HomeMy WebLinkAbout0025 VALLEY BROOK ROAD - Health 25 VALLEY BROOK RD., CENTERVILLE
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NO 7 3LOR
HASTINGS,MN
No. ` —0 G,1 Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Ys
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
YILation for MIS oSal b Stem Construction Permit
Application for a Permit to Construct( ) Repair l') Upgrade( ) Abandon( ) ❑Complete System M Individual Components
Location Address or Lot No. x S Vakkey 1 Y 6o k- fq Owner's Name,Addr el.No.
Assessor's Map/Parcel 8 S(,, I q S 6, $jfo �►��^,V` `'` �� -
Installer's Name�Address,and Tel. o.`.$56 6"g77-gI7 7 Designer's Name,Address,and Tel.No.
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size o� / sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) ® `
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Heal
S' ned Date
Application Approved by Date /
Application Disapproved by Date
for the following reasons
Permit No. 6 � ���j Date Issued /3
No. 0�4� 1 Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Y s
4
Zipplication for tispb$aY 6pstem Construction Permit
Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) ❑Complete System �dividual Components
Location Address or Lot No.;X 5,,V.Aey 0Ok Owner's Name,Addr and el No.
\ Th owaS Q��5
Assessor's Map/ParceT16, SG 1 q S d c v. v� '$�!o 1"� ►7 � I a`-
Installer's Name',A dress,and Tel: o. c S6$—qri-g$7 7 Designer's Name,Address,and Tel.No.
C �w � E.�Yth-r �' ►SAS
Type of Building: j
Dwelling No.of Bedrooms Lot Size .-3 /q lk - sq.ft. Garbage Grinder( )
i
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
V a
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
0
Nature of Repa s or Alterations(Answer when applicable)
Date last inspected.-
Agreement: �1
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Healt
Si ned ( Date
Application Approved by Date 30 �^
Application Disapproved by Date
for the following reasons
y, Permit No. C1��- " j Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
p c� BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
F•k
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( )
Abandoned( )by �6
at pt S YC0.\AI. �—OD k 9kl has been constructed in accordance J'
with the provisions of Title 5 and the for Disposal System Construction Permit No.,P 0/, -1�)7 Wated 3 /3 Q /J
Installer 01 �-w G.Y�tr�r��-`S Designer
#bedrooms 3 Approved design flow gpd
-- The issuance of this permit shall not be construed as a guarantee that the syste,Twill ncti designed.
Date ► Inspect o 7,-------------------------------------------------------------------------------------------------------------- ------ -----------
No. _ c / `�} Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Misposal 6pstem Construction Permit
'Permission is hereby granted to Construct( ) Repair(V� Upgrade( ) Abandon( )
System located at �0.�\may 6�c�o CQ"�'8r Vr\U--
C' and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this permit
Date Z/3 O h 2, t, \,.-Approved by
r
r
t
TOWN OF BARNSTABLE
0VOCAON rJ VfQLLIcy rj�G �j� SEWAGE#
E ed/U7-7tVII. A/4ASSESSOR'S�MAAP&PARCEL
INSTALLER'S NAME&PHONE NO. J • Sr�t I lam`
SEPTIC TANK CAPACITY !CQ
LEACHING FACILITY:(type) (size)
NO.OF BEDROOMS
OWNER
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist on "*
site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching(facility) Feet
FURNISHED BY
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TOWN OF BARNSTABLE
TION J i21 (c�.� J0=0� SEWAGE #
AGE ASSESSO MAP & //LOOT
Z01)6CMP, NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) �.�C. f%®,� (size)
NO. OF BEDROOMS
BUILDER O OWNER
PERMIT DATE: COMP LANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) 09
Feet
Furnished by ����„ 70
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Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
25 Valley Brook Road
Property Address
Gert Shiels
Owner Owner's Name
information is required for Centerville MA 02632 3/30/2012
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out A. General Information
When
forms on the
computer, use 1. Inspector: ' (�/)
.only the tab key
to move your Richard M. Capen
cursor-do not use the return Name of Inspector
key. Capewide Enterprises, LLC
Company Name
taa 153 Commercial Street .
