HomeMy WebLinkAbout0057 WHIDAH WAY - Health 57 WHIDAH WAY, CENTERVILLE
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
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TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 57 WHIDDAH WAY
CENTERVILLE
Owners Name: PETER ROBBINS 41
Owner's Address:
--J
Date of Inspection:6/27/05
Name of Inspector: (please print) Douglas A.Brown
Company Name: Douglas A.Brown Septic Inspections _
Mailing Address:P.O Box 145 "'. '
Centerville,MA 02632
n
Telephone Number: 508-420-4534
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:
X Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: 6/27/05
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving,
authority.
Notes and Comments
LIQUID DEPTH IN PIT IS ABOUT 2'FROM TOP OF PIT AT THIS TIME
****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.
lr-
Title 5 Inspection Form 6/15/2000 page 1 Revised on 10/11/2000
Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 57 WIDDAH WAY
CENTERVILLE
Owner's Name: PETER ROBBINS
Owner's Address:
Date of Inspection: 6/27/05
inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
X I have not found any information winch indicates that any of the failure criteria described in 3 10 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 Pase'section need to be replaced or
repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the following statements. If"not determined"please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health,
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 57 WIDDAH WAY
CENTERVII_,LE
Owner's Name: PETER ROBBINS
Owner's Address:
Date of Inspection: 6/27/05
C.Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health, safety or the environment
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ the system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 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 from a
private water supply well**.Method used to determine distance
**This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered.A copy of the analysis must be attached to this form.
3. Other:
Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 57 WIDDAH WAY
CENTERVILLE
Owner's Name: PETER ROBBINS
Owner's Address:
Date of Inspection:6/27/05
D. System Failure Criteria applicable to all systems:
You must indicate "yes or no to each of the following for all inspections:
Yes No
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow
_ X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
— of times pumped
X Any portion of the SAS,cesspool or privy is below high ground water elevation.
X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
X Any portion of a cesspool or privy is within a Zone 1 of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
X 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 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.]
NO (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as
described in 3 10 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.
You must indicate either"yes"or no to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
the system is within 400 feet of a surface drinking water supply
_ the system is within 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 you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
yeg'm 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
i
Page 5 of 11
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 57 WIDDAH WAY
CENTERVILLE
Owner: PETER ROBBINS
Date of Inspection: 6/27/05
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
X ^ Pumping information was provided by the owner,occupant, or Board of Health
X Were any of the system components pumped out in the previous two weeks ?
X Has the system received normal flows in the previous two week period?
X Have large volumes of water been introduced to the system recently or as part of this inspection?
X Were as built plans of the system obtained and examined?(If they were not available note as N/A)
X _ Was the facility or dwelling inspected for signs of sewage back up?
X _ Was the site inspected for signs of break out?
X Were all system components,excluding,the SAS,located on site?
X _ 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?
_ X 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
X _ Existing information. For example,a plan at the Board of Health.
