HomeMy WebLinkAbout0283 LONG BEACH ROAD - Health 283 Long Beach Road
Centerville
A= 185 —033
S M E A e
No. 53LOR
UPC 12543
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4
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
Application for Disposal Opstem. Construction Permit
Application for a Permit to Construct( ) Repair O0 Upgrade( ) Abandon( ) ❑Complete System Xlndividual Components
Location Address or Lot No. �g7y Lo"-r P (� Owner's Name,Address and Tel.No.
Assessor's Map/Parcel ' Q G,V(k-,LT 29 Wi4 50at
Installer's Name,Address,and Tel.No. .SOk-471-$$?l Designer's Name,Address,and Tel.No.
RZ>B�tT 13 oUV_ca T (+ Nr,4
A 5.
Type of Building:Dwelling No.of Bedrooms //�v Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) _�S"'f"i4LL �I� �(,� (^{• � �/
Uj 1� &
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Sign Date e(p e O �
Application Approved by Date ("
Application Disapproved by Date
for the following reasons
Permit No, ;__0 Date Issued
.,�-:t,'�:�,e"r ,::..y,ni•rt..r ��.,. ....._..•..-, a..'^,-uj:� ,n. F.,. ,, �f r_.,..,,�c*"s F� # t };:� :r..-Kr:.. r,.n•,r._
'F r. j i.. ir,r'�" •pt ay.�,..s#.•,r+cr n,..:rs... #'stG ova v .,
No. Fee
' THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
2pplitation for Disposal 6p$tem Construction joermit
Application for a Permit to Construct( ) Repair(h Upgrade( ) Abandon( ) ❑Complete System Individual Components
Location Address or Lot No. g E,pt,)& 1 L6:40{ (D Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel o Y(h��--TW&) Pj, k:__ t4
Installer's Name,Address,and Tel.No. „�Q - 7 Z• '�� Designer's Name,Address,and Tel.No.
Roslcmr
Type of Building:
Dwelling No.of Bedrooms /v Lot Size sq.ft. Garbage Grinder( )
Other Type of Building - No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs orAlteratiops(Answer when applicable) )< rAL. L JAI.1-4-��_�� `b
Date last inspected:
Agreement: ,
x The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in,operation until a Certificate of
Compliance has been issued by this Board of Health.
10
=--- -�-4, -� `' �. ,�,.� __ �lgne
A hcation� roved bY�"" - --- - •- .,.,.- -'-�`� Date
PP PP -.a-•�-^-
Application Disapproved by Date
for the following reasons
�V 7 X
'Permit No. Date Issued
R i
---- - -- ------ ---- - - - - ----"-- ----- - ----------------- - - -
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS .
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( Upgraded( )
Abandoned( )by RON,)&-r- p JP,, o
at 1, l-o&j r, �_ R� G't V/c.c has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No.-2lil'(65 dated
Installer T Designer Illl
#bedrooms IV Ift Approved design flow gpd
The issuance of this perm' shall pot be
construed as a guarantee that the system wil fianc n t ed.
Date & Q� Inspector
No. ;�_Oa 0 ^ ' �J Fee 7._5. ..
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Veposal :FPpstem Construction Permit
Permissionlis herebyanted to Construct Repair
granted ( ) epa Upgrade( ) Abandon( )
System located at RcwCb
and as described in the above Application for Disposal System.Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this permit. L14
_ 17,Date r Approved by / '
, V
Commonwealth of Massachusetts
fitje vMfcall Inspection dorm
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
283 LONG BEACH RD
Property Address
ROBERT ANGELO
Owner Owner's Name
information is CENTERVILLE required for MA 02632 3/15/10
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important: A, General Information When filling out
forms the
computer,
r,use 1. Inspector:
only the tab key
-to-mov€your 7jt7 VLAj A"BRt)V11iV
cursor-do not
use the return Name of Inspector
.WY: DGUGLAS-A'$RGWN 4,NC
Company Name
Company Address
CENTERVILLE MA 02632
City/Town State Zip Code
508-420-4534 S14297
Telephone Number License Number
B. Cedif cation
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Secti'oin 15.340 pf �
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails w y
❑ Needs Further Evaluation by the Local Approving Authority 11
Inspector ignature Date n
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
mad.captes,sent to tie buyer,of-apphcablA,a4d the approvmg-authority:
""This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
'~ 283 LONG BEACH RD
Properly Address
ROBERT ANGELO
Owner Owner's Name
information is CENTERVILLE required for MA 02632 3/15/10
every page. City/Town State Zip Code Date of Inspection
8'.Ic ritifh tirnr�carrt.j
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information,which indicates that any of the failure criteria described
`in 3-Zd It.3D3 or-in 31D CMR 133U4 exist.Any Tailure cntena ndt evalua"tea are
indicated below.
