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Home My WebLink About0461 PINE STREET (HY - Health (2) t61 Pine Street Centerville f A= 228 — 103 � UPC 12534 ' N0. 2 jl 3L2R .CQtiSJ��o- HASTINGS, MN I Commonwealth of Massachusetts a 'g` 103 ,_- Title 5 Official Inspection Form t' Subsurface Sewage Disposal 9 p System Form Not for Voluntary Assessments 9 461 PINE ST Property Address — DANIEL & SALLY ANNE SERPICO Owner Owner's Name information is CENTERVILLE required for every _ MA 02632 4/29/2021 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 f In A. pector Information filling out forms 5'.4t on the computer, 1 use only the tab _Christopher Maki key to move your Name of Inspector cursor-do not use the return Cape Cod Septic Services _ key. Company Name — -- 350 Main St. „b Company Address -- W Yarmouth _ MA _ 02673 City/Town State Zip Code 5Q8-775-2825_ _ _ SI-14423 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 4 4/30/2021 Inspector's Sig a ure Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner regional office of the DEP. The original form should.b sent to the system owner andrt to copies opihe s appropriate sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the, conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc-rev.7I26/2016 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form r Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c. f 461 PINE ST ..", _ Property Address - DANIEL & SALLY ANNE SERPICO Owner Owner's Name -- information is CENTERVILLE required for every MA 02632 4/29/2021 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: SYSTEM IS IN WORKING CONDITION 2) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): l5insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 2 of 18 Commonwealth of Massachusetts 1� - ---, Title 5 Official Inspection Fora r, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �; � 461 PINE ST Property Address DANIEL & SALLY ANNE SERPICO Owner Owner's Name information is CENTERVILLE required for every ___....__ _ _ MA 02632 4/29/2021 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstructiontis removed. ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: I t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts 1►=-_= - ,fs Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ( 461 PINE ST Property Address DANIEL & SALLY ANNE SERPICO Owner Owner's Name information is CENTERVILLE _required for every _ _ MA 02632 4/29/2021 page. CityrFown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 g q ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: . Yes No ElBackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 Commonwealth of Massachusetts 1r l Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 461 PINE ST Property Address DANIEL & SALLY ANNE SERPICO Owner Owner's Name information is CENTERVILLE required for every — _ MA 02632 4/29/2021 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No 0 ® 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 1/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: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,060 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 �y Commonwealth of Massachusetts -6P Title 5 Official Inspection Form s -- — , Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 461 PINE ST Property Address — --- - DANIEL & SALLY ANNE SERPICO Owner Owner's Name information is CENTERVILLE required for every MA _ 02632 _ 4/29/2021 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes" to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or no" for or each of the fo llowing for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] 15insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 461 PINE ST _ Property Address ^— DANIEL & SALLY ANNE SERPICO Owner Owner's Name -- information is CENTERVILLE required for every _ MA 02632 _ . 4/29/2021 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms 2 2 (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 220 Description: i Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry.on a separate sewage system? (Include laundry system inspection information in this report.) ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): '20-71 GPD Detail: 19- 52GPD Sump pump? ❑ Yes ® No Last date of occupancy: CURRENT Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 7 of 18 t � Commonwealth,of Massachusetts =_ __0 Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments t � �r 461 PINE ST L ` Property Address DANIEL & SALLY ANNE SERPICO Owner Owner's Name — — information is required for every CENTERVILLE _ _______ MA 02632 4/29/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: —_ Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: — - Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: UNKNOWN Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: — t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r -> . 