HomeMy WebLinkAbout0032 PARK AVENUE - Health ' L
ve. (Centerville)
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UPC 10259
No. H� 163OR �bsr:co `'�
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Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 32 Park Avenue Assessor's Map 208 Parcel 21
Property Address
Harry C. and Kathleen L. Calhoun
Owner Owner's Name
information is Centerville MA 02632 December 23 2013
required for every
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
on the computer, v11
use only the tab 1. Inspector: '07
key to move your
cursor-do not David D. Coughanowr, IRS
use the return Name of Inspector
key.
Eco-Tech Environmental
Company Name
P.O. Box 1265
Company Address
West Chatham MA 02638
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 m training and experience in the proper function and maintenance of on site
P Y 9 P P P
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
❑ Needs Further Evaluation by the Local Approving Authority
December 23, 2013
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 is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****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•3/13 Title 5 Official Insp io or
m:Subsurface ewage isposal System•Page 1 of 17
I�
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
32 Park Avenue Assessor's Map 208 Parcel 21
Property Address
Harry C. and Kathleen L. Calhoun
Owner Owner's Name
information is required for every Centerville MA 02632 December 23, 2013
page. Cityrrown 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
y in 310 CMR 1&303 or in 310-CMR 15.304 exist,-Any failure-criteria not-evaluated are
indicated below.
Comments:
Inspector's Note==> 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
��I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 32 Park Avenue Assessor's Map 208 Parcel 21
Property Address
Harry C. and Kathleen L. Calhoun
Owner Owner's Name
information is required for every Centerville MA 02632 December 23 2013
page. Cityrrown 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 cr.G'neven 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 32 Park Avenue Assessor's Map 208 Parcel 21
Property Address
Harry C. and Kathleen L. Calhoun
Owner _ Owner's Name
information is required for every Centerville MA 02632 December 23, 2013
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
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
El ® than '/day flow
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 32 Park Avenue Assessor's Map 208 Parcel 21
Property Address
Harry C. and Kathleen L. Calhoun
Owner Owner's Name
information is required for every Centerville MA 02632 December 23 2013
page. Cityrrown 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.
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
32 Park Avenue Assessor's Map 208 Parcel 21
Property Address
Harry C. and Kathleen L. Calhoun
Owner Owner's Name
information is required for every Centerville MA 02632 December 23, 2013
page. Cityrrown 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?
❑ ® 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): n/a Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): n/a
t5ins-3/13 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
32 Park Avenue Assessor's Map 208 Parcel 21
Property Address
Harry C. and Kathleen L. Calhoun
Owner Owner's Name
information is required for every Centerville MA 02632 December 23 2013
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
System was upgraded in 1992 by J. P. Macomber(Permit#92-443)Approved permit application
indicates a three bedroom dwelling, but no design plan was provided, and the spot on the permit
application form for indicating design flow was left blank. Installed components were adequately sized
for a three bedroom dwelling according to the design criteria in effect at the time.
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? ® Yes ❑ No
Water meter readings, if available last 2 ears usage d 68 gpd
9 � Y 9 (gpd)):
Detail:
2012: 37,000 gallons 2011: 13,000 gallons
Sump pump? ❑ Yes ® No
Last-date of occupancy-,--*--- Da- - August, 2013
Date
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•3113 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
32 Park Avenue Assessor's Map 208 Parcel 21
Property Address
Harry C. and Kathleen L. Calhoun
Owner Owner's Name
information is required for every Centerville MA 02632 December 23 2013
page. Cityrrown 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's agent
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 n
❑ 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 32 Park Avenue Assessors Ma
spa` p 208 Parcel21
Property Address
Harry C. and Kathleen L. Calhoun
Owner Owner's Name
information is required for every Centerville MA 02632 December 23, 2013
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
21+ years. A In 1976 an overflow cesspool was added (Permit#76-162) In 1992 a 1000 gallon
septic tank, a distribution box, and a 1000 gallon precast leach pit was added. (Permit#92-443).
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 2
feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Sewer line appears structurally sound with no evidence of leakage or backup into dwelling.
Septic Tank(locate on site plan):
Depth below grade: 1.5
feet
.Materiel 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:
4 in
15ins-3/13 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
32 Park Avenue Assessor's Map 208 Parcel 21
Property Address
Harry C. and Kathleen L. Calhoun
Owner Owner's Name
information is required for every Centerville MA 02632 December 23, 2013
page. City/Town 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 30 in
Scum thickness trace
Distance from top of scum to top of outlet tee or baffle 10 in
Distance from bottom of scum to bottom of outlet tee or baffle . 14 in
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 is not required at this time. Maintenance pumping is recommended every 2-4 years. Tank
and tees appear structurally sound and functioning as intended. No evidence of leakage in or out was
observed.
