HomeMy WebLinkAbout0136 GOFF TERRACE - Health 136 GOFF TERRACE, CENTERVILLE ' �
MAP-147, PAR._ 037
No. 42101/3 ORA
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ESSELTE
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No.(A�-' I Fee Y� �!
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
Rpplitation for Disposal 6pstem Construction permit
Application for a Permit to Construct( ) Repair(141 Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No./36 6�'®YV ��`�`jC Owner's Name,Address,and Tel.No. O�o
Assessor's Map/Parcel z—y �,'`7 83p—/?7r,
Installer's Name,Address,and Tel.No. 4rn� ./'rar'�'`% Designer's Name,Address,and Tel.No.
Gt/ urv�Vts�'y
Type of Building:
Dwelling No.of Bedrooms 37
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 Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) c��<�rrve �ytS o.r-* ctr� e
tr
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 and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Si ed — -- Date iz/7ZXd
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. C 6 Date Issued la
No.l/�/ Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
2ppliLatlon for Disposal 6pstem Construction Permit
Application for a Permit to Construct( ) Repair(t/'Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No./36" Go f�' ?p�iocQ Owner's Name,Address,and Tel.
ee.fle,,-"Yet
Assessor's Map/Parcel 2 7177 �.,%�.y%/� �/y
Installer's Name,Address,and Tel.No. 41, Designer's Name,Address,and Tel.No.
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 PA gpd
Plan Date Number of sheets Revision Date
i
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature
of Repairs.or Alterations(Answer when applicable) �P�rave G,Fp r os-a 3'Q�, ry E
i
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 and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
i S' ed Date
Application Approved by - Date
r
Application Disapproved b� Date
for the following reasons
Permit No. 0 Date Issued 7 /�b
� (
--------------- -----------------------------------------------------------------------------------------------------------------------
TH
I (r` E COMMONWEALTH OF MASSACHUSETTS
�C BARNSTABLE,MASSACHUSETTS
Ic Certificate of Compliance
S n(" THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(%� Upgraded( )
Abandoned( )by
at /3G G' ?-,e has been constructed in accordance
with the provisions o Title 5 and the for Disposal System Construction Permit NoZO 92?-dated [Z �1-9 , /h
0
Installer �y� �—� Designer h
#bedrooms A`�l4 Approved de flog N gpd
The issuance of this p rmrt shall not be construed as a guarantee that the system will fun h(on as desi ed.
Date +3 'j �, Inspector
---------------------------------------------------------------------------------------------------------------------------------------
No. 12� Fee q5
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Bisposal 6pstem Construction J)ermit
Permission is hereby granted to Construct( ) Repair(4_� Upgrade( ) Abandon( )
System located at /3C e5"
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:ConstWction must be completed within three years of the date of this permit
Date 1 Z �l Zo/(i Approved by
4
Town of Barnstable Barnstable
Regulatory Services Department ANWOmft
i '"MSIAS
MASS. Public Health Division I
1b39• 1�
' 200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Richard Scali,Interim Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL #7014 1200 0001 0358 4039
June 18, 2015
Ann C. Phillips
136 Goff Terrace
Centerville, MA 02632
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 136 Goff Terrace, Centerville, MA was last
inspected on 5/20/2015 by Paul Martin, a certified septic inspector for the State
of Massachusetts.
The inspection of the septic system showed that the system "Conditionally
Passes" under the guidelines of the 1995 TITLE 5 (310 CMR 15.00) due to the
following:
• Roots in septic tank & distribution-box..
• Roots need to be removed from tank & box then sealed with
cement.
You are ordered to repair or replace the septic system within two (2) years from
the date you receive this notification.
Failure to repair/replace the septic system within the deadline period will result in
future enforcement,action.
PER ORDER OF TH BOARD OF HEALTH
Thomas McKean, R.S. CHO
Agent of the Board of Health
Q:\SEPTIC\Conditionally Passes Ltr\136 Goff Terrace Cent Jun 2015.doc
6/16/2015 Parcel Detail
I
f 4 i MCI
rf ,
it
Logged In As: Parcel Detail Tuesaay, June 16 2015
Parcel Lookup
Parcel Info _
Parcel ID 147-037 ' Developer Lot LOT 12A� �
Location 136 GOFF TERRACE Pri Frontage ,120
Sec Road ` Sec Frontage
Village CENTERVILLE Fire District C-O-MM
Town sewer exists at this address No , Road Index 0610
g ,, .
Interactive Map l4V
- t,
Owner Info
CO-
0 wrier PHILLIPS, ANN C owner
Streetl 136 GOFF TERRACE Street2 Y
City CENTERVILLE state MA zip 02632� Country
Land Info
Acres 0.34 use Single Fam MDL-01 zoning RC Nghbd'0105
Topography Road
Utilities Location
Construction Info
Building 1 of 1
Year 1981 j Roof Gable/Hip wall Wood Shingle
Built �!Struct
Living 1240 Roof Asph/F GIs/Cmp� AC None
Area Cover Type
Bed
style Ranch wall Drywall Rooms 3 Bedrooms
in Bh
Model Residential Floor Carpet Roams ,1 Full-1 Half
Grade Average Type Hot Water Roomsl 5 Rooms J
Stories 1 Story Heat Oil Found Poured Conc.
