HomeMy WebLinkAbout0179 CEDRIC ROAD - Health 179 Cedr'c Road
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 179 Cedric Road
Property Address
Gingras
Owner Owner's Name
information is required for every Centerville Ma 02632 8/14/18
page. Cityrrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information J
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Chad Hathaway
use the return Name of Inspector
key.
H.P.S.
r� Company Name
P.O.Box 151
Company Address
Forestdale Ma 02644
F�n�X
Cityrrown State Zip Code
774-274-2581 12866
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
8/14/18
Inspectors Si ure Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
***"This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
/ M '< 179 Cedric Road
Property Address
Gingras
Owner Owner's Name
information is required for every Centerville Ma 02632 8/14/18
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
Septic is in working order. no failure criteria was observed during inspection
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 179 Cedric Road
Property Address
Gingras
Owner Owner's Name
information is required for every Centerville Ma 02632 8/14/18
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 179 Cedric Road
Property Address
Gingras
Owner Owner's Name
information is required for every Centerville Ma 02632 8/14/18
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/2 day flow
t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 179 Cedric Road
Property Address
Gingras
Owner Owner's Name
information is required for every Centerville Ma 02632 8/14/18
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
f
C vie-01
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
hwy
179 Cedric Road P,
Property Address ter
Gingras ns`
Owner Owner's Name `
information is required for every Centerville Ma 02632 8/14/18
page. Cityrrown State Zip Code Date of Inspection ram'
C. Checklist IN)
Check if the following have been done. You must indicate"yes" or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field(if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
I
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 179 Cedric Road
Property Address
Gingras
Owner Owner's Name
information is Centerville Ma 02632 8/14/18
required for every
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage(gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: currentDate
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 179 Cedric Road
Property Address
Gingras
Owner Owner's Name
information is required for every Centerville Ma 02632 8/14/18
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: 1000
gallons
How was quantity pumped determined? tank size
Reason for pumping: due for maintenance
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 179 Cedric Road
Property Address
Gingras
Owner Owners Name
information is required for every Centerville Ma 02632 8/14/18
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
1976
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 1.75'
feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: 24+feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
no signs of leakage or poor venting
Septic Tank(locate on site plan):
Depth below grade: 1.25'
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 H10
Sludge depth:
6"
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 179 Cedric Road
Property Address
Gingras
Owner Owner's Name
information is required for every Centerville Ma 02632 8/14/18
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
26"
Scum thickness
4"
Distance from top of scum to top of outlet tee or baffle
2"
Distance from bottom of scum to bottom of outlet tee or baffle
18"
How were dimensions determined? tape and sludge 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.):
pump every 2 years as maint. to protect leaching. tank is ok condition. light scaleing of concrete
normal with tank of this age. baffles in place. no signs of cracks or leakage
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title ,5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
179 Cedric Road
Property Address
Gingras
Owner Owner's Name
information is Centerville Ma 02632 8/14/18
required for every .
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
I
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
179 Cedric Road
Property Address
Gingras
Owner Owner's Name
information is required for every Centerville Ma 02632 8/14/18
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
no DBOX
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.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
179 Cedric Road
Property Address
Gingras
Owner Owners Name
information is required for every Centerville Ma 02632 8/14/18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1 6'x6'with 1 foot
of stone
❑ 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.):
current water level 16" below invert pipe to pit. no staining above current level to indicate historic
failure
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
t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
'( 179 Cedric Road
Property Address
Gingras
Owner Owner's Name
information is required for every Centerville Ma 02632 8/14/18
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan.):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition.of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
179 Cedric Road
Property Address
Gingras
Owner Owner's Name
information is required for every Centerville Ma 02632 8/14/18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 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
jCk
3 Go
2 - 3S' 3
3 �
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
179 Cedric Road
Property Address
Gingras
Owner Owner's Name
information is required for every Centerville Ma 02632 8/14/18
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: 25
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
® Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
