HomeMy WebLinkAbout0020 MAPLE AVENUE - Health 20 Maple Avenue
Centerville P
A 207 148
No. 4210 1/3 ORA
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Commonwealth of Massachusetts
M Title 5 Official Inspection Form
1` Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
11,
20 Maple Ave, Centerville, MA
Property Address
Kevin M &Linda G McElligott 3660 Executive Drive
Owner Owner's Name
information is required for every palm Harbor FL 34685 6/24/2020
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. Inspector Information l� 5
filling out forms
on the computer,
use only the tab Armando Pantoja
key to move your Name of Inspector
cursor-do not Accu Sepcheck Sae fA4v- i�J
use the return Company Name
key.
17 de Drive
Company
o
� Companyparry Address
South Dennis MA 02660
City/Town State Zip Code
508-385-5891 S114296
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above;the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
II ,
aimt. 7/7/2020
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP) within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
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
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
u
20 Maple Ave, Centerville, MA
Property Address
Kevin M &Linda G McElligott 3660 Executive Drive
Owner Owner's Name
information is required for every Palm Harbor FL 34685 6/24/2020
page. CitylTown 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:
NO RECOMMENDATION FOR PUMPING.
2) System Conditionally Passes:
❑ One or more system components as described in the "Cond' 'onal Pass"section need to be
replaced or repaired. The system, upon completion of the placement or repair, as approved by
the Board of Health,will pass.
Check the box for"yes", "no"or"not determined" (Y, N, )for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or a septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfilt tion or tank failure is imminent. System will pass
inspection if the existing tank is replaced with complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspect' if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank i ess than 20 years old is available.
❑ Y ❑ N ❑ (Explain below):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�n
20 Maple Ave, Centerville, MA
Property Address
Kevin M &Linda G McElligott 3660 Executive Drive
Owner Owner's Name
information is required for every palm Harbor FL 34685 6/24/2020
page. City/Town State Zip Code Date of Inspe ion
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass wit Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or breakout or high static w er level in the distribution box due
to broken or obstructed pipe(s}or due to a broken, settled r uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ ❑ 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 m re than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if( th approval of the Board of Health):
❑. broken pipe(s) are re aced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is rem ed El [IN ❑ ND (Explain below):
3) Further Evaluation s Required by the Board of Health:
❑ Conditions ex' t 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
Commonwealth of Massachusetts .
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
20 Maple Ave, Centerville, MA
Property Address
Kevin M &Linda G McElligott 3660 Executive Drive
Owner Owner's Name
information is required for every Palm Harbor FL 34685 6/24/2020
page. City/Town State Zip Code Date of Inspecti
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 etland or a salt marsh
b. System will fail unless the Board of Health (and Public ter Supplier, if any)
determines that the system is functioning in a manner th protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption Sys m (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surf a water supply.
❑ The system has a septic tank and SAS and the S S is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and t SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS an 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 a lysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and t presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that n 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.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
r= Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
>r n
u
20 Maple Ave, Centerville, MA
Property Address
Kevin M & Linda G McElligott 3660 Executive Drive
Owner Owner's Name
information is required for every Palm Harbor FL 34685 6/24/2020
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/Z day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory, for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303,therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must sere 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 th- ollowing, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet a surface drinking water supply
❑ ❑ the system is within 2 feet of a tributary to a surface drinking water supply
❑ ❑ the system is to ed in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWP r 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
c Commonwealth of Massachusetts
r� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
20 Maple Ave, Centerville, MA
Property Address
Kevin M & Linda G McElligott 3660 Executive Drive
Owner Owner's Name
information is required for every Palm Harbor FL 34685 6/24/2020
page. CitylTown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes"to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat.under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes" or"no"for each of the following for all inspections:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18
Commonwealth of Massachusetts
r� Title 5 Official Inspection Form
ii
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
20 Maple Ave, Centerville, MA
Property Address
Kevin M &Linda G McElligott 3660 Executive Drive
Owner Owner's Name
information is required for every palm Harbor FL 34685 6/24/2020
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): NA Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Description:
SYSTEM CONSISTS OF ONE 1000 GALLON SEPTIC TANK AND ONE 6'x6' LEACHING PIT WITH
2' STONE.
