HomeMy WebLinkAbout0123 PHINNEY'S LANE - Health 123 Phinney's Lane (Centerville)
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- Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
123 Phinney's Lane
Property Address
Marianne Hughes
Owner Owner's Name
information is
required for every Centerville MA 02632 9-16-14
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 A. General Information
filling out forms \,��pUlttu7lq��ry�
on the computer, �����`tH OF!(� �i,,,
use only the tab 1. Inspector. + lY .�.��,q• . Ssgc
key to move your t ••` o�,,.•• •• ••••"•
cursor do not
rat
use the return James D.Sears ;' JAMES ym
—
key. Name of Inspector = —
Capewide Enterprises,LLC =*W.
m�11 Company Name � j'e ��5��
153 Commercial Street N
Company Address -- � 1
"as _ MA 02649 _
City/Town 508-477-8877 St S ate ate Zip Code
Telephone Number License Number
B. certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 16.000). The system:
® Passes
❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
_ 9-16-14
spector'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.
ISins•3/13 T Ile 5 Oflidal hts an F Patti .Subsurface Sewage DisposaR System•Page 1 of 17
iSep 16 14 11:30p p.2
Commonwealth of Massachusetts
v. Title 5 Official Inspection Form
A Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
123 Phinney's Lane
Property Address
Marianne Hughes
Owner owner's Name
information is required for every Centerville MA 02632 9-16-14
page. Citylrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
The system is a 1000 Gal.Tank and Pit.
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 W13 Title 5 oHielal Inspection Form:Subsuface Sewage Dlsposal System-Page 2 of 17
Sep 16 1411:31 p p 3
COMMOnwealtth of Massachusetts
Title 5 Official Inspection Form
s. Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
123 Phinne 's Lane
Property Address
Marianne Hughes
Owner information is Owners Name
required for every Centerville MA 02632 9-16-14
page. Citylrbwn State Zip Code Date of Inspection
B. Certification (cunt.)
❑ Pump Chamber Pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or-due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed
❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction' is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1- System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet off-a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
Mrs•3113
Title 5 Otticial Inspection Form:Subsurface sewage Disposal System•Page 3 or 17
Sep 161411:31p p4
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
123 Phinnev's Lane
Property Address
Marianne Hughes
Owner Owner's Name
information is
required for every Centerville MA 02632 9-16-14
page. cityJTown Stale Zip Code Dale 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 nitrats 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 pond!ng 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
Q z Liquid depth in ONSIM is less than 6" below invert or available volume is less
than %Z day flow
Uins•M3
Title 5 Official rnspealon Fortre Substance Sewage Disposal System•Page 4 of 17
Sep 16 1411:31 p p 5
Commonwealth of Massachusetts
Title 5 Official Inspection Form
k Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
i•
123 Phinney's Lane
Property Address
Marianne Hughes
Owner information is Owner's Name
required for every Centerville MA 02632 9-16-14
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ®. Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails_I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303,therefore the system fails. The
system owner should contact the Board of Health to determine what.witl 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 11 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
lSns-3/13
Tllle 5 Miiciel Inspecdon Form:Subsurface Savaga oisposat system•pages of 17
Sep 16 14 11:32p p.6
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
123 Phinney's Lane
Property Address
Marianne Hughes
Owner Owners Name
information is
required
aired rnr every Centerville MA 02632 9-16-14
page. Cky/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following,-
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® 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 NfA)
® ❑ 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): NA Number of bedrooms (actual): 2
DESIGN flow based on 310 CMR 15.203(for example. 110 gpd x#of bedrooms): 220
15ins•3l13 Mile 5 o►rrcial Inspection Form;SW=Xace Sewage Disposal System•Pape 6 of 17
Sep 16 14 11:32p p.7
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
•r 123 Phinney's Lane
Property Address
Marianne Hughes
Owner Owners Name
information is Centerville
required for every MA 02632 9-16-14
Page, Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
The system is a 1000 Gal Tank and Pit.
