The URL can be used to link to this page

Home My WebLink About0018 STAGE COACH ROAD - Health 18 Stage Coach Road f Centerville P A = 172 108 C q A S No. 42101/3 ORA Pond0.O&K 1017 1®°l0 u a /-7a - 108 Commonwealth of Massachusetts Title 5 Official Inspection Form �. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments =' Coca C, Property Address t° Owner Owner's Name �� ? information is l _ required for every - ��l/l ✓-�� 14-- page. CitylTown State Zip Code Date of specti Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Info ation 5(--* (�� on the computer, / / / use only the tab __ /�►rY / '�rs / key to move your Name of Inspector cursor-do not / D / k c use the return Company Name / /� ,/7 Q{� key.m �0 (�O Company Address All, a�e�SA-a City/Town State Y076�L Zip Code Telephone ber License Number B. Certification 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;Passes* s 1. Z. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails '311 Z, �- inspector's P ignature Date The systep 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 103000 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.doo•rev.7/2 612 01 8 Tide 5 otficai;nspection=o. :Subsurtace Sewage D:sposai System•Page 7 of 18 Commonwealth of Massachusetts Ip Title 5 Official Inspection Form � Subsurface Sewage Disposal System Form -Not for Voluntary Assessments � sp l a ry coc,C� Property Address Owner Owner's Name information is PiN required for every -� page. City7own State Zip Code Date of I pectic C. Inspection Summary 6 Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System P sses: 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: 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.00c•rev.7/2 612 0 1 8 Title 5 0-t9aa;nspec on=om:suasurtace Sewage Disposai System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address COG,G LW v► Owner Owner's Name information is /�/f� v� 71A-,npr:ti�6n�_ 9 required for every /ew-+�✓1�l 4�� /i page. City/Town State Zip Code Date 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: L5insp.0oc•rev.7/25/2018 -ite 5 Official inspection Fo.=suosurface sewage Disposal system•?age 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments coac,4 Rd Property Address Za ti Owner Owner's Name information is /;),d required for every L/G '*vr v !!! ' �/r b JO'- 3 "IS page. City/Town State Zip Code Date of I pectin C. Inspection Summary (cons.) ❑ 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 / ❑ �_/ B p of sewage into facility or system component due to overloaded or !lIJJJ�� 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.7262018 Title 5 Offidai tnspectlor.Farm:Subsurface Sewage Disposal System.Page 4 of 18 Commonwealth of.Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments U cJ�G? Co';G Property Address Owner Owner's Name information is dd 6� 3 /�'� - required for every C,e4lyvtI page. City/Town State Zip Code Date ofinspe6fion 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 5" below invert or available volume is less han t/z day flow ❑ Required pumping more than 4 times in the last year NOT due to clogged or / obstructed pipe(s). Number of times pumped: ❑ Q/ 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. ❑ � ny 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.] n he system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. The system fails. I have determined that one or more of the above failure —� criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes'or"no"to each of the following, in addition to the questions in Section C.4. 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 El ❑ the system is located in a nitrogen sensitive area (interim Wellhead Protection Area—IWPA)or a mapped Zone It of a public water supply well Title 5 Qffical Inspection=onn:Subsu`ace Sewage Disoosal System-Page 5 of is t5insp.00c•my.7262058 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 609 Property Address Owner Owner's Name '� / information is d C required for every page. City[Town State Zip Code Date of I pecti 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 C.4 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 mping information was provided by the owner, occupant, or Board of Health ❑ Were any of the system components pumped out in the previous two weeks? s 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 i ❑ approximation of distance is unacceptable)[310 CMR 15.302(5)] Tite 5 ctdai inspection.=cr:sunsurace Sewage oisposal system•?age 6 of to t5insp.doc•rev.7/26/2018 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 f�.�rl� �/ D�p '3 required for every 11( page_ City/Town State Zip Code Date of In pectin D. System Information .1. Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): 3.30 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms). Description: //o 11 SQ np CIV :� 3 Number of current residents: Does residence have a garbage grinder? ❑ Yes Now Does residence have a water treatment unit? ❑ Yes L. o If yes, discharges to: Is laundry on a separate sewage system? (include laundry system inspection ❑ Yes No information in this report.) / Laundry system inspected? ❑ Yes [�Pd6� Seasonal use? ❑ Yes 9.40 Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes No k f eo Last date of occupancy oate "itie 5'�idai:nspecon=c'n.Sucsu'ace Sewage Disposal System•Page 7 of 18 t5insp.doc•rev.7126/2018 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Owner Property Address information is � d� Owner's Name C. /� e N ��/ / � required for every It ' page. City/Town State Zip Code Date of specti ---------------------------- 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: ' 1 Was system pumped as par of the inspection? ❑ Yes No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.00c-rev.7/2620/8 Tine 5 Officiai inspection.