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)): 7 GPD
Detail:
2019: 4000 G ; 2018: 1000 G
Sump pump? ❑ Yes ® No
Last date of occupancy: 6/24/2020
Date
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18
I
Commonwealth of Massachusetts
M Title 5 Official Inspection Form
�- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
20 Maple Ave, Centerville, MA
Property Address
Kevin M &Linda G McElligott 3660 Executive Drive
Owner Owner's Name
information is palm Harbor FL 34685 6/24/2020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Ga ns 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, dis/schargedht?
h t
Industrial waste holdi ❑ Yes ❑ No
Non-sanitary waste dile 5 system? ❑ Yes ❑ No
Water meter readingsLast date of occupanDate
Other(describe belo
3. Pumping Records:
Source of information: PUMPED IN 2003 PER HEALTH DEPARTMENT
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
r
Commonwealth of Massachusetts
M Title 5 Official Inspection Form
1- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
20 Maple Ave, Centerville, MA
Property Address
Kevin M &Linda G McElligott 3660 Executive Drive
Owner Owner's Name
information is required for every palm Harbor FL 34685 6/24/2020
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System: O QK
® Septic tank_dis�tr-bejc, 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:
AGE: 45 YEARS ; INSTALLED 1975, BUILDING CONSTRUCTION SOURCE:
ASSESSING
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
�2
Depth below grade: feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: >10
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
NO EVIDENCE OF LEAKS
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
20 Maple Ave, Centerville, MA
Property Address
Kevin M & Linda G McElligott 3660 Executive Drive
Owner Owner's Name
information is required for every Palm Harbor FL 34685 6/24/2020
page. CityTTown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank (locate on site plan):
Depth below grade: 0.5
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: APP 8'X6'X5', 1000 GAL
Sludge depth: 2,.
Distance from top of sludge to bottom of outlet tee or baffle
32"
Scum thickness
0"
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
14"
How were dimensions determined? CORETAKER
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage; etc,):
PUMPING NOT RECOMMENDED. HAS NO INLET TEE, HAS CONCRETE WALL BAFFLE.
OUTLET TEE IS CONCRETE. LIQUID LEVEL IS 48"AT OUTLET INVERT. NO EVIDENCE OF
LEAKAGE.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
20 Maple Ave, Centerville, MA
Property Address
Kevin M & Linda G McElligott 3660 Executive Drive
Owner Owner's Name
information is required for every palm Harbor FL 34685 6/24/2020
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 o affle
Distance from bottom of scum to bottom of tlet tee or baffle
Date of last pumping:
Date
Comments (on pumping recommend ions, inlet and outlet tee or baffle condition, struc ral integrity,
liquid levels as related to outlet inv , evidence of leakage, etc.):
8. Tight or Holding Tank (tank must be pumped at time of inspectio (locate on site plan):
Depth below grade: NOT APPLICABLE
Material of construction:
❑ concrete ❑ metal ❑ fiberglas ❑ polyethylene El other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
>r 9
20 Maple Ave, Centerville, MA
Property Address
Kevin M &Linda G McElligott 3660 Executive Drive
Owner Owner's Name
information is required for every Palm Harbor FL 34685 6/24/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank (cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working er: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping con ct (required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box (if present mu be opened) (locate on site plan):
Depth of liquid level above outlet invert N/A
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
NO DISTRIBUTION BOX.
t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
c °y Commonwealth of Massachusetts
M Title 5 Official Inspection Form
�- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
20 Maple Ave, Centerville, MA
Property Address
Kevin M &Linda G McElligott 3660 Executive Drive
Owner Owner's Name
information is required for every Palm Harbor FL 34685 6/24/2020
page. City/Town State Zip Code Date of Insp tion
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: /pumps
❑ No*
Alarms in working order: ❑ No*
Comments (note condition of pump chamnces, etc.):
* If pumps or alarms are not in rking order, system is a conditional pass.
