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Home My WebLink About0378 ELLIOTT ROAD - Health 378 Elliott Road A= 227- 141 Centerville S M E A D No.2453LOR UPC 12534 smaad.com • Made in USA 41 T— N). lttrp mumNDdNb011C Lm SFt �SR '®°"'�"'a"s WSRPROORMAOM Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 378 ELLIOTT RD co j Property Address P LEWIS Owner Owner's Name / I� information is Y : required for CENTERVILLE MA 02632 5-22-17 every page. City/Town State Zip Code Date of Inspection ' „ Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important9 When fillip out A. General Information forms on the computer,use 1. Inspector: only the tab key to move your DOUGLAS A BROWN cursor-do not Name of Inspector use the return key. D.A.BROWN INC Company Name P.O. BOX 145 Company Address CENTERVILLE MA 02632 City/Town State Zip Code 508-420-4534 S14297 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000.).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 5-22-17 Inspector' ignature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000.gpd or.greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. k t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal S stem•Page 1 of 17 �� VS I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 378 ELLIOTT RD Property Address LEWIS Owner Owner's Name information is required for CENTERVILLE MA 02632 5-22-17 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 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: AT TIME OF INSPECTION SYSTEM MET ALL MINIMUM PASSING REQUIREMENTS. THIS REPORT CAN NOT PREDICT THE FUTURE PERFORMANCE UNDER THE SAME OR INCREASED USE. SYSTEM IS ON THE OLDER SIDE FROM 1984 AND IS LOCATED IN THE FRONT YARD. 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M , 378 ELLIOTT RD Property Address LEWIS Owner Owner's Name information is required for CENTERVILLE MA 02632 5-22-17 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 378 ELLIOTT RD Property Address LEWIS Owner Owner's Name information is required for CENTERVILLE MA 02632 5-22-17 every page. CityrFown 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 El ® 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 Y2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 L Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 378 ELLIOTT RD Property Address LEWIS Owner Owner's Name information is required for CENTERVILLE MA 02632 5-22-17 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection ❑ ❑ Area—IWPA)or amapped Zone II fpublic water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3f13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 378 ELLIOTT RD Property Address LEWIS Owner Owner's Name information is required for CENTERVILLE MA 02632 5-22-17 every page. Cityrrown 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(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins•3113 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 378 ELLIOTT RD Property Address LEWIS Owner Owner's Name information is required for CENTERVILLE MA 02632 5-22-17 every page. City/Town State Zip Code Date of Inspection D. System Information Description: ACCORDING TO AS-BUILT CARD SYSTEM CONSISTS OF A SEPTIC TANK D-BOX AND 2 LEACH PITS. Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No . Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes M No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage AVER 2 YRS 9 ( Y 9 (gPd)) 347GPD Detail: PROPERTY ALSO HAS AN IRRIGATION SYSTEM. HOUSE HAD DISPOSAL THAT WAS DISCONNECTED. ( SEE ATTACHED PAPERWORK.) Sump pump? ❑ Yes ® No Last date of occupancy: occupied 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M , 378 ELLIOTT RD Property Address LEWIS Owner Owner's Name information is required for CENTERVILLE MA 02632 5-22-17 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: occupied Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: 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): t5ins•3/13 1 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 378 ELLIOTT RD Property Address LEWIS Owner Owner's Name information is required for CENTERVILLE MA 02632 5-22-17 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1985 per as-built 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: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No f Dimensions: appears to be 1000 gallon Sludge depth: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M , 378 ELLIOTT RD Property Address LEWIS Owner Owner's Name information is required for CENTERVILLE MA 02632 5-22-17 every page. City/Town 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 Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? wooden pole Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): If tank has not been pumped in the last 3 yrs I recommend pumping at time of transfer and every 2-3 yrs there after for maintenance. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 378 ELLIOTT RD Property Address LEWIS Owner Owner's Name information is required for CENTERVILLE MA 02632 5-22-17 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts w Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 378 ELLIOTT RD Property Address LEWIS Owner Owner's Name information is required for CENTERVILLE MA 02632 5-22-17 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" 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.): Box was level and liquid was flowing evenly between the two outlet lines. 