HomeMy WebLinkAbout0021 SEABURY LANE - Health 21 Seabury Lane
Centerville
A=208-081-002
S° OC—YcLro
UPC 10259No.H1630R
;
NA�TIMO�,YN
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
a DEPARTMENT OF ENVIRONMENTAL PRO'T'ECTION
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TITLE 5
OFFICIAL INSPECTION:FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A x 9 Ci
CERTIFICATION f�
MAP
Property Address:. PARCEL
Owner's Name: _ LOT `
Owner's Address: _
�;,&1A Q 10
Date of Inspection / (J �E(�,EIVED
Name of Inspector- (pleas print
Company Name: DEC 2 3 2002
Mailing Address: `7
4 oa&(%V TOWN OF BARNSTABLE
Telephone Number: / HEA!TH DEPT.
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information:reported
below is-true, accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The,system:
/Passes
Conditionally Passes
eeds.Further Evaluation by the Local Approving Authority.
UC-
�Inspector's Signature: 7° 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 I0,000
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. a
Pam
t .
Notes and Comments " ✓ zm4o -
""This report only describes conditions at the time of inspection and under the conditions of use at that
time. This 'inspection does not address how the system will.perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of I 1
OFFICIAL INSPECTION FORM—NOT'FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address.
Owner,
Date of Inspection:
Inspection Summary:. Check A,B,C,D or E/ALWAYS complete all of Section D
A. S stem Passes:
I have not found an information which indicates that
y t a any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired. The system,upon completion of the replacement or repair, as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the. for the following statements. 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.H.ealth.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years'old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution`box. System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or-replaced
ND explain:
The system.required pumping more than'4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if.(with approval of the Board of Health):_
broken pipe(s)are replaced
obstruction.is removed
ND explain: .
.2
'Page 3 of 1l
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SVSTEM INSPECTION FORM
PART A
CE..RTIFICATION(continued)
Property Address:
ffi� V. hI
Owner:
Date of tion-Vaeee / d
C. Further Evaluation is Required by the Board of Health:
Conditions.exist which require further evaluation by the.Board of Health in order to determine if the system
is failing to protect public health, safety or the environment..
1. System will pass unless Board of Health determines in accordance with 310.CMR 15.303.(1)(b)that the
system is not functioning ma 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.
The system has a septic tank and.SAS and the SAS is less than 100,feet but 50 feet or more from.a
private water supply well"..Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the.presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided.that no other
failure criteria are triggered.A,copy of the analysis must be attached to this form:
3. Other:
3
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Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: / dezi&A44 Z p
,dA
Owner, 4 Pb
Date of lnsp ctio J/ J00Q,
A System.Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No/
✓/ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
t9 Discharge:or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
/ clogged SAS or cesspool
I/ 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 ''/2 day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
VI Any:portion of the SAS, cesspool or privy is below high ground water.elevation.
Anyportion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
/ water supply.
Any portion of a cesspool or privy is within a Zone 1 of a public well _
_ Any portion of a cesspool or privy is within 50.feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than.50_feet from a private water
supply well-with no acceptable water quality analysis. [This system passes if the well water analysis,
c
performed at a DEP certified laboratory,for o 1'iform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen.is equal to or less than 5 ppm, provided that no other failure criteria
are triggered.A copy of the analysis.must be attached'to this forma ,
h(Yes/No)The system fails. I have determined that one or-more of the above failure criteria exist as
described in 310 CMR 15.303;therefore the system fails.The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a:large�system the system must serve a facility with a-design flow of`10,000 gpd to:159000
gpd•
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
_ the system is within 400 feet of a surface drinking water supply
the system is within 20.0 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 1I of apublic water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered
"yes" in Section D above the large system has failed.The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.,The system owner should contact the appropriate regional office of the Department.
4
' Page 5 of 1.1
OFFICIAL.INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
"PA
RMT.B
CHECKLIST
Property Address: / S
64
Owner: AJAV
Date of Inspection. U�
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:
,-Vere.any.ofthe system components pumped out in the previous two weeks?
_(Z'_ Has the system received normal flows in the previous two week period?
_ jZHave 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 Syste in:(SAS)on the site has been determined based on:
Yes no
Existing information. For example,a plan.at the Board of Health.
✓ _ Determined in the field(if any of the failure criteria related to Part C.is at issue.approximation of distance
is unacceptable) [310 CMR 15.302(3)(b)]
5
t
Page.6 of l l
OFFICIAL-hNSPE,CTION TORN=NOT FOR VOLUNTARY°ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYST1iJM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: Vt
Owner:.