Comments:
LEACH CHAMBERS WERE DRY AT THIS TIME, SOIL WAS DAMP WITH NO EVIDENCE OF
FAILURE
B) System Conditionally Passes:
` `OYr�bT'Pfr�'F�e�ysterPi��rrp�n�ri4s-�s`desribed're►�ti��`C�n�ditii�r�i'Pa�s"`��ctio�i ri�e�i"�b�
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Check the box for`yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not
determined,"please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
Y N ND(Explain below):
t5ins•09/D8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
283 LONG BEACH RD
Property Address
ROBERT ANGELO
Owner Owner's Name
informationis CENTERVILLE
required
wir for for MA 02632 3/15/10
every page. Cityfrown State Zip Code Date of Inspection
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
:safety;vAwl-the-envaao unen
❑ 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•09iD8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
'< 283 LONG BEACH RD
Property Address
ROBERT ANGELO
Owner Owner's Name
informationis CENTERVILLE
required
uired for MA 02632 3/15/10
every page. Cityfrown State Zip Code Date of Inspection
-B.-QYtifit+ M�&arff..)-
2. System will fail unless the Board of Health(and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within
1AA:feet:of&surface waxen.supply.or xributary Ao-.a surface-WA er-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**.
Mztfre"id vsed'td=def irnirre'dstditc '
**This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be
attached to this form.
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® -Lie�iit d ptPti rn r pz��l is IEss the 6"� i w lrry or vaita w�,s t 'ts ess
than%day flow
t5ins•09/D8 Title 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
283 LONG BEACH RD
Property Address
ROBERT ANGELO
Owner Owner's Name
information is CENTERVI LLE required for MA 02632 3/15/10
every page. Cltyrrown State Zip Code Date of Inspection
S.-C
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
antJv&laain-oToustody must be attao�asd.to Ws forrn:]-
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303,therefore the system fails.The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area--UNPA)*r a:raaapp®dZ-oneA-of--a publicm0ater soply`-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-09t08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
Commonwealth of Massachusetts
_ s
fi tl-e v O ficialaInspecUon Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
283 LONG BEACH RD
Property Address
ROBERT ANGELO
wrner Owner's Name
information is CENTERVILLE required for MA 02632 3/15/10
every page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner,occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
0 ,f1 Was Ali$Lacilixy.ordaielling inspectedlor.SkJM'-Ofss , back
® ❑ 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
rnspected irn fitrE LCiTl�itiOTl tiftFiE tiaffies Dr-tees,rrratanal of evrrstnactirm,
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:
M 0 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): 7 Number of bedrooms(actual): 7
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 770
t5ins-09/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
Wo
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
283 LONG BEACH RD
Property Address
ROBERT ANGELO
Owner Owner's Name
information is required for CENTERVILLE MA 02632 3/15/10
s
every page. City/Town State Zip Code Date of Inspection
f3:-S e Ti idf6— v
Description:
2000 GALLON SEPTIC TANK, D-BOX,AND 4 FLOW DIFFUSERS WITH STONE ACCORDING TO
AS-BUILT
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ❑ No
Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes ❑ No
Water meter readings, if available(last 2 years usage(gpd)): 09/210-08/400
Detail':"
Sufrip`pump? ❑ Yes"❑ No
Last date'•of occu CURRENT
' Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gauons.per day-.(ypd.).
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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
283 LONG BEACH RD
Property Address
ROBERT ANGELO
Owner Owner's Name
information is CENTERVILLE required for MA 02632 3/15/10
every page. Ctly/Town State Zip Code Date of Inspection
D S U '1'r
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/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
VY Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
283 LONG BEACH RD
Property Address
ROBERT ANGELO
Owner Owner's Name
information is CENTERVILLE required for MA 02632 3/15/10
every page. City/Town State Zip Code Date of Inspection
0. IS` t iTfi f ffOTT�0T1"(Corft.)
Approximate age of all components, date installed(if known) and source of information:
INSTALLED IN 1984 ACCORDING TO AS BUILT CARD
Were sewage odors detected when arriving at the site? ❑ Yes ❑ No
Building Sewer(locate on site plan):
Depth below grade:
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: 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: 2000 GALLON
Sludge depth:
t5ins•09M Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
i
Commonwealth of Massachusetts
lugTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
" 283 LONG BEACH RD
Property Address
ROBERT ANGELO
Owner Owner's Name
information is CENTERVILLE required for MA 02632 3/15/10
every page. City/Town State Zip Code Date of Inspection
ID. SySWimifif&fftfid (66M)y
Septic Tank(cunt.)
