HomeMy WebLinkAbout0071 CHILDS STREET - Health 71 Childs Street
Centerville P
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No. 4210 1/3 ORA
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Commonwealth of Massachusetts
H Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
71 Childs Street
Property Address
Beverly Joyce Trust
Owner Owner's Name /
information is
required for every Centerville V MA 02632 4/27/2017
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. General Information
filling out forms
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not James Ford
use the return Name of Inspector
key.
Ford Septic Services, LLC
tab Company Name
P.O. Box 49
Company Address
ram Osterville MA 02655
City/Town State Zip Code
508-862-9400 S 12482
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 E al tion by the Local Approving Authority
4/27/17
Inspe�tem
S Signatur Date
The 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.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
71 Childs Street
Property Address
Beverly Joyce Trust
Owner Owner's Name
information is required for every Centerville MA 02632 4/27/2017
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.).
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass".section need to be
replaced or repaired.The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
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
71 Childs Street
Property Address
Beverly Joyce Trust
Owner Owner's Name
information is required for every Centerville MA 02632 4/27/2017
page. City/Town 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
l5ins•3/13 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 71 Childs Street
Property Address
Beverly Joyce Trust
Owner Owners Name
information is
required for every Centerville MA 02632 4/27/2017
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 '/Z day flow
t5ins•3/13 Title 5 Official Inspection Form: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
71 Childs Street
Property Address
Beverly Joyce Trust
Owner Owners Name
information is Centerville
required for every MA 02632 4/27/2017
page. City/Town 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.
l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
71 Childs Street
Property Address
Beverly Joyce Trust
Owner Owners Name
information is
required for every Centerville MA 02632 4/27/2017
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
❑ ® Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
❑ ® Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms 3 2
(design): Number of bedrooms (actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°�M •''y 71 Childs Street
Property Address
Beverly Joyce Trust
Owner Owners Name
information is
required for every
Centerville MA 02632 4/27/2017
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 1
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?(Include laundry system inspection
information in this report.) ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use?
❑ Yes ® No
Water meter readings, if available(last 2 years usage (gpd)):
Detail
unavailable
Sump pump?
❑ Yes ® No
Last date of occupancy: currently
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present?
❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
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
71 Childs Street
Property Address
Beverly Joyce Trust
Owner Owner's Name
information is
required for every Centerville MA 02632 4/27/2017
page. City/Town State Zi Code
P Date of Inspection
D. System Information (cont.)
Last date of occupancy/use:
Date
Other(describe below):
General Information
Pumping Records:
Source of information: unavailable
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: 1500
gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
15ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection
nspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°` ,• 71 Childs Street
�M
Property Address
Beverly Joyce Trust
Owner Owners Name
information is
required for every Centerville MA 02632 4/27/2017
page. City/Town
State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
system installed - 1995 per info
Were sewage odors detected when arriving at the site? ❑ Yes No
Building Sewer(locate on site plan):
Depth below grade:
feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line:
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank (locate on site plan):
Depth below grade:
14"
feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene
El 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: 1500 H-10
Sludge depth: 2
t5ins•3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
71 Childs Street
Property Address
Beverly Joyce Trust
Owner information is Owner's Name
required for every Centerville MA 02632 4/27/2017
page. CitylTown 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 30
Scum thickness 3
Distance from top of scum to top of outlet tee'or baffle 5
Distance from bottom of scum to bottom of outlet tee or baffle 10
How were dimensions determined? measure stick
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
The tees were present. There was no sign of leakage. The tank was pumped after the inspection for
maintenance.
Grease Trap (locate on site plan):
Depth below grade: n/a
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
71 Childs Street
Property Address
Beverly Joyce Trust
Owner Owners Name
information is
required for every Centerville MA 02632 4/27/2017
page. City/Town 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
El other(explain):
N/a
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-3f13
Title 5 Official Inspection Form:Subsurface Sewage Disposal system-Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�.. 71 Childs Street
Property Address
Beverly Joyce Trust
Owner Owners Name
information is
required for every Centerville MA 02632 4/27/2017
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert even
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
The D-box was normal.
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
u v Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
a 71 Childs Street
Property Address
Beverly Joyce Trust
Owner Owners Name
information is
required for every Centerville MA 02632 4/27/2017
page. CitylT'own State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
® leaching trenches number, length: 1-4'x60'
❑ 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.):
There was no sign of failure from the leach field. A camera was used to ins
pect.