Date of Inspection. Q�
FLOW CONDITIONS
RESIDENTIAL V--1
Number of bedrooms(.design):: .�: Number of bedrooms(actual):
DESIGN flow based'on 310,CIv1Ft 13.203 (for exariiple: 11.0 gpd x#of bedrooms):
Number of current residents:
Does residence have.a garbage grinder(yes or no):
Is laundry on a separate sewage system (yes or no [if yes separate inspection required]
Laundry system inspected(yes or no
Seasonal use:(yes or no.1,4V ..
Water meter readings, if available(last 2 years usage(gpd)):0a-,2-Y1*1®D 01-1jVII-Mly
Sump pump(yes or n ): `
Last date of occupancy:
COMMERCIAL/INDUSTRIA
Type'of establishment:,
Design flow.(based on 310 CMR.15.203): gpd '
Basis of design flow(§eats/persons/sgft,etc,): : ..
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 system(yes or no):-_
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information:,
Was system.ptimped as part of the inspec ion(yes or n
If yes,.volume pumped: gallons--'How was quantity pumped determined?
Reason for,pumping: .
TYPF,OF.SYSTEM
VS`eptic iank,'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):
— roximate age of all co pon nls,a installed(if own)and s kce of informatioil
Were sewage odors•detected when arriving at the site(yes or nq
f
• 'Page 7 of I I
OFFICIAL INSPECTION FORM.—NOT,FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner:
Date of Inspectio / 00,
BUILDING SEWER(locate on site plan) .(r .
Depth below grade:
Materials of construction:_cast iron _40 PVC_other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting, evidence ofleakage,'etc.):
SEPTIC TANK: locate on site plan) '
Depth below grade:
Material of construction: ; concrete_metal fiberglass__polyethylene
—other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a.copy of
certificate)
Dimensions:—?—.
Sludge depth .
Distance from top of sludge to bottom of outlet tee or baffle: 713
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
How were dimensions determined:c �°�- ii 1 —
Comments(on pumping recommendations, nlet and outlet-tee or baffle condition,structural integrity, liquid levels
related to outlet invert,ev' ence of leakage,etc.): #
GREASE TRAY 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(on pumping recommendations, inlet and outlet,tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
7
Page 8 of 11
OFFICIALJNSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
.PART C
SYSTEM INFORMATION(continued)
Property Address -
1
Owner:,
Date of Inspection.rk)�aeP �hF.t . i1�000
TIGHT or HOLDING TANK-_Aj1_(tank must be pumped at time of inspection)(]ocate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass Polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: . _ Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm'and,.float switches,etc.):
DISTRIBUTION BOX: if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert equal,
��Comments(note if box is level and distribution to outlets any evidence of solids carryover,any evidence of
_14zakage into or out of box etc.): :
PUMP CHAMB!ERc� 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.):
I _
i
8
Page 9 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner:/��1
Date of Inspectio f
SOIL ABSORPTION SYSTEM (SAS):. V"'(locate on site plan,excavation not required)
If SAS not located explain why:
Type
eaching_pits, number:
leaching chambers,number:
leaching galleries,number:
leaching trenches,number, length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure, level of ponding, damp soil;condition of vegetation,
pte
L &*� /
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 or no):
Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,etc.):
P V (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
9
Page 10 of71 '
OFFICIAL INSPECTION FORM-=NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner:
Date of Inspectcbnc �i,(�
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.
km, q l
- f
LJ' b
t✓ O
V d
C)
1000
10
Page I 1 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner:
Date of Ins ection o�d0j-
SITE EXAM.
Slope
Surface water .
Check cellar.
Shallow wells
Estimated depth to ground water feet
Please indicate(check).all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design.plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked.with local Board of Health-explain:
Checked with-local excavators, installers-(attach documentation)
Accessed U.SGS database=explain;
You must describe how you established the high ground water elevation:
�?`1t9r
/ r I t5,PO e r
11
Permit Number: nn Date:
Completed by:
HIGH GROUND-WATER LEVEL COMPUTATION
Site Location: �� �� �/ ✓ Lot No.
Owner: A C. / J p Address:
Contractor: Address: 4t 111 1-1XY , 111
Not es:
STEP 1 Measure depth to water table
' to nearest 1/10 ft. .............
..............................................................:.. .Date
month/day/year
STEP 2 Using Water-Level Range Zone
and Index Well Map locate
site and determine:
(A) Appropriate index well....................................................