Fuel ation
Gross 2922
Area
.Permit History
Issue Date Purpose Permit# Amount Insp Date Comments
Visit History
Date Who Purpose
http:/fiissq l2fi ntranet/propdata/Parcel Detaii.aspx?I D=9648 1/3
6/16/2015 Parcel Detail
7/1 8/2007 12:00:00 AM Paul Talbot Cyclical Inspection
11/22/2000 12:00:00 AM John Greene Cycl Insp Comp
8/15/1992 12:00:00 AM ML Meas/Listed-Interior Access
Sales History
Line Sale Date Owner Booty/Page Sale Price
1 ' 10/28/1999 PHILLIPS,ANN C 12628/279 $152,000
2 7/22/1981 NOVELLO, MATTHEW A& CONSTANCE 3328/72 $0'
- Assessment History
Save Year Building XF Value OB Value Land Value Total Parcel
# Value Value
1 2015 $94,700 $36,300 $2,600 $105,100 $238,700
2 2014 $94,700 $36,300 $2,700 $105,100 $238,800
3 2013 $94,700 $36,300 $2,700 $105,100 $238,800
4 2012 $94,700 $35,700 $2,100 $105,100 $237,600
5 2011 $128,200 $3,300 $0 $105,100 $236,600
6 2010 $128,100 $3,300 $0 $105,100 $236,500
7 2009 $125,900 $2,700 $0 $141,800 $270,400
8 2008 $150,100 $2,700 $0 $147,700 $300,500
10 2007 $164,300 $2,700 $0 $147,700 $314,700
11 2006 $135,700 $2,700 $0 $149,100 $287,500
12 2005 $125,600 $2,600 $0 $135,100 $263,300
13 2004 $101,700 $2,600 $0 $114,800 $219,100
14 2003 $92,100 $2,600 $0 $44,600 $139,300
15 2002 $92,100 $2,600 $0 $44,600 $139,300
16 2001 $92,100 $2,600 $0 $44,600 $139,300
17 2000 $70,300 $2,500 $0 $30,100 $102,900
18 1999 $70,300 $2,500 $0 $30,100 $102,900
. 19 1998 $70,300 $2,500 $0 $30,100 $102,900
20 1997 $84,100 $0 $0 $26,800 $110,900
21 1996 $84,100 $0 $0 $26,800 $110,900
22 1995 $84,100 $0 $0 $26,800 $110,900
23 1994 $76,200 $0 $0 $30,100 $106,300
24 1993 $76,400 $0 $0 $30,100 $106,500
25 1992 $86,900 $0 $0 $33,500 $120,400
26 . 1991 $86,200 $0 $0 $53,600 $139,800
27 1990 $86,200 $0 $0 $53,600 $139,800
28 1989 $86,200 $0 $0 $53,600 $139,800
29 1988 $62,400 $0 $0 $19,200 $81,600
30 1987 $62,400 $0 $0 $19,200 $81,600
31 1986 $62,400 $0 $0 $19,200 $81,600
http:/fi ssq l2ti ntranet/propdata/Pareel Detai i.aspx?ID=9648 2/3
I
Town of Barnstable
• Hasuvsr"M
Regulatory Services Department
Public Health Division
200 Main Street, Hyannis MA 02601
Office: 508-862-4644 Richard Scali,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
Feb 6, 2007
Rev. 4/28/15
DEADLINES TO REPAIR FAILED SYSTEMS
(Town Code §360-44 and Title V: 310 CMR 15.000)
An"x"marked in the ❑ is the failure criteria and associated repair deadline
60 DAY DEADLINE CRITERIA
❑ Discharge or ponding of effluent to the surface of the ground
❑ Pumping more than 4 times during the last year not due to clogged or obstructed
pipe.
❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool
ONE (1) YEAR DEADLINE CRITERIA
❑ Static liquid level in the distribution box above outlet invert due to an overloaded or
clogged SAS or cesspool
❑ Any portion of the SAS, cesspool, or privy below high groundwater elevation
❑ Any portion of the cesspool within a Zone 1 to a public well
❑ Any portion of a cesspool within 50 feet of a private water "supply well with no
acceptable water quality analysis. (This system passes if the water analysis
indicates the well is free from pollution).
TWO (2)YEAR DEADLINE CRITERIA
❑ Single Cesspool
❑ Any"conditionally passed systems" (broken cover,relocation of a pipe, relocation
of a driveway due to H-10 components, etc)
❑ Leaching pit or cesspool with high liquid level, <1.2" below pit(per Town Code
§360-9.1)
OTHER
62VVN1eVl
Repair deadline: C
Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc
n 2
Commonwealth of Massachusetts -0 31
o Title 5 Official Inspection Foy
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
136 Goff Terrace —_
Property Address
Ann Phillips --
Owner Owner's Name
information is MA 02632 — 5/28/2015
Centerville
required for every — —
State Zip Code Date of Inspection
page. City/Town
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. General Information
filling out forms I r1 n I
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Paul Martin -- ---use the return Name of Inspector
key.
Cape Cod Septic Services
�y Company Name
350 Main St
Company Address
W.Yarmouth MA 02673
City/Town State Zip Code
508-775-2825 _ _ _ __ S15016
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 0 Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
6/3,2015
nspector'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 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. , ,
Lo no
t5ins•3/13 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 1 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
136 Goff Terrace
Property Address
Ann Phillips
Owner Owner's Name
information is required for every Centerville MA 02632 5/28/2015
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
❑ I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
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-3113 Title 5 Official Inspection Forth: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
136 Goff Terrace
Property Address
Ann Phillips
Owner Owner's Name
information is required for every Centerville MA 02632 5/28/2015
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed , ❑ Y ❑ N ❑ ND (Explain below):
® distribution box is leveled or replaced ® Y ❑ N ❑ ND (Explain below):
Septic tank and distribution box have eccessive roots. Tank needs to be pumped and roots removed.