X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [310 CMR 15.302(3 ))(b)]
5
Page 6 of 11
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 57 WIDDAH WAY
CENTERVILLE
Owner's Name: PETER ROBBINS
Owner's Address:
Date of Inspection. 6/27/05
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN How based on 3 10 CMR 15.203 (for example: 110 gpd x# of bedrooms): 330
Number of current residents: 3
Does residence have a garbage grinder(yes or no): NO
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or no): NA
Seasonal use: (yes or no): NO 03- g,C�00 �C&l
Water meter readings,if available(last 2 years usage(gpd)): OH - 57 Sump pump(yes or no): NO V
Last date of occupancy: cuxxsrrr
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no): _
Industrial waste holding tank present(yes or no):_
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: PUMPED TANK6-3-05
Was system pumped as part of the inspection(yes or no): NO
If yes, volume pumped: loon gal gallons--How was quantity pumped determined? OFF BILL
Reason for pumping: MAINTENANCE
TYPE OF SYSTEM
X 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)
_Tight tank _Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
system installed 1985 JJ DRISCOLL
-� Were sewage odors detected when arriving at the site (yes or no)? NO
Page 7 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 57 WIDDAH WAY
CENTERVILLE
Owner's Name: PETER ROBBINS
Owner's Address:
Date of Inspection: 6/27/05
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: cast iron _40 PVC other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK:_ (locate on site plan)
Depth below grade: 12"
Material of construction: X concrete_metal_fiberglass _polyethylene
-__other(explain)
If tank is metal list age: _ Is age confirmed by a Certificate of Compliance(yes or no): _(attach a copy of
certificate)
Dimensions: 1000 gal
Sludge depth: 0
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: 0
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
How were dimensions determined: TANK PUMPED 6-3-05
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.)-
GREASE TRAP: (locate on site plan)
Depth below grade:_
Material of construction:_concrete metal_fiberglass polyethylene other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 57 WIDDAH WAY
CENTERVILLE
Owner's Name: PETER ROBBINS
Owner's Address:
Date of Inspection: 6/27/05
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/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
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.):30
k
PUMP CHAMBER: (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
Page 9 of 11
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 57 WIDDAH WAY
CENTERVILLE
Owner's Name: PETER ROBBINS
Owner's Address:
Date of Inspection: 6/27/05
SOIL ABSORPTION SYSTEM(SAS): _(locate on site plan,excavation not required)
If SAS not located explain why:
Type
X leaching pits,number:
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.):
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer.
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes 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 of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
Page 10 of I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 57 WIDDAH WAY
CENTERVILLE
Owner's Name: PETER ROBBINS
Owner's Address:
Date of Inspection: 6/27/05
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.
3 - 30t 3_ `� `{i
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Page 11 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM ] INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 57 WIDDAH WAY
CENTERVILLE
Owner's Name: PETER ROBBINS
Owner's Address:
Date of Inspection:6/27/05
SITE EXAM
Slope:
Surface water:
Check cellar:
Shallow wells
Estimated depth to ground water 10 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:
PLAN DATED 9-16-85 ELDREDGE ENGINEERING
(.vh TOWN OF BARNSTABLE 33
LOCATION .S7 WCL4 SEWAGE #
VILLAGE ��'/��e� ���-� c ASSESSOR'S MAP & LOTZ
INSTALLER'S NAME&PHONE NO. lX�uCI-gS 43-128171
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO. OF BEDROOMS
B ,DER-&R OWNER
PERMITDATE: 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
Tr
/F Page 10 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Addreea:57 WIDDAH WAY
Owner's Name: PE IMROBBINS
Owner's Addma:
Date of Inspection:6/27/05
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent referenoe landnei a
benchmarks.Locate all wells within 100 feet Locate where public water supply enters the building.
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COM120\` aLTH OF 1VIASSACHL'SETTS
EXECUTIVE OFFICE OF EINVIRONMEITAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
OAE WL TER STREE". BOSTON D �,0210E (61") 292-550o
^�F
TRUDY COaE
Secretan•
ARGEO PAUL CELLUCCI DAVID B. STRL'HS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Prop"Address: 57 Whid.d.ah Way, Name of Owner Phillip/ Ann Cantor
Centerville , MA Address of Owner: same
Date of Inspection: F—[f—7cf
Name of Inspector:(Please Print)Wm. E . Robinson Sr.
1 am a DEP approved s erq inspector rsuant to Section 15.340 of rrde 5(310 CMR 15.000)
Co-PanyN�: Wm. E . Robinson leptic Service
MwingAddress: PO Box 1069, Centerville , MA
Telephone Number:
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function,and
maintenance of on-site sew ge disposal systems. The system: k
Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
_ Fails
inspector's Signature: t Date: G q
The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty (30) days of
completing this inspection. If the system is a,shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner
shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the
system owner and copies sent to the buyer, if applicable, and the approving authority.
NOTES AND COMMENTS
r, o �9p
RE�IVE0
AUG 2 0 1999
TOWN OF BARNSTABLE
S HEALTH DEPT. 11
s
revised 9/2/98 Page Ior11
n
few* Prated on Recy6ed Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
"ropertyAddress: 57 Whid.dah Way, Centerville , MA
Jwner: Ann Cantor
Date of Inspection: �`4 n
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure
criteria not evaluated are indicated below.
