HomeMy WebLinkAbout0035 MASTHEAD LANE - HealthFEA
MASTHEAD LANE, CENTERVILLE
193 063
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IN
UPC 12543
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HASTINGS,Mll
Commonwealth of Massachusetts
Executive Office of Enviromnental Affairs
Dept. of Environmental Protection
One winter Street Boston Ma. 02108 .Dol Graci
D.E.P. Title
V Septic hlspector
P.O. Box 2119
Teaticket, MA 02536
WILLIAM F.WELD (508) 564-6813
Governor
ARGEO PAUL CELLUCCI
Lt.Governor
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 35 MastheadX.Centerville Lot 27 Address of Owner:
Date of Inspection:7/23/97 (If different)
Name of Inspector: John Graci Villa
I am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000)
Company Name,Address and Telephone Number:
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
X Passes This inspection is based on criteria defined in Title V
Conditionally as e5 code 310 CMR 15.303.My findings are of how the system is
perrorminq at the time of the inspection.My inspection does
Needs Furt r eluation By the Local Approving Authority not Imply any warranty orquaranteeof the longevityofthe
Fails septic system and any of its components useful life.
Inspector's Signature: Date: 8/19197
S
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspections. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit
the report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority.
8 8
INSPECTION SUMMARY:
Check A, B,C, or D: � A �L�^£��� �
A) SYSTEM PASSES: (/�+ 2
X 1 have not found any information which indicates that the system violates any of the failure criteria T 4/ 6 1 1
M
defined
as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. p FPjTABlF99
B) SYSTEM CONDITIONALLY PASSES: 4*
_One or more system components need to be replaced or repaired. The system, upon completion E y
of the replacement or repair,passes inspection.
Indicate yes, no,or not determined(Y, N,or ND). Describe basis of determination in all instances. If "not determined", explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection; or
the septic tank,whether or not metal, is cracked,structurally unsound, shows substantial infiltration or exfiltration,or tank
failure is imminent.The system will pass inspection if the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
(revised 04127197)
One Winter Street • Boston,Massachusetts 02108 9 FAX(617)556-1049 • Telephone(617)292-5500
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 35 Masthead Rd.Centerville Lot27
Owner: Ville
Date of Inspection:723/97
— Sew.aae backup or.breakout.or hiah.static water level observed.in.the distribution box is due to a broken.
or obstructed pipe(s)or due to broken, settled or uneven distribution box.The system will pass inspection if
(with approval of the Board of Health). Describe observations:
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
—The system required pumping more than four times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the
system is failing to protect the public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS
NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER, IF APPROPRIATE)DETERMINES
THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
— The system has a septic tank and soil absorption system and is within 100 feet to a
surface of water supply or tributary to a surface water supply.
— The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply well.
— The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
— The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that.
the well is free from pollution from that facility and the presense of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method usedto determine distance (approximation not valid)
3)Other
D] SYSTEM FAILS:
You must Indicate either"Yes"or"No"as to each of the following:
I have determined that the system violates one or more of the following failure criteria as defined in
310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be
contacted to determine what will be necessary to correct the failure.
Yes No
_ — Backup of sewage in facility or system component due to an overloaded or clogged SAS or
cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters rhiP to an overloaded or cloggPri
cesspool.
SAS is in hydraulic failure.
(revised 0427/97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 35 Masthead Rd.Cerderville Lot27
Owner: vela
Date of Inspection:7/23/97
D] SYSTEM FAILS(continued)
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 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Numbers of times pumped
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
— Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
You must indicate either"Yes"or"No"as to each of the following:
The following criteria apply to large systems in addition to the criteria:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
Yes No
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)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further Information.
(revised 04/27/97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECLIST
Property Address: 35 Masthead Rd.Centerville Lot27
Owner: villa
Date of Inspection:7l23197
Check if the following have been done:YOU must indicate either"Yes"or"No"as to each of the following:
Pumping information was requested of the owner,occupant, and Board of Health.
x None of the system components have been pumped for at least two weeks and the and the system has been receiving normal
— — flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
inspection.
X — As built plans have been obtained and examined. Note if they are not available with N/A.
X — The facility or dwelling was inspected for signs of sewage back-up.
X — The system does not receive non-sanitary or industrial waste flow.