-- p
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 Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurfac
e Sewag
e Disp
osal posal System Fo
rm orm Not for Voluntary Assessments
71 Childs Street
Property Address
Beverly Joyce Trust
Owner Owners Name
information is
required for every Centerville MA 02632 4/27/2017
page. Cityfrown 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.):
N/a
15ins•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
;M a,•''y 71 Childs Street
Property Address
Beverly Joyce Trust
Owner Owners Name
information is
required for every Centerville MA 02632 4/27/2017
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
A , LJ , .
3
A 3
a aS ILI
3 3°► 3 I
t5ins•3113
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
71 Childs Street
Property Address
Beverly Joyce Trust
Owner Owners Name
information is
required for every Centerville MA 02632 4/27/2017
page. City/Town State Zi Code
Date of Inspection
P
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑. Shallow wells
Estimated depth to high ground water: 30'+/-
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:
Topo and water contours map.
❑ Checked with local excavators, installers -(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
see above
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
I
• ; Commonwealth of Massachusetts
v Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
a 71 Childs Street
Property Address
Beverly Joyce Trust
Owner Owner's Name
information is
required for every Centerville page. y/Town
MA 02632 4/27/2017
Cit
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 Form:Subsurface Sewage Disposal System-Page 17 of 17
i
COMMONWEALTH OF MASSACHUSETTS
tpAA EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS .
DEPARTMENT OF ENVIRONMENTAL PROTECTION
RECEIVED
ED
OCT 0 1 2003
Tw,HEFiLTH DEPTA6LE
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 71 Childs Street PARCEL ,—
r O Z
Centerville _ - ---- --
Owner'sName: William and Shirley Stamps ,,OT
Owner's Address: - - -
Date of Inspection:
Name of Inspector:(please print) W i 1 1 i am E_ • Robinson Sr.
Company Name: William E: Robinson Septic Service
Mailing Address: P 0 Box 1089
Centerville, MA
Telephone Number: (508) 775-8776
CERTIFICATION STATEMENT
1 certify that 1 have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
t/ Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: ` d� Date: " o
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 seat to the system owner and copies sent to the buyer,if applicable,and the approxing
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 71 Childs Street
Centerville
Owner: nd Shirley Stamps
Date of Inspection:
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. Syst Passes:
I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CUR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
re ired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Ans er yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please
expl in.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsol ind,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 rr etal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
Indic iting that the tank is less than 20 years old is available.
ND xplain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obs cted pipes)or due to a broken,settled or uneven distribution box.System will pass inspection if(with
appr val of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND xplain:
The system required pumping more than 4 tines a year due to broken or obstmacd pipe(s).The system will
p inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is rc=ved
N explain:
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 71 Childs Street
Centerville
Owner:-William and Shirley Stamps
Date of Inspection: 0 (,--a
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require father evaluation by the Board of Health in order to determine if the system
is ailing to protect public health,safety or the environment.
System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
_ Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or.a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
sys em is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
— The system has a septic lank and SAS and the SAS is within a Zone I 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 frond a
private water supply well•• Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered.A copy of the analysis must be attached to this form.
3. Other:
3
Page 4 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 71 Childs Street
Centerville
Owner: Willia and .Shirley Stamps
Dale of Inspection: --b
.. yytem Failure Criteria applicable to all systems:
You ust indicate`Yes"or"no"to each of the following for all inspections:
Yes o
Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
Liquid depth in cesspool is less than 6"below invert or available volume is less than'/,day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
y portion of the SAS,cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy is within I00.feet of a surface water supply or tributary to a surface
water supply.
_ Any portion of a cesspool or privy is within a Zone 1 of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well._
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private 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.]
( es/No)The system fails. 1 have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large stems:
To be consi Bred a large system the system must serve a faci!ity with a design now of 10,000 gpd to 15,000
gpd•
You must in icate either"yes"or"no"to each of the following:
('1lte follow g criteria apply to large systems in addition to the criteria above)
yes no
to 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
_ he system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
one 11 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 S tion D above the large system has fatted.Tlx owner or operator of arty large system considered a
significant hreat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.T system owner should contact the appropriate regional office of the Department.
4
Page 5 of l l
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 71 Childs Street
Centerville
Owner: william Shirley Stamps
Date of Inspection: Q
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
1/ 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?
V Have large volumes of water been introduced to the system recently or as part of this inspection?
_ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
Was the facility or dwelling inspected for signs of sewage back up?
_ Was the site inspected for signs of break out.?
,V_ Were all system components,excluding the SAS,located on site?
V _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
_ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on: .
Yes .no
Existing information.For example,a plan at the Board of Health.
_ — Deter mined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)[310 CMR 15.302(3)(b)J
5
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 71 Childs Street
Centerville
Owner: amps
Date of Inspection: 63
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):
Number of current residents14
.