OB Water-level.range zone ..................................................... C
STEP 3 Using monthly report"Current
Water Resources Conditions"
determine current depth to
water level for index well .:.........................
month/year
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 26) �'' .
determine water-level adjustment ....................
...............................................................:......
STEP 5 Estimate depth.to high water
by subtracting the water-
level adjustment (STEP 4)
from measured depth to water
levelat site (STEP 1) ..............................................................................................................
Figure 13.--Reproducible computation form.
15
i
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Commonwealth of Massachusetts c2( 8—Dot— co Cc—
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
a
21 Seabury Ln.
t
Property Address t)
Kevin Hall '
Owner Owner's Name I_.+
information is required for every Centerville MA 02632 5/17/2019
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. Inspector Informations r 3�3I filling out forms
on the computer, Paul C. Martin
use only the tab
key to move your Name of Inspector
cursor-do not Cape Cod Septic Services Inc.
use the return key. Company Name
350 Main St.
Company Address
West Yarmouth MA 02673
City/Town State Zip Code
retwn 508-775-2825 S15016
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
5/27/2019
nspector's Signatu a 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 shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
Commonwealth of Massachusetts
,P Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary y Assessments
21 Seabury Ln.
Property Address
Kevin Hall
Owner Owner's Name
information is required for every Centerville MA 02632 5/17/2019
page. Citylrown 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 in working conditon.
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):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18
Commonwealth of Massachusetts
,i Title 5 Official Inspection Form
I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
21 Seabury Ln.
Property Address
Kevin Hall
Owner Owner's Name
information is required for every Centerville MA 02632 5/17/2019
page. Cityrrown 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):
❑ obstruction is 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:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
-- I`R Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
21 Seabury Ln.
Property Address
Kevin Hall
Owner Owner's Name
information is required for every Centerville MA 02632 5/17/2019
page. City/Town 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 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
❑ ® 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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
F Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
21 Seabury Ln.
Property Address
Kevin Hall
Owner Owner's Name
information is required for every Centerville MA 02632 5/17/2019
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® 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 '/2 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.
0 ® 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 16,000 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
l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:.Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
lip Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
yy<
21 Seabury Ln.
Property Address
Kevin Hall
Owner Owner's Name
information is required for every Centerville MA 02632 5/17/2019
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 each of the following 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)]
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts
p Title 5 Official Inspection Form
' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
21 Seabury Ln.
V
Property Address
Kevin Hall
Owner Owner's Name
information is required for every Centerville MA 02632 5/17/2019
page. Citylrown State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 110x3=
330gpd
Description:
Number of current residents: 3
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 El Yes ® No
information in this report.)
Laundry system inspected? ® Yes ❑ No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available usage last 2 ears 2017=285gpd
( Y g (gpd))' 2018=326gpd
Detail:
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
Commonwealth of Massachusetts
I.? Title 5 Official Inspection Form
FI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
21 Seabury Ln.
Property Address
Kevin Hall
Owner Owner's Name
information is required for every Centerville MA 02632 5/17/2019
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: No Records
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
21 Seabury Ln.
Property Address
Kevin Hall
Owner Owner's Name
information is Centerville MA 02632 5/17/2019
required for every
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:
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 29"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 was checked with sewer camera and found to be properly pitched with no sign of root intrusion.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
l? Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
l% 21 Seabury Ln.
Property Address
Kevin Hall
Owner Owner's Name
information is required for every Centerville MA 02632 5/17/2019
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 ❑ 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:
1000Gal
Sludge depth: 2-41
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness 1-2'
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.):
1000Gal tank ij good condition. PVC tee in place on inlet with concrete baffle in place on outlet. 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
Title 5 Official Inspection Form
Fi Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
21 Seabury Ln.
Property Address
Kevin Hall
Owner Owner's Name
information is required for every Centerville MA 02632 5/17/2019
page. cityrrown 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):
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):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
21 Seabury Ln.
v
Property Address
Kevin Hall
Owner Owner's Name
information is required for every Centerville MA 02632 5/17/2019
page. City/Town 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
Oil
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.):
H-10 DB-3 with 1 line in and 1 line out in good condition. Box is clean and level with minimal solids
carryover. No sign of overloading or hydraulic failure. Cover 24" below grade.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
!% 21 Seabury Ln.
