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Commonwealth of Massachusetts
K Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 268 Huckins Neck Road
Property Address
Bill Hurley
Owner Owner's Name
information is required for Centerville AAA 02632 12/10/2011
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important: A. General Information
When filling out ////
forms on the (* 1 q
computer,use 1. Inspector:
only the tab key
to move your Adam R. Riker
cursor-do not
use the return Name of Inspector
key. R.L.C.
4a�. Company Name
PO Box 726
Company Address
South Yarmouth MA 02664
Cityrrown State Zip Code
5087766460 514590
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. 1 am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
12/10/2011
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.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins 09/08 Title 5 Official Inspection Form:Subsurface yeti a Disposal ystm• ge 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M s 268 Huckins Neck Road
Property Address
Bill Hurley
Owner Owner's Name
information is required for Centerville MA 02632 12/10/2011
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cunt.)
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:
System pass with no work or further eval.required
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•ORM 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
268 Huckins Neck Road
Property Address
Bill Hurley
Owner Owner's Name
information is required for Centerville MA 02632 12/10/2011
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):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
® Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 3 of 17
` 1
Commonwealth of Massachusetts
' Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary.Assessments
268 Huckins Neck Road
Property Address
Bill Hurley
Owner Owner's Name
information is required for Centerville MA 02632 12/10/2011
every page. Cityf town State Zip Code Date of Inspection
B. Certification (cost.)
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:
*k This system passes if the well water analysis, performed at a DEP certified laboratory, for 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 Y2 day flow
t5ins•09MB Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 4 of 17
c Commonwealth of Massachusetts
a Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
268 Huckins Neck Road
Property Address
Bill Hurley
Owner Owner's Name
information is required for Centerville MA 02632 12/10/2011
every page. Citylrown 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 colifor n bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 6 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•091W 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
M 268 Huckins Neck Road
Property Address
Bill Hurley
Owner Owner's Name
information is required for Centerville MA 02632 12/10/2011 St every page. City/Town ate zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes"or"no" as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
� ® Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440gpd
t5ins•09108 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
268 Huckins Neck Road
Property Address
Bill Hurley
Owner Owner's Name
information is required for Centerville MA 02632 12/10/2011
every page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
1500 gallon precast concrete tank with distribution box and two 6'x6'precast leach pits with 2+feet of
stone at perimeter.
Number of current residents:
vacant x2 yrs
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
Water meter readings, if available (last 2 years usage (gpd)): 2010= 0
2009=0
Detail:
no water use for past to years recorded / Readings from COMM water dept.
Sump pump? ❑ Yes ® No
Last date of occupancy: 2008Date
Commercial/Industrial Flow Conditions:
Type of Establishment: --
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M SV0'� 268 Huckins Neck Road
Property Address
Bill Hurley
Owner Owner's Name
information is required for Centerville MA 02632 12/10/2011
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: unk.
Date
Other(describe below):
General Information
Pumping Records:
Source of information: UNK. Unable to obtain
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-09108 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 268 Huckins Neck Road
Property Address
Bill Hurley
Owner Owner's Name
information is required for Centerville MA 02632 12/10/2011
every page. cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
installed 10/07/1976
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 3'feet
Material of construction:
® cast iron ❑ 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: 25'
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Plumbing exposed in basement dry and tight with no signs of leakage or deteriation present.Plunbing
for finishd walkout basement below concrete floor with no means of inspection with conventional
methods.
Septic Tank(locate on site plan):
1
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
1500 gallon precast tank with concrete baffles.
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
11'x 5'x 6'
Sludge depth: 4"
t5ins•09W Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
268 Huckins Neck Road
Property Address
Bill Hurley
Owner Owner's Name
information is required for Centerville MA 02632 12/10/2011
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
20"
Scum thickness
2"
Distance from top of scum to top of outlet tee or baffle
8"
Distance from bottom of scum to bottom of outlet tee or baffle 1.5'
How were dimensions determined? Sludge Judge and measure stick
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert,evidence of leakage, etc.):
Tank is 1500 gallon concrete tank with precast concrete baffles . No indications of high water staining
or significant deteriation.
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•Og108 Title 5 Official Inspection Form:Subsurface Sev✓age Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
268 Huckins Neck Road
Property Address
Bill Hurley
Owner Owner's Name
information is required for Centerville MA 02632 12/10/2011
every page. City/Town State Zip Code Date of Inspection
D. System Information (cunt.)
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•09t08 Title 5 Official In spec6on 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
M s. 268 Huckins Neck Road
Property Address
Bill Hurley
Owner Owner's Name
information is required for Centerville MA 02632 12/10/2011
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cunt.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert no indication of leakage or carryover
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Pump Chamber(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.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•09108 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
♦ 1
• Commonwealth of Massachusetts
u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
268 Huckins Neck Road
Property Address
Bill Hurley
Owner Owner's Name
information is required for Centerville MA 02632 12/10/2011
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cunt.)