Grease Trap (locate on site plan):
Depth below.gfade: ..r _ 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
•'' 32 Park Avenue Assessor's Map 208 Parcel 21
Property Address
Harry C. and Kathleen L. Calhoun
Owner Owner's Name
information is required for every Centerville MA 02632 December 23 2013
page. City/Town 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
32 Park Avenue Assessor's Map 208 Parcel 21
Property Address
Harry C. and Kathleen L. Calhoun
Owner Owner's Name
information is required for every Centerville MA 02632 December 23, 2013
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.):
D-Box appears structurally sound and functioning as intended. No evidence of leakage in or out was
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:
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
32 Park Avenue Assessor's Map 208 Parcel 21
Property Address
Harry C. and Kathleen L. Calhoun
Owner Owner's Name
information is required for every Centerville MA 02632 December 23, 2013
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1
❑ leaching chambers number:
❑ leaching galleries number: a
❑ 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.):
Soils above leaching pit appear unsaturated. No evidence of surface ponding, breakout, lush
vegetation, or other evidence of hydraulic failure was observed. Pit was dry at time of inspection.
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-3/13 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 32 Park Avenue Assessor's Map 208 Parcel 21
Property Address
Harry C. and Kathleen L. Calhoun
Owner Owner's Name
information is required for every Centerville MA 02632 December 23 2013
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.):
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
32 Park Avenue Assessor's Map 208 Parcel 21
Property Address
Harry C. and Kathleen L. Calhoun
Owner Owner's Name
information is Centerville MA 02632 December 23, 2013
required for every
page. City/Town 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
O
I�O CA I�§ON S�
-OF SEPTIC COMPONENTS
-DISTANCES IN DECIMAL FEET
A B C D
1 --- --- 11 15.5
2 --- _. --- 14 21
I 3 34 12
4 30 13.5 ---
---
Ll Pq 1'FD
0A/ q Y
IE�W 0S T§ � THIS SKETCH IS
BEST VIEWED IN
D WE 0 41n G COLOR FORMAT
Q L�L�L� 1/V
LA
PET C" 0 32
8
GAS LINE LJ V
pp n�n� JV DISTRIBUTION BOX n
UU m
2 1 a
1000 GALLON m
.SEPTIC TANK
PARK A VENUE 508 364-0894
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
32 Park Avenue Assessor's Map 208 Parcel 21
Property Address
Harry C. and Kathleen L. Calhoun
Owner Owner's Name
information is required for every Centerville MA 02632 December 23 2013
page. Cityrrown 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:
Town of 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
32 Park Avenue Assessor's Map 208 Parcel 21
Property Address
Harry C. and Kathleen L. Calhoun
Owner Owner's Name
information is required for every Centerville MA 02632 December 23, 2013
page. City/Town 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
PRECAST
LEACH
PIT
LO
N BOTTOM
OF
LEACHING
PIT
LEACHING IS - 1
ABOVE HIGH
GROUNDWATER
GROUNDWATER ELEVATION
PER GIS MAPS
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
4
No.�o 3 9 ? Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
4pliLatlon for Disposal *pstem Construction Permit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon je ❑Complete System ❑Individual Components
Location Address or Lot No. 3--2 4,r A(f — Owner's Name,Address and Tel.No.n 63-6 6—
Assessor's Map/Parceldop /doll I�1kru l`` r � ,i M 0 i�4,4 /'t
Installer's Name, dress,and Tel.No. �V�_r�+��_gg9 Designer's Name,Address,and Tel.No.
G�SM4X_A/00n =nQ-. GAIo��j N//�-
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Natur of Repairs or Alterations(Answer when applicable) o
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental C an of to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Signed Date
Application Approved by Date '
Application Disapproved by Date
for the following reasons
Permit No. oac 4,3 Date Issued I 1
No. 3 _ V 9 / Fee 5
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
2pplicatlon for �DisooSar 6pstem Construction permit
Application for a Permit to Construct( ) Repair{ ) Upgrade( ) Abandon,0 ❑Complete System ❑Individual Components
Location.Address or Lot No. a.r.k A u-e. Owner's Name,Address,and Tel No.nao3-
Assessor's Map/Parcel ao? doll 4a. (20- { 1vun 3. Fhr`( Ave.
Installer's Name,Address,and Tel.No. 6'C),S_.���_9 399 Designer's Name,Address,and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria(. )
Other Fixtures
�,Design Flow(min.required) gpd Design flow provided gpd.
Plan Date Number of sheets Revision Date
Title
Y
y Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) 42! Tl
P -
4
Date last inspected:
Agreement: +'
The undersigned agrees to ensure the construction and maintenance of the afore describe�n-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code an of to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health. _.
S'gned —�\ Date
Application Approved by Date
Application Disapproved by Date
for the following reasons.
Permit No. cgc /, _ Date Issued Cc� ( k 1 3
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY/ t/hat the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( )
Abandoned l by lj/t�(U(A� ` 0rl �C
at,;R P6rk, ,- ecop �c r{ ) l' has been constructed in accordance II
with the provisions of Title 5 and the for Disposal System Construction Permit No.�:(3 LA(-N dated )�.!-•I -
Installer G3��t Lily/./c. ( arS�ti ac.ti ny� .�.�C' Designer
#bedrooms Approved design flow gpd
The issuance of this permit shall not be lconstrued as a guarantee that the system willfunction^as d^es`iigne)d.
