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HomeMy WebLinkAbout0697 OLD STAGE ROAD - Health 69 01d Stage R®ad Centerville P A = 191 069 'ILLE ; .' I �lIIY ® �J�,REcvctFo�o2� UPC 12543 No.53L.OR o� -co = HASTINGS,MN - SEWAGE NSPECTIONS LOCATI�^`�°i4 GAR I CJ tt& , DATE to z v VILLAGE aAEZs ASSESSOR'S MAP & LOT - INS,PEyCT0R � �:( fz�, PDA 3EMC TANK CAPACITY OgSl FACING FACIL=: (type) (size) 0. OF BEDROOMS 3UILDER OR OWNER OWNER MAILING ADDRESS Icy 44 a vim' r � 60 i A Commonwealth of Massachusetts Title 5 Offici al In n /91 , OCR g Subsurface stem Sewage Disposal System ror� Y Form-Not for Voluntary Assessment s ; �;� 697 Old Stage Road Property Address Gerard& Kathleen Fulham Owner Owner's Name information is Centerville required for every Ma 02632 7I13/2020 e pie, CitylTown -......�___� —._........_. -__ State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered In any way. Please see completeness checklist at the end of the form. Important:forms p when fitting out f A. Inspector Information �� y,W- ' on the computer, use only the tab Sean M. JoneS key to move your tdame of Inspector - - cursor-do not S-M,Jones Title V Septic Inspection use-the return - - key. Company Name 74 Beldan Lane Company Address Centerville Ma 02632 Cftyff' State Zip Code 774-248-4850 smjonestitle5@gmail.com, SI4522 lean@smjonestitle5.com License Number B. Certification _. I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above-, the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 7/13/2020 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DER The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform In the future under the same or different conditions of use. t5instr.doc-rev:MUMS Title s dRciai inspection Form Subsurface Sewage Disposal System•Page t of IS l Commonwealth of Massachusetts t 0. Title 5 official. Inspection Form — Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 697 Old Stage Road Property Address ` Gerard& Kathleen Fulham Owner Owners Name information is required for every Centerville Ma 02632 7/13/2020 page, City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The property located at 697 Old Stage Road Centerville is served by a Title V septic system consisting of a 1000 gallon septic tank, and 2 1000 gallon precast leach pits. Although the system was found to be in proper working condition at the time of inspection this report does not guarantee future performance under similar or increased usage. 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) Is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp,doc•rev 7P260018 Title 5 Official Inspection Form.Subsurface Sewage Disposal System-Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form l= Subsurface Sewage Disposal System Form-Not for Voluntary Assessments = 697 Old Stage Road Property Address - — --- Gerard& Kathleen Fulham Owner — _......_.... _ — Owners Name information is Centerville _ required for every Ma 02632 7/13/2020 _ page. Cityrrown �— State Zip Code Date of inspection _..._. C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning In a manner which will protect public health, safety and the environment: t5hW.doc•rev.7126=18 Title 5 Official Inspection Form-Subsurface Sewage olspossi system-Page 3 of 18 Commonwealth of Massachusetts ` Title 5 Official Inspection F o rm ' � } Subsurface Sewage Disposal System Form -Not for Voluntary Assessments vh 697 Old,_. Stage Road Property Address Gerard& Kathleen Fulham Owner Owners Name -� information is required for every Centerville Ma 026_32 7/13/2020 page. Cityfrown State Zip Code Date of inspection C. Inspection Summary (coot.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health(and Public water Supplier, If any) determines that the system is functioning In a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply wellAA Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: :..�_._.... _._........._ ._.._.__._..............__._...__ 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Ye s No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7126f201e 71119 5 Official Inspection Forma Subsurface Sewage Disposal System-Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 4 Subsurface Sewage Disposal System Form -Not for Voluntary.,, y Assessments 687 Old Stage Road _..._. _ Property Address Gerard& Kathleen Fulham Owner —__ __._..._. ........Owner's _......____ information is Centerville required for every _ Ma 02632 7/13/2020 Cityfrown page. State � Zip Code Date of Inspectioni C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No El ® 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 ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a larg e system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section CA Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well 15insp.doc•rev.7126/2010 Title 5 Official Inspection For, Subsurface Sewage Disposal System•Page 5 of 18 f Commonwealth of Massachusetts TT = o Title 5 Official Inspection Form !) Subsurface Sewage Disposal System Form -Not for Voluntary Assessments -< 697 Old Stage Road _ _. _...._.... Property Address Gerard & Kathleen Fulham Owner Owner's Name information is Centerville _ Ma 02632 7/13/2020 required for every page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered Oyes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes"or"no"for each of the following for a//Inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? El 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)] 15insp dac•rev 7l26f20#8 TUe 5 ORiceal Inspection Form.Subsurtace Sewage Disposal system•page 6 of 9a Commonwealth of Massachusetts µ = =o Title 5 official Inspection Form ,Jrty Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 697 Old Sta a Road Property Address Gerard& Kathleen Fulham Owner Owner's Name — information is Centerville required for every Ma 02632 7/13/2020 page. Ctty/rf& State Zip Code Date of Inspection D. System Information 1, Residential Flow Conditions: Number of bedrooms(design): 4 - ---- Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 gpd Description: Number of current residents: 2 Does residence have a garbage grinder? v ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: -.