461 PINE ST Property Address _DANIEL & SALLY AN_NE_SERPICO _ Owner Owner's Name information is CENTERVILLE _ required for every __ _ _MA _ 02632 4/29/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 1985 PER ASBUILT CARD ON FILE AT BOH Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer (locate on site plan): Depth below grade: 26" feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 10+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): LINE CHECKED WITH SEWER CAMERA AND WAS FOUND TO BE CLEAN AND PROPERLY PITCHED _ t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts = -_; Title 5 Official Inspection Fora `l -- I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 461 PINE ST Property Address DANIEL & SALLY ANNE SERPICO Owner Owner's Name information is CENTERVILLE required for every MA _ _02632 4/29/2021 page. City/Town State Zip Code` Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: 18" feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene El other(explain) r If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of,certificate) ❑ Yes ❑ No Dimensions: 1000 GALLON Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle Scum thickness 111 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? ESTIMATED Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 1000 GALLON TANK IN GOOD CONDITION. PVC TEES IN PLACE AND CLEAN. TANK AT NORMAL OPERATING LEVEL. COVERS 18" BELOW GRADE t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts r, y�3 Title 5 Official Inspection Form — ly,, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 461 PINE S_T _ Property Address — — �— DANIEL & SALLY ANNE SERPICO Owner Owner's Name— in formation is required for every CENTERVILLE __ _ _ _M_A_ 02632 4/29/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): i Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle - Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. 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): i Dimensions: Capacity: gallons Design Flow: gallons per day 15insp.doc•rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts -p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 461 PINE ST _ Property Address ` --- DANIEL & SALLY ANNE SERPICO Owner Owner's Name information is CENTERVILLE required for every _ _ MA_ 02632 _ 4/29/2021 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank (cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: ---__ Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert EVEN Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): DISTRIBUTION BOX LEVEL AND WATERTIGHT 15lnsp doc•rev 7)2612018 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 12 of 18 ' Commonwealth of Massachusetts , - = Title 5 Official Inspection Form =!, - 1'. Subsurface Sewage Disposal System 9 p Form Not for Voluntary Assessments 461 PINE ST Property Address --- DANIEL & SALLY ANNE SERPICO Owner Owner's Name information is CENTERVILLE required for every MA_ _ 02632 _ 4/29/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1-6'X6' ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: -- ❑ innovative/alternative system Type/name of technology: -- -- t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form -- . Subsurface Sewage Disposal System Form Not for Voluntary Assessments 461 PINE ST Property Address - DANIEL & SALLY ANNE SERPICO Owner Owner's Name information is CENTERVILLE _required for every ___ MA 02632 _ 4/29/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 1-6'X6' PIT WITH STONE FOUND DRY DURING INSPECTION WITH STAINING AT 1' UP. COVER IS 12" BELOW GRADE 12. mus Cesspools p (cesspool t be pumped as part of inspection) (locate on site plan): Number and configuration _ Depth —top of liquid to inlet invert -- Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5msp doc•rev 7/26/2016 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts E. _ = ;f� Title 5 Official Inspection Forrn- _- _ loi Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 461 PINE ST a� r' Property Address - DANIEL & SALLY ANNE SERPICO _ Owner Owner's-Name --- information is y CENTERVILLE required for ever MA 02632 4/29/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: -- --_ Dimensions Depth of solids --- Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): i I 151nsp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments i " 461 PINE ST Property Address — -- DANIEL & SALLY ANNE SERPICO Owner Owner's Name " `- --- information is CENTERVILLE required for every _-. ... _.._ MA _ 02632 _ 4/29/2021 page. City/Town _w.. ...._..__.—_-.-- State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewa ge e disposal system,9 p y 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 r _ � 36 yu, 6 i t50sp doc•rev 7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 16 of 18 Commonwealth of Massachusetts � - -; Title 5 Official Inspection Form — j Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Ta=;% 461 PINE ST _ Property Address — DANIEL & SALLY ANNE SERPICO Owner Owner's Name ------� -- --— -- information is CEN1"ERVILLE required for every — _MA 02632 4/29/2021 page. City/Town State Zip Code Date of Inspection D. System Information (co nt.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: +15'_ 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: HAND AUGER PERFORMED ONSITE AT TIME OF INSPECTION TO 15' ENCOUNTERED NO GROUNDWATER. BOTTOM OF SAS AT T6". Before filing this Inspection Report, please see Report Completeness Checklist on next page. ,. t5insp.doc-rev 7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts `1 -= -;P Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 461 PINE ST _ Property Address — DANIEL & SALLY ANNE SERPICO_ Owner Owner's Name------- --- - - information is TERVILLE CEN required for every _E__.___.._,.________._______.