HomeMy WebLinkAbout0122 JUNIPER ROAD - Health 122 JUNIPER ROAD, CENTERVILLE
A= 230 074
J�p�CYC[Eppo
UPC 12534
No.2�-153LLOOfi
HASTINGS, MN
a3o- 07 4
Commonwealth of Massachusetts
�n : Title 5 Official Inspection Form
w Subsurface Sewage Disposal System Form Not for Voluntary Assessments
122 Juniper Road
u°
Property Address
Alyn Pinkofsky Revoc Trust
Owner Owner's Name /
information is Centerville ✓ MA 02632 06/22/2020
required for 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 forms A. Inspector Information
on the computer,
use only the tab Michael T Bisienere
key to move your Name of Inspector
cursor-do not Cape Septic Inspections
use the return Company Name
key.
52 Rivers End Road
VILA Company Address
Teaticket Ma. 02536
City/Town State Zip Code
508-280-3356 S13938
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system: � 3 0 FA. �ev% We
d
1. El Passes i` � mtt jAr
2. Conditional) Passes fn S S r
❑ Conditionally Passes 1 � s p J
4j,
3. ® Needs Further Evaluation by the Local Approving Authority S I
4. ❑ Fails
07/11/2020 �-
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 has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
i
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time. This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
f
Commonwealth of Massachusetts
- ,P Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
122 Juniper Road
Property Address
Alyn Pinkofsky Revoc Trust
Owner Owner's Name
information is Centerville MA 02632 06/22/2020
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
❑ 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:
2) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form
:m.Subsurface Sewage Disposal System•Page 2 of 18
Commonwealth of Massachusetts
�v Title 5 Official Inspection Form
lI; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
122 Juniper Road
Property Address
Alyn Pinkofsky Revoc Trust
Owner Owner's Name
information is required for every Centerville MA 02632 06/22/2020
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N FIND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
® Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
f
Commonwealth of Massachusetts
�v Title 5 Official Inspection Form
5 � Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
a
� 122 Juniper Road
>' u
Property Address
Alyn Pinkofsky Revoc Trust
Owner Owner's Name
information is required for every Centerville MA 02632 06/22/2020
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
Per letter from engineer Peter McEntee the bottom of the leaching is not in ground water but is less
than 4 feet from ground water.
4) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
,� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
............ !% 122 Juniper Road
Property Address
Alyn Pinkofsky Revoc Trust
Owner Owner's Name
information is required for every Centerville MA 02632 06/22/2020
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/z day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ®. Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. This
p Pp Y P q Y Y I
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The.system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
122 Juniper Road
Property Address
Alyn Pinkofsky Revoc Trust
Owner Owner's Name
requir required
is Centerville MA 02632 06/22/2020
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes"to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate "yes" or"no"for each of the following for all inspections:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
............ 122 Juniper Road
ul
Property Address
Alyn Pinkofsky Revoc Trust
Owner Owner's Name
information is requirred for every Centerville MA 02632 06/22/2020
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 plus
GPD
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ® Yes ❑ No
Water meter readings, if available last 2 years usage d Town water
Detail:
In 2019-61,000 gallons were used and 2018-68,000 gallons were used
Sump pump? ❑ Yes ® No
Last date of occupancy: Fall 2019Date
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
r -
Commonwealth of Massachusetts
Title 5 Official Inspection Form
- ��tiI� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
9 p Y rY
u—
122 Juniper Road
Property Address
Alyn Pinkofsky Revoc Trust
Owner Owner's Name
information is Centerville MA 02632 06/22/2020
required for every
page.• City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp-doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
�v Title 5 Official Inspection Form
+- �I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u—
122 Juniper Road
Property Address
Alyn Pinkofsky Revoc Trust
Owner Owner's Name
information is required for every Centerville MA 02632 06/22/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
12/15/1993
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 12"feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line. town water
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
122 Juniper Road
V�
Property Address
Alyn Pinkofsky Revoc Trust
Owner Owner's Name
information is required for every Centerville MA 02632 06/22/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 4"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:
H-10 1000 gallon
Sludge depth:
1"
Distance from top of sludge to bottom of outlet tee or baffle
35"
Scum thickness
1"
Distance from top of scum to top of outlet tee or baffle
5"
Distance from bottom of scum to bottom of outlet tee or baffle
13"
How were dimensions determined? sludge judge
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
recommend the new owner put the septic tank on a maint. plan with a local septic pumping co.