Distance from top of sludge to bottom of outlet tee or baffle
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
How were dimensions determined?
•carrtrmntt'(on-pumping Tecommendations,intetand ouW-tee ortaff a oonttition,structwat integjrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene
y El 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•09M Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
w 283 LONG BEACH RD
Properly Address
ROBERT ANGELO
Owner Owner's Name
information is CENTERVILLE required for MA 02632 3/15/10
every page. Cltyfrown State Zip Code Date of Inspection
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
TANK LOOKS FINE AT TIME NO LEAKAGE
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
El other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping:
Date
Comments(condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•09i08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
283 LONG BEACH RD
Property Address
ROBERT ANGELO
Owner Owner's Name
information is required for CENTERVILLE MA 02632 3/15/10
every page. Citylrown State Zip Code Date of Inspection
D- SyStOffi itftffn8 i'fin (cant.)
Distribution Box(if present must be opened)(locate on site plan):
I
Depth of liquid level above outlet invert 0.1
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evid€nce-of.leakage.into.orout of.box,,etc.):
BOX LEVEL NO LEAKAGE
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.):
Soil Absorption System(SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•09/08 Title 5 Official Inspection 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
283 LONG BEACH RD
Property Address
ROBERT ANGELO
Owner Owner's Name
information is CENTERVILLE required for MA 02632 3/15/10
every page. City/Town State Zip Code Date of Inspection
D S eTn tnFbTff ra i�?i -(cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 4 FLOW
DIFFUSERS
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
T ype/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
-vegetatior"etc.):
OPENED FIRST CHAMBERIT WAS EMPTY WITH NO SIGNS OF HYDRAULIC FAILURE
Cesspools(cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•09108
Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
l
i
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
283 LONG BEACH RD
Property Address
ROBERT ANGELO
Owner Owner's Name
information is CENTERVILLE required for � MA 02632 3/15/10
every page. CltyrFown State Zip Code Date of Inspection
D.S 1 Infor 4ian -(cohi.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc):
t5ins•09M Title 5 Official Insp
ection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
283 LONG BEACH RD
Property Address
ROBERT ANGELO
Owner Owner's Name
information is
required for CENTERVILLE MA 02632 3/15/10
every page. Cl mown State Zip Code Date of Inspection
D. Sysi em iniaftirtib i 'icon :}
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
Aravving attached separately
t5ins•09A8
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
N Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
283 LONG BEACH RD
Property Address
ROBERT ANGELO
Owner Owner's Name
information is CENTERVILLE required for MA 02632 3/15/10
every page. City/Town State Zip Code Date of Inspection
D.'SyMiefn i orml wiian(dint:)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 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:
SEE ATTACHED PAPER BY BAXTER NYE ENGINEERING
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
i
Baxter Nye Engineering & Surveying
78 North Street,3rd Floor, Hyannis,Massachusetts 02601
March 15th, 2010
Health Department
200 Main Street
Hyannis, Massachusetts 02601
Re: 283 Long Beach Road
To whom it may concern,
An observation well was set on this property and monitored for a month. The observed
groundwater level varied from El. 0.95 to El. 1.95 with an average of El. 1.45. This
correlates well with the observed groundwater (El. 1.5)used for the septic design at
Portledge by the Sea across the street.
The bottom of the leaching system at this property is at El. 3.0 and therefore is not in
contact with groundwater through out the observed range.
It is my opinion that the existing septic system meets the criteria set forth in 310 CMR
15.302 (Title V) and passes the inspection.
If you have any questions or comments please call me directly at 508-428-9131, ext.13.
Sincerely,
--4
Stephen A. Wilson, P.E.
#2009-024:01
AngeloBOHGW.doc
Phone (508) 771-7502; Fax (508) 771-7622
w
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
283 LONG BEACH RD
Property Address
ROBERT ANGELO
Owner Owner's Name
information is CENTERVILLE required for MA 02632 3/15/10
every page. Clty/rown State Zip Code Date of Inspection
E'R pb`a-Compie4enVss Ch ck1h§t
® Inspection Summary:A, B, C, D, or E checked
® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
BAXTER NYE ENGINEERING & SURVEYING
. Registered Professional Engineers and Land Surveyors
78 North Street,3rd Floor,Hyannis,MA 02601 Tel: (508)771-7502 Fax: (508)771-7622
August 25, 2010
Mr. Robert Angello
28 Wayside Inn Road
Framingham, MA 01701
Re: 283 Long Beach Road, Centerville
Dear Mr. Angello:
I have had an additional meeting with Health Department personnel to clarify the status of the septic
system at your house.