__X_ — The site was inspected for signs of breakout.
X All system components,excluding the Soil Absorption System,have been located on the site.
X The septic tank manholes were uncovered,opened, and the interior of the septic tank was inspected
— — for condition of baffles or tees,material of construction,dimensions, depth of liquid, depth of sludge, depth of scum.
x _ The size and location of the Soil Absorption System on the site has been determined based on
The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of
Sub-Surface Disposal Systens.
X Existing information. Ex. Plan at B.O.H.
X Determined in the field(if any failure criteria related to Part C is at issue, approximation of distance is
unacceptable)115.302(3)(b)J
r
(revised 04/27197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 35 Masthead Rd.Centerville Lot 27
Owner: Ville
Date of Inspection:7/23/97
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 220 g•p•d./bedroom for S.A.S.
Number of bedrooms: 2
Number of current residents: 3
Garbage grinder(yes or no): No
Laundry connected to system(yes or no): Yes
Seasonal use(yes or no): No
Water meter readings, if available:(last two(2)year usage(gpd):
n/a
Sump Pump(yes or no): No
Last date of occupancy: n/a
COMMERCIAL/INDUSTRIAL:
Type of establishment: n/a
Design flow:U gallons/day
Grease trap present:(yes or no) No
Industrial Waste Holding Tank present: (yes or no) No
Non-sanitary waste discharged to the Title 5 system: (yes or no) No
Water meter readings, if available: n/a
Last date of occupancy: n/a
OTHER: (Describe) n/a
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System has not been pumped in the last year.
System pumped as part of inspection:(yes or no)Yes
If yes,volume pumped: 1800 gallons
Reason for pumping: Maintenance.
TYPE OF SYSTEM
X Septic tank/distribution box/soil absorptions system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) ( if yes, attach previous inspection records,if any)
I/A Technology etc. Copy of up to date contract?
Other:
LAPPROXIMATE AGE of all components,date installed(if known)and source information:
ge odors detected when arriving at the site: (yes or no) No
o4/27/97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 35 Masthead Rd.Centerville Lot 27
Owner: Villa
Date of Inspection:7/23/97
SEPTIC TANK: x
(locate on site plan)
Depth below grade: 6"
Material of construction:x concreate_metalFRP Polyethylene_other(explain)
If tank is metal, list age 20 . Is age confirmed_by Certificate of Compliance Yes (Yes/No)
Dimensions: L 9'6'H 5'7'VV 4'10'
Sludge depth:t"
Distance from top of sludge to bottom of outlet tee or baffle: 26"
Scum thickness:t"
Distance from top of scum to top of outlet tee or baffle:6"
Distance form bottom of scum to bottom of outlet tee or baffle: 17"
How dimensions were determined: Measured
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,
evidence of leakage, etc.)
Septic tank and all components are structurally sound.Recommend pumping system every year for maintenance.
GREASE TRAP:_
(locate on site plan)
Depth below grade: We
Material of construction: concrete metal FRP Polyethylene_other(explain)
Dimensions: n1a
Scum thickness:n/a
Distance from top of scum to top of outlet tee or baffle:n/a
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
Date of last pumping,1.
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage,etc.)
n1a
BUILDING SEWER:
(Locate on site plan)
Depth below grade: t'
Material of construction:_cast iron_40 PVC_other(explain)
Distance from private water supply well or suction lin0own
Diameter: 4'
Cn/amments:(conditions of joints,venting, evidence of leakage,etc.)
(revised 04/27/97)
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 35 Masthead Rd.Centerville Lot27
Owner: Ville
Date of Inspection:7/23197
TIGHT OR HOLDING TANK:
(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_FRP_Polyethylene_other(explain)
Dimensions: n/a
Capacity: n/a gallons
Design flow: n/a gallons/day
Alarm level:_n/a Alarm in working order?_Yes No
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
n/a
DISTRIBUTION BOX: X
(locate on site plan)
Depth of liquid level above outlet invert: Liquid level with bottom of pipe.
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box etc.)
D-box is structurally sound.
