HomeMy WebLinkAbout0335 LAKE ELIZABETH DRIVE - Health (2) 33 LLAKE ELIZABETH RD., CENTERVILLE
___ A =
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
(335 Lake Elizabeth Drive
Property Address
Ellen Carberry
Owner Owner's Name
information is J t 0(_r V! MA f I g,
required for every " I tLd 02632 10�24/12
page. Cityfrown 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 and of the form.
Important:When A. General Information
filling out forms
on the computes,
use only the tab 1. Inspector:
key to move your
cursor-do not Michael Kellett
use the return Name of Inspector
key.
Aardvark Environmental Inspections
Company Name
PO Box 896
Company Address
ram„ East Dennis MA 02641
Cityrrown State Zip Code
508-385-7608 SI 3742
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 inspectipn
was performed based on my training and experience in the proper function and maifitenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant tol.Section 15.340 of =�
Title 5(310 CMR 15.000).The system: : Ws `:'
® Passes -"❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority 10
10/25/12
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.
it v
t5ins-11/10 Title 5Official Inspection Form ubsurface Sewage Disposal System•Page 1 of 17
1.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
6 335 Lake Elizabeth Drive
Property Address
Ellen Carberry
Owner Owner's Name
information is required for every Craig yille MA 02632 10/24/12
page. Cityrrown state Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary:Check A,B,C,D or E/ahaays 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 1-5.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired.The system,upon completion of the replacement or repair,as approved by
the Board of Health;will pass.
Check the box for"yes", "no"or"not determined"(Y,N, ND)for the following statements. If"not
determined,"please explain.
The septic tank is metal and over 20 years old*orthe 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-11/10 Title 501ficial Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
6 335 Lake Elizabeth Drive
Property Address
Ellen Carberry
Owner Owner's Name
information is required for every Craig yille MA 02632 10/24/12
page. City/Town 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(i)(b)that the system is not functioning in a mannerwhich 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•111113 Title 5Oftiai Inspection Form:Subsudece Sewage Dispomi System•Page 3 01 V
Commonwealth of Massachusetts
Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
a' 6 335 Lake Elizabeth Drive
Property Address
Ellen Carberry
Owner Owner's Name
information is required for every Craig yille MA 02632 10/24/12
page. Cityfrown 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 mannerthat protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well*".
Method used to determine distance:
**This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must
be attached to this form_
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
El ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6"below invert or available volume is less
than 1/day flow
t5ins•11/10 Idle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
6 335 Lake Elizabeth Drive
Property Address
Ellen Carberry
Owner Owner's Name
information is required for every Craig yille MA 02632 1024/12
page. City/Town state Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s).Number of times pumped:
❑ ® Any portion of the SAS,cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis,performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails.I have determined that one or more of the above failure
criteria e)dst 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 11/10 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
6 335 Lake Elizabeth Drive
Property Address
Ellen Carberry
Owner Owner's Name
information is Crai yille MA 02632 10/24/12
required for every g
page. City(rown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner,occupant,or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
i
® ❑ 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): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330
t5ins-11/10 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
uv Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
6 335 Lake Elizabeth Drive
Property Address
Ellen Carberry
Owner Owner's Name
information is required for every Craig yille MA 02632 10/24/12
page. Cityfrown state Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 0
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
Seasonaluse? ❑ Yes ® No
Water meter readings,if available(last'2 years usage(gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: 09/12
Date
Commercialfindustrial 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
6 335 Lake Elizabeth Drive
Property Address
Ellen Carberry
Owner Owner's Name
information is Crai yille MA 02632 10/24/12
required for every g
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
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/Altemative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the VA system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•11/10 Title 5Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
r
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
6 335 Lake Elizabeth Drive
Property Address
Ellen Carberry
Owner Owner's Name
information is required for every Craig yille MA 02632 10/24/12
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:
07/31/92 per BOH
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 0.9
feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints,venting,evidence of leakage,etc.):
Septic Tank(locate on site plan):
Depth below grade: 0.1
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: 1,000 gal
Sludge depth:
2"
t5ins-11/10 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
6 335 Lake Elizabeth Drive
Property Address
Ellen Carberry
Owner Owner's Name
information is Crai vllle MA 02632 10/24/12
required for every g
page. Citylrown 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 29".
Scum thickness
2"
Distance from top of scum to top of outlet tee or baffle
6"
Distance from bottom of scum to bottom of outlet tee or baffle
16"
How were dimensions determined? measured
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,
liquid levels as related to outlet invert,evidence of leakage,etc.):
The tank was sound and tight with tees in place and liquid at outlet invert.