Date �r-} /� Inspector
No. 3C, �! % —2 Fee r✓�
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
misposal 6pstem Construction 'permit
Permission is hereby granted to Construct( ) Repair( ) Upgrade
-( ) Abandon(kj
q-,t System located at , , 6t i'[^ UP 0 r1 _r L)l /!_
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this permit. ---------
Date �� ' 13 Approved by
-20
gkp
'Now
EIM
HEW R06P To
LAYOVER EXST"G
� RCIO►'
Ey
JP �Ey
h
(21 V&FIP.4DER W
VLYWOOD PLITGH
TYPKAL
RAKE RAKE
(2)2A'C HEADER W#'
PLYMK70D FLITCH
32 PARK AVE MEAGHER CONSTRUCTION
CENTERVILLE, MA 508-428-0458
ISSUED FOR REVIEW•17 MAY 2015
SCALE:1/4"=V-a" SCREEN PORCH ROOF FRAMING S1 .1
l
EXIST EXIST
11 j �4Tl:Y
I i I�1�uL
i j.� [LI �i �f i_I"L:ll,lr� u •u'�I
DECK CONVERTED TO DECK CONVERTED TO
EXISTING SCREENED PORCH SCREENED PORCH EXISTING
SOUTH NORTH
VIF 4 -1�4 VIF TYPICAL ROOF CONSTRUCTION:
�.T NEW ARCHITECTURAL GRADE ASPHALT
SHINGLES TO MATCH EXISTING OVER
��LI I �LIrr11 30* ROOF FELT OVER 8/9' COX
L1 L _6
T '.1�.__ PLYWOOD - CONTINUOUS RIDGE VENT
W/ RIDGE CAPS TYP WOVEN SHINGLE
I, HIPS AND VALLEYS, TYP,
r l ® ® ® LIL
TYPICAL WALL CONSTRUCT'•IOW.
11t - WHITE CEDAR SHINGLES
L4 R a R, 6'+- EXPOSURE OVER
[ 16' FELT. 1/2' CDX PLYWOOD
SHEATHING, 2X4 N0.2 OR BETTER
1.rI i I. 7L h�R ,
I. SPF STUDS a 16. O.G.
C : ,I
DECK CONVERTED TO
SCREENED PORCH
EXISTING
32 PARK AVE FASTMEAGHER CONSTRUCTION
CENTERVILLE,MA
ISSUED FOR REVIEW-17 MAY 2015 508-428-0458
SCALE:1/4"=1'-0^ NEW SCREEN PORCH ELEVATIONS A2.1
511
EXISTING �/ j-EXISTING ;,'
SITTING ; / SITTING j; ,/
ROOM j!'/�, ROOM
3260
MEW SGREEM POOR
WN
EXISTING �N NEW
42x12 _ J SCREENED $
DECK PORCH o T
N ey
IqN �N I
I _I
v
On
RO 103 60
Maw Hm4Fn
PORcr1 wrrN wALLs
FRAMED OM TOP OF
2 e.AwTiw cecx NO
HISAT.
14'-T1' Mew aai4a9A6 LVL
TM0fBRL,O0=AT 5'Or-
STAGGERED TO EXIBTPIG
RM AIP EXTEMPED OUT
TO SUPPORT C.ORMER8
F-X1ST1N b� NFL
32 PARK AVE MEAGHER CONSTRUCTION
CENTERVILLE. MA
_ ISSUED FOR REVIEW-17 MAY 2015 508-428-0458
SCALE:1l4"=1'-0" SCREEN PORCH PLAN Al .1
0ATE!:--- 01______
PROPERTY ADDRESS:- 32 Park Ave
____Centerville.Mass____
02632
f,h .
On the above data, I Inspeoted the aeptlo ,eyster� at the above address.
Thls system conslsis of (he following;
1 . 1 -1000 gallon septic tank.
2 . 1 - Distribution box
3. 2-1000 gallon rync 6nmI3p -Mnl9gc*0AlV-the following oonditlona:
4 . This is a title five septic system. ( 78 Code )
5. The septic system is in proper working order
at the present time.
6. One pit is dry and the other pit has waste water 38"
below the invert pipe. Set up this way. //��
SIGNATUREt„/ _..L:.4
N a m e :_.�,.P .ej S 4 m to-L. ——
Company; Jos• ph_F � Nacomb.r_b Son , Inc ,
Address :_ Box_ 66---------_„__
__CentslyiIIaL H6j_02632-0066
Phone: S08_775_>>78-______
THIS CERTIFICATION OOES NOT CONSTITUTe A GUARANTY OR WARRANTY
+
k
JOSEPH P. MAOOMBER & SON, INC,
T+nkt•Cesspool�•le+chfl+ld+
Pumped 4 Init311/d
Town Sewer Conneotlons
P.O. Box 66 CentsrYlll•, MA 02632-0066
776.3330 775.6112
r:
r
l
�-\ COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
Uq
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 32 Park Ave RECEIVED
CentervillP ,Mass
Owner's Name: Pam Rri Gran
Owner's Address: y,�mA JUL 5 2001
Date of Inspection: 6 6 01
TOWN OF BARNSTABLE
Name of Inspector: (please print P Macomber jjr= HEALTH DEPT.