Pipes and knock-outs need to be sealed with hydraulic cement. Roots need to be removed from d-
box and knockouts need to be cemented as well.
❑ 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
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 136 Goff Terrace
Property Address
Ann Phillips
Owner Owner's Name
information is required for every Centerville MA 02632 5/28/2015
page. CityTrown 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 '/day flow
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
136 Goff Terrace
Property Address
Ann Phillips
Owner Owner's Name
information is required for every Centerville MA 02632 5/28/2015
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
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
136 Goff Terrace
Property Address
Ann Phillips
Owner Owner's Name
information is required for every Centerville MA 02632 5/28/2015
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?
Z ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 110x3=
330gpd
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
136 Goff Terrace
Property Address
Ann Phillips
Owner Owner's Name
information is required for every Centerville MA 02632 5/28/2015
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 1
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ® Yes ❑ No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d 2013=96gpd
9 ( Y 9 (gp )) 2014=82gpd
Detail
Sump pump? ❑ Yes ❑ No
Last date of occupancy: Current
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
I
Water meter readings, if available:
t5ins•3/13 Title 5 Offidal 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
136 Goff Terrace
Property Address
Ann Phillips
Owner Owner's Name
information is required for every Centerville MA 02632 5/28/2015
page. City/Town 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:
No Records.
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
f ;
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
136 Goff Terrace
Property Address
Ann Phillips
Owner Owner's Name
information is Centerville MA 02632 5/28/2015
required for every i
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
20-30 Years Est.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 25
feet
Material of construction:
❑cast iron ®40 PVC ❑other(explain):
Distance from private water supply well or suction line: +10'feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Line checked with sewer camera and was found to be clean, properly pitched with no sign of root
intrusion.
Septic Tank(locate on site plan):
Depth below grade: 16"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:
1500Gal H-10
Sludge depth: 8-10"
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
136 Goff Terrace
Property Address
Ann Phillips
Owner Owner's Name
information is required for every Centerville MA 02632 5/28/2015
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness 4-6"
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? Estimated
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
1500 Gal H-10 tank has roots entering around inlet and outlet pipes and covers. Tank needs to be
serviced and roots removed. Pipes need to be sealed. Covers 16"below grade. Tank at normal
operating level.
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
136 Goff Terrace
Property Address
Ann Phillips
Owner Owner's Name
information is required for every Centerville MA 02632 5/28/2015
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑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
136 Goff Terrace
Property Address
Ann Phillips
Owner Owner's Name
information is required for every Centerville MA 02632 5/28/2015
page. Citylfown 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 011
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.):
H-10 DB-3 with 1 line in and 2 lines out in fair condition. Roots entering box through knockouts. If
knockouts cemented box will be in good condition. No sign of overloading or hydraulic failure. Cover
26" below grade.
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
w 136 Goff Terrace
Property Address
Ann Phillips
Owner Owner's Name
information is required for every Centerville MA 02632 5/28/2015
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 2-6x6
❑ 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.):
2-6x6 Leach pits on this system. 1 pit dry and 1 pit had 2'of effluent at time of inspection. No sign of
overloading or hydraulic failure.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•3113 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
136 Goff Terrace
Property Address
Ann Phillips
Owner Owner's Name
information is required for every Centerville MA 02632 5/28/2015
page. Cityrrown State Zip Code Date of Inspection
.D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of pond ing, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
136 Goff Terrace
Property Address
Ann Phillips
Owner Owner's Name
information is required for every Centerville MA 02632 5/28/2015
page. CityfFown 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
136 Goff Terrace
Property Address
Ann Phillips
Owner Owner's Name
information is required for every Centerville MA 02632 5/28/2015
page. CitylTown 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: +14feet
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:
Hand auger through bottom of dry pit to 14'with mo water encountered. Bottom of pit at 8'6".
Minimum of 5'6"separation.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 16 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
136 Goff Terrace
Property Address
Ann Phillips
Owner Owner's Name
information is required for every Centerville MA 02632 5/28/2015
page. City/Town 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
f �
13
1
A 9-
L r
DATE: 10/25/99
PROPERTY ADDRESS':. 1.36 Goff Terrace
--------------
Centerville ,Mass .
02632
------------------------
On the above date, I Inspected the septic system at the above address.
This system consists of the following: 4e rl
1 . 1-1000 gallon septic tank.
2 . 1—Distribution box.
3 . 1-1000 galloon precast leaching pit .
— 500 gal on on myginspec�iOiS Ip � t�$ t't �#oll8wing°co Ions: �F
/VO 0
5 . This is a title five septic system. ,j 0
6 . The septic system is in proper working order Al J!
at , the present time .
7 . System was upgraded 9/12/97
SIGNATURE:1
N a m e:_,L at tr-J r--------
Company: Jose.2h_P . Maco.mber_& Son , Inc .
Address:- Box 66
-------------------
Centerville , Ma . 02632-0066
--------------------
Phone:...508_775=3338_______
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
JOSEPH P. MACOMBER & SON, INC.
Tan ks-Cesspools-LeachfleIds
Pumped & Installed
Town Sewer Connectlons
P.O. Box 66 Centerville, MA 02632-0066
775.3338 775-6412
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET, BOSTON MA 02108 (617) 292.5500
TRUDY COXE
Secretary
ARGEO PAUL CELLUCCI DAVM B. STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 136 Goff Terrace Name of Owner Matthew N o v e 110
Centerville Mass . Address of Owner:
Date of Inspection: 10/2 5/9 9 Joseph P.Macomber J r .
Name of Print) P Inspector:(Please Print)
I am a DEP approved system inspector pursuant to Section 15.340 of Tide 5(310 CMR 15.000)
company Name: J. P.Macomber & Son Inc .
