HomeMy WebLinkAbout0440 OLD STAGE ROAD - Health 440 OLD STAGE ROAD, CENTERVILLE
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` Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
CIO
�M 440 Old Stage Road Assessor's Map: 190 Parcel: 190
Property Address
Elizabeth A. Reilly
Owner Owner's Name
information is Centerville MA 02632 Au ust 28 2017
required for every .9.
page. City/Town State Zip Code Dateof Inspection
CA,„t
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information (�[�
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on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not David D. Coughanowr
use the return Name of Inspector
key.
Eco-Tech Rapid Response
r� Company Name
155 George Ryder Road South
Company Address
Chatham MA 02633-1621
City/Town State Zip Code
508 364-0894 1328
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The 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 ❑ Fails
OF ly
El Needs Furt a Local Approving Authority
moo`' DAVID yG�
CO GHA OWR N nJ
August 28, 2017
Inspector's Signat 9 O Date
�GfSTEa�
The system ins a vs a copy of this inspection report to the Approving Authority (Board
of Health or DEP)wit ys 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 should be sent to the system owner and copies sent to the
buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This,inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
k U�l-IVS
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�.. r
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
440 Old Stage Road Assessor's Map: 190 Parcel: 190
Property Address
Elizabeth A. Reilly
Owner Owner's Name
information is g
required for every Centerville MA 02632 August 28, 2017
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
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:
Inspector's Notes==> The septic system described herein is deemed to pass this Real Estate
Transfer Inspection if it does not meet any of the failure criteria enumerated in Section D on pages 4-
5, or specified by local regulations. The scope of this inspection is limited to health and environmental
compliance and the septic system has been evaluated according to the conditions observed on the
day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing
determination.
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration.or'tank failure is imminent. System will pass
inspection if the existing tank is replaced with a'complying septic tank as approved by the Board of
Health. �.
*A metal septic tank will pass inspection if it is structurally.sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):, ,
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
r
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
440 Old Stage Road Assessor's Map: 190 Parcel: 190
Property Address
Elizabeth A. Reilly
Owner Owner's Name
information is August 28 MA ill 2017
t Cenerve 02632 Au
required for every 9
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
it
r
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
440 Old Stage Road Assessor's Map: 190 Parcel: 190
Property Address
Elizabeth A. Reilly
Owner Owner's Name
information is g
required for every Centerville MA 02632 August 28, 2017
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water
Y N
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® 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 %day flow
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 440 Old Stage Road Assessor's Map: 190 Parcel: 190
Property Address
Elizabeth A. Reilly
Owner Owner's Name
information is Centerville MA 02632 August 28, 2017
required for every 9
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no" to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—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.
l5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
r
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
440 Old Stage Road Assessor's Map: 190 Parcel: 190
Property Address
Elizabeth A. Reilly
Owner Owner's Name
information is required for every Centerville MA 02632 August 28, 2017
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate "yes" or"no" as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
Has the system received normal flows in the previous two week period?
❑ ® Y p
❑ ® 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)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd
t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 44_0 Old Stage Road Assessor's Map: 190 Parcel: 190
Property Address
Elizabeth A. Reilly
Owner Owner's Name
information is required for every Centerville MA 02632 August 28, 2017
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ❑ No
Seasonaluse? f ❑ Yes ® No
Water meter readings, if available last 2 ears usage (gpd)): 692 gpd
9 ( Y 9
Detail:
2015: 182,000 gallons 2016:>323,000 gallons
Sump pump? ❑ Yes ® No
Last date of occupancy: 1 week agoDate
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 440 Old Stage Road Assessor's Map: 190 Parcel: 190
Property Address
Elizabeth A. Reilly
Owner Owner's Name
information is g
required for every Centerville MA 02632 August 28, 2017
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: owner
Was system pumped as part of the inspection?,, ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 440 Old Stage Road Assessor's Map: 190 Parcel: 190
Property Address
Elizabeth A. Reilly
Owner Owner's Name
information is Centerville MA 02632 August 28 2017
required for every 9
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
Age: 21+ years. Certificate of Compliance for a new system was issued 3/17/1996 (Permit#94-96 at
Health Department).