-....------ Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): -----— Detail: Sump pump? ... ❑ Yes ® No Last date of occupancy: current Date t5inso.doe-rev,712t' O18 Title 5 official Inspection Form subsurface sewage oisposat system•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 697 Old Stage Road �— Property Address Gerard & Kathleen Fulham Owner _ ___.._..._..__. ..._._.�... ._...._.._ Owner's Name information Is Centerville Ma 02632 _7/1_3/2020 required for every _ page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: --- Design flow(based on 310 CMR 15.203): Gallons per day(ypd) - Basis of design flow(seats/persons/sq.ft., etc.): - Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: -- _ ___....................__ _ Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: - — Last date of occupancy/use: bate Other(describe below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons - How was quantity pumped determined? ---............----- Reason for pumping: t5insp,d0c•rev,M-612018 Title 5 offivaf Inspection Form tiubsurtace sewage Disposal system-Page 8 of Is Commonwealth of Massachusetts Title 5 Official Inspection Form `h Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 6_97_Old-Stage Road Property Address Gerard &Kathleen Fulham Owner Owner's Name information is required for every Centerville Ma 02632 7/13/2020 page, Citylrown State Zip Code Date of Inspection D. System Information (coat.) 4. Type of System: ❑ Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest. inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ® Other(describe): 1000 gallon septic tank, 2 1000 gallon leach pits Approximate age of all components, date installed (if known)and source of information: original system 1976 & new leach pit added 2004 Were sewage odors detected when arriving at the site? ❑ Yes M No 5. Building Sewer(locate on site plan).- Depth below grade: 1.5 feet Material of construction: ❑cast iron 0 40 PVC ❑ other(explain): Distance from private water supply well or suction line:. feet Comments(on condition of joints, venting, evidence of leakage, etc.): Joints in good condition, no leakage, vented through roof. t5insp,doc•rev.7/2612018 1ale 5 Dfficial Inspection Form.Subsurface Sewage Disposal System•Page 9 of 18 r Commonwealth of Massachusetts Title 5 official Inspection Form - i Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 697 Old Stage Road Property Address Gerard & Kathleen Fulham Owner Owner's Name information is Centerville Ma 02632 7/13/2020 required for every - --._..._._._..-_-. _.___ page. City/Town State_ Zip Code Date of inspection D. System Information (cont.) 6. 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: 1000 gallons - ------ 5" Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 3' Scum thickness 2" - - - - Distance from top of scum to top of outlet tee or baffle --- Distance from bottom of scum to bottom of outlet tee or baffle 10" How were dimensions determined? Opened covers and took measurements 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 was recently pumped and should be done again every 2 years for proper maintenance. water level was even with outlet, tank was not leaking and was structurally sound. 15msp.doc•rev 7/2612018 Title 5 Official inspection Form Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts r ow f7 Title 5 Official Inspection Form P Subsurface Sewage Disposal System Form Not for Voluntary Assessments 697 Old Stage Road Property Address Gerard& Kathleen Fulham Owner Owner's Name ....... information is required for every Centerville Ma 02632 7/13/2020 page- CityfTown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete 0 metal El fiberglass F1 polyethylene ❑ other(explain): ....................... Dimensions: Scum thickness Distance from top Of Scum to top of outlet tee or baffle Distance from bottom of Scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): .....-—---------- B. Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: El concrete 0 metal El fiberglass El polyethylene El other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp,doc-rev.7126t2018 Tillo 5 Offtial inspection Form Subsurface Sewage Disposal system-page i 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ' 5 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 697 Old Stage-Road� .. - -.__. Property Address Gerard &Kathleen Fulham Owner Owners Name Information is Centerville Ma 02632 7/13/2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank (cont.) Alarm present: ❑ Yes ❑ No Alarm level: - Alarm in working order ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.).- Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert N/A — Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): —- -- ............................. 15insp,doc•rev.71261`2016 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 12 of 18 f ., Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 697 Old Stage Road Property Address Gerard & Kathleen Fulham Owner Owner's Name information is Centerville Ma 02632 7/13/2020 required for every __.__,___ _ page, City/Town State Zip Code Date of Inspection D. System Information (coat.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No` Alarms in working order: ❑ Yes ❑ No` Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): 1 `If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: I Type: ® leaching pits number: 2 ❑ leaching chambers number: - ❑ leaching galleries number: — ❑ leaching trenches number, length.- El leaching fields number, dimensions: --.........