MaUiingAddress: Box 66 Centeryi l l p ,Ma$$ 02632
Teleplwne Number: 5-0$ ;;=5 3338
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the Information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site disposal systems. The system:
Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
_ Fails
Inspector's Signature: Date:
The System Inspecto hall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)wfthin thirty (30) days of
completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the Inspector and the system owner
shall submit the report to the appropriate regional office of the Department oKinvirorimenxal Protection. The original should'be sent to-"
System owner•and.copies sent to the buyer, if applicable, and the approving authority. .
NOTES AND COMMENTS
revised 9/2/98 Pagel of11
W.J Printed on Recycled Paper
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
PropertyAddress: 136 Goff Terrace Centerville ,Mass .
Owner: Matthew Novello
Date of k-pection: 10/2 5/9 9
INSPECTION SUMMARY: Check A, B, C, or A
A. SYSTEM PASSES:
)Li I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure
criteria not evaluated are indicated below.
COMMENTS:
B. SYSTEM CONDITIONALLY PASSES:
Ub 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.
Indicate yes, no, or not determined(Y. N, or ND). Describe basis of determination in all instances. If "not determined", explain why not.
The septic tank is metal, unless the owner or operator has provided the system Inspector with a copy of a Certificate of
Compliance(attached) indicating that the tank was installed within twenty(20)years prior to the date of the Inspection; or
the septic tank, whether or not metal, is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health).
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping-Tnore than four-times-a yeardue to broken or obstructed pipe(s). The system wilt-esr
inspection if(with approval of the Board of Health): -
broken pipe(s) are replaced
obstruction is removed
revised 9/2/98 Page 2of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 136 Goff Terrace Ceriterville ,Mass .
Owns: Matthew Novello
Date of 4upec6on:10/2 5/9 9
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Alb Conditions exist which require further evaluation by the Board of Health in order to determine if the system Is failing to protect the
public health,safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM
IS NOT FUNCTIONING IN A MANNER WHICH.YALL.PRQTECT THE PUBLIC HEALTH AND SAFETY AND THE EK=ONMENL-
4)b Cesspool or privy is within 50 feet of surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPUER,IF ANY)DETERMINES THAT THE SYSTEM IS
FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
�G The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or
tributary to a surface water supply.
.� The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
.dj:� The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the
well is free from pollution from that facility and the prase ce of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm. Method used to determine distance -.4A4 (approximation not valid).-
3) OTHER
revised 9/2/98 Page 3of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
F,rW.nyAd&eu: 136 Goff Terrace Centerville ,Mass .
Owner. Matthew Novello
Dart'of 4tspection: 10/2 5/9 9
D. SYSTEM FAILS:
You must Indicate either 'Yes' or"No' to each of the following:
VI) 1 have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this
determination Is Identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No/
•gyttern cornponent'due%to an overloaded or clegged"SiAS•or-cesspool.
Backup ofeewege irteofecility"or j—
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 distributionQ box a ove ou Invert due to an overloaded or clogged SAS or cesspool.
tfj{m LYE /V c"#41�fl ire rX 1 X 1iG rr X.jt f
Liquid depth In caaspoais less than 6" below Invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped_.
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy Is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 60 feet of a private water supply well.
Any portion of a cesspool or privy Is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. if the well has been analyzed to be acceptable, attach copy of well water analysis for
rcoliform bacteria, volatile organio-compounds, ammonia nitrogen•and nitrate nitrogen.
E. LARGE SYSTEM FAILS:
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:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public
health and safety and the environment because one or more of the following conditions exist:
Yss No
_ /•// the system Is within 400 feet of a surface drinking water supply
the system•IsrvitWm 200 foatof-e i�+�t►tary to+surtaoadr+nkk►g watar•+uPPly... _ . . .__... - -
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)
The owner or operator of any such system shall upgrade the system In accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Department for further Infognation.
revised 9/2/98 Page 4orit
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
PrpertyAddrass: 1,36 Goff Terrace Centerville ,Mass .
Owner: Matthew Novello
Date of Inspection: 10/2 5/9 9
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No
Pumping Information was provided by the owner, occupant, or Board of Health.
_ -None of the system compoaants.iwueboen poa►padJapatleast two-AvoWw awdthe•system hasJ;wwq*cairiwg+wMW flow
rates during that period. Large volumes of water have not been Introduced Into the system recently or as part of this
Inspection.
_ As built plans have been obtained and examined. Note if they are not available with N/A.
The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow.
_ The site was Inspected fou�rr�/signs of breakout.
_ All system components,Uoiuding the Soil Absorption System, have been located on the site.
_ The septic tank manholes were uncovered, opened, and the interior of the septic tank was Inspected for condition of baffles
or tees, material of construction, dimensions,depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System orrthe site has been determined based on:-
_ Existing information. For example, Plan at B.O.H.
_ Determined in the field(if any of the failure criteria related to Part C is at Issue,approximation of distance is unacceptable)
[15.302(3)(b)1
_ The facility owner.(and.occ,rpaaU jf different fray>_wetner).yuere prnyidad with Infncmatioa.on the proper maint f
SubSurface Disposal Systems.
4
i
I
i
revised 9/2/98 Page 5of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
PropertyAddress:136 Goff Terrace Centerville ,Mass .
Owner: Matthew Novello
Date of Inspection: 10/2 5/9 9
FLOW CONDITIONS
RESID04TIAL:
Design flow: 116 g.p.d./bedroom.