=om Suds,rface Sewage Disposai System•Page 8 of 18 Commonwealth of Massachusetts 3 Title 5 Official Inspection Form a H Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address I G�`�O✓I Owner Owner's Name �9 9 information is C&4-ken � V, 6,3.4 �� required for every page. CitylTown State Zip Code Date of In ection D. System Information (cons.) 4. Type of S em: Septic tank, 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: &41 o /9901 Were sewage odors detected when arriving at the site? ❑ Yes No 5. Building Sewer(locate on site plan): Depth below grade: feet Materia construction: cast iron 40 PVC ❑ other(explain): / b Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc_): '1,a 5 dai inspection Form:SUCSLrtace sewage Disposal system•Page 9 of 18 t5insp.doc•rev.7/26/2018 Commonwealth of Massachusetts Title 5 Official Inspection Form } Subsurface Sewage,DDiisposal System Form -Not for Voluntary Assessments ,ll S �P LAG G t, le Property Address Owner Owner's Name information is / h required for every Ceo-kiwl < sh 9 page. City/Town State Zip Code Date oft pectin D. System information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: feet Material o onstruction: ncrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy or certificate) ❑ Yes ❑ No Dimensions: �� X Sludge depth: 'T' Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle pro 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.): P,4 e ,n " KeC o titer&44/. 00 d o N r orr t5insp.doc-rev.7126/2018 ?me 5 oai I.specoon=orm:suosurtace sewage Disposai System-Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name information is required for every page. City/Town State Zip Code Date of Insp ction D. System Information (cost.) 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 ?itie 5 ot5aa:!nspev4on Pom:Suosurface Sewage Disposal System•Page 5 t of t8 t5insp.doc•rey.7@6i2056 Commonwealth of Massachusetts Title 5 Official Inspection Form %I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments s Property Address h Owner Owner's Name information is /�N I� '�` 14_ �� Al/•3 1 ?//S//required for every ( '*�I' � '/T �o`b o� ✓ page. City/Town State Zip Code Date of spedti D. System Information (cons.) 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. El Yes ❑ No 9. Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): p - o t5insp.doo•rev.7f28/2018 ?ale 6 v flual:nspecuon Form,suosurtace sewage Disposal System•?age 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name Cem-6v-l / /�0V / information is3. required for every page. City/Town State Zip Code Date of Inspiction 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.): i t 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: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovativeialtemative system Type/name of technology: — --'— t5insp.doc.Me-7128/20/8 -ive 5 5aai inspetion=cm:SuDs�rrace Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 4 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ! � GC Property Address Owner Owners Name /� Te "��✓� information is 6 required for every State Zip Code Date of Ins eotion page. City/Town 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.): ram- law C/1.0-001 At 04?14 /—c;44S a Low o 70 ✓!t (�f of/'q w r'C. - l4611G'Yr. 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.): me 5 off.cai mspecuon Forth.Sucsur ace Sewage Disposai System•Page 14 of 18 t5insp.coc-rev.726/2018 Commonwealth of Massachusetts P Title- 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary ry Assessments 4 !' coGr, 4 Property Address a Owner Owners Name information is required for every (_,��/� //,.,o � Q 6 page. City/Town State Zip Code Date of IrIspe on D. System Information (cons.) 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.): 45insp.Goc•rev.7/26/2018 -,Le 5 CfBaa fnspecaon Form.scos❑race sewage Disposal system•?age 15 of 1a I Commonwealth of Massachusetts Title 5 Official Inspection Form r� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments kv�' S� Property Address IV-4 d N Owner Owner's Name I reformation is C�Vh�/rY� /� (Jd b ��- �f T required for every page. City/Town State Zip Code Date of specti 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 nchmarks. Locate all wells within 100 feet. Locate where public water supply enters the build" Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately i � I ScP-�r� I OK.�fhG(/ // 901 6x� i A3- 36 123 3 y i I I t6insp.doc•rev.7/26/2018 Title 5 0twei In5pecaon Form:suoscrface Sewage Disposal system•Page 16 of 19 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for P y o Voluntary Assessments / S ► e Cow C' Property Address � -- Owner Owners Name information is required for everyr page. CdylTown State Zip Code Date of Inspe ion D. System Information (cons.) 15. Site Exam: 6 ❑ Check Slope 4 3`� D 3 ❑ Surface water 0'� ❑ Check cellar `�' VGJ ❑ Shallow wells Estimated depth to high ground water: 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 ❑ served site (abutting propertyiobservation hole within 150 feet of SAS) Checked wi�t�,lgpal Boar ' of Health - expP�S ❑ Checked with local excavators; installers- (attach documentation) ❑ Accessed USGS database-explain.- You must describe ow u established the high gro water elevation:��W Q l.1 t / r& ✓��(r—o�,/ Before filing this Inspection Report, pease see Report Completeness Checklist on next page. t5insp.doc-rev.7/262018 =o,-:Suosurace Sewage Disposal system•Page 17 of 58 V Commonwealth of Massachusetts ip Title 5 Official Inspection Form �l Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property Address Lf�'li`s�1 Owner Owners Name / Ile— information is t 0"3� 3/,� 7 Q required for every page. City/Town State Zip Code Date of Inspe ion 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 checked C. Inspection Summary: 1, 2, 3,or 5 completed as appropriate �DSystem lure Criteria)and 6 (Checklist)completed 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.00c•rev.7r26/2018 'ale 5 oT5aal':nspe=n Foy SuosuCace Sewage]isposai System•?age 18 cf 18 Commonwealth of Massachusetts Title 5 Official Inspection Farris Subsurface Sewage Disposal System Fp -Not for Voluntary Assessments 13 Stagecoach Rd roperty Address Bank Owned (Contact Daryll Perry @-D.B. Enterprises 1_508-776-8916) Owner Owner---- 's Name information is required for ever Centerville MA _ 02632 1-5-11 page. City/Town State Z—ip C—o-d..e........