PUMP CHAMBER:
(locate on site plan)
Pumps in working order:(yes or no)No
Alarms in working order(yes or no)_yes
Comments:
(note condition of pump chamber,condition of pumps and appurtenances, etc.)
n/a
(revised 04/27197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 35 Masthead Rd.Centerville Lot 27
Owner: Villa
Date of Inspection:723/97
SOIL ABSORPTION SYSTEM (SAS):X
(locate on site plan,if possible; excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
We
Type:
leaching pits, number: 1,000 gallon octagon pft
leaching chambers,number:n/a
leaching galleries, number: n/a
leaching trenches,number, length: n/a
leaching fields, number, dimensions:n/a
overflow cesspool, number:n/a
Alternate system: n/a Name of Technology:_n/a
Comments:(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
The overflow is structurally sound and functioning properly.It was 3/4 full.
CESSPOOLS:
(locate on site plan)
Number and configuration: n/a
Depth-top of liquid to inlet invert: nla
Depth'of solids layer: n/a
Depth of scum layer: n/a
Dimensions of cesspool: n/a
Materials of construction: nla
Indication of groundwater: n/a
inflow(cesspool must be pumped as part of inspection)
n/a
Comments:(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
n/a
PRIVY:
(locate on site plan)
Materials of construction: n/a Dimensions: n/a
Depth of solids: We
Comments:(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.)
n/a
(revised 0427/97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
35 Masthead Rd.Centerville Lot 27
Villa
723/97
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references, landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes into house)
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(revised 0427197) page ! of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
35 Masthead Rd.Centerville Lot 27
Villa
723/97
Depth of groundwater 12,
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from design plans on record.
Observation of Site(Abutting property, observation hole, basement sump etc.)
Determine it from local conditions
Check with local Board of Health
Check FEMA Maps
Check pumping records
Check local excavators, installers
x Use USGS Data
Describe in your own words how you established the High Groundwater Elevation.(MUST be completed)
USGS Maps and Charts
(revised 0427197) page 30 of 10
�a17
CERTIFIED SEPTIC SYSTEM REPORT
SEP 1 1995
LOCATION - WJUHDEPT.
35 MASTHEAD LANE 70=OF MUMM
CENTERVILLE, MA
MAP 193 PARCEL 063 LOT 27
PREPARED FOR
SELLER
MR. BOB LEWIS
P .O . BOX 325
GWYNN , VA 23066
BUYER
MR. RICHARD VILLA
8 CURLEW WAY
COTUIT , MA 02635
PREPARED BY
HILLIARD HILLER, JR .
P .O . BOX 250
CENTERVILLE , MA 02632
508-778-1472
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Address of property 3S h 25lff4,0 44'l-AC
owner' s name Jd/1A1
Date of Inspection
PART A
CHECKLIST
Check if the following have been done:
r/ Pumping information was requested of the owner, occupant, and Board of
Health.
e/ None of the system components have been pumped for at least two weeks
and the system has been receiving normal flow rates during that
period . Large volumes of water have not been introduced into the
system recently or as part of this inspection.
As built plans have been obtained and examined. Note if they are not
available with N/A.
c/ The facility or dwelling was inspected , for signs of sewage back-up.
L�l The site was inspected for signs of breakout.
c/ All system components, excluding the SAS , have been located on the
site .
The septic tank manholes were uncovered, •opened, and the interior of
the septic tank was inspected for condition of baffles or tees,
material of construction, dimensions, depth of liquid, depth of
sludge, depth of scum.
The size and location of the SAS on the site has been determined based
on existing information or approximated by non-intrusive methods.
r/ The facility owner (and occupants, if different from owner) were
provided with information on the proper maintenance of SSDS.