Number of bedrooms(desionilL c%� Number of bedrooms(actual):
Total DESIGN flow 5%6 6,1W,
Number of current residents:
Garbage grinder(yes or no):_�
Laundry(separate system) (yeses or no :_ If yes, separate Ins pecti on,required --.
Laundry system inspected [va or no)
Seasonal use (yes or no):
Water meter readings,if available (last two year
usage(gpd1: _ 7 ?' !�//
Sump Pump(yes or no):/lJ6 l Q i�49 S= IF •o 'l
Last date of occupancyl�L_4
COMMERCIAUINDUSTRIAL:
Type of establishment:
Design flow: VW-d ( Based on 15.203)
Basis of design flow
Grease trap present: (yes or no)&
Industrial Waste Holding Tank present: (yes or no)"
Non-sanitary waste discharged to the Title 5 system: (yes or no)"
Water meter readings,if available:
Last date of occupancy:_
OTHER:(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECO D}��jnd sQ�rce of information:
l f / 7Z/a1& 7JlA�I�7L
System pumped as part of ins action: (yes or no) q!44- ,
If yes, volume pumped: gallons
Reason for pumping: �►�l
TYPE O SYSTEM
Septic tank/distribution box/soil absorption system
06 Single cesspool
Overflow cesspool
Privy
,oVA Shared system(yes or no) (if yes, attach previous inspection records,if any)
41 I/A Technology etc. Attach copy of up to date operation and maintenance contract
M Tight Tank ,V,4 Copy of DEP Approval
Other 161
APPROXIMATE AGE of a components, date insta %Yf know )•end source of4nformation: � -
14* O .+�4��d �l�4�s-! S ��'X»'k "' x` LEA a
Sewage odors detected when arriving at the site: (yes or no) �
revised 9/2/98 Page 6of11
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
PrprtyAciciress: 136 Goff Terrace Centerville ,Mass .
Owner: Matthew Novello
Date of Inspection: 10/2 5/9 9
BUILDING SEWER:
(Locate on site plan)
gird,
Depth below grade: /7
Material of construction:.L cast iron_k/40 PVC424 other(explain)
Distance from private water supply well or suction line e f
Diameter V_
Comments: (condition of joints, venting, evidence of faakage>-etc.)
Joints appear tight No evidence of leakage
SEPTIC TANK:_!PZ qAkWeo
(locate on site plan)
I(
Depth below grader
Material of construction: concrete4!,Jrnetalti�Fiberglass,9/&olyethyleneN�ibther(explain)
If tank Is metal,list age M Is.age.confumed by Certificate of Compliant (Yes/No)
Dimensions:-9, 1',106 �Vldt
Sludge depth: oC �,.!( _.
Distance from toge to bottom of outlet tee ortaffle Rr
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
�.( ������
Distance from bottom of scum to bottom of outlet t e or baffle:��
How dimensions were determined:Am
Comments:
(recommendation for pumping, condition of inlet and outlet tees or-baffles, depth of liquid level in relation to outlet invert, structuroHntegrity,
evidence of leakage, etc.) Pump S —
tpps are in ' la�p inuid level at the out t invert is 91 " 1 _
The tank iG GtrtrrturaIIy eniinrl and Shows ne evi-deFiee e� leakage
GREASE TRAP:
(locate on site plan)
Depth below grade: 104
Material of constructionX4concretaifl�netal��FiberglassAl_&Polyethylene lgother(explain)
Dimensions: AIK
Scum thickness: AM
Distance from top of scum to top of outlet tee or baffle:��
Distance from bottom of to bottom of outlet tee or baffle:414
Date of last pumping: !!��
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage,etc.)
Grease trap is not present -
revised 9/2/98 Page 7or11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 136 Goff Terrace Centerville ,Mass .
Owner: Matthew Novello
Dace of Inspection: 10/2 5/9 9
TIGHT OR HOLDING TANK-A,6 L (Tank must be pumped prior to, or at time of, inspection)
(locate on site plan)
Depth below grade: A)iq
Material of construction:NQconcrete metal Y&Fiberglass,t/A Polyethylene Aother(explain)
.4V
AlR -- --
Dimensions: AJJ9
Capacity: AM gallons
Design flow:_gallons/day
Alarm present
Alarm level: Alarm in working order:Yes /'V4 No"
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
iQ t or Holding tanks are not nreseht _
DISTRIBUTION BOXL�
(locate on site plan)
Depth of liquid level above outlet invert: AJV
Comments:
(note-if level and distribution is equal, evidenoe of solids carryover, evidence of leakage into or out of box, etc.) — —
Distribution boxes have thrPP 1ntPTrn1g
Nn Pvi dpnre of solids aar—ry oyeF .* a evidenee of lealeage of
I-eekege into or out of bux .
PUMP CHAMBER:-1124f)Z
(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 appurtenances,etc.)
Pump rhamber is not nrPePnt
revised 9/2/98 Page 8of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
PropartyAd&—: 136 Goff Terrace Centerville ,Mass .
O` rw: Matthew Novello.
Dau of Inspection: 10/2 5/9 9
SOIL ABSORPTION SYSTEM(SAS): Y
flocats on site plan,If possible:excavation not required,location may be approximated by non•intruslve methods)
If not located, explain:
Type:
leaching pits,number:
leaching chambers,number:_ (:Y► /`a
leaching galleries,number:Q
leaching trenches,number, length:
leaching fields, number, dim�&Ions:
overflow cesspool,number:15
Alternative system: V-6�
Name of Technology: / I�J e
Comments:
jnote condition of soil, signs of hydraulic failure, [oval of ponding, damp soil, condition of vegetation, etc.)
