HomeMy WebLinkAbout0024 CARRIE LEE'S WAY - Health 24 Carrie Lee's Way,Centerville
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ae Health Division
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Hyannis, MA 02601
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Town of Barnstable Barnstable
Inspectional Services Department 1 c��1.1
BA ABLE,
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ASS,
9. Public Health Division
Ar�O�"AV 200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644
PAX: 508-790-6304 Thomas A. McK can,CHO
CERTIFIED MAIL47012 1010 0000 284.8 2435
June 26, 2019
BRIGHT, CURTIS G
24 CARRIE LEE'S WAY
CENTERVILLE, MA 02632
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 24 Carrie Lee's Way, Centerville, MA was inspected on
05/13/2019 by James D. Sears, certified Title V Septic Inspector for the State of
Massachusetts.
The inspection of the septic system showed that the system "Fails" under the guidelines
of 1995 TITLE V (310 CMR 15.00) due to the following:
• Leaching facility with standing liquid level at or above the invert pipe (per
Town Code 360 —20 h).
You are ordered to repair or replace the septic system within two (2) years from the date
you receive this notification.
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action.
PER ORDER OF THE BOARD OF HEALTH
o c can, R.S., CHO
Agent of the Board of Health
Q:\SE11T1C\Tit1e V Inspection Report Letters MailingWailed or Needs Further Evaluation Letters\24 Carrie Lees Way Centerville.doc
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Tow- n of Barnstable
•
+ BARNSfABLE,
p b 9 ,�� Inspectional Services Department
tED N4A'��
Public Health Division
200 Main Street, Hyannis MA 02601
Office: 508-862-4644
FAX 508-790-6304 Thomas A.McKean,CHO
Feb 6, 2007
Rev. 4/26/19
DEADLINES TO RE' PAIR FAILED SYSTEMS
(Town Code §360-44 and Title V: 310 CMR 15.000)
An"x" marked in the ❑ is the failure criteria and associated repair deadline
60 DAY DEADLINE CRITERIA
❑ Discharge or ponding of effluent to the surface of the ground
❑ Pumping more than 4 times during the last year not due to clogged or obstructed
pipe.
❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool
❑ Structurally unsound septic tank or SAS
ONE (1) YEAR DEADLINE CRITERIA
❑ Static liquid level in the distribution box above outlet invert due to an overloaded or
clogged SAS or cesspool
❑ Any portion of the SAS, cesspool, or privy below high groundwater elevation
❑ Any portion of the cesspool within a Zone 1 to a public well
❑ Any portion of a cesspool within 50 feet of a private water supply well with no
acceptable water quality analysis. (This system passes if the water analysis
indicates the well is free from pollution).
TWO (2) YEAR DEADLINE CRITERIA
❑ Single Cesspool
❑ Any "conditionally passed systems" (broken cover, relocation of a pipe, relocation
of a driveway due to H-10 components, etc)
*eaching facility with standing liquid level at or above the invert pipe (per Town
Code §360-20 h)
OTHER
Repair deadline:
Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc
r
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
F,
24 Carrie Leo Way
Property Address
Kelly Littleton
Owner Owner's Name
Information is
required for every Centerville ✓ MA 02632 5-31-19
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. ����U►tu�lnlupp7i
ZF1 OF&t4S
Important:When
filling out forms A. Inspector Information
on the computer, = JAMES
use only the tab James D.Sears
key to move your Name of Inspector S EIS
6)
cursor-do not �'•�' ��
use the return Jim The Inspector Man i •.,E ,. o
key. Company Name
P.O.Box 784 %mun11110`°
IL�I Company Address
West Yarmouth MA 02673
City/Town State Zip Code
508-364-4398 S1623
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspectoJ 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 Lased on my training and experience in the proper function
and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined
that the system:
1. ❑ Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ® Fails
6-1-19
pector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and°the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time.This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc•rev.7IM2018 Title 5 Official Inspection Forth:Subsurtace Sewage Disposal System•Page 1 of 18
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
11 Subsurface Sewage Disposal System Form • Not for Voluntary Assessments
24 Carrie Less Way
Property Address
Kelly Littleton
Owner Owner's Name
information is required for every Centerville MA 02632 5-31-19
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 15 and all of 4 and 6.
