HomeMy WebLinkAbout0253 NOTTINGHAM DRIVE - Health 253 NOTTINGHAM DR., CENTERVILLE
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HASTINGS,MN
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS?
' `' Pr E .
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION ..
Property Address: 253 Nottingham Drive Centerville
Owner's Name:_James Aalto
Owner's Address:
Date of Inspection:_8/24/05
Name of Inspector:(please print)_Eric Stevens �-; a
Company Name: c. Z ��a 14 /
Mailing Address:_p.o.box 71
Marston mills ma
Telephone Number:_508-776-9054
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 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 15340 of Title 5(310
CMR 15.000). The system:
x Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: z&/e,
_
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.
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 253 Nottingham Drive Centerville
Owner:_James Aalto
Date of Inspection:_8/24/05
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
_x_ 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: system seems to be in good working order and passes title V inspection.
Reccommend pumping tank now and every other year.
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 pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 253 Nottingham Drive Centerville
Owner:_James Aalto
Date of Inspection:_8/24/05
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 CAM 15.303(1)
(b)that the system is not functioning in a manner which will protect public health,safety and
the environment:
_ Cesspool or privy is within 50 feet of a surface water
_ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
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 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 I 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
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.
3. Other:
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 253 Nottingham Drive Centerville
Owner:_James Aalto
Date of Inspection:_8/24/05
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
_x_ Backup of sewage into facility or system component due to overloaded or clogged SAS or
cesspool
_x_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an
overloaded or clogged SAS or cesspool
x Static liquid level in the distribution box above outlet invert due to an overloaded or clogged
SAS or cesspool
_ _x_ Liquid depth in cesspool is less than 6"below invert or available volume is less than''/z day
flow
x Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe
(s).Number of times pumped
_ _x_ Any portion of the SAS,cesspool or privy is below high ground water elevation.
_ _x_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a
surface water supply.
_ _x_ Any portion of a cesspool or privy is within a Zone 1 of a public well.
x_ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_ _x_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private
water supply well with no acceptable water quality analysis. [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 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.
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 H 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.
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 253 Nottingham Drive Centerville
Owner:_James Aalto
Date of Inspection: 8/24/05
Check if the followinghave been done.You must indicate es or `no as to each of the following:
"Y g
Yes No
x _ Pumping information was provided by the owner,occupant,or Board of Health
x Were any of the system components pumped out in the previous two weeks?
_ _x Has the system received normal flows in the previous two week period?
_x_ Have large volumes of water been introduced to the system recently or as part of this inspection
_x_ _ Were as built plans of the system obtained and examined?(If they were not available note as
N/A)
_x_ _ Was the facility or dwelling inspected for signs of sewage back up?
x _ Was the site inspected for signs of break out?
_x _ 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?
_x_ _ 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)]
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:_253 Nottingham Drive Centerville
Owner:_James Aalto
Date of Inspection:_8/24/05
RESIDENTIAL FLOW CONDITIONS
Number of bedrooms(design):_3_ Number of bedrooms(actual):_3_
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):_330
Number of current residents:_4
Does residence have a garbage grinder(yes or no):_no_
Is laundry on a separate sewage system(yes or no): no_ [if yes separate inspection required]
Laundry system inspected(yes or no):_
Seasonal use:(yes or no): no_
Water meter readings,if available(last 2 years usage(gpd)):
Sump pump(yes or no): no
Last date of occupancy:_7/31/05
COMMERCIALANDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sg8,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: home owner
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
_x_Septic tank,distribution box,soil absorption system
_Single cesspool
_Overflow cesspool
_Privy
_Shared system(yes or no)(if yes,attach previous inspection records,if any)
_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:
unknown
Were sewage odors detected when arriving at the site(yes or no): no
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C "
SYSTEM INFORMATION(continued)
Property Address: 253 Nottingham Drive Centerville
Owner:_James Aalto
Date of Inspection:_8/24/05
BUILDING SEWER(locate on site plan)
Depth below grade:_34"
Materials of construction:_cast iron _x_40 PVC_other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.): tank is in good shape and
functioning
correctly
SEPTIC TANK: x (locate on site plan)
Depth below grade: 28"
Material of construction: x 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:
Sludge depth:_7"
Distance from top of sludge to bottom of outlet tee or baffle: 20"
Scum thickness:_16
Distance from top of scum to top of outlet tee or baffle:_2"
Distance from bottom of scum to bottom of outlet tee or baffle: 7"
How were dimensions determined: . measured
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid
levels as related to outlet invert,evidence of leakage,etc.): Tank is in need of pumping.Was
reccommended
GREASE TRAP:_(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.):
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:_253 Nottingham Drive Centerville
Owner:_James Aalto
Date of Inspection: 8/24/05
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass_polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/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: (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.): no d-box on system.tank and 1000 gal.leach and 1000
gal.