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•11/10 Title 6 official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
6 335 Lake Elizabeth Drive
Property Address
Ellen Carberry
Owner Owner's Name
information is required for every Craig yille MA 02632 10/24/12
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
t51ns-11110 Title 5 Official Inspection Form:Subsurrace Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
6 335 Lake Elizabeth Drive
Property Address
Ellen Carberry
Owner Owner's Name
information is required for every Craig yille MA 02632 10/24/12
page. Citylrown 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 even
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.):
The box was level and tight with no sign of carryover.
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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
6 335 Lake Elizabeth Drive
Property Address
Ellen Carberry
Owner Owner's Name
information is required for every Craig yille MA 02632 10/24/12
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1
❑ 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.):
This system has a 6'x6'precast pit surrounded by two feet of stone.There was a stain line 10"up
from the bottom.
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
i
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 13 of 17
L Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
6 335 Lake Elizabeth Drive
Property Address
Ellen Carberry
Owner Owner's Name
information is required for every Craig ville MA 02632 10r24112
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.):
I
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
6 335 Lake Elizabeth Drive
Property Address
Ellen Carberry
Owner Owner's Name
information is required for every Craig yille MA 02632 10/24/12
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
Nibs
3o
t5ins•11/10 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
6 335 Lake Elizabeth Drive
Property Address
Ellen Carberry
Owner Owner's Name
information is required for every yrr
Craig yille MA 02632 10/24/12
page_ Citown 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: 20.0
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked,date of design plan reviewed: Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators,installers-(attach documentation)
® Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
USGS maps show an elevation of over 20.0 feet.
Before filing this Inspection Report,please see Report Completeness Checklist on next page.
thins•11/10 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
6 335 Lake Elizabeth Drive
Property Address
Ellen Carberry
Owner Owner's Name
information is required for every Craig yille MA 02632 1 W4112
page. Citylrown 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•1 WO Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
V0
m
JUL 9 1999
N
COMMONWEALTH 0 ACHUSE
EXECUTIVE OFFICE OF FFAIRS John Grad
DEPARTMENT OF ENVIRONNE CTION DEP Title V Septic Inspector
ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119
TeaTicket,Ma.
(508)564-6813
TRUDY COXE
Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 335 LAKE ELIZABETH RD. CENTERVILLE MAP 227 PAR 012 L 3
Name of Owner HERBERT DAVIES
Address of Owner: SAME
Date of Inspection: 716199
Name of Inspector:(Please Print)JOHN GRACI
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)
Company Name: n/a
Mailing Address: n/a
Telephone Number: n/a
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate
and complete as of the time of inspection.The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems.The system:
X Passes The inpection is based on criteria defined in Title V
Conditionally Passes code MO CMR 15.303.My findings are of how the system is
Needs Further Eva tion By the Local Approving Authority performing at the time of the inspection.My inspection does
Fails not imply any warranty or guarantee of the longgevity of the
septic system and any of its components useful life.
Inspector's Signature: Date:7/7/99
The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of
completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner
shall submit the report to the appropriate regional office of the Department of Environmental Protection.The original should be sent to the
system owner and copies sent to the buyer,if applicable,and the approving authority.
NOTES AND COMMENTS
lua
THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING SYSTEM EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL
LIFE.
revised 9/2/98 Page 1 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 336 LAKE ELIZABETH RD.CENTERVILLE MAP 227 PAR 012 L 3
Owner: HERBERT DAVIES
Date of Inspection:7/6199
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated
are indicated below.
COMMENTS:
System passes Title V inspection
B. SYSTEM CONDITIONALLY PASSES:
nla One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the
replacement or repair,as approved by the Board of Health,will pass.
Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not.
nta The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or
the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank
failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
Wa Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health).
_ broken pipe(s)are replaced
obstruction is removed
distribution box is levelled or replaced
n(a 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
revised 9/2/98 Page 2 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 335 LAKE ELIZABETH RD.CENTERVILLE MAP 227 PAR 012 L 3
Owner: HERBERT DAVIES
Date of Inspection:7/6/99
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 IN ACCORDANCE WITH 310 CMR 16.303(1)(b)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 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 ANY)DETERMINES THAT THE SYSTEM IS
FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well,
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the
well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm,Method used to determine distance nLa_(approximation not valid).
3) OTHER
nLa
revised 9/2/98 Page 3 of 11
,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 336 LAKE ELIZABETH RD.CENTERVILLE MAP 227 PAR 012 L 3
Owner: HERBERT DAVIES
Date of Inspection:716/99
D. SYSTEM FAILS:
You must indicate either"Yes"or"No"to each of the following:
I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is
identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool.