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: feet
Material of construction:
® cast iron ❑40 PVC ❑ other(explain):
Distance from private water supply well or suction line. 10+
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
No evidence of leakage or backup into dwelling.
Septic Tank(locate on site plan):
Depth below grade: 1
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 8.5' x 5'x 6-1000 gallon
Sludge depth: 6 inches
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
440 Old Stage Road Assessor's Map: 190 Parcel: 190
Property Address
Elizabeth A. Reilly
Owner Owner's Name
information is g
required for every Centerville MA 02632 August 28, 2017
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle 28 inches
Scum thickness 2 inches
Distance from top of scum to top of outlet tee or baffle 9 inches
Distance from bottom of scum to bottom of outlet tee or baffle 13 inches
How were dimensions determined? permit application form
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 required at this time. Maintenance pumping is recommended within 2 years and every
2-4 ears thereafter with year round occupation. Tank and tees appear structural) sound and
Y Y p Pp Y
functioning as intended. No evidence of leakage in or out was observed.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
440 Old Stage Road Assessor's Map: 190 Parcel: 190
Property Address
Elizabeth A. Reilly
Owner Owner's Name
information is Centerville MA 02632 August 28, 2017
required for every g
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
`Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
i—
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 440 Old Stage Road Assessor's Map: 190 Parcel: 190
Property Address
Elizabeth A. Reilly
Owner Owner's Name
information is Centerville MA 02632 August 28, 2017
required for every g
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert at 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 adverse conditions observed.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
l5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
440 Old Stage Road Assessor's Map: 190 Parcel: 190
Property Address
Elizabeth A. Reilly
Owner Owner's Name
information is required for every Centerville9
MA 02632 August 28, 2017
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
No evidence of surface ponding, breakout, lush vegetation, or other evidence of hydraulic failure was
observed. Leaching pit was uncovered and found to be dry.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 440 Old Stage Road Assessor's Map: 190 Parcel: 190
Property Address
Elizabeth A. Reilly
Owner Owner's Name
information is required for every Centerville MA 02632 August 28, 2017
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
I
t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 440 Old Stage Road Assessor's Map: 190 Parcel: 190
Property Address
Elizabeth A. Reilly
Owner Owner's Name
information is Centerville MA 02632 August 28, 2017
required for every 9
page. Cityrrown State . Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal"system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
❑ hand-sketch in the area below
❑ drawing attached separately
i
n O AD NOT
MARS TO lf�/ SCALE
� o
/ LEACH p �ja p
/ PIT L�OC A §ONNSS
OF SEPTIC COMPONENTS
2 -DISTANCES IN DECIMAL FEET
1000 GALLON r� DISTRIBUTION BOX A 8
SEPTIC TANK
. 1 36 26
1 2 39 29 .
3 35.5 35
eF
� 4 40 46
A
Q
_ 3
w
EMS TWO
0
DV�i C LUNG
z 0 4400
J i
Q
W -
THIS SKETCH IS .C�
BEST VIEWED IN p E S?