- ❑ overflow cesspool number: ---- ❑ innovative/alternative system Type/name of technology: ---- t5insp.Goc•rev.7/25=18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts Title 5 official Inspection Form -# Subsurface Sewage Disposal System Form -Not for Voluntary Assessments T - 697 Old Stage Road Property Address Gerard & Kathleen Fulham _ Owner Owners Name information is Centerville Ma 02632 7/13/2020 required for every _. _.._. page, Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): s.a.s. consists of 2 leach pits in series. 1 s' leach pit had standing water to outlet invert. 2nd pit was located and opened and was found with 2"of standing water with a faint stain line approx 2'from bottom. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration ------------- -- Depth—top of liquid to inlet invert ----- Depth of solids layer Depth of scum layer Dimensions of cesspool — Materials of construction - - Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc rev.7/2S12fItS Title 5 Official Inspection Form Subsurface Sewage Dieposel System•Page 14 of 19 Commonwealth of Massachusetts a Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments s 697 Old Stage Road Property Address Gerard & Kathleen Fulham Owner Owner's Name Information is required for every Centerville Ma 02632 7/13/2020 CitylTown page. State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions _...... - - Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): l5insp.doc-rev WIM018 Title 5 pificral Inspection Form:Subsudoce Sewage Disposal System-Page 1 S of 18 I Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 697 Old Stage Road Property Address Gerard& Kathleen Fulham Owner Owner's Name information is required for every Centerville Ma 02632 7/13/2020 ., page. 6tyfrown State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately Al -5 Z� 30 3 tsinsp,dac•rev.7126=1a Title 5 t 17f1 c a Inspection form SrEbsdEAace Sewage Disposal System•Page 16 of 16 Commonwealth of Massachusetts �. Title 5 Official Inspection Farm == Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ' 697 Old Stage Road Property Address Gerard & Kathleen Fulham Owner Owners Name information is Centerville Ma 02632 7/13/2Q2Q required for every — . page. Cityrrown _ State - Zip Code Date of Inspection D. System Information (cunt.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain. You must describe how you established the high ground water elevation: Groundwater was established by accessing town of Barnstable groundwater contour maps. Before filing this Inspection Report, please see Report Completeness Checklist on next page. 15inap,9oc-rev.7126/2018 Title 5 official inspection Form.Subsurface Sewage Disposal System-Page 17 of 10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments �.fir' 697 Old Stage Road Property Address Gerard & Kathleen Fulham Owner ...- -------.._.__... __......._.. Owner's Name information is Centerville Ma 02632 7/13/2020 required for every — ----.--.-._...—. page. Cityrrown State Zip Code Date of Inspection--- E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist)completed ® D. System Information: For 8: TighVHolding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included 15insp.doc-rev.7f26=18 Title 5 Official Inspection Form Subsurface Sewage Disposal System-Pape 18 of 18 5Z25� 3 AP ,� �� I � r�ov i � 2004 /� G FARCE 1 ��� ABLE A-0� J OtT I2 T( dT dT. DATE 10127104 PROPERTY ADDRESS 697 Oid Stagy Rd.. h ' Centeay.iiie, Na., 02632 On the above date, the4eptic system at the address above was Inspected. _ This system consists of the following: ' 1. 1- 7000 gaeeon zept.ic tank. 2.,2-1000 gaiion .eeach.ing p.itz. Based on Inspection, I certify the following conditions: 3. 7h.iz .iz a 1-it$e dive zept-ic zyztem (78code) 4. 7he zept.ie zyztem .ie in Raope¢ woak.ing oadea at the paeaent time. 5. LP#1 ha-6 40' watea to .inveat.-LIP#2 .iz day SIGNATURE Name: Robert A. Paolini Company:-Joseph P. Macomber A Son Inc . Address: P. 0. Box 66 Centerville, Mass 02632 Phone: 508-775-3338 or 508-775-6412 mom .. (JO S PH P. MACOMBER.& SON, INC.. Tanks-Cesspools-Leachfields Pumped & Installed Town Sewer Connections P.O. Box 66 Centerville, MA 02632-0066 775-3338 775-6412 • COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFgIGE.OF EqR0rNj BN.T. AFFAIRS -,- DEPAjtTMENt•0F N� ON�3�NTA�pR,�� CTION d y y� Y A TITLE 5 OFFICIAL INSPECTION CORM-.NOT.:�OR'OSAL SY'I`E1NI p'ORMRY WNTS SUBSURFACE SEWAGE DISP PART-A CERTIFICATION Property Address: 697 O-e d ^S i s de Cente2v.iia l7� -- owner's NameAd2on Go"odaY-e Owner's Address: a Date of Inspection: Name of Inspector:(please print) Company Name: mac S:prt Sic. Mailing.Address: Cen ezv.c e, � u-.,02632 Telephone Number: 5 0 8-7 7 :3 3 3 8 CERTITICA,jjON STATEMENT personally inspected the sewage disposal system.at this address wasae rmed basaed on my I certify that I have perso y p ectton p below is true;accurate and complete as of the time of the inspection.The insp_ systems.I training and experience in the proper furicfion and maintenance itlo 5(3 0 CMR�15©00)disposal system' a DEP g approved system inspector pursuant to Section.l5:3 X,XX' Passes. Conditionally Passes the Local Approving.Authority AgNeeds ,IlluerEvation,by -' • DA . Inspector's Signaxure: rovin Authority.(Board of Health or The system inspector shall submit a copy of this inspection repore�to the.App g10,000 p 30 days of completing this inspection.If the system.ls a.shared sy�tetn°r has a design flow of of the DE ) roving. d or greater,the inspector and the system owner.slialT submit 4,t1�s nptoo lie buye p f pp�ableoa'd the 1 app i gP. DEP.The original should be sent to the system own authority. Notes and Comments er tions of use at-that und **** ' only describes conditions at the time of inspectioit-and he fgtureeunderlthe game or d different Thts report y v^ time.This inspection does not address how the system will perform to conditions of use. All 5/2000 page 1 . Page 2 of 11 OFFICIAL INSPECTION,FORM—NOT FOR NOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR " PARTA CERTIFICATION(continued) Property Address: 697 0—Rd. S.t a ge Rd.