Does residence have a garbage der(yes or no):kd
Is laundry on a separate sewage system(yes or no)—A-o [if yes separate inspection required]
Laundry system inspected(yes or no)'-M
Seasonal use:(yes or no):
Water meter readings, if available(last 2 years usage(gpd)): 2 0 01 —8 3,0 0 0
Sump pump(yes or no): k4o 2 0 0 2—1 0 7,0 0 0
Last date of occupancy: 9—& 3
COMMERCIAL/INDUSTRIAL
Type of establishm t:
Design flow(based n 310 CUR 15.203): gpd
Basis of design flo (seats/persons/sgft,etc.):
Grease trap presen (yes or no):_
Industrial waste h ding tank present(yes or no):_
Non-sanitary was discharged to the Title 5 system(yes or no):_
Water meter read' gs,if available:
Last date of occu ancy/use:
OTHER(desc ):
GENERAL INFORMATION
Pumping Records
Source of information: 4
Was system pumped as part of the inspection(yes or no):_
If yes,volume pumped:_gallons--How was quantity pumped determined?
Reason for pumping:
IYOFSYSTEM
c 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)
_Tigbt tank Attach a copy of the DEP approval
_Other(describe):
Approximate age of all components,date installed(f known)and source of information:
Were sewage odors detected when arriving at the site(yes or no):
6
Page 7 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:-71 Childs Street
Centerville
Owner: Jam and
Shirley Stamps -
Date of Inspection: — :. a
BUILDING SEWER(locate on site plan)
Depth below gr c:
Materials of cons ction:_cast iron _40 PVC_other(explain):
Distance from pri ate water supply well or suction line:
Comments(on co dition ofjoutts,venting,evidence of leakage,etc.):
SEPTIC TANK:/(locate
on site plan)
v6
Depth below grade: 62
Material of construction: concrete_metal fiberglass_polyethylene
—other(explain) —
If tank, is metal list age:_ Is age confirmed-by a Certificate of Compliance(yes or no):_(attach a copy of
certificate) ,�N
Dimensions: At, f•-(J�(y
Sludge depth: 5
Distance from top of sludge to bottom of outlet tee or baffle: o�
Scum thickness:L— 3 4
Distance from top of scum to top of outlet tee or baffle: 7
Distance from bottom of scum to bottom of outlet tee or baffle: Yr
How were dimensions determined:---�I
Comments(on pumping recommendations,inlet and outlet tee or baffle conditicn,structural integrity,liquid levels
as related to outlet invert,cvid of leakage,etc
GREASE TRAP:_(locate on site plan)
Depth below grade:
Material of construction:_concrete._metal_fiberglass_polyethylene other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom-or outlet tee or baffle:
Date of last pumping:
Comments(on pumping reconunendations, inlet and outlet tee or baffle condition,structural, integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
7
Page 8 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION continued
Property Address: 71 Childs; Street
Cc�ntPrvi 1 1 P
Owner: u7i1JiaPa and Shirley Stamps
Date of lnspectioa:
TIGHT or HO ING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grad :
Material of const ction: concrete metal fiberglass Polyethylene other(explain).
Dimensions:
Capacity: allons
Design Flow: allons/day
Alarm present(y s or no):
Alarm level: Alarm in working order(yes or no):
Date of last pu ping:
Comments(co dition of alarm and float switches,etc.):
DISTRIBUTION BOX: t /of present must be opened)(locate on site plan)
)
Depth of liquid level above outlet invert: Z)
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: ( cate on site plan)
Pumps in working order(y or no):
Alarms in working order cs or no):
Comments(note eonditio of pump chamber,condition of pumps and appurtenances,etc.):
8
Page 9 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 71 Childs Street
Centerville
Owner: wi 1 1 i am ani Shi ley Stamps
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS):ZI (locate on site plan,excavation not required) .
If SAS not located explain why:
Type
leaching pits,number:_
leaching chambers,number:
eaching 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.):
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth—top of liqu d to inlet invert:
Depth of solids lay r:
Depth of scum lay r:
Dimensions of ces ool:
Materials of cons ction:
Indication of grown water inflow(yes or no):
Comments(note c dition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: (loFateonite plan)
Materials of cons
Dimensions:
Depth of solids:
Comments(not condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
Page 10 of 1 l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: '7/ �d�a-/t s a�
Owner:
Date of Inspection: 9 - "dD
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building.
to
i 3
v
T
JJrrII
1 'ti r
10
Page I of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 71 Childs Street
Centerville
Owner. William and Shirley Stamps
Date of Inspection:
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
n
Estimated depth to ground water 0 feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-if checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
_L/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:
11
CO.lm1mox"T- ALTH OF MASSACHL;SETTS
_ r ExECLTNE OFFICE OF E 'VIRO\11E\TAI AFFAIRS
r F DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET. BOSTOA KA 0210c t617i 292.550v
TRL DY COXE
Secreta^%
ARGEO PALL CELLUCCI DAVID B STR'-*HS
Governor Corrumissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address:71 Childs Street Name of Owner William Sharon
Ce terville Address of Owner:
Date of Inspection: G—a 7—6—v
Name of inspector:(Please Print)Wm. E. Robinson Sr.
