day(gpd)
Basis of design flow (seats/persons/E�q.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present'? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. 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:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
16 Carrie Lees
Property Address
Owner Costa
information is Owner's Name
required for Centerville Ma 02632 4-21-21
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Typa of System:
® Septic tank, distribution box, soil absorption system
L� Single cesspool
❑ Overflow cesspool
❑ Privy
U Shared system (yes or no) (if yes, attach previous inspection records, if any)
Li 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
L_! Tight tank. Attach a copy of the DEP approval.
U Other(describe):
Approximate age of all components, date installed (if known) and source of information:
unknown but it seems to be original from 1978
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: feet
Material of construction:
❑ cast iron ❑ 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
I
l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
16 Carrie Lees Nary
Property Address
Owner Costa
information is Owner's Name
required for Centerville Ma 02632 4-21-21
every page. CityFrown State Zip Code Date of Inspection
D. System Information (cont.)
6. 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: appears to be 1000 gallon
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
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
How were dimensions determined?
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank was functioning at working level at time of inspection. Baffels were in place. If tank has not been
pumped in the past 3 yrs I recommend pumping at time of transfer and every 2-3 yrs there after for
maintenance.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
,p Title 5 Official Inspection Form
'1° Subsurface Sewage Disposal System Form Not for Voluntary Assessments
16 Carrie Lees l�la
Property Address
Owner Costa — - —
information is Owner's Name
required for Centerville Ma 02632 4-21-21
every page. City/Town State Zip Code Date of Inspection
D. System,Information (cont.)
7. 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
Cornrnents (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank (tank must bE+ pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachuseft
J4n Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
t,— 16 Carrie Lees Way
Property Address
Owner Costa
information is Owner's Name
required for Centerville Ma 02632 4-21-21
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Daie of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invE!rt
o"
Con'Inn:mts (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.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
16 Carrie Lees Way
Property Address
Owner Costa
information is Owner's Name
required for Centerville Ma 02632 4-21-21
every page. City/Town State Zip Code Date of Inspection
D. Eystem Information (coot.)
10. Puwa a Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
® leaching pits number: 1
❑ leaching chambers number:
leaching galleries number:
leaching trenches number, length:
leaching fields number, dimensions:
overflow cesspool number:
L i innovative/alternative system
Type/name of technology:
15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
^ il
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
=emu 16 Carrie Lees VVaY
Property Address
Owner Costa
information is Owner's Name
required for Centerville Ma 02632 4-21-21
every page. City/Town State Zip Code Date of Inspection
D. System Information (coot.)
11. Soil Absorption System (SAS) (cone.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Pit was dry with no clear signs of failure at time of inspection.
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth —top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
c � Commonwealth of MassachuseAs
6� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
/ 16 Carrie Lees Way
Property Address
Costa_ _
Owner Owner's Name
information is
required for Centerville Ma 02632 4-21-21
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Corm eats (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
l Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
16 Carrie Lees Way
Property Address
Owner Costa_
information is Owner's Name
required for Centerville Ma 02632 4-21-21
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal Systern:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
❑ hand-sketch in the area below
drawing attached separately
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
Commonwealth of Massachusei:ts
w l Title 5 Official Inspection Form
Subsurface Sewage Disposal System form - Not for Voluntary Assessments
16 Carrie Lees Way
Property Address
Owner Costa_
information is Owner's Name
required for Centerville _ Ma 02632 4-21-21
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Si'de ;exam:
Z Check Slope
Z Surface water
M Check cellar
Fj Shallow wells
Estimated depth to high ground water: greater than 5
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)
✓J Checked with local Board of Health -explain:
❑ Checked with local excavators, installers- (attach documentation)
U Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
septic installs in area at similar elevation show no ground water.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
IP Title 5 Official Inspection Form
Subsurface Sewage Disposal System form Not for Voluntary Assessments
v � 16 Carrie Lees Way
Property Address
Owner Costa__
information is Owner's Name
required for Centerville Ma 02632 4-21-21
every page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of thiG form inclusive of:
® A. Inspector Information: Comple'i:e all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
Z D. System Information:
For 8: Tight/Holding Tank— Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18
Code Lces cock
-----------------
A
OAT 22 00 52�
LID 1
' S
7 � 7�• 2 d'�
No................_....... Fps..............................