COLOR FORMAT
508 364-0894
_j
OLD STAGE ROAD
SEPTIC INFO) AT
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
440 Old Stage Road Assessor's Map: 190 Parcel: 190
Property Address
Elizabeth A. Reilly
Owner Owner's Name
information is required for every Centerville MA 02632 August 28, 2017
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 25+
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:
Barnstable GIS Department records
You must describe how you established the high ground water elevation:
Town of Barnstable GIS Department records indicate that the property is over 25 feet above
groundwater table
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 440 Old Stage Road Assessor's Map: 1 g p 90 Parcel: 190
Property Address
Elizabeth A. Reilly
Owner Owner's Name
information is Centerville MA 02632 August 28, 2017
required for every 9
page. CitylTown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
GEOHYDROLOGICAL PROFILE
- NOT TO SCALE
11 1111
PRECAST ,
LEACH
b v
PIT
N BOTTOM
OF
LEACHING
PIT
v LEACHING IS
ABOVE HIGH
GROUNDWATER
GROUNDWATER ELEVATION
PER GIS MAPS
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
I
tf ^t CA"
Commonwealth of Massachusetts Executive Office of Environmental Affairs 1996partment of �
Environmental Protection
Wllllam F.Weld a''
Goremor I
Siemer'.EOEA ' I
David B. Struhs
Comm"aner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
d r CERTIFICATION .
Property Address: yW0 e9/�` sr4f,Rd Ce"r`,-VI/II Address of Owner:
Date of Inspection: .3-A?-96 (If different)
Name of Inspector: jok" 0,Aa 1 to
Company Name, Address and Telephone Number:
/s'O u/ul.�.dSJ MarS�o s /V/,Ik M,A, 016 y�
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
Fails
Inspector's Signature: /)A Date: 3—14
The System Inspector shall 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:
I 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.
B] SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or.repaired. The system, upon completion 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', 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 8/15/95)
One W ntef Street • Boston,Massachusetts 02106 • FAX(611)356.1049 • Toilsome(617)262-MM
t0 Printed on Recycled POW
r
9
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
C-E�-RTIFIC/ATION (continued)
Property Address: ' LJ'�r0 90 s rye � CPti/eY yr`l
Owner: DoraA a v- pa v gar Se lv6i
Date of Inspections
B] SYSTEM CONDITIONALLY ASSES (continued)
Sewage backu or breakout or high static water level observed in the distribution boX'is due to broken or obstructed
pipe(s) or due t a broken, settled or uneven distribution box. The system Will pass inspection if(with approval of the
Board of Health):
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pu ping more than four times a year due to broken obstructed pipe(s). The system will pass
inspection if(with approv of the Board of Health):
roken pipe(s) are replaced
struction is removed
C] FURTHER EVALUATION IS REQUIRED BY THE B ARD OF HEALTH:
Conditions exist which require further evaluatio by the Board of Health n 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 ETERMINES T AT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AN SAFETY AN THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering veg aced wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (A PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PR ECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
_ The system has a septic tank and soil absorption syste and 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 a d is within a Zone I of a public water supply well.
_ The system has a septic tank and soil absorption system an is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and ' less than 100 feet but 50 feet or more from a private water
supply well, unless a well water analysis for coliform bacteria nd volatile organic compounds indicates that the well is
free from pollution from that facility phd the presence of amm is nitrogen and nitrate nitrogen is equal to or less than 5
ppm•
i; , '
D] SYSTEM FAILS:
have determined that the system viol /esone or more of the following failure 'feria as defined in 310 CMR 15.303. The basis
I e Y
for this determination is identified row. The Board of Health should be contact to determine what will be necessary to correct
the failure.
Backup of sewage int facility or system component due to an overloaded dogged SAS or cesspool.
Discharge or pond' g of effluent to the surface of the ground or surface waters;due to an overloaded or clogged SAS or
cesspool.
(revised 8/15/95) Z
j .
III
t
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: qoo ou t ��''� Ror' Ceh-7ee&l7le
Owner: Pvhhec -;i� na o' Si�vk
Date of Inspection:
DJ SYSTEM FAILS (c tinued):
Staticquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid dept 'n cesspool is less than 6" below invert or available vol d� is less than 1/2 day flow.
Required pumpin ore 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 pri is below the high groundwater elevation.
Any portion of a cesspool or privy�is within 100 feet of surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone of.a public well.
Any portion of a cesspool or privy is wilk�in 50 f t of a private water supply well.