1) System Passes:
❑ I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.,304 exist. Any failure criteria not evaluated are
indicated below.
Comments.
Note: Failed system -pit. The system is a 1000 Gal.Tank and pit.
2) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Check the box for"yes","no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old`or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
"A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less;than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
15irsp,doc•rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 2 of 18
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Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
24 Carrie Less Way _
Property Address
Kelly Littleton
Owner Owner's Name
Information is Centerville MA 02632 5-31-19
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont,):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect publil,health, safety or the environment.
a. System will pass unless Boarrl 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:
Nnsp.doc rev.712&2018 Title 5 Offic al Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form •Not for Voluntary Assessments
F
24 Carrie Less Way
Property Address
Kelly Littleton
Owner Owners Name
information is
required for every Centerville MA 02632 5-31-19
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Boarrl of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply,
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well`".
Method used to determine distance:
"•This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and they presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No" to each of the following for all inspections:
Yes No
® ❑
Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
El ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
tsinsp.doo•rev.T20018 Tie 5 omcial Inspection Form:Subsulace Sewage Disposal System•Page 4 of 18
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Commonwealth of Massachusetts
110 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form •Not for Voluntary Assessments
E�
>, 24 Carrie Less Way
Property Address
Kelly Littleton
Owner Owner's Name
information is required for every Centerville MA 02632 5-31-19
page. CitylTown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to AIII Systems: (cont.)
Yes No
❑ ❑ Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
® ❑ Liquid depth in Mortis less than 6" below invert or available volume is less
than A day flow Pd�
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s), Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis_ [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no ether failure criteria are triggered.A.copy of the analysis
and chain of custcdy must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- I
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 correi;;t 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 gld.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
t5insp.doc•rev.712612018 Title 5 Officia Inspection Form:Subsurface Sewage Disposal Swern•Page 5 of 16
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Q Subsurface Sewage Disposal System Form Not for Voluntary Assessments
V24 Carrie Less Way
Property Address
Kelly Littleton
Owner Owner's Name
information is required for every Centerville MA 02632 5-31-19
per. 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 systern in accordance with 310 CMR 15,304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes" or"no"for each of the following for all inspections:
Yes No
❑ ® Pumping information<<vas 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 NIA)
® ❑ 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)]
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
T� Subsurface Sewage Disposal System Form •Not for Voluntary Assessments
24 Carrie Less Way _
Property Address
Kelly Littleton
Owner Owners Name
information is required for every Centerville MA 02632 5-31-19
page. Cityrrown State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example; 110 gpd x##of bedrooms): 330
Description:
1000 Gal. Tank and pit.
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system'' (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available (last 2 years usage(gpd)): na
Detail:
i
Sump pump? ❑ Yes ® No
Last date of occupancy: Plesent
Date
I
t5nsp.doc•rev.7)2612018 Title 5 Offidal Inspeclion Form Subsurface Sewage Disposal System•Page 7 of 18
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
d Subsurface Sewage Disposal System Form Not for Voluntary Assessments
/. 24 Carrie Less Way
Property Address
Kelly Littleton
Owner Owner's Name
information is required for every Centerville MA 02632 5-31-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont)
2. Commercialllndustrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: NA
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
tSinsp.doc rev.M31MII Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 16
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c Commonwealth of Massachusetts
Title 5 Official Inspection Form
F Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
v 24 Carrie Less Way
Property Address
Kelly Littleton _
Owner Owner's Name
information is required for every Centerville MA 02632 5-31-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A systemm by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
Other(describe):
Approximate age of all components, date installed (if known)and source of information:
1978
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
22"
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, ventincl, evidence of leakage, etc.):
Pipeing is 4"PVC SCH 40.