Loamy sand to medium
i_ j ---- - --- „ di pp oils are dry VPgPrati nn i c nnr-mal
CESSPOOLS:
(locate on site plan)
Number and configuration:
Depth-top of liquid to Inlst Invert: AIA
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Matsrials of construction:
Indication of groundwater: AIW
Inflow (cesspool must be pumped as part of Inspection)
Cesspools are not nrespnt .
Comments:
(note condition of soil, signs of hydraulic failure,.level of_ponding,condition of-vegetation, etc.)
essDools are not prpspnt
PRIVY:'JI9.(ll;'—
(locats on site plan) /�
Matsrjals of constructign: ��A Dimensions: 14
Depth of solids:
Comments:
(note condition of loll, signs of hydraulic failure,level of ponding, condition of vegetation,etc.)
Privy is not Present -
revised 9/2/98 Page 9ofII
SUSSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM LNFORIdATION(corttlrti+od)
Nop.nyAd&-mll 136 Goff; Terrace Centerville ,Mass .
OWW1 Matthew Novello
D". °14"°OC'd ':10/25/99
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include t)ss to at least two psrmansnt reference landmarks or benchmarks
louts 4,11 wells within too' (Locate where public water supply comes Into hours)
i
\Yy d 6 / A6ancioned IS Is 7 cE
\\�A -� With, 1 ° 6Y J p that
Ma
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jnsta/er p J��sions of
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,e Issuance of Ma combe,, the for.
1 'Date this ennit s & Sc
hat]not be
� revise
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 136 Goff Terrace Centerville ,Mass .
Owner: Matthew Novello
Date of Inspection: 10/2 5/9 9
NRCS Report name
Soil Type_
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep _
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells
Estimated Depth to Groundwater Feet
Please indicate all the methods used to determine High Groundwater Elevation:
_ZObtained from Design Plans on record
bserved.Site(Abutting prop bservation hole, basement sump etc.)
determined from local conditions
Checked with local Board of health
Checked FEMA Maps
_ZChecked pumping records
x"Checked local excavators, installers
Used USGS Data
I
Describe how you established the High Groundwater Elevation. (Must be completed)
Used water contours map .
Gahrety & Miller Model
12/16/94
revised 9/2/98 Page 11of11
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'TOWN OF Barnstable BOARD OF HEALTH
SUBSURFACE SEW TOWN
DISPOSAL SYSTEM INNSPECCTION FORM - PART D .- CERTIFICATION I
-TYPE OR PRINT CLEARLY-
PROPERTY INSPECTED
STREET ADDRESS 136 Goff Terrace Centerville ,Mass . '
ASSESSORS MAP, BLOCK AND PARCEL #
OWNER' s NAME Matthew Novello
PART D - CERTIFICATION
NAME OF INSPECTOR Joseph P.Macomber Jr . ,
COMPANY NAME J. P.Macomber & Sdffi ' Inc .
COMPANY ADDRESS ' Box• 66 Centerville ,Mass . 02632.
Street Tovn or city State EIP
COMPANY TELEPHONE ( 508) 775 -3338 FAX ( 508 ) 790 _ 1578
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at
this address and that the information reported is true , accurate , and
omplete as of the time of -inspection . The inspection was performed and any
recoinmendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems .
Check one ; '
Systeui PASSED
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
health or the environment as defined in 310 CMR 16 . 303 . Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form.
System FAILED*
The inspection which I have con(:rtcted has found that the system fails to
protect the public health and the environment in accordance with Title
5 , 310 CMR 15 , 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form .
Inspector Signature Date
3(
r
ne copy of this certification must be provided to the OWNER, the BUYER
where appl ioable ) and the 130ARD OF HEALZ'II.
* If the inspection FAILED, the owner or"roperator shall upgrade ' the system
within ohe year of the date of the inspection, unless allowed or required
otherwise as provided in 3.10 CMR 16 . 306 .
partd .doc
TOWN OF BARNSTABLE
LOCATION l G G o SEWAGE # 17
VILLAGE ASSESSOR'S MAP& LOT.
JNSTALLER'S NAME&PHONE NO.
E
..;'SEPTIC TANK CAPACITY N
';.LEACHING FACII.TTY: (type)& �
l%:.0F BEDROOMS
�'t ���/(size)V.1 � I
BEJILDER OR OWNER
'PERMIT DATE: 1 — I) ,2-1—COMPLIANCE DATE:
Separation Distance Between the: r
Maximum Adjusted Groundwater Table and 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(U any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
\. / �g
v� �
Ns
$ 50.
No, Fee 00
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
01pprication for Mqu of *pgtem Conotruction Permit
Application for a Permit to Construct( )Repair�X)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No.1 3 6 Goff Terrace Owner's Name,Address and Tel.No.
Centerville,Mass. 02632 Matthew Novello
Assessor'sMap/Parcel 136 Goff Terrace
Installer's Name,Address,and Tel.No. 5 0 8—7 7 5—3 3 3 8 Designer's Name,Address and Tel.No. 5 0 8—7 7 5—3 3 3 8
J.P.Macomber & Son Inc. J.P.Macomber & Son Inc.
Box 66 Centerville,Mass. 02632 Box 66 Centerville,Mass. 02632
Type of Building:
Dwelling XXCNo.of Bedrooms 3 Lot Size sq.ft. Garbage Grinderigo )
Other Type of Building Res_ No. of Persons 2 Showers( ) Cafeteria( )
Other Fixtures
Design Flow 330 gallons per day. Calculated daily flow 3 x 1 1 0 gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Existing 1 000 Type of S.A.S. Existing 1 000 pit.
Description of Soil
Medium sand to fine sand.