� Cen.te2v.i.P.ee, Ma., Owner: {la2onnn�/r�,0� Date of Inspection: 9 0/2 7/0 4 Inspection Stinrmary: Chit& A;B C,D or.E/ALWiAVS:.complete:all of Section, A. System Passes: no I have not found any information which indicates'thAf any of the failure criteria described in 310 CMR 1 3 3.or in 310.CMR 15.304 exist.,Any failure criteria not evaluated are indicated below. 2. Comments: The zept.ic zuz.tem .i. in /2,oj P_ . o r- _g o �_ at .the a2e.sen.t iime , B. System Conditionally Passes: no One or more system components.as described in the"Conditional Pass"lsection.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. no The septic tank is metal and.over 20 years old*or the septic-tank(whethor metal.or not)is:structurally unsound,exhibits substantial infiltration or ex.filtration.or tank.failure is lmmineni: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: n o 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. . obstraction is removed distribution box is leveled-or-replaced ND explain: n o 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 pipes)are replaced obstruction is removed ND explain- 2 Page 3 of 11 OM. --CIAL UV'SM- CTION FORM.NOT OR INS1�VOLUNTARY , ��ASSESSMENTS SUBlt t"A�CE SEWAGE OISROSAL PART°A . . CERTIFIC 'RON(6oritinued) : Property Address: h 9 7 OLd S Owner. n a,n o n r o•o r�-2 e...._ Date of Inspection: °n i ') 7 4/1, C. Further Evaluation-is.Requiired by,the Board of Health: no Conditions.exist which require further..e.valuation-by the Board.of Heaith;in order.:to;detertriine ifthe system is failing to protect public-health, safety or the environment. 1. System will:pass unless Board oi'.11lealth deteronestin&ccordance with 310.CM1Et 15:303(1)(b)that the system is-not fuiretionitrg iu.a•mantrermwhieb w111•protect public health,safety anil.tbe*nVironment: n o Cesspool or privy is.within:50 feet of asurface water n 0 Cesspool or privy is within 50 feet of-a bordering vegetated wetland or a salt marsh. t Board-of (and and Public Water Supplier;-If any),dk ermines that the e 2. System will fail unless h a system is functioning in a mariner.that protects the public Health,safety and environment: The system has a septic tahk and soil absorption system-(SA•S)..and the SAS is within 100 fe.et.of a surface water supply or-tributary to a surface water-supply. n o The system-has a.septic tank and SAS and the:SAS is!w•ithin a Zone 1 of a-public water�supply. -the SAS is within:.50 feet of a private water.supply well. n o The system has a septic tank and.SAS and a oo The system has a septic tank and SAS and the?SAS is less than 100 feet.but 50 feet or.rdore fromfi 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: Page 4 of 1 I OFFICIAL•INSPECT.ION FORM-NOT'FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL:SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 6 9 7 0.9d Stage Rd, Cent eavi e ee, Na., Owner: 4uaon. Gooda-ge Date of Inspection:)0 Y 7/lf4 D. System Failure Criteria applicable to all systems:. You must.indicate."yes"or"no"to.each.ofthe:following,for s1l-inspections: Yes No x Backup.of sewage:into fat'hity.or system component dueto overloaded.or*clogged SAS....or.cesspool x Discharge.or ponding of effluent to thm i4face bf the...gound 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 thank"below invert or.available volume is less than'Wday 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 Ariy_portion of cesspool or privy is within 100 feet of a surface water supply.or tributary to a surface water supply. x Any portion:ofa cesspool or.privy_iswithin-a:Zone!1ofapublic.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 510.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 colifortn bacteria and volatile organic compounds indicates:that the well is.free from pollut;ok.from:-.tb t.facflity and:the presence of ammonia nitrogen and nitrate nitrogen is equal to or less thaii.5 ppm,provided that no other failure criteria are•triggered.A copy of the analysis must be attaehed.to this foriq.] no (Yes/No).The system fails.I have determined that-one ormore 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 convect the failure. E. Large Systems: To be considered a large system the:system mustserve.ataeility,with a design flow of 10;00.0 gpd-to 15;Q00. gpd• A. 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 x the-system is within 400 feet of a surface drinking water supply x the system.is within 200 feet of a tributary.to a surface drinking water supply x. the:system is located In a nitrogen sensitive area Qnterim 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 tender 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. 4 Page 5 of I 1 OFFICIAL INSPECTION TORM—NOT FOR VMUNTARy ASSESSMENTS �- AtSURFACE-SEWAGE DISPOSAL"SYSTEM INSPECTIOON F RM PART CHECKLIST Property Address: 6 9 7 O ed .S t a ye Rd., Cen e2v.� .fie, ('la.• - Owner:: 4 ali o a- �o o d_a_L9_- Date of Inspection: I M Check if the following have been done You must indicate"yes"yr"no"as-to each.of the f owing: Yes No s " -x — Pumping informationvwas provided-by the Qwner,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 d1inspoction? x Were as built plans of-he system'obtained and examined?(If they were not available note is N/A) W x Was the facility.or•dwelling inspected for signs of sewage back up? x Was the site inspected for signs of break out? z • _ Were all system components,excluding the SAS;located on site'? x _ Were the septic tank manholes uncovered;opsned,and the interior of the tank inspected for the condition of the baffles or tees,material 6f construction,dimensions,depth of liquid,depth of sludge and depth of scum? x _ Was.the facility owner(and occupants if diffdrent 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 deternlined based on: •Yes no . . x Fxisting information:For example,a plan at the Board of.Health. _ x Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distan( is unacceptable)[310 CMR 15.302(3)(b)] u ram. _ 5 Page 6 of 11 OFFI?