t5insp.doc-rev.712612018 Title 5 Offidal Inspection Form:Subsurace Sewage Disposal Syslem,Page 9 of 1e
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Commonwealth of Massachusetts
p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
24 Carrie Less Way
Property Address
Kelly Littleton
Owner Owner's Name
Information Is required for every Centerville MA 02632 5-31-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
1'
Depth below grade: 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. Precast H-10
Sludge depth:
2"
Distance from top of sludge to bottom of c4utlet tee or baffle 28
Scum thickness
1"
Distance from top of scum to top of outlet tee or baffle 12
Distance from bottom of scum to bottom of outlet tee or baffle 1
How were dimensions determined? Asbuik-TapeSludge Judge
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 at working level.Tank and cover's at 1' below grade.Note; Outlet cover under deck.No sign
of leakage•
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c Commonwealth of Massachusetts
Title 5 Official Inspection Form
r �I, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
24 Carrie Less Way
Property Address
Kelly Littleton
Owner owner's Name
information is required for every Centerville MA 02632 5-31-19
page. CitylTown 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 1:1 fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
b
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendation:;,, 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 purnped 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
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i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
24 Carrie Less Way
Property Address
Kelly Littleton
Owner Owner's Name
information is required for every Centerville MA 02632 5-31-19
page. City/Tom State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required), Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert
Comments (note if box is level and distribt.ition to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
t5insp.doc•rev.'12612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
24 Carrie Less Way
Property Address
Kelly Littleton
Owner Owners Name
iequired o r e Centerville MA 02632 5-31-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber,condition of pumps and appurtenances,etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan,excavation not required):
If SAS not located, explain why:
Type:
1
® leaching pits number:
❑ leaching chambers number:
Cl leaching galleries number:
❑ leaching trenches number,length:
❑ leaching fields number,dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
tSinsp.doc•rev.7/28/2018 Title S Official Inspection Form:Subsu face Sewage Disposal System•Page 13 of 18
6 a5ed xed dH LtQ2 ME Z0 unr
Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
` Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
24 Carrie Less Way
Property Address
Kelly Littleton
Owner Owners Name
information is required for every Centerville MA 02632 5-31-19
Pam. City/Town State Zip Code Date of Inspection
D. System Information (cont,)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leaching is a preacast pit. Pit and cover at 20" below grade. Pit is full to cover. Pit not leaching.
Need to replace system.
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
gl, a5ed xeJ dH LVZZ 6X2 ZO unr
Commonwealth of Massachusetts
Title 5 Official Inspef'-tion Form
r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
v 24 Carrie Less Way
Property Address
Kelly Littleton
Owner Owner's Name
information is required for every Centerville MA 02632 5-31-19
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
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.);
*insp.doc-rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
96 a5ed xed dH LtQZ 6I.0Z ZD unf
Commonwealth of Massachusetts
r Title 5 Official fnspettion Form
Subsurface Sewage Disposal System Form •Not for Voluntary Assessments
24 Carrie Less Way
u Property Address
Kelly Littleton
Owner Owner's Name
information is required for every Centerville MA 02632 5-31-19
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
loll
Li
A- 9
o
pir CovER A �LO
tsinsp.doc•rev.7126/2018 Title 5 Otfidal Inspection Form.Subsurface sewage Disposal system•Page 16 of 18
L 1, a5ed xe� dH Lt;,ZZ 6 X0 ZO unf
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
24 Carrie Less Way
Property Address
Kelly Littleton
Owner Owner's Name
information is required for every Centerville MA 02632 5-31-19
page City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
PC
Estimated depth t high ground water: 12
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: 1978
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 I:he high ground water elevation:
T.H. 1978 12' no G.W.. Bottom of pit at 8' below grade. Bottom of pit at 4'above T.H.Depth.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
Mksp.doc rev.7126/201 B Title 5 Off W Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18
91, a5ed Y2J dH LbZZ 6 60Z ZO unr
1
4'\ Commonwealth of Massachusetts
: Title 5 Official InspEction Form
Subsurface Sewage Disposal System Forst-Not for Voluntary Assessments