Property Address
Kevin Hall
Owner Owner's Name
information is required for every Centerville MA 02632 5/17/2019
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: 1-6x6
❑ 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.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18
Commonwealth of Massachusetts
R Title 5 Official Inspection Form
X Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
IJ�
21 Seabury Ln.
Property Address
Kevin Hall
Owner Owner's Name
information is required for every Centerville MA 02632 5/17/2019
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.):
1-6x6 Leach pit with stone. 1' of effluent in pit during inspection. No sign of overloading or hydraulic
failure. Cover 3' below grade.
12. 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.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
,I Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u
!% 21 Seabury Ln.
Property Address
Kevin Hall
Owner Owner's Name
information is required for every Centerville MA 02632 5/17/2019
page. Cityrrown 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.):
t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18
Commonwealth of Massachusetts
,IF Title 5 Official Inspection Form
S Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
-tir- 21 Seabury Ln.
Property Address
Kevin Hall
Owner Owner's Name
information is Centerville MA 02632 5/17/2019 required for every 'i
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
❑ hand-sketch in the area below
® drawing attached separately
l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
V 21 Seabury Ln.
Property Address
Kevin Hall
Owner Owner's Name
information is required for every Centerville MA 02632 5/17/2019
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: +14'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 to 14' did not encounter water. Max bottom of leaching is 10'.
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
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
v 21 Seabury Ln.
Property Address
Kevin Hall
Owner Owner's Name
information is required for every Centerville MA 02632 5/17/2019
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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
Page 10 of 11
OFFICIAL-INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL-SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION-(continued)
Property Address:
Owner: '
Date of Iidspectio
SKETt-A"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.
kt" 4
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1.
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 21 Seabury Lane
Property Address
Cara Genoy
Owner Owner's Name
information is required for Centerville Ma. 02632 8/24/2010
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important: A. General Information
When filling out
forms on the computer,use 1. Inspector:
only the tab key (�
t0 move your Robert Paolini
cursor-do not Name of Inspector
use the return I
` key. Ca ewide Enterprises,LLC. AUG 3 1itcl, �l
Company Name
r� P.O.Box 763
Company Address Y
Centerville Ma. 02632
City/Town State Zip Code
(508)428-4028 S14454
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
8124/2010
Insasignatr, 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.
q ---� I
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 21 Seabury Lane
Property Address
Cara Genoy
Owner Owner's Name
information is required for Centerville Ma. 02632 8/24/2010
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.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
r
. .�
r,
_ Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 21 Seabury Lane
Property Address
Cara Genoy
Owner Owner's Name
information is required for Centerville Ma. 02632 8/24/2010
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board or Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
21 Seabury Lane
Property Address
Cara Genoy
Owner Owner's Name
information is required for Centerville Ma. 02632 8/24/2010
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
r s:
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a•manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y2 day flow
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
21 Seabury Lane
Property Address
Cara Genoy
Owner Owner's Name
information is required for Centerville Ma. 02632 8/24/2010
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply
well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
.from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory, for fecal coliform bacteria indicates absent and the Presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
;M 21 Seabury Lane
Property Address
Cara Genoy
Owner Owner's Name
information is required for Centerville Ma. 02632 8/24/2010
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)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
21 Seabury Lane
Property Address
Cara Genoy
Owner Owner's Name
information is required for Centerville Ma. 02632 8/24/2010'
every page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 3
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 2008:75,000
g ( y g (gp ))' 2009:19,000
Detail:
2008:205gpd 2009:52gpd
Sump pump? ❑ Yes ® No
Last date of occupancy: 8/24/2010
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CM 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
- Grease trap present? - ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
;M 21 Seabury Lane
Property Address
Cara Genoy
Owner Owner's Name
information is required for Centerville Ma. 02632 8/24/2010
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no)(if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 21 Seabury Lane
Property Address
Cara Genoy
Owner Owner's Name
information is required for Centerville Ma. - 02632 3/24/2010
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
"
Depth below grade: 31
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.):
Joints appear tight.No evidence of leakage.System vented through the house vents.
Septic Tank (locate on site plan):
2'
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000GL.
2,.