The system as it is,presently,passes the Title V inspection and will not have to be upgraded if you
sell the house.
The Town of Barnstable issues two types of building permits. An Express permit issued for re-
roofing,re-siding or replacement of windows or doors does not require a signoff by the Health
Department and will not trigger a septic system upgrade.
A full building permit requires a signoff by the Health Department and may trigger a septic upgrade.
As there is no established Board of Health policy on this, each building permit is reviewed
individually. If a building permit, such as adding a bedroom,were applied for,this would trigger a
septic upgrade as the sewage flow is being increased.
It is unclear if other building permits for interior remodeling, such as kitchen or bathroom
1,
renovations, would trigger a septic system upgrade.
If you have any questions or comments,please do not hesitate to call me directly at 508-771-7502
ext.13.
Very truly yours,
Baxter Nye Engineering& Surveying
Stephen A.p Wilson, PE EUG.
cc: T. McKean Health De t pCD
2009-024:01:
0:\2009\2009-024\ADMIN\LETTERS\Angall6,283 Long Beach Road,8-25-IO.doc
SAW:kb
Land Surveys • Site Design • Subdivisions • Septic Design • Wetland Filings • Planning
J
C
R'
Town of Barnstable
i + MASSE L
A 1639, 1. Inspectional Services Department
rfa Mati
Public Health Division
200 Main Street, Hyannis MA 02601
Office: 508-862-4644
FAX: 508-790-6304 Thomas A.McKean,CHO
Feb 6, 2007
Rev. 4/26/19
r
DEADLINES TO REPAIR FAILED SYSTEMS
(Town Code §360-44 and Title V: 310 CMR 15.000)
An "x" marked in the ❑ is the failure criteria and associated repair deadline
60 DAY DEADLINE CRITERIA
❑ Discharge or ponding of effluent to the surface of the ground
❑ Pumping more than 4 times during the last year not due to clogged or obstructed
pipe.
❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool
❑ Structurally unsound septic tank or SAS
ONE (1) YEAR DEADLINE CRITERIA
❑ Static liquid level in the distribution box is above the outlet invert due to an
overloaded or clogged SAS or cesspool
❑ A portion of the SAS, cesspool, or privy is below the high groundwater elevation
❑ A portion of the cesspool is located within a Zone 1 to a public well
❑ A portion of the cesspool is located within 50 feet of a private water supply well
with no acceptable water quality analysis. (This system passes if the water analysis
indicates the well is free from pollution).
TWO (2) YEAR DEADLINE CRITERIA
❑ Single Cesspool
❑ Any "conditionally passed systems" (broken cover, relocation of a pipe, relocation
of a driveway due to H-10 components, etc)
❑ Leaching facility with standing liquid level at or above the invert pipe (per Town
Code §360-20 h)
OTHER
J rr zd��- 4�
s�
�,c7�'�
Repair deadline:
Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc
f�
S t Commonwealth of Massachusetts lgs— 033
— Title 5 Official Inspection Form
�I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
283 Long Beach rd '
u Property Address '
Bob &Joyce Angelo _
Owner Owner's Name
information is �/
required for every Centerville Ma. 02632 5-28-20
page. City/Town State Zip Code Date of Inspection f
t
r
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 y
{ on the computer,
use only the tab Michael Sears
key to move your Name of Inspector
cursor-do not Robert B Our Co INC.
use the return Company Name
key.
363 Whites Path
r Company Address
South Yarmouth Ma. 02664
City/Town State Zip Code
508-477-8877 S 114430
Telephone Number License Number
B. Certification
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:
1. ❑ Passes -\N OF rMq
S �
2. ® Conditionally Passes s9�'��';
�0�. •tiGy
.' MICHAEL to
3. ❑ Needs Further Evaluation by the Local Approving Authority 'o SEARS
*: No.SI14430
4. ❑ Fails
''1 �u p SP�����X��``��
�✓ 5-28-20
Inspector's S' nature 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.