�IAL.ANSPTCTI?ON..- ,Q M'-NOT FOR VOLUNTARY ASSESSMENT5 SUBSUIR'ACE S VAGE OISPOSA:L SYSTUM INSPEMON:FORM PART.0 SYSTEM I 'ORPgTATLOAt Property Address: 6 9 7 Ud Stage Cent e2v.ebt, Ma., Owner: A.u.2o.rz Go oda-ee Date of Inspection: -1 0 14 2,.7/0 4 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(desxgn):,,.4- Number of.bedrooms.(actual): 4 DESIGN'how based on�310 CMA 15.,03':(for example:-1 IO'gpd x#ofbedroomsy. ''4 x:110=4 4 0 gpd Number of current residents .: 2 Does4esidence have a garbage grinder(yes br no):yx Is laundry on a separate sewsge.system(yes or:no):.ao [if yes separate inspection required] Laundry system inspected(yes or no): h . Spasonal use:(yes or no): rzo 2002_35,. 000 ga2ioaz q.�P.,D. _95.-89 Water meter readings,if available(last 2 years usage(gpd)): 2 0 n 3-31, 0 0 0 as 2 o n�s G. 1. D.- 84. 03 Sump pump(yes or no): n o Last date of occupancy:�2 e2 e-s e n t COMMERCIAL'a6USTRIAL Type of estab ; ,•. at: n a Design flaw. ' ed on310 CIv1R 15.203):. na cud Basis.of dMi i flow(seats/persons/sq%etc J; n a Grease trap`present(yes or no):`rz o Industrial waste holding tank present-(yes or no):na Non-sanitary waste discharged to the Title 5 system•(yes or no): Water.meter readings,if available: na Last-date of occupancy/use: , n n Ot4ER(describe)'. ..,.:.:.: y QENERA,L INFQRMATION Pumping Records Source of information: .a.'�•`�acom&ea and eon Was system pumped as part of the inspection(yes or no):Le2 If yes,volume pumped:1000. gallons--How was quantity.pumped determined? m e a s u lt e d _ Reason for.p..umping: TYPE OF SYSTEM , .K.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 15EP.approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: 19R - Were sewage odors detected when arriving at.the site(yes or no): n 6 Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 6 9 7 0.2d Stage Rd. CPn#v_nuiJ�l�v� as Owner: R a z o rz y o o a e Date of Inspection: 1 n f 7/'a z w WELDING SEWER(locate on site plan) Depth below grade: 147 Materials of construction:_oast iron xx 40 PVC_other(explain): Distance from private water supply,,wel�or suction line: l 0 t , Comments(on condition of joints,venting,evidence ofleakage,etc.): Io.intz aRRea2 tight 4o ev.idencg o,P .Peakage System vented thnouyh house vent.a.� SEPTIC TANK:oe 4locate on site plan) Depth below grade: 16" 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 certificate) or no):_(attach a copy of Dimensions: $' 6-.Pon g/4, 1 n',,),r/n l ' R"h.igh Sludge depth: p Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: f4n Q a Distance from top of scum to top of outlet tee or baffle:n os c u Distance from bottom of scum to bottom of outlet tee or baffle: n o 3 c u m How were dimensions determined; A„„o rl Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7nnk nnnonn•,t Alai! c1jinn00ii tni,nr/ Tn0 rrn� nl/f0of tees ate 7 Sep -ic tank z-hM r' e umpe , m . - GREASE TRAP;n o (locate on site plan) Depth below grade:n a Material of construction:_concrete metal—fiberglass_polyethylene,other (explain): n n Dimensions: n a Scum thickness: n n Distance from top of scum to top of outlet tee or baffle: n a Distance from bottom of scum to bottom of outlet tee or-baffle: n n Date of last g�in " p�P� csa Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 2ea-6e t2a2 not 22 nt TWA S TnO AMAn Tang►„Aii tionnn 7 Page 8 of OF1F'ICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS :5 WR ACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 6 9 7 O ed S t a ae R owner-• Ala Gooch Date of Inspection: 1_Q,./27 C.a 4 TIGHT or F Q.LDING TANK:rLa_(tank must be pumped at time of inspettion)(locate on site plan) Depth be'lowgrade:na Materiat of construction: concrete metal fiberglass polyethylene other(explain): Dimensions: Capacity:aci n n gallons \ Design Flow: nrt gallons/day Alarm present(yes or no): Alarm level:na Alarm Ln working.order(yes or no): na Dote of last pumping: n,7 Comments(condition of alarm and float.switches,etc.): T:94 f o h o.g d bra 4 a n do no 4 "Q 6 3 A.ra DISTRIBUTION BOX-no (if present must be opencd)(locate on site plan) Depth of liquid level above outlet invert:n g 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.) Dizta.igu.t"ion Sox no.t R aeheht... . PUMP CHAMBER: no (locate on sife.plan) Pumps in working order(yes or.no): na_ Alarms in working order(yes or no): nn Comments(note condition of pump,chamber,condition of pumps and appurtenances,etb): imnfhrimPP,? nnf• 41?pAnnf_ 8 . Page 9 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS -- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued). Property Address:6 9 7 L Qc[ C{a-9 Pd_' E te 61 Owner:. 4¢2or�, Gee _ Date of Inspection: Z n 2 7/n G w A A' SOIL ABSORPTION SYSTEM(SAS): g_.(locate on site plan,excavation not required) If SAS not located explain why: Type beaching pits,number:, 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.): � �. Al., n,, :rinnnn n1/ h�r�[��i / Qi'r nlhl/no nn 'nn nG. S0'�Q a/2Rea2h CESSPOOLS:n o (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: -na Depth—top of liquid to inlet invert: o Depth of solids layer: a Q Depth of scum layer: „n 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.): CehzP00ih not paesent.' PRIVY-no (locate on site plan) Materials of construction: na Dimensions: na Depth of solids: na Comments(note condition of soil,signs of hydraulic failure,level of'ponding,condition of vegetation,etc.): Q2ehen.t�__— Page 10 of 11 O»'F11 iA T�ISPFJC�'TQN T`OR�VI 0T.rFOR•?�A'T:UNT—A '.Y ASSESSMENTS. SUBSURFACE'SE AGE�MISROSAL S EA�f`.II�SBEG''i30N:FQR11f PARS'IC" SYSTEM YN g.RMATT.ON(e©nthiged)" Property Address: 697 0 J d Stage Rd,,. en ezv c e, a.' Date of Inspection: SKETCH OF . to Provide a sketch of the sewage disposal system inclu whe eeSubl�c least two s supply enar tthe building. or benchmarks.Locate all wells within 100 feet.Locate p — _ Ci.: 10 Page 1] of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY AS N FORM SESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM IN SPECPART C SYSTEM INFORMATION(continued) Property Address: 6 9 7 01 d e 12d. Owner:,An,L Ci � o -w Date of Inspection: 10 ' "4 i- - SITE EXAM Slope Surface water Check cellar. Shallow wells _ — - Estimated depth to ground water .