11. Soil Absorption System ( S) (locate on site plan, excavation not required):
If SAS not located, expl In why:
Type:
® leaching pits number: 1, 6'X6'W 2'
STONE
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
1- 4i-$% Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
20 Maple Ave, Centerville, MA
Property Address
Kevin M &Linda G McElligott 3660 Executive Drive
Owner Owner's Name
information is required for every Palm Harbor FL 34685 6/24/2020
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 6'x6' LEACHING PIT WITH 2' STONE. LIQUID LEVEL IS 0"WITH LIGHT STAINLINE AT
PIPE ENTERING PIT. MODERATE STAIN LINE AT T ABOVE PIT BOTTOM. NO SIGNS OF
HYDRAULIC FAILURE.
12. Cesspools (cesspool must be pumped as part of inspection) (locate on s' 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 f hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/2612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
20 Maple Ave, Centerville, MA
Property Address
Kevin M &Linda G McElligott 3660 Executive Drive
Owner Owner's Name
information is required for every palm Harbor FL 34685 6/24/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy (locate on site plan):
Materials of construction: NOT APPLICABLE
Dimensions NOT APPLICABLE
Depth of solids NOT APPLICABLE
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
NOT APPLICABLE
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
20 Maple Ave, Centerville, MA
Property Address
Kevin M &Linda G McEliigott 3660 Executive Drive
Owner Owner's Name
information is required for every Palm Harbor FL 34685 6/24/2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
W
CIO
I I
PORCH
l- - -- - - — - - -�
DlsrA��
❑ A1=18' 81- No"
z O R3-23' 83=2q.s�
o
3 A2= 0 g2" 28�
AY =32 , 1314 3 �.
Y CO)
t5insp.doe•rev.7/26/2018 Title 5 Official Inspectlon Form:Subsurface Sewage Disposal System•Page 16 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
M �
1- o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
20 Maple Ave, Centerville, MA
Property Address
Kevin M &Linda G McElligott 3660 Executive Drive
Owner Owner's Name
information is required for every Palm Harbor FL 34685 6/24/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: 24
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:
GOOGLE MAPS, CAPE COD COMMISSION GROUNDWATER CONTOUR MAP,
FRIMPTER.
You must describe how you established the high ground water elevation:
SITE IS 4V ASL W A GROUNDWATER CONTOUR OF 12'AND A MAX RISE OF<5' FOR MIW29A.
GRADE TO SAS BOTTOM IS 8'. SEPARATION MATH: 41-(12+5+8)=16'
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 20 Maple Ave, Centerville, MA
Property Address
Kevin M &Linda G McElligott 3660 Executive Drive
Owner Owner's Name
information is required for every Palm Harbor FL 34685 6/24/2020
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 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
r
�1
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL P 01ED
SEP 0 4 2003
kit
TOWN OF BARNSTABLE
HEALTH DEPT.
TITLE 5
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 20 Maple Avenue
Centerville. MA 02632 (BAR
Owner's Name: Patti Sterns&Letha McElligott
Owner's Address: PARCEL,
LOT
Date of Inspection: August 14, 2003 '
Name of Inspector: (Please Print) James M. Ford
Company Name: James M. Ford
Mailing Address: P.O. Box 49
Osterville,MA 02655-0049
Telephone Number: (508)862-9400
CERTIFICATION STATEMENT
1 certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
✓ Passes
Conditionally Passes
N urther Evaluation by the Local Approving Authority
Fail
Inspector's Signature: Date: August 30, 2003
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Pranwrty Addre-u_ 20 Maple Avenue_._
Page 2 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 20 Maple Avenue
Centerville, AM
Owner: Patti Sterns&Letha McEllikott
Date of Inspection: Au ust 14, 2003
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
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.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please
explain.