r p
. H
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION
FLOW CONDITIONS
If residential
number of bedrooms
number of current residents
--)V'_ garbage grinder, yes or no,
XC5 laundry connected to system, yes or no
_ /moo seasonal use, yes or no
If nonresidential, calculated flow:
Water meter readings, if available:
PR�s � Y Last date of occupancy
GENERAL INFORMATION
Pumping records and source of information:
mo RWoe'a �/�/1 UU�w
/y0 System pumped as part of inspection, yes or no
if yes, volume pumped
Reason for pumping:
�oc.�,os w�R� Nor /firm �ti �� i� h''r c�vii--•:� �J' avr
_ow�y�'/I S FoGGow2a d G0.•i�,,�,f/,bfJiirl.v� 1y /f/9��' ./% .q'�iri/�.�•D
Type of system
_L,,,' 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)
Other (explain)
Approximate age of all components. Date installed, if known. Source of
information:
i
/,�?77 77- 85'/
Sewage odors detected when arriving at the site, yes or no
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SEPTIC TANK: �
(locate on site plan)
depth below grade:
material of construction: //concrete metal FRP other(explain)
dimensions: ��� X
AG sludge depth
A„ distance from top of sludge to bottom of outlet tee or baffle
O 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
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles,
depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, recommendations for repairs, etc. )
7-614- 4//.y T/%'Is
Ge"'A?x 6
DISTRIBUTION BOX:
( locate on site plan)
D— depth of liquid level above outlet invert
Comments:
(note if level and distribution is equal, evidence of solids carryover,
evidence of leakage into or out of box, recommendation for repairs, etc. )
PUMP CHAMBER:
(locate on site plan)
pumps in working order, yes or no
Comments:
(note condition of pump chamber, condition of pumps and appurtenances,
recommendations for maintenance or repairs,etc. )
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SOIL ABSORPTION SYSTEM (SAS) : _
(locate on site plan, if possible; excavation not required, but may be
approximated by non-intrusive methods)
If not determined to. be present, explain:
Type
leaching pits and number
leaching chambers and number
leaching galleries and number
leaching trenches, number, length
leaching fields, number, dimensions
overflow cesspool, number
Comments:
(note condition of soil , signs of hydraulic failure, level of ponding,
condition of vegetation, recommendations for maintenance or repairs, etc. )
XA/ S/GAJ OF
CESSPOOLS ( 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 (cesspool must be pumped as
part of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding,
condition of vegetation, recommendations for maintenance or repairs, 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, recommendations for maintenance or repairs, etc. )
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SKETCH OF SEWAGE DISPOSAL SYSTEM: 3S
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100 '
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DEPTH TO GROUNDWATER
c?5,7' depth to groundwater
method of determination or approximation:
ai9h'e/sT�Q/ £ 731. 1 H
®�PfIG�/.vG S/�r,�-a %/�s.." l3onosi �/= T/�,E '�/�- T•..� /..�F 5�,�' ,Doui,r/ /=/day
1`9.31.� J U,�E /99a �i?h+t..•/ice a.�`15
571
79 -8a - 3S/ -y = aS 2 '
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
FAILURE CRITERIA
Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of
determination in all instances. If "not determined" , explain why not)
Backup of sewage into facility?
XV Discharge or ponding of effluent to the surface of the ground or
surface waters?
AIV Static liquid level in the distribution box above outlet invert?
Alfl Liquid depth in cesspool <6" below invert or available volume< 1/2 day
flow?
Required pumping 4 times or more in the last year?
number of times pumped
A� Septic tank is metal? cracked? structurally unsound? substantial
infiltration? substantial exfiltration? tank failure imminent?
Is any portion of the SAS , cesspool or privy:
below the high groundwater elevation?
;a within 50 feet of a surface water?
4V within. 100 feet of a surface water supply or tributary to a surface
water supply?
A� within a Zone I of a public well?
Ala within 50 feet of a bordering vegetated wetland or salt marsh
(cesspools and privies only, not the SAS) ?
A� within 50 feet of a private water supply well?
less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis? If the well
has been analyzed to be acceptable, attach copy of well water analysi
for coliform bacteria , volatile organic compounds, ammonia nitrogen
and nitrate nitrogen.
TOWN OF BOARD OF HEALTH
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D - CERTIFICATION
-TYPE OR PRINT CLEARLY-
PROPERTY INSPECTED
STREET ADDRESS S "S-,rll WA CCIVY-dil""rezz
ASSESSORS MAP, BLOCK AND PARCEL # I,5;,3 161G3 LoT o?7
OWNER' s NAME ISIX IWS cQh',v
PART D - CERTIFICATION
NAME OF INSPECTOR
COMPANY NAME
COMPANY ADDRESS
Street Town or City State ZIP
COMPANY TELEPHONE ( SUd ) 77� - /y�� FAX
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at
this address and .that the information reported is true , accurate , and
complete as of the time of inspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems .
Check one :
_ L�-' System PASSED
The inspection which I have conducted has"' not found any information
which indicates that the system fails to adequately. protect public
health or the environment as defined in 310 CMR 15 . 303 . Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form.