Company Name: J.P. Macomber & Son Inc
Mailing Address:P n Rnx 66
Centerville Ma 02632
Telephone Number:
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true, accurate and complete as of the time of 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 ection 15.340 of Title 5(310 CMR 15.000). The system:
Passes
_ Conditionally Passes
_ Needs Further Evaluation by the Local Approving Authority
F ils
Inspector's Signature: Date; "'!�
The system inspector shall mit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design now of 10,000
gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
I -
Page 2 of
OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 32 Park Ave
en ervi e, as .
Owner: Pam Briden
Date of Inspection: 6 6 11
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A S stem 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 septic system is in proper working order at the
present time.
B. System Conditionally Passes:
A-0 One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass.
Answer yes, no or not determined(Y,N,ND) in the for the following statements. If"not determined"please
explain.
100 The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
•A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
_L-"Q 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 pipc(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
lod The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
_obstruction is removed
ND explain:
2
Page 3 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 32 Park Ave
en ervi e, ass.
Owner: Pam Bri en
Date of inspection: 6 6 01
C. Further Evaluation is Required by the Board of Health:
41P Conditions exist which require f u-ther evaluation by the Board of Health in order to determine if the system
is failing to protect public health,safety or the environment.
I. 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 surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the
system is functioning in a manner that protects the public health,safety and environment:
0_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or rributary to a surface water supply.
SL The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply.
The system has a septic tank and SAS and the SAS is within SO feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 0 feet but 50 feet or more from a
private water supple well". Method used to determine distance ��I
"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����
3
r
`— Page 4 of I 1
OFFICIAL INSPECTION FORM —.NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:32 Park Ave
en ervi e, ass.
Owner: Pam Bri en
Date of Inspection: biblUl
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
Zclogged SAS or cesspool
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
squid depth in4eesp*vHs less than 6"below invert or available vol=c is less than '/,day flow
_
�equired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
Ztimes pumped�.
y 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
— �wa[cr supply.
�y portion of a cesspool or privy is within a Zone I of a public well.
y portion of a cesspool or privy is within 50 feet of a private water supply well.
, Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. (This system passes If the well water analysis,
performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.)
(Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303. therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve.a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either'yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
_ '/the system is within 400 feet of a surface drinking water supply
l/ th system is within 200 feet of a tributary to a surface drinking water supply
iv Wellhead n Area— IWPA r a mapped
_ _ the system is located m a nitrogen sensitive area(interim ellhe d Protection )o pp
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.
4
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 32 Park Ave
Centervl e,Mass.
Owner: Pam Briden
Date of Inspection: 6 6 01
Check if the following have been done. You must indicate`yes"or"no"as to each of the following:
Yes No
Pumping information was provided by the owner, occupant,or Board of Health
Were any of the system components pumped out in the previous two weeks'
_ Has the system received normal flows in the previous two week period?
Have large volumes of water been introduced to the system recently or as part of this inspection?
Were as built plans of the system obtained and examined?(If they were not available note as N/A)
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, eluding the SAS, located on site?
Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees, material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
TExisting information.For example,a plan at the Board of Health.
Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) (310 CMR 15.302(3)(b))
5 �
Page 6 of I 1
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:32 Park Ave
Centerville,Mass.
Owner: Pam Briden
Date of Inspection: 6/6/01
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):4- Number of bedrooms(actual): .3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x# oedrooms):f b
Number of current residents: 4-
Does residence have a garbage grinder(yes or no): 40
Is laundry on a separate sewage system (yes or no): (if yes separate inspection required)
Laundry system inspected(yes or no):
Seasonal use: (yes or no): .C.'9
Water meter readings, if available(last 2 years usage(gpd)):
Sump pump(yes or no): 0(
Last date of occupancy:
COMMERCIAL/INDUSTRIAL
Type of establishment: le
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.): Aeei
Grease trap present(yes or no): IV*
Industrial waste holding tank present(yes or no):VOL
Non-sanitary waste discharged to the Title 5 system(yes or no):.(4
Water meter readings, if available: ,rjJyl
Last date of occupancy/use: AIW
OTHER(describe): .(t�
GENERAL INFORMATION
Pumping Records
Source of information: 107- i0L11"ft1 e
Was system pumped as pal of the inspection(yes or no):_
If yes, volume pumped: C5 gallons-- How was quantity pumped determined?