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection
information in this report.) ❑ Yes ® No
Laundry system inspected? ❑ Yes 0 No
Seasonal use? ® Yes ❑ No
Water meter readings, if available(last 2 years usage(gpd)): 2012-67,OOOGal
Detail: 2013-64,000Gal's
Sump pump? ❑ Yes ® No
Last date of occupancy: NA
Date
CommerciallIndustrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.fL, 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, d available:
t5ins•3713 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Sep 16 14 11:32p p 8
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
r 123 Phinney's Lane
Property Address --
-Marianne Hughes
Owner Owners Name
information is
required for every Centerville MA 02632 9-16-14
page. Cityrrown State Zip Code Dale of Inspection
D. System Information (cons.)
Last date of occupancy/use:
Date
Other(describe below):
General Information
Pumping Records:
Source of information: NA
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box,soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no)(if yes, attach previous inspection records, if any)
❑ Innovative/Altemative 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):
t5ns•3n 3
nue 5 Ofridal Inspection Form:Subsurface sewage❑isposal system Page 8 ct 17
Sep 16 1411:33p p g
Commonwealth of Massachusetts
Title 5 Official Inspection Form
,a a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
123 Phinney's Lane
Property Address
Marianne Hughes
Owner Owner's Name
information is
required for every Centerville MA 02632 9-16-14
page. Citylrown State Zip Code Dale of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
1993 Permit 93-408.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 34"
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_):
Pipeing House to tank 4" PVC SCH 40 Pipeing tank to pit 4"PVC SCH 20
Septic Tank(locate on site plan):
Depth below grade: 22"feel
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 Gal. Precast H- 10
Sludge depth:
1"
Bins•3/13 Tine 5 official inspection Form:Subnafaca Sewage Disposal System•Page 9 of 17
Sep 16 14 11:33p p.10
Commonwealth of Massachusetts
�t Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
1.23 Phinney's Lane
Property Address
Marianne Hughes
Owner Owner's Name
information is
required for every Centerville MA 02632 9-16-14
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 29
11
Scum thickness
0"
Distance from top of scum to top of outlet tee or baffle 12"
Distance from bottom of scum to bottom of outlet tee or baffle 18e
How were dimensions determined? Asbuilt-Tape
Sludge Judge .. ._ _
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 at working level. Tank and outlet cover at 22"w/inlet cover at 6". inlet tee-outlet baffle. No
sign of leakage or over loading
Grease Trap(locate on site plan):
Depth below grade:
feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑polyethylene El 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-3113
Title 5 Oaklal Inspection Form:SubsuAace Sewage Dis"ad System-Page 10 of 17
r —
Sep 16 14 11:33p p.11
Commonwealth of Massachusetts
Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
123 Phinney's Lane
Property Address
Marianne Hughes
Owner Owners Name
information Is Centerville
required for every MA 02632 9-16-14
page. Cltyfrown 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 [I 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•3113 Tille 5 Official Inspection Form+Subsurface Sewage Dispose System-Page 11 of 17
Sep 16 14 11:34p p 12
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I- Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
123 Phinney's Lane
Property Address
Marianne Hughes
Owner Owner's Name
information is
required for every Centerville MA 02632 9-t6-14
page_ Cityli'own State Zip Cade Date of Inspection
D. System Information (cunt.)
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
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-3/13
Title 5 Omuoi inspeGion Form:SubSIlfaoe Sewage Disposal System-Page 12 of 17
Sep 16 14 11:34p p.13
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
123 Phinney's Lane
Property Address
-Marianne Hughes
Owner Owners Name
information required for e very Centerville MA 02632 9-1 fi-14
page. Cltylrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1 El leaching 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.):
Leaching is a 1000 Gal. Precast Pit. Pit at 18" below grade. Pit dry w/stain line at around 30".
No sign of over loading or solid carry over. No high stain fine.
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-3113 - Tiee 5 01111[7al Inspection Fonrr.Subsurface Sewage Disposal System-Page 13 of 17
Sep 16 14 11:34p p.14
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
123 Phinneys Lane
Property Address
Marianne Hughes
Owner owners Name
information is Centerville required for every MA 02632 9-16-14
page. CrtyrTown State Zip Code Date of Inspedfon
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.):
15ins-3N 3
Tllle 5 0Mdal trspectlon Form:Suesurraco S"V96 Disposal System•Page 14 of 17
Sep 16 1411:35p p.15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
123 Phinney's Lane
PrOPertV Address
Marianne Hughes
Owner Owner's Name
information is
required for every Centerville MA
02632 9-16-14
page. Ci ty/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)east 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
Cl drawing attached separately
G'�IRA�z
9-3 : 3 7
3
3-. 33 'A�
15irw-3/13
Title 5 0fflclal tnspedim Form:Subsurface Sewage Disposal System•Page 15 of 17
Sep 16 14 11:35p p.16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
123 Phinney's Lane
Property Address
Marianne Hughes
Owner Owner's Name
information is
required for every Centerville MA 02632 9-16-14
page. cityr town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
ND
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:
Auger T.H. 12' no G.W.. Bottom of pit at T-6" below grade Bottom of pit at 4' 6"above T H Depth
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
a Title 5 Offeisi inspection Form:Subsurface&ewe a Di g sposal System•Page 16 oI 17
Sep 16 1411:35p p.17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
123 Phinney's Lane
Property Address
OwneMarianne Hughes
inform Owner's Name
information is required for every Centerville MA 02632 9-16-14
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary:A, 8, 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
!Sins•3113 Title 5 Official Insp
ection Famr.Suhsufiaoe Sewage Disposal system-Pale,7 of 17
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMEN AL AIRS
DEPARTMENT OF ENVIRONMENT PRO
< 0p
t ,�
007
h�gCTyoF,o�ge<
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS.
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address:. ell
Owner's Name.
Owner's AddressC '9"J,
Date of Inspection:
Name of Inspector: lease print)
Company Name: c � A
Mailing Address: R0.x3e S!
/iPA Docogg,
Telephone Number: 4;ot -7'7/-g 3- ,9!7
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported'
below is true, accurate and.complete as of the time of the inspection. The inspection.was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.00.0). The system:
/Passes
Conditionally Passes
ZZ
N ds.F her Evaluation by the Local Approving Authority.
ails
Inspector's Signature: ~ Date: �d/
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the.
DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will.perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page l
r
Page 2 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 3 / /JtQ
Owner
Date of Inspec on:
Inspection Summary: Check AlB,C,D oe E/ALWAYS complete all of Section D
A.jystem Passes:
I have not found.any information which indicates that any of the failure criteria described in 310 CMR
15:303 or in 310 CTAR 13304 exist.Any failure criteria-not evaluated are indicated below.
Comments:
B. System Conditionally Passes:.
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please
explain.
The-septic tank is metal and over20 years old* or the septic tank(whether metal or not)is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as'approved by the Board of Health.
*A metal septic tank will pass inspection.if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the'distribution box due to broken or
obstructed pipe(s)or due to a broken;settled or uneven distribution box. System will pass inspection if(with
approval of Board of Health.):
broken pipe(s)are.replaced
obstruction is removed
distribution box is leveled or replaced .
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s):The system will
pass inspection if(with approval of the Board of Health):.
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
' Page 3 of 11
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued).
Property Address: Api91�,ld �p/ i
J A A, „ r4 -
Owner y. _
Date of Inspec on: � /D/
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
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 healthi 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 aseptic tank and SAS.and the SAS is.within 50 feet of a private:water supply well.
_ The system has a septic tank and SAS and the SAS is less than 100,feet but 50 feet or more from a
private water supply well",Method used to determine distance.
"This system passes if the well water analysis,performed at a DEP certified laboratory;for coliform
bacteria and volatile orjanic 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 ,F
Page 4 of 11
OFFICIAL,INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
Owner:
Date of Inspec on:
A 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 ar 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
V 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 '/z day flow
Required:pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
/ of times.pumped
V 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
watensupply.
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 coliform bacteria and volatile organ ic.compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen.and nitrate nitrogen.is equal to or1ess than 5 ppm,provided that no otherfailure 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
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 questibn 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:
Owner:
Date of Insp
Check if the following have been done.You must indicate"Yes"or"no"as to.each of the followin--:
Yes No,
Pumping.information was.provided,by,the owner,occupant,or.Board of Health.
V-1"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 breakout?
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:
Yes no
Existing information.For example,a plan.at the Board of Health.
Determined.in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [310 CMR 15.302(3)(b)J
5 II
Page 6 of 1 l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION`.FORM
PART C
SYSTEM INFORMATION
Property Address:
Owner:
Date of Inspec ion:
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):,3 Number of bedrooms(actual):.- 0 .
DESIGN flow based on 310 CR 15.203 (for example: 110 gpd x#of bedrooms):
Number of current residents:
Does residence have a garbage grinder(yes or no):./�E(1`
Is laundry on a separate sewage system(yes or no)✓J [ifyes'separate inspection required)
Laundry system inspected(yes or no):,,J�!}—
Seasonal use: (yes or no):
Water meter readings, if available'-(last 2 years usage(gpd)):
Sump pump(yes or no):.
Last date of occupancy: 4e4ta<dO
COMMERCIAL/INDUSTRIAL �
Type of establishment'; .
Design flow(based on.310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):—
Industrial waste holding tank present(yes or no):_
Non-sanitary waste discharged to'the Title 5 system (yes or no):_
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information::. G�.t,7L�
Was'system.pumped as part of the inspecti (yes or no):J/ -
If yes,volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
Septic tank,distribution box, soil absorption system
Single cesspool
_Overflow cesspool
—Privy
—Shared system(yes or no)(if yes,attach previous inspection records, if any)
_Innovative/Alternative technology.Attach a copy of the current operation and'maintenance contract(to be
obtained from system owner).
_Tight tank _Attach a copy of the DEP approval
her'(describe): 1 _ ci
Approximate age of all components,date installed(if known)and source of information:
Were:sewage odors detected when arriving at the site(yes or no)
6
I
Page 7 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM
PART.C
SYSTEM INFORMATION(continued)
Property Address:
Owner:4ze
Date oflnspe ion: !,�l/C�Zo/
BUILDING SEWER(locate on site plan) //XU-
Depth below grade:
Materials of construction:_cast iron _40 PVC_other(explain):-
Distance from private water supply well or suction liner
Comments(on condition of joints,.venting;evidence ofleakage,etc.):
SEPTIC.TANK: (locate on site plan)
Depth below grade:rX�ere,
Material of construction:_/concrete_metal_fiberglass_polyethylene
—other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a.copy_of
certificate)"
Dimensions: ;�'- 'X' `X
Sludge depth: /_)If J/
Distance from top of sludge to bottom of outlet tee or baffle: z
Scum thickness;
Distance from top of scum to top of outlet tee or baffle:7,
Distance from bottom of scum to bottom f outlet tee or baffle:_
How were dimensions determined: ��1C' _ �Ch f1%[I 7>4)
Comments(on pumping recommen at`�ions, and outlet,tee or baffle condition,structural integrity,liquid levels
related to outlet invert,evidence of leakage,etc.): si
f
a�LJTv .
GREASE TRAP: ' .ocate on:site plan)
Depth below grade:_
Material of construction:_concrete_metal_fiberglass_polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
-as related to outlet invert,evidence of leakage,etc.):
L •
Nee 8 of'I 1
OFFICIAL LNSPECTION FORM-'NOT-FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: / A Q�a
�4
Owner:.
Date of Inspect
TIGHT or HOLDING TANK -(tank must'be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass . _polyethylene._other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm.present(yes or no):
.Alarm level: Alarm in.working order(yes or no):
Date of lastpumping:
Comments(condition of alarm and:float.switches, etc.):
DISTRIBUTION BOA► (if present must be opened)(locate on site plan)
IV
Depth of liquid level above outlet invert:
Comments-(.note if box is level and distribution to outlets equal, any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
PUMP CHAMBER" ocate on site plan)
Putnps.in.wo"rkin�-nrder.(yes or no):
Alarms in working order.(yes or.no):. . . _
Comments(note condition of pump chamber,condition'of pumps and appurtenances,etc.):
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: a Xa1AJ_'
Owner: :. . "
Date of Inspec n. R /q?bO
SOIL ABSORPTION SYSTEM (SAS): on site plan,excavation not°required)
If SAS not located explain why:
Type '
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,
CESSPOOLS,y2e- (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth—top.of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil, signs of hydraulic failure, !evel of ponding,:conditlon.of,vegetation,etc.):
PRIVYA 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.):
9
Page 10 of 11
OFFICIAL-INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: P
Owner: '
yt✓
Date of Inspect'
SKETCH OFSIWAGI; 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 supplyen ers the building.