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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
i; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
283 Long Beach rd
Property Address
Bob & Joyce Angelo
Owner Owner's Name
information is Centerville Ma. 02632 5-28-20
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:Subsurface Sewage Disposal System•Page 2 of 18
I_
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
283 Long Beach rd
V�
Property Address
Bob &Joyce Angelo
Owner Owner's Name
information is required for every Centerville Ma. 02632 5-28-20
page. City/Town 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 ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
® distribution box is leveled or replaced ❑ Y ® N ❑ ND (Explain below):
D box wall are one, needs to be replaced
❑ 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
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Mln� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
.............. , ,. 283 Long Beach rd
Property Address
Bob&Joyce Angelo
Owner Owner's Name
information is
required for every Centerville Ma. 02632 5-28-20
page. City/Town 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:
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
283 Long Beach rd _
Property Address
Bob & Joyce Angelo
Owner Owner's Name
information is required for every Centerville Ma. 02632 5-28-20
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 1/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
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 co of the analysis
p gg copy Y
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
<f\, Commonwealth of Massachusetts
�� :• Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u
283 Long Beach rd
Property Address
Bob&Joyce Angelo
Owner Owner's Name
information is Centerville Ma. 02632 5-28-20
required for every
page. Cityfrown 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 a//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?
O ® 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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
283 Long Beach rd
Property Address
Bob & Joyce Angelo
Owner Owner's Name
information is Centerville Ma. 02632 5-28-20
required for every — --
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 7 Number of bedrooms (actual): 6
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x.#of bedrooms): 770
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 (gpd)):
NA
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: NA
Date
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
i
I Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
`cc � 283 Long Beach rd
Property Address
Bob &Joyce Angelo
Owner Owner's Name
information is required for every Centerville Ma. 02632 5-28-20
page. Cityrrown State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): Number of bedrooms (actual): 6
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x.#of bedrooms): 770
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 ears usage d NA
9 ( Y 9 (gp ))�
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: NA
Date
t5insp.doc-rev.7/26/2018 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
283 Long Beach rd
Property Address
Bob &Joyce Angelo
Owner Owner's Name
information is required for every Centerville Ma. 02632 5-28-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
j 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: 2016 _
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18
l
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
l% 283 Long Beach rd
Property Address
Bob &Joyce Angelo
Owner Owner's Name
information is required for every Centerville Ma. 02632 5-28-20
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:
10-22-05 #84-958
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 30"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.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
283 Long Beach rd
u� Property Address
Bob &Joyce Angelo
Owner Owner's Name
information is Centerville Ma. 02632 5-28-20
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
F
6. Septic Tank(locate on site plan):
Depth below grade: 20„feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
2000 gal
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
2000 gal
Sludge depth:
4"
Distance from top of sludge to bottom of outlet tee or baffle 24
Scum thickness
2"
Distance from top of scum to top of outlet tee or baffle
8"
Distance from bottom of scum to bottom of outlet tee or baffle
12"
How were dimensions determined? Sludge gudge, tape
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
2000 gal tank, in and out tees in place
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
��- Title 5 Official Inspection Form
II; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
283 Long Beach rd -
Property Address
Bob & Joyce Angelo
Owner Owner's Name
information is Centerville Ma. 02632 5-28-20
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:
I
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
t5insp.doc-rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
. /% 283 Long Beach rd
Property Address
Bob & Joyce Angelo
Owner Owner's Name
information is required for every Centerville Ma. 02632 5-28-20
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 0 -
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D box 16x21 with one outlet pipe, cover is 34" below gade
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
L
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
283 Long Beach rd
v-
Property Address
Bob &Joyce Angelo
Owner Owner's Name
information is required for every Centerville Ma. 02632 5-28-20
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: 4 flows
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number: —
❑ innovative/alternative system
Type/name of technology:
t5insp.doc-rev.712 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18
s
cam, Commonwealth of Massachusetts
Title 5 Official Inspection Form
i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
!% 283 Long Beach rd
�— Property Address
Bob &Joyce Angelo —
Owner Owner's Name
information is Centerville Ma. 02632 5-28-20
required for every
page. City/Town 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.):
SAS is 4 Flow difusers with 4' of stone
SAS is 3' below grade
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.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
I- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
. �!% 283 Long Beach rd
u
Property Address
Bob &Joyce Angelo
Owner Owner's Name
information is Centerville Ma. 02632 5-28-20
required for every
page. Cityrrown 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.):
I
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
h 283 Long Beach rd
u— -
Property Address
Bob & Joyce Angelo
Owner Owner's Name
information is required for every Centerville Ma. 02632 5-28-20
page. City/Town 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
- 19a -31
3- q1 -b 3 - 33•��
W —,36,8 y y
B �
O1
A 01
0
0
i
t5insp.doc•rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
r
cam, Commonwealth of Massachusetts
�Y is Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�c 283 Long Beach rd
V�
Property Address
Bob &Joyce Angelo —
Owner Owner's Name
information is Centerville Ma. 02632 5-28-20
required for every
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: 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:
See attached paper by Baxter Nye Engineering
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
c Commonwealth of Massachusetts
,p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
`.............. �!% 283 Long Beach rd
Property Address
Bob &Joyce Angelo
Owner Owner's Name
information is required for every Centerville Ma. 02632 5-28-20
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
Baxter Nye Engineering & Surveying
78 North Street,3rd Floor,Hyannis,Massachusetts 02601
March 15'',2010
Health Department
200 Main Street
Hyannis,Massachusetts 02601
Re: 283 Long Beach Road
To whom it may concern,
An observation well was set on this property and monitored for a month. The observed
groundwater level varied from El. 0.95 to El. 1.95 with an average of El. 1.45. This
correlates well with the observed groundwater(El. 1.5)used for the septic design at
Portledge by the Sea across the street.