overflow
PUMP CHAMBER: (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.):
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
'SYSTEM INFORMATION(continued)
Property Address: 253 Nottingham Drive
r
Owner:_James Aalto
Date of Inspection: 8/24/05
SOIL ABSORPTION SYSTEM(SAS): x (locate on site plan,excavation not required)
If SAS not located explain why:
Type
x leaching pits,number:_2_
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.): first pit contained 36"liquid.Overflow pit was dry at time of inspection.No sign
of liquid over 40"mark in overflow pit.
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 or no):
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.):
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 253 Nottingham Drive Centerville
Owner:_James Aalto
Date of Inspection:_8/24/05
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.
f::,r-o I
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3
4
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 253 Nottingham Drive Centerville
Owner:_James Aalto
Date of Inspection:_8/24/05
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 28 .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:
_x_Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:_Previous inspection done on
property in 1998 shows ground water information.John Aalto(uncle of prop owner) installed most systems
in nieghborhood when built.
COMMON\\WEALTH OF MASSACHUSETTS 7�j
y EXECUTIVE OFFICE OF ENVIRONMENTAL AFF S RECEIVED .�
DEPARTMENT OF ENVIRO'�MENTAL PROT IN QV 2 1998
ONE WINTER STREET. BOSTON. MA 02108 61,-292-5j00 TOWN OFFAP'
�• H'1ir
WILLIAM F.WELD \LJ_L,,�TRU Y COXE
Govcmo:
Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Lt.Govcmor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner
I PART A
CERTIFICATION
/I/vf/rtiyLJan. �7r;�.c CPrvil/�
Property Address: S Address of Owner: �
Date of Inspection: 6-'��—98 / (If different) 7(� /l'lysf%E �� ��rs/v�S /t/,,��
Name of Inspector: �(�Ljv�f� �a
I am a DEP appf oved system ins ector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: hh .qU a kCktidP .Sorl-)4c-1
Mailing Address: /S'iJ 1!/w bu7` St WPr1 o:vS/yi��S ti v�'6r/B
Telephone Number: �7h rL- ��15"K
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:
!/Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
_ f 'Is
zkInspector's Signature: Date: 11
The System Inspecto hall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this
inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit
the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
INSPECTION SUMMARY: Check A, B, C, or D:
A] SYSTEM PASSES:
have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
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.
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 04/25/97) Page 1 of 10
DEP on the Worid Wide Web: http://www.magnet.state.ma.us/dep
0 Printed on Recycled Paper
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART'A
CERTIFICATION (continued)
,i+�
Property Address:
Owner: 1:5--ed 0- T06;Nh1
Date of Inspection: /
B] SYSTEM CONDITIONALLY PASSES (continued)
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the
Board of Health). Describe observations:
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled 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 PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or
tributary to a surface water supply.
_ The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
_ The system.has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that
the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method used to determine distance (approximation.not valid).
3) OTHER
(revised 04/25/97) Page 2 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
J CERTIFICATION (continued)
Propertv Address: 2 //a /„'� yAtil a,✓/f C!/yTi-v/��-r
Owner: AW v 70A.v/+ e ��i vss✓r
Date of Inspection: j
Dj 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 into 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 due to an overloaded or cfrxxgged 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 1/2 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 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 wa9$r supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water suppfy well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well wa*r analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
F] 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 above:
The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
Yes No
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 It 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 treaty ent program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 04/25/97) Page 3 of 10
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
�� CHECKLIST
A/
Property Address: 2�3 /�/r3///++
Owner: .G�� / -}
!/r JUUr7/'JI su
Date of Inspec ion: p�Q
I
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No
✓ — Pumping information was provided by the owner, occupant, or Board of Health.
— 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.
— The facility or dwelling was inspected for signs of sewage back-up.
— The system does not receive non-sanitary or industrial waste flow.
— The site was inspected forrr, signs
--BBof breakout.
N
All system components,— P axe�tie Soil Absorption System, have been lo
cated 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 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 System.