24 Carrie Less Way
Property Address
Kelly Littleton
Owner owner's Name
information is required for every Centerville MA 02632 5-31-19
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete ail 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)tompleted
® D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal:Gystem drawn on pg. 16 or attached
For 16: Explanation of estimated dephh to high groundwater included
4d
r��r car
No
�.w
15insp.doc•rev.7126WI S Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 16 of 1a
66 a5ed xezl dH Lb:ZZ 660E ZO unf
Commonwealth of MOSSOChuSettS
Executive Office of Environm:.-ntal Affairs Jahn Grad
D.E.P. Title V Septic Inspector
Department of P.O. Box 2119
' .Environmental Protection Teaticket, MA 02536
wuuam F.Wald (508) 564-6813
rioremor '
Trudy toxe
Benetary,EOEA
David B. Struhs
comminioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM l(repDortedbe
PAKir A
CERTIFICATIONProperty Address: C. `���e— > Address of Owner:Date of Inspection: (If different) �99Name of Inspector: �Company Name, Address and Telephone Number:CERTIFICATION STATEMENT f certifj that I have personally inspected the sewage disposal system at this address and that the informationue, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system-
Passes
_ Conditionally Passes
Needs Further Evaluation By the. local Approving Authority
Fails
Inspector's Signature: Date: Z\ZA 'j Q
The System Inspector shall submit a copy of this inspection report to the! Approving Authority within thirty (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 Department of Environmental Protection.
The original should be sent to the s\srem owner and copies sera u, tier buyer, if appiicable and the appro,ing authority.
INSPECTION SUMMARY:
Che k A B, C, or D:
A) SYSTEM_ PASSES:
have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
B) SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,
passes inspection.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not)
The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as
approved by the Board of Health.
(revised S/15/95)
One VAnter Strwt . Boston,Massachusetts 02106 i FAX(617)Stab-1049 . TN.phon.(617)292-MW
Punted on RwycWd Pipe,
SUBSURFACE SEWAGE DISKXAL SYSTEM INSPECTION FORM
PAiT A
CERTIFICATON (continued)
Property Address:
Owner: �\A
Date of Inspection:
B) SYSTEM CONDITIONALLY PASSES (continued)
_ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the
Board of Health):
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced >
_ The system required pumping more than four 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
C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH'DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or prvv� is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
_ 1 nP �\sten) nd> a >eunt tan.K allU Wli dUDUfpllon sy',Irni elij 6 Kiiful 100 (cci i� a iujaCE '.:diCf 5:;Pp!" G. i .uu:u'f iG
surface water supply.
_ The s\s!Pn ha, a septic tank and soil absorption system and is within a Zone I of a public water supply well.
_ The system has a septic tank and soil absorption sy0em and is within 50 feet of a private water supply well.
_ The s,stem has a sep;i: tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water
supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is
free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5
ppm•
D) SYSTEM FAILS:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
Backup of sewage into facility or system componew due to an 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
(revised 8/15/95) 2
x
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
D] SYSTEM FAILS (continued):
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
Any portion of the Soil Absorption System, cesspool c+r privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I 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 fetrt but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
El LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above:
The design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety
and the environment because one or more of the following conditions exist:
the system is within 400 feet of a surface drinking wa(er 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 (Inte4m Wellhead Protection Area (IWPA) or a mapped Zone ll of a
public water supply well
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6,00. please consult the local regicioal office of the Department for further information,
(revised 8/15/95) 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART IJ
CHECKOST
Prope ress: 3`A
Owne (ZL<'
Date of Inspection:
Check if the following have been done:
gimping information was requested of the owner, occupant, and Board of Health.
�ne of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
Q built plans have been obtained and examined. Note if they are not available with N/A.
e facility or dwelling was inspected for signs of sewage Mick-up.
t
�TKe system does not receive non-sanitary or industrial waste flow
iJke site was inspected for signs of breakout.
_!:-All system components, excluding the Soil Absorption Systern, have been located on the site.
