HomeMy WebLinkAbout0113 COTTONWOOD LANE - Health 1. 13 Cottonwood Lane
Centerville
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Commonwealth of Massachusetts
v26a..#oa�
p Title 5 Official Inspection Form r
.. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments t t
I
113 Cottonwood Lane
Property Address t
FRANCHOT, CHARLES J & MARY J TRS e
Owner Owner's Name /
information is Centerville ✓ Ma 02632 9/18/19
required for every , .
page. City/Town State Zip Code Date of Inspection r,,
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. Inspector Information
on the computer,
use only the tab Michael DiBuono
key to move your Name of Inspector
cursor-do not DiBuono Sewer And Drain
use the return Company Name
key.
35 Content Lane
rab Company Address
Cotuit Ma 02635
City/Town State Zip Code
508-364-9587 SI 13522
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
9/23/19
I spector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time. This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
cam, Commonwealth of Massachusetts
Title 5 Official Inspection Form
I a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u 113 Cottonwood Lane
Property Address
FRANCHOT, CHARLES J & MARY J TRS
Owner Owner's Name
information is required for every Centerville Ma 02632 9/18/19
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
® 1 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:
System contains a 1,000 Gallon septic tank as well as a concrete distribution box and a concrete
leach pit. System is functioning as designed
2) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u 113 Cottonwood Lane
Property Address
FRANCHOT, CHARLES J & MARY J TRS
Owner Owner's Name
information is required for every Centerville Ma 02632 9/18/19
page. Cityfrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
16.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
� � 113 Cottonwood Lane
V
Property Address
FRANCHOT, CHARLES J & MARY J TRS
Owner Owner's Name
information is required for every Centerville Ma 02632 9/18/19
page. Citylrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the 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.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
113 Cottonwood Lane
Property Address
FRANCHOT, CHARLES J & MARY J TRS
Owner Owner's Name
information is required for every Centerville Ma 02632 9/18/19
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/2 day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® 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 2000 gpd-
10,000 gpd.
❑ ❑ The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA) or a mapped Zone II of a public water supply well
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
�. Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
. � 113 Cottonwood Lane
Property Address
FRANCHOT, CHARLES J & MARY J TRS
Owner Owner's Name
information is required for every Centerville Ma 02632 9/18/19
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes" to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate "yes" or"no"for each of the following for all inspections:
Yes No
❑ ® 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)]
l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
c � Commonwealth of Massachusetts
Title 5 Official Inspection Form
I� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
113 Cottonwood Lane
Property Address
FRANCHOT, CHARLES J & MARY J TRS
Owner Owner's Name
information is required for every Centerville Ma 02632 9/18/19
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x.#of bedrooms): 330
Description:
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ® Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d 193 Gpd
9 ( Y 9 (gP ))�
Detail:
Sump pump? ❑ Yes ❑ No
Last date of occupancy: Date
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
e Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
V � 113 Cottonwood Lane
Property Address
FRANCHOT, CHARLES J & MARY J TRS
Owner Owner's Name
information is required for every Centerville Ma 02632 9/18/19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. 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
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: Pumped on 9/17/19
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: 1,000
gallons
How was quantity pumped determined? Emptied 1,000 gallon tank
Reason for pumping: Maintenance
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
113 Cottonwood Lane
Property Address
FRANCHOT, CHARLES J & MARY J TRS
Owner Owner's Name
information is required for every Centerville Ma 02632 9/18/19
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
Original to home
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 3
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.):
System is vented at the roof line
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u
113 Cottonwood Lane
Property Address
FRANCHOT, CHARLES J & MARY J TRS
Owner Owner's Name
information is required for every Centerville Ma 02632 9/18119
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 2
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
1,000
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1,000
Sludge depth: 0
Distance from top of sludge to bottom of outlet tee or baffle 0
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 0
How were dimensions determined?