The bottom of the leaching system at this property is at El. 3.0 and therefore is not in
contact with groundwater through out the observed range.
It is my opinion that the existing septic system meets the criteria set forth in 310 CMR
15.302 (Title V) and passes the inspection. j
If you have any questions or comments please call me directly at 508-428-9131,ext.13.
Sincerely,
Stephen A. Wilson,P.E.
#2009-024:01
AngeloBOHGW.doc
Phone(508) 771-7502; Fax(508) 771-7622
r
Commonwealth of Massachusetts ■
100199796
Asbestos Notification Form ANF-001 Decal Number
C
Important:When filling out A. Asbestos Abatement Description
forms on the
computer,use 1. a. Is this facility fee exempt-city, town, district, municipal housing authority, owner-occupied
only the tab key residence of four units or less?❑✓ Yes ❑No
to move your
cursor-do not b. Provide blanket decal number if applicable: Blanket Decal Number
use the return
key. 2. Facility Location: yti
BOB AND JOYCE ANGELO Z. 283.LONGBEACH ROAD
a.Name of Facility b.Street Address
BARNSTABLE 102632
c.City/Town d.State e.Zip Code f.Telephone Number
INSTRUCTIONS 3. Worksite Location:
1.All sections of this BASEMENT
form must be a.Building Name/Building Location b.Building# c.Wing d.Floor e.Room
completed in order
to comply with 4. Is the facility occupied? ❑✓ Yes ❑ No
DEP notification
requirements of 310
CMR 7.15 5. Asbestos Contractor:
and the Division
of Occupational INEW ENGLAND SURFACE MAINTENANCE 1 850 WASHINGTON STREET
Safety(DOS) a.Name b.Address
notification requirements of 453 WEYMOUTH 02189 J 17813372117
CMR 6.12 c.City/Town d.Zip Code e.Telephone Number
AC000196 -
f.DOS License Number g. Contract Type: El1Nr",itten Verbal
h.FacilitV Contact Person i.Contact Person's Title
JOHN P.VALLIQUETTE I JAS060773
6' a.Name of On-Site Supervisor/Foreman b.Supervisor/Foreman DOS Certification Nurdog
RICK BOWEN I JAM035129 E "`
7' a.Name of Project Monitor b.Project Monitor DOS Certification Number
FLI ENVIRONMENTAL AA000144
8' a.Name of Asbestos Analvtical Lab b.Asbestos Anal tical Lab DOS Certification Number
=0 9. 06/17/2014 1 106/17/2014
a.Project Start Date mm/dd/ b.End Date mm/dd/
_0 8-4
�N c.Work hours Mon-Fri. d.Work hours Sat-Sun.
=o 10. a. What type of project is this?
=o ❑ Demolition ❑ Renovation
❑✓ Repair ❑Other, please specify: b.Describe
11. a. Check abatement procedures:
_o ❑Glove bag —1 Encapsulation
o ❑ Enclosure ❑ Disposal only
=LL ❑Cleanup ❑Other, specify:
❑✓ Full containment b.Describe
—z
=Q 12. Is the job being conducted: ❑✓ Indoors? ❑Outdoors?
■ anf001ap.doc•10/02 Asbestos Notification Form•Page 1 of 3■
Commonwealth of Massachusetts ■
I 100199796
` Asbestos Notification Form ANF-001 Decal Number
A. Asbestos Abatement Description (cont.)
13. Total amount of each type of Asbestos Containing Materials(ACM)to be removed, enclosed, or
encapsulated:
410 10
a.Total pipes or ducts(linear ft) o. I otal other su aces square
c.Boiler,breaching,duct,tank
surface coatings Lin.ft. Sq.ft. d.Insulating cement Lin.ft. Sq.ft.
e.Corrugated or layered paper 410
f.Trowel/Sprayer coatings
• pipe insulation Lin.ft. Sq.ft. Lin.ft. Sq.ft.
g.Spray-on fireproofing LinLin� SgSq� h.Transite board,wall board Lin.
i.Cloths,woven fabrics j.Other,please specify:
Lin S� Lin.ft. S .ft.