1 am a DEP approved systerrl inspector rsuarrt to Section 15.340 of Title 5(310 CMR 15.000)
Company Name: Wm. E . Robinsoneptic Service
Mailing Address: PO Box 089, Centerville.L—M
Telephone Number: �8 0
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 inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewa a disposal systems. The system:
_ Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
_ Fails �+
Inspector's Signature: ► t Date: G"—� 7 ��
The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)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
system owner and copies sent to the buyer, if applicable, and the approving authority.
NOTES AND COMMENTS
Y
�r`
•.� r�U
JUL 20a� o0
HCA,81HHPlSIi
revi.Sed /2/9E Page Iof11
H '
• ^!ed o Recvdrd Pape
1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
"ropertyAddress: 71 Ch-ild.s St . , Centerville
awner: Wm. Sharon
Date of Inspection: — q
INSPECTION SUMMARY: Check A� , C, or D:
A. 7he,PASSES:
e not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure
criteria not evaluated are indicated below.
COMMENTS:
B. S)yes
M CONDITIONALLY PASSES:
e or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon
mpletion of the replacement or repair, as approved by the Board of Health, will pass.
Indicat 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, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty (20)years prior to the date of the inspection; or
the septic tank, whether or not metal, is 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 complying septic tank as
approved by the Board of Health.
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
revised 9/2/98 Page 2of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Add►ess: 71 Childs St . , Centerville
Owner: William Sharon
Date of Inspection: {^ �i?_C
C. FUR ER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Co ditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
pu is health, safety and the environment.
1) SYS WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM
IS N T FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) S STEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS
NCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS 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. Method used to determine distance (approximation not valid).
3) O HER
revised Page 3ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
PropertyAddress:71 Childs St . , Centerville
Owner: ,,,
Date of Irup on. Sharon
D. SYSTEM FAILS:
You must'ndicate either "Yes" or "No" to each of the following:
I ave determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this
d termination is identified below. The Board of Health should be contacted to determine what will be necessary to correct.the failure.
Yes No
Backup of sewage into facility-or system component 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.
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 112 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 or 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 feet 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.
E. LARGE YSTEM FAILS:
You must indi ate either "Yes" or "No" to each of the following:
The ollowing criteria apply to large systems in addition to the criteria above:
The s stem serves a facility with a design flow of 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:
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(interim Wellhead Protection Area-IWPA)or a mapped Zone 11 of a public
water supply well)
The owner or oper nor of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Depai tment for further information.
revised 5%2/9S Pagc4ofII
• SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM.
PART B
CHECKLIST
Property Address: 71 Childs St . , Centerville
Owner: Wm. Sharon
Date of Inspection:
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
as No
Pumping information was provided by the owner, occupant, or Board of Health.
None 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.
_ As built plans have been obtained and examined. Note if they are not available with NIA.
_ The facility or dwelling was inspected for signs of sewage back-up.
_ The system does not receive non-sanitary or industrial waste flow.
_ The site was inspected for signs of breakout.
All system components, excluding the Soil Absorption System, have been located on the site.
_ The 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.
/ The size and location of the Soil Absorption System on the site has been determined based on:
V _ Existing information. For example, Plan at B.O.N.
_ Determined in the field(if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable)
115.302(3)(b))
_ The facility owner (and occupants,if different from owner) were provided with information on the propermaintenanc&.of
Subsurface Disposal Systems.
revised 9/2/98 Page 5ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
'rop"Address:71 Childs St . , Centerville
Owner: Wm. Sharon
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow: X5U g.p.d./bedroom.
Number of bedrooms(design): Number of bedrooms (actual):,}'
Total DESIGN flow / 6
Number f current residents:o
Garbage grinder(yes or no): U
Laundry(separate system) (yes or no):A�.t>; If yes, separate inspection required
Laundry system inspected (yes or no)
Seasonal use (yes or no):A, 1999 106, 000 gal.
Water meter readings, if available (last two year's usage (gpd):
Sump Pump(yes or no): N Un 1998 98, 000 gal.'