Company Address
Mashpee MA 02649
City/Town State Zip Code
508-477-8877 SI 13385
Telephone Number License Number
B. Certification
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
3/30/2012
Inspector' nature 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 DER The or1gin6lish�m1d be sent to the system owner
and copies sent to the buyer, if applicable an_d'the app oving*auiliik►ty.
""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 sys�teT,, ill perform in the future under
the same or different conditions of use. LEI LL ff 1
IV+
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
25 Valley Brook Road
Property Address
Gert Shiels
Owner Owner's Name
information is required for Centerville MA 02632 3/30/2012
every page. City/Town State Zip Code Date of Inspection
B. Certification(cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
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-11/10 Title 5 Official Inspection Form:Subsurface Sewage.Disposal System•Page 2 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 25 Valley Brook Road
Property Address
Gert Shiels
Owner Owner's Name
information is required for Centerville MA 02632 3/30/2012
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N : ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board 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
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Ti
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 25 Valley Brook Road
Property Address
Gert Shiels
Owner Owner's Name
information is required for Centerville MA 02632 3/30/2012
every 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 '/day flow
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Aisposal System•Page 4 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
25 Valley Brook Road
Property Address
Gert Shiels
Owner Owner's Name
information is required for Centerville MA 02632 3/30/2012
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
El ® 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.
El ® 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
Elthe 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
25 Valley Brook Road
Property Address
Gert Shiels
Owner Owner's Name
information is required for Centerville MA 02632 3/30/2012
every page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
El ® 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?
El
® 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
N El
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:
® El approximation
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•11/10 Title 5 Official Inspection Form:Subsurface Sewage.Disposal System•Page 6 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
25 Valley Brook Road
Property Address
Gert Shiels
Owner Owner's Name
information is required for Centerville MA 02632 3/30/2012
every page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes Z No
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: 2011
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? El Yes
❑ No
Water meter readings, if available:
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form -
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
25 Valley Brook Road
Property Address
Gert Shiels
Owner Owner's Name
information is required for reQ Centerville MA 02632 3/30/2012
every page. CityTTown State Zip Code Date of Inspection
D. System Information (cont.)
2011
Last date of occupancy/use: Date Date
Other(describe below):
General Information
Pumping,Records:
Source of information: Customer
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy .
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator Under contract
❑ Tight tank. Attach a copy of the DEP approval:
❑ Other(describe):
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
25 Valley Brook Road
Property Address
Gert Shiels
Owner Owner's Name
information is required for Centerville MA 02632 3/30/2012
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
30 years as-built
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
8,
Depth below grade: feet
Material of construction:
® cash iron ®40 PVC Schedule 20
® other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank (locate on site plan):
1,
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
Sludge depth:
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
25 Valley Brook Road
Property Address
Gert Shiels
Owner Owner's Name
information is required for Centerville MA 02632 3/30/2012
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
26"
Scum thickness 8" inlet side only
Distance from top of scum to top of outlet tee or baffle Baffle 15"
Distance from bottom of scum to bottom of outlet tee or baffle Baffle 15"S
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.):
System structurally sound at time of inspection. Commonwealth suggests pumping every 3 years.
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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
25 Valley Brook Road
Property Address
Gert Shiels
Owner Owner's Name
information is required for Centerville MA 02632 3/30/2012
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Scum level 8"thick on inlet side sludge measured 6"
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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
-Commonwealth of Massachusetts
W Title 5 Official Inspection Form -
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
c�M 25 Valley Brook Road
Property Address
Gert Shiels
Owner Owner's Name
information is required for Centerville MA 02632 3/30/2012
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
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.):
New D-Box installed prior to inspection.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
l5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
c�M 25 Valley Brook Road
Property Address
Gert Shiels
Owner Owner's Name
information is required for Centerville MA 02632 3/30/2012
every page. Cityrrown 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.):
Normal vegitation no signs of break-out or ponding.