Reason for pumping: y�
TYP F SYSTEM
eptic tank,distribution box, soil absorption system
Z,ZQ Single cesspool
j!e Overflow cesspool
Privy
/,/,I 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)
ICA Tight tank ti�)_Attach a copy of the DEP approval
Other(describe):
Approxj{nate amO all components date ins led fky�own) d sou a of formation:
Were sewage odors detected when arriving at the site(yes or no):,tfP
6
• d_
Page 7 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Propene Address: 32 Park Ave
Centervi e,Mass.
Owner: Pam Briden
Date of Inspection: 6/6/01
BUILDING SEWER (locate on site plan)
Depth bolo" grade: �+
Materials of construction: cast iron 40 PVC other(explain): - ,4$ �
Distance from private water supply well or suction line: 1d't
Comments (on condition of joints, venting, evidence of Icakage, etc.):
Joints appear tight;No evidence of leakage;System is vented
1000 gha�b through the house vent.
SEPTIC TANK: 4/(locate on site plan)
ri
Depth below ade: v`l
p I�
Material of construction: concrete.f/*netaLotk fiberglass t/__ppolyethylrne
,j other(explain)_ 4/7
I'tank is metal list age:A)2 is age confirmed by a Certificate of Compliance (yes or no):,O(attach a copy of
certificate) r v
Dimensions: �,�rr 1 l0 JXa
Sludge depth: „uet-
Distance from top of sludge to bonom of outlet tee or baffle:
Scum thickness:
Distance from top of scum to top of outlet tee or baffler
D:s:ar.ce from bonom of scum to bonom of outlet fee or Me:
Hoµ Here dimensions determined
:-;l 2_224&r,! ,<
Comments (on pumping recommendations, inlet and outlet to or baffle condition. srmct teal integrity, liquid levels
as related to outlet inven, evidence of leakage,etc.):
Pump the septic tank every 2-3 years Inlet & outlet tees are
in p l'ace-Thp tank i structurally sound and shows no "T—
evidence of leakage.
CREASE TRAA X41ocate on site plan)
Depth below gradc:4y
Material of construction: concrete metal.✓s�fiberglass,l/�polyethylent,(R other
'explain):_ &,,4
Dimensions: 40
Scum thickness: 141
Distance from top of scum to top of outlet tee or baffle: XIR
Distance from bonom of scum to bottom of outlet tee or baffle:�__,�fs,�
Date of last pumping: 4,W
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage, etc.):
Grpa-c;e trap is not present
7
i
Page 8 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 32 Park Ave
en ervl e,Mass .
,
Owner:Pam Briden
Date of lospection: 6/6/01
TIGHT or HOLDING TANG (tank must be pumped at time of inspect ion)(locate on site plan)
Depth below grade: N�
Material of construction: Z?±concrete,&O—metal V4 fiberglass / polyethylene.449 other(explain):
.410
Dimensions:
Capacity: ,V,/' gallons
Desien Flow: gallons/day
Alarm present(yes or no): _4
Alarm level: li44 Alarm in working order(yes or no):�A
Date of last pumping: 414
Comments (condition of alarm and float switches, etc.):
Tight or holding tanks are not present.
DISTRIBUTION BOX: Zif present must be o ened)(locate on site plan)
P P )
Depth of liquid level above outlet invert:_je,
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.):
Distribution box has two laterals.No evidence of solids
carry aver:No evidence of leakage into or out of the box
PUMP CHAMBER4#<(locate on site plan)
Pumps in working order(yes or no): //
Alarms in working order(yes or no): _
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
Pump chamber is not present.
r
8
Page 9 of 1 I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 32 Park Ave._
Centervi e,Mass .
Owner: Pam Briden
Date of Inspection: 6 6 01
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Lncaterl;ThP consists of 1 -10QO gallon septic tank;
_1 —Qi Gt•ri hut-i nn hox;2-1 000 gallon precast leaching pits
Type
leaching pits, number:
leaching chambers, number: D
leaching galleries,number: n
_.d2j2 leaching trenches, number, length:
_,QL leaching fields,number, dimensions:
overflow cesspool, number: C7
NU �1� " ,
innovative'/alternative system Type/name of technology: 111�J
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,
etc.):
Loamy sand to medium fine sand.No signs of hydraulic failure
or nondi_ng_Soils are dry Vegetation is normal New pit has waste
water 38" below the invert pipe the old pit is dry1This is the way
s stem
was set up.
(cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: D
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum laver:
Dimensions of cesspool: If J1
Materials of construction: Ali
Indication of groundwater inflow(yes or no):
Comments (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
Cesspools are not present.
PRIVY�Oe(locate on site plan)
Materials of consuuctio: yi9
Dimensions:
Depth of solids: NA—
Comments
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
Privy is not present.
9
Page 10 of I I r
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 32 Park Ave
en ervi e, ass.
Owner: Pam Bri en
Date of Inspection:6/T7-0-7
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
I�
�q
10
Page 1 1 of 1 1
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 32 Park Ave
Centerville,Mass.