COMMENTS:
B. SY TEM CONDITIONALLY PASSES: e t
One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon
ompletion of the replacement or repair, as approved by the Board of Health, will pass.
Indicate y s, no, or not determined (Y, N, or ND).' Describe basis of determination in all instances. If "not determined-, explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached)indicating that the tank was installed within twenty (20)years prior to the date of the inspection: or
the septic tank, whether or not metal, is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipets)
or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health).
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
revised 9/2/98 Page 2of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 57 Whid.dah :Way;`-::C(Pnterville , MA
Owner: Ann Cantor s e 4
Date of Inspection:
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
nditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
pu lic health, safety and the environment.
1) SYS WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM
IS N FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYS WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS
FUN TIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or
tributary to a surface water supply.
The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the
well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm. Method used to determine distance (approximation not valid).
3) THER
revised 9/2/98 Page 3of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
t t
Property Address: 57 Whid.d.ah Way, Centerville , MA
Owner: Ann Cantor
Date of Inspection: "r-9 y 5
D. SYSTEM FAILS:
You m6ft indicate either "Yes" or "No" to each of the following:
I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this
determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes o
Backup of sewage into facility or,system component due to an overloaded orclogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped_.
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_ Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E. LA GE SYSTEM FAILS:
You mu indicate either "Yes" or "No" to each of the following:
The following criteria apply to large systems in addition to the criteria above:
he system serves a facility with.a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public
health and safety and the environment because one or more of the following conditions exist:
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
Y Y 9
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 o ner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Department for further information.
revised 9/2/98 Page 4ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM,
PART B
CHECKLIST
Prop"Address: 57 Whid.d.ah Way, Centerville , MA
Owner: Ann Cantor
Date of Inspection: fl-`l IF 4l
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes/ No
Pumping information was provided by the owner, occupant, or Board of Health.
None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow
rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
inspection.
L _ As built plans have°been obtained and examined. Note if they are not available with NIA.
,✓ _ The facility or dwelling was inspected for signs of sewage back-up.
v _ The system does not receive non sanitary or industrial waste flow.
_ The site was inspected for signs of breakout.
_ All system components,excluding the Soil Absorption System, have been located on the site.
_ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles
or tees, material of construction, dimensions,depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on:
_ Existing information. For example, Plan at B.O.H.
_ Determined in the field(if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable)
115.302(3)(b))
1L _ The facility owner land occupants,if different from owner) were provided with information on the proper maintenanca-0f
SubSurface Disposal Systems.
revised 9/2/98 Page 5of11
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Prop"Address: 57 Whid.d.ah Way, Centerville , MA
Owner: Ann Cantor 4 ,
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 3(o ug.p.d.!be,droom.
Number of bedrooms(design):3 Number of bedrooms (actual):,3
Total DESIGN flow 3 C 0
Number of current residents161
Garbage grinder(yes or no):
Laundry(separate system) (yes or noA ; If yes, separate inspection required
Laundry system inspected (ye or no)
Seasonal use (yes or no): jj//0
Water meter readings, if a ailable (last two year's usage (gpd): 1998 68 r CCC�l.
Sump Pump(yes or no): 4/O , ga .
Last date of occupancy: PL
y
COMMERCIAL/INDUSTRIAL:
Type p establishment:
Desig flow: qpd ( Based on 15.203)
Basis of design flow
Grea a trap present: (yes or no)_
Indu trial Waste Holding Tank present: (yes or no)_
Non sanitary waste discharged to the Title 5 system: (yes or no)_
Wa er meter readings, if available:
Las date of occupancy:
O ER:(Describe)
La of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and spurce of information:
System pum ed as part of inspection: (yes or noz-4
If yes, volume pumped: gallons
Reason for pumping:
TYPE OF YSTEM
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)
I/A Technology etc.Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components, date installed(if known)and source of information: F -` Jr 6
d
Sewage odors detected when arriving at the site: (yes or no)
revised 9 2 98
Page 6 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
'ropertyAddress: 57 Whidd.ah Way. , Centerville , MA
Owner: Ann Cantor
Date of Inspection:
BUILD NG SEWER: OO
(Local on site plan)
Depth b ow grade:_
Material f construction:_cast iron_40 PVC_other(explain)
Distance from private water supply well or suction line
Diamete
Comme ts: (condition of joints, venting, evidence of leakage,-etc.)