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank is sound with no leaks. Levels are normal. Tank was pumped as part of routine maintenance
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
_ 1a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
v � 113 Cottonwood Lane
Property Address
FRANCHOT, CHARLES J & MARY J TRS
Owner Owner's Name
information is Centerville Ma 02632 9118/19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
I
Capacity: gallons
Design Flow: gallons per day
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
cam, Commonwealth of Massachusetts
,p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
113 Cottonwood Lane
Property Address
FRANCHOT, CHARLES J & MARY J TRS
Owner Owner's Name
information is required for every Centerville Ma 02632 9/18/19
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert Replaced at time of inspection
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.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
113 Cottonwood Lane
Property Address
FRANCHOT, CHARLES J & MARY J TRS
Owner Owner's Name
information is required for every Centerville Ma 02632 9/18/19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No"
Alarms in working order: ❑ Yes ❑ No"
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
® leaching pits number: 1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18
c Commonwealth of Massachusetts
le
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
9 P Y rY
u
113 Cottonwood Lane
Property Address
FRANCHOT, CHARLES J & MARY J TRS
Owner Owner's Name
information is required for every Centerville Ma 02632 9/18/19
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leach pit was dry at time of inspection with no indication of failure
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth —top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
!� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
113 Cottonwood Lane
u
Property Address
FRANCHOT, CHARLES J & MARY J TRS
Owner Owner's Name
information is required for every Centerville Ma 02632 9/18/19
page. City(rown State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth &Massachusetts
1p Title 5 Official Inspection Form
ISubsurface Sewage Disposal System Form -Not for Voluntary Assessments
� 113 Cottonwood Lane
w
Property Address
FRANCHOT, CHARLES J & MARY J TRS
Owner Owner's Name
information is required for every Centerville Ma 02632 9/18/19
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
❑ hand-sketch in the area below
® drawing attached separately
t5ins .doc•rev.7/26/2018 Title 5 Official Insp
ection on Form:Subsurface Sewage Disposal System•Page 16 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
113 Cottonwood Lane
Property Address
FRANCHOT, CHARLES J & MARY J TRS
Owner Owner's Name
information is required for every Centerville Ma 02632 9/18/19
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 10+
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:
Data at B.O.H.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18
Commonwealth of Massachusetts
-p Title 5 Official Inspection Form
b Subsurface Sewage Disposal System Form - Not for Voluntary
- g p o o unta Assessments
Y rY
113 Cottonwood Lane
Property Address
FRANCHOT, CHARLES J & MARY J TRS
Owner Owner's Name
information is required for every Centerville Ma 02632 9/18/19
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
❑ A. Inspector information: Complete all fields in this section.
❑ B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
❑ C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
❑ D. System Information:
For 8: Tight/Holding Tank— Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
.b TOWN OF BARNSTABLE
#rA � N SEWAGE # S-��Co 7
VILLAGE 6A71,h ASSESSOR'S MAP & LOT -Oa
g,
%1je P /Z NAME&PHONE N —
. t 6�
SEPTIC TANK CAPACITY
LEACHING FACII.ITY: (type) ` C (size) C n . sd o
NO. OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
Separatien Dstance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
u�
,
c DO Uvnlox
o
ce
rv'
NO. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in com uter:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
Rptication for -Misposar 6pst>ern Construction Permit
Application for a Permit to Construct( ) Repair(VI pgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No.��'� C@i Qs1 yr, Qy li. Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel u Z — Sa 09 C C h
Inst�allller's Name,Address,and Tel.No. L� Jam! .�'vT'�� Designer's Name,Address,and Tel.No.
wS wv a°t9elcL'd O 4 l�1
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank ',0 Type of S.A.S. L ri
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) e, _C•► �� PleaC
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code andn lace the system in operation until a Certificate of
Compliance has been issued by Board of Health,.w
Date 6 '�
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. Date Issued 17
Il -- ----------------- s�- -=a
��� �No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in cguter:
PUBLIC HEALTH DIVISION,,-;TOWN OF BARNSTABLE, MASSACHUSETTS
application for Misposal *pstem (Construction Permit
Application for a Permit to Construct( ) Repair(/Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 3 C� ���� �/�/ Owner's Name,A ess`and'Tel.No.
Assessors Map/Parcel
Installer's Name,Address,and Tel.No.S:A f 7cq,.�Jt-�7 Designer's Name,Address,and Tel.No.
-.- f
Type of Building:
Dwelling No.of Bedrooms k Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures E
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title ~
Size of Septic Tank [ C) Oy Type of S.A.S.