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 rtviewed: 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: h rT� �Q���' u�'' �� �--. You must describe how you established•the high ground water elevation: used;Gahert & Miller model 12 1 used•USGS observation w 1 nj used- :'Technical bull — wa er a eva ions. IF Leaching �9 Pit : :eet l Groundwater: Feet Below Bottom-of Pit High Groundwater Adjustment 1.8 ft per 1ginVteeMethod S' I C'11 Therefore,the,vertical.separation distance between the bottom otthe leact ing pit and the adjusted groundwater table is � feet: e a•rrnnrrn+'Rr'•'TrT�r n ���R��'' *��j Tn � �owl w" r BOARD OF 11EAL, T11 TOWN OF ----� SIIIISU11FACR SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART D C0TIFICATIONr� ..�+,t.T.;.;;T��Iir.�•T.T'r1:RT.lII•RRRI TM1ilC6L7lST�R1T5M T•.•I+!lRrM anT7Cr'�l� -TYPE OR PRINT CLEARLY- PROPERTY INSPECTED , STREET ADDRESS :697 Oed' Stage R 0 a d 191-069 ASSESSORS MAP , Bly,O X AND ,PARCEL # 1. , Aaaon goodaie OWNER' s NAME PART D CERTIFICATION �2oge2.t l ao-2:�2�. i_ NAME OF INSPECTOR - COMPANY NAME Joseph P. Macomber &'' on Tnc COMPANY ADDR-ESS Box 66 Cent stree Tow, yr city state EIP t COMPANY TELEPHONE ( 508 ? 775 3338 FAX ( 508 •� 790 CERTIFICATION STATEMENT I certify that I have personally inspected ns ectedrted ith sewage distesil System a+ this address and that th.e information rep omplete as of the time of �inspection . The inspection was performed and any WecommendAions regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on. site sewage disposal systems . + Check one: XXX System PASSED i The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR. 15 , 303 , Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this. form . System FAILED* r The inspection which I have con � ' ted has found that the system fails t Protect the jau in accordance with 'Title blid health and the environment 5 , 310 CMR 15 , 30.3 , and as specifically noted on PART�C -_F_AILURE CRITERIA of this inspecti form . Date r f0 Z9221 Inspector Signature ne copy of this certification must •be provided 'to the OWNER, the BUYER (where applicable ) and the DOARD OP' HEALTH. . ..,,— * If the inspection FAILED , the►e owner or operator sh.a1] upgrade the system. within obe year of the date of the inspection., unless allowed or requi,red otherwise as provided in 3:;10 CMR 16 . 3-06 , partd .d; i COMMONWEALTH OF MASSACHUSETTS i EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION � d W= FI TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY SUBSURFACE SEWAGE DISPOSAL SYSTEM FO PART A CERTIFICATION MAY 14 2002 Property Address: 697 OLD STAGE RD CENTERVILLE,MA 02632 TOWN OF BAR.NSTABLE HEALTH DEPT. Owner's Name: MR THOMPSON Owner's Address: 2250 WEST CROWNPOINT BLVD#226 NAPLES, FL 34112 1 �� Date of Inspection: 4/8/02 �6 Name of Inspector: (please print) JOHN GRACI NAP k 9 Company Name: SEPTIC INSPECTIONS PARCEL ;. Mailing Address: _ P.O.'BOX 2119 TEATICKET, MA.02536 '+.••. LOT Telephone Number: 508-564-6813 FAX 508-564-7270 CERTIFICATION STATEMENT 1 certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the-time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: X Passes I Vh _ Conditional) Passes _ Needs Turth r aluation by the Local Approving Authority Fails Inspector's Signature: 6 Date: 4/8/02 The system inspector shall submit a ci y 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 v sent to the system owner and copies sent topthe buyer, if applicable,and the approving authority. Notes and Comments THE SYSTEM PASSES TITLE V INSPECTION. RECOMMEND PUMPING NOW AND EVERY TWO YEARS TO PROLONG THE SYSTEM'S-USEFULL:LIFE. "**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. ` t Title S i,_npriinn Pnrm i smnn I II- Page 3 of 1 1 d' { OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 697 OLD STAGE RD CENTERVILLE, MA 02632 Owner: MR THOMPSON Date of Inspection: 4/8/02 C. Further Evaluation is Required by the Board of Health: _ Conditions exist which require further evaluation by the Board of Health in ordl-r 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 feefof a bordering vegetated wetland or a salt marsh 5. 2. System will fail unless the Board of Health (and Public Water Supp,.'er,if any)determines that the system is.functioning in a manner that protects the public heaKh,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 aseptic tank and SAS and the SAS is within a Zone I of a public water supply. _ The system has a septic t9rik 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 n/a **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 b'e attached to tliis form. 3. Other: n/a , ` r f Page 4 of k OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 697 OLD STAGE RD CENTERVILLE,MA 02632 Owner: MR THOMPSON ' G Date of Inspection: 4/8/02 D. System Failure Criteria'applicable to all systems: You must indicate"yes"or"no."'to each of the following for alLinspections: 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 %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 Wa. _ 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 cesspooll'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.) (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'sj temtfails. 