SEPTIC TANK:
(locate on site plan)
Depth below grade:Iy
Material of construction: l.Concrete_metal_Fiberglass _Polyethylene_other(explain)
If tank is metal,list age Is.age confirmed by Certificate of Compliance_ (Yes/No)
Dimensions: D<
Sludge depth: °� t
Distance from top of sludge to bottom of outlet tee or.baffle:y-
Scum thickness: t��S
Distance from top of scum to top of outlet tee or baffle: y r
Distance from bottom of scum to bottom of outlet leg or baffle:/a
How dimensions were determined: w
'omments:
(recommendation for pumping, condition of inlet and outlet tees of baffles, depth of liqui vel in relation to outle nvert,_structural'integrity,
B evidence of leakage, etc.) A b-U row/ )�'L-DC. d ;u zz. ��G li
C�G' nn-
GR SET RAP:
(local on site plan)
Depth elow grade:_
Materia of construction:_concrete_metal_Fiberglass _Polyethylene_other(explain)
Dimensi ns:
Scum th ckness:
Distanc from top of scum to top of outlet tee or baffle:
Distanc from bottom of scum to bottom of outlet tee or baffle:!
of of last pumping:
Com ants:
(rec mendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evi ce of leakage, etc.)
revised 9/2/98 Page 7of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ,
PART C
SYSTEM INFORMATION(continued)
'roperty Address: 57 Whid.dah Way, Centerville , MA
Owner: Ann Cantor
Date of Inspection: ,_!fir _�e7
TIGHT_OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection)
(locate n site plan)
Depth b low grade:_
Material of construction:_concrete_metal_Fiberglass_Polyethylene_other(explain)
Dimensi r
Capacity gallons
Design fi w: gallons/day
Alarm pr sent
Alarm le el: Alarm in working order: Yes_ No
Date of revious pumping:
Comm ts:
Icondi on of inlet tee, condition of alarm and float switches,etc.)
DISTRIBUTION BOX.`,
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and distribution is equal, evid� f solids carryover, evidence of leakage into or out of box, etc,) -
PUMP CHAMB
(locate on site Ian)
Pumps in work ng order: (Yes or No)
Alarms in wor ing order(Yes or No)
Comments:
(note conditio of pump chamber, condition of pumps and appurtenances,etc.)
revised 9/2/98 Page 8of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
'rop"Address: 57 Whiddah Way, Centerville, MA
Owner Ann Cantor
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS):_✓
(locate on site plan, if possible; excavation not required, location may be approximated by non-intrusive methods)
If not located, explain:
Type:
leaching pits, number:
leaching chambers,number:_
leaching galleries, number:_
leaching trenches, number, length:
leaching fields, number, dimensions:
overflow cesspool,number:_
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure, level of po ding, damp soil, condition of vegy tation, etc.)
� a air.,. ► �t �
CES OOLS:_
(locate n site plan)
Number nd configuration:
Depth-to of liquid to inlet invert:
Depth of olids layer:
)epth of cum layer:
Dimension of cesspool:
Materials f construction:
Indication f groundwater:
i flow (cesspool must be pumped as part of inspection)
Commen s:
(note co dition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY-_
(loca a on site plan)
Ma ials of construction: Dimensions:
Dept of solids:
Com ants:
(not condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
revised 9/2/98 Page 9ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
'iropertyAddress: 57 Whid.dah Way, Centerville ,. MA
i
)wner: Ann Cantor S
Jane of Inspection:g_4`
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
C> c
d'
L1 L�
revised 9/2/98 Page 10of11
Y '
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
ropertyAddress:57 Whiddah Way, Centerville , MA
Owner: Ann Cantor
Date of Inspection:
NRCS Report name
Soil Type_
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells
Estimated Depth to Groundwater-J�-Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observed Site (Abutting property, observation hole, basement sump etc.)