Description of Soil ,
Nature of Repairs or Alterations(Answer when applicable) Q �, K. ✓� /JZ hC-e
Date last inspected:
a
Agreement: "M
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in =_
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Date —
Application Approved by U Date
Application Disapproved by� Date
for the following reasons
Permit No. Date Issued
THE,COMMONWEALTH OF MASSACHUSETTS
r ��p BARNSTABLE,MASSACHUSETTS $ '
y� Certificate of Com Ciauct
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired Upgraded( )
Abandoned( )by l J .'��t, o.� O 5in, '-C. olJ Qor&,1j�
at //, 3 /a dd an GJ Ij d has been constructed in accorda4c--
with the provisions of Title 5��and the for Disposal System Construction Permit No. �.. ad
Installer A 4._r/ //1 Ag ^4 h Designer
#bedrooms Approved design flow ,(Jg and
The issuance of this permit shall not be construef as a guarantee that the system�rirftin ioas designed.
Date Inspector,
_ ------------- --------------------�-] I ►-------------- --- -------------- - - -�N
--- ------- ---- --s�A�---------- -
No. Fee �-
UV 1 THE COMMONWEALTH OF MASSACHUSETTS
.PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS
Misposal *pstem Construction Permit
Permission is hereby granted to Construct( ) Repair(vr Upgrade( ) Abandon/( )
System located at 3 �,� G L. 'AV 0 a���
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Constructioqs�te co�eted within three years of the date of this permit.
Date Approved by
v r
A'• 5 • I
-\ COMMONWEALTH OF MASSACHUSETTS
Z EXECL`1^IVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTIWJ FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURI?ACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: �'Zf;Ltt�x' i/,1�
r.
Owner's Name.
Owner's Addr _
tr A-
Date of Inspection:
Name of Inspecto (please rint)
Company Nam �C°
Mailing Address: )
Telephone Number: • '7"7I•
U 9
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that theZmformatior repory�d
below is true, accurate and complete as of the time of the inspection.The inspection was performed based on myy
training and experience in the proper ftinction and maintenance of on site sewage disposal systems. I am a DE.P
Cz
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The sys`em:
6/ Passes
-� Conditionally Passes
Need Further Evaluation by the Local Approving Authority
Fai,S
Inspector's Signature: #w `' Date:
i.,
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 sydte`m owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to th:j system owner and copies sent to the buyer, if applicable, and the approving
authority.
4
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.
y
Title 5 Inspection Form 6/15/2000 .; page 1
Page 2 of l 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property.Address: _
Owner:
Date o spection.
'
Inspection Summary: Check A,B,C,D or E./ALWAYS complete all of Section D
A. ystem Passes:
I have not found any information which indicates that any of the f,;iIure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist.And 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,quill pass.
Answer yes,no or not determined (Y,N.ND) in the 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 inspectiol_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 le-o-1 in the distribution box due to broken or
obstructed pipe(s)or due to a broken,sertled 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 repla(;ecl ,
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
obstnction is removed
ND explain:
2
Paee 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SE4'AGE DISPOSAL SYSTEM INSPECTION FORM
PART A
sl CERTIFICATION(continued)
Property Address: , R , /,(,
Owner:
Date of, pection:
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 Boarc+'of Health determines in accordance with 310 CMR 15.1303(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 Beard 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 ta.akand soil absorption system (SAS)and the SAS is within 100 feet of
surface water supply or tributa'.y to a surface water supply.
,
1„
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 ta..;iK and SAS and the SAS is within 50 feet of a private water supply well.
4i
_ The system has a septic t�`k.and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well**. M!.-thod 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 flee 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:
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3
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Page 4 of I 1
OFFICIAL INSPECTION-FORM.—.NOT FOR V01JUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continud)
Property Address; l/'
Owner.
Date of spection
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes N_ .
_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
Discharge or ponding of efi_uent to the surface of the ground or surface waters due to an overloaded or
/ clogged SAS or cesspool
+J Static liquid level in the distribution box above outlet invert .iue to an overloaded.or clogged SAS or
cesspool
Liquid depth in cesspool is less than 6"below invert or availE;);le volume is less than %2 day flow
Required pumping more than 4 times in the last year NOT dLe,to clogged or obstructed pipe(s).Number
_ Jof 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 surAac.,,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.priva:e water supply well.