Any portion of a cesspool or privy is less th\ 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the w7l h been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compo nds, a onia nitrogen and nitrate nitrogen.
El LARGE SYSTEM FAILS:
The following criteria apply to large syst7�in addition to the criteria bove:
The design flow of system is 10,000 gpd'or greater (Large System) and th system is a significant threat to public health and safety
and the environment because one or,,fnore of the following conditions exist.
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 sup ly
the system is locsted in a nitrogen sensitive area (Interim Wellhead Protectio 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 wit the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department foK further information.
F /
,4 r • r
(revised 8/15/95) 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: if4fI 0111 -�/ /�.,t Rol e-Oh fey iISe.
Owner: Pohh o, % Dai/1D ""R
Date of Inspection: 3 9 '99
Check if the following have been done:
Pumping information was requested of the owner, occupant, and 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.
fAs buik plans have been obtained and examined. Note if they are not available with N/A.
r/The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow
i/The site was inspected for signs of breakout.
K,f,1 9.
I�AII system components, tiding the Soil Absorption System, 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 Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
r,Ithe facility owner (dnd occupants, if different from owner) were provided with information on the proper maintenance of Sub-
Surface Disposal Svstem.
(revised 8/15/95) 4
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
/ SYSTEM INFORMATION
Property Address: '/] 11'90 D�d fe P R� CQyh Zrii��P /1Jfa,
Owner: 00j1 pia q-)90V' ,r u
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 330 gallons
Number of bedrooms:
Number of current residents:
Garbage grinder(yes or no):�i
Laundry connected to system (yes or no):�r e3
Seasonal use (yes or no): 911 T
Water meter readings, if available:
Last date of occupancy: 9Y1ZKf"7 dcGk�'��
COMMERCIAUINDUSTRIAL:
Type of establishment:
Design flow:_gallons/day.
Grease trap present: (yes or no)_
Industrial Waste Holding Tank prese\(yesr )Non-sanitary waste discharged to them: (yes no)_
Water meter readings, if available:
Last date of occupancy:
OTHER: (Describe)
Last date of occupancy:
GENERAL NFORMATION
PUMPING RECORDS and sour of information:
System pumped as'pan of inspection: (yes or no)_f p
If yes, volume pumped: gallons
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)
Other(explain)
APPROXIMATE AGE of all components, date installed (if known) and source of information: AW a i,f ��crvH �� Gti�^►1�51i
Sewage odors detected when arriving at the site: (yes or no) 11/p
(revised 8/15/95) S
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: �Iqo 0161 a-g-o Rd
!/
Owner: 017 it a a- P.*Vd or Sri 4'a
Date of Inspection: 3-1,?-96 ,
SEPTIC TANK: AS
(locate on site Ian)
Depth below grade: /3
Material of construction: - concrete —metal —FRP—other(explain)
Dimensions: X$
Sludge clepth_-____42E
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: I"
Distance from top of scum to top of outlet tee or baffle: 3
Distance from bottom of scum to bottom of outlet tee or baffle: /2-, ,
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relationto outlet invert, structural
integrity, evidence of leakage, etc.)
GREASE TRAP:40
(locate on site plan)
Depth below grade:
Material of construction: concrete —me FRP—other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of Fcum to bottom of outlet tee-o►baffl .
Comments:
(recommendation for pumping, co�i ion of inlet and outlet tees or ba s, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage,ytc.)
in -!. . . ..
(revised 8/15/95) 6
6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: G/y0 0/d �St y.o Rdv,
Owner: a NAB pavr�+ �'�l va
Date of Inspection:
TIGHT OR HOLDING TANK:
(locate on site plan)
Depth below grade:
Material of construction: _concrete etal _FRP other(explain)
Dimensions:
Capacity: Gallons
Design flow: gallons/day
Alarm level:
Comments:
(condition of inlet tee, condition of alarm and fl at switches, c.)
DISTRIBUTION BOX: / t
(locate on site plan)
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, etc.)