Determined from local conditions
Checked with local Board of health
Checked FEMA Maps
Checked pumping records
Checked local excavators, installers
Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
63 0C S J /Yo/L-S k
� I .
revised 9/2/98 Page 11of11
�? TOWN OF BARNSTABLE
LOCATION per/ SEWAGE #
VI'L.LAGE b`�� ASSESSSDR'S JMAP&�SL-O� `�� —
JVS AME&PHONE NO.
SEPTIC TANK CAPACITY 666 ��
LEACHING FACILITY: (type) .f'�` ��1 (size) Z(L)an S'
NO. OF BEDROO
BUILDER O OWNER +✓ d C'//�%S�/��. �1�.
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility /6 Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) N//r` Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 3 ��e_�t hin of/ g leac fac ) / Feet
/47
Furnished bIJXi ea �� ���'�t.5—
UP
fLy-
o ,
t BORTOLOTTI CONSTRUCTION, INC.
S� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Address Prop
Date of Inspec},7 �� 7�7 M
PART A — CHECKLIST
CHECK IF THE FOLLOWING HAVE BEEN DONE:
PUMPING INFORMATION WAS REQUESTED OF THE OWNER,OCCUPANT,AND BOARD OF HEALTH.
NONE OF THE SYSTEM COMPONENTS HAVE BEEN PUMPED FOR AT LEAST TWO WEEKS AND THE SYSTEM HAS BEEN
RECEIVING NORMAL FLOW RATES DURING THAT PERIOD. LARGE COLUMES OF WATER HAVE NOT BEEN INTRODUCED INTO
THE SYSTEM RECENTLY OR AS PART OF THIS INSPECTION.
S—BUILT PLANS HAVE BEEN OBTAINED AND EXAMINED. NOTE IF THEY ARE NOT AVAILABLE WITH N/A. u
HE FACILITYOR DWELLING WAS INSPECTED FOR SIGNS OF SEWAGE BACK—UP.
HE SITE WAS INSPECTED FOR SIGNS OF BREAKOUT.
LL SYSTEM COMPONENTS,EXCLUDING THE SAS,HAVE BEEN LOCATED ON THE SITE. /' ✓�� ���
HE SEPTIC TANK MANHOLES WERE UNCOVERED,OPENED,AND THE INTERIOR OF THE SEPTIC TANK WASi ySPEC7ED,j ® , g�
FOR CONDITION OF BAFFLES OR TEES,MATERIAL OF CONSTRUCTION,DIMENSIONS,DEPTH( �I°QUID,DEPUD9(
DEPTH OF SCUM.
THE SIZE AND LOCATION OF THE SAS ON THE SITE HAS BEEN DETERMINED BASED ON EXISTING INFORMATION OR Co
APPROXIMATED BY NON—INTRUSIVE METHODS,
C-11HE FACILITY OWNER(AND OCCUPANTS,IF DIFFERENT FROM OWNER)WERE PROVIDED WITH INFORMATION O r E PROPER
MAINTENANCE OF SSDS.
PART B — SYSTEM INFORMATION
FLOW CONDITIONS
RESIDENTIAL
No of Bedrooms /4/ No of Current Residents Garbage Grinder
Yes Laundry Connected to System 14110 Seasonal Use
NON RESIDENTIAL:
Calculated flow
WATER METER READINGS,IF AVAILABLE:
Pumping Records and Source of nformation: GALLONS
,'� e41fiVJd1e& 44 of
SYSTEM PUMPED AS PART OF INSPECTION? IF YES,VOLUME PUMPED = GALS
Reason for Pumping:
TYPE OF S STEM:
Septic tank/distribution box/soil absorption system
.MSingle Cesspool Overflow Cesspool ' Privy
Shared system (if yes,attach previous inspection records, if any)
Other(explain)
App ximate age of all components. Date installed,if known. Source of information.