— Existing information. Ex. Plan at B.O.H.
— Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) (15.302(3)(b))
(revised 04/25/97) page 4 of 10
}
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR,tit
PART C
SYSTEM INFORMATION
Propem /!Address: as3 o,#-,' A,, Pl o;" C,o 0/7///I.-
Owner: `I,�Or 7ljarJn.! �/ivgN
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow: -3-� .p.d./bedroom for S.A.S.
Number of bedrooms:
Number of current residents:
Garbage grinder (yes or no):
Laundry corrected to system (yes or no): f
Seasonal use tyes or no):—h-19
Water meter readings, if av Table (last two (2) year usage (gpd):
Sump Pump (yes or no):_z
Last date of occupancy: ! �J
COMMERCIAUINDUSTRIAL:
Type of establishment:
Design flow: r;allons/day
Grease trap present. (yes or not_
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 o•-cupancy:
OTHER: ;Describe)
Last date of occupant),.
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as pan of inspe ion: ( s or no)�!s
If yes, volume pumped: POGO gallons
Reason for pumping-
TYPE OF SYSTEM
Ii Septic tank/dFstfih�.iea-berx/soil absorption system
Single cesspool r
ti Overflow Eestpcei 4/a.ac4" t
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
APPROXIMATE AGE of all components, date installed (if known) and source of information: .?S Gars ai'W'40l-al,""'ft
Sewage odors detected when arriving at the site: (yes or no)
(revised 04/25/97) Pago 5 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: y�r,
Owner: Tr�� 9—TOprjs7 e ��/i
Date of Inspection:
BUILDING SEWER:
(Locate on site plan)
Depth below grade:
Material of construction: _cast iron 40 PV _other (explain)
Distance from private water supply well or suction hri
Diameter
Comments: (condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK:_
(locate on site plan)
I
Depth below grade:
Material of construction: concrete metal _Fiberglass _Polyethylene _other(explain)
If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No)
Dimensions:
g� f,
Sludge depth: d.41
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: 2 •,
Distance from bottom of scum to bottom of outlet tee or baffle: /0�'
How dimensions were determined: iGs'Pbs(,tp-,
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.) r'�Cv/rI.[.H es�e�� 02AL.Wd2".2 crr -"M-Ar A' ao- //Was Ae.. e
GREASE TRAP:
(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:
(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.)
(revised 04/25/97) Page 6 of 10
r d
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: '453v� C- Psi �rv/rJ,/N�"r
Owner: F'-eol f�jGHNI ��f i✓a-r
Date of Inspection:
6-/�-7,17
TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection)
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain)
Dimensions:
Capaciry: gallons
Design flow: gallons/da�
Alarm level: Alarm in working order _ Yes, _ No
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:JI/O
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and distribution is equal, evidence ofso)ids carryover evidence of leakage into or out of box, etc.)
Flo 13O7X 9 s St�S H"
PUMP CHAMBER:_
(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.)
(revised 04/25/97) Page 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
�y
SYSTEM INFORMATION (continued)
Property Address: ,? S� A1,1Z:- A-VaIr A" '-e
Owner: /r�� 4' �OAHy1 'S7 /j'
Date of Inspection: ad
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, number: z
leaching chambers, number:__
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
Alternative system:
Name of Technology:
Comments: 1QioG�,0�7� .AvX,' 4
f it ins of hydraulic failure level of ondin , condition of vegetation, etc.)
(note conditiono so , s p g
g
CESSPOOLS: _
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum laver:
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, 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.)
(reviiad 04/25/97) Page a of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
—.�� SYSTEM INFORMATION (continued)
Property Address: �✓ A7T,
Owner: F44l? 4 7(Ju rJr+.Q �l/cipr.
Date of Inspection:
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)
GAr Gc�-�
4 3/
(revised 04/25/97) Page 9 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFFO�RMAT—ION (continued)
r
Property Address: �S� c ~f h�ter' Q�" ' C:o HZ&- 9le
Owner:
Date of Inspection:
Depth to Groundwater 28 Feet
Please indicate all the methods used to determine High Groundwater Elevation:
V Obtained from Design Plans on record
r
✓ Observation of Site (Abutting property, observation hole, basement sump etc.)
