HomeMy WebLinkAbout0048 HENRY F LORING ROAD - Health 4 Henry F. Loring Road
Centerville
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SMEAD
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Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility S 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
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Commonwealth of Massachusetts CCOP
a e Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
y� 48 Henry F. Loring Road
Property Address
John Bagge
Owner Owner's Name
information is required for Centerville MA 02632 February 13, 2012
every page. Cityrrmn 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: A. General Information
When filling out
forms on the
computer,use 1. Inspector:
only the tab key
to move your Patrick T. Sullivan
cursor-do not Name of Inspector
use the return
Ivey. Ready Rooter, Inc.
Company Name
P.O. Box 371
Company Address
Sandwich MA 02563
Cityrrown State Zip Code
508-888-6055 S112843
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 sitp
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15�40 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
z
❑ Needs Further Evaluation by the Local Approving Authority "=
February 16, 2012 `
Inspector'scignature 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.
l
t5ins•09108 Tine 5 Official IneFor.m: bsurface Sewage Disposal System•Page 1 of 1
Commonwealth of Massachusetts s
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°y< 48 Henry F. Loring Road
Property Address
John Bagge
Owner Owner's Name
information is
required for Centerville MA 02632 February13, 2012
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:
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 y ars old"or the septic tank whether metal or not is
structurally unsound, exhibits substa tial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing t7nk is replaced with a complying septic tank as approved by the
Board of Health.
"A metal septic tank will pa nspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that a tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•09f08. Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 2 of 2
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
°y< 48 Henry F. Loring Road
Property Address
John Bagge
Owner Owner's Name
information is
required for Centerville MA 02632 February13, 2012
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cunt.)
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):
i
❑ obstruction is removed %� ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
1
❑ 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 unles;;'.Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the sysi fm 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-09/08 Tittle 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 3 of 3
Commonwealth of Massachusetts
U
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
48 Henry 9 F. Lorin Road
Property Address
John Bagge
Owner Owner's Name
information is required for CentervilleFebruary MA 02632 Feb 13, 2012
every page. City/Town state Zip Code Date of Inspection
Bo 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 aseptic tank/and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic�ank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank nd SAS and the SAS is less than 100 feet but 50 feet or
more from a private water su�ply well**.
Method used to determine distance:
**This system passes if th�well water analysis, performed at a DEP certified laboratory, for coliform
bacteria indicates absent nd the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provid.pd that no other failure criteria are triggered.A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6° below invert or available volume is less
than'/2 day flow
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 4
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
y` 48 Henry F. Loring Road
Property Address
John Bagge
Owner Owner's Name
information is Centerville MA 02632 February 13, 2012
required for
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:
❑ to Any portion of the SAS, cesspool or privy is below high ground water elevation.
E] ® 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 16,000 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 wit in 400 feet of a surface drinking water supply
❑ ❑ the system is Rhin 200 feet of a tributary to a surface drinking water supply
❑ ❑ the syste is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—1 PA) or a mapped Zone II of a public water supply well
If you have answered "yes° o any question in Section E the system is considered a significant threat,
or answered "yes" in Se 'on D above the large system has failed. The owner or operator of any large
system considered a Sig ificant 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•09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 5 of 5
Commonwealth of Massachusetts
ugTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 48 Henry F. Loring Road
Property Address
John.Bagge
Owner Owner's Name
information is
required for Centerville MA 02632 February 13, 2012
every page. city/Town state Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(if they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 2 Number of bedrooms(actual): 2
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): >220 GPD
t5ins•09/08 Title 5Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 6
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
y 48 Henry F. Loring Road
Property Address
John Bagge
Owner Owner's Name
information is Centerville MA_ 02632 February 13, 2012
required for —
every page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
4
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes ® No'
2010= 380,GPD*
Water meter readings, if available (last 2 years usage (gpd)): 2011=436 GPD*
Detail:
*Very high water usage in summer months due to irrigation.
Sump pump? ❑ Yes ® No
Current
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., c.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank presen . ❑ Yes ❑ No
Non-sanitary waste discharged to�the Title 5 system? ❑ Yes ❑ No
i
Water meter readings, if available:
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Serfage Disposal System•Page 7 of 7
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
48 Henry F. Loring Road
Property Address
John Bagge ---
Owner Owner's Name .
information is Centerville MA 02632 February 13, 2012
required for State Zip Code Date of Inspection
every page. Cityrrown
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: Ready Rooter records: pumped 04/15/2010
Was system pumped as part of the inspection? ® Yes ❑ No
1000
If yes,volume pumped: gallons
How was quantity pumped determined?