SEWAGE ODORS DETECTED WHEN ARRIVING AT THE SITE? 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B - SYSTEM INFORMATION (Continued)
SEPTIC TANK:
Depth below grade/0 Dimensions: /
Material of construction: oncrete Metal FRP Other} l0
Sludge Depth Distance from top of sludge to bottom of outlet tee or baffle
Scum Thickness Distance from Top of Scum to top of outlet tee or baffle
Distance from bottom of Scum to bottom of outlet tee or baffle
C mments:
SC42
DISTRIBUTION BOX:
Comments: i e DEPTH OF LIQUID LEVEL ABOVE OUTLET INVERT
�
PUMP CHAMBER: Pum s in working order?
Comments:
SOIL ABSORPTION SYSTEM AS):
IF NOT PRESENT,EXPLAIN:
TYPE:
Zwo mSnts: Al
42
r I
CESSPOOLS: Number and configuration
Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer
Dimension of cesspool Materials of construction
Indication of groundwater inflow(cesspool must be pumped)
Comments:
PRIVY:
Materials of construction
Dimensions Depth of solids
Comments:
ISUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B — SYSTEM INFORMATION (Continued,..)
SKETCH OF SEWAGE DISPOSAL SYSTEM:
INCLUDE TIES TO AT LEAST TWO PERMANENT REFERENCES,LANDMARKS OR BENCHMARKS.
LOCATE ALL WELLS WITHIN 100'
((I SV
G�
O
DEPTH TO GROUNDWATER: DEPTH TO GROUNDWATER
METHOD OF DETERMINATION OR APPROXIMATION:
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C - FAILURE CRITERIA
/ (Indicate Y—yes N—no ND—not determined.Describe basis of determination.If"not determined",explain why not.)
Backup of Sewage into Facility?
I� Discharge or ponding of effluent to the surface of the ground or surface waters?
I
Al Static liquid level in the districution box above outlet invert?
41,4 Liquid depth in cesspool, 6"below invert or available volume, 1/2 day flow?
ARequired pumping 4 times or more in the last year? Number of times pumped
Septic tank is metal?cracked?structurally unsound?substantial infiltration?substantial exfiftration?
tank failure imminent?
Al Is any portion of the SAS,cesspool or privy, below the high groundwater elevation?
I/ Within 50 feet of a surface water?
I
Within 100 feet of a surface water supply or tributary to a surface water supply?
Within a Zone I of a public well?
AWithin 50 feet of a private water supply well?
Within 50 feet of a bordering vegetated wetland or salt marsh (cesspools&privies only, not the SAS)?
Al Less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water
quality analysis? If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria,volatile organic compounds,amonia nitrogen and nitrate nitrogen.
PART D — CERTIFICATION
INSPECTOR: ROBERT J. BORTOLOTTI ADDRESS: 765 WAKEBY ROAD, MARSTONS MILLS
iCOMPANY: BORTOLOTTI CONSTRUCTION INC. MA 02648 (508) 771-9399
t CERTIFICATION STATEMENT
I CERTIFY THAT I HAVE PERSONALLY INSPECTED THE SEWAGE DISPOSAL SYSTEM AT THIS ADDRESS AND THAT THE INFORMATION
I REPORTED IS TRUE,ACCURATE AND COMPLETE AS OF THE TIME OF INSPECTION. THE INSPECTION WAS PERFORMED AND ANY
I RECOMMENDATION REGARDING UPGRADE,MAINTENANCE AND REPAIR ARE CONSISTENT WITH MY TRAINING AND EXPERIENCE
IN THE PROPER FUNCTION AND MAINTENANCE OF ON—SITE SEWAGE DISPOSAL SYSTEMS.
CHECK ONE:
I HAVE NOT FOUND ANY INFORMATION WHICH INDICATES THAT THE SYSTEM FAILS TO ADEQUATELY PROTECT PUBLIC
HEALTH OR THE ENVIRONMENT AS DEFINED IN.310 CMF 15.303. ANY FAILURE CRITERIA NOT EVALUATED ARE AS
i STATED IN THE"FAILURE CRITERIA"SECTION OF THIS FORM.