Type:
® leaching pits number: 2 X 6'x6' precast
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number,dimensions:
❑ overflow cesspool number:
El 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.):
Both pits were inspected with staining less then half of total volume. No indication of structual defects.
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•09M8 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
M 5v0 268 Huckins Neck Road
Property Address
Bill Hurley
Owner Owner's Name
information is required for Centerville MA 02632 12/10/2011
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:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M , 268 HuGcins Neck Road
Property Address
Bill Hurley
Owner Owner's Name
information is required for Centerville MA 02632 12/10/2011
every page. Cityfrown 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
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t5ins•09W Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
J
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
268 Huckins Neck Road
Property Address
Bill Hurley
Owner Owner's Name
information is required for Centerville MA 02632 12/1012011
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cunt.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: 9.9
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: 10/07/1976
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:
Water level was determined with standing water within 150'of SAS.Augur was done within 150'of
sas to confirm standing water height of pond was equal to initial observation.
Before filing this Inspection Report,please see Report Completeness Checklist on next page.
t5ins-091W Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
lugTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form--Not for Voluntary Assessments
268 Huckins Neck Road
Property Address
Bill Hurley
Owner Owner's Name
information is required for Centerville MA 02632 12/10/2011
every page_ 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 Forth:Subsurface Sewage Disposal System•Page 17 of 17
Ir r To Lk,-, Cc
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
"t 268 Huckins Neck Road
Property Address
Bill Hurley
Owner Owner's Name
information is required for Centerville MA 02632 09/15/2009
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out A. General Information
forms the
computer,
r,use 1. Inspector:
only the tab key
to move your Adam R. Riker
cursor-do not Name of Inspector
use the return
key. R.L.C.
Company Name
PO Box 726
Alf Company Address
South Yarmouth MA 02664
City/Town State Zip Code
5087766460 S14590
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 kg Section %,340ZI
Title 5(310 CMR 16.000).The system: °
`- c�
® Passes ❑ Conditionally Passes ❑ Fails t
' v m
❑ Needs Further Evaluation by the Local Approving Authority
Ins is 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.
I�
t5ins-09/08
Tide 5 Official Inspection Form:Subsurface Disposal L1,
Page 7 of 17
i
t Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�f 268 Huckins Neck Road
Property Address
Bill Hurley
Owner Owner's Name
information is required for Centerville MA 02632 09/15/2009
every page. City/Town State Zip Code Date of Inspection
B. Certification (cunt.)
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:
System pass with no work or further evalsequired
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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts
Tit
le 5 Official e Ins i
p
ct on Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
'< 268 Huckins Neck Road
Property Address
Bill Hurley
Owner Owner's Name
information is required for Centerville MA 02632 09/15/2009
every page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
C) Further Evaluation is Required by the Board of Health:
® Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
a
Commonwealth of Massachusetts
lugTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
268 Huckins Neck Road
Property Address
Bill Hurley
Owner Owner's Name
information is required for Centerville MA 02632 09/15/2009
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health(and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for 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•09108 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
268 Huckins Neck Road
Property Address
Bill Hurley
Owner Owner's Name
information is required for Centerville MA 02632 09/15/2009
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
® ❑ Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP Certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or 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-09108 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
�t 268 Huckins Neck Road
Property Address
Bill Hurley
Owner Owner's Name
information is required for Centerville MA 02632 09/15/2009
every page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes"or"non 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)
ED ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
❑ ® Was the facility owner(and occupants if different from owner)provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)[310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440gpd
t5ins•09108 Title 5 Of cW Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
lugTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
268 Huckins Neck Road
Property Address
Bill Hurley
Owner Owners Name
information is required for Centerville MA 02632 09/15/2009
every page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
1500 gallon precast concrete tank with distribution box and two 6'x6' precast leach pits with 2+feet of
stone at perimeter.
Number of current residents: unk.
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
Water meter readings, if available last 2 ears usage d 2008=52gpd
9 ( Y 9 (gp )) 2007=73gpd
Detail:
2007=total 27,000 gallons 2008= 19000 gallons Readings from COMM water dept.
Sump pump? ❑ Yes ® No
Last date of occupancy: unk.
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•09= Title 5 official Ins
pection Form:Subsurface Sewage Disposal System•Page 7 of 17
f -
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
268 Huckins Neck Road
Property Address
Bill Hurley
Owner Owner's Name
information is required for Centerville MA 02632 09/15/2009
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: unk.