Last date of occupancy:�,7—&-"v
COMMERCIAL/INDUSTRIAL:
Type f establishment:
Desig flow: gpd ( Based on 15.203)
Basis design flow
Grease rap present: (yes or no)_
Industri I Waste Holding Tank present: (yes or no)_
Non-so itary waste discharged to the Title 5 system: (yes or no)_
Water eter readings, if available:
Last da a of occupancy:
OTHE :(Describe)
Last d of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and so c e of information:
System pumped as part of inspection: (yes or no)�
If yes, volume pumped: gallons
Reason for pumping:
TYPES 0 YYSTEM
V Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or not (if yes, attach previous inspection records;if any)
I/A Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other07
APPROXIMATE AGE of all components• date installed lif known)and source of information: F-7
Sewage odors detected when arriving at the site: (yes or no) A,0
rev' sed 9/2/9c Page 6of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
'ropertyAddreas: 71 Childs St . , Centerville
owner: Wm. Sharon
Date of Inspection: 6--0
BOIL G SEWER:
(Lotn site pla ate n)
Depth b low grade:_
Material of construction:_cast iron_40 PVC_ other(explain)
Distan from private water supply well or suction line
Diam er
Comm nts: (condition of joints, venting, evidence of leakage,-etc.)
SEPTIC TANK:_
llocate on site plan)
9
Depth below grade:
Material of construction:_concrete_metal_Fiberglass _Polyethylene_other(explain)
If tank is metal,list age_ Is.age confirmed by Certificate of Compliance_(Yes/No)
Dimensions: 4--
Sludge depth:_ ' 4 �� 1 '
Distance from top of sludV)to bottom of outlet tee or baffle:
Scum thickness: '§e t t
Distance from top of scum to top of outlet tee or baffle: T t 1
Distance from bottom of scum to bottom outlet tee or baffle:
How dimensions were determined:
comments:
(recommendation for pumping, condition of inlet and tlet tees or baffles depth o liq id level.in relation to tlet iryvert, structural integrity,
evidence of leakage, etc.) l 5-0 bo j+-dC i"
Az Li&� ) i A^ /-
GREASate E P:
(loc on ite plan)
Depth be(ation
e:_
Material uction:_concrete_metal _Fiberglass _Polyethylene_other(explain)
Dimensio
Scum thi
Distance of scum to top of outlet tee or baffle:
Distancettom of scum to bottom of outlet tee or baffle:
Date of Iing:
Commen
(recomm for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidencege, etc.)
revised 9/2/58 Page 7of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
J,roperty Address: 71 Childs St . , Centerville
Owner: Wm. Sharon
Date of Inspection: (_2 07_p--c
TIG OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection)
(locat on site plan)
Dept)he
ow grade:
Matef construction: concrete metal_Fiberglass_Polyethylene_other(explain)
Dimes:
Capa gallons
Desiw: gallons/day
Alarsent
Alarel: Alarm in working order: Yes No_Dateevious pumping:
Coms.
(con of inlet tee, condition of alarm and float switches, etc.)
Ir
DISTRIBUTION BOX: L
(locate on site plan)
Depth of liquid level above outlet invert:`
Comments:
(note if level and distribution is equal, evirle of solids carryover, evidence of leakage into or out of box, etc.) -
PUMP CH)te
R:_
(locate onan)
Pumps in g order: (Yes or No)
Alarms in g order(Yes or No)
Comment(note condf pump chamber, condition of pumps and appurtenances,etc.)
revises 9/2/98 Page 8of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
'fop"Address: 71 Childs St . , Centerville
Owner: Wm. Sharon
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS):_
(locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods)
If not located, explain:
Type.
leaching pits, number:_
leaching chambers,number:_
leaching galleries, number:_ IV 1
leaching trenches, number, length:
leaching fields, number, dimensions:
overflow cesspool, number:_
Alternative system:
Name of Technology:
Comments:
lnote condition of soil, signs of hydraulic failure, level of ponding. damp soil condition of vegetation, etc.)
CES OOLS:_ _
(locate n site plan)
Number d configuration:
Depth-top of liquid to inlet invert:
Depth of s lids layer:
)epth of sc m layer:
Dimensions f cesspool:
Materials of onstruction:
Indication of groundwater:
infl w (cesspool must be pumped as part of inspection)
Comments-
(note con ion of soil, signs of hydraulic failure, level of ponding. condition of vegetation, etc.)