_. Date of-.I..n...s.-pec,tio n D. System Information (cont:) -- - Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. a Locate where,public water supply enters the building. �x�=� _ 37 I [,u�sp o1'iclal document•03N8 Tale 5Official Inspection Form;SuOsurface Se*aage Drsoosal System•Facie 14 of 15 ��. ... �_ �� , a -.� r .,....< 7�L i g� 4` 1 z"Soto TOB£ Ca pis"� A ' N� �e 17'X !O` ;� ExsTr NG t D rX 15' POOL- w �` li i I 1�� EX 1s71N G H om 6- GR-F c701S 1�) TS 1 � y C-0 � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Stagecoach Rd Property Address Bank Owned (Contact Daryll Perry @ D.B. Enterprises 1-508-776-8916) Owner Owner's Name information is required for every Centerville MA 02632 1-5-11 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. A. General Information 1. Inspector: Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name 29 Atwater Dr Company Address E. Falmouth MA 02536 City/Town State Zip Code 508-495-0905 S13971 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 Fu valuati by the Local Approving Authority 1-5-11 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and-the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. I II t5insp official document•03108 Title 5 Official Inspection Form:Subsurface Sewage Dispo I System•Page 1 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Stagecoach Rd Property Address Bank Owned (Contact Daryll Perry @ D.B. Enterprises 1-508-776-8916) Owner Owner's Name information is required for every Centerville MA 02632 1-5-11 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: System is in good working order with no sign of failure. 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 Health. " A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: , ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed t5insp official document-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Stagecoach Rd Property Address Bank Owned (Contact Daryll Perry @ D.B. Enterprises 1-508-776-8916) Owner Owner's Name information is required for every Centerville MA 02632 1-5-11 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 16 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Stagecoach Rd Property Address Bank Owned (Contact Daryll Perry @ D.B. Enterprises 1-508-776-8916) Owner Owner's Name information is required for every Centerville MA 02632 1-5-11 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate Yes "or No„to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/ day flow ❑ ® 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. t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments yr 18 Stagecoach Rd G"M Property Address Bank Owned (Contact Daryll Perry @ D.B. Enterprises 1-508-776-8916) Owner Owner's Name information is required for every Centerville MA 02632 1-5-11 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ' ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ 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. t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Stagecoach Rd Property Address Bank Owned (Contact Daryll Perry @ D.B. Enterprises 1-508-776-8916) Owner Owner's Name information is required for every Centerville MA 02632 1-5-11 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 CM 15.302(5)] t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Stagecoach Rd Property Address Bank Owned (Contact Daryll Perry @ D.B. Enterprises 1-508-776-8916) Owner Owner's Name information is required for every Centerville MA 02632 1-5-11 page. City/Town State Zip Code Date of Inspection 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 Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: 10-2010 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste.holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Stagecoach Rd Property Address Bank Owned (Contact Daryll Perry @ D.B. Enterprises 1-508-776-8916) Owner Owner's Name information is required for every Centerville MA 02632 1-5-11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Town--2001 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Maintenance Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) 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: 1992 Were sewage odors detected when arriving at the site? ❑ Yes ® No t5insp official document-03/08 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Stagecoach Rd Property Address Bank Owned (Contact Daryll Perry @ D.B. Enterprises 1-508-776-8916) Owner Owner's Name information is required for every Centerville MA 02632 1-5-11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 8 feet Material of construction: ® cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Good conditon. Septic Tank(locate on site plan): Depth below grade: 1 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: 1000 gal Sludge depth: 8" Distance from top of sludge to bottom of outlet tee or baffle 24 Scum thickness 1 Distance.from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? Tape t5insp official document-03/08 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 18 Stagecoach Rd Property Address Bank Owned (Contact Daryll Perry @ D.B. Enterprises 1-508-776-8916) Owner Owner's Name information is required for every Centerville MA 02632 1-5-11 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.): Tank is in good condition with baffles installed and no sign of leakage. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: f Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): t5insp official document•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 N, Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y 18 Stagecoach Rd 4'M Property Address Bank Owned (Contact Daryll Perry @ D.B. Enterprises 1-508-776-8916) Owner Owner's Name information is required for every Centerville MA 02632 1-5-11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert N/A Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No t5insp official document•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts w Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Stagecoach Rd Property Address Bank Owned (Contact Daryll Perry @ D.B. Enterprises 1-508-776-8916) Owner Owner's Name information is required for every Centerville MA 02632 1-5-11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): I� Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 2-1000 gal ❑ 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.): Both leach pits in good condition with second pit empty at inspection with stain line at 20" below inlet. t5insp official document-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 18 Stagecoach Rd Property Address Bank Owned (Contact Daryll Perry @ D.B. Enterprises 1-508-776-8916) Owner Owner's Name information is required for every Centerville MA 02632 1-5-11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 18 Stagecoach Rd Property Address Bank Owned (Contact Daryll Perry @ D.B. Enterprises 1-508-776-8916) Owner Owner's Name information is required for every Centerville MA 02632 1-5-11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. aGG� i a b C -6_ / 7 ram_ 3� C OD , _ t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Stagecoach Rd Property Address Bank Owned (Contact Daryll Perry @ D.B. Enterprises 1-508-776-8916) Owner Owner's Name information is required for every Centerville MA 02632 1-5-11 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: 20 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: USGS and town maps show groundwater at 20'. t5insp official document•03/08 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 COMMONWEALTH OF MASSACHUS l + ETT$ EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION MAP `Z PARCEL LOX TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: SZecelJ l Owner's Name: -A Owner's Address: e1 �tC Date of Inspection: �` 12 2003 TOWN OF BARNSTABLE Name of Inspector. (please print)Mor� �sf// HEALTH DEPT. Company Name: E ✓#O— %�G Mailing Address• 0 p>e �6" d 4 � Telephone Number 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 p mspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sews a di approved system inspector pursuant to .340 of Title 5(310 CMRsposal 15.000). The sy am a DEP Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: /i / The system inspector shall su t a cwpm of this inspection DEP)within 30 days of completing this' �o�to the Approving Authority(Board of Health or gpd or greater,the' inspection.If the system is a shared system or has a design now of 10,000 inspector and the system owner shall submit the report to the appropriate regime office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approvingauthority. Notes and Comments "This report only describes conditions at the time of ins pection tions of use at that time.This inspection does not address how the system will perform indthe future under u dercond�the same or different conditions of use. Page 2 of 11 OFFICIAL INSPEC TION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A // CERTIFICATION(continued) Property Address: sTGj A,4 sm ✓v, Owner. —o,-1 d Date of Inspectio . / Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. �Sm sses: . . I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: or more system components as described in the"Conditional „ repaired.The system, upon completion of the h0�Pass section need to be replaced or 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" lease explain. p The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhrbrts 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 a *A metal septic tank will pp�'ed by the Board of Health. indicating that the tank is less than 20 years old is available.structurally sound,not leaking and if a Certificate of Compliance 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 pipes)are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS : SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A �j 1 CERTIFICATION(continued) Property Address: /O Owner. Oar Ya t� Date of Inspectio 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 system is not functioning in a manner which will protect public health,safety and the environnment::the 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 system is functioning in a manner that protects the public health, afety tySupp an,if any)determines that the 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 ptiOPM,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form 3. Other. Page 4 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 0 �a�� Coac 4 IQ CI Owner. kGll Date of Inspection // O D. System Failure Criteria applicable to all systems: You must indicate`yes"or"no"to each of the following for an in spections: Yes No Backup of sewage into facility or system component due to overloaded or clogged Discharge or ponding of effiuent to the surface of the SAS or cesspool _logged SAS or cesspool ground or surface waters due to an overloaded or Static liquid level in the distribution box above outlet invert due to an overloaded or clo cesspool gged SAS or V/ Liquid depth in cesspool is less than 6"below invert or available volume is less than%day flow— —+ Required wing 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 saiface water supply water supply. Pp y or to butary to a surface �_ Any portion of a cesspool or privy is within a Zone 1 of a public well. v portion of a cesspool or privy is within 50 feet of a private water supply (/Any portion of a cesspool or piny is less than 100 feet>nrt fe well. supply well with no acceptable water �than 50 feet from a private water sty analysis. (This system passes if the well water analysis, performed