�Q\ THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
ApplirFatiun for Disposal Works Tonstrnrtiun JIrrmit
Application is hereby made for a Permit to Construct (,I) or Repair ( ) an Individual Sewage Disposal
S steA at• /
/ t n-Address or Lot
Owner Address
Installer Address
Type of Building L3 Size Lot _.7.6/1....Sq. fee
a Dwelling—No. of Bedrooms..................................._.___._..Expansion Attic ) Garbage Grinder
p� Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
a' Other fixtures ............................ .
d -- ---------------- ..
Design Flow..... .........................gallons per person per day. Total daily flow------___.�.�1_...............__._._..gallons.
W e ,
WSeptic Tank—Liquid capacity/PgPgallons Length A,,.: Width__6---------- Diameter................ Depth.........
x Disposal Trench—No..................... Width...P.............. Total Length........... Total leaching area....................sq. ft.
Seepage Pit No-----/...--._-__-- Diameter.................... Depth below inlet....6............. Total leaching areaa.0Z......sq. ft.
Z Other Distribution box Dosing t n (r qV
~' Percolation Test Results Performed by...... °..1 j__ __�j�_._oL._. '_......_.. Date....... __7 ........
f
a
a Test Pit No. 1... .......minutes per inch Depth of Test Pit.................... Depth to ground water.__.. ..v_h.
Gz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a -•-•-•----•---- -•--------• ...... ....---•••......•..................•-
0 Description of Soil.........................
x :: ....
W ----••-•-----------•----•-----...-•-••-•-•---••-----•----------•-•-•--•-----•--••-•----•--------•-----•---••---•-------------------•--••-•---------•-------------......._--•.•-••-...-----•......._.....
UNature 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 TITI:L 5 of the State Sanitary Cod(:—The undersigned further agrees not to place the system in
p p Si d \ and of health.
operation until a Certificate o Compliance as en issued 1� � �1 �- 7�
.--
Date
Application Approved By-------- .... --- .... .. ... - ,r .......7.................
Date
Application Disapproved for the following reasons:..............................................••...--••----------•-------------•-----•--•--D ---.....•--••-
----------------------------•--------••-..._.._.....---•--•-------------•------•-------••.............••••••--------•----•••••••--••-•--------------••-----------•------•------•--------•------•••......
Date
PermitNo......................................................... Issued-.......................................................
Date
` 7P. I
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
!... .....OF..... ... o?Al..4. ;''A 0 .......
Appliration for Uiipngat Works Tnntrnrttnn Prrutit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at
captn-Address or Lot
..._ ........................ .-----.............._._...._............... ..._......-••---......•................._.. ..............._........_.._._.........._.....
Ownerr Address
Installer Address d Al
U Type of Building Size Lot .......Sq. fFpt
Dwelling—No. of Bedrooms.............................................Expansion Attic 4 Garbage Grinder f
a� Other T e of Building No. of persons............................ Showers
YP g -------••------------------- P ( ) — Cafeteria ( )
dfi3tures". ----------------------•---•-------...................................................... " ..................................
Design Flow_Ot-P..
W g + gallons per perso per,�iy Total ay flow....... 1$ns.
WSeptic Tank—Liquid capacit/ gallons Length ?.......... Width. ........ Diameter................ Depth...
x Disposal Trench o .................... W>dt #,............. Total Length ....o,__.__._ Total leaching area.._ '_ ..sq. ft.
Seepage Pit No_____ __________ Diameter ..._._.__........ Dep i below ..........Total leaching area !...---sq. ft.