I HAVE DETERMINED THAT THE SYSTEM FAILS TO PROTECT PUBLIC HEALTH AND THE ENVIRONMENT AS DEFINED IN
310 CMR 15,303. THE BASIS FOR THIS DETERMINATION IS PROVIDED IN THE"FAILURE CRITERIA"SECTION OF THIS
FORM.
INSPECTOR'S SIGNATURE: a14
DATE:
ORIGINAL TO SYSTEM OWNER,COPIES:BUYER(f applicable),APPROVING AUTHORITY
i0CATION SEWAGE PERMIT NO.
C_-c::)+ 0 yJ 67 151-- <6'-1:�
,Pill L LAG E
c-e�
It, INSTA LLER'S NAME ADDRESS
'mil
S U I L D E R OR OWNER
G f-e
DATE PERMIT ISSUED
DAT E COMPLIANCE ISSUED
G
�a
�Q pro
zg
2�
Casa r��
I
v
No..... 5.......... FRis..............................
THE COMMONWEALTH OF MASSACHUSETTS
---------BOARD OF HEA TH/
f...-..1 ?....._OF..��%�r�. {•--1 ..............
Appliration for Dhipaii a1 39orkii Tonitnu#ion frrmft
Application is hereby made for a Permit to Construct (�or Repair ( ) an Individual Sewage Disposal
System t
1 r
Lo.cation Add r � !'� r•Lot No.J
C 1r'.... Q 1l.. �............
O' - -------------•- ---._..� .�.tr. '
T [Owner / S Address
J_Q�} 7_�_ nst J---------------------^--•--_..._ ............................................�. ' -------------------------------------------
Type
� ]ler dress
U of Building Size Lot a-.5^ L.-Sq. feet
Dwelling—No. of Bedrooms._._____: Expansion Attic ) Garbage Grinder
pa, Other—Type of Building ____________________________ No. of persons____________________________ Showers ( ) Cafeteria ( )
p-' Other w,tu e
Design Flow____________ ___ ___________________gallons per person per day. Total daily flow........ o gallons-
WSeptic Tank=Liquid capacit UVv.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
a Percolation Test Results Performed by..__ �����CJ�._ ..�._,*.'/7 �1l.C_.e�"l ate______��.
a Test Pit No. 1 _�/S�_____.minutes per inch Depth of"Pest Pit._._ Z----- Depthground water..___�. j
rX4 Test Pit No. ?_sz�_._minutes per inch Depth of Test Pit_��_________. Depth to ground water_..!/.��.
�f --•-•••. �.
O Description of Soil---- - �� �---- `5 .............................................................................................
U ..................................� - -1 ------- ��•••••------••--•------•-•-------•--•-------••--•----••---•-------••---•-••-•----•---••-•••-•----••---------•--•-•-..----
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
W
UNature 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 iITLE 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been i saa
ed by the boa!�44 health.
g�s � -
Signe -•••--
Date
Application Approved By.......... - • -•• -••-• ••••• -••••------......................................... �_^�-5....! ..
Date
Application Disapproved for t following reasons:................................................................................................................
- -••-------•-•---•-•-------------------•--•-•-----••-----•-----•-•----------••-----•--•-•----------•--.._-----•-------------------•-••-•-••-----•_...._...---•--•----- ...............................
Date
PermitNo......................................................... Issued..............................................---------
Date
No................ .....I Flea.... . ...._
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEA TH
.......OF... ::! ---Z/_> .........................
Appliratiun for Disposal Works Tonstrur#inn rrrmit .
Application is hereby made for a' Permit to Construct ( "or Repair ( ) an Individual Sewage Disposal
System t
A
... _
p Location Addr s Lot No r
,�C-:•,jam:................ ....?... _..... °.�r ._.. _taf7.. ....4Ki l f ._. ..........---
Owner Address
-• ------•-•----•-- I -... a......._-'- # ---wire---.........
nstaller ddress �� � ��
Type of Building Size Lot..___. .:.............Sq. feet
a -10
Dwelling—No. of Bedrooms......... ............................... xpansio Attic (7e) Garbage Grinder
04 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
P 1 Other u
P e --
. -------------------•--•-------------•-----.-••---••-•---------------------------••----•-- ...