at a DEP certified laboratory,for coliiform 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 S ppm,provided that no ather failure criteria are triggered.A copy of the analysis must be attached to this form.] / O (Yes/No)The system Lail,%I have determined that one or more of the above failure criteria exist described in 310 CMR 15.303,therefore the system e Health to determine what will be system owner should contact the Board of necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design gpd- flow of 10,000 gpd to 15,000 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) /yeshe system is within 400 feet of a surface drinking water supply e system is within 200 feet of a tributary to a surface drinking water supply e system is located in a nitrogen sensitive area(InterimWellheadProtection Area—IWPA)or a mapped one II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a si "Yes"in Section D above the large system has failed.The owner or gruficant threat,or answered significant threat under Section E or failed under Section b shall u operator of any large sy�m considered a 15.304.The system owner should contact the a l��the system in accordance with 310 CMR pprnpriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B Property Address: I Q �Ti►�e�qyc v� Owner. Date of Inspecti ; Check if the following have been done.You must indicate es"or"no"as to.each of the followin ir Y o Pumping information was provided by the owner,oaupant,or Board of Healffi _/ Were any of the system components p�out in the previous two weeks ✓ — Has the system received normal flows m the previous two week period . Have large volumes of water been introduced to the system recently or as pert of this inspection Were as built plans of the system obtained and tined?(If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage bads up [/ Was the site inspected for signs of break out Were all system components,excluding the SAS,located on site of Were,the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition baffles tees,material of construction,dimensions,depth of liquid;depth of and depth of scum 7 _ Was the facility owner(and oa,WOU if different from owner)prm ded with information on the pr maintenance of subsurface sewage disposal systems; oper The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes Exdsting information,For example,a plan at the Board of Health. Determined in the field(if any of the Wore criteria related to Part C is at issue approximation of dislaone is unacceptable)[310 CMR 15.302(3)(b)] s Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address; L G Owner*. Date of Inspectiod / p FLOW CONDPPIONS RESIDENTIAL Number of bedrooms(design):3-- Number of bedrooms(actual): DESIGN flow based on 310 CUR 15.203(for example:110 gpd x#of bedrooms): Number of current residents: Does residence have a garbage grinder(Npes or no):,'a Is laundry on a sepaTate sewage system(Yes or no):,i/ [if yes separate inspection mq dmd) Laundry system inspected(yes or no): Seasonal use:(yes or no):�► Water meter reading,if available(last 2 years usage(gpd)): SumP Pump(ym or no):*v Last date of occupancy: 4 COMMERCIAL IMUSTRIAL Type of establishinew: Design flow(based on 316 CUR 15.203) gpd Basis of design flow(seatsfpersonstsgft Ctc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no): n-sanitary waste discharges}to the Title 5 system(yes or no):_ Water to Last date ��if available: Yam: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: �N«� O O/_ a Lr vLu Was system pumped as pact of the inspection(yes or no): If yes,volume pumped:—kl��—How was quantity pumped determined? Reason for pumping: � SYSTEM Septic tank,disinbution box,soil absorption system _Single cesspool _Overflow cesspool _Privy —Shared system(yes or no)(if yes,attach previous inspection records,if any) o�va ystem to technology. Attach a copy of the current operation and maintenance contort(to be --Tim tank _Attach a copy of the DEP approval Other(desmlx): Approximate age of all components,date'i talled(if known)and of info�m�atioa: f/P _e, Were sewage odors detected when arriving at the site(Yes or no):�� Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C _ SYSTEM INFORMATION_(continue Property Address: Owner: !� w Date of Inspection: BUILDING SEWER pocate on site plan) Depth below grade: O Materials of construction cast iron C65VC oth"(expo): Distance from private water supply well or suction line: Comments(on condition of joints,venting evidence of leakage,etc.). SEPTIC TAN1K.- _,(locate on site plan) Depth below grade: / Material of constr wRon:_concrete_metal_gym--polyethylene —offO If tank is metal list age:_ Is age confirmed by a Certificate of Compliance es or no certificate) P (y ) (attach a copy of Dimensions: j X� Sludge depth:Distance from top of � sh�dge to bottom of outlet tee or bale: OW ScumDistance from top of scum to top of outlet tee or ba$Ie: Distance from bottom of scam to bottom let tee or e: - . How were moons determined /"o�e rl c Comments(an pumping recommendations,inlet and outlet or battle conditio as fated to outlet invert, dence of leaks e 4 structural integrity,liquid levels J i h 00 OH o ti . GREASE TRAP:/—V'Oocate on site plan) Depth below grade:_ Material of construction:_concrete_metal—fiberglass_polyethylene_other (explain): Dimensions: Scum thiclmess: Distance from trip of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or bale: Date of last pumping Comments(on pumping recommendations,inlet and outlet tee or baffle condition, as related to outlet invert,evidence of leakage,etc.): stri>ctural integrity,liquid levels page 8 Of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM/ N INFORMATIO (c ontiuued� Property Address: �� '0 lac a �p1 ✓�, �3oZ Owner. 