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 desigr, 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'systerns in addition to the criteria above) yes no " X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a'tributary to a surface drinking water supply y . X the system is located in a nitrogen'sensitive area(Interim Wellhead Protection Area—I WPA)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 5ecfio i D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. a Page 5 of 1 l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 697 OLD STAGE RD CENTERVILLE, MA 02632 Owner: MR THOMPSON Date of Inspection: 4/8/02 Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No X _ Pumping informationnwas 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 v er2,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'? X _ 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`? ta; The size and location of the Soil Absorption System (SAS)on the site'nas been determined based on: Yes no X _ Existing information. For'exairiple,a plan at the Board of Health. X _ 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)], .h` 5 Page 6 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 697 OLD STAGE RD CENTERVILLE, MA 02632 Owner: MR THOMPSON Date of Inspection: 4/8/02 FLOW CONDITIONS RESIDENTIAL .; Number of bedrooms(design): 4 Number.of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 1 10 gpd x#of bedrooms): 440 Number of current residents: 0 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): NO Seasonal use: (yes or no): NO, Water meter readings, if available.(last 2 years usage(gpd)): n/a Sump pump(yes or no): NO Last date of occupancy: 4/1/02 COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR'15203): n/agpd Basis of design flow(seats/persons/sq t,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the'Title 5 system(yes or no): NO Water meter readings,-if available:,n/a Last date of occupancy/use: o/a OTHER(describe): n/a if GENERAL INFORMATION Pumping Records Source of information: n/a ` Was system pumped as part of the inspection(yes or no): NO If yes, volume pumped: n/agallons`L- How'was quantity pumped determined?n/a Reason for pumping: n/a i 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 tech nology.,Attach`a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank Attach a copy of the GEP'approval Other(describe): n/a Approximate age of all components,date installed (if known)and source of information: 27 YRS BY OWNER-NFW,LFACH PIT BY MACOMBER 10 YRS. Were sewage odors detected when arriving at the site(yes or no): NO Page 7 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 697 OLD STAGE RD CENTERVILLE,MA 02632 Owner: MR THOMPSON Date of Inspection: 4/8/02' BUILDING SEWER(locate on site plan) Depth below grade: 18" Materials of construction:_cast iron X40 PVC_other(explain): n/a Distance from private water supply w1211 or suction line: n/a Comments(on condition of joints,venting,evidence of leakage,etc.): TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade: 12" Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age,confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: 1000G L 8' 6" H 5' 7" W 4' 10"" Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle:31" Scum thickness:3" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 15" How were dimensions determined: MEASURED Continents(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage;etc.): THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING SYSTEM NOW AND EVERY TWO YEARS. GREASE TRAP: _(locate on site p!.an) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): " n/a t ,t 7 Page 8 of I l • '.s OFFICIAL INSPEN TION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTE1sl INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 697 OLD STAGE RD CENTERVILLE, MA 02632 Owner: MR THOMPSON Date of Inspection: 4/8/02 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal fiberglass_polyethylene_other(e.xplain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day.; ;. . Alarm present(yes or no): N/A; =�; Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a .} Comments(condition of alarm and Float switches,etc.): n/a DISTRIBUTION BOX:X(if present,.must be opened)(locate on site plan) Depth of liquid level above outlet invert: n/a Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): NO D-BOX PUMP CHAMBER:_(locate on site plan) r., Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a a , i . 1! R Page 9 of I l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 697 OLD STAGE RD CENTERVILLE,MA 02632 Owner: MR THOMPSON Date of Inspection: 4/8/02 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation riot required) If SAS not located explain why: n/a Type 1000 GAL 6' X 6' leaching pits, number: 2 n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a fi innovative/alternative system Type/name of technology: n/a Comments(note condition of soil;�signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): THE LEACH PITS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.THE NEW PIT WAS 1/2 FULL AT TIME OF INSPECTION. HAS SOME SOLID CARRYOVER IN BOTH OLD AND NEW PIT RECOMMEND PUMPING NOW. BOTTOM OF NEW PIT AT 8' CESSPOOLS: (cesspool mukV.e pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil, signs of hydraulic failure, level of ponding,codition of vegetation,etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a 4 Page 10 of r OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 697 OLD STAGE RD CENTERVILLE, MA 02632 Owner: MR THOMPSON Date of Inspection: 4/8/02 SKETCH OF SEWAGE DISPOSAL.SYSTEM Provide a sketch of the sewage disposal system including ties to at least two per maaent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. t b I t s ag 0 o A( A) 3& M �Vt 00 PO t, Page 1 I of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 697 OLD STAGE RD CENTERVILLE, MA 02632 Owner: MR THOMPSON Date of Inspection: 4/8/02 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water'12+feet Please indicate(check)all methods used to determine the high ground water cicration: NO Obtained from system design plans on record- If checked,date of design plan reviewed: n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) NO Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: HAND AUGER- 12+ FT. 3 II r LOCATION SEWAGE PERMIT NO. 6 ?? D/w VILLAGE / INST ALL ER''S)') NAME i ADDRESS BUILDER OR ONVNER DATE PERMIT ISSUED f� DATE COMPLIANCE ISSUED �� y� �. . , P. � `� _ � � � � ti, � �� i f � � 1 w� �� � � � � � .