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: Depth with no risers, owners had just landscaped the yard and preferred we did as little damage as possible t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , 378 ELLIOTT RD Property Address LEWIS Owner Owner's Name information is required for CENTERVILLE MA 02632 5-22-17 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 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 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 378 ELLIOTT RD Property Address LEWIS Owner Owner's Name information is required for CENTERVILLE MA 02632 5-22-17 every page. City/Town 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.): 15i�s•3/13 Title 5 Official Inspection Fonn: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 378 ELLIOTT RD Property Address LEWIS Owner Owner's Name information is required for CENTERVILLE MA 02632 5-22-17 every 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 t5ins•3/13 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 378 ELLIOTT RD Property Address LEWIS Owner Owner's Name information is required for CENTERVILLE MA 02632 5-22-17 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: greater than 5 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ❑ 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: Adjacent septic system data. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 378 ELLIOTT RD Property Address LEWIS Owner Owner's Name information is required for CENTERVILLE MA 02632 5-22-17 every page. City1rown 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 40 1 __ A JIM ST PIERREMINI PLUMBING&HEATING P.O.Box 253 West Yarmouth,MA 02673 DATE INVOICE# 6/l/2017 392 BILL TO: John L.CWU 378 Elliott Road Celnterviflle,MA 02632 DESCRIPTION AMOUNT ftmved Dis wd 0.00 /Y-/,4'1 ,�Z j / 65.00 Paid in full Check#4357 - 50.00 r -115.00 TOTAL $0•00 Assessing As-Built Cards Page 1 of 2 LOCATION rj"" '79 t%� SEWAGE PERMIT NO. A-07 P 1 S-L L \m— rw� VILLAGE INSTALLER'S NAME A ADDRESS R UILDER OR OWNER • D &U Rm b Imo-t�J 1 L S DATE PERMIT ISSUED q_ S _24 DATE COMPLIANCE ISSUED 1 h� td I 2� .let, . 3C , http://www.townofbamstable.us/Assessing/HMdisplay.asp?mappar=227141&seq=1 6/7/2017 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 378 ELLIOITT RD Property Address MITCHELL Owner Owner's Name information is required for CENTERVILLE MA 02632 3-30-15 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: Wheri filling out A. General Information y U '-I forms on the computer,use 1. Inspector: onlyhe k the tab key i to move your DOUGLAS A BROWN cursor-do not Name of Inspector use the return key. D.A.BROWN INC Company Name VkA P.O. BOX 145 Company Address CENTERVILLE MA 02632 Cityrrown State Zip Code 508-4204534 S14297 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 3-30-15 I ctor nature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""*"This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments v1M , 378 ELLIOITT RD Property Address MITCHELL Owner Owner's Name information is required for CENTERVILLE MA 02632 3-30-15 . every page. CityrFown 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: AT TIME OF INSPECTION THE SYSTEM WAS 30 YRS OLD BUT MET THE MINIMUM PASSING REQUIREMENTS. THE HOUSE HAS BEEN OCCUPIED BY ONLY 2 PEOPLE FOR THE PAST SEVERAL YRS. FUTURE PERFORMANCE UNDER THE SAME OR INCREASED USE CAN NOT BE DETERMINED FROM THIS REPORT. PIT# 1 WAS OPENED AND WAS FOUND TO BE IN WORKING ORDER WITH ABOUT 18 INCHES OF USABLE SPACE B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. . The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 378 ELLIOITT RD Property Address MITCHELL Owner Owner's Name information is required for CENTERVILLE MA 02632 3-30-15 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 378 ELLIOITT RD Property Address MITCHELL Owner Owner's Name information is required for CENTERVILLE MA 02632 3-30-15 every page. Cityrrown 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 1/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 ,M 378 ELLIOITT RD Property Address MITCHELL Owner Owner's Name information is required for CENTERVILLE MA 02632 3-30-15 every page. Cityfrown 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 waterelevation. ❑ ® 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,50Sfeet 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 analy_s ;,,, and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with;a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, • or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins 3113 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 w„ 378 ELLIOITT RD Property Address MITCHELL Owner Owner's Name information is required for CENTERVILLE MA 02632 3-30-15 every page. Cityrrown 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(design): 4per Number of bedrooms(actual): 4 per town asbuilt web site DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins-3113 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 378 ELLIOITT RD Property Address MITCHELL Owner Owner's Name information is required for CENTERVILLE MA 02632 3-30-15 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: according to as-built system consists of a septic tank d-box and two leach pits Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ❑ No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): Detail house has irrigation system 2013------------309 2014------------289 gpd per c.o.m.m water Sump pump? ❑ Yes ❑ No Last date of occupancy: 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 