✓ Determine it from local conditions
`r Check with local Board of health
Check FEMA Maps
Check pumping records
so"O' Check local excavators, installers
r/ Use USGS Data
Describe in your own words how ,you established the High Groundwater Elevation. Must be completed)
4.3
00
(rrvisad 04/25/97) Pag• 10 of 10
84-- 553 1 $ 15.00
No......................... FEE..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..............T.�n..--------OF..............Barnstable
------------------------------------------------------•......-••.•-•--
Appliration for R Vas ai Workii Tonstrnrtinn ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( x) an Individual Sewage Disposal
System at:
253 Nottingham Drive, Centerville, MA 02632
................_................................................................................ ................---•••-----•----•---••-------•----•-..........•--•--------..__.....------......••.
FredSul ........................•---.....----•--•--..............._..---•---------- ..........--......................................................................................
dd
W A & B Cesspool Service, Inc. 128 Bishops Terrace, i1 .
Installer Address
UType of Building 3 Size Lot----------------------------Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
a'4 Other—Type of Building No. of persons............................ Showers
g ---•--------------------•--• P ( ) — Cafeteria ( )
dOther fixtures ...................-----•-•--•----------------•-----..•....--------•-----•-----........---•------•-•-•---------•------•---•-•----•-•--------...------
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No................•.... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
a
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
fZq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
0 x ---------------------
Description of Soil............aand......................................................................................................................-...
x
v
w
x --•---•-••---------•---------•••-••----•-•-------•••-•-•-••---•-••••-•-----••--•-------••...------•---•--•---•--•-•••-----•----•----•--•--•----•----------••-----•••---•-••-----•--------•------•-•••---
U Nature of Repairs or Alterations—Answer when applicable...._installation.__of..a-_.1,000_.Ea11on,___pre—cast,
storms -packed ]e �kl__pit �cnrefow�'...............•---------••-----------•----------------•---------•---------------•-••-------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITA IE 5 of the State Sanitary Gode— The undersigned fu th agrees not to lace the system in
operation until a Certificate of Compliance has issued by the bo rd
• /
igned � C ....:.... .................•.---- = ------7l-24184
ApplicationApproved BY-•-- =----------------------------••-•----•-------.................................... 7� e�84•
Date
Application Disapproved or t following reasons:................................................................................................................
---------••--•-•---......---•-------------•-•-----------....----•---....---------.......-•----•-•------------•-•------.....--•------••-••----------•-•-•-----•-••---..................................
Date
/84
Permit No._- .............................................. Issued_..........7/2
Date
` � f
No.... . ..... .�. FEs........�...1 .00
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
-------------------_.Tmn.------..OF................Banstahle----•-----------...--------.......----.......--
Appliratiun for BiuvuuFal Workii Tuntrurtiun Famit
Application is hereby made for a Permit to Construct ( ) or Repair ( X) an Individual Sewage Disposal
System at:
..?51:I ott 1 ultun..D-xim Qwt.er+:ilia.._n......Q26.3?.............................................................................................
Location-Address or Lot No.
.tared Sulliy al....................................... 25. ---Zm,tti r m..� � �±@.,..Celntery l e� %'A....02632
Owner Address
aA = Cesspool_•Servicz�:_Tic.___......................... 2& BishopsTerracs1.Hya?rlis,...i A-----0?601----
Installer ' Address
Type of Building Size Lot............................Sq. feet
1-1 Dwelling—No. of Bedrooms............................. .............Expansion Attic ( ) Garbage Grinder ( )
Other—a Type of Building g ____________________________ No. of persons..............._............ Showers ( ) — Cafeteria ( )
Other fixtures ...............................................
Design Flow............................................gallons per person per day. Total daily flow........................................:...gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................-Diameter................ Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter.........---._...... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit...........--....... Depth to ground water_----------------------
4q Test Pit No. 2................minutes per inch Depth of Test Pit...---.............. Depth to ground water....................---.
a ••-•••••••---•----•-••------•--•--••......-----••••••-••-•--••••-••-•••-•....--------•--••-•-•-•---•-••-•--------••-.....---•••.....................•-•.--.--
O Description of Soil.............Sand.....................................................................................................................
U ---...••-----•-•-------•-•••-••••..............................................................................................................................
W
x ,---------------------------------------------------------------------------------------------------------
U Nature of Repairs or Alterations—Answer when applicable..-_.5-mtallati-on---Of.a..1,000---gall an,...p2amaa.et,
..sty---Pra,cked__1.each--pJ_t...(czar'1rK).......................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITA IE 5 of the State Sanitary,Code—The undersigned further' agrees not to place the system in
operation until a Certificate of Co m i ce has een issued.by the board hea
d .� :Signe ���'j�- _ >. 7.2 411
Date
Application Approved ...... 7 •
Date
Application Disapproved f o the following reasons---------------------•--------------•---•--......-=-'
--------------------•----•------------------•------•--------•------------...............------------------------------......