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•11/10 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
25 Valley Brook Road
Property Address
Gert Shiels
Owner Owner's Name
information is required for Centerville MA 02632 3/30/2012 .
every page. City/Town State Zip Code Date of Inspection
D. System Information.(cont.)
Comments (note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy.(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
25 Valley Brook Road
Property Address
Gert Shiels
Owner Owner's Name
information is required for Centerville MA 02632 3/30/2012,
every page. City/Town 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
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t5ins•11/10 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
wM 25 Valley Brook Road
Property Address
Gert Shiels
Owner Owner's Name
information is required for Centerville MA 02632 3/30/2012
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high.ground water: 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:
examined groundwater calculations from house next door with similar elevations.
® Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Gaherty&Miller model 12/16/94 ground water elevation above sea level.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 25 Valley Brook Road
Property Address
Gert Shiels
Owner Owner's Name
information is required for Centerville MA 02632 3/30/2012
every page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information- Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 oft
1
�T r Town of Barnstable Barnstable
Y
Regulatory Services Wl AmericaCi N
* IAMSfABLE,
9
„�. Thomas F. Geiler,Director
Public HDivision Q 6
Health 2007
Thomas McKean,Director
Office: 508-862-4644 Q 200 Main Street Hyannis,MA 02601 Fax: 508-790-6304
� Ql�s
88
Thomas Shiels
145 Ocean Avenue / rs QGJ'o 0✓1
Palm Beach Shores,FL 33404
V a
f� December 14,2012
RE: 2013 Rental Re:;istration—Chapter 170 Rental Properties 4
REMINDER: G, l
It is time to renew your rental registration for the Town of Barnstable. All rental
registrations expire each year on.December 31St. Checks should be payable to: Town of
Barnstable and sent to Public Health Division; 200 Main Street, Hyannis, MA 02601. .
Enclosed is a rental application form. Please be sure to reference the address and unit number
of each rental unit you are registering on separate forms, as well as updated tenant info (name
and phone number).
Should you need more applications, they are available online at
www.town.barnstable.ma.us Go to the Department Menu. Locate the Regulatory Department.
Then, within the Regulatory Department, you will find the Health Division and its
Applications: .You may printout as many as you need, and return them to the Health Division
with the appropriate 2013 fees included. A $10 late fee will be assessed to those that renew
after January 15,2013.
• Failure to comply with this ordinance will result in the issuance of a non-criminal ticket
citation in the amount of$100. Each day of non-compliance is considered a separate offense
Should you have any questions, please contact the Health Division at 508-862-4644.
We appreciate your attention to this matter.
Thank you.
Enclosure
�
i
TOWN OF BARNSTABLE
BOARD OF HEALTH
/ ) ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION
Date l�J 6 Time: In Out
Owner (ter} / -��-��l'� ��� �%LS Tenant
Address Iy4 ,41 Aft% AddressZ IALU� 1 ` 4 k)
Air
Compliance Remarks or
Regulation# Yes NO Recommendations
2. Kitchen Facilities
3. Bathroom Facilities �*
4. Water Supply
5. Hot Water Facilities (®c. S
6. Heating Facilities O ru S T
7. Lighting and Electrical Facilities
8. Ventilation
9. Installation and Maintenance of Facilities
10. Curtailment of Service
11. Space and Use
12. Exits
13. Installation and Maintenance of Structural
Elements
14. Insects and Rodents
15. Garbage and Rubbish Storage and Disposal
16. Sewage Disposal
17. Temporary Housing dA
18. Driveway Width
19. Number of Tenants Observed
PART II
37. Placarding of Condemned Dwelling;
Removal of Occupants; Demolition
Number of Bedrooms Number of Vehicles Ilo x)
Number of Persons Allowed (max)
, 5
Person(s) Interviewed! �l � Inspector
If Public Building such as Store or Hotel/Motel specify here
Hazardous Materials Inventory Sheet Checklist
�2 Date
Physical Street Address-Check database to ensure it exists
Working Phone Number
Actual Amounts -( ie. gas being used to fuel machines,thinner to
/ clean brushes all count as hazardous materials)
✓ " Storage Information -location of storage, how long is storage for?
If none, note that.
Disposal Information -where and who? If none, note that.