W Design Flow.._.........Q... t%....................gallons per person per day. ;Total daily flow........:..:.E.........................gallons.
WSeptic Tank—Liquid capacity . d.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 ) ye- ~.
~-' y "r. _ .i '. ! .C't�'✓" .: ate_. .. ..
a Percolation Test Results Performed b . ._.. .....
Test Pit No. 1 s�.....minutes per inch Depth of `�"'est Pit..___:_ ..�`.... Depth o�ground water...... f.
fsl Test Pit No. ..............minutes per inch Depth of Test Pit../......._,__._.. Depth to ground water.. ' .
------.....-•-....
O .....................•----•---...........................................................
Description of Soil _ �.. �r C7 ....------------
.... ........... ...........
---------------------- ----------- --�-/ -- --� -..---------------._.-----.--------••---------- ---------- --.----------------------------
Uw ......----•-------•---•-•---•------------------•----•-......----------------------••---••••••---....-•----......------------------......-----•---•.................................._........._.........
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 TITlIE 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been iced by the boar health.
Signe /l . _,_� �� `> ....... .... .
Date
Application Approved By.......... = :: ... _.........................................
Date
Application Disapproved for thk following reasons:------•...................•---.........-•--•-•----.........-••-•---•-•-••••••--...--------•-•-•---••-•-•-......
....................•--....--•--...................------•--•-----.......--•-----------------.........-----•...._.................----..........-•••-•----------...------•--------......................
Date
PermitNo........................••-••-......----••-•-•-•.._. Issued-....................................................._
-• Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD .OF HEALTH
............OF....
.................
Trrtif utttr of Tntttplianir
T IS TO CRTIFY, That the Individual Sewage Disposal System constructed ( r Repaired ( )
by....., ✓fie P r ='-ECG- ... ...... .. .........-•-----•-......_...... ................. ............
! / I staller 1 ,
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........................................ dated___.____-_.._-.................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE..........-•--•••.....�..: _...S:: 5... ....- ............. Inspector.............. . •... .....E,_. .......................... +,
THE COMMONWEALTH OF MASSACHUSETTS
BOARDHEALTHr_� y// f
A. F i.G I F^y<
No.. -.. .F=.....
.....
Disposal Works OnAknrl,inn 1rrmit
.Permission is ereby granted... ' . ............. .. .........................._....
to Constr t �or,Rep it )f an Individu Sewage Disposal System 4
at No...... . .......k 14 C,---'.I .�,.tl ._. �_ �J 1.1 s- --......................-•-----• ...............................
• 6- ..•
Street d
as shown on the application for Disposal Works Construction Permit Nog4rd Dated..?r .
............................ ;
.........................
of ealth :
DATE............ •... :
FORM 1235,e A. M. SULKIN, INC., BOSTON
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�_EksOTON9: CONTOUR -- ' -- CERTIFIED PLOT PLAN
r ;J 'fN�SNED SPOT ELEVATI ,
t,CONTO0I o r�.///3•3
'f 'I'hek Aoc,ation 'of. any*existing under :ound sewerage, --
F voliis ox athex;ut lities shown ion• this` plan. is approx- IN
mae only as dot ermined, from records_and/or verbal A ,�� at•� .\ r�
A p14 anon. Tl a contractor As :responsible for the d,11 r7e .�8•.�
of`the'.',`e.xisting locat,ions.. in- they,€field, SCALES / "= 4 b
�rt3
��x '���Q�� `�'AI(�lk19EE`/�BAP�i:��•illl ;VENT, ✓�'
7 a 1 CERTIFY THAT THE PROPOSED
R�a3ii�
, T1»�AtEQ � JA A `8-3h� I BUILDING SHOWN ON THIS PLAN
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