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow,
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped nLa.
X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
X Any portion of a cesspool or privy is within a Zone I of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well,
X 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 ompounds,
ammonia nitrogen and nitrate nitrogen.
X The liquid level in the SAS is over the invert pipe,is in Hydraulic Failure.
E. LARGE SYSTEM FAILS:
You must indicate either"Yes"or"No"to each of the following:
The following criteria apply to large systems in addition to the criteria above:
_ The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and
safety and the environment because one or more of the following conditions exist:
Yes No
X the system is within 400 feet of a surface drinking water supply
X the system is within 200 feet of a tributary to a surface drinking water supply
X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public
water supply well)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the
Department for further information.
revised 9/2/98 Page 4 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 336 LAKE ELIZABETH RD.CENTERVILLE MAP 227 PAR 012 L 3
Owner: HERBERT DAVIES
Date of Inspection:7/6/99
Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following:
Yes No
X Pumping information was provided by the owner,occupant,or Board of Health.
X None of the system components have been pumped for at least 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.
X As built plans have been obtained and examined.Note if they are not available with N/A,
X The facility or dwelling was Inspected for signs of sewage back-up.
X The system does not receive non-sanitary or industrial waste flow.
X The site was inspected for signs of breakout,
X All system components,excluding the Soil Absorption System,have been located on the site.
X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles
or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption
System on the site has been determined based on:
X Existing information,For example,Plan at B4O,H,
X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)
r
11 5.302(3)(b))
X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of
Subsurface Disposal Systems.
revised 912/98 Page 5 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 335 LAKE ELIZABETH RD.CENTERVILLE MAP 227 PAR 012 L 3
Owner: HERBERT DAVIES
Date of Inspection:7/6199
FLOW CONDITIONS
RESIDENTIAL:
Design flow:-=g.p.d./bedroom
Number of bedrooms(design): 3 Number of bedrooms(actual):I
Total DESIGN flow: =
Number of current residents:2
Garbage grinder(yes or no):NQ
Laundry(separate system)(yes or no): NO If yes,separate inspection required
Laundry system inspected(yes or no).M
Seasonal use(yes or no):JLQ
Water meter readings,if available(last two year's usage(gpd): nLa
Sump Pump(yes or no): NQ
Last date of occupancy: nta
COMMERCIAL/INDUSTRIAL
Type of establishment: Wa
Design flow: nLa gpd(Based on 15.203)
Basis of design flow: nLa
Grease trap present:(yes or no):M
Industrial Waste Holding Tank present:(yes or no): !1Q
Non-sanitary waste discharged to the Title 5 system:(yes or no):NQ
Water meter readings.if available:n&
Last date of occupancy: WA
OTHER: (Describe)
n1a
Last date of occupancy: n&
GENERAL INFORMATION
PUMPING RECORDS and source of information:
nLa
System pumped as part of inspection:(yes or no):NQ
If yes,volume pumped nbL gallons
Reason for pumping: n&
TYPE OF SYSTEM
X 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)
I/A Technology etc.Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other: n&
APPROXIMATE AGE of all components,date installed(if known)and source of information:
1992
Sewage odors detected when arriving at the site:(yes or no): NQ
revised 9/2198 Page 6 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 336 LAKE ELIZABETH RD.CENTERVILLE MAP 227 PAR 012 L 3
Owner: HERBERT DAVIES
Date of Inspection:7/6/99
BUILDING SEWER:
(Locate on site plan)
Depth below grade: Z
Material of construction:_ cast iron X 40 PVC _ other(explain)
Distance from private water supply well or suction line: TOWN
Diameter: nLa
Comments: (condition of joints,venting,evidence of leakage,etc.)
nLa
SEPTIC TANK: X
(locate on site plan)
Depth below grade: L"
Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain)
D&
If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): MQ
nta
Dimensions: L 8'6"H 5'7"W 4'10"
Sludge depth: L"
Distance from top of sludge to bottom of outlet tee or baffle: M
Scum thickness:4
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: 11
How dimensions were determined: MEASURED
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,
etc.)
SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND RECOMMEND PUMPING SYSTEM EVERY TWO YEAR
GREASE TRAP:
(locate on site plan)
Depth below grade:
Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain)
nLa
Dimensions: nla
Scum thickness: nta
Distance from top of scum to top of outlet tee or baffle:iVA
Distance from bottom of scum to bottom of outlet tee or baffle Wit
Date of last pumping: Wa
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,
etc.)