PUMP CHAMBER:
(locate on site plan) _.
Pumps in working order.(yes or no)
Comments:
(note condition of pump chamber, condition of pumps a j app enanees, etc.)
(revised 6/15/95) 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM IN-�F-O—RMATION (continued)
Property Address: I-1 vg o lvr0 S �c✓ R� 6pi,75rvi�lle-
Owner: Qp�'IYl c� a .06 '4S/wo
Date of Inspection: 3-19—91
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: /
leaching chambers, number:_
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
Comments: (note conditioDn of sPil, sign of hydraulic failure, level of ponding, condition of vegetation,etc.)
Ll cur(/ 74 t / �s mH 1 . .4 '1 49,492
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 b umped as part of inspecti
Comments: (n 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, a ell of ponding, condition of vegetation, etc.)
(revised 8/15/95) 8
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
j SYSTEM INFORMATION (continued)
Property Address: y�0 ®!� eS � R� Ce., Ilej
Owner: V�NN R pa vI�ot '/w4
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
3 v
�o �b
DEPTH TO GROUNDWATER _
Depth to groundwater. feet
method of determination or approximation: 9r&,tiv 14,m.n ��1 tsd4o✓vt� k.L,yk s., e�.-. ��i5 ��1�
9
(revised 8/1S/9S)
19,
No.......I.......-- .............r..............
AM' OVEO
Barnstable Conwruct*n0,- COMMONWEALTH OF MASSACHUSETTS
14 B ARD OF HEALTH
OF BARNSTABLE
Signed ?
Apphratiun for BiuVuuttl 3 odw Tunutrnrtiun ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
............................................... . ---- --••-•-•------••--.-••-----------•...------------------•----------•---.-- --...------....----
� ocatio� - ddress or Lo N i
,���� e01 lv�, '`yea 01� S k Cam, `.✓o�� -
--...-•-------•-------. / --- ...._..-- ••-•-•------------------------- ---- --••---------•-•-•--...--•- ve...--• .....................
fwne �k ��Lolhl:i 5 Addrsj�yt � < ///,/(S
Installer Address
UType of Building Size Lot............................Sq. feet
r, Dwelling—No. of Bedrooms...------------_•---------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
a' Other fixtures ------------------------------- - -
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length---------------- Width---------------- Diameter................ Depth................
x Disposal Trench—No. .................... Width-------------------- Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No________ ___________ Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by-------------------------------------------------------------------------- Date------------------------------------....
a Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water-.--__._._-.-•--_-------
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P+ ..................... ...........................
O Description of Soil--------------------5".!"- t_A.Leet. --••----•---......------•------••-•---------• ••-•--------.-------•-•-•.......-•----•.
W -•••••••••-••-•-••••-•--•-----••-•---•-•--••---••-•-•-•-------------........................................................................................................................
...........
x ••.-------•-------------- --------- ----------•••------------•---•---.......---------•----------•---.........------------------------•---.....•-- •-•--
U Nature of Repairs orfAlte/,t'ations—Answer when a licable---.-.__ �_. ._... .._.
s S lea / �O is ea S LJ/�!`. �i !� /fyfs�!� �� d"�� !/C
.........................:fir ._.......--••--... -••--•-•-•-•...... -•- . ......A... �---------- ��°----.......-....------,�--
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a 4EiPE:9
the board of health.
3 ......... �.9..:
.........................................
Application Approved By - o ----- 1N-
D�e
Application Disapproved for the following reasons- -------------------- ------------- ------------------------ ---------------------------------.......
..
Permit No. � ................... Dace
`............. . Issued ...... ....-
............... ......
a
No.... .....
THE COMMONWEALTH OF MASSACHUSETTS
I� l� m("Z Vp/BOARD R D OF HEALTH
WN OF BARNSTABLE
ApV tratiou for Uijapuittl Wor1w Tomitrurt"tun Vanttt
Application is hereby made for a:Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
¢ ....•-.../ c'j_.....c vr-r/!�v,�r ..