PRIVY:_
(locate on site an)
Materials of con truction: Dimensions:
Depth of solids:
Comments:
Inote condition soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
Pdgc9of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM V
PART C
SYSTEM INFORMATION(continued)
Nop"Address: 71 Childs St . , Centerville
.Pwfw: Wm. Sharon
Jate of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
1 '
1 �
revised 9,12/98 Page 10of11
`l_ ---- _.._
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
roperty Address: 71 Childs St . , Centerville
owner: Wm. Sharon
Date of Inspection:
NRCS Report name
Soil Type_
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow- Moderate Deep
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells J�
Estimated Depth to Groundwater+ Feet
Please indicate all the methods used to determine High Groundwater Elevation:
/Obtained from Design Plans on record
• !/ Observed Site(Abutting property,observation hole, basement sump etc.)
Determined from local conditions
Checked with local Board of health
Checked FEMA Maps
Checked pumping records
Checked local excavators, installers
Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
r
revised 9/2/95 PaFc11of11
!�7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Address of property '7 t G �, !�S S/I ��y►n��
Owner's name ID. Dt g4kri I O
Date of Inspection
PART A
CHECKLIST
Chec if the following have been done:
7Pumping information was requested of the owner, occupant, and Board of
/Health.
+� None 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.
/Asbuilt plans have been obtained and examined. Note if they are not
vailable with N/A.
/The facility or dwelling was inspected for signs of sewage back-up.
i/ The site was inspected for signs of breakout. .
All system components, excluding the SAS, have been located on the
site.
The 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.
__ZThe size and location of the SAS on the site has been determined based
on existing information or approximated by non-intrusive methods.
The facility .owner (and occupants, if different from owner) were
provided with information on the proper maintenance of SSDS.
MGM
S EP 15 1995ING
N
8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION
FLOW CONDITIONS
If residential
number of bedrooms
_ number of current residents
Al garbage grinder, yes or no
laundry connected to system, yes or no
seasonal use, yes or no
If nonresidential, calculated flow:
Water meter readings, if available: ,t q 00
Last date of occupancy
GENERAL INFORMATION
Pumping records and source of information:
Gv �ob i x•S u s- S�� io f; c:
System pumped as part of inspection, yes or no
if yes, volume pumped
Reason for pumping:
Typ of system
7�
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)
Other (explain)
Approximate age of .all components. Date installed, if known. Source of
information:
Sewage odors detected when arriving at the site, yes or no
9
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SEPTIC TANK•
(locate on site plan)
depth below grade: _
material of construction: /concrete metal FRP other(explain)
dimensions:
_Q sludge depth
�. distance from top of sludge to bottom of outlet tee or baffle
r2 'scum thickness
_0 distance from top of scum to top of outlet tee or baffle
0 distance from bottom of scum to bottom of outlet tee or baffle
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 leak e, recommendations for repairs, etc. )
ll i i t `l 4CI —C)
DISTRIBUTION BOX: ✓
(locate on site plan)
depth of liquid level above outlet invert
Comments:
(note if level and distribution is equal, evidence of solids carryover,
evidence of leakage into or out of box, recommendation for repairs, etc. )
/fi 01 Ci S"
PUMP CHAMBER:
(locate on sit plan)
pumps in working order, yes or no
Comments:
(note condition of pump chamber, condition of pumps and appurtenances,
recommendations for maintenance or repairs,etc. )
r
10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued J
SOIL ABSORPTION SYSTEM (SAS) :
(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 and number
leaching chambers and number
leaching galleries and number r
leaching trenches, number, length 'C '
leaching fields, number, dimensions
overflow cesspool, number
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding,
condition of vegetation, recommendations for maintenance or repairs,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 groundwater
inflow (cesspool must be pumped as
part of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding,
condition of vegetation, recommendations for maintenance or repairs,etc. )
PRIVY:
(locate on site plan)
materials of construction
dimensions
depth of solids
Comments:
(note condition of soil, signs of hyd ulic failure, level of ponding,
condition of vegetation, recommendations for maintenance or repairs,etc. )
11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
i
,Z I
V,
DEPTH TO GROUNDWATER
depth to groundwater
method of determi ation or approximation:
12
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORK
PART C
FAILURE CRITERIA
Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of
determination in all instances. If "not determined" , explain why not)
Backup of sewage into facility?
Discharge or ponding of effluent to the surface of the ground or
surface waters?
'V Static liquid level in the distribution box above outlet invert?
Liquid depth in cesspool <6" below invert or available volume< 1/2 day
flow?
kRequired pumping 4 times or more in the last year?
number of times pumped
JZ Septic tank is metal? cracked? structurally unsound? substantial
infiltration? substantial exfiltration? tank failure imminent?
Is any portion of the SAS, cesspool or privy:
Al below the high groundwater elevation?