Applicant Signature - understand what is listed and noted
Staff Initial -any questions, know who to ask
Vehicle Washing/Rinsing? -provide_ a vehicle washing policy and
explain it-note that it was given
Attach the Business Certificate with your sign off and comments
"The inventory form should explain what the business consists of and the procedures
they are doing. Notes need to be left to explain what you discussed with them.
YOU WISH TO OPEN A BUSINESS?
For Your Information: Business certificates (cost$30, far 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which :}
-�.._...
you must do by M.G.L.-it does not give you permission to operate.) Business Certificates are available at,the Town Clerk's Office, 1'FL., 367
Main Street, Hyannis, MA 02601 (Town Hall)
DATE:. 10 Fill in please:
3 "g APPLICANT'S YOUR NAME/S: ;acnv\
a ' BUSINESS YOUR HOME ADDRESS:-
.................... TELEPHONE # Home Telephone Number 5 O'�, - 2 A`L
sr
NAME OF CORPORATION:
NAME OF NEW BUSINESS TYPE OF BUSINESS
IS THIS A HOME OCCUPATION? ES , NO
ADDRESS OF BUSINESSr-F� \��,n�-�•i, - �n r� �J 3Z MAP PARCEL NUMBER tl6q" 15 Co (Assessing)
When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of
Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth
Rd. &Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town.
1. BUILDING COMMISSIONER'S OFFICE
This individual has been informed of any permit requirements that pertain to this type of business.
Authorized Signature*
_.i COMMENTS:
2. BOARD OF HEALTH
This individual has bee rmed of the permit requirements that pertain to this type of business. MUST COMPLY WITH ALL
L •+-rlcr-v I n HAZARDOUS�MATERIALS REGULATIONS
Authorized Signature*
COMMENTS:
3. CONSUMER AFFAIRS (LICENSING AUTHORITY)
This individual has been informed of the licensing requirements that pertain to this type of business.
Authorized Signature
COMMENTS:
a-►e Said �c will W
6vtc� o�c�+ni� �rtd�Els
N� �ilaiwU he WDV�=� �J�
I
iZ / 3
TOWN OF BARNSTABLE Date: / 16
TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY
NAME OF BUSINESS: �,����
BUSINESS LOCATION: INVENTORY
MAILING ADDRESS: j 9,\1Ro.��1� �(t� C�,✓��c r��\� � o~�(Q��� TOTAL AMOUNT:
TELEPHONE NUMBER:
CONTACT PERSON: 7®,.,1
EMERGENCY CONTACT TELEPHONE NUMBER: MSDS ON SITE?
TYPE OF BUSINESS: Lc, r, a5;( T
INFORMATION/RECOMMENDATIONS: Fire District:
Waste Transportation: Last shipment of hazardous waste:
Name of Hauler: Destination:
Waste Product: Licensed? Yes No
NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use,
storage and disposal of 111 gallons or more a month requires a license from the Public Health Division.
LIST OF TOXIC AND HAZARDOUS MATERIALS
The board of health and the Public Health Division have determined that the following products exhibit toxic or
hazardous characteristics and must be registered regardless of volume.