_�fThe septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or
tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
Kfie size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods
�..Er�'2.�I{e,• n,...nn, ran,.4 r+�r�.inantc, if difir rant frnm owne,) were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 8/15/95) 4
r
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C:
SYSTEM INFORMATION
Propert ress: �� C-la<�(1� Lxc�
Owner: +(S�f1S
Date of Inspection: 3�Zk\Ckte
FLOW CONDITIONS
RESIDENTIAL-
Design flow: 7JJ galloons
Number of bedrooms:
Number of current residents:
Garbage grinder (yes or no):—Q ;J
Laundry connected to system (yes or no):-\.A eS
Seasonal use (yes or no):n
Water meter readings, if available:
Last date of occupancy:
COMMERCIAUINDUSTRIAL: (�\
Type of establishment:
Design flow: gallons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non-sanitary waste discharged to the Title 5 system: (yes or no)_
Water meter readings, if available:
Last date of occupancy:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of informat on '
System pumped as pan of inspection: (yes or no), b
If yes, volume pumped gallons
Reason for pumping:
TYPE OF SYSTEM
Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool.
Privy
Shared system (yes or no) (if yes, attach previous inspection retards, if any)
Other (explain)
APPROXIMATE AGE of all components, date installed (if known) and source of information: �Q1
Sewage odors detected when arriving at the site: (yes or no)
(revised 8/15/95) 5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
I?ART C
/�►��>> SYSTEM INFORMATION (continue
1.. d)
Prope dress: DLA a( l —LCeS
Owner: VC
Date of Inspection: 3I Z\`G
SEPTIC TANK:_i_----
(locate on site plan)
t
Depth below grade:
Material of construction: j.tMcrete_metal _FRP_,other(explain)
Dimensions: ! (_,lt I{c,i r>, ,Nt tC't
Sludge depth:
Distance from top 9f sludge to bottom of outlet tee or baffle1z"I
Scum thickness: U1
it
Distance from top of scum to top of outlet tee or baffle: (I
Distance from bottom of scum to bottom of outlet tee or baffle: I :`-��t
Comments:
(recommendation for pumping, condition f inlet and outlet tees of baffles, depth of liquid level in relation to outlet invert, structural
integrity evidence age, etc.) w_ �.r (7 V-' t �` `c__ _ .�( _ 1l
era
GREASE TRAP:C1�A
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _FRP—other(explain)
I
Dimensions:
Scum thickiie».
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom ni <rorn to hottom of outle! tee or bahle:_�
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity-, evidence of leakage, etc.i
(revised 8/:5/95) 6
SUBSURFACE SEWAGE DISPOSAL. SYSTEM INSPECTION.FORM
PART C
SYSTEM INFORMATION (continued)
Property
Owner. G�SC�S
Date of Inspection: 3` 1A G l,
TIGHT OR HOLDING TANKA,\i
(locate on site plan)
Depth below grade:
Material of construction: _concrete_metal _FRP—other(explain)
Dimensions:
Capacity: Rallons
Design flow: gallons/clay
Alarm level:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:CINVIC
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and dutriuutwr. i� eyuai, e.'d�i,ce of solid, ca:r��,er, evidence of leakage into or out of box, etc.)
PUMP CHAMBER:w�
(locate on site plan)
Pumps in working order.(yes or no)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 8/15/95) 7
SUBSURFACE SEWAGE DISPf)SAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Tess:. DLk
L�e W C
Owner: ��S�
Date of Inspe ton: .6)iz\k '�W
SOIL ABSORPTION SYSTEM (SAS):_I,-;-'
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type:
leaching pits, number:—AffS)
leaching chambers, number:_vV
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
Comments: (note cot.4ition of soil, signs of by auli failure, level of pond condition of ve etation,etc.)
CESSPOOLS:
(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 ground„xc-.
inflow (cesspool must be pumped as part of inspection)_
Comments: (note condition of soil, signs of hydraulic failure, level oil 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.)
(revised 8/15/95) 8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property-Address: Q-C,
Owner: Yc(+'' ",C,,S
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
A �_
S^1 L ��
DEPTH TO GROUNDWATER
Depth to groundwater: Q'-feet
method of determination or approximation:��j 0-of C.
(revised 8/15/95) 9
LL �"s .TOWN OF BARNSTABLE
LC'-A 1ON GY ,'(��. �PeS U"A' CUJ SEWAGE #
VILLAGE ASSESSOR'S MAP&LOT b L O S-64 '
INSTALLER'S NAME&PRONE NO.
SEPTIC TANK CAPACTTIT 16n
LEACHING FACILITY: (t�pe) 606 CI CO tco 91(kize)
NO.OF BEDROOMS-
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
a the:Separation Distance Betweei
Maxirpum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well zind 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 eachitig fa 'lity) Feet
Furnished
1
41
L
56 �L
VA P R N .
L0 E E M I T 0
V I, GE
10 03 q4�
I N ST,A LLE S NAME & ADDRESS
' BUII ER OR NE
6
DATE E MIT ISSUED 3�
DAT E COMPLIANCE ISSUED
r
..- . . ,
,.,� , �.
����
�3
No........' .......... Fims.........s.`'.....
THE COMMONWEALTH OF MASSACHUSETTS
_ BOAR® OFT HEALTH
2'7..............OF........er. ?.. ?... .......................................
A.VVfiration for Uispooal Works Tnn15trnrttnn ramit
teA�pplication is hereby made for a Permit to-Construct ( or Repair ( > ) an Individual Sewage Disposal
Sys(._R i�Ir /c. �e e W�V, �l �e7 G�Y11iG� /% SS.................................................... ---------------..
Local -Address i> or/ t No. /�
� l / / ` r � Pvl
G'�j �ee 7'1 _.CG✓� �l _
-•-- TTT - ............................................... ............................................................. ----- --•-- --
w n ` Owner Address
a ............ ._._... ................................ • -••---.........................._.
I er Address
UType of Building Size Lotl ,_ -----Sq. feet
Dwelling—No. of Bedrooms.............................................Expansion Attic Garbage Grinder (W4.,
Other—T e of Buildin ............................ No. of persons.................... Showers —
a � g -------------].._....----- ._._.. ( ) Cafeteria ( )
Otherfixtures ------------------------•----... ---------•-•------------------......--
w Design Flow__________s ��...................gallons per person per day. Total daily,flow.._.._._�� _._..__.._.___.._..gallons.
WSeptic Tank—Liquid capacityAWI(( allons Length.e� _.___ Width............... Diameter................ Depth k_.........
x Disposal Trench—!o. .................... Width..........._-------- Total Length.................... Total leaching area------------.___.__.sq. ft. ! f
Seepage Pit No_____________________ Diameter.___.__.._..... Depth below inlet____..__...__... Total leaching area.__€. >__sq. ft.
Z Other Distribution box c0) Dosing tank Oita _
a Percolation Test Results Performed by....../-...0.4 /-y R_ `...... �e............. Date....-c�1417t----__..
Test Pit No. 1......s2......minutes per inch Depth of Test Pit------A.......... Depth to ground water../� ___F�L.
(14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
04 --------------i.,. _.,..----............_�/............... .... --•---••------...>- ------------------•-----------------------------
O of Soil-•------------•--------- .4- k...�--- ..----------------
Description ..- �- { .
x
w
VNature 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 iI'A 1Z- 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Complia*haseen oard of health----- ------- ...------......------------.....
Date
Application Approved By---••--- " ;
Date
Application Disapproved for the following reasons:............................................................................................ •-----........•----
Permit No......................................................... Issued_.......�7---
C� Da$8
---•------------ --------•--
Date
No.......... .......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...........
....... ............ OF..........0 k..........5..'V........................................
AVI-ifiration for-Ditipaiial Muds Tomitrurtion jinmit
Application is herebyto`-Construct (OX or Repair an Individual Sewage Disposal
made for a Permit to-Con
74,?
e
ee '
... ......................... ------ - .................
.............../.......