-AL within 50 feet of a surface water?
within 100 feet of a surface water supply or tributary to a surface
water supply?
within a Zone I of a public well?
within 50 feet of a bordering vegetated wetland. or salt marsh
(cesspools and privies only, not the SAS) ?
within 50 feet of a private water supply well?
less than 100 feet 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 analysi-
for coliform bacteria, volatile organic compounds, ammonia nitrogen
and nitrate nitrogen.
TOWN OF BOARD OF HEALTH
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D - CERTIFICATION
-TYPE OR PRINT CLEARLY-
PROPERTY INSPECTED /
STREET ADDRESS
ASSESSORS MAP, BLOCK AND PARCEL
OWNER' s NAME -1), 41n I
PART D - CERTIFICATION
NAME OF INSPECTOR W.E. Robinson Sr
COMPANY NAME W.E. Robisnon Septic Service
COMPANY ADDRESS P.O. Box 1089 Centerville MA 02632
Street Town or City State LIP
COMPANY TELEPHONE ( 508 ) 775-8776 FAX
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage dis osa-1 system at
g P Y
this address and that the information reported is true , accurate , and
complete as of the time of inspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems.
Check one:
System PASSED
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
health or the environment as defined in 310 CMR 15. 303 . Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form.
System FAILED*
The inspection which I have conducted has found that the system fails to
protect the public health and the environment in accordance with Title
5 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form.
Inspector Signature Da�e_
One copy of this certification must be provided to the OWNER, the BUYER
(where applicable ) and the BOARD OF HEALTH.
* If the inspection FAILED, the owner or operator shall upgrade the system
within one year of the date of the inspection, unless allowed or required
otherwise as provided in 310 CMR 15 . 305 .
partd.doc
/3.,.
ASSESSORS MAP NO-,_&_Lf �
PARCEL NO`_ Z6
FiciJP.-.0.0..............
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
TOWN OF BARNSTABLE
Appltrattvtt for Diopoial Work.6 TouBtrurtiou 1rrmit
Application is hereby made for a Permit to Construct ( ) or Repair (x ) an Individual Sewage Disposal
System at:
71 Childs St Centerville
...........................................•--------•---....----------------------------••-------- -----•--•---•-••--------------•----•.....------------•-...-----•-•-------•-----------•---------•--
D D. D'Rami o Location-Address or Lot No.
......................_.......................................................................... ••-•-••-----•--•---•----•-------------.....----••-------......----_...._................_.....•...
W W.E. Robinson S8Vtic Service P.O. Box 1 089 CeWtbsrville
Installer Address
d Type of Building Size Lot............................Sq. feet
Dwelling— No. of Bedrooms-___•__�
----------------------------------Expansion Attic ( ) Garbage Grinder PO)
`4 Other—Type e of Building ________________p� yp g ......__._.. No. of persons_____I__ ________________ Showers Cafeteria ( )
a' Other fixtures __________________________________
W Design Flow--------------------------------------------gallons per person per day. Total daily flow--------------------------------------------gallons.
WSeptic Tank—Liquid capacity__-__-_____gallons Length________________ Width---------------- Diameter---------------- Depth___-________----
x Disposal Trench—No. .................... Width-------------------- Total Length.____..•-___-__-____ Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by---- --------------------------------------------------------------------- Date........................................
Test Pit No. 1________________minutes per inch Depth of Test Pit-------------------- Depth to ground water....................._..
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
.---.......
Description of Soil. gravel----------------- - --- -- - -- ---------- ---------------------•-••----••--•-•----•-----------------------•-•--•-----__•-------
-•-----------------•--------------------------••--------------------------------------------------------------------------------------........_...__..
W
U -------•------------•---•-•••••-••-•-•••-•----•-•--------------------------•---------•--•----------•-••-•---•-----------•--•-------------•--....••------•--------••------------------•--•----------•----
W
UNature of Retpairs or Alterations—Answer when applicable._install a 1 , 500 gal tank, d—bOx
and 60 leach—trench. Pump & fill in old cesspools
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has be issu y the board ealth. Q
Signed -s --------------- ...................3.`...../....`J
g �� -f�- � Dace
Application Approved By ............. ......... '✓ _......------.....�.-------------- _...... �-� ... .�
�,�.��.�7L�f Dace
Application Disapproved for the following reasons- -------- ------------------- ------------------------------------------------------------------------------------------------------
........ --------------------------------------------------------------------------------------------------- ------------ ------------------- ........................................
Permit No. �.-?......�.�r.� Issued ......: .. ........................... ---
Dace
•.00............