Site tube on truck
Maintenance
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/Altemative 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•00/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 8
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°e 48 Henry F. Loring Road
Property Address
John Bagge
Owner Owner's Name
information is Centerville MA 02632 February 13, 2012
required for i'y
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
System installed Nov. 1977. Certificate of Compliance on file at Board of Health.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 15"
feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: WA
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade: 6"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: 8.5'X 4.5'X 4.5' 1000 gallons
Sludge depth:
3"
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 9
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
y� 48 Henry F. Loring Road
Property Address
John Bagge
Owner Owner's Name
information is Centerville MA 02632 Februa
required for ry 13, 2012
every 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
33"
Scum thickness
4"
Distance from top of scum to top of outlet tee or baffle
6"
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined? Tape measure and dip tube.
Comments (on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Inlet and outlet PVC tees in place. Liquid level is at outlet invert. Outlet tee has Zable filter in place.
Recommend cleaning filter every year and maintenance pumping every two years.
Grease Trap (locate on site plan):
Depth below grade: �: feet
Material of construction:
❑ concrete ❑metal f ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scu to top of outlet tee or baffle
Distance from bottom f scum to bottom of outlet tee or baffle
Date of last pumping Date
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 10
Commonwealth of Massachusetts
Title 5 Official Inspection Form
subsurface Sewage Disposal System Form -Not for Voluntary Assessments
48 HenryF.Loring Road
Property Address
John Bagge
Owner Owner's Name
information is Centerville MA 02632 February 13 2012
required for State Zip Code Date of Inspection
every page. Cityrrown
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
t5fn 09f08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 11
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
48 Henry F. Loring Road
Property Address
John Bagge
Owner Owner's Name
information is Centerville MA 02632 February 13, 2012
required for State Zip Code Date of Inspection
every page. Citylrown
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
0"
Depth of liquid level.above outlet invert
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
One inlet, one outlet. No solids carryover. No high water staining over outlet invert. Riser brings cover
within 6" of grade.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments (note condition of pum chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-09108 Title 5 Official Inspection Form:Subsurface sewage Disposal System-Page 12 of 12
e
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
'< 48 Henry F. Loring Road
Property Address
John Bagge
Owner Owner's Name
information is Centerville MA 02632 February 13, 2012
required for
every page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number.
1-6'X6'w/stone ,
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Camera used to locate and inspect leach pit. Liquid level 3'below invert at time of inspection. No sign
of past hydraulic failure. Clean stone still visible through side wall of pit.
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.-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 13
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
lug
48 Henry F. Loring Road
Property Address
John Bagge
Owner Owner's Name
information is Centerville MA 02632 February 13, 2012
required for ry
every page. Citylrown 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: %
i
Dimensions %
Depth of solids /
Comments(note condition of soil, igns of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•09= Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 14
8 ✓/
Commonwealth &Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
48 HenryF.Loring Road
Property Address
John Bagge
Omer owners Name
infomration is Centerville MA 02632 February 13, 2012
required for State Zip Code Date of Inspection
every page. CWTown
D. System Information (cunt.)
Sketch Of Sewage Disposal System:Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building.Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
�.a
2 0
3 33
�( 0
0 6 �C-� � `
t5ins•0901 Title 5 official Inspection Forth:SubsuAece SO~Disposed SYstem•Rage 15 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�t 48 Henry F.Loring Road
Property Address
John Bagge
Owner Owner's Name
information is Centerville
required for MA 02632 February 13, 2012
every page. cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
® Check cellar
❑ Shallow wells
Estimated depth to high groundwater: >15
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: 1977
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:
ma.water.usgs.gov terraserver-usa.com
You must describe how you established the high ground water elevation:
No ground water found during system installation. (1977). Property elv= 52+-. Ground water contours
show adjusted ground water at elv=35. No high ground water in area of system
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 16 of 16
e r�
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
48 Henry F. Loring Road
Property Address
John Bagge
Owner Owner's Name
information is required for CentervilleFebruary MA 02632 Februa 13, 2012
every pagg. Cityrrown. 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
t,
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
V
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 48 Henry F.Loring Road
Centerville
Ower's Nime: Margaret O'Connor �a ,
User's A dress: 30 Hope Avenue
Pocasset,MA 02559 g p f
c Date of Insl extion: 10/5/2006 J
ci
< NWe of In tor: (please print) Patrick T.Sullivan
' Company Nkess:
e: Ready Rooter
N Oing Ad P.O.Box 371
�t Sandwich,MA 02563
Tphone Number: (508)888-6055
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The System:
asses
Conditionally Passes
Needs Further Evaluation by the Local Authority
Fails
Inspector'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.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
' r
Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 48 Henry F.Loring Road
Centerville
Owner: Margaret O'Connor
Date of Inspection: 10/5/2006
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:
B. System Conditionally Passes:
One or more system components as described in the"C nditional Pass"section need to be replaced or
repaired.The system,upon completion of the replacement o repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined (Y,N,ND)in the for the following statements. If"not determined"please
explain.