based on the future use of the home. At the time of inspection the liquid level was at working level
and the tee's were in place.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
�� ,p Title 5 Official Inspection Form
h �1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
122 Juniper Road
Property Address
Alyn Pinkofsky Revoc Trust
Owner Owner's Name
information is Centerville MA 02632 06/22/2020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
l�
`.............. . .� 122 Juniper Road
u�
Property Address
Alyn Pinkofsky Revoc Trust
Owner Owner's Name
information is required for every Centerville MA 02632 06/22/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert N/A
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.):
I ran a camera down the discharge pipe into the leaching and I did not see a D-Box.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
Commonwealth of Massachusetts
�v Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
V � 122 Juniper Road
Property Address
Alyn Pinkofsky Revoc Trust
Owner Owner's Name
information is required for every Centerville MA 02632 06/22/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
® leaching trenches number, length: 3 Infiltrators
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18
Commonwealth of Massachusetts
�A 6!A Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u
122 Juniper Road
Property Address
Alyn Pinkofsky Revoc Trust
Owner Owner's Name
information is required for every Centerville MA 02632 06/22/2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
At the time of the inspection the leaching was dry and no visible failure criteria was found.
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
`' •, 122 Juniper Road
Property Address
Alyn Pinkofsky Revoc Trust
Owner Owner's Name
information is required for every Centerville MA 02632 06/22/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
122 Juniper Road
Property Address
Alyn Pinkofsky Revoc Trust
Owner Owner's Name
information is required for every Centerville MA 02632 06/22/2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately '
** As-Built from the BOH attached on next page**
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
j
Cam, TOWN OF BARNSTABLE
LOCATION_MA U SEWAGE k -SOS
VILLAGE C.,,r«vi//t ASSESSOR'S MAP G LOT a. D
INSTALLER'S NA1[E 6 PHONE NO:&.A.,/aff
SEPTIC TANK CAPACITY !Ovv ( /
LEACNNG FACILITYitype)1,�`( (3) (size) 7 x.'+•173"
NO.OF BEDROOKS_3___PRIVATE WELL OR PUBLIC WATER44L,c
BUILDER OR OWNER J),.Llrx.
JJ �
DATE PERMIT ISSUED:__-
DATE COMPLIANCE ISSUED: J-1
i
VARIANCE GRANTED: Yes No
j
i 3�' o u'
f
i
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
1, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�� 122 Juniper Road
u°
Property Address
Alyn Pinkofsky Revoc Trust
Owner Owner's Name
information is required for every Centerville MA 02632 06/22/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: see engineers letterfeet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
® Checked with local excavators, installers- (attach documentation)
I
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
See engineers letter
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u 122 Juniper Road
Property Address
Alyn Pinkofsky Revoc Trust
Owner Owner's Name
information is required for every Centerville MA 02632 06/22/2020
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
® D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
Engineering Works, Inc.
Engineers-Surveyors-Soil Evaluators
12 West Crossfield Road, Forestdale, MA 02644
Tel/Fax(508)477-5313
June 18, 2020
Alyn Pinkofsky
3 Northwood Lane
Wayland, MA 01778
Re: Existing leaching system elevation at 122 Juniper Rd, Centerville
Dear Mr. Pinkofsky:
Per your request, we have determined the elevation of your existing leaching system
with respect to the established maximum water surface elevation of Wequaquet Lake
used as a reference by the Town of Barnstable Board of Health (EL. 34.8 NGVD. The
top of the infiltrator units is EL. 37.16 NGVD. The record as-built is the only reference
that the town could provide about you septic system. The as-built card describes the
system as having a 1000 gallon septic tank and 3 infiltrators surrounded by 2' of stone
on all sides, for a footprint of 7' x 22.75'. The public record does not state whether the
infiltrators are standard size or high capacity. Assuming they are high capacity(worse
case), the bottom of the leaching system would be EL. 35.8 NGVD. Therefore, there is a
1' separation between the bottom of the existing leaching system and the maximum
water surface of the lake.
