HomeMy WebLinkAbout0580 PHINNEY'S LANE - Health (2) 580 Phinneys Lane
Centerville
A=250-016
UPC 12534 '
0.2-153L2.R
,f Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 580 Phinneys Lane
Property Address
Dominic Mazzola
Owner Owner's Name
information is required for every Centerville MA 02632 3/14/12
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,
use only the tab 1. Inspector:
key to move your
cursor-do not Ricky L. Wright
use the return E3
key. Name of Inspector �� 1-13
B & B Excavation, Inc.
Company Name
—ai
14 Teaberry Lane
Company Address =;
Forestdale MA 02644 5
City/Town State Zip Code,,0
508-477-0653 S 14595 '
r-s �
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
C-
3/14/12
Ins ctor's Sign 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.
l5ins•09/08 Title 5 Official Inspection Form:Sub a ewage Disposal System•Page 1 of 17
�e Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
580 Phinneys Lane
Property Address
Dominic Mazzola
Owner Owner's Name
information is required for every Centerville MA 02632 3/14/12
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:
® 1 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:
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):
I
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 580 Phinneys Lane
Property Address
Dominic Mazzola
Owner Owner's Name
information is required for every Centerville MA 02632 3/14/12
page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health): )
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•09/08 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
580 Phinneys Lane
Property Address
Dominic Mazzola
Owner Owner's Name
information is required for every Centerville MA 02632 3/14/12
page. Cityfrown 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 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:
I
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/day flow
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
580 Phinneys Lane
Property Address
Dominic Mazzola
Owner Owner's Name
information is required for every Centerville MA 02632 3/14/12
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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°°�M 5•�'` 580 Phinneys Lane
Property Address
Dominic Mazzola
Owner Owner's Name
information is required for every Centerville MA 02632 3/14/12
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): 3 Number of bedrooms(actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
;M 580 Phinneys Lane
Property Address
Dominic Mazzola
Owner Owner's Name
information is required for every Centerville MA 02632 3/14/12
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonaluse? ® Yes ❑ No
Water meter readings, if available last 2 ears usage d n/a
9 ( Y 9 (gP ))�
Detail
Sump pump? ❑ Yes ❑ No
Last date of occupancy: 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•09/08 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
� 580 Phinneys Lane
Property Address
Dominic Mazzola
Owner Owner's Name
information is required for every Centerville MA 02632 3/14/12
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:
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:
Y
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
)❑
Other(describe):
(
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 580 Phinneys Lane
Property Address
Dominic Mazzola
Owner Owner's Name
information is required for every Centerville MA 02632 3/14/12
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
cesspool original to dwelling leach pit installed in1983
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 1
feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
>20'
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
At time of inspection building sewer appears to be in good condition. No sign of leakage
Septic Tank(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass. ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
Sludge depth:
t5ins•09/08 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
;M 580 Phinneys Lane
Property Address
Dominic Mazzola
Owner Owner's Name
information is
required for every Centerville MA 02632 3/14/12
page. Citylrown 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
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
How were dimensions determined?
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 580 Phinneys Lane
Property Address
Dominic Mazzola
Owner Owner's Name
information is required for every Centerville MA 02632 3/14/12
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•09/08 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
,M 580 Phinneys Lane
Property Address
Dominic Mazzola
Owner Owner's Name
information is required for every Centerville MA 02632 3/14/12
page. City(rown 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
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.):
i
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.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
580 Phinneys Lane
M
Property Address
Dominic Mazzola
Owner Owner's Name
information is required for every Centerville MA 02632 3/14/12
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
At time of inspection leaching appeared to be in good working order- no sign of hydraulic failure-
Leaching was dry at time of inspection.Water stain was 3' below invert.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration 1 in-series with pit
Depth—top of liquid to inlet invert
2'5"
Depth of solids layer no solids
Depth of scum layer no scum.