Date
Other(describe below):
General Information
Pumping Records:
Source of information: UNK. Unable to obtain
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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
268 Huckins Neck Road
Property Address
Bill Hurley
Owner Owner's Name
information is required for Centerville MA 02632 09/15/2609
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:
installed 10/07/1976
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 3'feet
Material of construction:
® cast iron ❑40 PVC ❑ other(explain):
Distance from private water supply well or suction line: 25'
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Plumbing exposed in basement dry and tight with no signs of leakage or deteriation present.Plunbing
for finishd walkout basement below concrete floor with no means of inspection with conventional
methods.
Septic Tank(locate on site plan):
Depth below grade: 1
feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain)
1500 gallon precast tank with concrete baffles.
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 11'x 5'x 6'
Sludge depth:
4"
t5ins 09/08 Title 5 Official Inspection Forth:Subsurface Sewa
ge age Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
yY 268 Huckins Neck Road
Property Address
Bill Hurley
Owner Owner's Name
information is required for Centerville MA 02632 09/15/2009
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
20"
Scum thickness
2"
Distance from top of scum to top of outlet tee or baffle
8"
Distance from bottom of scum to bottom of outlet tee or baffle 1.5'
How were dimensions determined? Sludge Judge and measure stick
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank is 1500 gallon concrete tank with precast concrete baffles . No indications of high water staining
or significant deteriation.
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•09/08 Title 5 Official Ins
pection 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
268 Huckins Neck Road
Property Address
Bill Hurley
Owner Owner's Name
information is Centerville MA 02632 09/15/2009
required for
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•09108 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
`( 268 Huckins Neck Road
Property Address
Bill Hurley
Owner Owners Name
information is required for Centerville MA 02632 09/15/2009
every page. CityrTown 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 level of water at outlet inverts
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.):
D-box need replacing due to deteriation of concrete sides of box
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.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 12 of 17
J
Commonwealth of Massachusetts
A Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
268 Huckins Neck Road
Property Address
Bill Hurley
Owner Owners(dame
information is required for Centerville MA 02632 09/15/2009
every page. City/Town state Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number:
2 X 6'x6'precast
❑ 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.).
Both pits were inspected with staining less then half of total volume No indication of structual defects
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 Tide 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
" 268 Huckins Neck Road
Property Address
Bill Hurley
Owner Owner's Name
information is required for Centerville MA 02632 09/15/2009
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•09/08 Title 5 Officiel Inspection Forth: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.
268 Huckins Neck Road
Property Address
Bill Hurley
Owner Owner's Name
information is
required for Centerville MA 02632 09/15/2009
every page. Cdy/town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
❑ hand-sketch in the area below
® drawing attached separately
' I n►d
lsss �
� I
/ \
i
II
[Sins-09/08 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
"t 268 Huckins Neck Road
Property Address
Bill Hurley
Owner Owner's Name
information is required for Centerville MA 02632 09/15/2009
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: 9.9
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: 10/07/1976
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:
Water level was determined with standing water within 150'of SAS. Augur was done within 150'of
sas to confirm standing water height of pond was equal to initial observation
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
268 Huckins Neck Road
lug -
Property Address
Bill Hurley
Owner Owner's Name
information is required for Centerville MA 02632 09/15/2009
every 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
Wins•0910E Title 6 Official Inspection Form:Subsurface Sewage Disposal System Page 17 of 17
z �
7b i
No. 7 ..=.. Fps... ..................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O F HEALTH ASSESSORS MAP N0: ZO&
.... ......... . .OF................................----• ....................................PARCEL( <<
ppliration -for Uhipoiitt.l Works Tonotrurtioo Prrotit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
Location,-Address ... N
..............•--•- or o
W Owner Address
Installer Address
U Type of Building Size Lot-._ __ _ _40c).*. feet
Dwelling—No. of Bedrooms.............. -------------------------Expansion Attic ( ) Garbage Grinder
aOther—Type of Building ___________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
dOther fixtures ------------------------------------------------------------------------------------------------------------------------------•...
W Design Flow...........................a'%.6........gallons per person per day. Total daily flow............�,� __-_-_____.__.--....gallons.
WSeptic Tank—Liquid capacity`J70%kallons Length---------------- Width................ Diameter...........----- Depth----------------
x Disposal Trench—No. .................... Width......._------------ Total Length..................... Total leaching area--------------......sq. ft.
Seepage Pit No---------I........ Diameter--------- L.°.__ Depth belo in t--
------------
Total leachin area-----._.-___....sq. ft.
z Other Distribution box ( ) Dosing nk ( ) - ?- 1
Percolation Test Results Performed by._ ilVk�rf., _.. ;Ag-14-i.:asm&...... Date------------------------------------- .
--Jest Pit No. 14__',7___mmutes per inch Depth of Test Pit....... oo�__.. Depth to ground water.._A11MAJ .---
(3:1 Test Pit No. 2...........I.....minutes per inch Depth of Test Pit.................... Depth to ground water------------------------
W .