Observed / Maximum Observed / Maximum
Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive
❑ NEW ❑ USED Cesspool cleaners
Automatic transmission fluid Disinfectants
Engine and radiator flushes Road salts (Halite)
Hydraulic fluid (including brake fluid) Refrigerants
Motor Oils Pesticides
❑ NEW ❑ USED (insecticides, herbicides, rodenticides)
Gasoline, Jet fuel,Aviation gas
Photochemicals (Fixers)
Diesel Fuel, kerosene, #2 heating oil ❑ NEW ❑ USED
Miscellaneous petroleum products: grease,
Photochemicals (Developer)
lubricants, gear oil ❑ NEW ❑ USED
Degreasers for engines and metal Printing ink
Degreasers for driveways&garages Wood preservatives (creosote)
Caulk/Grout Swimming pool chlorine
Battery acid (electrolyte)/Batteries Lye or caustic soda
Rustproofers Miscellaneous Combustible
Car wash detergents Leather dyes
Car waxes and polishes Fertilizers
Asphalt& roofing tar PCB's
Paints, varnishes, stains, dyes Other chlorinated hydrocarbons,
Lacquer thinners (including carbon tetrachloride)
❑ NEW ❑ USED Any other products with "poison" labels
- - (including chloroform, formaldehyde,
Paint&varnish removers, deglossers hydrochloric acid, other acids)
Miscellaneous. Flammables Other products not listed which you feel
Floor&furniture strippers may be toxic or hazardous (please list):
Metal polishes
Laundry soil &stain removers
(including bleach)
Spot removers&cleaning fluids
(dry cleaners)
Other cleaning solvents
Bug and tar removers
Windshield wash
WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applicant's Signature Staff's Initials
' tip d
U
L 1998 w
0 '
BORTOLOTTI CONSTRUCTION, INC. 40
765 WAKEBY ROAD,MARSTONS MILLS, MA 02648
508-771-9399 508428-8926 FAX: 508428-9399 S
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: _ . �C&0
Date of Inspection: fispector's Name:
ner's Name Address:
I certify that I have personally inspected the sewage disposal system at this address and that the informa-
tion reported below is true,accurate and complete as of the time of inspection. The inspection was per-
formed based on my training and experience in the proper function and maintenance of on-site sewage
disposal stems. The System:
Passes `
Conditionally Passes
Needs Further Ev on the Local Aproving Authority
Fails
Inspector's Signature: Date:_ J,�U F_
The System Inspector shall submit a copy of this inspection report to tite Apppproving authority within thir-
ty(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 atpropriate regional
office of the.Department of Environmental Protection. The original should be sen:to the system owner
and copies sent to the buyer, if applicable and the approving authority.
INSPECT1i
A)tSYSTGI PASSES:
V/ I have not found any information which indicates that the system violates any of the failure
criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated
below.
B)SYSTEM CONDITIONALLY PASSES;
One or more system components need to be replaced or repaired. The system,upon comple-
tion of the replacement or repair, passes inspection.
Indicate yes,nor,,or not determined(Y,N,OR ND). Describe basis of determination in all instances. If
not determined",explain why not.
The septic tank is metal,cracked,structurally unsound,shows subs tanti.d infiltration or
exfiltration,or tank failure is imminent. The system will pass in.�pectioe if the existing sep-
tic tank is replaced with a conforn irig septic tank as approved by The x3taard of Health.
Sewage backkup or breakout or high static water.level observed in the distribution box is due
to broken or obstructed pipe(s)or due to a broken,settled or uneven di Alibution box. The
system will pass inspection if(with approval of The Board of Health):
- 1 -
1 SUBSURFACE
SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Broken pipe(s)replaced
Obstruction is removed
Distribution Box is levelled or replaced
The System required pumping more than four times a year due to broken or obstructed pipe(s).
The system will pass inspection if(with approval of The Board of Health):
Broken pipe(s)are replaced
Obstruction is removed
FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further y f rther evaluation b The Board of Health in order to determine if
the system is failing to protect the public health, safety and the environment.
1)SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE
SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE
PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 Feet of a surface water
Cesspool or privy is within 50 Feet of a bordering vegetated wetland or a salt marsh.
`y 2)SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER
SUPPLIER,IF APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTION-
ING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 Feet to a surface
water supply or tributary to a surface water supply.
' The system has a septic tank and soil absorption system and is with a Zone I of a public
water supply well.
The system has a septic tank and soil absorption system and is within 50 Feet of a private
water supply well.
The system has a septic tank and soil absorption system and is less than 100 Feet but 50
Feet or more from a private water supply well,unless a well water analysis for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from
' the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm.
D)SYSTEM FAILS:
I have determined that the system violates one or more of the following failure criteria as defiled
in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health
should be contacted to determine what will be necessary to correct the failure.
Backup of sewage into facility or system component due to an overloaded or clogged SAS
or cesspool.
Discharge or ponding of efluent to the surface of the ground or sut face waters due to an
I " overloaded or clogged SAS or cesspool.
Static liquid level.in the distribution box,above outlet invert due to an overloaded or clog-
ged SAS or cesspool. y
Liquid depth in cesspool is less than G"below invert or available volume is less than 1/2
day flow.