The septic tank is metal and over 20 years o d*or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltr tion or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septi tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it i structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 2/yead
is available.
ND explain:
Observation of sewage backuout or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken uneven distribution box. System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain: ,
The system required umping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with ap oval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
f� Page 3 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 48 Henry F.Loring Road
Centerville
Owner: Margaret O'Connor
Date of Inspection: 10/5/2006
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by a Board of Health in order to determine if the system
is failing to protect public health,safety or the environme .
1. System will pass unless Board of Health det mines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner whi will protect public health,safety and the environment:
_Cesspool or privy is within 50 feet o a surface water
_Cesspool or privy is within 50 feet f a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
f system is functioning in a manner that protects the public health,saf ty and environment:
_The system has a septic tank and soil absorption system(S S)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 ' within a Zone 1 of a public water supply.
_The system has a septic tank and SAS and the S is within 50 feet of a private water supply well.
—The system has aseptic tank and SAS and th AS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to de rmine distance
"This system passes if the well water analy s,performed at a DEP certified laboratory,for coliform
bacteria and volatile organic compounds indic s that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate itrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered.A copy of the alysis must be attached to this form.
3. Other:
' r
Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 48 Henry F.Loring Road
Centerville
Owner: Margaret O'Connor
Date of Inspection: 10/5/2006
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 and overloaded or clogged SAS or
cesspool
Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow
_ -,Z Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
_ _Z 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 I of a public well.
_,Z Any portion of a cesspool or privy is 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
jkJo (Yes/No)The system fails. I have determined that one or more of the above 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 f ility with a design flow of 10,000 gpd to 15,000
gpd•
You must indicate either"yes"or"no"to each of the fol wing:
(The following criteria apply to large systems in addit' n to the criteria above)
yes no
the system is within 400 feet of a surfa a drinking water supply
_the system is within 200 feet of a ' utary to a surface drinking water supply
_the system is located in a nitro n sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a public water sup y well
If you have answered"yes"to any uestion in Section E the system is considered a significant threat,or answered
"yes"in Section D above the lar system has failed.The owner or operator of any large system considered a
significant threat under Sectio or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The system owner s uld contact the appropriate regional office of the Department.
i
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 48 Henry F.Loring Road
Centerville
Owner: Margaret O'Connor
Date of Inspection: 10/5/2006
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?
_ Z Has the system received normal flows in the previous two week period?
_ _Z 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 than owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes No
_ Existing information.For example,a plan at the Board of Health.
Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)[310 CMR 15.302(3)(b)]
Page 6 of l 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 48 Henry F.Loring Road
Centerville
Owner: Margaret O'Connor
Date of Inspection: 10/5/2006
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):�_ Number of bedrooms(actual): a
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 33t--> ,P, ,fl
Number of current residents: CD
Does residence have a garbage grinder(yes or no):.L�
Is laundry on a separate sewage system(yes or no):tag.)[if yes separate inspection required]
Laundry system inspected(yes or no):
Seasonal use:(yes or no):
Water meter readings,if available(last 2 years usage(gpd)): &_-)c7 c zs:e��e. c, �,-- —
Sump Pump(yes or no):_NJ(:)
Last date of occupancy: �6
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15Ze
d
Basis of design flow(seats/persons/s
Grease trap present(yes or no):_
Industrial waste holding tank presenNon-sanitary waste discharged to the (yes or no):
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part of the inspection(yes or no):J.�
If yes,volume pumped: Qallons--How was quantity pumped determined?