System FAILED*
The inspection which I have conducted has found that the system fails to
protect the public health and the environment in accordance with Title
5 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form.
Inspector Signature Date 9 A� 5.s—
One copy of this certification must be provided to the OWNER, the BUYER
(where applicable ) and the BOARD OF HEALTH.
* If the inspection FAILED, the owner or operator shall upgrade the system
within one year of the date of the inspection, unless allowed or required
otherwise as provided in 310 CMR 15 . 305 .
partd.doc
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DAT E COMPLIANCE ISSUED 1 - 79 ,
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VILLAGE ASSESSOR'S MAP &LOT t�f3 GCS 2oTa7
INSTALLER'S NAME&PHONE NO. �P &ef
SEPTIC TANK CAPACITY /U:�;70 6.9 L
LEACHING FACILITY: (type) p/r (size) Gi�L
NO.OF BEDROOMS o�
-BbMDM OR OWNER �s �ai �yfft� L�cdiS
PERMIT DATE: Id-3,> -1-7 COMPLIANCE DATE: YZ/i��
Separation Distance Between the:
Maximum Adjusted Groundwater Table and 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
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HE L
.....O F........
,� lirtttivtt for Di¢pnittl Worko Tomotrurtintt f rrmit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
Syst
'�..____---- �...
Lo Addr ss or jot No.
--------- - --.---•----------------------------------------
Address
ner
Installer Address
Ty of Building Size Lot.1..5y.-9L -F.r..__.Sq. feet
U Dwelling—No. of Bedrooms.---�...................................Expansion Attic ( ) Garbage Grinder ( )
a4 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
P4Other fixtures ..ns-a-r..R ------ -----•-•.........................................................•---•--............--0-•-----•-•----•--------------
U-----------------_-------gallons per person per day. Total daily flow..--.---......R_4....--..--..-.---.--.-.gallons.
W Design Flow._.__.,,_....__ g� P P P Y• Y
WSeptic Tank—Liquid capacity/4 gallons Length................ Width.........--..... Diameter......---....... Depth....--..........
Disposal Trench—No. .................... dth--------:... Total Length__.,...... _. Total leaching area....................sq. ft.
Seepage Pit No.--- ......... �}...... ......... T�op1 leaching area. O�,F sq. ft.
Other Distribution box ( Dosing tank ( ) 0
Z Percolation Test Results Performed ------------------ Date-_:-1,-__- .........
Test Pit No. I----4.?c_niinutes per inch Dep h of Test Pit-------------------- Depth to ground water.....:..................
Li Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground wa-ter:.......................
Ri - .............. ........... - -
O Description of Soil.... •0- .-... .------`6- � .... -t..`.. �........... ............ ...........
x
w ...:....................................................................................................................................................................................................
UNature of Repairs or Alterations—Answer when applicable...............................................................................................
..-•--•••-•............................•-------......---.------•-•-•-••----•-••---...-••--•••-••••--•-•.•-•••••....•••..........•-•--•......-•....--•-.....--•-----.........................•••-•-••---•
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of T III LF, 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the ,booyd of lie lth.
Sign -G- .--.- ��/..�i�'�--� _._ f.................. ...
� / Date
Application Approved BY--------- .................. .....
/- ......
Date
Application Disapproved for the following reasons--------------•-•-•--•--......_..----••-----•---...--•---------•---•------------------------••-••.........•••-•-
.....--••-•---------•--------------------------------------------------------------....................................................................................................................
Permit No. Issued .._ _.l-f!••���•------Date ..--
Data
THE COMMONWEALTH OF MASSACHUSETTS
BOARDD OF HEAL H
............... .lj ....OF...:!:: ....-1.................... ...........................
Trrtif irtttr of Tomphatta
THIS IS TO CERTIPY,,iI'hat the Individual Sewa p Dis osaI System constructed ( or Repaired ( )
i
b ---=` cz_'�1--------. - � r..c�. . -----• = I ................ --------------------
Y
`r� i.' A Insaller
7 , -�'
at...--:-..�:: .: == .dad.%�: .?. .... fs.�.- +::,.errs
Ilas been installer) in accordance with the provisions of T !; of The State Sanitary.. Code`aa sde��described in the
I I
application for Disposal Works Construction Permit N_ ��..... ^
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE..................
I l..:I... IirSnector.......1 1