� � roe �� THE COMMONWEALTH OF MASSACHUSETTS _ BOARD OF HEALTH ® i�1...............OF. ................................. . pplira#ion for Dispaa l Vurkg Tonotrnrtion ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ...... ..9.." .......-� ...... 1��::. .... ...._ ..--'-"'----.....---'------------'-'---'-------------------'---•--•---......---.....------. ocation n ress or Lot No. .f/jf_� ......... "A.. ? :�?V------. ------------------- ------------------------------•-------•--- ---•---------- --- t�I® -.........- a ....f.... ! ..... .' Address.....'................................... Installer Address Type of Building l Size Lot............................Sq. feet U Dwellin o. of Bedrooms.............................. .....Ex Expansion Attic g --------- p ( ) Garbage Grinder ( ) 't, Other—Type of Building .......:.................... No. of persons............................ Showers ( ) — Cafeteria ( ) 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 ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ fTq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Ix1'r------------- . ---•--•-----. Description of Soil.. ,�?�'....._ 1.Q, &��. --------------------------------------•------------------..._._...--'----•••..... x V --------------------••----'-----------.._...-•-......----------------••'-----.....---•-----....-----'---...--•------•------ ----------•-------------------------------- ----------•-----------•-------•-----•----•'-------....._... - --- V Nature of Repairs or Alterations—Answer when applicable... =�.____' ......_ m ZA)......................... .......0.Y.a tpg..Fl d.Gd/-'----------------•-------------------•------••---...•'---••----•-----•--------------------------------................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITU 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Cer4ofiance has been issue by t boar of health. Sign --- �m`' ... _... Application Approve Dat---------------------------- --------------- ,. �DateApplication Disapprowing reasons:............................................... ......._._.. •'------------------•---••--•--•----.........------•----••--------•-----•-----:-'••---•----.........---------------------------------------------------------------------------------------•--. Date Permit No........................•....---------'--------'-:....... Issued_.............................._... Date U114-�..-J�........... Fss..�-� o THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Appliratinn for 14spu,sa1 Works Tnn,strnrtion Vamit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: f ...... .' ......t a : .Loc . . ......d.:f��................ ..... - ............................ g f Location- ress or Lot No. Address ::........--:•d�1v_.... l:t Installer , Address UType of Building ,r Size Lot...............•.... Sq. feet Dwelling o. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ....................-------- No. of persons............................ Showers ( ) — Cafeteria ( ) 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 ( ) a Percolation Test Results Performed by------------------------------------------------- ....... .------- --•••--- Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit._..............__.. Depth to ground water---------............... 4� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ R' r ODescription of Soil.....'*. ....... C! ... ----------------------------------------------------------- x U , ...............................................-----•-----------•---•----------------....------------•-------------------------•-------------------------••--------------•-------...------•-•••----•-•--- W ...................... - - -------------------- - = U Nature of Repairs or Alterations—Answer when applicable_ -__ .:_.......... .......................... rlf-w.----••--•••••--•-•••---•---••••---•-•--•-•......•--.....-•-•-•-••••••-------••••-------••••••--•••••----•••-----••••-•-.....•-••-•......•--••-•---•-•-•••••• Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T I T U 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issue by thie board of health. Sig 1,�' f ------ --,c�,�'.... Application Approve ...... ----------•-••• ..................... ............................. Dat Date Application Disapproved f r t e following;reasons: .............................................. ........................................................ -•----------------------------------------•-------------------.-_------------•---------------- Date PermitNo......................................................... Issued-....................................................... Date THE COMMONWEALTH OF MASSACH SETTS BOARD OF HEALTH,or �rr�ifirtt�r ,af fanatt�rlittnr�e ��'�.-� y THIS )IS CERTIFY, That the individual Disposal System constructed ( -�'<�or Repaired x 1 P taller has been installed in accordant with the provisions of TI F the State Sanitary Code as de cr}brd in the application for Disposal Works Construction Permit No--- `........j................. dated__ '"' _P__.. I/ ------------------••.•• THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRU AS A GUARANTEE THAT THE SYSTEM WIL U CTION SATISFACTORY. DATE....._.7 a l s�.. .................................................. Inspector.... ... .. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 1J' r rt ..........OF.......e. ` " fs*` ..... No. . ._.---•• FEE. . ... is�rrrs�tl. '?,rkii Tonstrnrtia t rruti Permission is hereby granted..i_'`. -<r.�''........... -_-._ ...---.-/.... to Construct(,,j ) or,Aep it Indrvidual;lSeKrage/D>sposal System :f Street as shown on the application for Disposal Works Construction Permit No. ......... Dated.......................................... .......... ......... .. DATE-•--4�lj�ll'- --.-. '-_.-•- Board of.Health FORM 1255 A. M. SULKIN, INC., BOSTON