Reason for pumping:
TYPV OF SYSTEM
Septic tank,distribution.box,soil absorption system
_Single cesspool
_Overflow cesspool
_Privy
_Shared system(yes or no)(if yes,attach previous inspection records,if any)
_Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight tank _Attach a copy of the DEP approval
_Other(describe):
Approximate age of all components,date installed(if known and source of informatio
c�M�.�.v..c-2
Were sewage odors detected when arriving at the site(yes or no):,e- Q
Page 7 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 48 Henry F.Loring Road
Centerville
Owner: Margaret O'Connor
Date of Inspection: 10/5/2006
BUILDING SEWER(locate on site plan)
o�
Depth below grade: 4E
Materials of construction:_cast iron-IZ40 PVC other a lain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: (locate on site plan)
Depth below grade: —elo
Material of construction: oncrete_metal_fiberglass,_)olyethylene
_other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions: 4'-5-
Sludge depth:
Distance from the top of sludge to bottom of outlet tee or baffle: 33.1
Scum thickness: Q"
Distance from top of scum to top of outlet tee or baffle: 'I Cp
Distance from bottom of scum to bottom of outlet tee or baffle:
How were dimensions determined:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
l '4 V'.k'�
a
GREASE TRAP:_(locate on site plan)
Jf'
Depth below grade:_
Material of construction:_concrete_metal_fiberglass_polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations;inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
Page 8 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 48 Henry F.Loring Road
Centerville
Owner: Margaret O'Connor
Date of Inspection: 10/5/2006
TIGHT or HOLDING TANK: (tank must be ped 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: Oons/day
Alarm present(yes or no):
Alarm level: ;a1aand
orking order(yes or no):
Date of last pumping:
Comments(condition o float switches,etc.):
DISTRIBUTION BOX:—Zif present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:=�
Comments(not if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
PUMP CHAMBER: (locate /ber,
Pumps in working order(yes or no):
Alarms in working order((yes or no):
Comments(note condition of pump cdition of pumps and appurtenances,etc.):
Page 9 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 48 Henry F.Loring Road
Centerville
Owner: Margaret O'Connor
Date of Inspection: 10/5/2006
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
P Y
Type
leaching pits,number:_
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/altemative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.):
arm ,
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 or ):
Comments(note condition of soil,signs 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 o hydraulic failure, level of ponding,condition of vegetation,etc.):
Page 10 of 11 a
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: . 48 Henry F.Loring Road
Centerville
Owner: Margaret O'Connor
Date of Inspection: 10/5/2006
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building.
a3 4-7
a �{ �
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Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 48 Henry F.Loring Road
Centerville
Owner: Margaret O'Connor
Date of Inspection: 10/5/2006
SITE EXAM
Slope
Surface water
Check cellar v,"-
Shallow wells
Estimated depth to ground water .3 feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record—If checked,date of design plan reviewed:
_2'bserved site(abutting property/observation hole within 150 feet of SAS)
Checked with the local Board of Health-explain:
Ahecked with local excavators,installers-(attach documentation)
ccessed USGS database-explain: r,,--r._
You must describe how you established the high ground water elevation:
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Agreement:No6 ............. .........
THE COMMONWEALTH OF', MASSACHUSETTS
BOARI
(fll '11 E A L I(I
Application is hereby'made for a Permit to Construct or Repair an Individual Sewage Disposal
System at: 4—
r Address
Type of Building Size Lot.... C.-DAP-Sq. feet
1:4 Septic Tank—Liquid capacity.
Z Other Distribution box (_7�) Dosing tank ( )
0-1
`
The nodecxiguo6 agrees to install the uforcdcsoribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the S -Sanitary C�e The nd agrees not to plq(� thesystem in
operation until a Certificate of Compliance has b cd by
bt of healtp
- Si o�—. .----.--..
�^ ~ A
' (
Application Approved By.-..- —'—._-__--_--__--.----_'-- '_------------
�
{� ="
}\pp!�a�onDisapproved for t�o following reasons:................................................................................................................ _
--------------------------------``----'-------`--`----'—'----'---------`
u�~ -7_ _e
| Permit Iuuoed--_— .-.-------'.----.--__—'_
| Date
~--------------------------------------------------------------------------------------------------------------------------=
THE FOLLOWING
IS/ARE THE BEST
IMAGES FROM POOR
QUALITY ORIGINALS)
I M ^C&L
DATA
No..- wA..s
W.. FRic..............................
THE COMMONWEALTH Cie MASSACHUSETTS
, # BOARD .OF HEALTH
_ .. ...
Applirativ t -fur IN-4poiittf Workii Cnutuarurtion Vrrntit
Application is hereby'made for a Permit to Construct ( ) or Repair ( ) an Individual-Sewage Disposal
System at:
-- . ........--- --
Location-Address ` t� e{ or Lot No.
Owner ` Address
Installer Address
Q Type of Building Size Lot_... ____1 _____�._ _ .
U � t �Sq. feet
Dwelling—No. of Bedrooms______________ -----_-_.___-----_---__.Expansion Attic ( ) Garbage Grinder (t,2)
aOther—Type of Building --_-----.. -_-____--___-_ No. of persons___________________________ Showers ( ) — Cafeteria ( )
dOther fixtures ----•----------------------------------------------------------------------------------.---•----•------•---------------•------
W Design Flow.................................:::.:."_:.gallons per pet-son per day. Total daily flow............................................gallons.