Any portion of a cesspool or privy is less than 100 feet but grt.'!ater 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 baciteria 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 El_e analysis.must be attached to this form.]
(Yes/No).The system fails. I have determined.that one or more of the above failure criteria.exist as
described in 310 CMR 15.303,therefore the system fails. T:h:,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.
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 9
— ^ 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 Wellli6ad Protection Area—I'WPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any quest on in Section E the system is cor.sidered a significant threat, or answered
"yes"in Section D above the large systeni has failed.The owner or opetra or 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.
4
e
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Propert ddress:
Ownea.J� ..,
Date o spection:
Check if the following have been don&, You must indicate"Yes"or"no"as to each of the followine:
Yes No
Pumping information was Irovided by the owner, occupant, o-Board of"Health
Were any of the system cot jnponents pumped out in the previous two weeks?
_ V Has the system received noi;mal flows in the previous two week period ?
Have large volumes of wat°*,r been introduced to the system recently or as part of this inspection?
JZ.— Were as built plans of the s`.�stem obtained and examined?(If they were not available note as N/A)
v Was the facility or dwelling:;inspected for signs of sewage back up ?
i
V Was the site inspected for<,-,gns of breakout?
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
1
The size and location of the$oil Absorption System (SAS)on the site has been determined based on:
Yes no
Existing information. For example, a plan at the Board of Health.
Determined in the field(if.any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [310 CMR 15.302(3)(b)]
7a
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Page 6 of I 1
OFFICIAL INSPECTION FORM—NOT FOR Vj' UNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTE'.`4 INSPECTION FORM
PART C `a
SYSTEM.INFORMATION
Property Address:
Owne U p
Date o spectio
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):_a Number.of bedrooms(actual):
DESIGN flow based on 310 C R 15.203 (for example: 11.0 gpd x#of bedrooms):
Number of current residents:
a, .
Does residence have.a garbage grinder(yes or no):
Is laundry on a separate sewage system (yes or no) .[if yes separate inspection required]
Laundry system inspected(y s or no):��3
Seasonal use: (yes or no):
a`' /�R:
Water meter readings, if $ailable (last 2 years usage(gpd)): � � i
Sump pump(yes or no):_
Last date of occupancy:
COMMERCIAL/INDUSTRIAL//O
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(yos 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 t.
Source of information:
Was system pumped as pa of the inspection(yes 6r no): (�
If yes, volume pumped: gallons=-How was quantity pumped dete-mined?
Reason for pumping:
TYP-1�- 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)
—Tight tank _Attach a copy of the DEP approval
Other(describe):
pproximate a4e of all components, ate ins ed if own)and source of information:
Were sewage odors detected when arriving at the site(yes or no):
6
Page 7 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
n
Owner: i 6`
Date of pection: 1.14
r
BUILDING SEWER(locate on site pl lz) U
Depth below grade:
Materials of construction:_cast iron 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:Zaocate on site plan)
Il ;
Depth below grade:
Material of construct :, concrete metal_fiberglass ion ___polyeth ,lene
—other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions: >.
Sludge depth:—/*it
Distance from top of sludge to bottom df outlet tee or baffle: . ZO
Scum thickness: fr
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bPdatid�"nl,
of outlet tee or baf e:
How were dimensions determined ' Q °
Comments(on pumping recomme inlet and outlet tee or baffle condition, structural integrity, liquid levels
as elated to outlet invert, evi ence of leakage,etc):
/i q f r
GREASE TRAP (locate on site pl?'n)' 7�Lb ZO&O pall)-)VII-e-ze
Depth below grade:_ }
Material of construction:_concrete metal_fiberglass_polyethylene : other
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:
Comments(on pumping recommendations,, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage, etc.):
�I .
7
Page 8 of l l
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION,,continued)
Property Address: _
Owner"--
Date of - ection: —
p � ! r
is
TIGHT or HOLDING TANK: 7AZt(ank must be pumped at time of ii)spection)(locate on,site plan)
I
Depth below grade:
Material of construction: concrete metal fiberglass 'pt.�yethylene other(explain):.
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments (condition of alarm and floa-c switches, etc.):
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 outlet ual an evidence of solids carryover,an evidence of
( 9 � Y �' y
kage into or out of box, tc.)
77
PUMP CHAMBER: (locate on site plan).