. k.Thermal,solid core pipe
insulation Lin.ft. Sq.ft. I.Specify
14. Describe the decontamination system(s)to be used:
AS REQUIRED
15. Describe the containerization/disposal methods to comply with 310 CMR 7.15.and 453 CMR
6.14(2) (g):
AS REQUIRED
16. For Emergency Asbestos Operations, the DEP and DOS officials who evaluated the emergency:
a.Name of DEP Official b.Title
c.Date mm/dd/ of Authorization d.DEP Waiver#
e.Name of DOS Official f.DOS Official Title
N g.Date(mm/dd/yyyy)of Authorization h.DOS Waiver#
�
_0 17. Do prevailing wage rates as per M.G.L. c. 149, §26, 27 or 27A—F apply to this project? ❑Yes❑✓ No
B. Facility Description
�N
=0 1. Current or prior use of facility: RESIDENCE
�o
2. Is the facility owner-occupied residential with 4 units or less? ❑✓ Yes ❑No
SAME
3' a.Facility Owner Name � b.Address
o c.City/Town d.Zip Code e.Tele hone Number area code and extension
u- 4.
a.Name of Facility Owner's On-Site Manager b.On-Site Manager Address
Z
�Q c.Cityffown d.Zip Code e.Telephone Number(area code and extension)
■ anf001 ap.doc•10/02 Asbestos Notification Form•Pa a 2p of 3■
- Commonwealth of Massachusetts
k` 100199796
Asbestos Notification Form ANF-001 Decal Number
B. Facility Description (cont.)
5' a.Name of General Contractor b.Address
c.City/Town d.Zip Code e.Telephone Number area code and extension
f.Contractor's Worker's Comp.Insurer q.Policy Number `,. h.Ez ,Date mm/dd/ i
6. What is the size of this facility?
a.Square Feet b.Number of floors
C. Asbestos Transportation and Disposal
x 1. Transporter of asbestos-containing material from site to temporary storage site (if necessary):
NESM, LLP
Note:Transfer a.Name of Transporter b.Address
Stations must
comply with the c.City/Town d.Zip Code e.Telephone Number
Solid Waste
Division 2. Transporter of asbestos-containing waste material from removal/temporary site to final disposal site:
Regulations 310
CMR 19.000 RED TECHNOLOGIES
a.Name of Transporter b.Address
c.City/Town d.Zip Code e.Telephone Number
3.
a.Refuse Transfer Station and Owner b.Address
c.Citvrrown d.Zip Code e.Telephone Number
4. IMINERVA ENTERPRISES INC
a.Final Disposal Site Location Name b.Final Disposal Site Location Owner's Name
9000 MINERVA ROAD I IWAYNESBURG
c.Final Dis osal Site Address d.City/Town
OH 144688
9_M e.State f.Zip Code g.Telephone Number
_o
D. Certification
�N
The undersigned hereby states, under the IKEN FURTNEY
�o penalties of perjury, that he/she has read the a.Name b.Authorized Signature
�o Commonwealth of Massachusetts regulations 1 15/27/2014
for the Removal, Containment or c.Position/Title d.Date mm/dd/
Encapsulation of Asbestos,453 CMR 6.00 and
310 CMR 7.15, and that the information I I NESM, LLP
contained in this notification is true and correct e.Telephone Number f.Re resentin
o to the best of his/her knowledge and belief.
o q.Address
�Z h.City/Town i.Zip Code
anf001ap.doc•10/02 Asbestos Notification Form•Page 3 of 3
�XISiIN�- �SiC� i31S-1'�1�M
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L 0 CATION SEWAGE PERMIT NO.
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VILLAGE
I N S T A LLER'S NAME i ADDRESS
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BUILDER OR OWNER
STERHEN P. SPEN�1 N H�vEtrZ
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DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED ��� s�
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BOARD OF HEALTH
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��� Disposal���«��lxr«�tweu� �4�� xwm� l Works T«wnptrur4mwn 11a»x»it
�
^ ^^ is hereby made-for u Permit to Construct or Repair an Individual Scwu8c I6upnou
System
'----'--------'___'--_--_'--________-__---_-.
----_-~�.
W Address'---~_�'. '~~---'---'---~'^-'------_'
' znsmn= Address
Ivoec� S�� {��
'' - �
Dwelling of Bedrooms Attic - Grinder ( )
Other--Type of Building ............................ No of persons---.'_---_'—.. Showers ( ) Cafeteria
( )
c� Other .—'-----------.----..---__--.-_---._'-----.-.----_----_-------------
� Design Flow'-.----.����---------gallons per person per day. Total daily flow............................................galloon. �
Septic Tank--Liquid Length................ Width................ Diameter................ Depth................