town gis mapping lot el. 60' ground water in area el. 35. bottom of pit is at el 53'
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 179 Cedric Road
Property Address
Gingras
Owner Owner's Name
information is required for every Centerville Ma 02632 8/14/18
page. Citylrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D(System Failure Criteria Applicable to All Systems) completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 17 of 17
TOWN OF BARNSTABLE
BOARD OF HEALTH
ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION
Date Time: In J ® Out
Owner I'' 1�� Tenant�'f t���
Address 60/- 4 Address l q I
VU
Compliance Remarks or
Regulation# Yes NO Recommendations
2. Kitchen Facilities V
3. Bathroom Facilities
4. Water Supply
5. Hot Water Facilities \1140LA t Opi 4 OG _ VcD
6. Heating Facilities - T � alp EL I 'DA
7. Lighting and Electrical Facilities
8. Ventilation
9. Installation and Maintenance of Facilities
10. Curtailment of Service
11. Space and Use
12. Exits
13. Installation and Maintenance of Structural /
Elements
14. Insects and Rodents
15. Garbage and Rubbish Storage and Disposal
16. Sewage Disposal 3��
17. Temporary Housing
18. Driveway Width l zo l —Z
19. Number of Tenants Observed
PART II
37. Placarding of Condemned Dwelling;
Removal of Occupants; Demolition
Number of Bedrooms 3 Number of Vehicles Allowe )
Number of Persons Allowed (max) 5
Person(s) Interviewed 0&0 A7 C (Z Inspector
If Public Building such as Store or Hotel/Motel specify here
COMMONWEALTH OF MASSACHUSETTS
Z EXECUTIVE-OFFICE-OF ENVIRONMENTAL.AFFAIRS
9 M
DEPARTMENT OF ENVIRONMENTA , PROTECTION
AqM Svey
TITLE 5 .
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FflRM
PART A
CERTIFICATION
Property Address: 179 Cedric Rd.
Barnstable,MA
Owner's Name:David Rice
Owner's Address:179 Cedric Rd. RECEIVED
Centerville,MA 02632
Date of Inspection:April 17,2001
MAY ._ 8 2001
Name of Inspector:(please print)Gary J and/or Jane E Rabesa
Company Name;Warren Cesspool Service TOWNHEALTH DEPTABLE
Mailing Address:72 Sandwich Rd
East Falmouth,MA 02536-5602
Telephone Number:506-540-7143
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 Section 15.340 of Title 5(310 CMR 15.000). The system:
X Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: April 27, 2001
The system inspector shall submit a 4�yZsinspection 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 1,000 gallon septic tank with a 1,000 gallon leach pit in working condition.
****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 t�
conditions of use.
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 179 Cedric Rd
Barnstable,MA
Owner: Rice
Date of Inspection:April 17,2001
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes: YES
X I have not found any information which indicates that any of the failure criteria described in 310 CUR 15.303
or in 310 CMR 15.304 exist Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes: NO
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the T 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 inffltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
_ distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or Obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
r
ND explain:
o,.....:.._ cno cen '71 A')
•Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 179 Cedric Rd
Barnstable,MA
Owner: Rice
Date of Inspection:Apri117,2001
C. Further Evaluation is Required by the Board of Health: NO
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(l)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has aseptic tank and soil absorption system(SAS)and.the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
_ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well".Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of 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:
Warren Cesspool Service 508-540-7143
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 179 Cedric Rd
Barnstable,MA
Owner: Rice
Date of Inspection:April 17,2001
D. System Failure Criteria applicable to all systems:
You must indicate`yes"or"no"to each of the following for all inspections:
Yes No
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
_X_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
X Liquid depth in cesspool is less than 6"below invert or available volume is less than lh day flow
_X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
_X Any portion of the SAS,cesspool or privy is below high ground water elevation
X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
X_ Any portion of a cesspool or privy is within a Zone 1 of a public well.
_X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_X_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
NO (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as
described in 310 CUR 15.303,therefore the system fails.The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems: N/A
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either`Yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
the system is within 400 feet of a surface drinking water supply
— the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a public water supply well
Yyou have answered"yes"to any question in Section Ethe system is considered a significant threat,or answered
"yes"in Section D above the large system has failed..The owner or operator of any large system considered a
significant threat under-Section Eor failed under Section D.shA upgrade the system in accordance with-310 CUR
i c �n e art....._._.,.... ,,.._.___w_.. a .............t,.,..._._............__.,,........i ..lac:_,,.,r mow,T................�
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 179 Cedric Rd
Barnstable,lVlA
Owner: Rice
Date of Inspection:April 17,2001
Check if the following have been done. You must indicate`Yes"or"no"as to each of the following:
Yes No
x _ Pumping information was provided by the owner,occupant,or Board of Health
Y_ X Were--any of the.system components_bout ituthe-previous,two weeks?
x _ Has the system-received normal flows in the previoustwo week period?