Pumps in working order(yes or no):
Alarms in working order(.yes or no):
Comments(note condition of pump chamber, condition of pumps and apDurtenances, etc.):
i
8
Page 9 of 1 1
OFFICIAL INSPECTI6.i FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEV,AGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SY?$TEM INFORMATION(cc-ntinued)
Property Address:
Owner:
Date of I s ection: '
SOIL ABSORPTIO SYSTEM (SAS):'Llocate on site plan,excavation not required)
If SAS not located explain why:
Type leaching pits,number: /
leaching chambers,number:
leaching galleries,number:
leaching trenches, number, length:
leaching fields,number, dimensions:
overflow cesspool,number:_
innovative/alternative system Type/name of technology:
Comments(note condition of soil, sign of hydraulic failure, level of ponding,damp soil, condition of vegetation,
t.:
�l.
CESSPOOLSA& (cesspool must l r;pumped as part of inspection)(locate on site plan)
Number and configuration: a
Depth—top of liquid to inlet invert:
Deptb of solids layer:
Depth of scum layer:
Dimensions of cesspool-
Materials of construction:
Indication of.groundwater:inflow(yes:-or.no)-
Comments(note condition of soil,.signs of hydraulic failure, level of ponding, condition of vegetation, etc:):
PRIVY;,/V6(locate on site plan)
Materials of construction:. s
Dimensions:
Depth of solids:
Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.):
i,
Sk ,
e? 9
t.:
Page 10 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM
]PART C
SYSTEM INFORMATION(continued)
Property Address: -�/wnlx
Owner:
Date of pection: 0
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 b ilding.
9
Iwo Q lbo
A)
�Sep
' a
cAo
Lead.
10
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Page 1 1 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Proper4Adress:
Owner:
Date ofction LOPA
c �
SITE EXAM
Slope E
Surface water '
Check cellar 1'
Shallow wells
Estimated depth to ground water }ifeet
Please indicate(check)all methods us&(1 to determine the high ground water elevation:
Obtained from system design plarrs on record-If checked, date of design plan reviewed:
Observed site(abutting property/;observation hole within 150 feet of SAS)
Checked with local Board of Hea' h-explain:
hecked with.local excavators, ir,';tallers-(attach documentation)
Accessed USGS database-explain
You must describe how you established the high ground water elevation:
%leg
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f
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'H.
�F
f k
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11
Permit Number: Date:_
Comoleted by: �6A
HIGH GF,`DUN D-WATER LEVEL COMPUTATION
Site Location: �^z,,/A Lot No.
Owner: Q Address:
Contractor:_!�'/)T�G� .,�t
Address:
i
Notes: � ..���'/�/�"fi'/!�'✓� .��'`�°
STEP 1 Measure depth to wale. table -
to.nearest 1/1Oft. ........
.............._.....-..-........-........... ............... .Date
month/day/year
STEP 2 Using Water-Level Racy-3 Zone
and Index Well Map Ixat�l
site and determine: _
--..-. _
CB Water-level range =cne - -
-• ...................................
STEP 3 Using monthly report. ' :u'rrent
Water Resources.Cond
determine curre.nt.depth to
water level for
index ...................
i mdnth'/Year
STEP tP 4 Using Table or Water-eeeF-adLstm -
for index well STEP 2. 'J o
to water level for index:v,-pt;' (STEP 3) x"
and water-level zone (STEP,26)
determine water-level ecju -!:ment .....................
� . .;..
{ ..
"AZ'"=
STEP j Estimate depth to high wa;ar
by subtracting the water-
level adjustment (STEP?;
from measured depth to water,
level at site (STEP 1)
r tir
� k r
Figure 13.--Reproducible corJputation Corr-1.
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No.��..s..:,1.�.7 Fx
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............................. ..... ......OF..........................................-----------------..........------...............
ApplirFatiou for UtsposFal Works Tomitrurtiun Permit
Application is hereby made for a Permit to Construct ((--for Repair ( ) an Individual Sewage Disposal
System at:
,l........../ 5 ....................... .................................................................................................
.L.. tion-Address or Lot No.
' /Vo.C.�r�c�c�-•, Address---•------•----------------•-•..........---
1/51
Installer Address
d Type of Building Size Lotl5v.,P ........Sq. feet
V dms___... ----------------------------- Ex Expansion A Garbage GrinderDwelling—No. of Beroo ttic
( )
per, Other—Type of Building ...... __.._. No. of persons--________________________ Showers ( ) — Cafeteria ( )
p" Other fixtures ----------------------------------
--------------------------------------- --------
Design Flow..-,//O...............................gallons per person per day. Total daily flow.-_33&.....:_.....................gallons.
04 W Septic Tank—Liquid*capacity.JSA®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 (✓f Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
rT4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water....................
a ..........-..................................................................................................................................................
0 Description of Soil........................................................................................................................................................................
x
U -----------------•---- ....-----••-•---...----------•------------••--••-••--•---•••-------------•---------------------------------•-•-•------- .........................................................
w
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
V Nature of Repairs or Alterations—Answer when applicable...............................................................................................
.................-........................................................................................................................................................................=.........
Agreement:
The undersigned agrees to install the aforedescribed Indivi�� wage Disposal System in accordance with
the provisions of TL I T=j 5 of the State Sanitary Cod i 141nndkigned further agr es not to place the system in
operation until a Certificate of pli ce h en ' by t o of
Igned .._ 1
eal p��
-- �.. ---•............. z�-
Date
ApplicationApproved -.............(3':- .................................................._.... ...----�' ./ ---------
Date
Application Disapproved for the following reasons-----------------------------•-------------------------••--------------------•--•---------------------......-•---
.............................•-•----------•-•------------------------........--------------•----------------•-----•---•-•--•--•-------•------•-----------------•--•---------••-----------•••-----._...._
Date
PermitNo......................................................... Issued---------•--------....................................
Date
- ---- --- - - -- - --— -�.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...............::..............O F................-...-....
Appliration for Disposal Vorkg Tonotrurtion Vrrtnit
Application is hereby made for a Permit to Construct (✓) or Repair ( ) an Individual Sewage Disposal
§y9toln at:
yCI
�/v j�cation-Ad r ss o,
ryCJ �7 v l�"�J or Lot N
-•--•r . _.:. -- - � � ---^��-------------------------•---.. .......C� ?. r,1J .`..eCzl�e�aS ....._.__...._._.........-----.........-----
�� / e J 4 • y / Address
a --�-----------•.......--••--....... ..... .✓. �[k�_ ZJ4.4. . --�J -•
Installer Address
S feet
Q Type of Building Size Lor/�_�f�, .......... q.
V Dwelling No. of Bedrooms.__._ _____g— �............................ Expansion Attic ( ) arbage Grinder ( )
Other—Type of Building _._ .'°U .._._____ No. of persons____________________________ Showers ( ) — Cafeteria ( )
Otherfixtures -----------------------------------------•--•--•----...-------•--------------•----------•-------...--------------------•-•-------._....------------••.
Design Flow_& _________________________________gallons per person per day. Total daily flow_, __ lions.
WSeptic Tank—Liquid capacity/__________gallons Length................ Width................ Diameter__---__.._______ Depth................
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........................
(s, Test Pit No. 2................minutes per inch '.Depth of Test Pit.................... Depth to ground water........................
•� ---------------------------------------j....................................................................................................................
.
O Description of Soil........... .....................................i.......................................................................................-............................
W
UNature of Repairs or Alterations—Answer when applicable................................................................................................
------------------------------------------•------------------------------------•---------------....-----•-----------------------------------•----------•-----------------------------•-•-----........._-
'Agreement:
The undersigned agrees to install the aforedescribed Indivi aid Sewage Disposal System in accordance with
the provisions of TIT LE 5 of the State Sanitary Co � 1g and signed further agrees not to place the system in
operation until a Certificate of pl• ce h ids ed by the bpard of,health.
Signed'_ //% •-------------•--- ' ...-....
Application Approved B -'" __._" -- ---_----__--
Date
Application Disapproved for the following reasons---- -------------------------------•-------•--------------•------------------•--- ........................
....................•-----•-••---•---••------------....--------------•-•----------•-----------•---------•-•---------------•----•----•-----•------------•-•-----•----------•---•-•----•-----•---------•--
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF, HEALTH
...........................................O F...............-..-..............................................._........:....._...