Date
PermitNo-----84.=............................................. Issued.......... . ...........................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Zown...O F.............Barns tahle............ ...............................
f�rrtif irFatr of Tompli�an�
THIS IS TO CERTIFY, That the Individual Sewage Disposal System konstructed ( ) or Repaired
by A &.B Cessp ool Service, Inc. _12 EiShopa terrace, Hyannis, A!A 0260i
. -----•--•-••-•-•••...
Installer
at....2 _.iJottin�ham Drive, Centerville, iA �2b e S�allivg�n
has been installed in accordance with the provisions of TI; F The State Sanitary Cods s Qjscrlbed in the
application for Disposal Works Construction Permit No. ........................... dated_-...---7%2� 8
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE/CONSTRUAS A GUARANTEE THAT THE
SYSTEM WILL FU/NCTION SATISFACTORY.
DATE. 1..�L.�.............•--------••••-••.......-•---••--•--.. Inspector --•-••--------••••...-----•-•---•••.....-••--••-•-•.....--
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................zo'n.........OF........Bax�st b.1.Q.......--------••-------•--...---................. 15.00No.---•-.4pr.-
FEE........---•-•-•-•--....
Disposal Workii Tundrurfiurt anti#
Permission is hereby granted................A..& B..Cesspool__S.....9ciee_--.?-C-...........................................................
to Construct ( or\Repair ( X) an Individual Sewage Disposal System
at No..._.-_X ll �-------z53..ST.nttinpham.-DxLv-e,...Cater-vi118-r- 632-•---Fxt��d..aul7.ivatl...............
Street
as shown on the application for Disposal Works Construction Pe ..
•-••-•........ Dated .7.24•.••••.•--...
• -•-•------------------•-.........................................................
•-•-•-----------------•--••-----..........................•... Board of Health
DATE.7,��/�-•-•-
FORM 1255 A. M. SULKIN, INC., BOSTON
2/11/2021 ShowAsbuilt(1700x2800)
cs.u•rr.
LOCATION /' � SEWAGE PE)p�I'P N0.
VILLAGE —7
A & B CESSPOOL SERVICE
128 BISHOPS TERRACE, HYANNIS, MA 02601
BUILDER OR OWNER
�•�- //6/LG-a�As[" dirLJ r h��-GC..(/
0
DATE PFRMIT ISSUE
2/a s%s�
DATE COMPLIANCE ISSUED
R.Y3 AJOfthny/i eri ✓/tii 2 Cara c
y
O �
d
__ jJew
;. \Iomo Tit
Ieaeb Fit
tc
https://itsqldb.town.barnstable.ma.us:8431/Home/ShowAsbuilt?mp=171046&sq=1 1l1
........ % F$c 0.........:....... ......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Town Barns table
....................... o�................-.-.................. ...-........ ........ ...
Applirativa fir i imial Works Toustrurtiuit Prrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
Lot 118 Nottin ham Dr. Centerville
.............. .... .............. ... .. ...... ............................ ..... �.�53........................ ......................................,.
ation.Address Add or No.
,Normest Homes nc ....Ashley.Dr. 3 .Centerville............................
Owner dyes
a James---Dollowa�........................................................ ................................................Corners R`�x.._�enterville.--........-_
Installer Address
Type of Building Size Lot._1.599Q...........Sq. feet
04 Dwelling—No. of Bedrooms...........................................Expansion Attis ( ) Garbage Grinder ( )
a'4 Other—Type of Buildin wood frame No. of persons............................ Showers
g -•--------•-•-------------•- P ( ) — Cafeteria ( )
Otherfixtures -----------••--••---------------•-••---•-----•-•-----------•-•-•----•--•----...---....._........--.---•- ��
w 3
Design Flow.........................9Q..._...._...._gallons per person per day. Total daily flow............................................
WSeptic Tank—Liquid capacity J.QQOgallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No..................... Wi tt%.at e.... Total Length.................... Total leaching area..........02....sq. ft.
Seepage Pit No..................... Diameter...._ _.�?...C.- Depth below inlet.................... Total leaching area.....3.__._.....sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
w Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
------ -----•---------------------------•-------......-----.......---- -----------...........................