Sludge depth:
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 21 Seabury Lane
Property Address
Cara Genoy
Owner Owner's Name
information is required for Centerville Ma. 02632 8/24/2010
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
30"
Scum thickness
1"
Distance from top of scum to top of outlet tee or baffle 711
Distance from bottom of scum to bottom of outlet tee or baffle 13" "
How were dimensions determined? Measured
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 two years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears
structurally sound.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction: ,
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M
21 Seabury Lane
Property Address
Cara Genoy
Owner Owner's Name
information is required for Centerville Ma. 02632 8/24/2010
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.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions: .�
Capacity: gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
r
Commonwealth of Massachusetts
W Title 5 Official Inspection- Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
21 Seabury Lane
Property Address
Cara Genoy
Owner Owner's Name
information is required for Centerville Ma. 02632 8/24/2010
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert No
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.):
Box is Ievel.Box has one outlet Iateral.No evidence of solids carryover.No evidence of leakage.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
21 Seabury Lane
Property Address
Cara Genoy
Owner Owner's Name
information is required for Centerville Ma. 02632 8/24/2010
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type
® leaching pits number: 1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•09/08 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
°M 21 Seabury Lane
Property Address
Cara Genoy
Owner Owner's Name
information is required for Centerville Ma. 02632 8/24/2010
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Map Page 1 of 2
.Town of Barnstable Geographic Information System
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Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 21 Seabury Lane
Property Address
Cara Genoy
Owner Owner's Name
information is required for Centerville Ma. 02632 8/24/2010
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 high ground water: Bottom of LP 26'
feet
Please indicate all methods used to determine the high ground water elevation:
r r:•
❑ 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
❑ Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
USED:USGS Observation Well Data.USED:Technical Bulletin 92-0001 plate#2 annual ranges of
groundwater elevations.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•09/08 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
21 Seabury Lane
Property Address
Cara Genoy
Owner Owner's Name
information is required for Centerville Ma. 02632 8/24/2010
every page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary:A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
Z. System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
I
� ► /Y1 ; off-08%
LOCATION �' a/ / _ SEWAGE PERMIT N0.
VILLAGE
� INSTA LLER'S NAME i A'DDRESS
� 9UILDER OR OWNER
DATE PERMIT ISSUED jc� s
DAT E COMPLIANCE ISSUED
40 30
5� 3L 31
C
�cT Z
..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
-------- / - ..-..oF................ `,
Appliration for Disposal Warks Tonstrurtiun Frrutit
Application is hereby made for a Permit to Construct ( • or Repair ( ) an Individual Sewage Disposal
System at• A'tip .• 'G
oction y�1dd. �� —'Jr
0
__'
caner ............................................Addr
� I aller Address
d Type of Building Size Lot__ Sq. feet
Dwelling—No. of Bedrooms................... _______________Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building a —Type g ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
d Other fixtures
Design Flow____________________________________________gallons per person per day. Total daily flow_____________.____ gallons.
w ��_�_._.___ lions.
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 ( ) 1
aPercolation Test Results Performed by________________________�11.b__.__.aw.. •- Date._______ 1
Test Pit No. I._._.__.5.____minutes per inch Depth of Test Pit____________________ Depth to ground water......._................
LL, Test Pit Nol ;_O_minutes per inch Depth of Test Pit____________________ Depth to ground water........................
9 ----------------------------
Descriptionof Soil------------------------------------ ....__________.______-•-------------------_____------------------.____._._.__________________....__-------•-•-
x
w
VNature of Repairs or Alterations—Answer when applicable..........................................................................._....................
-----------------------------------------------------------•------------•----____._•-•--...__-----•---______._----------_._--------_______------------•-----_.___------•-•-----_________...._••--------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TI L LE 5 of the State Sanitary Code—The undersigned further agrees not to place the system
er�ca
'o until C cate, Hance has been issue e board Signed .
AppAXpiproved B -------------
- ____...._. ______________� ___
Date
Application Disapproved for the f l wing reasons:..............................•-••-•--•----••••-•-•••-•---•••--------•-••••---••__---------•...................
__________________________•----•-_____________.______------_____-----•---•---------_____....--------•••- -----------___________----------___.----------.__--------------------__.-----=--------•------•-
Date
PermitNo......................................................... Issued.......................................................
Date
FEsNo.. j ..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......... ........OF................16-
Applirati % for Disposal Works Tonstrurtion t1rrmit
Application is herebyor Repair an Individual Sewage Disposal
made for a Permit to Construct
System at: If -, ff) —
/9
........................................................... ............................ ........................................ .. .. .. ........
L - Add or,] 0.
'o
- ----------- ---------------� -------------------7 ---af ----------
ddrps ------
.........................................................................................
I 40aller Address
Type of Building Size Lot_147.19)......Sq. feet
U
Dwelling—No. of Bedrooms__________________ ...............Expansion Attic Garbage Grinder
PL4 Other—Type of Building ............................ No. of persons___.__..._._________.___.._. Showers Cafeteria
04
Other fixtures ........................................................................................................................