Wa
revised 9/2/98 Page 7 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 336 LAKE ELIZABETH RD.CENTERVILLE MAP 227 PAR 012 L 3
Owner: HERBERT DAVIES
Date of Inspection:7/6/99
TIGHT OR HOLDING TANK: NO (Tank must be pumped prior to,or at time of,inspection)
(locate on site plan)
Depth below grade: n&
Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain)
n&
Dimensions: n&
Capacity: nLa gallons
Design flow: n& gallons/day
Alarm present: NQ
Alarm level:jila- Alarm in working order:Yes_No_: NO
Date of previous pumping: n&
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
Wa
DISTRIBUTION BOX: _
(locate on site plan)
Depth of liquid level above outlet invert:n&
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.)
1L
PUMP CHAMBER: NQ
(locate on site plan)
Pumps in working order:(Yes or No): NO
Alarms in working order(Yes or No): NQ
Comments:
(note condition of pump chamber,condition of pumps and appurtenances.etc.)
n&
revised 9/2/98 Page 8 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 335 LAKE ELIZABETH RD.CENTERVILLE MAP 227 PAR 012 L 3
Owner: HERBERT DAVIES
Date of Inspection:7/6/99
SOIL ABSORPTION SYSTEM(SAS): X
(locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods)
If not located,explain:
nLa
Type.
leaching pits,number: 1000 GALLON LEACH PIT
leaching chambers,number: _nLa
leaching galleries,number: llLa
leaching trenches,number,length: nLa
leaching fields,number,dimensions: n&
overflow cesspool,number: nla
Alternative system: nLa
Name of Technology: nLa
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.)
THE LEACH PIT IS STRUCTURALL SOUND AND FUNTIONING PROPERLY.THE PIT HAD V IN IT AT THE TIME OF THE INSPECTION.NEVER MORE
THAN 1•
CESSPOOLS: _
(locate on site plan)
Number and configuration: n&
Depth-top of liquid to inlet invert: n&
Depth of solids layer: Wit
Depth of scum layer. n&
Dimensions of cesspool: DLa
Materials of construction: n&
Indication of groundwater: n& inflow(cesspool must be pumped as part of inspection)n&
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
n&
PRIVY: _
(locate on site plan)
Materials of construction:n& Dimensions:n&
Depth of solids: n&
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
Wa
revised 9/2/98 Page 9 of I I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 336 LAKE ELIZABETH RD.CENTERVILLE MAP 227 PAR 012 L 3
Owner: HERBERT DAVIES
Date of Inspection:7/6/99
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes into house)
n/a
B
revised 9/2/98 Page 10 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 336 LAKE ELIZABETH RD.CENTERVILLE MAP 227 PAR 012 L 3
Owner: HERBERT DAVIES
Date of Inspection:7/6199
NRCS Report name: nLa
Soil Type: n&
Typical depth to groundwater: Wa
USGS Date website visited: Wa
Observation Wells checked: NO
Groundwater depth:Shallow _ Moderate _ Deep _
SITE EXAM _ Slope
_ Surface water
_ Check Cellar
_ Shallow wells
Estimated Depth to Groundwater 12 Feet
Please indicate all the methods used to determine High Groundwater Elevation:
_ Obtained from Design.Plans on record
_ Observed Site(Abutting property,observation hole,basement sump etc.)
Determined from local conditions
Checked with local Board of health
Checked FEMA Maps
Checked pumping records
_ Checked local excavators,installers
XUsed USGS Data
Describe how you established the High Groundwater Elevation.(Must be completed)
USGS MAPS AND CHARTS AND VISUAL-12+FEET
revised 9/2/98 Page 11 of 11
s �• ASSESSORS MAP NO:
PARCEL NO: d .
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF H E A LT H Barnstabi �PROVEO
ConsorvatiQn DcPatomm
TOWN OF BA"STABLE 7�
Appliration for 14sposal Works TomitrurtlWTami ✓
Application is hereby made for a Permit to Construct ( ) or Repair ) an Individual Sewage Disposal
System at: ''
3 3 2 l�L3 E
................ ........ ..�'f.. ... ........... .. ...... .............
L tion-Address or Lot No.
...................... , ..... ��' ------------------ ---------�. `-.=-r--------•--- .......---...........-----•....
Owner
Address
2e H 5? S
...... ........... ......
Installer Address
Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms........ ..............................Expansion Attic ( ) Garbage Grinder ( )
pa., Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
a' 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 ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
,.� Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water......................
..-
�Zq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a ------------------------------•---------•----------•---•------------•-•-••----------••-•-•--•-------.........................................................