Required pumping more than 4 times in the last year NO'I due to clogged or obstructed
pipe(s). Number of times pumped
-2-
„
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Any portion of the Soil Absorption System,cesspool or privy is:below the high groundwater
elevation.
Any portion of a cesspool or privy is within 100 Feet of a surface water supply or tributary to
a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 Feet of a private water supply well.
Any portiop of a cesspool or privy is less than 100 Feet but greater than 50 Feet from a private
water supply well with no acceptable water quality analysis. If the well has been analyzed
to be acceptable,attach copy of well water analysis for coliforin bacteria,volatile organic
compounds,ammonia nitrogen and nitrate nitrogen.
E)LARGE SYSTEM,FAILS:
The following criteria apply to a large system in addition to the criteria above:
The design flow of a system is 10,000 gpd or greater(Large System)and the system is a significant.
threat to public health and safety and the environment because one or more of the following
conditions exist:
' The system is withirf400 Feet of a surface drinking water supply
The system is within 200 Feet of a tributary to a surface drinking water supply
The system is located in a nitrogen sensitive area Interim Wellhead Protection Area
(IWPA)or a mapped Zone II of a public water supply well.
The owner or operator of any such system shall bring the system and facility into frill compliance with the
groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local
regional office of the Department for further information.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
t CHECKLIST
Check if the following have been done:
Pumping information was requested of the owner,occupant,and BoaQd of Health.
`,None of the system components have been pumped for atleast two weeks and the system has
been receiving normal flow rates during that period. Large volumes of water have not been
introduced into the system recently or as part of this inspection.
-built plans have been obtained and examined. Note if they are not available with N/A.
e facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow.
-,he site was inspected for signs of breakout.
+/All system components,excluding the Soil Absorption System,have been located on site.
he septic tank manholes were uncovered,opened,and the interior of the septic tank was in-
spected for condition of baffles or tees,material of construction,dimensions,depth of liquid,
th of sludge,depth of scum.
yThe size and location of the Soil Absorption System on the site has beep determined based on
existing information or approximated by non-intrusive methods.
-3-
r �
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST(continued)
I/The facility owner(and occupants, if different from owner)were provided with information on
the proper maintenance of Subsurface Disposal System
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
/ FLOW CONDITIONS
RESIDENTLAI:V /
Design Flow: llons Number of Bedrooms:_1_ Nu!pbcr of Current Residents: c. t
Garbage Grinder: Laundry Connected To System:' Seasonal Use:
Water Meter Readi s,if v 'fable:
Last Date of Occupancy:
COMME )LiSTRL 4L:A)U
Type of Establishment: ,
Design Flow: aallonstday Grease Trap Present: (yes or no)
Industrial Waste Holding Tank Present: _.�_...w
Non-Sanitary Waste Discharged To The Title V System: _
Water Meter Readings,If Available: Last Date of Occupancy:
OTHER: Describe)
Last Date of Occupancy: —
GENERAL INFORMATION
BUMPING RECORDS and source of information:
System Pumped as part of inspection: A)l j if yes,volume pumped:._ gallons
Reason for pumping: .
TYr�OF SYSTEM:
Septic Tank/Distribution Box/Soil Absorption System
Single Cesspool
Overflow Cesspool
Privy
Shared System(If yes,attach previous inspection records, if any)
Other(explain):
AP ROXIMATE AG fall compone�'date installed(if known)and source'of information:
VY
Sewage odors detected w en arriving at the e: 4 26 a
-4-
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
GENERAL INFORMATION (continued)
SEPTIC TANK:
Depth below grade: ',' Material of Constnuction: L--Cloncrete metal FRP Other
(explain)
Dimisions:_- ,5 "/&A',S' Sludge Depth: Scum ffl Thickness:__
Distance from top of sludge to bottom of outlet tee or baffle: 155
'/
Distance from bottom of scum to bottom of outlet tee or baffle: g �'
Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid
1 1 in don too et in ert,structural integrity,evi nce oC leakage etc. Q 1�
AD
/i
GREAS �T - /t.1tCd
Depth Below Grade: Material of Constniction: concrete ntetal FRP Other
(explain) — — — —
Dimensions: Scum Thickness:
Distance from top of scum to top of outlet tee or baffle:
Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid
level in relation to outlet invert,stnuctural integrity, evidence of leakage. e(c.)
a
TIGHT OR HOLDING TANK
Depth Below Grade: Material of Construction:__concrete—n►etal__FRP—Other(explain)
Dimensions: Capacity: gallons Design Flo%v: kallons/day
Alarm Level: _
Co nments: (condition of inlet tee, condition of alarm and floarsivitches. etc.)
DISTRIBUTION BOX:
Depth of liquid level above outlet invert:�1�1�L�� ,�c
Comments: (note if 1 el and distribution is equal,eviden a of solids carq,over, evidence of leakage into
or out of box—etc.)
PUMP;CHAMBER: )
Pump is in working order:
Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) t
_5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
SOIL ABSORPTIO14 SYSTEM(SAS):
(Locate on site plan, if possible;excavation not required,but may be approximated by non-intrusive
methods) If not determined to be present,explain:
Type:
Leaching pits,number: Leaching chambers, number: Leaching galleries,number:
Leaching trenches,number,length:
Leaching fields,number,dimensions:
Overflow cesspool,number:
Comm nts: (note condition of soil igns of I rauH failure level of pondin ,condition of vegetation,
etc. fZ
rr
,k
ii
CESSPOOLS:/Jb
Number and configuration:' Depth-lop of liquid to inlet invert:
Depth of solids layer: Depth of scum layer: Dimensions of Cesspool:
Materials of construction: Indication of groundwater:
Inflow(cesspool must be pumped as part of inspection)
Comments: (note condition of soilk,signs of hydraulic failure, level of ponding,condition of vegetation,
etc.)
N ,,9
PRIVY: /"y
Materials of construction: Dimensions:
Depth of Solids:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,
etc.)
-6 -
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM .
PART C
SYSTEM INFORMATION (confirmed)
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include des to adeast two permanent references, landmarks or benchmarks.
Locate all wells within 100 Feet.
r
1 1
3
1'bit
DEPTH TO GROUNDWATER:
Depth to groundwater: Feet
Meth of Detbrminadon or Approximati n:
0
-7-
[ OCAT10N SEPIA E PERMIT NO.
_ L07-Yf 9 I- LEY A312.ocn r7®
VILLAGE
INSTALLER'S NAME 6 ADDRESS
VF- T®/e11L,O ff/Zo! -tLc-
/ � L
S U I-L WE R OR 0WN ER
Sm IT*
DATE PERMIT ISSY. ED 7-cgdL
QAT E COMPLIANCE ISSUED 3//�y
f �4
h
THE COMMONWEALTH.OF MASSACHUSETTS
BOAR® OF HEALTH
...... OF.............. ..Gv1-(!- `. -- .....................
Applira#ion for Uiap.aaal Works Cfnnatrnrtinn ramit
Application is hereby made for a Permit to Construct (✓) or Repair ( )` an Individual Sewage Disposal
System at:
&V1 lOn�ro s�V ....... ...................... ................. ►: 11 - ---.---....._.............°t
.Loca io Address Lot o.
....._._',.�J-C.m.c.a. .. A----... ------------ ------------------- s. .. -------------.................
..
Owner Add
a .................. � --------• .... . s------------------- -------------------I_ A...0.. -......----------------...
Installer Address
UType of Building Size Lot__%1 D 3 A......Sq. feet
Dwelling—No. of Bedrooms.............3..................._..._..Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ---------------------------- No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Other fixtures ----------•--- --------------- .
W Design Flow............ g P P P Y Y o � -
�.�VV0..........
gallons per person per day. Total daily flow__.__._......___..._�..._._._.._.._._._.. Ions.
WSeptic Tank—Liquid"capacity.w.4gallons 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 to ( ) n l
~' Percolation Test Results Performed by._._.._. -AG.k ......&.....N N. ........... Date...........................
a
Test Pit No. 1................minutes per inch Depth of Test Pit.................... epth to ground water--.-_--______-__--__--_.