Nature of Repairs or Alterations(Answer when applicable) Adding 2-500 gallon chambers and
one distribution box toan existing tank & pit.
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 and not to place the system in operation until a Certifi-
cate of Compliance has been iss ed by thi B d o ealth.
Signed Date
Application Approved by Date
Application Disapproved for the following reason
Permit No. 9 Date Issued " �
0317
No. /' 7 Fee $ 50.00
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: !/
Yes
y PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
Zippricatiou for Mie;paar *p.5tem Construction Permit
Application for a Permit to Construct( )Repair�X)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. Gott Terrace n r' am A ress an 1.No.
Centerville,Mass. 02632 a Irieui Covello
Assessor's Map/Parcel 13 6" Goff Terrace
I t is ame,Ad ress,and Tel.No. —3338 Designer's Name,Address and Tel.No. 5 0 8—7 7 5—3 3 3 8
.i�acom�er & Son Inc. J.P.Macomber & Son Inc.
Box 66 Centerville,Mass. 02632 Box 66 Centerville,Mass. 02632
Type of Buildin
Dwelling RkCNo.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder>�l0)
Other Type of Building Res. No. of Persons 2 Showers( ) Cafeteria( )
Other Fixtures `
Design Flow 330 gallons per day. Calculated daily flow 3 x 1 1 0 gallons.
Plan Date Number of sheets t Revision Date
Title
Size of Septic Tank ExIstIng IUUU Type of S.A.S. Existing 1000 pi .
Description of Soil
Medium sand to fine sand.
Nature of Repairs or Alterations(Answer when applicable) Adding 2-500 gallon chambers and
one distribution box toan existing tank & pit.
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 and not to place the system in operation until a Certifi-
cate of Compliance has been i=edbyB d o ealth. ''i �
Signed �`'{ p Date 9-11-912
Application Approved by Date
Application Disapproved for the following reason
P.
t.r
Permit No. y Date Issued y v
r ,1
- --------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired�XX)Upgraded( )
Abandoned( )by J]PP.Macomber & Son Inc.
136 Goff Terrace Centervi a MaSS.
at a� en construc d i��c coe
with the provisions of Title 5 and the for Disposal System Construction Permit No. dated
Installer J.P.Macomber & SOrA Inc. Designer J.P. acorn er Son Jnc,
The issuance of thisrrmit tall?t�$e construed as a guarantee that the system will function as designed.
Date / Inspector
--- — —————————————————————————— ---
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
xigponf *pgtent Construction Permit
Permission is hereby frantedGtoo C struct( )Repair�X)U afi�( )Abandon( )
System located at ..ii bb f Terrace Center 1 e,I""Mass.
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided: Construction in be co pletedpi k}}n three years of the date of this permit.
Date: V / Approved by
CERTIrICA'I'ION Or SI<L'I'CII AND AI'I'LICA'1'ION FOlt A DISP(.; .
WORKS CONSTRUCTION PL R�,II'I' (NVI'I'flOU'1' DESIGNED YLANSI
I,Joseph P.Macomber Jr.,. tll:lt tllc application for disposal works
construction permit signed by tug �':1tcd _ 9/10/97 , concerrung the
pr:.,perty located at 136 Goff Terrace ce-p-l-ervi 1 1 e.,1 ss. meets all of the
following criteria:
There are no wetlands within 300 fc�t of tllc proposed septic system
Thcre are no prk,te %,clis within 151 tvct of t1w proposed septic systerll
• The observed groutld\vater tubl,� :s •; ftcl or �icatcr bclo%y tlla boltotll of illc leacllitlb facility
• There is no increase in flow und/oi cllanbc in use proposed
There are no variances requested or needed.
SIGNED DATE: 9/1 0/97
LICE D SEPTIC SYS'fE,�1 :ivS'!'ALLCR IN'1'RE TOWN OF BA.MSTABLE NUMBER
(Attach a sketch plan of the propose! Also if 111e licensed installer posesses a certified plot plan,
this plan should be submittcd).
i
�j 00
I /'
TOWN OF BARNSTABLE
LOC 'i:N l 6 C9 0 `T£t• SEWAGE # %7- L#
VII,I::GE �' �����'•tr!I I ASSESSOR'S MAP & LOT ,
INSTALLER'S NAME&PHONE NO. liifJejn [3€ 2, s
SEPTIC TANK CAPACITY A6� . IQ
LEACHING FACILITY: (type)—.,Qnn �ey(size)�
NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: — Il -� J COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and 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
3
i
LM
)
r�
k-� 6 'Fv '
LOCATION SEWAGE PERMIT NO.
VILLAGE
jNSTA LLER'S NAME,. Yi ADDRESS
7 w
S U I l D E R OR OWNER
DATE PERMIT ISSUED �/-/ �- -
DATE COMPLIANCE ISSUED _
/000 ��I
tom d o
a
Z.
G�
...................
THE COMMONWEALTH.OF MASSACHUSETTS
BOAR® OF HEALTH
...........................................O F...........................-..........._..
Appliration for Rspao al Works Tonotrnr#iun thrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
Location-Mdress �.
�................................. � LI �t.�f.l v L�
Owner Address
a .... = .... ..............................................i.i:..........----------...........---•--.....----
Installer Address
Type of Building Size Lot../_:5�... ....Sq. feet
►. Dwelling irNo. of Bedrooms............. ..........................Expansion Attic ( ) Garbage Grinder ( )
a'4 Other—T e of Building No. of persons............................ Showers.
YP g •-----•-•------------------- P ( )--- Cafeteria ( )-
dOther fixtures -------•---•------------------------------------------.....---------------•--...------------ .._..