Owner: Pam Briden
Date of Inspection: 6/6/01.
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:
/bta' from s i lans on record-If checked,date of design plan reviewed: --5
bserved site(abutting prope bservation hole witkin 150 feet of SAS)
ecked with loca oard of Health-explain:6V,141a ¢S
Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high round water elevation:
.-Installed system. 9/11 /92 Permit # 92-443
Used water contours map.
a re y & Milier Model
94
No water encountered at 14 '
11
•rT.'STr•fl.TTT.'rr lTR�lIIf'1T1'TR'TfitSR.lT'RI`.TT:T7f►JTRR1'TT\TfTr11L 11f'�lTiR RSA �'
TOWN OF Barnstable BOARD OF HEALTH
0 SUDSURFACE SFHACE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION I
"i^T••.•:• -S.IiT.^.�T TT•!.1'R.'TIfTTIriE'!?I1'T'RT'r-'.•I r111'i�771'111QrTITTCY�'�t'1tr� iRfF 11 ..rtr.'T•T•1. •�..^
-TYPE OR PRINT CI.EARL1'-
PROPERTY INSPECTED
STREET ADDRES$ 32 Park Ave Centerville,Mass. '
ASSESSORS MAP , BLOCK AND PARCEL # 298-021
OWNER' s NAME Pam Brided
PART D - CERTIFICATION I
NAME OF INSPECTOR Joseph P.Macomber Jr.
COMPANY NAME J.P.Macomber & Son Inche '
COMPANY ADDRESS Box 66 Centerville,Mass. 02632
Street Town or City State LIP
COMPANY TELEPHONE (508 ) 775 - 3338 FAX ( 508 1 790 - 1578
R
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at
this address and that the information reported is true , accurate , and
omplete as of the time of ,inspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems ,
• � i III;{ I,
Check one ;
zSy
steui PASSED
The inspection %4hich I have conducted has not found any information
which indicates that the system fails to adequately protect public
healLh or LIIe environment as defined in 310 CMR 161303 . Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form ,
System FAILED*
The inspection which I have con ucted has found that the system fails to
Protect the public !health and the environment in accordance with Title
5 , 3.10 CMR 15 . 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form .
Inspector Signature Date
Dne copy of this certification must be provided to the OWNER, the BUYER
where applicable ) and the BOARD OF HEAL1'll.
* If the inspection FAILED, the owner or"" orator shall u P pgrAde ' the system
within one year of the date of the inspection , unless allowed or required
otherwise as provided in 3.10 CmR 15 . 305 .
partd .doc
Sewage Inspection Instructions
A
1. Di u system.g P y m• f
2. What kind of pipe?�'/fie-G4 6D I
3. How deep are the covers ?,17M 3
4. How deep down is the pipe?
S. Show water line on diagram. 3 f`��
6. How far away leaching area is from water line.
7. How old is house ?
8. How many bedrooms?
9. Is there a garbage disposal?
10. How many people live in house?
11. Is house seasonal or yearround?
Pumping history
3 Engineers drawn or asbuilt.
Is sprinkler system present?
. If near wetland measure distance from there to leaching.
. If system is near water table dig hole near leaching. At
least 5ft below leaching area.
If it needs to be pumped let us or owner know.
Laundry ?-Ig
Size of tank? (060
. What size leaching pits or cesspools?
2 What size leaching fields or trenches?
I Town Of Yarmouth add these:
2 Dimensions & amt of stone surrounding pits, gallies,
infiltrators etc.
2 Location of stain lines?
24 Distance from bottom of SAS to grade.
// /� A . .
/rY
��
l!
TOWN OF BARNSTABLE
SEWAGE #
V_ILL,r:,E Cey%erVi'lre. ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO. l ��ar'! �ci��To✓� �C.
SEPTIC TANK CAPACITY 'ZCOO
LEACHING FACILITYAtype) (size)
NO. OF BEDROOMS- —3 PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER rtl- :
DATE PERMIT ISSUED: q y —9
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
l
o /
O tg
No.... $ 30 00
. . . /� Fps.............................
THE COMMONWEALTH OF MASSACHUSETTS �•/ -
BOAR® OF HEALTH APPROVED
TOWN OF BARNSTABLE E;ar�xf 'i§dual
Appliration for Disposal Works Tons Date
Application is hereby made for a Permit to Construct ( ) or Repair (KXX an Ind Sewage Disposal
System at:
.....2.2...]? ---------------------•------ --•--•-•--------------� --------- 0 a r .....................
Location-Address or Lot No.
Bredin
Owner Address
W Jr .J.P.Macomber a ...........
Installer Address
Type of Building Size Lot............................Sq. feet
U Dwellin X-No. of Bedrooms_____________3____________._-_--___---.-_._Ex anion Attic� � p ( ) Garbage Grinder ( )
aOther—Type of Building ---------------------------- No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures ------------------------------------------------•--•----•-•••------•-----•-•----•-•-•---..-...-•-•--••--•••-••-•-••--•----••••••••-•--...............
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........................................
4
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
f14 Test Pit No. 2................minutes per inch Depth of.Test Pit...:................ Depth to ground water........................
a ....................-...............................................................................---••-•••-•---•--•----•-•----•••••----------...---•_...--
0 Description of Soil........................................................................................................................................................................
............................................................................ ----------------•--••---•----•-•-----._......._..••-••-••-•-•-••-•--••••---.....--••----
W
U Nature of Repairs or Alterations—Answer when applicable...--...........................................................................................
l_-1IlIlflgallan..Tank...l_-1IlDD...gallon__.].eac_p.i-t---1--_di-stribut-ion--•box..............................
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 Certificate of Complia ce has be n,hued b�'the boar of ealth.
Signed 1.s..�I.... `l�l/..�'1-------------- <------------------- 9/4/9 2
Dare
Application Approved By -------- ---- ---_ 1 ...... .�...^-
Date
Application Disapproved for the fo owing reasons- -------- -----------------_----_ ------ ---....
....................................................................................... ...... .. .................. ......................................................... ..... .............. ......................................
Dace
Permit No. ...... .� — -------------------- Issued ...........................
Date
,
X.
' r
No.--7�=-Y /� Fs$_.....1-3 0.0 0
THE COMMONWEALTH OF MASSACHUSETTS l/
BOARD OF HEALTH - -
TOWN OF BARNSTABLE
Applutttion for Disposal Works Construction A r ft �_g2_
Application is hereby made for a Permit to Construct ( ) or Repair (KX): an Individual Sewage Disposal
System at
...-3 2 P a,.r 1__-Ame..len t e r-Y__i 11 e-----•---------- ---------
Bredin ---------
Location-Address or Lot No.
Owner Address
aJ._•...Maco.....rer Jr.------------------------------------------------- ----------•----------------------------------.........---------......-•-••-•-••------...........--
Installer Address
Type of Building Size Lot----------------------------Sq. feet
U DwellinyX No. of Bedrooms-------------3.............____._..........Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Buildin
a yp g ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
dOther fixtures ---------------------------------------------------------------------------------------------------------------•------------------------•------------
W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area--------------------sq. ft.
Seepage Pit No--------------------- Diameter..-_-___-_-_-_.---_- Depth below inlet.................... Total leaching area------------------sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
HI Percolation Test Results Performed by.......................................................................... Date--------------------------------------..
W
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water.......................
fT4 Test Pit No. 2----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
P4 ------------------------------------------------------------------•------------------------------------------------------------------------------------------
0 Description of Soil...............................................................................------
V .-----------------------•...---•••-------•••-••-•-------------------........SaAd...&--Gravel------------------•------------
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
U Nature of Repairs or Alterations—Answer when applicable______________________________•__._-_____._-.-..-__•_-_.•...._-..---.-.-.-.--•--•--------------
1_-1_� allan•.leach_...pi_t...1.-distribution box.
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
n is fled bD the boar of ealth.
system In operation until a Certificate of
�Coa plia ce has beg s�/�/�'-/���/����/ YC
------------ -- .9/4/92
�!Y Z,t/ -- --- ---------------- ---------------
Date
Approved By ------------------- ----- --- .--� --`- ------
Application a`
--------------------------�`------------------ ---------
Dare
Application Disapproved for the fol owing reasons:
--------------------------------------------------------------------------------------------- -----------------------------------------
---------------------------------------------------------------------------- --------------------------- --
- - --- ------
Dare
PermitNo. ....... �__--y --..�>------------------- Issued ------------------------------------------------------------------- -
Uare �
THE COMMONWEALTH OF MASSACHUSE17S
BOARD OF HEALTH
TOWN OF BARNSTABLE
Cer#tfirak of C9outplianre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( XXX)
by----------J_._P-.-Macomber-- Jr.
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Installer
at ....--------32 Park Ave Centerville
.....................................I...............................................---------------------------------------------------- -----------------------=-------------------------------------------------------
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. ------7_ --_--- - - -- dated ------------------------------------------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
:- -
DATE--------------------------fit 7 l Inspector
THE COMMONWEALTH OF MASSACHUSETTS
BOARD - OF HEALTH
p J� TOWN OF BARNSTABLE
Disposal Works Tonstrurtion jkrmit
Permission is hereby granted_._J_.P.Macomber Jr.
- - - - - - ------------------------------------------------------------------------•---------------------------
to Construct ( ) or Repairx(XX) an Individual Sewage Disposal System
at No..--32...Park Ave Centerville,Mass .