Location-,\ddress or Lot NV.
)9a ei � y Hh� 1 vu `7`�✓ d�r.� S 4i.� �C' �p�a��`v i -�
cane/r� �C �} Addr ss
a � !Jul �Ca /5 V .... / J/i /��vjy..rs Gh .
Installer Address
d Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria (�)
dOther fixtures --------------------------------------------------------------------------_--------.._._::.---._._.........-•------••----•-•-------....- i
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.
3 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........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit_----------------- Depth to ground water........................
a .................... - ------------------------/-----
•----------------
•-•-•-----------•---------------------------------------
•----------
-.............
x Description of Soil.....................5,1.tz.. -...... �^��•t�-P..l---------------------------------------------------- ----------------------------------•--•-------------
- ._.._.
----------•-----•------------------------------•--•--
x ...........
----- •------------------------------------------------------------------------------••---u--------_-_-•-•-. --------��----��--...._ ----••----------------
U Nature of Repar�r or terations—Answer when applicable._.__..._._ __�Y __.__ e._.___.._ _L..f
j
Agreement: loe
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compiiance'"as been issued b the board of health.
JF
i . ...��-Signed ..... . . ........ ...................................... ............
�y ._..�._...--. /J---------
Application Approved By .� -- � ` - - - •--� � -f,�..�._.. :........ -- .....,..��.��e
Application Disapproved for the following reasons- --------------------------- -------------------------------------- ............_........................----------------------------
--------- ----------- ----------- ------
�/ Vlb
------------ .....-
Permit No. ....� .° ----- /.. Issued -- -----------------------ate......
e% ............... ..�:
—--—————————————————— _ ————— ——— —._._ ——. P _
THE COMMONWEALTH OF MASSACHUSE�S
TOWN OF BARNSTABLE
Tie rttftcttte of Tompliamp,4,
THI � TO C RTIFY Tin t e Individual Sewage Disposal System constructed ( ) or Repaired ( )
by ...... � I. . .. ----
�� r ---- _.. - ------ ----
1.
at ----------------- .......��.... .L- ..... 3/l`�V �, .tlip,
��... (� >r.V l..M1 � ---------------------------------------------
has been installed in accordance with the provisions of TI fLEWoThe )t�jte Envlronmental Code as described in
the application for Disposal Works Construction Permit No. -- �. dated ..._...............................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRU'6b AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.....`�.1.),I.1.�L� ---- -------- Inspector ----- � -
__............. .._..... . ..........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH �P
TOWN OF BARNSTABLE i
FEE.---..
uiapo'sttl urk Tone ion "amit
Permission is hereby gran ed. __-__�_ l,.. �� 1........__0---------------------------------
- . - --•....f....._._ 0........................................
to Construc ( or a air, an, Sewage o sposal Syst
at No. t _ V'.
...............-�
p p Street �as shown on the a lication for Dis osal Works Construction Pe-mitNO3. :...... atc�d�g_�....... .......�!...0..............
:..
-----• ---------•------
......,••_•...... ................. Board of-flealth
DATE.----•.............�----;---------
FORM 36508 HOBBS&WARREN.INC..PUBLISHERS
TOWN OF BAR lNSTABLE /� c�
X p C
LOCATION �-®- G lot 5 rtZ-e 1eae SEWAGE # 94
VILLAGE ph«/'ti/ ��-A ASSESSOR'S MAP & LOT 70
INSTALLER'S NAME & PHONE NO. JU�� /r/ , )9,
SEPTIC TANK CAPACITY /490 U
LEACHING FACILITY:(type) /010 , Lf (size) /0 X
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER
DATE PERMIT ISSUED: 7:7- /e,s 9"
DATE COMPLIANCE ISSUED: l 7
VARIANCE GRANTED: Yes Nol
�e�t- � �-
l C @
� . rk