W Design Flow........... .....................gallons per person per day. Total daily flow......._.._..3. .(�...._..............gallons.
WSeptic Tank=Liquid'capacity...lded.gallons Length..T`!a"_=: Width..��4`.... Diameter................ Depth 5...............
x Disposal Trench—No............_......... Width.................... Total Length- .Total leaching area... �..... q. ft
Seepage Pit No........L........... Diameter......... . .... Depth below inlet.................... Total leaching area....2.�_sq. ft.
Z Other Distribution box Dosing tank ( )
aPercolationjTestRults Performed bY--•••••••--•••••-••-•••......•........•-•••-••---•--------••••-•--••-•_... Date-----------•-•---•--•-•-.......••-••-..
Test �r2.-minutes per inch Depth of Test Pit..... 2...�_.__ Depth to ground water.._-_ :.fs, L4S$ Test P ..Z.�.O.minutes per inch Depth of.Test Pit.......12...__.. Depth to ground water.._.. t e
�'h�v ------------ .- -- ---•-•• -•-.•---.---• .........................................................
O Description of Soil............ �" r� l_®/{.l'?.... �1r ........ 'v.b•S®i......•••• Z �p�5'e iv
x P
U ---••-••-•••-•••-•--•--•...-••--••-•-•-----•---•••-...-•-•-•---•-•......••-•----•----••-••-----------------•••••••••--•.........•-•-•••----•-•------•-•••-•-••---•---••••-•----•---•---•••-•......----•-
W
VNature of Repairs or Alterations—Answer when applicable................................................................................................
-•------••------------------•--•----------------•-•-----•--•---........------••••••.....--••----••--•--•--•-••-••--•••-•••••-----•--•---•••--•••...---•-•••. ...........................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of T1Ti IE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has be issued by the board of health.
igned.....--................................=----(G
Date
Application Approved BY ...a. 6 /��---------------•----------. /lj!/p ------------
Date '
Application Disapproved for the following reasons-------------------------------------•------------------------•----------------...---------------.......---•--...
-•-•-•-•-•----------------------------•-----•---•--•--------•--------•-----------..................---.•..--....--------------------------------- ...................
11-.................................
1 Date
Permit No. Issued_ .._...�.................................
Date
No..O..A6u FRi&.3.0.. ........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF.........................................................................................
Appliration for Uhnpgal WorkS Tomitrurthin ramit
Application is hereby made for a Permit to Construct or Repair ( L<an Individual Sewage Disposal
System at: 41 .
Go Pr ,.T Z_
...... .....................T......................;2T.......... ...............
Location-.'Adklss t No.
............. ...... C�2jr —............. .................... . ..........wa ........
Owner— Address
.................................. ...................:j;;
..... .... ------- ..................................................................................................
Installer Address
Type of Building Size Lot.... .....Sq. feet
U
Dwelling—No. of Bedrooms.............. .........................Expansion Attic Garbage Grinder ( )
'4
P4 Other—Type of Building ...... No. of persons............................ Showers Cafeteria ( )
Otherfixtures ......................................................................................................................................................
Design Flow............................................gallons per person per day. Total daily flow.............3_3 2..................gallons.
1:4 Septic Tank—Liquid capacitylfk!...gallons Length.A'.4'.. Width...-/".4.' Diameter-------------_ Depth..VV�...
Disposal Trench—No. Width..` . Total Length.................... Total leaching area.-_-r--.-.--_-sq. ft.
Seepage Pit No---------I.......... Diameter..0..XJ_V_. Depth below inlet.................... Total leaching area.... A�.sq. ft.
Z Other,Distribution box ( � Dosing tank ( )
Percolation Test Results Performed by..................................................... ..." Date----------------------------------------
�.4 .1; ............*
,4 Test-Pit No _12�.P....minutes per inch Depth of Test Pit......L�.... .. Depth to ground water...
4-4Test Pit N ..O..niinutes per inch Depth of Test Pit.__.... Depth to ground water----A.'�zV.-.rQ_.
......................... -----------------*----------- ...................
--------------------------------------*--------------------------"......"',0 SC1bS__ e e7 a-V-4
............................................................................. .........................................
U .........................................................................................................................................................................................................
....................................................................................................................................I....................................................................
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 TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
n i operation until a Certificate of Compliance has ssued by the board of lie*1_4
Signed------. ........ .................C .0
................................ ................................
• Date
Application Approved By....4�21_.A-e��.. ...... ............................. -------------
Date
Application Disapproved for the following reasons:..............................................................................................................
............................. ............................................................................................................................................................................
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....7 a w...Ae...............OF........ ..............................................
(9rdifirate of Toutplitturr:
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or.Repaired
------------
..........................................................
at---..........
e,4--------_-- t ..... . ....... ----------------------------------------------------
\has been insta,Iled in accodance with the prd7sions of TIT LE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit N(ZU:z�.)-----�,6'.j....... dated-...............................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE....�IZ11.,l
/..( ../;;;/-,::f. .........................................
..... ............................................ Inspector.........../
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF . HEALTH
/,��. ...........OF.........4�7
...1:1i ..........m..........................
N
(�D . FEE....
Dispasal Works Towitrurtion "panfit
Permission is hereby granted............ ------------------------------------------------------------------------------------
to Construct 14
- ) or Repair an Individual Sewage,Qisposal System
—1
atNo..............05421-1r = -----------------.C... ::� .......1...................................................................................
Street
as shown on the application for Disposal Works Constructio it No__________________ Dated........ ................................
4r----------- ---------------------------
DATE---------- ...................................... Boar of Hea
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