o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 378 ELLIOITT RD Property Address MITCHELL Owner Owner's Name information is required for CENTERVILLE MA 02632 3-30-15 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: 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): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 378 ELLIOITT RD Property Address MITCHELL Owner Owner's Name information is required for CENTERVILLE MA 02632 3-30-15 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1985 per as-built 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: 3 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: appears to be 1000 gallon Sludge depth: moderate t5ins•3/13 Title 5 Official Inspection Forth: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 wM 378 ELLIOITT RD Property Address MITCHELL Owner Owner's Name information is required for CENTERVILLE MA 02632 3-30-15 every page. City/Town 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 Scum thickness moderate Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? wooden pole Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): recommend pumping every two to three yrs Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w„ 378 ELLIOITT RD Property Address MITCHELL Owner Owner's Name information is required for CENTERVILLE MA 02632 3-30-15 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °wM 378 ELLIOITT RD Property Address MITCHELL Owner Owner's Name information is required for CENTERVILLE MA 02632 3-30-15 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0r. 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.): box is fairly deep recommend risers Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: _ t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 378 ELLIOITT RD Property Address MITCHELL Owner Owner's Name information is required for CENTERVILLE MA 02632 3-30-15 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): pit# 1 was opened and found to be functioning properly with about 18 inches of usable space, recommend installing risers. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 13 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 378 ELLIOTT RD Property Address MITCHELL Owner Owner's Name information is required for CENTERVILLE MA 02632 3-30-15 every 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.): F t5ins•3113 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 378 ELLIOITT RD Property Address MITCHELL Owner Owner's Name information is required for CENTERVILLE MA 02632 3-30-15 every page. Cityrrown 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 S 1 OZ/tl/t, I=basal I t,I LZZ---mddutuLdsL,•XuidsipWH/2uissossV/sn•aiguisumgloumot-nnwm//:dllu Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments wM 378 ELLIOITT RD Property Address MITCHELL Owner Owner's Name information is required for CENTERVILLE MA 02632 3-30-15 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: greater thah 5 ft 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: property sits high on a hill 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 Z 3o Z 32t d spiuD timg-sV ifurssossV SIOZ/tl/t, I=basWItbILZZ=juddLtuLdsu-SuldsipWI-1/5uissossV/sn-aiguisu ugjoumot-AvAm//:duu Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments l 378 ELLIOITT RD Property Address MITCHELL Owner Owner's Name information is required for CENTERVILLE MA 02632 3-30-15 every page. Cityfrown 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 Z jo Z aftd sp u D tTmg-sV 2urss3ssV Assessing As-Built Cards Page 1 of 2 LOCAvTION n"" wc-ISEWAGE PERMIT ND. VILLAGE 11/I 0 S ZN-r,eo i L-, t7 I N S T A LLER'S NAME i ADDRESS BUILDER OR OWNER d Iry S 1; h1a_2j1X BLS DATE PERMIT ISSUED q_ S _Q4 DATE COMPLIANCE ISSUED l td 2q 7 y2� 3C ' �t http://www.townofbamstable.us/Assessing/HMdisplay.asp?mappar=227141&seq=1 4/4/2015 R - `�'7fY pz � moo. No. ......._... Fss...S........W.............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEAt_TH A, �d Au!�.....................0 F......,�./�?.i: .............. Appliratiou for Bh4paii al Works Tuatutrurti au Prrutit Application is hereby made for a Permit to Construct (i') or Repair ( ) an Individual Sewage Disposal System at: :.........SCOT--`?!!.......... GLi O�....................................... a/i P.----••--••-••-•-••--•---•----'...............'-------•--• Location-Address or Lot No. J ...... __.................................. .................................. ...............•••. .................... ..! .......................... Owner i Address a .._... ......................................... .......... Installer Address Q Type of Building Size ....Sq. feet aDwelling—No. of Bedrooms--- U v'e............. .....Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building _____SAP P......_ No. of persons.....!K................... Showers ( ) Cafeteria ( ) a Other fixtures ---------------------------------------------•---- . W Design Flow.......... .............gallons per person per day. Total daily flow................ y_ .................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 Distribufion'box ( ) Dosing tank ( ) Percolation Test Results Performed by..��__!«-___-_'e.----!� r" '._._...•.................... Date...._^"�_.._:.- _.....___..... 1-1 Test Pit No. 1.....4?.......minutes per inch Depth of Test Pit------Zn�._..._. Depth to ground water.......o............ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a --•-•-----•-----------------•--•••-••---....