ODescription of Soil...........................aan ._&...&raVel....-••-•----...----•----•---------•••---•.....----•----••----•-•••••••-•-•--•-•------•------------••••.
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 Article NI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has een issu by the board of health.
Si ed - ---Y !- ..................
....•----//-----a..t.e.....'}••_•.-.•*•�."....L..
Dat
f ...........................Approved By... -•-•- --
Application Disapproved for the following reasons:--•-------------------•••------•---•--••---••-•-------•---•---------•-••---•-•.................................
•--•--•------------------------------------------------------------------------•-------...--------......-.....-•-------....-----------------------------------------------•--•-------••-•-----•-......._.
Date
Permit No......................................................... Issued.- !®7. ,...:...............-
Date
LOCATION SEWAGE PERMIT NO.
VIILL}LAGE
A & B CESSPOOL SERVICE
128 BISHOPS TERRACE, HYANNIS, MA 02601
BUILDER OR OWNER
ot'e-�
DATE PERMIT ISSUE /
DATE COMPLIANCE ISSUED
a
EZ
O `
AP f�
leac 4 Pit'
t
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
f ..-•.TOM_............. OF.... ,-rust ble...................................................
Applirntion. for RoVooa1 Warkii Tontrnrtion runfit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
.. ..0.8... t tk�,,, �e�. ... a $gg: j i. e.................................................. ..........................................,
L 'a�t on•Address or Lot No,
........................................„...... ., v� ...........................
O�vfier d�reas
a .&M"...Do1llonaay.. .................................................... .... ............
Installer Ad�ress
UType of Building Size Lot... . ...:.:`....Sq. feet
Dwelling—No. of Bedrooms................a-------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building WoQd..,.r..& No. of persons..................6........ Showers ( ) — Cafeteria ( )
Other fixtures
Design Flow.....................:.... gallons per person per day. Total daily flow......_..._.. gallons.
W ......... .g P P P Y Y &
WSeptic Tank—Liquid capacity..to;oQallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No..................... Width---_. n.......... Total Length.................... Total leaching area------
sq. ft.
b �
Seepage Pit No..................... Diameter �� epth below inlet.................... Total leaching area.... �?....sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
w Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
---------------- ------------------------------------•--------------•-•--•-•----------.------•-------.--.--------------------------•--..---•-
O Description of Soil................'........... 9r-eivel........................................................................................................
x
U ------------••----------.................................................................................................................................................................................
W
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 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 byte board of health
Sig Cl.,. „
Date
Application Approved B ! '�y ,����'•-----...•______________•__
Application Disapproved for the following rza.sons:................. ...........................................................................................
----------------------•---........_•-----•---......----•-••--• -•-----••-•••--•-------•-••---•--------•-•-------•-......_._...
Date
Permit No......................................................... Issued. •.:` ..............................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..............I....TOM...........OF... rids.t.bl e..................................................
- _ (�rrtiftrn#� of f�,ant�rlittnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repairedby ( )
-•---•----- ------------------------------ ------•- ............
.......
.........--------
Installer st
at.----------•-........_..Ut---1 .5.., 5? 17C1 1tL 1 __ .« eXx18X' .1 - -----------------------------------------•----------•--------------------
has been installed in accordance with the provisions of Article XI of The State Sanitary Code as des ribed in the
application for Disposal Works Construction Permit-No.............................9.1d_.t dated___���,1.��_�--_-....._
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEMLJ. FyN9T10K SATISFACTORY.
DATEInspector......f%:j. ... '.......................................... .................. r .+........................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Ot ....::.:............O F....Barns��bI6.....................----•----...................
No.......:....... ...... FEE ...............
Rapwinl Works Cfunstrnrtion Perutit
Permission is hereby granted..........................Ja�?es..:'Do.......
lp!-,!o
....... .......•-------..................--•-..................
to Construct ( ) or:Re air ((,� an Individual Sewage Dis osal System
Lot 1,1 Nottingham Dr Centervll.le_
at No.. ............... ....... ........ ................................... , ---- .............................................................
Street
as shown on the application for Disposal Works Construction mit o .......�.......... Dated___.r/ � -- f' '
--_��__
....r.................
rs -•- r•--.,�° -,•:••- ,lam�•• ............................
/ ��?� l f y ) Board of calth
DATE _....%`..... ... ....... ......... d°'..................
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS