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HomeMy WebLinkAbout0348 STRAWBERRY HILL ROAD - Health 348 Strawberry Hill Road Centerville A=248 134 IN UPC 12534 No.215�3LO�Rms MAi1t1YpY.MY 0 a , Mfg 3�f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments :20 y 348 Strawberry Hill Rd A-11 Property Address r8- Neary Owner Owner's Name information is Centerville �' required for every Ma 02632 4-2-18 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be alteredlin any way. Please see completeness checklist at the end of the form. Important:When A. General Information S°� filling out forms :# ��� S C7 on the computer, use only the tab 1. Inspector: key to move your cursor-do not Chad Hathaway use the return Name of Inspector key. H.P.S. Company Name P.O.Box151 Company Address R Forestdale Ma 02644 Cityrrown State Zip Code 774-274-2581 12866 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 4-2-18 Inspector's ' ature Date The system inspector s II 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. t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 348 Strawberry Hill Rd Property Address Neary Owner Owner's Name information is required for every Centerville Ma 02632 4-2-18 page. Cityrrown 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: Septic in good working order. Recommend pumping septic tank every 2 years under normal use to prolong life of septic system. Do and don't and how to care for your septic system pamplets can be found online or at local health departments. 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•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M s 348 Strawberry Hill Rd Property Address Neary Owner Owner's Name information is required for every Centerville Ma 02632 4-2-18 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 16.303(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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 348 Strawberry Hill Rd Property Address Neary Owner Owner's Name information is required for every Centerville Ma 02632 4-2-18 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for 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. 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 '/2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 348 Strawberry Hill Rd Property Address Neary Owner Owner's Name information is required for every Centerville Ma 02632 4-2-18 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �< 348 Strawberry Hill Rd M ry Property Address New Owner Owner's Name information is required for every Centerville Ma 02632 4-2-18 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) E ❑ 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? ® El information 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 348 Strawberry Hill Rd Property Address Neary Owner Owner's Name information is required for every Centerville Ma 02632 4-2-18 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: seasonal part time Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ® Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: seasonalDate 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 348 Strawberry Hill Rd Property Address Neary Owner Owner's Name information is required for every Centerville Ma 02632 4-2-18 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: owner 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): l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 348 Strawberry Hill Rd Property Address Neary Owner Owner's Name information is required for every Centerville Ma 02632 4-2-18 page. Citylfown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1995 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2.25'feet Material of construction: ® cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: 20+feet Comments (on condition of joints, venting, evidence of leakage, etc.): none Septic Tank(locate on site plan): Depth below grade: 1.75' 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: 2" t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 348 Strawberry Hill Rd Property Address Neary Owner Owner's Name information is required for every Centerville Ma 02632 4-2-18 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 32" Scum thickness V. Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 18" 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.): pump every 2-3 years as maint. to protect leaching. baffles in place. no visable cracks or leaks 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 348 Strawberry Hill Rd Property Address Neary Owner Owner's Name information is required for every Centerville Ma 02632 4-2-18 page. Citylrown 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �,M • 348 Strawberry Hill Rd Property Address Neary Owner Owner's Name information is required for every Centerville Ma 02632 4-2-18 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 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): no carry overs Dbox is solid. (camera inspection) on Dbox PumpChamber locate on site plan): ( p ) 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. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 348 Strawberry Hill Rd Property Address Neary Owner Owner's Name information is required for every Centerville Ma 02632 4-2-18 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.): leach pit opened at time of inspection pit was dry and in good condition 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 348 Strawberry Hill Rd Property Address Neary Owner Owner's Name information is required for every Centerville Ma 02632 4-2-18 page. Cityrrown 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•3/13 Title 6 Official Inspection Forth:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M '< 348 Strawberry Hill Rd Property Address Neary Owner Owner's Name information is required for every Centerville Ma 02632 4-2-18 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately JrI' Ue W��7 � i 3 � G G 19 r A, 2 _ �s ' t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 348 Strawberry Hill Rd Property Address Neary Owner Owner's Name information is required for every Centerville Ma 02632 4-2-18 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: 45' 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: town GIS mapping You must describe how you established the high ground water elevation: lot el. 48' low el. in area 3.15' Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 348 Strawberry Hill Rd Property Address Neary Owner Owner's Name information is required for every Centerville Ma 02632 4-2-18 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 ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 a \ COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS . DEPARTMENT OF ENVIRONMENTAL PROTECTION° ' x: 0 .... 26 TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address- 348 Strawberry Hill Road Centerville. 1��/ Owner's Name: George Poyant70 J2 Owner's Address: Date of Inspection: Name of Inspector:(please print)'Wi 1 jam _ :Rob' nson Sr. Company Name: William E. Robinson. Septic Seryice Mailing Address: P O Box 1 089 Centerville, MA Telephone Number:_(508) 775-8776 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 Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: _l �,_.__`, .. Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Heattkor DEP)within 30 days of completing this inspection.If the system is a shared system or has a design now 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. Notes and Comments "This report only describes conditions at the time or 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: 348 Strawberry Hill Road Centerville Owner: George Poyant Date of Inspection: Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Sys`t(em//Passes: 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CM 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 riot 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 exftltration 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 tanZwill 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 obstoacd pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is rc wvod ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:_ 348 Strawberry Hill Road Centerville Owner: George Po ant Date of inspection:, C. Further Evaluation is Required by the Board of Health: -IConditions exist which require further evaluation by the Board of Health in order to determine if the system is fading 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 I 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 front 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 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 348 Strawberry Hill Road Centerville Owner: George Poyant Date of inspection: /—/S--o D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: t 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 i 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 I00,feet of a surface water supply or tributary to a surface r water supply. ! Any portion of a cesspool or privy is within a Zone 1 of a public well. t 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 ttte well water analysis, performed at a DEP certified laboratory.,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this forma (Yes/No)The system fails.I have determined that one or more ofthe 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 faci!ity with a design flow of 10,000 gpd to 15,000 gpd- You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _ the system is within 400 feet of a surface drinking water supply Lthe 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 11 of a public water supply well If ou'have answered"yes"to any question in Section E the system is considered a significant threat,or answered Y , ..yes"iI Section D above the large system has fatted.The tmmcr 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 15.3040 The system owner should contact the appropriate regional office of the Department. 4 Page 5 of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 348 Strawberry Hill Road Cen ervi e Owner: George Poyant Date of Inspection: 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 t/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? L — 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? t- _ 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 ortees,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: Yes no / 1-� 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)13 10 CUR 15.302(3)(b)) 5 Page 6 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION •348 Strawberry Property Address. Hill Road Centerville Owner: Geor e Po ant _ Date of Inspection -li G FLOW CONDITIONS RESIDENTL41 Number of bedrooms(design): Number of bedrooms(actual): ,; DESIGN flow based on 310 CMR 15.203(for example: 1 10 gpd x#of bedrooms):✓" Number of current residents: .. Does residence have a garbage grinder(yes or no): /f,U Is laundry on a separate sewage system(yes or no):4!:�e)[if yes separate inspection required] Laundry system inspected(yes or no).-,1, U Seasonal use:(yes or Water meter readings,if available(last 2 years usage(gpd)): 2005 - 47 ,0 00 Sump pump(yes or no):,i) 2003 - 48,000 Last date of occupancy: COMM ERCIAL/INDbSTRIAL Type of establishment: Design flow(based on,310 CMR 15.203): gpd Basis of design flow(s�eatslpersons/sqft,etc.): Grease trap present(yes or no _ Industrial waste holding tank present(yes or no):_ Non-sanitary wastAischaarged to the Title 5 system(yes or no):_ Water meter readings,if available: Last date of occuAncy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no): If yes,volume pumped:__gallons--How was quantity pumped determined? Reason for pumping: et-a 1'0 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 ob_tained from system owner) - _Tight tank Attach a copy of the DEP approval —Other(describe): Approximate age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no): 6 Paw 7 of I I OFFICIAL INSPECTION FOI01 —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 348 Strawberry Hill Road Centerville Owner: George Poyant Date of lnspectlon: °// ;� -�y : BUILDING SEIVER'°(locale on site plan) Depd,below gradc:7 Materials of constriction:_cast iron _40 PVC_other(explain): Distance Gom p %vale ,vater supply well or suction lute: Comments(o condition of juilts,venting,cvidcncc of Icakagc,etc.): SEPTIC TANK:Gale on site plan) Depth below grade: `/ Material of construction: y.'cuncrete metal fiberglass�,ol)•cdiylene _odur(cxplain) — — If tank is metal list age:_ Is age confnnned•by a Certificate of Compliance()-es or no):_(attach a copy of certificate) g- Dimensions: Sludge depth:_/—aj P Distance Gom top of sludge to buuom of outlet Ice or battle: Scum thickness:_�y / I t Distance from top of stun,to lop of outlet tee or baffle: t` Distance Gorn bottom of stun,to bottom of outlet tee or baffle: f�/ l lo%v"•crc dimensions deter,nincd: Q 4,/ Comments(on pumping recommendations,inlet and outlet tee or battle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 16 r GREASE TRAP:�1 (locate on site plan) Depth below grade:_ Material of eons' coon:_Concrete_I11clal_fiberglass`pol)-clllylCnC _other (explain): Dimensions: f+ Scum thickness: Distance Gonl/lop of scum to top of outlet lee or baffle: Distance from bottom of scum to bolton,of outlet tee or battle: Date of lasti'pumping: Conunentsi(on pumping recommendations,u11et and outlet ice or battle conditio:l,structural integrity, liquid levels as related to outlet invert,cvidcncc of leakage,etc.): 7 w 7 'age li of I I OFFICIAL INSPECTION FORM-NOT Il OR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORIIIATION(continued) Property Address: 348 Strawberry Hill Road Centerville Owner: George Poyant Drtte or Inspectlon: --0 Cr TIGHT or HOLDING TANK: (Imik must be pumped at time of inspection)(locate on site plan) Depth below grade:: Material of constrt ction: concrete_metal_fiberglass_pulyethylene oQrer(explairt): Dimensions: I Capaci(y: i gallons Design Flow: gallons/day Alann present(ycs or no): Alarm level: 1 Alarm in working order(ycs or no):_ Date of last pu,`mpmg: Comments(condition of alarm and float switches,etc.): r DISTRIBUTION BOX: 1`(present must be opcncd)(locate on site plan) Depth of liquid level above outlet invert: •d Conuncnts(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.): (7 l� PUA1P CRAMBER f�, (locate on site plan) Pumps in working order(yes or no):— Alarms in workingfordcr(yes or no): Comments(note,��ondilion of pump chamber,condition of pumps and appurtenances, etc.): Page 9 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 348 Strawberry Hill Road Centerville Owner: George Poyant Date of Inspection: 1-1-6-6 4 SOIL ABSORPTION SYSTEM(SAS): a-'(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: innovative/altemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): 1-7 J 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.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth ofsolids:1 Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of 1 l v OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 348 Strawberry Hill Road Centerville Owner: George Poyant Date of Inspection: 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. j o 5f� ^ j V 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 348 Strawberry Hill Road Centerville Owner. George Poyant Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells Jy 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 USGS database-explain: You must describe how you established the high ground water elevation: � U !�/ /6) �172 11 TOWN OF'BARNSTABI,r:'. ` LOCATION 1 c�i �%�, �l:ft✓�� 1 SE1vA";E # VILLAGE �` r� ASSESSOR'S MAP & LOT 13Y / r INSTALLER'S NAME & PHONE NO. '7 5 97') SEPTIC TANK CAPACITY / CI O LEACHING FACILITY:(type) 16 &-- (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED- VARIANCE GRANTED: Yes No � " \! !`ram''+ L._- � V - �. s _ �- ��`I t 1 4����� � e �� 1`�--� ��. i. e �., %� � �, �� ;? ��� / .� No..... r FRiis 3.0.....0.0 THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH TOWN OF BARNSTABLE Appliration for Diinpwml Wor1w ( omitrurtion ramit Application is hereby made for a Permit to Construct ( ) or Repair (x ) an Individual Sewage Disposal System at: 348 Strawberry Hill Rd Centerville ------- -----------•-..............------•••---------------------------------------------..._... ----•••----------••--•--••---------------------•-•---•.....••-•------------------------.......--•- George Poyanto``;`1011-Address or Lot No. W W.E. Robinson Sepfic Service P.O. .O. Box 1089 C�'69rville IcistalIer Address Type of Building 3 Size Lot----------------------------Sq. feet Dwelling— No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) pa, Other—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. Seepage Pit No.......... .......... Diameter.........----------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by-------- -------------------------•-----•-------•-----•-•-•------------... Date.....---------------------------------- ,-a Test Pit No. I----------------minutes per inch Depth of Test Pit......_..-_---._.._. Depth to ground water.....-..-------- ....... fi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ p� ....-----•.....................................................•.........---• ........................................................................... O Description of Soil...............sand............................................................ •. --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- U Nature of Repairs or Alterations—Answer when applicable.-.-.-insta_l_1-- a__ 1 000 gal septiC___tank, & D-box --------•------------------------------------------------------------------- ---.-----------------------------------------------------------------------------------------------...................-----. 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 has been issued by the board of health.. . _ . Signed - ��.; ./L3.... - _--------------- ...Q-�---- ��------.--- Date Application.Approved By ------._-------- ._'D. .. - - ----------- .7_.-. �. Dace Application Disapproved for the following reasonf: .....................-----------------------------------------------------_................................................. ... .......................................... ................... .. .. .. .. ._..._.._.... .. .. :-------------------------------------- -------------------------------------- ^ cy Dare Permit No. ......� D...... -f ..._.........._ Issued . --. ..........D ....... Dare . A ( ! L/ . No....- FEB...3.0.....0.0 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE . pVfira ion for Diti-pagal Works Toms#rnr#tnn Urrmit Application is hereby made for a Permit to Construct ( ) or Repair (x ) an Individual Sewage Disposal System at: - 348 Strawberry Hill Rd Centerville ..............••------...............----.-..__.....-------•-------•---.......................... --•-•--•---••-----••-•-•---•---------------------••-•........................................... George Poyangoc;ttion-Address or Lot No. Own Address W W.E. Robinson Septic Service• P.O. Box 1089 CenIcerville Installer Address •' Type of Building 3 Size Lot............................Sq. feet U'" Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons.............--------------- Showers ( ) — Cafeteria ( ) PA Design Flow............................................gallons per person per day. Total daily flow......._...._._.___. d Other fixtures ---------------- - --- - - - i W ---------------------gallons: WSeptic Tank—Liquid capacity------------gallons Length---------------- Width-----.---------- Diameter___-_---.-.__.- Depth................ x Disposal Trench—No. .................... Width-------------------- Total Length.------------------- Total leaching area--------------------sq. ft. Seepage Pit No...................... Diameter-------------.------ Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.----------_----- ...................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water:__...-..---_-_-__-... rz, Test Pit No. 2.........::.....minutes per inch Depth of Test Pit.................... Depth to ground water._-.................... 9 -•--•....•-------------------------•...•••-•-•---••••----••--••--...•--•---•••••-•-.._....---••_._........................................................... DDescription of Soil---------------- A2'1d.----•-•--------------•-•----------•-•---•--•--•-••------------------....---- x W ---- -------------------------------------------------------------------------------------------------------------•---•---------------------•---•-•-•-------•------•••-------------•--- VNature of Repairs or Alterations—Answer when applicable._....install------1----000-_c7a1___septic•--ta... & D-box -•--------------------------•-------•---------------•------...----------------------•---•--------------------------------------------------------...---------------------------------------------------- Agreement: d 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 has been issued by the board of health. r� ✓ Signed . ........ ... - -- ..72 :( . ...e...........:...... Dat Application.Approved By ----------------- ..-� ....... - 7."�Date Application Disapproved for the following reafons- ---------------------------------------------.........-----------------------------.-.............-..------------------------------- ....................................---------..................----.----..........--.--------...............-------------.........._-..--------.......---.---------...._...........---------- .................................... Dace .. ..<- Permit No. ......��.`� ..'._.�.... a ----------------- Issued _..... . -- ........................................_ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Ge>rtifirate of Czlontylianve THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( x) WE Robinson Septi.c....S.ervice------- _---------- --------------__--------------------.._...--------------.......................................... by ........... �............ ..._._. .. Installer at ......348 Strawberry h -l.l....Rd--- - Centerville------------------------------------------------------------------------------_--------------------.-. has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit o. ............c/ ... dated ..--..._........._. PP N P � :5 r. I� -------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE -....... .. ........ .. ...-..- - -. Inspector .....-.... - THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE FEE.3 0.0 0 �io�roottl orb$ �rrno#r�r#ion �prnti# W.E. Robinson Septic Service.... I Permission is hereby granted______________________ _____________________----_ to Constru t ( ) or Repair ( x ll an Individual Sewage Disposal System at No................................................................................................Strawberry 'Till Rd Centerville • • - - - - - ---------------------------•---••••---------•------------------•---•--•-------.....- ." Street as shown on the application for Disposal Works Construction Permit No._7,3_4/- ,_Dated---------j-----__�......... -- °°-t-... .................................................... -' Board of Health 1 DATE................... G. Po ant FORM 36508 HOBBS 6 WARREN.INC..PUBLISHERS Y b... No........t✓..... ---- Fxs.. ................. THE COMMONWEALTH OF MASSACHUSETTS T BOAR® OF HEALT .0F.... ..OLtiY� ... .......... . . . .................... Appliration for Di-qVniiFal Workii Tomarurtinn anti# Application is hereby made for a Permit.toConstruct ( ) or Repair ( ) an Individual Sewage Disposal System at: " cation-Address or Lot No. fb" ............................. .....................•----...---•-----••---....--•---......•-•----•---------------.........._..... ner Address Instal er? Address PQ Q Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( � .)` — Cafeteria ( ) d Other fixtures .. =-------=- ----------------------•-- W Design Flow............................................gallons per person per day. Total daily flow....................... .........gallons. W x Septic Tank—Liquid capacity............gallons Length................ Width---------------- Diameter---------- Depth................ Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area...:,...............Sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet................:... Total leaching area----------------_.aq, ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed bY.........................................................................• Date......................................... Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water........................ (� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ --------•-------------------------------------•-•---------------------------._.....-------------------------._.----.-.............. ••----- ---- --------------- 0 Description of Soil........................................................................................................................................................................ w -••.......•--•----•-••----•--•-•-•-•-----•---•-------•••-•-•.......................•••••••--•-•-----•--••--•--•-•-•--- .......................................-...................................... x -•-•--•-------------••---•--------------------•--•-------------. ..•-•---•-•--.....--•----•-•-••--•----•------- ------------------------ F U Nature of Repairs or Alter Answer when applicable...... ___ __ ......................... .... .....••. P --------------------------•------------------------ -----------•---------------------------------------•--------•-•----- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITi. 5 of the State Sanitary Code— The undersigned furth r agrees not to place the system, in operation until a Certificate of Compliance has een 'ssued y the boardpf I ' S' edJ ;.... ... Dat Application Approved B ..................... •--••-... --u-n. L . .. -.e_7 1....... Date Application Disapproved for the following reasons---------------•--------------------------------------------------------------------------------------.....•---•- --•••-•-•------••------•-------------•----••-- -••••-----••-••-•--•••-------•----..................-----•••--•---•-•-......-----••-•------•--------.................................................... Date PermitNo..................................................... Issued....................................................... Date l� t NV, Fps.. I...... ............. THE COMMONWEALTH OF MASSACHUSETTS s BOARD OF HE.ALT Appliratiou for Uhip Baal orki Tomitratrtioat ami# Application is hereby made for a,Permit INto Construct ( ) or Repair ( ) an Individual Sewage Disposal System , ^ , 4 - .. ..... ... . .............................. cation Address or t No. ...... - --_. .._. ........................... ...........••-------------....--•--............__._.............................................. 4 ner Address 'h, W .�e .............. i._ ......------.............................. --...-----•---........_...............•-•--------••... gr a Instal a Address dType of Building '4y Size Lot............................Sq. feet U Dwelling—No. of Bedrooms .............................. ......:Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ...................... ..... No, of persons:........................... Showers ( ) — Cafeteria ( ) QI Other fixtures ._. �' --•- --------------•••--•---••-•--------- ?i :� ..K- df 52•Y WDesign Flow............................ a _gallons per person per day. Total daily flow .,_....................___._:______._____gallons. t2' Septic Tank—Liquid capacity 4 r .gallons r Length Width____ _________ Diameter, _____-______- Depth....... ......... d;. Disposal Trench—No............. r, ..'"Width .. :'_ Total Length ............. Total leaching area___....._.........._sq. ft. r'. De th'';below in -----• Total leaching area_________________sq. ft. Seepage Pit No..................... Diameter, p Other Distribution box ADosing aPercolation Test Results Performed bye '.. Date r `'. ............................ Test Pit No. I................minutes per inch,„Depth of test Pit................ Depth-to'rground"water........................ r fs, Test Pit No. 2................minutes per inch Depth of Test Pit.................s. Depth to ground water.._._................__. _ .......................... --------------------------- �O Description of Soil................................................................. <. -----•----------------------------------------------- ••----------•------------- �/ ... U W ........................................... .___ .......___._..__....._.......... UNat, e of Repairs or Alter Answer when applicable L� Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned furtheF agrees not to place the system in operation until a Certificate of Compliance has en •ssued�theoard f 1 ,,, °....................... ' r Date Application Approved B -.-- « .--....._`.S`"---7.1.A PP PP Y ..... "t Da te Application Disapproved for the following reasons:_ ..___._ ........................................... ............................................. . :. Date Permit No....... Issued--------...........................--......---•--•---- .. Date : THE C0MM0NWEALTF ,,OF MASSACHUSETTS z. `BOARD OF 'HEALTH ' tam'...... oF. ... .. (Irr#ifiratr of Toutplianrr TH I TO.CE TIFY, Th, the In idual Sewage Disposal System constructed"( ) or Repaired .....:. ---- ------------------•-••----- ...........................................` by........ .... ..: _ Ad has been installed in accordance with tl provisions of N 5 of The State Sanitary Code as described in the application for Disposal Work§ Construction Permit-No,- - 6. ................. dated......�j S"`- --%r�°==�-------------• THE ISSUANCE OF THIS CERTIFICATE SFIALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WI L F NCTI TISFACTORY k � DATE.... �IY ` � Inspector� '� a- F ju. i v m 7 w sgfp 4nro,r .ta.� ( �' -::.Fw S 4 e '^'Y.F �4 � t V THE 'COMMONWEALTH OF MASSACHUSETTS' BOAR`D.:OF­-HEA, ;f .,... 4 ` 3 S s .......................... No._.._...:�...--- ._.. �_.._.. ;� ,`, - r.>� FEE ............. -F iaa11 r .. nraiti grant,-...... � , Permission Is hereby --......... to Construct ) o - r ( an Inds 1 ual e a ` isposal Sin at No...,. 3 ::__..v� aI F ; tt_ Street ;;. , as shown on the application for Disposal Works Construction P.�r mt No h...... ____ D }}ed S .... ._P ��A� ♦ .. Aw ° J{ / ' Boar of ealt DATE 4. (/ FORM 1255 HOBBS & WARREN. INC PUBLISHERS u "�LOC_ATI.OKA SF-\MA. _P_ERN_tIT U0-. V_I-l_-L IZ-G E I_N_ST AL_L -- - -►J-�,.t�/l Ei -A_D D�R E S S -AM E- _A D D R E_SS DACE-P-E_R_MOS-I-SSUED D_AT_E�COI�/_lPL_I_Q,t�ICE-ISSUED - ��__� . . .. — .� .. _... o. -- . ... �.. ,. ,. . � z , 1 ' / ,�� Y \, 1 �.