The septic tank is metal and over 20 years 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.
ND explain:
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
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
fir._. ...i. , _ .1 n i I'll
Page 4 of 1 I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 20 Maple Avenue
Centerville, MA
Owner: Patti Sterns&Letha McElligott
Date of Inspection: August 14, 2003
D. System Failure Criteria applicable to all systems:
You must indicate either"yes"or"no"to each of the following for all inspections:
Yes No
✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/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 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 coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
No (Yes/No)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 System:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd-
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)
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.
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OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 20 Maple Avenue
Centerville, MA
Owner: Patti Sterns&Letha McElligott
Date of Inspection: August 14, 2003
Check if the following have been done: You must indicate"yes"or"no"as to each of the following:
Yes No
✓ _ Pumping information was provided by the owner,occupant,or Board of Health
✓ Were any of the system components pumped out in the previous two weeks?
✓ Has the system received normal flows in the previous two week period ?
✓ Have large volumes of water been introduced to the system recently or as part of this inspection ?
✓ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
✓ Was the facility or dwelling inspected for signs of sewage back up?
✓ Was the site inspected for signs of break out?
✓ Were all system components,excluding the SAS, located on site?
✓ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum ?
✓ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes No
✓ Existing information. For example,a plan at the Board of Health.
✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [310 CMR 15.302(3)(b)].
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Page 6 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 20 Maple Avenue
Centerville, MA
Owner: Patti Sterns&Letha McElligott
Date of Inspection: August 14, 2003
FLOW CONDITIONS
RESIDENTIAL
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
Number of current residents: 1
Does residence have a garbage grinder(yes or no): Yes
Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required]
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings, if available(last 2 years usage(gpd)): Unavailable
Sump Pump(yes or no): No
Last date of occupancy: Currently occupied
COMMERCIAL/MUSTRIAL
Type of establishment:
Design flow(based on 310 CUR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no)
Non-sanitary waste discharged to the Title 5 system (yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: Unavailable
Was system pumped as part of the inspection(yes or no): 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)
Tight Tank Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Nov. 8174-per as built card
Were sewage odors detected when arriving at the site(yes or no): No
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Page 7 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 20 Maple Avenue
Centerville, MA
Owner: Patti Sterns&Letha McElligott
Date of Inspection: August 14, 2003
BUIELDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: _cast iron _40 PVC _other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: 10"
Material of construction: ✓ concrete _metal _fiberglass _polyethylene
_other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1000 gal.
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 30"
Scum thickness: 6"
Distance from top of cum to top of outlet tee or baffle: 8"
Distance from bottom of scum to bottom of outlet tee or baffle: 10"
How were dimensions determined: Measuring stick
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
Tees were present. The liquid level was even with the outlet invert. There did not appear to be any signs of leakage. Recommend
pumping every two years for maintenance.
GREASE TRAP: None (locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _fiberglass _polyethylene _other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
7
Page 8 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 20 Maple Avenue
Centerville, MA
Owner: Patti Sterns&Letha McEllixott
Date of Inspection: August 14, 2003
TIGHT or HOLDING TANK: None (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/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: None (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
PUMP CHAMBER: None (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no)
Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.):
8
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Page 9 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 20 Maple Avenue
Centerville, MA
Owner: Patti Sterns&Letha McElligott
Date of Inspection: August 14, 2003
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
✓ leaching pits,number: I -6'x 6'(1000 gal.)
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.):
The pit had 2' of water on the bottom. There did not appear to be any signs of failure. The cover was 20"below grade.
CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth -top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
PRIVY: None (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.):
9
Page 10 of 1 I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 20 Maple Avenue
Centerville, MA
Owner: Patti Sterns&Letha McElligott
Date of Inspection: August 14, 2003
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
I
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Page I 1 of 1 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 20 Maple Avenue
Centerville, MA
Owner: Patti Sterns&Letha McElligott
Date of Inspection: August 14, 2003
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 25 +/- feet
Please indicate (check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record - If checked, date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
✓ Checked with local Board of Health-explain: topographic and water contours maps
Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Using the Barnstable topographic map and the Cape Cod Commission water contours map,the maps were showing approximately
25'+/-to ground water at this site.