414�1- Date of Inspectfoa: TIGHT or HOLDING TANK: (tom mug be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction concrete metal fiberglass_polyeth lene Y othec(explain): Dimensionw- Capacit)r Raton Design Flow. r llons/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:/k/ (1f present must be opened)(locate on site plan) Depth of liquid level above outlet invert'--- Comments(note if box is level and distribution to outlets equal,any evidence of solids ca nyover,any evidence of leakage or out of boy,etc t't a �J O� ot'�G PUMP CHAMBER:,,j'—"'(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 a PPuteoances,etc.): Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C .Q SYSTEM INFORMATION(contimied) Property Address: O v✓ CoA o l� /'2 cJ Owner. `►Z'h Date of Inspection: / SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: tL leaching pits,number (l/ /� L ,5�0 leaching chambers,number, u.� leaching galleries,number leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovativetalternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic faihue,level of etc.): old P°n g.dame soil,condition of vegetation, 37 q owf-/ee W j4`2 CESSPOOLS• cesspool must be pummped as part of mspectionxlocate 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(rote condition of soil,signs of hydraulic failure,level of (loading,condition of vegetation,etc.): PRIVY:4,0' (locate on site plan) Materials of constn>ction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic W ure,level of (loading,condition of vegetation,etc.): • Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(contimmd} Property Address; �� ST9se&c,c, v- ry 7 �c31 Owner. Date of Inspectio • 7 SKETCH OF SEWAGE DLSPOSAL SYSTEM Provide a slaetch of the sewage disposal System including ties to A least two pennant en reference landa>i or benchmarks.Locate all wells within loo feet.Locate where public water supply enters the building _ ILI �Lt- 37 i Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION-(continued)_ Property Address: opt v Owner, l� ode ? ) Date of lnspeWoa: 0 SM EXAM" Slope Surface water_ Check cellar Shallow wells Estimated depth to around water Meet Please indicate(check)all methods used to determine the high ground water elevation: obtained from system desigp plans on record-1f checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board ofHealth-explain: Checked with local excavators,installers-(attach dooamentation) Accessed USES database-explain: You most how ou established the him groa4d water G o�7`0�'7 � dew eS i .� o► I f Qhis q OOO 0Q ` � r 3 > AC y TO"OF B LE C-A ,O 'T-ION U _Q GUrc `f SEWAGE # ILL'AGE <. 2- rUIr``e ASSESSOR'S ALAI'&LOT NSTA.I:,I,EP'S NAME&FHOME NO. - — -- EE'1'1C 'TA.NIC-CAPACITY ,P,ACP.MIG FACILM: (type) (size,) 10.OF'BEDROOM5 3 ULDER OR OWNER ERMI'TDATE: COWUANCE DATE: eparation Distsance Between the. Maximum Adjusted Groundwater'Tab[e to the Bottom of Leaching)aaCility met rivate Water Supply Welrl and Leaching Facility (I'any Edell$exist on site or within 200 feet of leaching facility) , meet ,Age of Wedand and Lcacigng Facility(if any wetlands exist within 300 feyttf leaching facility) Feet tarnished I ,ee,, Clye :c I -- A' l , 41-6-_ ! 7 rc_ 3C 3�' 7 . _37 ' -` 3�' I 1I- i TO �F BARNSTABLE LOCATIO SEWAGE # 667 VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. �� SEPTIC TANK CAPACITY I LEACHING FACILITY:(type)At-4� OAo�.�(size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: �j VARIANCE GRANTED: Yes No ✓ C r , i1 5$7 No...71:_.' Fimic 3a........... THE COMMONWEALTH OF MASSACHUSETTS . BOARD OF HEALTI' APPROVED TOWN OF B A R N ST A B L stable Conservation Department Appliration for Dirivniiul Workii Tome r rMi# oat: S' ' %2. Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ......1. ............... ... ..... .........•.................... ...-----•-••-----•--•-•••------...•-•------•--••-•---------•••------------------------------------ ocation-•Address or Lot No. ..... ... ......_.........--: .... ------..............------..... ern ess Installer Address UType of Building Size Lot............................Sq. feet . t Dwelling— No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons-----------.---------------- Showers ( ) — Cafeteria ( ) Q' Other fixtures ----------------------_ ............................ W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length---------------- Width....--...----... Diameter-----........... Depth.--..--..---.--- x Disposal Trench--No. .................. Width---....---...--..... Total Length.---......--....,.-. Total leaching area....................sq. ft. 3 Seepage Pit No--------._------.-- Diameter.................... Depth below inlet.....--............. Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) a Percolation Test Results Performed by--------------------------------------------------------- •................ Date........................................ Test Pit No. I................minutes per inch ,Depth of Test Pit---.--.............. Depth to ground water............................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit--.................. Depth to ground water........................ Q+' ---------------------------------- ----------------------------- ............... ......--- .------------ ------ ........ .......... ......... *... .... .----------- ••-- 0 Description of Soil................-....................................................................................................................................................... x V .....-•---•-----••-----•---•-••-••--•------------•-•----•-••----•----------------•--••---....••-•----•-•-•-•-•--•----•-•••••----------------•-•--•--••----•-••--•••••---•-------•--•--••--•--•--•---•---- ------------------ -- ------------ U Nature of Repairs or Alterations—Answer when applicable.-..'., ✓cam-- do°i! N ------------------------------- .....................•---••............----•-•-------••--•••---•-•-----------------------------•----••-•---••-----...------....----•--•----•-••-••-----....------------------------••----------•----•-- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance as been issued 'bby� the board of health. Signed . ..... ...C�- ... �... .. .................................. Dace Application Approved By ............... ... ..... .......... .... ....................................................... ....//.:--�-e ............ Application Disapproved for the following reasons: ...................................... . ... ... .................. ....................................................... .................... ......................................... .. . .............. ..................................................--- . ......... ........................................ LT. PermitNo. ......... o .-............................................� Issued ...................................................... .......... Daze 7 17 / 05' 140....� 4.7. Figs.. ........... THE COMMONWEALTH OF MASSACHUSETTS . BOARD OF HEALTH TOWN OF BARNSTABLE Apphration for Diripwial Worka Towitrurtion Pumit 4`1 � - 7-2- Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: V........�. c:.�................................ .................................................................................................. �Location Address or Lot No. ........................................ .................................................................................................. 'W Address- e " 'W . .'Z.. ............ ... ........ ,V:. '. .2..Z........................................ ...P ... Installer Address U Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic Garbage Grinder Other—Type of Building ---------------------------- No. of persons--_------------------------ Showers Cafeteria Other fixtures -------------------------------------------------------- -- Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 9 Septic Tank—Liquid capacity------------gallons Length................ Width_.......___..... Diameter._._.._......._. Depth........._...... 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 ( ) Percolation Test Results Per-formed by.......................................................................... Date........................................ Test Pit No. I----------------minutes per inch Depth of Test Pit............_....... Depth to ground water.......____..._...._.... fT4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water..._-_..............._.. 0 9 ............................................................................................................................................................. Description of Soil........................................................................................................................................................................ �4 U ............................................................ ........................................................................................................................................... W ............................................... ................................................................ .................................. 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 TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance as been issued by the board of health. C_7 Signed .......................I--------<n/L� ................ .................................... ......... .. Date Application Approved By ..... ...... ........ ...... ................................................11.................. .... ........6; re Application Disapproved for the following reasons: ........................................................................................................................................ ................................................................................................................................................................................................................ ........................................ Dale Permit No. ......... ...................... Issued ................................... Dare THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE d1lertifirate of Tompliance THIS IS��,-...........- TO CERTIFY, at the In ivi ua ewage Disposal System constructed or Repaired by ..................... ----P_m"A ................. ............... ...... - --------------- t�� Instdier at ...............1-3. .............. - ----------------i dz . vl�u-------------------- . .............................................................. has been installed in accorAa, ce with the provisions of TITLE 5 of The State Environmental Code as described in -1 the application for Disposal Works Construction Permit No. ...... -4...7...... dated ........ ........... .................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. Ir - DATE .........................------- ............... Inspector ... ............ I..- .......................................... --------------—------------ ---------------- --------------?-------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE FEE.3�:..)....= ... .... ... . ....... Disposal lVorkii Tomitrurtion "amit Permissionis hereby granted------------ _-c..........16 ................................................................................. to Construct or Repair an Individual Sewage Disposal System ------------------------------------------------------ at No.. 1. -mac '``- e�......r --------4---------- 0 Street as shown on the application for Disposal Works Construction Permit No..19 U.. Dated........................................... ------------- ------ -- -------------------------------------------------------- Board of Health DATE------------ ------------------------------------ FORM 38808 HOBBS 6 WARREN.INC..PUBLISHERS No... 1-•---- ................_ THE COMMONWEALTH OF MASSACHUSETTS ®A►RD F HEALTH Apphratinn for Disposal Workn Tonfitrurtion Pumit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal WYSemSt t� -'------------ --- ----_-_- -- --------------------------------------------------- \ Location- dress or Lot No. ._ ��/t_. .._. ......e -•- '-.