Based on the findings described above, the leaching system does not constitute a
failure as stated in 310 CM 303(1)(a)(7).
Please include this letter with the inspection report by Cape Septic Inspections.
You,
Peter T. McEntee P.E.
Barnstable
Town of Barnstable
Board of Health �' ►
200 Main Street, Hyannis MA 02601 2007
March 14, 2018
Public and Environmental Health Program
Policies, Procedures, and Guidelines
Enforcement of Section 360-20 (C) of the Town of Barnstable Code/When to Require an
Applicant to Appear Before the Board of Health for a Determination as to Whether the
System Requires Repair or Replacement -
No. 2018-001
Criteria for Determining System Repair or Replacement:
According to current wording in Section 360-20 of the Town of Barnstable Code,the Board of Health may require the repair or
replacement of an on-site sewage disposal system if any of the following apply: (C). The bottom of the cesspool or leaching facility
is less than four feet from the maximum adjusted groundwater elevation.
When to Require an Applicant to Appear Before the Board:
The Health Inspector shall inform the applicant that their proposal requires Board of Health
review at a public meeting to determine whether or not a system replacement or repair is required
if it was previously determined and documented (information is maintained on file at the Health
Division from a professional engineer, registered sanitarian, or certified septic system inspector)
that the existing leaching facility is less than four feet above the maximum adjusted groundwater
table and the existing leaching facility is located within 250 feet of a water body (or within 150
feet of a private well) and if one or more of the following three conditions apply:
a) there is an increase in flow proposed (i.e. to construct an additional bedroom) or;
b) the applicant proposes to raze and rebuild the dwelling/building or;
c) a repair, upgrade or replacement is proposed to one or more of the major existing
septic system components (i.e. septic tank, pump chamber).
The Board will consider proximity to wetlands, age of system, engineering plans and other
documentation on file, the existence of innovative/alternative technology or a secondary
treatment unit, pressure dosing, location in regards to an estuary protection zone, groundwater
protection zone, well protection zone, proximity to private wells, perched groundwater, and other
environmental factors when rendering a decision.
Paul J. Canniff, DMD Donald A. Guadagnoli, M.D.
Junichi Sawayanagi
Q:\POLICIES\Four Feet Separation Enforcement Policy.docx
Examples:
---------------------------------------------------------------------------------------------
• A homeowner is seeking a building permit to construct a 12' by 12' shed. The existing
SAS is approx. two feet above the groundwater table according to a private DEP septic
system inspector.
ANSWER: No, this applicant will not be required to appear before the Board because the
proposed construction will not involve habitable space.
--- -----------------------------------------------------------------------------------------
• A commercial building is located within 250 feet of a wetland. A contractor is seeking a
building permit to raze the building and construct a new building. There will be an
increase in the estimated wastewater discharge flow. The existing SAS is approximately
three feet above the groundwater table according to a private DEP septic system
inspector.
ANSWER: Yes, the applicant must be informed by the health inspector that this proposal
must be reviewed by the Board of Health at a public meeting because the building will be
razed and a new building is proposed.
--------------------------------------------------------------------------------------------
• An applicant is proposing to replace the septic tank at a single family residential
property, located within 250 feet of a wetland. The SAS is two feet above the maximum
adjusted groundwater table according to engineering plans kept on file.
ANSWER: Yes, the applicant must be informed by the health inspector that this proposal
must be reviewed by the Board of Health at a public meeting because there is an upgrade
proposed to one of the septic system components.
Q:\POLICIES\Four Feet Separation Enforcement Policy.docx
3d. OIL - . •_� �► _._ .
BORTOLOTTI CONSTRUCTION, INC.
765 WAKEBY ROAD,MARSTONS MILLS MA 0264
508-771-9399 508-428-8926 FAX: 508-428-9399 . E jg9
(Q
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION
PART A
CERTIFICATION `
^ Z
Property Address: o!
Date of Inspection: Inspecto s N e:
fi)vfnees Name and Address.
CERTIFICATION STATEMENT,
I certikthat I have personally inspected the sewage disposal system at this address and that the informa-
tion reported below is true,accurate and complete as of the time of inspection.The inspection was per-
formed based on my training and experience in the proper function and maintenance of on-site sewage
disposal stems. The System:
V Passes
Conditionally Passes
Needs Further ti a Local Aproving Authority
Fails
Inspector's Signature, Date:
The System Inspector shall submit a copy of this inspection report to the Approving authority within thir-
ty(30)days of completing this inspection. If the system is a shared system or has a design now of 10,000
gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional
office of the Department of Environmental Protection. The original should be sent to the system owner
and copies sent to the buyer, if applicable and the approving authority.
INSPECTIONSUMMARY-
A)SYS�PASSES:
I have not found any information which indicates that the system violates any of the failure
criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated
below.
B)SYSTEM CONDITIONALLY PASSES;
One or more system components need to be replaced or repaired. The system,upon comple-
tion of the replacement or repair,passes inspection.
Indicate yes,nor,or not determined(Y,N,OR ND).Describe basis of determination in all instances. If
"pot determined",explain why not.
The septic tank is metal,cracked,structurally unsound,shows substantial infiltration or
exfiltration,or tank failure is imminent. The system will pass inspection if the existing sep-
tic tank is replaced with a conforming septic tank as approved by The Board of Health.
Sewage backkup or breakout or high static water.level observed in the distribution box is due
to broken.or obstructed pipe(s)or due to a broken,settled or uneven distribution box. The
system will pass inspection if(with approval of The Board of Health)
- 1 -
A E DISPOSAL SYSTEM t , SUBSURFACE SEW STEM INSPECTION FORM G ..
PART A
CERTIFICATION(continued)
Je te� Broken pipe(s)replaced
Obstruction is removed
Distribution Box is levelled or replaced
t The System required pumping more than four 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
Obstruction is_removed_.__..
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 the public health,safety and the environment.
1)SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE
SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE
PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 Feet of a surface water
Cesspool or privy is within 50 Feet of a bordering vegetated wetland or a salt marsh.
2)SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER
SUPPLIER,IF APPROPRIATE).DETERMINES THAT THE SYSTEM IS FUNCTION-
INd IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT: ,,, f. .
The system has a septic tank and soil absorption system'and is within 100 Feet to a surface
water supply or tributary to a surface water supply:
The system has a septic tank and soil absorption system and is with a Zone I of a public
water supply well.
The system has a septic tank and soil absorption system and is within 50 Feet of a private
water supply well.
The system has a septic tank and soil absorption system and is less than 100 Feet but 50
Feet or more from a private water supply well,unless a well water analysis for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from
the facility and the presence of ammonia,nitrogen and nitrate nitrogen is equal to or less
than 5 ppm.
D)SYSTEM FAELS:
I have determined that the system violates one or more of the following failure criteria as defined
in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health
should be contacted to determine what will be necessary to correct the failure.
Backup of sewage into facility or system component due to an overloaded or clogged SAS
or cesspool.
Discharge or ponding of efluent to the surface of the ground or surface water_s due to a,n
overloaded or clogged SAS or cesspool.
.a Static liquid level in the,distribution box above outlet invert due
,to an overloaded or clog-
°s ged SAS or cesspool,,
,= Liquid depth in cesspool.is less than 6"below invert orYavailable-Nolume is'less than 1/2
day flow.
Required pumping more than 4 times in the last year NOT due Yto clogged or obstructed
pipe(s). Number of times pumped
-2.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater
elevation.
Any portion of a cesspool or privy is within 100 Feet of a surface water supply or tributary to
a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 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. If the well has been analyzed
to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic
compounds,ammonia nitrogen and nitrate nitrogen.