0 Description of Soil........................................................................................................................................................................
x
V ---------------------------------------••••----------------------------------•-----------•---------------------------------•--------------------•--------------•------•---...........------••-•••--•---.
W -----------------------------•---------------------------------------•--------------------------------------------------.....
V Nature of Repairs or Alterations—Answer when applicable_l<P ��,__,!-q '= �7_7 �,� bi
Oct 5-% � G J." d
------------------------- -------- --- .. . ----••------------------------------------••--------------------•--•--•--•---------•--------.------
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 Corn Ila ce has been iss ed b t o alth.
Signed �---------------- --------------------- --------- 2..
Z� e
l 7 -
Date
ApplicationApproved By ------------ --- �- - -*- ---------------------------------------------------------------------- ----?--- -... .::2--
Date
Application Disapproved for the following reasons- -------------------------------------------------------------------- -------- ----------------------- --------------------------
.. ..................... .. ..--- --- ---...............---------.-----
Date
pp .............._
Permit No. -------1 .-a'-- .a-.S_5 - ... Issued ---------------------------------------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE -
Appliratiun for Disposal Worku Tomitrnrtiun amit
Application is hereby made for a Permit to Construct ( ) or Repair ( an"Individual Sewage Disposal
System at:
.... Z-A � -�-.•..-�2 egl3E Tt/
Lo lion-Address d or Lot No.
......................f--�--�`....f.T---•-.= f-=� 4...................................... ........•--.............-..._------...---•-••-------•--..........------•.........................
Owner Address
./A.4Z...!_-S ---•..................................•....
Installer Address
UType of Building Size Lot............................Sq. feet
�-� Dwelling—No. of Bedrooms___......,..............................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
da• 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
Percolation Test Results Performed by..........................................................................
Date..........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
f14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
9 .-••-•-•-•-•--------------------•-•------•-•--•--••--•-••••••-•--••-•••••-•••••-•-••....--•-•----------------•-----•------•----._........ ------------------
0 Description of Soil.............................................................................................................................. --------••....................
W
V ......•---•--•-•••-••---•--•••••••-••---••--•••••-•-••--•--••------•--•••••--••-•-•--•-•-•------••-•-•••-•••----•--••••••-••••---•-•••-•----•.._..---•-•••••----•-•••-•-•-•-•-------••--••--•-•------•••.
W ------------------------------------------------------------------------------------------------------------------------------------ ---------
U Nature of Repairs or Alterations—Answer when applicable._.�fPC_9A.___.. ___...��!_ j ...r��......................
_ -••-•- .
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 Signed Compliance has be&issued b the bo
Y P � P Y
- Date
Application Approved BY .. ......: ....-......................... ......----'----.....--------.... Dale
Application Disapproved for the following reasons- -------------- -- ----------------------------------------------------------------------------------------------------- -------
................... ...................... ...
Date
PermitNo. . .----- ------------------- Issued --.----------..------ -----------------.---------.....-----
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
C11er#Yft.cate of C110rapti ace -'
THIS I TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
by ------------- ----ti/ -------------------------------------------------------....------..................------------------------..........-----......----------------......
Installer / ar
at ..._ ......................................................- c /-2.-7 (3� T y - ��✓� E
. . -- . ..... ..................................... .........---..........---------------.........................
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. ...........!. . dated .....------------------------------------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................ 1................................................ Inspector --------................. ...----------------..............--------......-..
i-.. '_j F 1...
THE-COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
NO......
�u`Z...:.�•:�� FEE.. ...^"
Uiupuul Works %Tunu#r ion amit
Permission is hereby grantee-------------�-��-�--•••-••••--•-•-------------------------------
•-----------
............
...._....-.--...
to Construct ( ) or Repair ( ) an Individual Sewage Disposal System
at No. ---••••--
Street
as shown on the application for Disposal Works Construction Permit No.Jd__ .��1__ Dated................I........................
•---••---•-•------•----•••..•--- ,I --......................................................
Board of Health
DATE.
--••-----------•--------•-•-•----•--•-------•....................•....._......
FORM 36508 HOBBS h WARREN.INC..PUBLISHERS
TOWN OF BARNSTABLE
LOCATION 3 ��A��= ��ga��� �n SEWAGE #
VILLAGE C/l�• �-� �� ASSESSOR'S MAP & LOT �7��1`�
INSTALLER'S NAME & PHONE NO. ,A,--aN Ca,s
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type)(;j) 419 fa 06) (size) x
NO. OF BEDROOMS 3 PRIVATE WELL OR PUBLIC WATER
OWNER A45- OL P-t 2T
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED:. Yes No C/
i
r
a 33
/uou
ST
�y s9