-. .----'...... .........•----------------•---................------....----•----•------------....--------------- W � n Owner ° Address Wit._.....-^ ---- v ....... � . '- ---------- Installer Address Q Type of Buildin Size Lot____________________ q. feet V Dwelling TNo. of Bedrooms----�............................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building .:.......................... No. of persons__.----_-____________--__- Showers ( ) — Cafeteria ( ) Other fixtures W Design Flow-- ---------- - -' - .._.. -.lions per person per day Total daily flow-------- '--- _ gallons. g WSeptic Tank Liquid capacit .. -. lions Length.................. Width---------------- Diameter--------........ Depth___.________.... x Disposal Trench—N .- 'W id ____-- -, eugtli ........... ..t l leaching area-------::...........sq. f t. Seepage Pit No.____:`_____________ Diameter `(/' D low e .- '_......._ al leaching area------------------sq. ft. z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date------------------------------------ Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water------------------------ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water___.-._-_..____-______-- ---------- -•-•-• •=•--------------------•-•-------•----------------•-------------.....-----------•-----------•-•••-••--------•- 0 Description of Soil..................... . ..---------•---------------------------------------------------------------------------------------------------- x V ------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------- - 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 Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee issu d y t lth. Signed- = - --------- - --- ----- --------- -- ------ ---------------------- ................................ Dat ' Application Approved By-------- . --------- _ ------- ' , !L�L�....... �f� �' -�-7_5--- ate Application Disapproved for the following reasons:.....................................I--------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------•----------------------------------------------------------------------------------- Date PermitNo......................................................... Issued........................................................ Date � A Ftzu.... ................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH _...__, OF....... - • .. ... Appika$ivan for 4%wosai Works C omirustiou rumit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at Y Lot No •. ocavti�on-A ress �r+� .................. --'---....-.....................................--.....-'--'-•••'---^---•-•.-----'--'-•--'------ a r Address ._.....----'------------•-•'-•....................................• Installer Address Q Type of Buildin Size Lot____________________ _____Sq. feet aDwelling No. of Bedrooms___:_ ______________Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures ••-•-----•-•---•-•-•-----------•••-------------••--.----- Desi n Flow____ __7,- W g ____.____.__ ._ -------------gallons per person per day. Total daily flow__._.____ '_ ----------_...gallons. WSeptic Tank Liquid capacity IlIons Length---------------- Width---------- ----- Diameter'- ............. Depth---- --•-------- x Disposal Trench—No........•... ........ Width--------------------T Uength______________._ _- Tolal leaching area....................sq. ft. Seepage Pit No......./_......... Diameter_ _ ',+ _ D n -�." {otal leaching area------------------sq. ft. Z Other Distribution box ( ) " Dosing tank ( ) Percolation Test Results Performed bY-------- ----------------................................... -----•- .... Date_---------------------------------- Test Pit No. L_______________minutes per inch. Depth of Test Pit.................... Depth to ground water-___________________-_-- (� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water___________-___._____-_- W _______. __. .e_____________ .......... ........................._.........._......................................................................... Description of Soil.................... f •---•-------------------------------------------------- W U Nature of Repairs or Alterations—Answer-when applicable-------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- g A reement:; -,-The. undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee issu by toe board of-h lth. `11- `_ s ro -----•--------------- ................................ Signed _..�" ate / � di � D Application Approved BY ,� 46, ---••• $ ate Application Disapproved for the following reasons:------------------------------------------------ ------------------------------------------------------------ •--....-•'•••-••'---••-•••-••-----------•••'-----------------••••••---'-•'•-••--•'••-'•-----•- f -- ._�at.3 PermitNo......................................................... Issued--�--+'---. -----------•----------•---------•-------- Date r THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH AT Tntif ira-tr of Tomphatt r THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (- -)--or Repaired ( ) w.a __. _ at ±-_---- ----�---� - --• .....` *—' In r i r st ller I � t— / ✓t has been installed in accordance with the provisions of Article XI of T.lae State Sanitary Code as described in the application for Disposal Works Construction Permit. No............„3_sf:_<<'_,1_------------- dated________ , � _ '-, THE ISSUANCE OF THIS CERTIFICATE SMALL NOT BE CONSTRUED AS A GUARANTEE TI AT THE SYSTERA �ll9 LL PICTIOPI SATI ACTORY. DATE- - ~ _... ••---- Inspector - THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No.... FEE...` 1 t Permission is hereby granted••---------r ---- to Construct ( or-Repair ( ' ) an jndividual Sewage Disposal System Street' as shown on the application for Disposal Works Construction Permit—No ,� ��a�terd rra Z,.1� DATE..... L Board of Health . .. � FORM 1255 -HOBBS & WARREN. INC., PUBLISHERS A