ROW
� e
10
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: J03 a
Owner:
Date of Inspe `on: (�X/
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 reviewed:
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: . �r
I1
�t TOWN' OF BARNSTABLE \`
00CATION //v, it/ SEWAGE # .3 C
VILLAGE ASSESSOR'S MAP & LOTl4d '--0J-%Z
INSTALLER'S NAME & PHONE NOn b/ So "�✓ �J �'�
.'SEPTIC TANK CAPACITY 1S
LEACHING FACILITY:(type) G� l�e yS (size) / 8
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER�PO b
BUILDER OR OWNER At[2f�
DATE.PERMIT ISSUED:
DATE COMPLIANCE ISSUED: /3
VARIANCE GRANTED: Yes No
L
�Jvl'.
o�o�
No.--- v ---- Fim$.�...�...............
- 'THE COMMONWEALTH OF MASSAC14USETTS
BOAR® OF HEALTH
TOWN OF BARNSTABLE
Disposal Works Tonstrurtion Fumit
Application is hereby made for a Permit to Construct ( ) or Repair (x) an Individual Sewage Disposal
System at:
123 Phinn.ys Lane
................__..- s......................... -------------
.......... ......
.-------------------------------------o rL-••---ot--•No.-..............
............ ------
oca
R. Scott Mac otionna A dres7c�
......................-.......................................................................... ........•-•••-•-••----•-------•-•.._...........------•-----•-----•-•--.........------.............
W W.E. Robinson S0(96tic Service P.O. Box 1089 Ceriferville
Installer Address
UType of Building Size Lot............................Sq. feet
�-, Dwelling—No. of Bedrooms.........4.................................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 ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water..---.--................
44 Test Pit No. 2................minutes per inch Depth of.Test Pit---................. Depth to ground water...---..............---.
O9 ----•••-••---•-•••----------•-----...---••-•----•--•----•----.....•••.....-•---•......-•-•-••.---•--........................................................
Description of Soil.................send...&---Gravel--•---•-•-•-••-------••-----------------------------------------------------------•---------------•-•-------------
W
U
W
x •---•--•--- ------------------•------------------•--------------•----------••----•....--•••---------•-•----•----------------- -•-•-------•------•-••---•--•-----•-•-•--•----------•-•-------.......
U Nature of Repairs or Alterations—Answer when applicable...Pump.-and...fill---old--Cesspools_._____________
install___a-__1__,_5.00_-_gal_•t- n}c_,__--d-box___and__4_--stonepackecl galli-es_,_-__________
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 fur!>er agrees not to place the
system in operation until a Certificate of Com lia ce has baisr
y th bo o ealtH �J r�
Signed ��� �`— J
-12---------- ------------__�fe....'------------
Application Approved By ..-
Dale
Application Disapproved for the following reasons: . ............................ -......................................---------------------------------- -----------------
..............................------------- .......... .. ....................--- -- ------------------
-' Dare
Permit No. ..... ..........-- Issued ...... _ ........................
No...�,� $30.00
........ . Fxs............._...............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE +
7 Applira#ion for Disposal Works Minstrur#iun j1prutit
Application is hereby made for a Permit to Construct ( ) or Repair (x) an Individual sewage Disposal
System at:
•123 Phinnys Lane
........__ . -- -......-•- ....._... ....................... ............
..•--------------------------------
...........................
R. Scott MaC1e®I1gtd Tess or Lot No.
......................_.- ....--- - ..-----------------••-••-•--•---• ..........-•............................................................:.........................
W W.E. Robinson EP4Ric Service P.O. Box 1089 Ceriterville�
I.a .._..-••-•..................•••--••-••-•----••--•-•----••-•....--•---•--•••......-•-•-•........... ------------------------------------.......:...------......--•••-•..._........................
Installer Address
Type of Building Size Lot----------------------------Sq. feet
�- Dwelling—No. of Bedrooms.........4---------------------------------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 ( )
Percolation Test Results Performed by.......................................................................... Date........................................
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.........................
O . Description of Soil----•------_._- ;��?�=s�'s•--p---�-�^�-mil. -•----•---•---•--...----••--------••-•-----•---------------------•--------•--•------------------•---••----•-----
--• - --•--•-------------------
U ---
••------------------------------
•--------------------------------------------------------------------
•------------------------------------------------------------
•--------------
•-------------------
W
U Nature of Repairs or Alterations—Answer when applicable....1?ump._and...fill....