THE COMMONWEALTH OF MASSACHUSETTS_
` BOARD OF HEALTH
' TOWN OF BARNSTABLE
Appliration for Di�5vwial Workg C owitrnrtinn runtit
Application is hereby made for a Permit to Construct ( ) or Repair (x ) an Individual Sewage Disposal
System at:
71 Childs St Centerville
................................................................................................ ------•---•-••---•-••---••••••-----•---------•--------•---......._..............--•••-••-•••------
D. D'Ramio Location-Address or Lot No.
......................_.......................................................................... ---••-•-------------••--•---•---------•-------•-••••--••••-•-•--------.........................._.
W W.E. Robinson S�Vtic Service P.O. Box 1089 C IL.Vrville
Installer Address
UType of Building 2 Size Lot............................Sq. feet
Dwelling— No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder (no)
`4 Other—T e of Building No. of persons a YP g --------------------------•- P �----------•--.. Showers (-/-)--- Cafeteria ( )
d Other fixtures
W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons.
WSeptic Tank—Liquid capacity--.--.......gallons Length---------------- Width--------.------- Diameter...-.--_------ Depth....--------....
x Disposal Trench—No. .................... Width-------------------- Total Length.................... Total leaching area-----------.........sq. ft.
Seepage Pit No...................... Diameter....------.--------. Depth below inlet--.................. Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit...--.--.-.--------- Depth to ground water.-.--_----------------�
fs Test Pit No. 2................minutes per inch Depth of Test Pit_................. Depth to ground water....................
------------------•------••-----••-•••--------••-•--•--•--••-•-•-----....•----------------•-•-••------••-•----•-•••-•---.............------.
O ................rer
Descriptionof Soil............•--•-a a.ve- -----------------------------•--••--•--------------------------------------------------------------------------------------................
x
W
UNature of Repairs or Alterations—Answer when applicable.--install a 1 , 500 gal tank, d-box
and 60 , leach-trench. Pump & fill in old cess oos
-----------------------------------------------------------••-----•-••-•••. -------•••---------------------•-•-------------------- -----------------...--------------••••......----.....--------•••
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has bee ,issu : y the board of✓health.
/. - /�� -7
Signed .. ,//' .......... �!'t�' " �� ..9
Application.Approved BY --- �'���'. �-`�'—� �: �.�j%'-�'`�.�
Dare
Application Disapproved for the following reasons- -------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ --------------------------------------
-.. e Permit No. p >' ` �.. ..... Issued ------- .. .......
- '.
Dace
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
TP1Ctifirate of (ITIImplianve
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( x )
W.E. Robinson Septic Servicw
--------------------------------------- ----------------------------------------------------------------------------------------------------
71 Childs St Centerville Installer
at --------------------------...............................
has been installed in accordance with the provisions of TITLE,,, of The S.a.te-Environmental Code as described in �-
the application for Disposal Works Construction Permit No. `�. ��� .. dated r�--- ---------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE...__.... ''.�" - Inspector ..,- 1-.--'
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE 30,o0
No. ....... •---•---•--- FEE........................
�t��ns�a1 urk� �lan�tr>�rtinn �rrutit
Permission is hereby granted-------W.E......RobinSOI1-,-Seta r---Srx� .ce...........................
to Construct ( ) or Repair (x ) an Individual Sewage Disposal System
71 Childs St---_--Centervill�-------------------------•...----------------•------------------------------..-..--------•----•----•--
at No. - - ---
StreetQ/y :� .�
as shown on the application for Disposal Works Construction Permit�IVo�J" ^- Dated_-- � .-�.'-
�. Board of Health
DATE...........-------=r-...........•---------------7-..........................
FORM 36508 HOBBS&WARREN.INC..PUBLISHERS
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS)
I, hereby certify that the application for disposal works
construction permit signed by me dated concerning the
property located at �, meets all of the
following criteria:
• There are no wetlands within 300 feet of the proposed septic system
• There are no private wells within 150 feet of the proposed septic system
• The observed groundwater table is 14 feet or greater below the bottom of the leaching facility
• There is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
L
SIGNED: b DATE:
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
[Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan,
this plan should be submitted].
� l
G y
4Y
L P — TOWN OF BARNSTABLE p
LOCATION ` , SEWAGE # 95 i577
VILLAGE 21 Ck JS S+P �ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO. WC— Rokio,561J -77$-S?Z�
SEPTIC TANK CAPACITY 1500
LEACHING FACILITY:(type) (size)
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER.
BUILDER OR OWNER —D, rZ
DATE PERMIT ISSUED: (o l a•.� 65
DATE COMPLIANCE ISSUED: -715 /,q �
VARIANCE GRANTED: Yes No X
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