Disposal Trench--No.-'=1------------ Width-.��............ Total Length.................... Total area.----'---'-og f t. ?
Seepage Pit No'------.. Diameter.................... Depth hdmvinlot--_------' Iotu leaching area.-..---.---ml. f t.
Z Other Distribution box ( ) Dosing tank ( )
~~ Percolation Test Results Performed bv.......................................................................... Date........................................
1.4
Test Pit No. l.------.mduutesperinch Depth of Test Pit.---.----- Dcpth tn ground water---_--'_..
44 Test Pb No. 2................minutes per inch Depth of Test PiL.-------- Depth to ground water........................
........................... ...............................................
.........................................................................................................................................................................................................
the provisions of TL ITL ILj 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
�
operation until a Certificate of Compliance ha&4ieen-wsi�ed b h b
< ac.l..by e I oFo ea t
Date
Date
I Date
Date
*�|
/
----------------------______________ _
No., ............__...... FEs..............................
iYrE G�SiIIMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.-- .... ................OF.............................-........------------------.......----------.................
Appliratinn for Uhipos al Works Tonstrurtinn rumit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:, _ j'J
................_. .._. ..._...............-•----............. ----•••---.....................--•---•..... -----•------.............................
Location Address �j or t No.
...............�• .. f• ...1......7. «...:._..__.._ ..... ......�..T.,..._...... _.........___ _.._.._... ....q.-----.................................
y'Owner Address
`-:--- �--- .:.............. ....... .............................
..............f!.. i1..r .............................................
Installer Addres
Type of Building Size Lot............................Sq. feet
1—, Dwelling—No. of Bedrooms........7..............................Expansion Attic ( ) - Garbage Grinder ( )
Other—T e of Building No. of persons............................ Showers —
a YP g ---------------------------- P ( ) Cafeteria ( )
Otherfixtures ......................................................I-•-•--......-••••--•-•---•••-•-------•---••••-•-••------••--•----•......••---•--•........-•---•
W Design Flow...............:�2....................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid ca acit}t _galloriis,, Length................ Width................ Diameter................ Depth................
x Disposal Trench—No. __rl............ 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........................................
a
a Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
(s, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
�+ ---•----------------------------------------- ...........................................
�
O Description of Soil------.... --------- � -1"A+ .:.......spa, �t�!�_ ......................................................, -��
x
U ----------------------•--------•-••---•-•-----•----•-•-----------••-----••-•----••---...---•-•-----•---...-•-------------------•-------------------------------------•----
W
----•------•-- --------------------------------------------------------------------•----•----------------------------------------------------------.
V Nature of Repairs or Alterations—Answer when applicable-------A-p_o�`_______ t?�?�:?____'`:�.!�'.±� 0 4 ..Z%A K,
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
\ the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliancethas-beert-issued by the board of health.
---'__'•_'_•...:r:.��c.,. � _ '
-Signed._ .. _ •_•�)_•s-..---•-...= Date
Application Approved By................... "
. ............. Date
Application Disapproved for the following reasons-------------------- ----•----•-------------------------------------------------•-• -----•---••--•--••-
..............................................---•-----------•-••-----------------.....--------...--••--...............................................................................................
Date
PermitNo......................................................... Issued......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS '
BOARD OF HEALTH
................................
Trrfifiratr of (9outplitanrr
THIS IS-TO CERTIFY, That:the-Iudiwdual Sewage Disposal System constructed ( ) or Repaired ( )
•-•_..
t Ii{s,ller
has been installed in accordance with the provisions of TIT1k 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No..............:. .?..5 4-__-_
PP P �..- ._ - dated-- --------------------------------------------•
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE........................... 4 = . - ... Inspector.....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BQAR. OF HEALTH
No.... :.:... FEE..�•-•••.............•
RaposFal.- orks Tonstrurtion ramit
Permission is hereby granted =� -------------------------•----•------•----•••--•-------••-••-----•---•••••--•---•••-•••-•-•--•-••-•----....................
to Construct ( ) or,Repair ( ) an Individual Sewage Disposal System
aa:
at No.............
....................vv5 c,
--••--•-•-------•.............•---•-..........-------•-••••...
Street
as shown on the application for Disposal Works Construction Permit No..................... Dated..............._..........................
Board of Health
DATE................................................................................
FORM 1255 A. M. SULKIN..INC.. BOSTON