<11 �*------------
W Design Flow............................................gallons per person per day. Total daily flow.._.....____.______.�M.! ........gallons.
9 Septic Tank—Liquid capacity./g2!-*9gallons Length________________ Width.._.__._.._._.._ Diameter-_--_-________-_ Depth__.______.__....
W
Disposal Trench—No_ .................... Width____._._____.__.____ Total Length____._______.___._._ Total leaching area....................sq. f t.
Seepage Pit No_____________________ Diameter._._..__._..____.._. Depth below inlet______.____..._..... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( ) 11.1
~4 Percolation Test Results Performed by.........................':-T 1'V
�4 ....472" Z O/L).. Date______._( ' -.1
..............
Test Pit No. I................minutesperinch Depth of Test Pit__.__._...____.__.__ Depth to ground water..._____.__.________.__.
fro Test Pit No.�.A.,�6?.minutes per inch Depth of Test Pit____________________ Depth to ground water______._.______.__.:_...
----------------------------
0 Description of Soil ----------------------**-------------**"*--------------------------- ------------------------------------
...........
....................................1... ...................... ............................................................................
-----------------------------------------------------------------"---------------------------------------------------------------------------- ----------------I------------
-------------------------------------------------------------------------------------------------------------------------------------------------------------------....................................
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 T I TALL4 5 of the tate Sanitary Code— The undersigned further agrees not to place the system M
er 0 until C�gsa;;�e liance has been issue E board of-healrZ.
0 ..........
Sign
d..
-—----—------_---- ................................... ............... .4
J) Oi
y-----------------
A�plicatlon Approved By................ . ......6...... .... . ..... ................... .........
ate
Application Disapproved for the fo I wing reasons:................................................................................................................
............................................................................................................................................................................... ......................
i,' Date
PermitNo................................................... Issued L...... ............................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
. ..........................................OF....................................................................................
Tntifiratr of T-ampliattrr
THIS IS TO CERTIFY, That the Individual Sewag Disposal constructed ) or Repaired
by-------- ------------ .............. ..........................................%...................w...................
0� nstaller
at.................
..................................................................
has been installed in accordance with the provisions of TIT f
LE 0 The State Sanitary Code as described in the,
iy Q_— ;k -_a3
application for Disposal Works Construction Permit No._:!�� ---64L.............. dated....._._ -------- ......................
, THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CO STRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. I C,
DATE.............in.......... --. --------- ............................ Inspector... .................
THE COMMONWEALTH OF MASSAC USETTS
BOARD OF HEALTH
...... ......................OF...................................................................................
No.c;. FEE.__....................
Disposal Marks T-51instrudion Prrutit
Permission is hereby granted............VWJO�/-.r......Cevg�.I#.Le_$.D�v........................................................
>4 to Construct ( or Repair an Individual Seepage Disposal System
........................................................................................
at No...................�;i.......x- ....... V'_' L-4 6
Street
as shown on the application for Disposal Works Construction Permit No5�t�Y6_ Dated....-le)
- - -- ---- -------
................................-.......I.. 04.4./.k.............
......................
DATE. Cpoard of Health
.............te... ............. .....................................
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-4EGEND 64 R1'Dcr N
sExls'f1N4 $POT ELEVATION 0,�0 CERTIFIED PLOT PLAN
VEx19TINA :`CONTOUR
kfl" ellEQ" .$PDT ELEVATION
I } IMIIMOONTOHR o L'v T z. 8g
� z r` The :location of. afiy existing un er o sewu'rage:; ,
wplXs` or :oth'eT utilities shown `on this plan is approx-
+r'} ,"�U1>atBsOnly'as determined from records and/or verbal
' f �formato» The contractor is responsible for the
mow, Ywx f .catlan"lof the,:existing locations in tl e,,field. SCALE ATES 7/
AlIck ul—A-S
'� .ReW E'NG/NE NG CO1 /N CLi NT. CERTIFY THAT THE 'PROPOSE'p' f '
rk aE0181TE111E REGISTERED JOB NO. BUILDING SHOWN ON THIS PLAN
vfl
h•�`'CIVIL LAND CONFORMS T0, THE ZONING LAWS ,
DR-BY' OF BARNS MASS.
x 6we
y� as c
TI2''MAi N. STREET; `': • CH. BYr� F : %t `Y.
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f $MEET�1 OF: 'L A E REG. LAND SURVEYOR