0 Description of Soil_ _;�r4 03e.�-- ----sue AA_X? s. ---------- -- ... ------------------------------
-
V ----------------------------------------------------------------------`;---•---••-•----•------••-•.......-----•-••-••--••-----•-•--••----------•---•--•--•.....---------------------------------------
W
V 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 Article \I of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the boar o health.
- 410----- ----------
`
Application Approved BY ---.-. --� J�'.`..ZC......
. �.'�' Date
Application Disapproved for the following reasons:--'__!___---•--------------------------------------------------------------------------------------------------
--•---•-•-•-----------••••-•-...-•-----------------------------------------------------------------------I-----------------------------------------------------------------------------------------------
Perm .� 7 � Date
-
rt No. Issued '���.-----•--- . '.
Date
----------------------- ------------------------------
........................
,. -
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
... ... .... . ... ... . ................OF.............................'.........:.................
Appliratiun -fur 43iupaa ial Workii Tonstrurtiun Vamit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
. u r../.!tl. ' ..y ' ............D.... ...................... 1l s--.�.-------•--•-••------------------........---•---•---
Location-Address or Jot No
�„
4�4! .....;ak7�''' _. ale�f __. .................... ..474mr .._;�.��. __---_- .........
Owner Address
Installer Address
U Type of Building Size Lot.._. A16_CJ___*q. feet
�-, Dwelling—No. of Bedrooms---------------�-----------------------Expansion Attic ( ) Garbage Grinder
aOther—Type of Building ............................ No. of persons..----__---____-___------_- Showers ( ) — Cafeteria ( )
dOther fixtures ...................................•-------.....------................................................................
W Design Flow............................-5-4-------gallons per person per day. Total daily flow............._'-�...................gallons.
WSeptic Tatik—Liquid capacitv.OJ.:0-Vallons Length---------------- Width................ Diameter................ Depth................
x Disposal Trench—No-____________________ Width.................... Total Length---------------_.... Total leaching area--------------:-----sq. ft.
Seepage Pit No........../-------- Diameter----------I -- Depth below inlet___ _ _---------- Total leaching area..................sq. ft.
z Other Distribution box ( ) Dosing tank ( ) ['1�' /'✓C -
Percolation Test Results Performed by---- ?. _ ... 'S� .r/:✓ ►• ....... Date--------------------------_._.__--.-._..
Test Pit No. 1_4',__.�2___minutes per inch Depth of Test Pit-------- ___ Depth to ground water.... <JE.....
fs Test Pit No. 2----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water--.-.._--__--_. -_-_-. -
(�
. �-IZJ�4t- � -p_ ��_ _ -------t--- ---` --A------•----------------------Description of Soil._
x
v --------•---------------------------------------------------------------------------------------------------------------•-------•----....-----•-----------------------------
--------------------------
W
UNature of Repairs or Alterations—Answer when applicable-------------------------------------------------.-.___-----------.--.--_-..-.-------------.....
----•------------•---•-•---------------------------•---•---------------•--•------•---------------•-------•--------------•--------------•-----•---------•---------------------••------------•-----------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board o health.
Signed--- -_
r `
Date
Application Approved By......
=' 1 . e =-- .. / L-.l-__ / .....
- —�f Date
Application Disapproved for the following reasons:---•--•T-----------------•-------------•--------•--.....-•-----•-•-••-------•-••---------............•--••••-----
-•-•--•----•--•--•--------------------------------------------•-------------------------------------_----
Date
PermitNo......................................................... Issued...................... ..................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�J r
....... 1'".L. ,17.'.:1...............OF....._..... ' .l�r'LZ.?--Y! .......... •.....................
Tutifiratr of fU"IMplittnrr
THIS lkS TO CERTIFY T is the Individual Sewage Disposal System constructed ( 1 or Repaired ( )
by .._.. ----- ---
------------
Installer
at...61 �_.._.� .....- -- � - •---•----------------•-------------------••-•---------------...-•--••-•---•-----•--•---•---•----•-------
has been installed in accordance with.the provisions of Ark(le XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No..:_ .____Z 7(�------------ dated---._�__'`_9.'....1G_______________
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE ---•_... Inspector...................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
(7 BOARD OF HEALTH,
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Permission is hereby granted------- `..__��-�.._t!'_.!1_. 2%______________________ __ n
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to Construct (/ /or Repa r f( ) antIndividual Sewage Disposal System' ''`�`
Street t�
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as shown on the application for Disposal Works Construction Permit No,.��-.f,:--______..:l Dated__.___._.__�___.f.....................
Board of Health
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FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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DATE COMPLIANCE ISSUED
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