Seepage Pit No.--l-Z Other Distribution box (f)' Dosing t (4*
Percolation Test Resul Performed b .. -
Y . Date. .•••• -- .•••-•---...
.
� .Test Pit No. 1.....: .......minutes per inch Depth of Test Pit.........:.:_...___. Depth to ground water-----------__........_..
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
---- -------.-------------------------
DDescription of Soil . ----- .. ................•----------------------......--------------------------------------------•----------•-••••••---.-----
x
W
----------------------------------------------------------------------------------------••...•-•---•-•-•----- --------------------•--... --•--•---•---•-----•---•---•••......................_----•-
U Nature of Repairs or Alterations—Answer when applicable----------------------:__`...........................................:.........................
--------------------------•------------------------------------------------..........................................................................................................................
Agreement:
The undersigned agrees to install the aforedesc--ibed Individual Sewage Disposal System in accordance with
the provisions of'I'!L- 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
:operation until a Certificate of Compliance has en ls�ue k e aid of health.
Sigr ................................. ..... .t.............
Application Approved By...... t�--- •.... .... . ._. .d' ..................... --- '-� -----------
fDate
Application Disapproved for the following reasons-----------------------••--------------------------------------------------------•---------------.........-•--•-.
---------•.............•......------•----•---------------•------ ---•--•-•------•------•----....-----------------•-----•--------••••--•---•-••-••••-•--•--••---•---••---•------•--•---•----•------......
Date
PermitNo.......................... Issued........................................................,
.. Date
A-
THE COMMONWEA[.TH OF MASSACHUSETTS
BARD OF EALTH
rr .OF...... '........................................... ''
�rr�i�irtt#r of ( .utxt�li�tnrr
b T ,�S�IS T CERTIFY That t f Individual Sewage Disposal System constructed ( ) or Repaired ( )
Y u�' ...--. ... .-- . -
.Z/ ♦ Install
G r
......... ................................
77
at
.••----. •... ............ - -- •--•--•. -••----•-•--------•--.._...•-•--
has been installed in accordance with the provisi is of T r of The State Sanitary Code s desc abed in the
d
application"for Disposal Works Construction Permit No...:: _�`. �..:.............. dated ;.. '_ ......� ..................
THE JSSUANCE OF THIS CERTIFICATE SH111. N®7 BE CONST lIE® A5 A GUARANTEE THAT THE
SYSTEM`WI FUNCTION SATISFACTORY:
DATE._.. �-.._......- - ........ Inspector
THE COMMONWEALTH OF MASSACHUSETTS
'BOARD HEALTH
fi Ct�..
No.........................
.FEE. .............
i �rla tt or nnstrurtinn firrmit
Permission is hereby granted....... �"
to Const r 2ep ( ) an nd vi al ,�ewa rsposal Sy�i.
atNo. 5 ,.. -:... fir '
lr t
as shown on the application for Disposal.Works Construction Pe No. Dated.._. ..
--- �"'- .. ... .
Board of Health�t � ..
DATE---• �---4�
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS
.� t-A
7
Ja
Y E. 4 A Z Y .S / s
71016
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19 --- -
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` %y a r
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w PLAN OF LAND
(.._.lit p-r ee "S &lay IN
cG'�N TES. V/ E MASS.
OWNED BY
0 k OF P44.p . p
�O-S,E,F��^i
/ FRANK FRANKS FRANK CONERY 5 TRENTO"NI S7.
CONE" r„ � CON H HYAHNIS, MASS. 02601
No. 6573 0 No. 6232
O a AZISTURSD K NoiNWw a LAND 9URvcrc'w
F �
O C•f �.� C787E,c O
FSS/ONA ��6 �'�'0 SURN�`'+ SCA" 1 1 N -250 PT.
0 A0>7 1077 / G 4 77 �f/c d/ W / �jIJ/��. C. . /q , J Ll� ./ �0 717r
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