P4 Septic T uik—Liquid capacity--.----.-._gallons Length---------------- Width................ Diameter----------.----- Depth................
x Disposal Trench—No..................... Width-_.--------__--._-__ Total Length-_---_-.-______--- Total leaching area-..-.---_---.--___-_sq. ft.
Seepage Pit No------1A.......... Diameter____________________ Depth below inlet.................... Total leaching area------------------sq. ft.
Z Other Distribution box ( Dosing tank ( )
Percolation Test Results Performed by-------------------------------------------------------------------------- Date--_--_------------------ ------------
Test Pit No. 1----------------minutes per inch Depth of "Pest Pit.--_----_-_-_____-. Depth to ground water....---.-.-.------..---.
(X, Test Pit No. 2----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water-_.-.._.-.-.-..-__--_-.
1:4 ------------------- --- ---- --- --- --•-------------------------------------•------------------------------------
D Description of Soil----------- ....._ .VeO/4&.....,I '
U ------------------------- - `- -- -r- ---- - � :T! -- _ �"------------ -------------------- -
- -
x -- -----------------------------------------•-•------------•-•----------•----------------......---------------. -----------------------------------------------------
U Nature of Repairs ot,'Alterations—Answer when applicable.------.......................................................................................--
------------•-------•-••----•-••----•--•--...`Yr`---------------------------------------••--------------------•-•------------•------------------•----•--•----
Agreement:
The undersigned agrees to install the aforedescribed'',I-ndividual,Sewage Disposal System in accordance with
the provisions of Art •Of:the S-taxe,^Santtary undersigned further agrees not to place the system in
operation until a Certificate of Compliance.has.been issued by tfie boagd of health./ /
I
Signed ' r 1 , ----- ------------------------ ---�'`_--
Date
;' .
ApplicationApproved By......---- 1+�..................................................:. ----------------_.---- ....................... -------------
a Date Application Disapproved for t e ...
following reasons_________________________________________________________•_--_----_--,_
---------•-----------•--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Date
PermitNo.----- i --------------------------•------: Issued................. ......................................
"THE`COMMONWEALTH OF MASSACHUSETTS
4'
" BOARD OF HEALTH
1. OF.. ....................................:...
ifs K' Cnrrtifiratr of 015111nipiiattre
THIS IS TO CJERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by......--.. Zfe,.� 4e f`GGLG. --- --- ----- --•- ----------
at 40 r� /� e.P t f Af/^ j Installer �6)�LJ . ���� � �P ...
•:.�•.� ______________ ___________________~.._... _.____ -- _ __--_--__ -_--------_--_-_---- ----_-._ .........
has been installed in accord' id with the provisions of :�rt/icle XI/„pf The State Sanitary Code as described in the
application for Disposal Worlts Construction Permit N til r .................... dated..------ ............
THE ISSUANCE OF THIS CERTIFICATE SHALL. NOT BE CONSTRUE AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE:.N F = , << __ Inspector . q
•-• .
f'�.„n .ran ��"' 9t`.:^t,� ".rw, � �.rr �'� �'�..�'w' •v
N!
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O`FP F EALTH
-...? O F.......... C_
No. rG?!!/f•�sT �-
FEE .-•-•°-----•-----.....
i>n � ttl yk,i AT>a tion. Prrmit
Permission is hereby granted.__._",41_l_`.!jG�_____.'XI.4�-
--•-----------------------------------------------------------------------------------------•-_... .
to Construct (A-lor Repair ( an Individual S gage Disposal Syst�,m 47'
atNo.. d ; - ........... ��4`• ---- --- .........................................
u -,�"43� Street
as shown on the application for D sp saI Works Constru-t xnx '1W No v1A4--_--_ Dated------ 9' •7--.¢.__.__
•tea, � �t� � ����.�-:-� k�s"x-
-------------------------------
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DATE................................................................
,zrs; Board of Health
r' Ake/i '$�
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LOCATION �Z �z SEWAGE# 77-
VILLAGE ��,�- a-i�;��� ASSESSOR'S MAP&PARCEL /`7 '?
INSTALLERS NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) (size) /
NO. OF BEDROOMS
OWNER
PERMIT DATE: ✓ COMPLIANCE DATE: ,�/'� "�
l
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility g�' 6 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
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L"0-C°-A T--0N SEWAGE PERMIT N0.
1,oT i11 q rfr'.yR y Fh 40A,,:y4 ; P ?7- (AS
V-1LLAGE
C,C)y,reA
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