This report has been prepared and the system inspected and passed as of the date of inspection. This report is
not a warranty or guarantee that the system will function properly in the future. There have been no warranties
or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report.
11
LOCt�T10N ' ��°y'7/ SEWACaE PERMIT ►CIO
IKISTALLER�5 1 &ME ADDRESS
�tIV � - - - - - - -
BUILDER 5 Q &MF- ADDRESS
Do►TE PERNAIT ISSUED
DATE COMPLI &&ICE ISSUED :
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))TOWN OF BARNSTABLE
LOCATION ao MAOL. SEWAGE #
VILLAGE" Ctn?tr%/J ASSESSOR'S MAP & LOT AQ7 149f
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY I M
LEACHING FACILITY: (type) 6;x(I P' r (size) UUb GAl.
NO.OF BEDROOMS P BUILDER OR OWNER i, Mnn�S
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) (+ Feet
Furnished by�/I T tt,T+u^ t'd
044k
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ao a.8'
a 3a 38'
+90
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THE COMMONWEALTH OF MASSACHUSETTS
BOAR® HEA T.H.-----._OF...... .... .. . ... .....
2.® Appliration -for Di_q uiittl Works Towitrurtion Vrrmit.
�- Application is hereby made for a Permit to Construct (/4"Or Repair ( ) an Individual Sewage isposal
System at
Lo atto Addre or Lot No.
--- - ----
��
_� �� .fie--- - -�--..--- ------- ----------------------------------?�/� .................... ...-----------------.
Owner / -
Address
.......
-
Installer Address
d Type of Building Size Lot_-an?f_7.�!d......Sq. feet
U Dwellin a g—No. of Bedroom ............. _ __________________________Expansion Attic ( ) Garbage Grinder (f'G)
a ?!!Ct Other—Type of Building V - No. of persons__________________________- Showers (jr) — Cafeteria ( )
dOther fixtures ------- -------------------------•--------------•-•-------------------------------------_..._-----------_-------•--
t W Destgn Flow..........��___---------------------------gallons per person per day. Total daily flow..........3-�..__0_0-----------------....gallons.
WSeptic Tank Liquid capacity 0_0-.O.gallons Length---------------- Width---------------- Diameter__--___-_-._____ Depth................
x Disposal Trench—No_____________________ Width..................... Total Length---------------------Total leaching area------------.-------sq. ft.
Seepage Pit No.___._._. _.____ Diameter_..I�M.0._. Depth—below inlet. _P _. Total leachingsq. it.
{ f stC�,y area s
Z Other Distribution box ( ) Dosing tank
Percolation Test Results Performed by-----------------------------------------------........................... Date-------____-___--_---------_---------...
a
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water-_-___________-__--_----
L14 Test Pit No. 2....._..........minutes per inch Depth of Test Pit.................... Depth to ground water......................
dl 1 --• • = -- -------
--- - -------
Descri Description of Soil____.._-__ __.._.- c --_ _J'---
P --
U X'�s °
i
--------- -------------------- ----------------------------------------------------------------------------------------------------------•-------------------------------...•. ---------------------
U Nature of Repairs or Alterations—Answer when applicable........................................................_.......................................
-----------------------•-----------------------------------------------------------------•-------------------•----------=------........................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article NI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued the board of health.
J .
Sign .-_... L ............. I-----
- Date
A lication Approved B � ................ -'r c�-...-_ ,�.
PP PP Y
Date
Application Disapproved for the following reasons:.________________________________________________________________
W
F---------------------
Permit No. .:____
- -- 8 •- Date
_ - - ++�+ Issued -- ---•------
ate
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........ ..............OF...........:,:. . ... .. .......... ............