___ _ __ _ MA 02632 4/29/2021 page. City/Town State— Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank— Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2D18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 461 Pine Street Property Address Daniel Serpico Owner Owner's Name information is required for Centerville Ma. 02632 4/04/2007 every page. City/Town State Zip Code Date of Inspections Inspection results must be submitted on this form. Inspection forms may not be altered/in any way. Important: A. General Information When filling out forms on the computer,use only the tab key 1. Inspector. I to move your Robert Paolini cursor do not Name of Inspector „L c use the return key. Capewide Enterprises,LLC Company Name ras P.O.Bow 763 Company Address _..; Centerville Ma. 026321 c remm City/Town State Zip Code" r- (508)428-4028 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 ❑A_N.eed', rth Ev tion by the Local Approving Authority 4/04/2007 In cors g 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. 461 pine st.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 2 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 461 Pine Street Property Address Daniel Serpico Owner Owner's Name information is required for Centerville Ma. 02632 4/04/2007 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The septic system is in proper working order at the present time. 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 t 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. 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 461 pine st.-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 2 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 461 Pine Street Property Address S Daniel Serpico Owner Owner's Name information is required for Centerville Ma. 02632 4/04/2007 every page. City/Town State Zip Code Date of Inspection B. Certification cont. B) System Conditionally Passes (cont.): ❑ 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: 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 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. 461 pine st.•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 3 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 461 Pine Street Property Address Daniel Serpico Owner Owner's Name information is required for Centerville Ma. 02632 4/04/2007 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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: r" 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 0 ® 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 Y2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ S 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. 461 pine st.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 4 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 461 Pine Street Property Address Daniel Serpico Owner Owner's Name information is required for Centerville Ma. 02632 4/04/2007 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® 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 0 ❑ 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. 461 pine st.•06/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 5 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 461 Pine Street M ' Property Address Daniel Serpico Owner Owner's Name information is required for Centerville Ma. 02632 4/04/2007 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® 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)] 461 pine st.-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 6 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 461 Pine Street Property Address Daniel Serpico Owner Owner's Name information is required for Centerville Ma. 02632 4/04/2007 every page. City/Town State Zip Code Date of Inspection 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 Number of current residents: 2 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 Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 2006:93,000 g ( y g (gpd)): 2006:93,000 Sump pump? ❑ Yes H 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: Last date of occupancy/use: Date Other(describe): 461 pine st.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 7 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ° 461 Pine Street M Property Address Daniel Serpico Owner Owner's Name information is'required for Centerville Ma. 02632 4/04/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Capewide Enterprises,LLC Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1000 gallons How was quantity pumped determined? Measured Reason for pumping: Maintenance 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. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: System installed in 1985 Were sewage odors detected when arriving at the site? ❑ Yes ® No 461 pine st.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 8 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 461 Pine Street Property Address Daniel Serpico Owner Owner's Name information is required for Centerville Ma. 02632 4/04/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): 16" Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: 20'+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of Ieakage.System vented through the house vents. Septic Tank (locate on site plan): Depth below grade: 18"feet Material of construction: ® concrete ❑ metal ❑fiberglass- ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 8'6"c4'10"x57' Sludge depth: none Distance from top of sludge to bottom of outlet tee or baffle na Scum thickness none Distance from top of scum to top of outlet tee or baffle na Distance from bottom of scum to bottom of outlet tee or baffle na How were dimensions determined? Tank pumped empty 461 pine st.-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 9 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 461 Pine Street Property Address Daniel Serpico Owner Owner's Name information is required for Centerville Ma. 02632 4/04/2007 every 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.): Pump tank every 2-3 years.lnlet and outlet tees are in place.Tank appears structurally sound.No evidence of leakage. 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 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): 461 pine st.-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 461 Pine Street Property Address Daniel Serpico Owner Owner's Name information is required for Centerville Ma. 02632 4/04/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) 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 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 461 pine st.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 11 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °wM 461 Pine Street Property Address Daniel Serpico Owner Owner's Name information is required for Centerville Ma. 02632 4/04/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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: Type: ® leaching pits number: 1 ❑ r leaching chambers number: ❑ leaching galleries number: leaching trenches number, length: ❑ 9 9 ❑ 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.): Sandy soil.No signs of hydraulic failure.Leaching pit was 18"water to invert at time of inspection. 461 pine st.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 12 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 461 Pine Street Property Address Daniel Serpico Owner Owner's Name information is required for Centerville Ma. 02632 4/04/2007 every page. City/Town State Zip Code Date-of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 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.): 461 pine st.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal.System Form -Not for Voluntary Assessments 461 Pine Street Property Address Daniel Serpico Owner Owner's Name information is required for Centerville Ma. 02632 4/04/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. I' I: "tin r \ � l r' F kr yam- 9tR!V1pY 9 i I, i dS` ... ......./Q ... OF:... .Cc�' 91AN71!T. ... , FEE.� ......... 11 1-1 Permission is hereby anted...... f...-t ...........!,��r� .......... ..... �/ ..,..........._.... fo;Construct or( fir (A-"an vidual wage sP Y o stem a�t'No....... ..Z. � -as shown on the application for Disposal Works Construction Permit No S ....... Dated.....4. � , ........ .............................. ._... DATE:....'... . ,� ...25.....--•--•-•----••................. era ,FORM 1255 A. M SULKI INC., BOSTON - 461 pine st.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 14 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 461 Pine Street ,M Property Address Daniel Serpico Owner Owner's Name information is required for Centerville Ma. 02632 4/04/2007 every 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 ground water: 40' 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: As-Built card ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Usede:Gaherty& Miller model 12/16/94 ground water elevations.Used:USGS observation well data June 1992.Used:Technical bulletin 92-000-01 plate#2 annual ranges of ground water elevations. 461 pine st.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 LOCATION SEWAGE PERMIT NO. 441 12s-- 4�� VILLAGE Cmnay, ( lf INiTA LLER'S NAME & ADDRESS r e UILDER OR OWNER tl SE DA E--RMIT ISSUED /95 ( I— DAT E COMPLIANCE ISSUED r} 1 w _. ` � ' ,�.. . s� `, �a k �. ,. �� 3� d 4 , .,6 � � S�, �� No.. _.I.Lk Finc.. .....`..�...r......... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ti ----7e ...........OF............ ..s !Q !;741h14---" .................................................... Appliration for Disposal Works Toustrnrtinn rnmit Application is hereby made for a Permit/toy Construct ( ) or Repair ( Ian Individual Sewage Disposal System at: P> -. Loc *olz-Address or Lot No. ..... . .0,v...._.. .......................................... ..---...•.. •.................................................. Address a ems - cO.v Installer Address dType of Building�� Size Lot............................Sq. feet U Dwelling rNo. of Bedrooms................................ .Expansion Attic ( ) Garbage Grinder ( ) ............................ No. of ersons............__.......__.____ Showers — Cafeteria pa,,, Other—Type of Building p ( ) ( ) aOther fixtures ...............••--•--•------•---•--------•-------...-•---•-------•--------•---•--------•--._...---••-•----------------------•----•----------------. d W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width............:....... Total Length....................Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area.........._.......sq. ft. Z Other Distribution box ( ) Dosing tank ( ) '-� Percolation Test Results Performed by......................................................................... Date........................................ ,4 Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ (i Test.Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ x Description of Soil_.__..... x w -•--- . ----•-. . ----•-•-•--•. -- -------- V Nature of Repairs or Alterations—Answer when applicable._.�4®0_____________ ._ . _____..._ --------••-•---------------------------------------------------•--------------------...---••-------•-•-••-•-- -1® ------ -- -------------L�------......---. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITIL 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has beeS L .n ' sued by t boar f healt . ,,� r mate Application Approved By----•---- ..... -- � . ---- Da Application Disapproved for th allowing reasons:-----•-----------------------------•---------------------------•••--• -•-•--------. .......................... ---•--•-----------------------------------------------•--------------------------•------------...------------------------•-------------•----------------------•-•- ........................ • Date Permit No............. S�-� -�----------. Issued-------•--- ...... �•.. .•-- --•-S ---------- Date ?s No......................... Fss.f�`.h .................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..._-......r-'--....---------------------OF - Appltration for Biopooal Works Tonitrur#ton Frrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ,�✓�i „� ,f -... :.r.... ........x.: ........................ ... .. ............................................... ..... -- •-----••-•-•---- .......-•--------••---------------------- „ e•:"- Location-Address or Lot•No. •. -- •_,.v.. Owner - ................................................................•---•^------•---.........---.... ,. 'f, Address a �✓�, b:✓ �✓✓sl{ram. ,I Od .................._ .. _ T......... ........_........_ ......... ............... .........................................................................._....................... Installer Address Type.of Building Size Lot............................Sq. feet �-. Dwelling`"<o. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) d Other fixtures W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter...._............... Depth below inlet.................... Total leaching area..................sq. ft. _z Other Distribution box ( ) Dosing tank ( ) a Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutesp er inch Depth of Test Pit.................... Depth to ground water........................ (14 Test Pit No. 2................minutes per inch Depth of Test Pit..............._.... Depth to ground water........................ O .............._ .......................................................................................................................... Description of Soil...... _ x ---•--------------------------------------------------------------------------------------------------- y � U Nature of Repairs or Alterations—Answer when applicable `_.:.. �§ .............. s' ....N' J _...---....•......................................•-.---.................._.................._.............. ._LL•fy= 1'%✓' .s r.. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITIE 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- 141111 ....; ................................. Application Approved B '••.. Date Date Application Disapproved for the following reasons---------------•-------•--•-•----•-----------------------------•-------------------------------------------•••--- -•------••.......•----•---•-•-----•------•-----....--••------------------•...-----•-••--•....----•--•-------•-----------•••--.._..._...---•---••--•••-----••-=------•---•-------•------•----••--•-•--- /J o Date Permit No.----- ................... Issued-------` __ --•---------......... ......--- Date _ I I THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH :...'.....:...:..:..:..............OF...' ......... Tnrtifsratr of flu t li ttrr THIS IS TO,CERTIFY, That the In�..'vidual Sewage,Disposal System constructed ( ) or Repaired by. `_y... .. ' _•- -------------•----•---._...-----------------------------------------------._..........-•-- / / Installer 4 at... �l` ``^ /4............................r+``i ,u�. a ..... has been installed in accordance with the provisions of TIT 5 o The State Sanitary C e as des ibed in the application for Disposal Works Construction Permit No------- ._' �?_-_---_- dated.... __._.`-...�-___g$............. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONS RUE® AS A GUARANT E THAT THE SYSTEM WILL NUNCTIOIJ SATISFACTORY. DATE � ,...... ------•-----•-•------.---- Inspector -C------------------------------------------ m THE COMMONWEALTH OF MASSACH SETTS BOARD OF HEALTH , ' .f; .............O F....-'`, ! % ?ram <: ' ` "� �1 �._. ......._ ................. Diopos4j Works Tatuitrudiatt rrrnttt Permission is hereby granted.....=== :.. -" '" . 4'�----. '. -. to Construct ( ) or nR air (o -y a Ivldual Sewag >�l�isposaV System y,`' �: rf ..................................................... Street as shown on the application for Disposal Works Construction Permi'�N ................ ----------•------•-----••------- ----- -- ---------•--------------•--.----•---.-.-- • d of health DATE ------ FORM 1255). M. S LKIN, INC., BOSTON • r \ �� O� �`-vtJCJ � J i I .sBuilt Page 1 of 1 LOCATION SEWAGE _PE jI �1f'S tin n I VILLAGE nv, � � INSTA LLER'S NAME A ADDRESS+ w a- C V'k t e U I L D E R 0It OWNER S£ R' I D A IT—E R-E R'M I T I S S U E D DAT E COMPLIANCE ISSUED � y�t r r 16 j http://issgl2/intranet/propdata/prebuilt.aspx?mappar=228105&seq=1 9/29/2010