E)LARGE SYSTEM FAILS:
The following criteria apply to a large system in addition to the criteria above:
The design flow of a system is 10,000 gpd or greater(Large System)and the system is a significant
threat to public health and.safety and the environment because one or more of the following
conditions exist:
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 interimWellhead Protection Area.
(IWPA)or a mapped 4ne,II of a public water supply well.
The owner,or,operator of any such system shall bring the system and facility into full,compliance,with the
groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local
regional office of the Department for further information,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Check if the following have been done: .
_Jumping information was requested of the owner,occupant,and Board of Health.
_None of the system components have been pumped for atleast two weeks and the system has
been receiving normal flow rates during that period. Large volumes of water,have not been
introduced into the system recently or as part of this inspection.
i� built plans have been obtained and examined. Note if they are not available with N/A.
The facility or dwelling was inspected for signs of sewage back-up. ,
The
The system does not receive non-sanitary or industrial waste flow.
site was inspected for signs of breakout:
t/isystem components,excluding the Soil Absorption System,have been located on site.
e septic tank manholes were uncovered,opened;and'the interior of the septic tank was in-
ed for condition of bafltes ortees,matenai of construction,dimensions,depth of liquid,
. ': ,depth of sludge,depth of scum .
The size and location of the Soil Absorption System`on the site has been determined based on .
existing information or approximated by non-intrusive methods.
-3-
r
L 9 �
i
SUBSURFACE•SEWAGE DISPOSAL`SYSTEM INSPECTION FORM
PART B
CHECKLIST(continued)
The facility owner(and occupants,if different from owner)were provided with information on
the proper maintenance of Subsurface Disposal System
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
.. -SYSTEM INFORMATION
/ FLOW CONDITIONS
RESIDFNTIAI.i V
Design Flow: 330 ganons Number of Bedrooms: Nu ber of Current Residents:
Garbage Grinder: Laundry Connected To System:Va. Seasonal Use:
Water Meter ReadlKggs.if available,
Last Date of Occupancy:
CO MF.R AI AND 1ST IAi:A7
Type of Establishment: U.
Design Flow: _ gallons/day" Grease Trap Present: (yes�or no
Industrial;Waste Holding Tank Present:
Non-Sanitary Waste Discharged To The Title V System:
Water Meter Readings,If Available: Last Date of Occupancy:
OTHER: Describe)
Last Date of Occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information: /2J
System Pumped as part of inspection: If yes,volume pumped: gallons
Reason for pumping:
TYPE OF SYSTEM:
Septic Tank/Distribution Box/Soil Absorption System
Single Cesspool
Overflow Cesspool
Privy
---Shared System es,attach previous inspection records,if any
Other(explain). s, y
ROIQMATE ACA of alCOMMnents,date in talled(if known)and'sou'rce'of,• information:
Sew ge odors detected when arriving at the site:
-4-
r
SUBSURFACE SEWAGE UISPOSALlYSTEM INSPECTION FORM
PART C
GENERAL INFORMATION (continued)
a'
-_ SEPTIC TANK:
Depth below grader Material of Construction: `concrete metal FRP Other
i' (explain) —
°! Dimisions.^q•5'>Xp'X T,1 Sludge Depth: Scum Thickness: 41
Distance from top of sludge to bottom of outlet tee or baffle: ,y
Distance from bottom of scum to bottom of outlet tee or battle: 7
Comments:(recommendation for pumping;condition of inlet and outlet tees or baffles,de th of liquid
IPWI in relation to outlet invert,struc ral integrity,evid nce of leaks e•etc. /GYM v
�i
I
R..
GREASE TRAP: A)_0
Depth Below Grade: Material of Construction: concrete metal FRP Other
(explain) — - - —
Dimensions: Scum Thickness:
Distance from`top of scum to top of outlet tee or bile:
Comments: (recommendation for pumping,condition of inlet and outlet tees or ba131es,depth of.liquid
level in'relatton to outiefinvert;stnictural integnly evidence of leakage;.etc.)
TIGHT OR HOLDING TANK:
Depth Below Grade: Material of Construction:—concrete—metal_FRP_Other(explain)
Dimensions: Capacity: gallons Design Floc: Rallons/day
Alarm Level:
Comments: (condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:
Depth of liquid level above outlet invert:
Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into
or out of box,etc.)
-...f-PUMP CHAMBER i
_...,....Pump t9 in worlui g order:
- Comments: (note condition of pump chamber,condition of_pumps and appurtenances,etc.)` .
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued) '
SOIL ABSORPTION SYSTEM(SAS): V
(Locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive
methods) If not determined to be present,explain:
Type
Leaching pits,number: Leaching chambers, number: Leaching galleries,numberLg
Leaching trenches,number,length:
Leaching fields,number,dimensions:
Overflow cesspool,number:
Commen :(note condition of soil,signs of hydraulic failure level of ponding,condi of epetation,
etc.) _ -
CESSPOOLS: ,
Number and configuration: '' Depth-top of liquidto inlet invert:
Depth of solids layer: Depth of scum layer: Dimensions of Cesspool:
- Materials of construction: Indication of groundwater:
Inflow(cesspool must be pumped as part of inspection)
Comments:(note condition of soilk,signs of hydraulic failure, level of ponding,condition of vegetation,,
etc.)
PRIIVY:�
Materials of construction: Dimensions:_
Depth of Solids:
Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,
etc.)
-6
SUBSURFACESEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include ties to atleast two permanent references, landmarks or benchmarks: '
Locate all wells within 100 Feet.
fly'
�3
DEPTH TO GROUNDWATER:
Depth to groundwater: Z Feet S D�
Meth of Determination or App oxim lion:
D
-7-
li
� Est
� TOWN OF BARNSTABLE
LOCATION SEWAGE
VILLAGE CYH�t/N/��� ASSESSOR'S MAP & LOT A,- 6
INSTALLER'S NAME 6i PHONE NO. 1,1-v y,2Ir-
SEPTIC TANK CAPACITY C OUv
LEACHING FACILITYAtype) T,��'L ik.la-s (3) (size) 7 x
.NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER SL/�
BUILDER OR OWNER P,-(d2w-
DATE PERMIT ISSUED: 9 -OXA3
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes , No
X
����- I
f���¢ i ,
/U
' 3j` y3' �`' ,�
o07y
No.../ - ® — Fi$......,� �..�...........
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
TOWN OF BARNSTABLE
Appliration for Uiripoonl �ii ork,i Tomitrnr#ion rami#
Application is hereby made for a Permit to Construct ( ) or Repair (✓) an Individual Sewage Disposal
System at:
at.Tu!�.l.. k3......R>- = .....-- .�..�C'�.I',l-r R. .._.k.�.f.
I Location-: rc s �—r or Lot No. .........._.
a+� !2 2 ,1_u.N�..orLc�...... .... .... .........
-----------
Oacncr Addr ss
� l LL,�-------------------------
Installer Address
Q Type of Building Size Lot............................Sq. feet
U Dwelling No. of Bedrooms.............................. . . -Expansion Attic Garbage Grinder
aOther—Type
of Building ____________________________ No. of persons---------------------....... Showers ( ) — Cafeteria ( )
QOther fixtures ----------------------------------------------------------------------------------------
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity------------gallons Length................ Width---------------- Diameter................ Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------._--_-___ Diameter____________________ Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit_................. Depth to ground water........................
a ._...---•......................•-•••----••-•-•--•.......••••........--••-••-••••.............••••••...•-••••••••••••••--•--•••............._........--•......
0 Description of Soil......................................................................................................--------------------•---------------------------............•••--
x
W
x --------------------------------------•---•---•-••-•---•---•--••----•-----------•-••••••••-------•••---...._..-----------------•---•--•--•-••••-----•---••----•------••-•-......•-•••-••••.............
UP Nature of. Repairs or Alterations—Answer when applicable----(,!_P-.GR^A_E._..•7nTL, -5.........................
..•. •-•••-•-----•-•-----••---••••••--•---••---•-••--•-•--•---•••-----•-•---••-----••••••••••-•-•••-•••••-•-••-•--•••-•-------------------------------•------------•-•------•••-•-••••••-••-•----......