�rxttfrl��le�.>Qf � �Dlm�rli�nrr
T1 I TO CERTIFY That t ndividual Sewage Disposal System constructed ( <or Repaired ( )
by....- (/ - ---- -----. ------------ -- ----- ------- ................................... - --- ---
Installed
7 N
at...^. ll'?.G i . - ---s -R._._ yt
has bee insta ed in accordance with'& provisions of Article XI'of The ate Sar�it v Code as described ii}the
application for Disposal Works Cons�R'TIFICATE
ction Permit'No------------------_---------------------- dated..,./.k..y...�.. 7.41_.__.____.........
THE ISSUANCE OF THIS C� SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACT®RY.
DATE ; ------------- ----------------- " Inspector..................................................................................
THE ,COMMONWEALTH OF,MASSACHUSETTS
BOARD,, OF HEALTH
:....` ..........O F.......-
VVV ..
NO--�y-5------ FEE.. 1.�.._F � may,
iifr nt rrmit
r
e \ Permission s hereby granted.. -----
to Construe ( or Rep it ( , an ndividual wag spo ystem
at No. J 71. .... ----So,
as shown on the application for Disposal Works Construction PoMiti N . . -.-, ------- Dated..../-►...! - •.7�/.........
;.� /
..i �# e h.DATE----�/..-------•------ ----- -.------- ........................................
FORM 1255 HOBBS &.WARREN. INC., PUBLISHERS
i
" THE COMMONWEALTH OF MA,SSACH!SETTS
BOARD OF HEA TH
e •' ... s
.� Iir tine -fur Dispos; I Works Tonstrurtiou• Vrrmit
Application is hereby made_foT a Permit to Construct,( , r r Repair ( ) an Individual Sewage isposal
System at `
Lo do Addre or Lot No.
Owner Address
nstal er �:"" Address
UType of Building ` Size Lot__�,.Z.__7.aQ------Sq. feet
,-� Dwelling—No. of Bedrooms............... ________ Expansion Attic ( ) Garbage Grinder
CL4 Other—Type of Building _VA4X 1._-V&-Nd. of persons____________ ____________ Showers (x) — Cafeteria ( )
Otherfixtures -------------------------------------------- ------------------------------------------------------------ -------------------....-----------------
W Design Flow.........0.45 _____..................gallons per person per day, Total daily flow----------3- QC2___________-_--.--:gallons.
R; Septic Tank J-Liquid capacit�0_QO.gallons Length------------- Width................ Diameter_-----_-..-_-__ Depth---_----------
Disposal Trench—No- ____________________ Width--_---------------- Total Length------------_------ Total leaching area---------------_-----Sq. ft.
Seepage Pit No........I.......... Diameter.__IDQ.G?... Depth below inlet__i�-Ia
/� ___ Total leaching area------------------ It.
z Other Distribution box ( ) Dosing tank ( ) -0 4- 11— /-
aPercolation Test Results Performed by........................................................................... Date----------------------------------------
Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water..------_-_--------...
G% Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water__.-_._.___--_--_-__-.-.
o _ ..� - i
el
----------------
Description of Soil--- P`I - -- ---� --- - ------� �„ `-- �
W
U Nature of Repairs or Alterations—Answer when applicable........_................_-------------------------------------__------_-_-......_._._...........
-------------------------------------------- -------------------------------------------------•----------------------------------------------------- '--- ---------
-•F
Agreement: t r 2
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System�in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued ky the board of health.
. Sign
to
Application Approved By--------_ _ �*' 7
... ...
Date
Application Disapproved for the following reasons_________________________________________________________________________________________________________________
--------------------------------------------- ...........=-..............................................................................................................................................
Date
PermitNo......................................................... Issued.:------------------------------•=--------------._....._
Date
THE FOLLOWING
IS/ARE THE BEST
IMAGES FROM POOR
QUALITY ORIGINALS)
I M ^C&L
DATA
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