Dimensions of cesspool 6x6
Materials of construction block
Indication of groundwater inflow ❑ Yes ® No
t5ins-09/08 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
580 Phinneys Lane
'M
Property Address
Dominic Mazzola
Owner Owner's Name
information is required for every Centerville MA 02632 3/14/12
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.):
At time of inspection cesspool appears to be in working order no sign of high vegitation or hydraulic
failure.
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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System form -Not for Voluntary Assessments
�M 580 Phinneys Lane
Property Address
Dominic.Mazzola
Owner Owner's Name
information is required for every Centerville MA 02632 3/14/12
page. Cityfrown 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
e1 J r
y` ,
t5ins•09/08
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 580 Phinneys Lane
Property Address
Dominic Mazzola
Owner Owner's Name
information is required for every Centerville MA 02632. 3/14/12
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: >12feet
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:
Hand auger threw dry leaching.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
l5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
i -
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
'M 580 Phinneys Lane
Property Address
Dominic Mazzola
Owner Owner's Name
information is required for every Centerville MA 02632 3/14/12
page. Cityrrown 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
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
.\ COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
d DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A 6 9
L
CERTIFICATION
Property Address: 59Q /11 '4.0ys L��e , �P� °�V/
Owner's Name: e-5-tqk Of TA l 0--e? C� �/�dt�tJ✓l
Owner's Address: Q /p �{r e,•� M e( T L I a`t q Po 6 d X 1-!Q
j '
Date of Inspection:
M <rshp-ee Ins} oz
Name of Inspector: (please print) Joseph M. i artins
Company Name: Accu Sepcheck
Mailing Address: 17 Northside Dr., S. Dennis,MA 02660
Telephone Number: 508-385-5891
CERTIFICATION STATEMENT
I certify that I have personalty 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(3I0 C°v1lt 5.000). The SystCrn:
Passes c-
_ Conditionally Passes + ;
___ _ weeds Further Evaluation by the local Approving Auttierity U�
E�ails t;; =.}
Inspector's Signature Date:
t..�
The system inspector shall submit a copy of this inspection report to the Approving Authority(Boar of Health or n
DEP within 30 days of completing this inspection. If the system is a shared system or has a design tl w of 10,000
rpd 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 owwer and copies sent to the bu�cr, if applicable,and the approving
authority.
Notes and Comments:
:`*'';r T%is report only 5e�5crjbes conditic,-as at the timeaf inspection a:ad Andes-a.;:,ccmditio:°as of-,ise at ts:at
:.tie. This i:iSi�'Cii�311 . i:t S :ivt za�l.I.i of e1a3:� 1:1.'.�y;.:id a.a ,v'lll f " "f ° ,,�i2"lbi,fn In .ar �u. d'k. .a'.ader deEe a+i7e o adi �e'S;GFt
_onditions of-ase.
Page 2 of I 1
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
580 Phinneys Lane,Centerville, MA
Owner: Estate of Florence Brown
Date of Inspection: 5/17/2006
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:
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. I " of determined"please
explain.
The septic tank is metal and over 20 years old*or the septic tan Whether metal or not)is structurally
:m ound;exhibits substantial infiltration or exfiltration or tank fai�c�is iruninent. S;stent will pass inspection if the
existing tank is replaced with a complying septic tank as approed by the Board of Health.
*A metal septic tank will pass inspection if it is structura sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is aye' .
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 broker,settled or uneven distribution box. Sy:stcm will pass inspection if(with
approval of Board of Healthy
broken pipe(s)are replaced
_ obstruction is removed
distribution box is leveled or replaced
ND expiai�
T he system required pumping more Than 4 times a year due to broken or obstructed pipe(s).The system wilt
pass inspeoion if(with approval ofthe Board of Health):
broken pipc(s)are replaced
_._obstiuction is rciitoved
ND��xpkiin:
'Page 3 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 580 Phinneys Lane,Centerville,MA
Estate of Florence Brown
Owner: 5/17/2006
Date of Inspection:
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 deter ' es in accordance with 310 CMR 15.303(l)(b)that the
system is not functioning in a manner wh' will protect public health,safety and the environment:
Cesspool or privy is within eet of a surface water
_ Cesspool or privy is wi ' 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
'The system has a septic tank and SAS and the SAS is within a Zone I of3}xtblic water supply.