. Old_ Cesspools,
._-_- x.a�� .._,_a__.1. 500 cral-_tank_.____d-box• and 4 stonepacked dallies.
-----•--•--••--•.....
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 furt r agrees not to place the
.system in operation until a Certificate of Compliance has been 3 issue ib'y thc�board�o ealtlf.
� J
Signed /.
Date
Application Approved BY ----.---.... / U '�l T.�./�'. -..
v ........................------------------
Date
Application Disapproved for the following reasons- -------------------------- ------------------------------------ ------------- ------. ---....------.--------.
------
- ------------
�._....'.......Date
r .�Permit No. ------ ••�-------------------------�----- ------- ---- Issued ---------w--
r.....--Aare ........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Tertifi a e ti (fantylianre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( x )
by W.E. Robinson Septic Servic
123 Phinnys Lane Centervll---------------Installer
at ---------------
has been installed in accordance with the provisions of TITL o� he Sttte ronmental Code as described in
the application for Disposal Works Construction Permit No. -----.- .^.....�f"/j dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT E C NST`RUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE O L...../-- -- ------------------------------------------------ Inspector --------- .` �-'
v
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
NORTOWN OF BARNSTABLE $3 O.O O
No. FEE. ....
Disposal Works Tnriu#rurtion prrmit
Permission is hereby granted____Kj E. Robinson Septic• Service
......................................... --------------•-------•---•--••---•-••---...........-•..............
to Construct ( ) or Repair (x ) an Individual Sewage Disposal System
at No.....123_._Phinnys Lane Centerville
Street
as shown on the app icati n for Disposal Works Constructi r 't N ...._._ at d 4ll._...a?_______________ �- G
DATE. Bard/of Health l
FORM 36508 HOBBS Q WARREN.INC..PUBLISHERS
iYr7'1
L-O C A T ION ` , SEWAGE PERMIT NO.
VILLAGE
(1 tKYN L L-
INSTA LLER'S NAME i ADDRESS
lc�u I yo ti tc k<
S3Pr�S�R$L� i
OR OWNER 4
DATE PERMIT ISSUED C-'3 -
DATE COMPLIANCE ISSUED ��
.� , ��
•�,_.
,�
a�
� ,,
, b
j o :.
® — "rt _il Gl q. J
COMMONWEALTH OF MASSACHUSF-TTS
THEBOARD F HEALTH
.......OF.......... .. .�,�,/Yl-•---
Appliration for Diipuia1 Workii Tunutrurtinn Prrutit
Application is herebade for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System at: /;2-T �"\
...----... lo. �t�"-'-'......_�.o.crkA.............. W.A�A..... ,_> ..............................................r1 -Z---'--
Locati -Address or Lot No.
- .............................................. . ..............................................
owner Address
Installer Address
Q Type of Building Size Lot-___-__-•-----------------Sq. feet
U g— .....Expansion Attic ( ) Garbage Grinder ( )
Dwelling No. of Bedrooms__._._.�?_ _.__,�.............
PL4 Other—Type of Building ............................ No. of persons............. Showers ( ) — Cafeteria ( )
Q' Other fixtures ............................... ..
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
1:4 Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
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......................................
W
,-4 Test Pit No. 1________________minutes per inch Depth of Test Pit.................... Depth to ground water............_...........
GT, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------_.................
04 --------------•---------------•-----•••-----•-----------......-----------.........----------._...---.........................................................
ODescription of Soil-------....................................-..........................................................................................................................
W
- - - - --------------------
U Nature of Repairs or Alterations—Answer when applicable_----1-N-4,7`t-- ----_---0_p..MP1 -T_L-----_-_lU-�.........
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iT T
p of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Sig -•-�`'/ /✓ Date
Application Approved By.....-- ....- � '1 -f1
Date
Application Disapproved for the following reasons:_... =•-------------------•----••--------------
.....................•--------••-•-••-------•---•--•----•••----------------------•--•••-•----------.....'--------•--•---•--•••--•------•----•-------•-------------------•--------...--------------------
r ..........Date
Permit No. Issued. •--- '-•___.__..
Date
LOCATION SEWAGE PERMIT NO.