- ----------------------------------------•-------------------------------------------------------------------------------------------------------------------
Street CC���,, //ff
as shown on the application for Disposal Works Construction Permit Dated------------------------------------------
------------------------------ ------------------------------------------------------
^ C) Boa
DATE 1•q- �� " f.............•---------------------------- ��JJ rd of Health
FORM 36508 H088S Q WARREN.INC..PUBLISHERS
L0C-&T10N ' G, SEW&GE PERMIT MO.
l
IPISTQLLE 5 IJ E hDDR S
BUILDER ' t\1 [� E A DDRESS
-plaTE PERMIT ISSUED '— 72 —�
D ATE COMPLI &MCE ISSUED :
o� 2
J
� yJ
�i�
�` dp
THE COMMONWEALTH OF MASSACHUSETTS
.._._� BOARD- F H ALTH
..........OF. ... .... l v .... .......
Appliration -for 13hipwiat' lVarkii TouBtrurtion Vautit
Application is hereby made for a Permit to Construct ( ) or Repair ( L) an Individual Sewage Disposal
System at
----------------- -_----_ - --------------------------------------
ocation-Address or Lot No.
......... ........ � .. L . ............... ------------------•--••-•---•----------•••••---
Ow/er;,o
----- ----••- .....Address
a �
In Address
UType of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ---------------------------- No. of persons............................ Showers ( ) — Cafeteria ( )
d 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 "lest Pit.................... Depth to ground water........................
f� Test Pit No. 2................minutes per inch Depth of Test Pit.-_--_----_.____-_- Depth to ground water............----------
--------------------------------------------------------------------------------------------•--------------------------------------
.----------------------
ODescription of Soil------------------------------------------------------------------------------------------------------------------------- .......---------------------------------------
x
-------------------------------------------------------------------------------------------------------------- ------
} J
V Nat e of Repairs or Alt a i —Answer when appli 1 -1...-_lam i--------..
X -`�.-^---------•------•----••------------------------------------------
greement
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b n sued b the board of he
g .............. .........-----�------. ------- --------------
' ate
Application Approved BY f� � s ----------------------------
Date
Application Disapproved for the following reasons:---------------------------------------------------------------------- ---......---•--•-----_ ---•--........
----•-....-------•-•--....--•-------•........................•--•........--------•-----••--•--------=---•-----•------..--•-•-•-••------•-----------------•-•-----------..-•••--------......------------.
- Date
Permit No.....................................-................... Issued... .��:�4_c�. �--•---•--- •--•-•-
Date
P7 / ®c%
No.. . ........... Fps.. :7:777=......
THE COMMONWEALTH OF MASSACHUSETTS
--�.... BOARD". F H LTH
1 �- - OF ...r .
...................
Appliration -for i o tt1 orkii Towitrurtion Vrrui t
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
Location-Address or Lot No.
........ •......... ....... r --- ----------- ••.----------------
...........:-.....................................................................................
Owner G ............•..................Address...
In alley Address
UType of Building Size Lot----------------------------Sq. feet
Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building _........................... No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures -----------•-----------•------•------•--------••--------------------------------------------------------------------------------------------• ------
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--.--_---------------------------- F kY
a Test Pit No. 1................minutes per inch Depth 'of Test Pit.................... Depth to ground water.___-_.____--__._..__.
Gi, Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water_-___._..__-________.._.
a ---------------------------..................................................................................................................................
ODescription of Soil----------------------------------------------------------------•-------------------------------- --------------------------------------------------------------------
x --------------------------------------------------------- ---•-•---------••-••-•--••-••••-•-=
W -------------------------------------------------------------------------------------------------------------- ^
U Na re of Repairs or Alt ratt —Answer when appli b . -? ..._.__ .___________f .r� __ %-____{---------
1-4._G 2 1 T`�✓/f •--•----- �.^-------•-------•-------•---••----------•------------ ---- --
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has e�n issued by the board of he ltli
Si e -':'1 A -•--------------
Date
Application Approved By-----.! ll�} -------------------------------
Date
Application Disapproved for the following reasons:_..............................................................................................................
-----------------•-•-------------•--------•-••--•---••----------•---•---------------•----------------•---------------------------------------------.-----•---•--•---------------------------------.-•---
Date
PermitNo----------_----------................................. Issued...................---- ................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEALTH
..........OF.... ... tip .. . . ...... .......................
uIrrtifiratr of f6om li�tnrr
THIS IS T ERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (�
t Inst ------------
er �1
at----- `--------2--Z--••/1t-'-1-k- -- --
has been installed in accordance with the provisions of u 'cl XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit N .._:._._ _ ____________________ ---.---•-.__•-_-
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE............. r ---��-----•-•-----•-•---•------- Inspector-- G
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O/F7 HEALTH ._
G/ ...............O F-- .......
z �
No. FEE•- ••--•••-•......-----
Bi-sVo,ittl Work LIT rnrtiott , rmit
PerV�.Ct..Oi��
is hereby granted ' �y` °. '•---•----------- .......................•------
to Cons �o Repair (�/) an ividua e�ge Z__
;
at No....... N -----------------
Street //
as shown on the application for Disposal Works Construction/ ��_.__. Dated_.. ___ _ --- .......
o HHeal
DATE.........I•----••••--...•--•-----•----•"-•--••-------•--------•-....---••-....
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS