HomeMy WebLinkAbout0017 SEA MEADOW CIRCLE - Health 17 Sea Meadow Circle, Centerville
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UPC 12543 a
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HASTINGS, MN
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Commonwealth of Massachusetts
w Title 5 Official Inspection Form
o
Subsurface Sewage Disposal System Forma Not for Voluntary Assessments
y.y
\ e„ 17 S'ea Meadow:Girc.le
Property Add ress:
Gonnellan
Owner Owner's Name "
information is IIw
required for every Be� �I�� tX� MA 02630 June 18, 2018 �1..
page. City/Town State Zip Code Date of Inspection
Insper ion results-must-be:submitted on,this form...Inspection forms-may-not-be alteredAn_.eoy
way. Please see completeness checklist at the end of,the form.
Important:V-V A
hen GeneraI Information (51*- f 3czlo
filling out forms, °
on the computer,
use only the tab
1.. Inspector.,
key to,move;you r
cursor-do,not Edwin G...Gibbs Jr.
use the;return
key. Name.of Inspector..
Gibbs Septic Service
r Company Name
2,Oriole:.Lane
Company Address
e Sandwich MA 02.563
CitylTow.n .State Zip Code
(508).888 5871 175.0
relephon.e Number License Number
R Cer i'fication
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:
Jam' Passes ❑ Conditionally.Passes. ❑ Fails.
❑ Needs Further Evaluation by the Local Approving Authority
i
1
t
Inspector's Signature Date
The-.system insp.ector.shall submit a copy of this inspection report to the Approving,Auth:ority (,Board
of+i:ealth or_DEP) within 30 days of-mmpleting this inspection If the:system isA-:shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit they
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. t,
****This report only describes conditions at the time of inspection andvinder the conditions of use
at that time:This inspection does not address how the system,will perform in the-future under
the same or different conditions of use...
t5ins•3113 Title 5 Offi�`s\i)al Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
' Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
17 Sea'Meadow C:ircle:,.
Property`Address.
Conneilan
Owner Owner's Name
information is required for every Barnstable MA 02630 June 18 2018
page. City/Town State Zip Code Date of Inspection
Bo CerPfofucafuon (cons.)
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 o.ve:r 20 years:old*or the:septiclank(whether metal or not)is structurally,
unsound, exhibits:substantial infiltration-or exfiltration-ortank 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 b'elow):
f ,
t
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
�J
' Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
5
17Sea Meadow—Gircle
Property Add ress:
Con n el la n
Owner Owner's Name
information is required for every Barnstable MA 02630 June 18, 2018
page. City/Town State Zip Code Date of Inspection
Bo Certification (cont.)
❑ Pump Chamber pumpslalarm-s not operational `S.ystem Will pass With Board,of Kealth�approval if
pumpslalarms::are repaired.
'B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are,replaced ❑. Y ❑ N ❑ ND (Explain below)
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system.wi.11.pass i.nspection..if.(with.a.p.prova.l..of.the..Board..of...Hjealth).:
❑ broken pipes)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(j)(b)that the:system is not functioning in a manhsrwhic:hwill 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•3/13 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
17•Sea Meadow Circle
PropertyAddress
Connellan
Owner Owner's Name
information is required for every Barnstable MA 02630 June 18, 2018
page. City/Town State Zip Code Date of Inspection
B. Cerfificataon (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.tankand SAS:.and the SAS Is within 50.feet of a private-.water
su.pply:•wel 1.
❑ 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:
Tbis:.system.pass:es if the well water,ara1ysis., .perform.ed,.at a DE`P:;certified.laboratory, for-fecal
coliform bacteria indicates:absent and the presence ofammonia nitrogen and nitrate nitrogen,is equal
to zor less thah.5 ppm,, provided that no,other failure criteria:are tri.ggered.,A.copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You_must indicate "Yes" "Na" 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:.outletinvert due to,an overloaded
Rk or clogged SAS.or cesspool
❑ Liquid depth in cesspool is Less than 6"'below invert or available volume is less
than 1/day flow
t5ins-3/13 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
17.Sea-Meadow-Circle
Property,Addres-&
Cortnellan
Owner Owner's Name
information is required for every Barnstable MA 02630 June 18 2018
page. City/Town State Zip Code Date of Inspection
Bo Certification (cont.)
Yes -No
❑ Required-pumping more than 4 times in the.last year NOT.due to clog:g,ed or
obstructed pipe(s). Number of times pumped:
❑ Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ R Any portion of cesspool or privy is within 100 feet of a surface water supply or
tri,bu-taryto..a.surface,water supply.
❑ Any portion of-a.cesspool or privy is:within a Zone 1 of public:well.
❑ 5 Any portion of a cesspool or privy is within 56 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-et qal to-or less than,5 ppm,
provided that no other failure criteria arentriggered,_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
criterra.exist as.described.in 11G CUR.T5.303„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.
'des 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 Ll of a public water supply well
If you have answered"yes`' tol 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 orfailed 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
`'- 17 Se.a.Meadow Circle
Property.Address
Connellan
Owner Owner's Name
information is required for every Barnstable MA 02630 June 18 2018
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 foll-owing:
Wes No
❑ R Pumping information was provided by the owner, occupant, or Board of Health
❑ Cj Were any of the system components pumped out in the previous two weeks?
❑ Has.the.system received normal flows.in the pre.vious two:.week.period?.
Have large volumes of water been introduced to the system recently or as part of
this inspection?
0 ❑ 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?
❑ E& Was,the facility owner(and occupants.if different from owner) provided.with
Information on the proper maintenance;ofsubs;urfacesewage.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 distanee`is un;acceptabie) [310 C'MR 1:5.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design,}: N.umbe.r.of..bedrooms:(actual):
DESIGN flow•based on 3.10.CM'R 15.203>(for example- 1.10:gpd.x>#ofbedrooms)':.
l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
17 Sea Meadow Circle.
Property Address.
Canne:llan
Owner Owner's Name
information is required for every Barnstable MA 02630 June 18 2018
page. City/Town State Zip Code Date of Inspection
D. System Information
Description.
Number of current residents:
Does residence have a garbage grinder? ❑ Yes [Q No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ar No
information in this report.)
Laundry system inspected? ❑ Yes Q No
Seasonal use? ❑ Yes 9 No
Water meter readings, if available(last'2 years usage(gpd)):
Detail:
Sump pump? ❑ Yes 0- 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 M. 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
Property.,Address..,
Owner Owner's Name
information is
required for every Barnstable MA 02630 June 18, 2018
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last'date of occupanqy/use: Date
General Information
Pumping Records:
Source of information:
Wassystem pumpe-d.as part of the inspection? Yers 'No
If yes, volume pumped:
gaKons
�
� How was quantity pumped determined?
Reason for pumping:
Type of'Syntemn:,-
�8 SeDtiCtonk. disthbUti0ObOx. Soi| 8bGoroUonsyste[n
E] Single cesspool
Overflow cesspool
�] ^Prh{Y
[l Shared system (yes or no) (if yes, attach previous inspection records, if any)
�] lnnovative/Alternative technology. Attach a copy of the current operation and
maintenance contract (to be obtained from system owner) and a copy oflatest
inspection of the VAaysbaro by,system operator under contract
Tight tank` Attach acopDof the OEPappnzvaL
El Other(describe):
wm 'ano Title 5 Official Inspection Form:Subsurface Sewage Disposal System'Page omn
K
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
17 S.ea.Meadow Circle,
Property Address.
Connel.lan
Owner Owner's Name
information is required for every Barnstable MA 02630 June 18, 2018
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approxim-ate:aige of-dcyyl components., date installed (if known.)and:source:of information::
A9 /P6
Were sewage odors detected when arriving at the site? ❑ Yes No
Building Sewer(locate on site plan):
Depth below grade: fee.
Material of`construction
❑ cast iron ❑40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
'Comments (on condition ofjoints;�uenting :evid:enoe•of leakage;°:etc:):
Septio.Tank(locate on site plan).:
Depth below,grade: feet
Material of construction:
EY 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Fora - Not for Voluntary Assessments
�t
't 17 S.ea.:Meadow:Circle
Pro,perty Add ress;;
Conne.11an
Owner Owner's Name
information is required for every Barnstable MA 02630 June 18, 2018
page. City/Town State Zip Code Date of Inspection
D. System Wormation (cont.)
;Septic Tank (cunt..)
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
�Q
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 ❑.polyeth;yl:ene El :other,(:explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of'scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins-3/13 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
17 Sea,Meadow-Circle.
Property,Address
Co.nnellan
Owner Owner's Name
information is required for every Barnstable MA 02630 June 18, 2018
page. City/Town State Zip Code Date of Inspection
D. System Wormatoon (cont.)
Gomments(on pumping recommendations„ inlet-and:outlet tee or baffle:condition,:.structural'integrity,
liquid levels as%late:d.to,outlet invert,-evidence.ofleakage' etc:):
cza
Tight or Holding.Tank(tank must be pumped at-time-of inspection) (locate on site plan)
Depth below grade:
Material of construction:
,❑:concrete ❑.m:e.tal ❑ 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 p:ump:ing_co.ntract(required).. Is..copy,a.ttached? ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
I
Commonwealth of Massachusetts
w Title 5 Official Inspection orm
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
17 Sea:Meadovu Clrc.le
Fropertj,Aiddress
Conneilan
Owner Owner's Name
information is required for every Barnstable MA 02630 June 18 2018
page. City/Town State Zip Code Date of Inspection
D. System Wolrmation (cont.)
D.istributi:on:.Box'(ifpre,sent must b:e opened),�locate,on.site piana.
Depth of liquid level above outlet'invert 0
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.):
x�
ag ..®. �
Pump`Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comme:nts::(no.te,condition of pump chamber,,condition.ofpump.s,and a:p.p.urte.nances,.etc,),';
' If pumps.or.alarms:.are not in working order,-system is a conditional p-a-ss_
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
UUK
Ti l ffl I I ISubsurface Sewage Disposal System Fora a Not for Voluntary Assessments
17 Sea_Me:adow Circle:
Property,Address
Conneilan
Owner Owner's Name
information is required for every Barnstable MA 02630 June 18, 2018
page. City/Town State Zip Code Date of Inspection
D. System Wolrmatoon (cont.)
Type
e
leachingpits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching.,trenches, number,,length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type'/name:of technology:
'Comments (note,condition.of soil, signs of•hydraulic failure,Level of,ponding, damp soil, condition of
vegetation, etc.):
fJ
4
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
"Number:and::coofig.uration
Depth —top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions,.of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
s
17 Sea MeadowCircle .
Property Address.: .
Co:nnellan
Owner Owner's Name
information is required for every Barnstable MA 02630 June 18, 2018
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Pomments (note:condition-of.soil,; signs.of hydraulic fi ilune,,-level.of p-onding, condition.of vegetation,
Privy.(locate,on site plan):
Materials of construction:
Dimensions
Depth.of solids
Comments.(note,condition,.of,.soil„signs of hydraulicfailurejevel:of ponding; condition.of-vegetation.,
'etc.)-.
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal Systems Form Not for Voluntary Assessments
17 Sea Meadow Circle•
Property,Add ress-
Po.nnellan
Owner Owner's Name
information is required for every Barnstable MA 02630 June 18, 2018
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
.Sketch Of'Seuuage D sposal'Sy-stem: Provide=a,avfew of thexsean.age,disposal:system, including ties to
at.,[ two:prermanent reference lan:dmarksror benchmarks. Locate::all�ellswithin 1:00 feet. Locate
where public water:supply,enters the building.lCheck onezof the boxes below:
❑ hand-sketch in the area below
❑ drawing attached separately
6
J,
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
W Title ffi i tin Form
Subsurface Sewage Disposal System Form a Not for Voluntary Assessments
s
17 Sea.Meadow Circle
Property Address
Connelian
Owner Owner's Name
information is required for every Barnstable MA 02630 June 18 2018
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site-Exam:
`Check Slope
❑ Surface water
Check cellar
❑ Shallowwells: 1
Estimated depth to high groundwater:
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'hdle within 1 b0 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:
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
17 Sea Meadow?Circl&
Property Address
Conneilan
Owner Owner's Name
information is required for every Barnstable MA 02630 June 18, 2018
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
irtspectionZummary: A, B,•C, D,_-or E checked
Inspection Summary D (System ROure'Criteria Applicable to All Systems) completed
System Information— Estimated depth to high groundwater
[s� Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 r'
r "
FS
H OM SCOMMONWEALTF I
w 1
EXECUTIVE OFFICE OF ENVIRONMENTAL AFF
DEPARTMENT OF ENVIRONMENTAL PRO TO N
ONE WINTER STREET, BOSTON, MA 02108 617-292-550 C�` ` .
(� 2-2.s
Bg9Nsl
WILLIAM F.WELD r oFpr ye(E TRUDY fOXE
Governor , �` S cmury
ARGEO PAUL CELLUCCI C T)W1DjB.STRUHS
Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 9 Commissioner
PART A
ceiv CERTIFICATION
L
` �f L�
Property Address: f� S� m erld ow U.rG Address of Owner:
Date of Inspection: i O- 9 9 7 (If different)
Name of Inspector: A., o r S
I am a DEP approv system inspect r pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: (��; p ,pC_
Mailing Address: 2 c'x-Fe'r o )d
Telephone Number: 7.7 g'- O b X Y
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
Passes
— Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
_, Fails 01
Inspector's Signa ure: Date:
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(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 Department of Environmental Protection. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
INSPECTION SUMMARY: Check A, B, C, or D:
AI SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria a9 defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
COMMENTS:
BI 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.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
(revised 04/25/97) page 1 of 10
DEP on the World Wide Web: http:/Mv4w.magnet.3tate.ma.us/dep
ej Printed on Recyded Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: i 1 S� VAe-"_d � c`
C�Vf—C wcq y;(le—
Owner: G1'L 1 i h t J
Date of Inspection: 10 917
B] SYSTEM CONDITIONALLY PASSES (continued)
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection.if(with approval of the
Board of Health). Describe observations:
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four 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
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 the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND 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 APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
_ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or
tributary to a surface water supply.
The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis 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. Method used to determine distance (approximation not valid).
3) OTHER
4
I.{G (revised 04/25/97) Page 2 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 1-7 S 2 c� C,c��^-) C �\ ,�r0.i C�U, (�
Owner: G i fl,h
Date of Inspection: 1 0-°I- cl 1
Dj SYSTEM FAILS:
You ust indicate ei;�,er "Yes" or"No" as to each of the following:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
Yes No/�
Backup of sewage into facility or system component due to an 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 1/2 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation.
✓ Any portion of a 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 I of a public well.
1 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
You must indicate either "Yes" or "No" as to each of the following:
The following.criteria apply to large systems in addition to the criteria above:
NThe system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
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)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 04/25/97) Page 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 1 7 se-0— mev,. OuJ �.�t('G,e , CCC', 0'.-
Owner: &i+I;h
Date of Inspection: 1 O •- -cl 1
Check if the following have been done: You must indicate either "Yes" or"No" as to each of the following:
Yes No
Pumping information was provided by the owner, occupant, or Board of Health.
_ None of the system components have been pumped for at least two weeks and the system has been receiving normal
flow rates during that period. Large volumes of water have not been introduced into the system recently or
as part of this inspection.
t� As built plans have been obtained and examined. Note if they are not available with N/A.
_ The facility or dwelling was inspected for signs of sewage back-up.
_ The system does not receive non-sanitary or industrial waste flow.
_ The site was inspected for signs of breakout.
_ All system components, excluding the Soil Absorption System, have been located on the site.
_ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of
baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
—The size and location of the Soil Absorption System on the site has been determined based on:
The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of
Sub-Surface Disposal System.
Existing information. Ex. Plan at B.O.H.
_ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) [15.302(3)(b))
(revised 04/25/97) Page 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: I7. SeA- �leci�ou3 C�rC`Q �CK'0'\3Ji���
Owner: G j t i i h
Date of Inspection: 1 -9 - °I -
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 3Qg. d./bedroom for S.A.S.
Number of bedrooms:
Number of current residents:
Garbage grinder (yes or no):-13
Laundry connected to syste (yes or no):
o) �
Seasonal use (yes or n : "I S 12 g 6"3v q(p g3 tTa-r) 9 7
Water meter readings, if av ilable (last two (2)year usage (gpd): ) f,, e,L_g /
Sump Pump(yes or no):
Last date of occupancy: ss Y
COMMERCIAUINDUSTRIAI:
Type of establishment:
Design flow: aallons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non-sanitary waste discharged to the Title 5 system: (yes or no)_
Water meter readings, if available:
Last date of occupancy:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as part of inspection: (yes or no)_
If yes, volume pumped: (tallons
Reason for pumping:
TYPE O SYSTEM
TYPE
tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
I/A Technology etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information: Y6
Sewage odors detected when arriving at the site: (yes or not
(revised 04/25/97) Page 5 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 1 7 Sec, M zAA oLo C. 4-CA -�C V,CL V 1 �1 .
Owner: G ;+( ; h
Date of Inspection: I — Cj cj -7
BUILDING SEWER:
(Locate on site plan)
Depth below grade:
Material of construction: _cast iron /40 PVC_other (explain) "
Distance from private water supply well or suction line
Diameter Li
Comments: (condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK:
(locate on site plan)
df /
Depth below grader f/
—
Material of construction: _concrete _metal Fiberglass —Polyethylene —other(explain)
If tank is metal, list agep_ Is age confirmed by Certificate of Compliance _(Yes/No)
Dimensions:
Sludge depth: LPIttiW
Distance from top of sludge to bottom of outlet tee or baffle: 3
Scum thickness: 1 W1tt
Distance from top of scum to top of outlet tee or baffle: 4 tf
Distance from bottom of scum to bottom of ou t tee or baffle:_
How dimensions were determined:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relatiio °outlet invert, structural
4'Q
integrity, evidence of leakage, etc.)
_16 L kA _
GREASE TRAP:
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.)
(reviaad 04/25/97) Page 6 of 10
t
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Sec. 'Mea-aaw C �c�t,C14-C,
Owner:
Date of Inspection: i > - y - 9 -7
TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection)
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm level: Alarm in working order_Yes; _ No
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert:SQk
Comments:
(note if level and distribution is equal, evidence of solids carryover,.evidence of leakage into or out of box, etc.)
u(� GG�-vY`�- U.rG✓ D��� S r�� '
PUMP CHAMBER:
(locate on site plan)
Pumps in-working order: (Yes or No)
Alarms in working order (Yes or No)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 04/25/97) Page 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
V,.9
Property A dress: I 1
�`&oW C rc�e--)CV-0,
Owner: t t + 1 i h
Date of Inspection: t o — "► —H -
SOIL ABSORPTION SYSTEM (SAS):_
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type:
leaching pits, number: t
leaching chambers, number:_
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of ve tation, etc.)
CESSPOOLS:
(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 (cesspool must be pumped as part of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY: 1
(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.)
(revised 04/25/97) Page a of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
r 0, �Yle-
Property A ess: 1 �
Owner: , +I i h
Date of Inspection: 1 '9 ' 9 7
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
0
0
(revised 04/25/97) Page 9 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
\ SYSTEM INFORMATION (continued)
Property AA ress: 1 Ste"`- (Y�mac.,a a t�J C- ; C�4L C M c{ ✓i l l er
Owner: i f-(-Vh u
Date of Inspection: 10 -�i- Q17
NO w`WV'
Depth to Groundwater 362 Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observation of Site (Abutting property, observation hole, basement sump etc.)
Determine it from local conditions
Check with local Board of health
Check FEMA Maps
Check pumping records
Check local excavators, installers
Use USGS Data
Describe in your own wordshow you established the High Groundwater Elevation. Must be completed)
O 'Poo L—S a-r't—' Ou t'r 5 Y D W
I
(revised 04/25/97) Page 10 of 10
I�
fags
1.. 0 CAT ION SEWAGE PERMIT NO.
1-7
VILLAGE
INSTA L , E$'S NAME iA ADDRESS
JOHN A. AALTO RA(-KHnF CFRvrrP
s 150 Wa!nuf 5.;eet
_ Wact ,Rirnctahle, Masi t)2 6@
8 U I L D E R OR OWNER
ti
r I<ev,'k, S�PuweK
o� �-
DATE P ERMIf ISSUED
DATE COMPLIANCE ISSUED ��
Ns,
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
7 6W4................OF..........
t3L� ...
f Appliration for Disposal Works Tons rnr#inn rumit
Application is hereby made for a Permit to Construct (— ror Repair ( ) an Individual Sewage Disposal
P
System at:
........... .C1..... ------------------- ................................. .........................................
Location- ddress or Lot No.
.. .........................
Owner Address
... ."�� � ----------------------------------------------- �c1 .. '
Installer I Address
Type of Building Size Lot............................Sq. feet
�..� Dwelling—No. of Bedrooms... ..................................:Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons--... Showers —
a YP g ---------•------------------ P ( ) Cafeteria ( )
dOther fixtures --------------- ---------------------------------------------------•---•-----------....--•------•------------------------...-•---------...-•------
W Design Flow.........5. .........................gallons per person per day. Total daily flow............................................Jgallons.
WSeptic Tank—Liquid capacity%�"ogallons Length._...!®..... Width.. Diameter................ Depth_...4._......
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
3 Seepage Pit,No....../............. Diameter.._...f V....... Depth below inlet.....`9............ Total leaching area.4 1.9:L.-eq-€t--9Pj.
Z Other Distribution box ( A,�' Dosing tank ( )
1.4 Percolation Test Results Performed by..... ....................... Date...... -6._-'k-S.............
Test Pit No. 1...!4�.L....minutes per inch Depth of Test Pit....i.3`......... Depth to ground water.&4.0..k AMVY-
w7JG6 U7i4,,lC�
f=, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water...................._...
a --•----•-•-----------------------------•--•---------------•--.......---•-------•-------------•---......•-----.._...--------•--••--.........._.._..-------•--
ODescription of Soil.......................150�...-vo. ------------.......---.......-------------------------------------------•--------
U •------
-----
-----
-...
-----------------------------
.--------------------------------
-------------------------------
•-••-•••----------- ---------------------------.--------------- --------------
VW ...-•----•--------•---------••---•------------------------------------------------------------•----•----•---...-----------...----- ----•---------------•------•------------.........--•--------.........
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 iITL 5 of the State Sanitary Code—The and rsigned further agrees not to place the system in
operation until a Ce ' sate of mpliance has been issued by oard of health.
Signed.." --------- - Gait-t'_
-- ------ --------------•---•----------•---------------..---- ................................
Application Approved By... ........ . ...... ...�qat
Application Disapproved for the following reasons---------------••--•------•----•-----•-------------------------------------------•---------•-•-----•-•-----------
...........-•-••-•..........................••---•-•-----•------.............------------................._...-------•----------------------•----•-----------------------...----•------------•--•--•--•--
Da
Permit No.------... =� -I- co------.... Issued----------•---_---------•............... Date...---
Date
No :. Fss.
THE COMMONWEALTH OF MASSACHUSETTS-
, BOARD. OF HEALTH----- .-
...........OF.
Aplifiration for 11iopoaal Works Tonotrur#ion Vrrmi#
Application is hereby made for a Permit to Construct .-
PP Y ..t ct (� or Repair ( ) an Individual Sewage Disposal -
System at:
____ .... c��- i _
.......... � __MF J ... .. .. .... ------•------•--•---
/� Location-Address -
, .........................
Owner Address
,.a •....................,........---------•------... .................------------------........----- .........Installer Add.................. ..... .......
ress
Type of Building Size Lot..............................Sq:feet
Dwelling—No. of Bedrooms.._13-----------------------------------Expansion Attic ( ) Garbage Grinder ( )
p� Other—Type of Building ---------------------------- No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Other fixtures
W Design Flow........... ..........................gallons per person per day. Total daily flow.......-3---3Q.........................gallons.
WSeptic Tank—Liquid capacity./5?'0gallons Length-----1Q...... Width._ .5..__. Diameter................ Depth....d..........
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
3 Seepage Pit No....../.............. Diameter...._.i?:........ Depth below inlet....'4............ Total leaching
Z Other Distribution box ( A,)' Dosing tank ( )
..1 Percolation Test Results Performed by..... !?..f. !?el���'•1 >•......................... Date.....-4-. _-.fir. .............
Test Pit No. 1...K Z-___minutes per inch Depth of Test Pit__-t.3.._....... Depth to ground water-M _.!✓. x
C�C6Jh+�rC�Q f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water......
a •-••••-•-•-•--•----•----••--•--•-••••.......••--•••--•-••...•-••-••..............................••-----•-......................_............................
O Description of Soil.....................<_--e k... �
ptJct e =
V ...............•--••-•-•-•-•---•••---••-•-•-•••--------••••-•--••-••-•••---•------••-••--•-••--•-----•-••••••----•-•••--••-•--•-•-••••--•••-••--••--••-•-••--•-•----•••-••--•-.............._............
W
x ---------------------------------------------------------------------------------------------------------------------------------------•----------------------•---....-----------......--•--••-•-••-•-••
U 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 LITU 5 of the State Sanitary Code—The undersigned further agrees not to Y place the system in
operation until a Certificate of Compliance has b en issued by e��oard of health.
Signed........--•--- --------------••-----•--•-----•-•--••...-••-•-•---......-
Application Approved By---
.............. ---...
Date
Application Disapproved for the following reasons:........................'.......................................................................................
......•-----•---•••......-•---••--•---•-••••-•••••---•--•••-•----•-••--••-•••---•-••-........••.•-•--•--.......•••--....._-•••••-••--•-••....•--•-•••-----•---••-••••...............••••..........----..
.Date
Permit No........_ �..(,1��.(�?---------- Issued---.._._..•--•-.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
J010 OF......................... ".'t':............
(9rrtifirtt#.r of Tomplianrr
THIS IS TO CERTJFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by.. "� ------------------•-------------•-----................----•-•---......--•--•-----•--............................--••--
�+ /►�Installer
at. •. o ! J �1/1D1•9 sue..._G�f! cL F----------•--•------------------•--.----.---------------
has been installed in accordance with the provisions of TJTL; 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.._�rl�? -�4 .���n. dated....... I =r.- =--•---•-------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. r� ,
li , f i Inspector........................ .....DATE.................... V.........y....... --.----•--------
----------------------------------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
r BOARD OF HEALTH
...... ...............OF............ ...............................
FEE .
�.
......... ..... .....
�io�o� 1 ork,� �ono� ion �rrntit
Permission Is hereby granted .t..�Z ...-� l.....--•-------------------
to Construct ( ) or Repair ( ) an Individual Sewage Disposal System
at No.................................oi Sl�sMf p oc�w.. C���cG -------------------- ------....--------......... ............................
_c •--
Street
as shown on the application for Disposal Works Construction Permit No _7 Dated.._.__.__�....... _.. .
Board of Health
DATE.--- ------.Jj.) _-•--_----•------•----- •••--
i 1 i.ui .: . , .- - . . ----"-- ti'' : t . -—--- -- ---
• a>
HIGH GROUND-WATER LEVEL COMPUlAlION
Site Location (.eJ�/ GY y Lot
Owner:
i5 ,A _ Address: 3Z,5-4 (F((2 D2 Address:
Contractor:
Notes:
' r1
STEP 1 Heasure depth to water .table 1� �5
to nearest 1/1.0 ft. . . . . . . . . . . . . . . . . . . . . . . . . . - - --
date
0
STEP 2 Using Water-Level Range Zone S 5
and Index :fie 1 1 Nap locate 3,
site and determine:
A) Appropriate index well -
B) Water-level range zone . . . - - . - - - - - - to it
STEP 3 Using monthly report"Current
Water Resources Conditions"
determine current depth to43
water level for index well . . . . 5 g5
mo yr
STEP 4 Using Table of Water-level-
Adjustments for index well
STEP 2A , current depth to
water level for index well
(STEP 3) , and water-level
zone (STEP 2B) determine
a
water-level adjustment . . . ... ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
STEP $ Estinate depth to high water
by subtracting the water-
level adjustment (STEP 4) y�
from measured depth to water 1 �
level at site (STEP 1 ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Figure 3
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