X Have large volumes of water-been.introduced.to the system recently-or as part of this inspection?
n/a Were as built plans of the system obtained and examined?(If they were not available note as N/A)
x _ Was the facility or dwelling inspected for signs of sewage.backup?
x _ Was the:site inspected for signs of break out?
x. _ Were all system.components,excluding.the SAS,Iocated on site?
x _ -
of Were the-septwtank manholes uncovered;opened andtiminteriorof the tank inspectedfor the
condition the baffles or-tees-,material of construction,dimensions;.depth.of liquid,depth of sludge and depth of
scum?
x _ 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
x _ Existing information.For example,a plan at the Board of Health
x Determined in the field(if any of the failure criteria related to Part C is at issue approximation of
distance is unacceptable)f310 CMR 15.302(3)(b)]
Warren Cesspool Service 508-540-7143
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS UNT�R SS SSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 179 Cedric Rd
Barnstable,MA
Owner: Rice
Date of Inspection:April-17,2001
FLOW CONDITIONS
RESIDENTL4L-
Number of bedrooms(design):3 Number of bedrooms,(actual): 3
DESIGN.flow.:based on 310CMR 15.203(for example: 110gpdx#of bedrooms): 330
Number of current residents: one
Does residence have a garbage grinder(yes or no):yes
Is laundry on a separate sewage system(yes or no): no [if yes separate inspection required]
Laundry system inspected(yes or no):n/a
Seasonal use: (yes or no):no
Water meter readings,if available(last 2 years usage(gpd)): 2000 avg 55 gpd/1999 avg._66 gpd
Sump pump(yes or no-) no
Last date of occupancy: occupied
COMMERCLU,ANDUSTRIAL :N/A
Type of establishment:
Design flow(based on 310 CMR 15.203} gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):_
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 system(yes or no):_
Water meter readings;if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: Owner: every two years,last done two years ago.
Was system pumped as_part of the inspection(yes or no):no.
If yes,volume pumped gallons--How was quantity-pumped determined?
Reason for pumping:
TYPE OF SYSTEM
X Septic tank,no distribution box,soil absorption system
_Single cesspool
Overflow cesspool
—ivy
no_Shared system.(yes.or.no)(if.yes,.attach.previous inspection.records,.ifany)
_Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from.system-wAmer)
_Tight tank _Attach a copy of the DEP approval
_Other(describe):
Approximate age of all components,date installed(if known)and source of information: 1976 building permit filed
Were sewage odors detected when arriving at the site(yes or-no):no
Page 7 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 179 Cedric Rd
Barnstable,MA
Owner: Rice
-Date-of Inspection:April 17,2001
BUILDING SEWER(locate on site plan)
Depth below grade: 20"
Materials of construction cast iron X 40 PVC_other(explain);
Distance from private-water supply well.or suction line:
Comments(on condition of joints,venting,evidence of leakage,.etc.):
SEPTIC TANK:YES(locate on site plan)
Depth.below.grade:. 14"/12'.'
Material of construction:X concrete^metal fiberglass_polyethylene
___other(explainl
If tank is metal list age:_ Is age confirmed by a Certificate Compliance(yes or no): (attach a copy of
certificate).
Dimensions: standard 1,000 gallon tank
Sludge depth: 8"
Distance from top of sludge to bottom of outlet tee or baffle: 26"
Scum thickness: 1"
Distance from_top of_scum to_top of outlet tee or baffle: 8"
Distance from bottom of scum to bottom of outlet tee or baffle: 15"
How were dimensions determined:onsite
Comments(on pumping recommendations,.inletand.outlet.tee:or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.): Appears to be in good structural condition with no failure
criteria. DEP recommends annual pumping for systems with disposals in use.
GREASE TRAP:NO(locate on site plan)
Depth-below grade:_
Material of construction: concrete_metal fiberglass_ __
other
other
(explain): T
.Dimensions:
Scum.thickness:
Distance.from.top of:scum.to.top_of:outlet tee-or baffle:
Distance froin bottom.of-scum.:to bottom of outlet tee or baffle:
Date of last..pumping:..
Comments(on pumping recommendations,.inlet:and outlet tee.or baffle.condition,structural integrity,liquid levels
as-related to outlet invert,evidence..of ieakage;.etc.):..