-•---..._......------•-•---••--........._•••••.__.___-_•......................................................... O Description of Soil...........!.:0?_._________a a-91'2 �sc�eso/ C ••-••----•.......-•--•-•------------------------------------------------------ -------------------------------•------ V W U Nature of Repairs or Alterations—Answer when applicable..........................................................•.._..........__.._..._......._...... •---------------------------------------------•--------•------......--•-------------•-----.............------•-------- ---------------------------------------......................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITL U 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed - -- �� ' �o ..... Date ApplicationApproved By.................................................................................................. Date Application Disapproved for the following reasons:-----•--------••--------------------•--•-----------•--••------------------------•------•---••--•-•--•-•--.•_.._. -••••-•---•-•••--••..._...--•---•---------•-•---•-•-------•---•--•---•--......•--•................••-•--•'--•-•.••---•-•--•--••-•---•••••---••---•------•-------••--•----•-•------•.. ......._...__. Date PermitNo..•-••._��----•---•-- - •__. Issued.--•••-•----•--------------•---....___......_......-•-- Date f No....k.`L—..7--1"Y FRs...5.....r ............... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .... Applirtttion for-Biipnsttl Works Tonstrnrtinn Errant Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at: .447' e// s' ? Ge J 7 ................_......._ ...................... --•--••-•••-------•-•-------------••••------•----•.....-----------•-------••------•--..........._. y Location-Address r� ,�` ,�j or Lot No. ......................,- �✓/� (.✓r>r. �"J`�le O.'ter✓', j• 4"�'i C,�7 ��i � C '�i 9'!�."'L.�t ........................ ................................ .......... ................................................................... ............................ Owner Address .........................../•---...n`_.....-- .. ........................................... ......•.. ... ........ ...----•-••---••........................__. Installer Address r / Type of Building / - r \ 1( ,_/� Size Lot_ _____ ......Sq..feet DwellingNo.`of Bedrooms__ f�e`.`_:,..........................— Expansion Attic ( ) Garbage Grinder aOther—Type of Building ___ '" ..'._._.... No. of persons________________________ Showers ( ) — Cafeteria ( ) dOtherfixtules ----------------"•---------------------••-------------------......---....---------------.._..----•---------{------••-•-------....-•--------------.. 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 ( ) Percolation Test Results Performed ______r?�z_sr - -__________________________________ 04 Test Pit No. 1:_ ..........minutes per inch Depth of Test Pit____!. __._.___ Depth to ground water_.___4?---------------- 4-4 Test Pit No. 2................minutes per"inch Depth of Test Pit.................... Depth to ground water........................ Ri _....-----•-•••--.... O Description of Soil.........ci =J...........4.4z_=n= .....`' ""`4:F-= ?------------- U -------------------------------------- :: ............. 1__r_.:__.:—----- ________________-__________-_______-_----_____-____________ UNature of Repairs or Alterations—Answer when applicable..............................................................._................................ --------------------------------•---•-------------•--------•---•--•---------"--••---------•----•---•--------•-•----------------------------•--•---------------------------------------••---•--.......--- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITI 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed 1. �.�r. �� r��.�c rr........................... Date ApplicationApproved By...............---------•----------•...........................•-----------•-•......_........•-- Date Application Disapproved for the following reasons-------------------------------•-------------------------------------------------------------------•-----•.....-- ' , .._....... __!____.. ._. I --•-----------Date Permit No Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......................................... OF.: ............................._..._.... ............... • C�rrtifirtt�e ',af��u�t�littnr�e �� T h YS7 K CERTIFY, That the Individual Sewage Disposal System constructed `or Repaired ( ) by..r �...j. .t� _ z-- -----------------------------------/ = ll r f7 at.. Eff �iia --_ l __'----------- -fry% --''... - -••........................................... has been installed in accordance with the provisions of TI T IF j of The State Sanitary Code as described m the application for Disposal Works Construction Permit No.l�,�_t__ _____________ dated_..................... ....................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTR D AS A GUARANTEE THAT THE `SYSTEM WILL UNCTIO SA STORY. ,;.,. . DATE......_.... ---------------------------- Inspector------.._._..-•-- :'..-- THE COMMONWEALTH OF MASSACHUSETTS r BOARD OF HEALTH Noy--�....:_:.�-- ��' FED_Fs................... `F 15ispnlittl ►gfis "nntrnrtion .rrniit Permission is hereby granted_.__.__.:'C .:f :%_. ............. _______ __ ............................................................ to Construct (i or.Re ,��` ) an Idid u Dis salt, "s 'j t C at No. ......... ...... 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