The system has a septic tank and SAS and the SAS is w he50 feet of a private water supply well.
_ 'The system has a septic tank and SAS and AieSAS is less than 100 feet but 50 feet or more from a
private water supply well**. Method used rc etermine distance._____________.__
**This system passes if the we ater analysis,performed at a DEP certified laboratory, for coliform
bacteria and volatile orga i compounds indicates that the well is free from pollution from that facility and
the presence of amm a nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria• riggered. A copy of the analysis must be attached to this form.
.3. Other:
Page 4 of I I
OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 580 Phinneys Lane, Centerville, MA
-- Estate of Florence Brown
Owner: 5/17/2006
Date of Inspection:
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
_AZ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
_Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
_&/ Liquid depth in cesspool is less than 6"below invert or available volume is less than %day flow
j/ 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.
_ v 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.
_ yAny 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 forma
No
(Yes/No)The system fails. 1 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 inust 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 criteriaI��v }
yes now
the system is within-400 Ieet of a�e drinking v4ater supply
_ the system is within M t to F a tributary to a surface drinking water supply
:he system is -ited in a nitrogen s,_nsitive area(Int:,rim le ellhead Protection :area Ib IIA)or-a!n pped
Zone It c public water<upply ;cell
I t oU ha`' answered "yeS' tU any C�uCSIWn to "e-tion i the JVsteni is tconsidCr-d 21'il; nl(:C int L'?rc'at, of—i ls; -wred
es" in Section D above the large system has ialled. The owner of operator of any large system considered a
significant threat under Section E or tailed tinder Section D shall upgrade the systern in iccord:ince`:vith ?i 0('Mil
he sy tern c vncr should ccnttact alit;apprcpraite r;,��.;nal i:f�1C:'.:�t. D:9p:r:'inr-ilt.
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
580 Phinneys Lane, Centerville, MA
Owner: Estate of Florence Brown
Date of Inspection: 5/17/2006
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
/1C(-
�/ _ Were all system components. mg 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, inatcrial 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
manitenance 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
t",_ Existing information. For example,a plan at the Board of Health.
Determined in the field(if any of the failure criteria related to tart C is at issue approximation of distance
is unacceptable) [310 GM 15.30243)(b)]
Page 6 of I l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
580 Phinneys Lane, Centerville,MA
Owner: Estate of Florence Brown
Date of Inspection: 5/17/2006
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): NI'l Number of bedrooms(actual): 2,
2 2 d
DESIGN flow based on 310 CMRU5,203(for example: 110 gpd s#of bedrooms):
Number of current residents: Air /�)
Does residence have a garbage grinder(yes or no):
Is laundry on a separate sewage system(yes or no):No [if yes separate inspection required]
Laundry system inspected(yes or no):
Seasonal use: (yes or no): N 0 c/
Water meter readings,if available(last 2 years usage(gpd)): Uo r/Z
Sump pump(yes or no): /W (/
Last date of occupancy: a�0
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(ypwaf no):_
Non-sanitary waste discharge e Title 5 system(yes or no):_
Water meter readings, ' ailable:
Last date of occ cyi use:
OTHE describe
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part of the inspection(yes or no). /j6
If yes,volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
_peptic tank,distribution box,soil absorption system
Single cesspool
Overflow cesspool
--Privy
_Shared system (yes or no)(if yes, attach previous inspection records, ifany)
_ Innovative/Alternative technology. %ttach a copy of the current operation and maintenance contract(to be
obtained from system owner)
_-fight tank Attach a copy oi'the DEP approval
DGrOaim !tc f.,Se of a1I CG I'n ponwilts 'ite l!1,tal1ed(if yn G`.Vii).'nd Source o ':n fr in--ti+:ri'
t i'e seS.zigc odors detected vvhen arrivii'11at ttho site(\es or no : /j V
page 7 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
580 Phinneys Lane, Centerville, MA
Owner: Estate of Florence Brown
Date of Inspection: 5/17/2006
BUILDING SEWER(locate on site plan)
Depth below grade: 2--
Materials of construction: cast iron —40 PVC_other(explain):
Distance from private water supply well or suction line: �v
Corn" nts(on condition of joints,venting,evidence of leakage,etc.):
D IE
SEPTIC TANK:_(locate on site plan)
Depth below grade:
Material of construction:—concrete_metal_fiberglass_polyethylene
_other(explain)
If tank is metal list age:— Is age confirmed by a Certificate mpliance(yes or no):—(attach a copy of
certificate)
Dimensions:_:_
Sludge depth _
Distance from top of sludge to of outlet tee or baffle:
Scum thickness:
Distance from top o m to top of outlet tee or baffle:
Distance from tom of scum to bottom of outlet tee or baffle:
Now we imensions determined:
Co ents(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels
s related to outlet invert,evidence of leakage,etc.):
GREASE TRAP:_(locate on site plan)
Depth below grade:
Material of construction: _ concrete metal fiberglass___polyetleue- 'iil �f
(explain).- --- - -- — ------
Dimensions: — =
Scum thickness:
Distance from top of scum to top of: et tee or baffle:
Distance from bottom of scu' .t6ottom of outlet tee or baffle: -___--
Date of last pumpingy,y'_____
Comments(on ping recommendations, inlet and outlet tee or l aifle condition, ,truct.;rlI integrity, liquid lcv`Is
cis related to tlet invert,evidence of leaka ge, cte.):
`Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
580 Phinneys Lane, Centerville, MA
Owner: Estate of Florence Brown
Date of Inspection: 5/17/2006
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal o 6erglass_polyethylene other(explain):
Dimensions:
Capacity: gall
Design Flow: lons%day
Alarm present(yes or no): _
Alarm.level: in working order(yes or no):
Date of last pumpin _
Comments(condi ion of alarm and float switches,etc.):
DISTRIBUTION BOX: (if present pidst be opened)(locate on site plan)
F'
Depth of liquid level above outletirtvert:
Comments(note if box is lev `and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of bo.><ctc.):
PUMP 6?A ABER: (locate on site nlan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of purnp,cnamber,condition of pumps and appurtenances,etc.):
��r
Page 9 of I I
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner: 580 Phinneys Lane, Centerville, MA
Date of Inspection: Estate of Florence Brown
SOIL ABSORPTION SYSTEM(SAS): —_.(locate on site pIVA M tion not required)
If SAS not located explain why: ---._--- -- ---------------------------
Type �// p /�GtGle ��
leaching pits,number: Qy X6 IN S�4 e, H
teaching chambers,number:
leaching galleries,number: _
leaching trenches,number,iengnh:_
_— 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.): L;A e— e 5 al- 5 --
CESSPOOLS: (cesspool must be pumped as part of inspection.) locate on site plan)
Number and configuration d &Lock
Depth—top of liquid to inia invert:
Depth of solids layer: ___-__..__
Depth of scum layer:
Dimensions of cesspool: _ � Lj 1 D X-7
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure level of ponding,condition of vegetation,etc ):
PRIVY: (locate on site&m)
�taturials of construction:
Dimensions:
Depth of solids: -------------- -jy, _:.
Comments(note condition of,cil, failure, !evul of,ondin`, condition -if vegutar:oi , etc.;:
y
Page 10 of l l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
580 Phinneys Lane,Centerville, MA
Owner: Estate of Florence Brown
Date of Inspection: 5/17/2006
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.
Aj
7/vL
W
1
�_ S S
• Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner: 580 Phinneys Lane, Centerville, MA
Date of Inspection: Estate of Florence Brown
5/17/2006
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water
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(abeftirfg-proprM/observat °
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: — ~-
5 le Vq b At C( )01� ......
a� T TT> L c�
3 ad eve, r-Dad 4 f 0ex f-& l '?W orc
\I
3 . 1-�eIs I eac4 p iT /s 7 / / '; r
(9A I mjayvgyvPf Z:?k-e
s• /Vo a a f us Imes-t rm Qgo ve,
C
LOCATION SEWAGE PERMIT NO.
f n l?e- 47-~
VILLAGE
(fe�le,,-,P T�
INSTA ,LLER'S NAME i ADDRESS
d f S��
B U I L D E R OR OWN ER
rn
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED a � � &13
d
0
No........................ F�$......... D.`. 4�.
4.'
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH ���
lTu _oF........0 �c............................
Appliration for UWpaiittl Workii Tonstrnrtinn ranfit
Application is hereby made for a Permit to Construct ( ) or Repair (4-) an Individual Sewage Disposal
System at:
-....... ............................................ ---.--------•------=--...--........._...----.
on A re Lot No.
Owner ddrass
Installer Address
d Type of Building Size Lot............................Sq. feet
V Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
04 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
a' Other fixtures ------------------•----••---------.---------•-
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter..........--.--..... Depth below inlet.................... Total leaching area..................sq. ft.
Z OtherDistribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.....................--.
Gz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P4 ............... --------------------- --- ...................................---......--••--••-----•-•--............••-•------•-•-•...
ODescription of Soil................... --?Y.q.rn� ...........................................................................................
x -
V ------------------•---••---•---•---•-•----•--•--••------•----•---.....•-----••••--............-----•-•-•-••-•-••---••--•---••--............_.•--•---•...............•---•..........---•-----•••.........
-------------------------------------------------------------------------------------------•-------- -- -- -----------•-------------------
-•-••--.----------....
U Nature of Repairs or Alterations—Answer when applicable....j.=,�L1(�(.J...�,�/.._._��.�..................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iI'l IL 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has be issued by the!bo r of health. ¢ t
Signed.. --- a�=ems ....... C.�_: 1' .....
Da
Application Approved By..
....
Application Disapproved for the following reasons:............................................................................................ ...................
--•- -----•---•----------------------•--.............---............---•--•------•---•-----............----•--•-•------•---•-----•-------•-•--••-------•----••-----••••--•-•-••---•----•----....--_-----
Date
PermitNo................................•------------------------ Issued.......................................................
Date
r
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.........OF....... !-.% --� t �C�............................
Appliration for Bhipouttl Works Tonutrurtion ramit
Application is hereby made for a Permit to Construct ( ) or Repair (4--) an Individual Sewage Disposal
System at:
....... .......•-•--•-- ..--•---••..--------.---. ........---------------.----......_.............
s L�eation-Addres t No.
l ...............................................
Owner j ddress
Installer Address
d Type of Building Size Lot--_--_----__--•-------_--Sq. feet
U Dwelling—No. of Bedrooms................... .....___......Expansion Attic ( ) Garbage Grinder (' )
aOther—Type of Building ................:........... No. of persons............................ Showers ( ) — Cafeteria ( )
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........................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
0 Description of Soil...................... .. ....-.__.._
V ------------------------•-•-----•-••-•----------•••-•-•--------•------••---•--••••-•-•-----...---•------•-•----•••••-•------••--
--------------------------------- -'-----•----------------------•---------------------•------.._..------------------------.......-•---......--•--f---•••-•-••-...
U Nature of Repairs or Alterations—Answer when applicable..__ __.�1.al.....A..,........................................
------------------------------------•••••-•-•-•--•--•--------•••-••---•---•--•--•-----...•-•---------•-------...•-••--•-••••..••••••--•-•••----•-•--•---•••----••-•---------•-----•--•--•-------•..-•---
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has be issued by the board of Health.
� =� . �. ..Si Signed.
Dat
Application Approved BY .. ...J��_
Date
Application Disapproved for the following reasons:---•--•••-•-----•---••-•------•-------------•-•----•-•--•-•---•-••---•- .........................................
.....................................•-•-•-...........•--•-•••----••----.......-•---•--------•-••--....•-------.............-•--•-----------•-------•--•-----..........................................
Date
PermitNo......................................................... Issued_.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD] OF HEALTH
�r
(. , ...........OF........ ........................
Trrfif iratr of Toutpliana
THIS--IS O 1C RTIFY That Xhe Individual Sewage Disposal System constructed ( ) or Repaired (
by ... r �(..--••-• ---------------------------------•--•._ ......--
al er
..:.has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit ............ dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector....................................................................................
. ^" THE COMMONWEALTH OF MASSACHUSETTS
-- BOARD OF HEALTH
...... .1/. LO.../...............OF.................�t„a'. d. ............... FEE..:.. ( to
.....
"BilivooAlVogii TonsrionPermission is hereb' ranted....- -. . _ lr!. f�'! -. -.!�V-Q.Y g ......
to Construq. , ) or-,R air ( 24 n Indi.irjual Sewa Ispos Syst
at
1 ...................................
7 Street
as shown on the application for Disposal Works Construction Permit No..................... Dated..........................................
r ••.....................................................
Board of Health
DATE................................................................................
FORM 1255 A. M. SULKIN, INC., BO.$TNTON'
t r
TOWN OF BARNSTABLE
LOCATION ,5 Zil SEWAGE # 5�2
VILLAGE 4(-v2_7"_z'rV111 '
ASSESSOR'S MAP & LOT 0116 ��
INSTALLER'S NAME & PHONE NO. �g�►�, /ydr � ,7
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) ` (size)on_
NO. OF BEDROOMS PRIVATE WELL O PUBLIC�WATE
BUILDER O OWNE
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
r -
y \
Q?l
ASSESSORS MAP NO: le
No.../.0 .��5 -• PARCEL NO.: l y r7 FIm$...../.L?..z........._
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.................OF.......... ............................
Appliration for Uitipnattl Marks Cnonstrnrtiun ramit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at:
Locati n. dd or Lot No.
a
ner 414
Add
r l
a ......................................... ....•....
Installer Address
U Type of Building Size Lot.....b�.,_QZ?' -ISq. feet
Dwelling—No. of Bedroo �... i 4a ------------------Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building regai.clexle.0 No. of persons..... ..................... Showers (.2 — Cafeteria ( )
Q' Other fixtures ..... ...... ..... .
...........
W Design Flow..............................%_ gallons per person per day. Total daily flow..................
WSeptic Tank—Liquid capacitylPVC->-.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........................
LT4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water............-...........
a --•-•--•-•••----•--•••••••---••-•-•--•-•••.................................•---..................-••--.............•---•-....-•---•----•-•--•--......-----••.
ODescription of Soil---.------- e•-- ... ...................:W............................................................................
A
..............P.,Ai�
. ,�� -�� ............................................
-----------------------
VNature of Repairs or Alterations—Answer when applicable.
------------------------------------•-----•--------........----•----•--...............--•-•----....---•-•-•-•-••-----------------------------........--•--•------..............••••-•-•--------......._.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in
operation until a C ificate of Compliance has b7ee * s ed by the bo rd of health.
Signed ....... o�-� •:,r•.•��`�
Date
Application Approved By........... ----------------------------------------------- ...........;_t.-:-j_ - �'- ......
Date
Application Disapproved for the following reasons:--•--••••-•---•-••••-----•-•-•-•---•••••-••••-•-••-••-•-•-••--•••--••--•-•--••....•--...._...-•..............._
.............................•------•----------------------------------------------------------------------••-.._...-••------••••-•--•--•-•----••-•---••-••••-•--•••--•••-•••••--•••••-•._.........-----
Date
Permit No....�an.= `� Issued-.......................................................
Date
THE FOLLOWING
IS/ARE THE BEST
IMAGES FROM POOR
QUALITY ORIGINALS)
I M ^C&L
DATA
No. Fzjc
f< THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......... .'..+.....J.................OF............n..............:........ ....l. .I.F............._.................
Appliration for Uhipaaal Workii Tnnitrurtiun 1hrmit
Application is hereby made for a Permit to Construct (-.N) or Repair ( ) an Individual Sewage Disposal
System at:
-•..:....... __..................................:.•--•-----•............•-•--_............. .................................. - ........_...--••••••........_.
Location-Addriss- or Lot No.
/ _. Owner —• Addre/ss //
.......................................•_•-__-•-__--_-•-_-_-._........._ ......._._........_....................................._..._.._......._(_ ....._.....
Installer Address
UType of Building f Size Lot...............Lt'...........Sq. feet
a Dwelling—No. of Bedrooms........2.... ..::.:....................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building . ............ . No. of persons...... Showers ( ) — Cafeteria ( )
d Other fixtures ... ---------------------•-----_---------- -----------------------.-_._.-..---------------------
.....
W Design Flow...................................:... .gallons per person per day. Total daily flow........................:/._...............gallons.
W Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water--------
.-.-------------
9 -..`-------------------------------------------------------------------------------------..... .. ........................
DDescription of Soil--------------- - ............---.........-.........................................•..........................................................0............
.................................................::................:�_..�._�!r_�__.__..... ._.:_.. __.__.__....�....._...___.______�._.___._._:._.
- .._•__•__...-------------
••••......
0--------
---------------------------------------------------------------------------------------------------------------------W i /
V Nature of Repairs or Alterations—Answer when applicable..........................................................
---......................................................•---......-•--------.............................--------...---------•--------------...-----------..._-.........................-•-•-•••.....
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITL,I 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.
Signed..................................------- -•--•••-•-••-------••-•-•-------•.....--•..---• -•------
Date
Application Approved BY ==J.........'-:._::-_. _ . -. .. Date �._........
Application Disapproved for the following reasons:..............•-•_•............_.....______._____._._____.....____._._______•..••--•------------....•••--....._
..............................................................-......................-........................................................................................................-..-----••.
Date
Permit No...... =L .. Issued............................----.....--------..._....
------------------------------- Date ..
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
......:... ..............oF........ .....r...uv. .......................................
(Irrtif irate of Tuntpliana
THIS IS TO CERTIFY Thatthe Individual Sewage Disposal System constructed (�) or Repaired ( )
by-- :r(.:. 1�. .t'- .. :....._.._.. ...
` Installer
at.....................-...... .... _2.-.. •............. -'.._.... �1 r
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No....__l.)...__.l.`.................. dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE- AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION S�TISFAC � ��- ' i 1�
DATE /L. .....= Inspector........ = -•------------------------------------
V
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
/ Z:2.>a r. r
(.................OF..........1. :1t' �.r<2 �... ...............................
No.......................... FEE..... ......_....
Disposal Worko Tunstrnrtiun rrrntit
Permission is hereby granted.......... ...............................................0....................................
to Construct ( ;{) or Repair ( ) an Individual Sewage Disposal System
at No...........:.:.....�_ 1 /, -
..........------•-----•-•.._..--•••-.---=- _...........................................--•----•••...---•••----..........__.._.....
J
Street as shown on the application for Disposal Works Construction Permit No.., .......... Dated..........................................
.....--••-•-••---•................•---••- ------•-•-••-••---..................................._•--••-
DATE...........................-....................................................
Board of Health
FORM 1255 A. M. SULKIN, INC., BOSTON
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LOCATION SEWAGE #
VILLAGE Cin iV/�l'�- ASSESSOR'S MAP& LOTd
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILr Y: (type) X (size) d
NO. OF BEDROOMS '
BUILDER OR OWNER V
PERMTTDATE: COMPLIANCE DATE: O
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist /`
on site or within 200 feet of leaching facility) N(14— Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of 1 achin facility) N '� Feet
Furnished by JX (jv /�� CG
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