(Inrtifiratle of Tontplianrr
THISIS TO CERTIFY That the Individual Sewage Disposal System constructed �-) or Repaired ( )
by---- -J...............`c.. .......'
_.,,..Installer
Installey� �ZQ
at. .......................................... k� Z n r v a. ...............................................................
has been installed in accordance with the provisions of TI= 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No----- ............ dated, _`I�/::.___________________
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONST UED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION� S�AQ/TISFACTORY. 7
DATE-----------•--•---------••...............` "•--- ....--•---•--------------..._. Inspector.-•-------------- --- -- -----.....-•--••----......................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
r r6,7 ...........................................OF._.......--.-....-•------•----.............------....-----..._...___•--•--•--....._.. 00
No......................... FE ..............
INS ` K]Vorko �onotrttrtion an it
Permission is hereby grante .. ---•--------------•---------__.._....------......._....... ....._
_.. .------•----,�
to at Const M
, ) or Re i ( ) an Individual Se r,age 1)4osal System
�� ��� , :
Streeter
as shown on the application for Disposal Works Construction Permit Ilo�' _� ________ Dated.2 I&
Board of Health
DATE............ D -•-----•----------•----•--•........
E
FORM 1255 A. M. SULKIN, INC., BOSTON
el N SEWAGE PERMIT NO.
V E
I N S T A LLER'S NAME i ADDRESS
7-St W, 041 eh .54 46le i,"0,:p s,
f UILDER OR OWNER
r1y����J
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED _ _
.. a
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\ y� , 2�,' , , � /
., ,
. ` \\ p I��
..
��
•, _ _ __
�-�.r�r/
D G
, BSI
51►�6Lt FAMILY i= 3•:,6E020oM
.. S
I WO GARBAGE 6jQ'wr>GP-
4G.. q � .
� �� DAIL.y Flow .. IIU X 3 - 7306.Po � �/ ...
II �EPTIO TANK = 330xI5c>% =-497G.P. o n 3�3 9
u51= 1000 GAL, 9
I. DISPOSAL PIT u5E 1000 GAL..
j' -5 t mWALL AF TzCIs - 1�o (� �zoP
r. S,F 9y�150 5• X . 2.5 - 3?5 6R.c 97 ,91) Pir aaA
'
50T r.0M AREA 0 •5 F•
5 c S.F x 1. 0
PRoI�
-TOTAL DA I LI? F%_bW = 33o G,PO,
o I vi
PE2G LAT 04 SZA?Es 1��IN 2MW OI`Lr= C�
-1'ow►J .WATa,�'Z. A�/A 1 L�a,r31..r� 2� t v►w'pd;4
� !, ,,�� +v..4,I� LPL •t��� '��� �,
PETER
F ( �� RICHARD �:'y a SULLIVAN 1:
A.
w BAXTER `�b No. 29733
`. No 240 $Q 97.
TOP FWD=1oo•5
f' I Sv3SotC. �' 1000 tN�.
2 DIST. INV GAL. el 9
1000 BpX Q,' � SePTIG
INV. TALIK 1c�
LEAGLI
I ,
PIT INW INY
GoAr1?S,[ • .
. � wlTu 9�-� �� 4 •
SIaN� 1��3/q•I� '
I (/tAVtIL WA'Wr.D ,
G1=2T1►-IG0 PLOT PLAW
I Z N o S CAa:E` _ C113TTi ��
Sc 44
1 GE QTIGY -THAT 'TNrc �avN�r�'r'tolJ 51•ioµ1N P L-At`l RE1=62EIJ GE•
KEREoN COMPl.YS Y�lITF•1'CNE SIoELIN�
AVJD SETleAGK R.6GjV1R.�1�l1=NTH 0 'CµE IS S
TOWN dF 'T3A,tZia'-i•fA�Lt�ANU IS N�`r G
LOC- .TED MITNIM TN•E GLOdD PL�+.11.1 i L , G,�, 20'Z 3q
CHAT Z.`� e, t
6AxTEtze Myt- INC.
MA I$ P LL N I S N oT t3 n 5 F A o kl A N R.EG I VT SQ.6•'D'L AI4 D S u my EYce,5,
IM,5-MuM1✓N'T oFr5E75 SUout,D aSTE2.VILLE• • MA-�S.
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