Warren Cesspool Service 508-540-7143
Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 179 Cedric Rd
Barnstable,MA
Owner: Rice
Date of Inspection:April 17,2001
TIGHT or HOLDING TANK:NO(tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass____polye0ylene other(explain):
Dimensions;
-Capacity: gallons
Design Flow. gallons/day
?alarm-present(yes.or no),-
Alarm level: .. , Alarm.in.v"Idng order(yes or no):
,Date of-last.pumping
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX:NO(if present must be ppened)(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 CHAMBER:NO(locate on site plan)
Pumps in working order(yes or no):T
Alarms.in working.order.(yes.or.no)-
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
Warren Cesspool Service 508-540-7143
r
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 179 Cedric Rd
Barnstable,MA
Owner: Rice
Date of Inspection:April 17,2001
SOIL ABSORPTION SYSTEM(SAS): YES (locate on site plan,excavation not required)
If SAS not located explain why.
Type
X .leaching pits,number: one
leaching chambers,number:
leaching galleries,numben
leaching trenches,number,.length:
leaching.fields,number,.dimensions?
overflow cesspool,number:
.innovativelalternative_system Type/name-of-technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.): 6'by6'precast leaeh..pit.(with 2'of stoned original-plan)had.one half of.total volume available at time
of observation with no signs of previous failure. Cover 17"below grade.
CESSPOOLS:NO(cesspool must be pumped as part of inspectionxlocate on site plan)
Number and configuration:
Depth—..top of liquid to inlet'
Depth of solids layer:
Depth.of.scum.layer:
Dimensions of cesspool:
Nlaterrials.of-construction:
Indication of-groundwater-inflow(yes:Dr.no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY:NO(locate on site plan)
Materials of construction:-
-Dimensions:
Depth of solids:
arkments(note c"tionto soil,-signs of hydraulic€ailure,level-o(ponding,condition of vegetation,etc.)-
Page 10 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 179 Cedric Rd
Barnstable,MA
Ow4w: Rice
Date-of Inspection:April 17,2001
SKETCH OF SEWAGE,DISPOSAL SYSTEM NOT TO SCALE
11tovide-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
i
-----------
WeAer
line.
pipe
dcrK
Warren Cesspool Service 508-540-7143
f
Page 11 of 11
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 179 Cedric Rd
Barnstable,MA
Owner: Rice
Date of Inspection:April 17,2001
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water is greater than 12 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:
X Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Grade to bottom of leach pit is 8'611. The topography of #251 is lower than#179 and there are no
signs of groundwater.
,Warren Cesspool Service 508-540-7143
No.......—� ----• Fs$ ....................
THE COMMONWEALTH OF MASSACHUSETTS
,lgBOARD H
'--..........OF..... - ... - --------..................................
Applirtttiun -fur 43Wpauttl Worko Tonmrurtiun Vrrniit
Application is hereby made for a Permit to Construct ( or,Repair ( ) an Individual Sewage Disposal
Systemat..........................................A...—
...3 -- Ze e aY----.. ..........
oc/fit/orgy Ad ess / or Lot No.
........................L
•--------------------- Vtd ---- �• V i-.--........ .--------- -..t�J�r'�'I-------------•------ -•-•---•-------------------•-------
w Address
w �-�mx- 1� ,"'�
-- -- -- -- -----
Installer Address �-^ 4-
Type of Building Size Lot.--1,!_;__ -----Sq. feet
U Dwelling—No. of Bedrooms------- _____Ex Expansion Attic Garbage Grinder
P ( ) g ( )
p`4 Other—Type of Building _________________________•__ No. of persons.._______________________-__ Showers ( ) — Cafeteria ( )
a' Other fixtures
w --------------------------- --- w .Design Flow............. ______________________gallons--per-petsonperTotal �_......__---__--_--gallons.
WSeptic Tank—Liquid capac�---gallons Length---------------- Width................ Diameter---------------- Depth_..............
x Disposal Trench—No ____________________ W' ._._..._...._ otal Le th__..__ _____. -- Total leaching area... ""_.sq. ft.
Seepage Pit No....... -_ _--- ----- -------------- e lo in .................... Total leaching tl�l------------------sq. ft.
z Other Distribution box ( ) Dosing tank ( ) !) f"/ =_ 7 e /"� /4
aPercolation Test Results Performed by-------------------------------------------------------------------------- Date__:____----_-__-----_----------_------.
Test Pit No. 1----------------minutes per inch Depth of "Pest Pit.................... Depth to ground water---_________--_____----.
�14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------------.__-____---.
R; ._.,.
O Description of Soil Gy �`d - - `-- •------•----- :- _ •-
✓��•• `a
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 Article NI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b n ssuedl bi,yt Lh boa of h
op _-e--Signed `
Date
Application Approved BY
Date
Application Disapproved for the following reasons______________________
__-_-/-___--•--•-------•--------------------------------------•--- --••----------
------------•-------------•-•-------•-----------------------------•--------------------------------------
Date
PermitNo......................................................... -Issued--------------•-----------------------------------------
Date
No.......''�-�T......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD HE
71(5� .__... .OF.....! �'—............................ .............................
Appliration -fur Uiipuiittf Works Tonmrurtiun Permit
Application is hereby made for a Permit to Construct (G-Kor Repair ( ) an Individual Sewage Disposal
System at
------•............�-----------�Q�G ..... Cat'---------r-----------------------------------•--------•------------
oc�ttot�•A ress Z ............. .../k/...... ... o. I.ot_l.......•.-•----•••-•--•---•---......•--•----
ler
/�.'_.... �.. f/"5t�!! Add�ess ....................................
Installer ddress
Type of Building Size Lot...41_,__!� -----Sq. feet
V Dwelling No. of Bedrooms.---.._ -----EY Expansion Attic Garbage Grinder g— P ( ) g ( )
aOther—Type of Building ____________________________ No. of persons_-.---__---.--_-__--______-_ Showers ( ) — Cafeteria ( )
Q' Other fixtures ------------------------------ --
W Design Flow------------ .......................gallons per person per day. Total daily flow..........F.o'er_--_---__-_.-----..gallons.
WSeptic Tank—Liquid capaX _-gallons Length---------------- Width------......---- Diameter-----...._...... Depth._..-_---_.-----
x Disposal Trench—No------------------- W -- - -z-3
----� otal Le th-a.— Total leaching area_.. -4�-.-_sq. f t.
Seepage Pit No......./i e .... .......... e elo in e - Total leaching area sq. ft.
Z Other Distribution box ( ) Dosing tank ( ) U /— / 7 G —
Percolation Test Results Performed bY----------------------•-•------ .......................................... Date........----- --------------------------
,� Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water__-._-_-_------.--.-_---
f� Test Pit No. 2----------------minutes per inch Depth of Test Pit................. Depth to ground water------------------------
O Description of Soil �._ .... =
U - --------------------------------•----•---•---------------
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 Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b n ssued by th boa of he
Signe .............. `�'l�!/ - --- {------• -----,
Date
Application Approved By.— -/ ---- ---- u�
e
:._.._.... .Q.D.-a.t_e
Application Disapproved for the following reasons:------------------------
- •---------------------•-•-----•---------•------------------- .7-----�-----.•,-.-
---------------•---•---------------------•----------------------------•-----------------------------•.---' -----------------
Date
PermitNo......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
y�py" BOARD OF
FH�ET//'�
......./�l/...-.........................O F.....'✓. ...� ` "C.....................................
Urrtif irate of f-11,out;if aurr
THIS IS TO CERTI Y, T t the ;nc idual Sewage Disposal System constructed ( or Repaired ( )
------- ------ � !by Y
Insta
at------------------------------ ----------- --------------- .. ----------------------------------..........-•-•-••-•-•--••-••--•--••-----•---
has been installed in accordance with the provisions of Alr XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No_ ____ ________ ��__--__--___. v...........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE......3........ ........... ............................ Inspector.!__ - ------ �._._.
3
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEA T
Z4
.................OF... .. ............................
FEE./O__r...
on�trttrtuatr_ era,tit
Permission is hereby granted_.......l �.�.... 3/L e �' -
_______________ _______________________________ ..9 __�_.___...___ g._._.._ .t__ ._..__.�_____....__.........._..
to Construct pat ( ) rZ In 'victual Sew ge isposal ste
Street
as shown on the application for Disposal Works Construction Per o._�_ j..__ _ Dated__2-_./Q__-76
-----------------------
(� _
Nr of Heal—{th
DATE................................................................................
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