4tev _�
-----------
Lo- ' Address
.................................. ....!............................................................
Owner , Address
...................................................................................................I. ..................................................................................................
Installer Address
Size LotZ9_,#. 0.......Sq. feet
Type of Building
U Dwelling—No. of Bedrooms......... --- El:i cpansion Attic (49 Garbage Grinder (40
' p Cafeteria
Other fixture
Other—Type of Building ....................... No. of erEons........................... Showers
s ............................. -------------------------------------------- -----
)erday. Total dilypow----------Design Flow.......I ... ..._ gallons,per person.Z Ions.
.. . .._.__gallons
Length_A��'s. Width................. Diameter__.____ 1)1
1:4 Septic Tank—Liquid capacity -------- Depth_ .._....
Disposal Trench No...................... Width..... ............. Total Length.............i..... Total leaching area___._ __.sq. ft.
Diameter...:..f........... D'epth. elow inlet.....6........... Total leaching area--- ft.
Seepage Pit No------- -----------
Other DistributionDosing Z Percolation Test Results Perfor4ed by...../—----------- ............
I , 48, '�;E0
box D 'ng tank
Test Pit No. I____-_�q-----minutes,per Inch Depth of Pi- ------ ......... Depth toiground water...
I I - --------------------
t ...14 .1 ; . J. 1.
Test Pit No. 2.................nimu esper inch Depth of Tes\Pi .................... Depth to ground water: ........
.......... . .............. ..
0 ' . . ' ,A ..........
-----------------------
Description ofSoil... . . -4 ----------
74......7.......................................................................I..........................................
............... .........
.............................................................................................................................
------------------------------------------------i--------------- -
..........................................................................................................................................
---------------------------- -----------
U Nature of Repairs or Alterati6fis—Answer when applicable., ------------------------7.................................................................
-----------
.......................................................................................................... - ----------------------------------------- ......................................
Agreement:
The undersigned agrees to install the. aforedescribed Individual Sewage Disposal Systerdt'in accordance with
ITI-E
L i F the State Sanitar Co'de The undersigned further agrees not t e the provisions of T 5 of to the system in
operation until a Certificate of Compliance has b en issued by e bqar(T'bj health.
Sign �Z-,e;t 7 r
----------------- ----- ----- --------I-------
Date
ApplicationApproved By......... ......... .. ......... ..... .... ....................................... .......................................
Date
Application Disapproved for the,following reasons:.................:..............................................................................................
.........................................................................................................................................................................................................
Permit No.._..__
......... .... .............. t-•--••--• Issued.....7:::5......-
Date
THE COMMONWEALTH 01-- MASSACHUSETTS
BOARD 5,4F HEALTH
............................. ..........................
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Irate of Coutpliattrr .
THIS IS TO CERTIFY, That, the Individual Sewage Disposal System"constructed or Repaired
by................................ ------- ........................................................ ....................................................
------------------------Install
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has been installed,in accordance with the pro-6s4ns of T I` of The State Sanitary C�oeas desc'b d in the
70—
application for Disposal Works Construction Permit N ............... dated Aa__-7;2_7...........................
THE ISSUANCE"OF THIS CERTIFICATE SHALL�NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FYNCTION SATI,$FACTOkY.�
DATE..... ...... . ........ ... ....... .............................................
............. ..................... Inipector- ....
THE COMMONWEALTH OF MASSACHUSETTS
PPARD QjF 'HEALTH
4—
lto4i
........ ............:1111*1 OF........... .......I....................................
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Dispumt Workg.'Tonstrudion "WrMit
Permission hereby granted-- ................................ ........
..........................................................................................
to Construd fTcor Re V�i e rage 1:1 Jr an 4s 0 S
"Pok
............at No.---JVV .........&..............A -------------------------------------------------------------------------------
Street
- Dispost 1ATo,rks''Construction, er it as shown on the application foi. Dated.._..�%""_...........................
'&..............
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Board of Health
DATE...............................................................................
FORM 1255 HOBBS* & WARREN. INC., PUBLISHERS
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