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
x .--- -----------j ----...----••------------...... - ---...:- ------------
-.-------------------------------------------------
Description of Soil-----------Q--- 3-----------`0-Q�---------------5 V�DS c_�. .
Q s
v ....'� CQ .;ct_ ..... a ------------- ��-----------------------
------------------------------------------ &�---------------
�► --------------------------------------------------------------------•--------
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 iITI,L 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of heal .
Signed...------. - �--.------1�------ --- ���.J g
V �y O at
Application Approved By............... :.rQ�......., l ------------------- -_ f J0"t ........
Date
Application Disapproved for the following reasons------------------------------------------------------------------------------------------------------------_....
-------------------------------------------------------------------------------------•----.......--------------------....-•-----------•--------------•--------------------------------•-------........_
Date
PermitNo......................................................... Issued_............................ ....................
Date
No.- -3.. FRE.,3f,,...............
THE COMMONWEALTH OF MASSACHUSETTS
_ BOARD OF HEALTH
........ 1_L*'h_0.r-N...........OF............ICOD.5 c-b --
Alipfiration for Di-spo5Fal Works Tontratrtion thrutit
Application is hereby made for a Permit to Construct () or Repair ( ) an Individual Sewage Disposal
System at:
-----.... ..... .�....... � -- �.-------- -......`�-- .. ------....------. . a...........�
Locatio} Address,,... x
..................................................
-----.— o Lot o.
Owner Address
a ram,-r . ' ..... ....... s ?.....................LAr\, . ..�
..................... ...----- .................................
CLA Address
Type of Building Size Lot.........,`...................Sq. feet
Dwelling—No. of Bedrooms............................................' Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
al Other fixtures -__•..............................
W Design Flow...........\ ��..........C...... _.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 t ( )
�-- _ ,
Percolation Test Results Performed by........ ._C .............................. _.. Date...._.�°. . ......................
1. -.. C•----...----
,.� Test Pit No. I................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........................
a ........................... ..............................................................................................................................
0 Description of Soil............ _ '..��............ .G>_t:k.�. v ?S`' , l ------.
_......
-------------•-----•-------...--------........ .-----------....�-( K,ti a 5 c� c . - - v e SL,,:. -
-
VW •--------•--......----••-----•------ ------------------------------------------------------------------------------
Nature of Repairs or Alterations—Answer when applicable.-_--------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------••--•-•-....----•------•••-----•-----------•---•-•--••---•-------•--••••--•••-•--•------................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of heal
Signed........=:'\Ca-'''rY�, V
at
» .. .. �-
/�/
Application Approved BY - `./1,�.. ------------------ •------ / = jt-•------
Date
Application Disapproved for the following reasons:.................................................................................
---------.. ......-----•--
....................•-----...........----.....--•-•----------•---•-----•---------•--•-•---...------........•-----........._..•-----••------•-••--••-----•------•------•_...----••-------•••---•_._..•..--
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD�?OF HEALTH
Trrtifiratr of Tomph anrr
THIS 1 TO CERTIFY, That the Individual Sewage Disposal System constructed r-51"or Repaired ( )
by...................... �-�--�--� ---•---•-----•- -�- .........................•------------..._.... -----------•---•----.-....:..............
--------
----•---------------
Installer �T l `
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the .
application for Disposal Works Construction Permit No..._.c�.�."__�.7��.......... dated-.------------------- ..........................
THE ISSUANCE OF THIS CERTIFICATE SMALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE........................�f � ��� .............................. Inspector..... s
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.........i ...OF................ ..G......................................................... J
FEE........................
�i��o��t1 ork� �on�#� ton rrutit
Permission is hereby granted... .....--�--- ---"�---•------------�- .... .
............. ------
.......Construct �(i''f or Repair ( ) an Individual Sewage Dispo al System
at No Y -.. .{!` �.. `�.. .f ` 4 ---- A
�J =
Street
as shown on the application for Disposal Works Construction Permit No..................... Dated---------_................................
l� Bo of ealth
DATE........................................ ZL/
...............................•
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS
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