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code —The undersigned further agrees not to place the
system.in operation until a Certificate of CompliaInce has bee issued by toe board of health.
Signed ....: .. .........�. ........�..........................--...................... .................
Dace...................
Application Approved B z, ....... , -..tea- .. �3
Dace
Application Disapproved for the following reasons: ...................................... . . .............. ..............................................---..................
............. .................................................... . ......................... ... ....................... . ......................................... .. ................................
Uace
Permit No. ......9. �e) -------------- --- Issued -----------------------_..............................
Dace
07L
No... -. a. - Ft:$ ........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliration for Ali;ipoial Wi ork.6 Towitrurtion ramit
Application is hereby trade for a Permit to Construct ( ) or Repair (/an Individual Sewage Disposal
System at:
jz �► F)e..R..----R_ ....................... ... _rl_T- _v J__- Y MA,.........................
j Location.:ba ressr Lot
�.�. �a. _....
�.._�_1 ..... ........
+.► _L ��S ?'TT'�... c�_nS't rGr------ -C _t ,�� I. -� .........................
r ss
•-
Installer Address
Type of Building Size Lot............................Sq. feet
►� Dwelling— No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building _-_----------------_-.___ No. of persons............................. Showers ( ) — Cafeteria ( )
Other fixtures ...............................
----------
•-••-........................
w Design Flow--------------------------------------------gallons per person per day. Total daily flow..._..__.__._.__._.___._.._._______._.______gallons.
WSeptic Tank—Liquid capacity............gallons Length________________ Width---------------- Diameter................ Depth................
x Disposal Trench--No. .................... Width.................... 'Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
~I Percolation Test Results Performed by.......................................................................... Date........................................
a
,.1 Test Pit No. I................mmutes per inch Depth of Test Pit.................... Depth to ground water........................
�Z4 Test Pit No. 2................minutes per inch Depth of Test Pit_----______________ Depth to ground water........................
�+ •---••-••........................••----•---•----••••••••-•••••--_.--•-•--••••••••••••--...----••-•--........._......-........................................
Descriptionof Soil..................................................................................... ---------------_..--------------...-----•---------•--------------------------_....
x
w _
U P PP �.l.P-.Cs11A-�_.t_.....rlT.E---��-•.......-----••---•--•----
Nature of Repairs or Alterations—Answer when applicable.-.. _
--------------------------•------........------------------•------•-----------------._....-•----------------------....------------------------------•-------•--------------------------------•----_..._.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has been issued by the board of-health.
g yr� -� .......
Signed ....?: ' ....... ..............�........... .................................
Dare
Application Approved By .......... .-� , .......�..� °�`'� - -.....�...,3
`........................................................................ .. Date
Application Disapproved for the following reasons: .. .................................................................. ..................................
............................................................................. ..................................... ... ... ._...................................................... .......-.............................
Dare
Permit No. ......rl � - JC.C�-—------------------- Issued ......................................................... am......
' Dare
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
C erti irate of Compliance
i THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( �)
b ................ - ry' ....... _...
....................................
V_ � , ...Insrdler
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. .._9 -'._ _ ......._ dated ......_......... ................... .
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE .. ...._......... '.-.- Inspector -' _.....I.. ................. _.......-- ..... ................_.......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
� r TOWN OF BARNSTABLE
No.?—).. FEE....�n.z........
�i��ooitl or� �oiiotr�tion �rrmit
Permissionis hereby granted1 � .e- -------------------------------•--•------...---------------•-------•-----.._........---
to Construct ( ) or Repair (>O an Individual Sewage Disposal System
atNo......... ---•-•• ....... --•--•-•.___.. . �� ���AQ QO. --------------------••-•---......_
Street
as shown on the application for Disposal Works Construction Permi' No �:5'Q_')__Dated...........................................
�j� Board of Health
DATE................ .:'_�---?------------=---------•--•----
FORM 36506 HOBBS&WARREN.INC..PUBLISHERS