VILLAGE
INSTA LLER'S NAME i ADDRESS
UILDEIII OR OWNER
DATE -,PERMIT ISSUED
DAT E COMPLIANCE ISSUED `
®�owsFD w�.� .
o � w
ct 4 � .. :.
O�� ��
.._: �
� �� /
iS
i
i
__
No..- ---...!........... F.Rs.... .. .. ....:.
THE COMMONWEALTH OF MASSACHUSFT,TS
BOARD F HEALTH ;k c
-..-----�_ _ .............OF......... :. - -•. .
Appliratinn for Bigpogal nrkp Tnnitrnrtinn rumit
Application is herebyj;made for a Permit to Construct ( ) or Repair ( an I dividual Sewage Disposal
System at:
..... ..... .5::............. ....------------...---'------------------...L....•-•..........---•--
Locati Address or Lot No.
...... _ ............................................... .......----••.............................. _.............•-•-•-............-••-...-----•.
Ow,
ne /� Q ��N Address
Installer Address
U ' Type of Building Size Lot.................... Sq. feet
,-1 Dwelling—No. of Bedroomsj...ale.....2 ...................Expansion A tic ( ) Garbage Grinder ( )
a`4 Other—T e of Building .............
—Type g _______________ 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.
3 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-___-.___--_-_--__-___.
Ll� Test Pit Ni o. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
•------••--•---------------------------•---•-------------•--•---....----•---._...-•----'-'-'..........--•---------••.........-----'-----...-•-...-'••-'-•----
0
Descriptionof Soil........................................................................................................................................................................
W
--------------------------
V Nature of Repairs or Alterations—Answer when a plicable...___1. ��h R� ...__ _ .
...... ..SC . - - Oho----- ..-A-tLOr..' .... Pi'K` ±�' ! A ......
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of T i:LE
p 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the,board of health.
Sig d '` '` ................... 6__3 , a o
f -------t...-----..
-•-••-----•----.--•-- --
%4N� / ,� ate
Application Approved BY-------�e' ---- --------------- -��.--- ---�----------�-'J='-•---------- -------��-----�-�4(j--�••V-----
Date
Application Disapproved for the following reasons-----------------•--•--------------•-------------------•------------------------------------•--•------•---------
-------•---------------------------•-•---•--••••-------•-------•----•-----------•---•----------....................---................................................................................
Date dr
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O �EALTe
, 'l. OF........... , ................
......... �'..............�rrtifirtttr of f�untpltanrr
T I IS TO CE Ik ,That the Individual Sewage Disposal System constructed ( ) or Repaired
by � .,..._.. '----......-••---"----•- ---
Installer"
at--# .. . . .-- ---f 2 --- --------,
has been instalee in accordance with the provisions of 'II j of The State Sanitary Code as described iii the
application for Disposal Works Construction Permit No ___.. ....._
.25.5 3• A
---- da.ted_... - --
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS-A GUARANTEE THAT THE
SYSTEM, WI L FUNCTION SATISFACTORY.
DATE.-•----... ....��
.-.•------------------•---•--------------- Inspector......- ...................'................................................ a
...:..........-.-.»<��..:.` '� ,.;.�:+ .-«�.x. •++a-.:. _ - ,-4.. t. ��asw.,..J�iw.ifL i�.wA..�vw'.ew.�.air,+rc+•iwJ.3+.,....wi.�.:�:,i.Y.ww�.iw:::+,....�:...w.-•uA;..hnw.,-...s.�ae .,...a....n-.w..».._��
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O HE H
OF....---- � r.. .... .. ....................... ,��-• „„
No........... .......... .... ....... . ..... tV
FEE........................
i r e n k � iuliv rrntit
Permission is hereby granter -•••-------- G- -- -- �---•-•--------•-----•--•-----•-----•-•---•------•--•--.........-••'---'-••-
.�
to Construct ( ) r epair ( ) an I 4 vid Sever ge Dis Syst
at No.....�.i�.f'-•-- %'?! �' . ...o_................ - --- ---- -- -----•....................................................•..
• ...--
Street ff
as shown onbthe application for Disposal Works Construction Perini 0.... ..... ........ ted..........................................
-/ -----
e#.{j • Boar of Health
DATE...... -•----------------- ---------------
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS