HomeMy WebLinkAbout0003 WASHINGTON BURSLEY WAY - Health 3 Wash Bursley Way
Centerville P
A 172 185
1i
c�
yv-)
,j Or
3 LN-.ArS W t AJJ OAJ sc
to pc�j C. v i ��t /o�.* a
� l �
H ecxLt-
DATE 3/16/06
PROPERTY ADDRESS 3 Washington Burs ley way
Centerville
MA 02632
On the above date, the septic system at the address above was
Inspected.
This system consists of the following:
1. 1- 1000 ga.e2on zept.ic tank.
2. 1-1000 ga ion ieach.ing pit.., j ,7 a
Based on inspection_ , I certify the following conditions: a
3.1 7hiz .ins a 7.iUe . Five .6ept.ic .3y3.teM (78Code',') ,.
4. SeRi-ie zyztem .iz .in plLopea woak.ing oadea at �--he pzeeent t.im,� 4
-;' C-
4 PO -
SIGNATURE
-/k
Name: Robert A. Paolini
Company: Joseph P. Macomber & Son Inc..
Address: P. O. Box 66
Centerville, Mass 02632
Phone: 508-775-3338 or 508-775-6412
JOSEPH P. MACOMBER & SON, INC.
Tan ks-Cesspools-Leachf lelds
Pumped &.Installed
Town Sewer Connections
P.O. Box 66 Centerville, MA 02632-0066
775-3338 775-6412 > .
COMMONWEALTH OF MASSACHUSET'TS
ExEcuTiVE OFFICE of EwmoNmENTAL AFFAIRs
DEPARTMENT of ENvIRoNMENrAL PRowcnow
TME s
OMCIAL INSPECTION FORM-NOT FOR.VOLUNTARY
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
tPAAT A
CERTIFICATION
Prop,Adapem, 3 Washington Bursley Way
Cent-Prvi 1 l Q MA '09632
Owner's Nufte: U l c t G1r R T 4S S l
Owaer'sAddre:rlk 43 not anQw ��Y4
u;;�z ol� D-4- -OZ0It1
Oate.oflnspe�: - .I' L/p.6
Nam dimpector:(please ...Robert A Paoli
CaupwyNaxnet J.P.Macomber & Son Inc.
Nhdit Addnesss Rn x- RA ♦.
Centerville MA 02632
Tef pbwNun*ee:5 0.8-7 7 5-3 3 3 8
CERTIFICATION STATEMENT
I certify that I have personally i rsp xted the sewage disposal system at this address and that the information reported
below is true,accusate 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:
XXhl�asses
Conditionafly. Passes ,
Needs Further Evaluation by the 1A)cai Apprcmnrg Authoriity
ai
Inspector's Stgamt ure: e?ZDate:
The system inspector shall submit a copy of this inspection repot to the Approving Authority(Hoard 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.,OOD
gpd or greater,the inspector and the,system owner-shall,submit the report to the appropriate regional office of the
DIR The original should be sent to the system owner and copies seam to the buyer,if applicable,and the approving
authority.
Notes and Comments
***wM report only domes condition at the tkw of inspection and wiftr the conditions of we at dot.
tirne6 This inspection does not a ddrew hww the my will pert m In the future under the same or differsut
�ese+
i
Tide 5Inspection Form' 61IN2000 page I
Page 2 of 11
OFFICIAL INSPECTION,FORM—,NOT- FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORil+ii
PART A
CERTIFICATION(continued)
Property Address: 3 :Washingtnn it 1 y Way
Centerville MA 02632
Owner: Victor. Barossi
Date of Inspection:_ 3/1 6/0 6
Inspection Summary: Check A,B,C,D or)E/ALW>AV'veemplete2all of Section:D
A. System Passes: 1a(ES
NO 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:
.S.ynfir AUAIom j*.c in nnnnon nm)7kino nnnl" rid fho ��Pitonf ti�n2
B. System Conditionally Passes:
NO One or more system components as described in the"Conditional Pass"jsection need to be.replaced.or.
repaired.The system,upon completion of the replacement or repair,as approved lay the Board of Health,will pass.
:a
Answer yes,no or not.detern ned(Y,N,ND)in:the for the following statements.If"not determined"please
explain.
NO The septic tank is metal and,aver 20 years old*or the septic tank(whether metal or not)is atructurally
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:
NO 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 br replaced
ND explain:
NO The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain: ; .
2:
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 3 Washington Burslev Way
Centeryill _ MA 02632
Owner: Vi ntnr Rarncsi
Date of Inspection: 3.11 6.1 n 6
C. Further Evaluation is Required by the Board of Health:
NO 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(i)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
n o Cesspool or privy is within 50 feet of a surface water
no 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 Sup1hier,if any)determines that the
system is functioning in a manner that protects the public health,safet y and environment:
n o 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.
n o The system has a.septic tank and SAS and the SAS is within a Zone I of a public water supply.
no The system has a septic tank and.SAS and the SAS is within 50 feet of a private water supply well.
no 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 v.iz ua i
"This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia.nitrogen and nitrate nitrogen is equal to or less than 5.ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
3
Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 3 Washington Bursley Way
Centerville MA 02632
Owner: Victor. Barossi
Date of Inspection: 3/16 0 6
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
v Discharge or ponding of effluent to the surface of the.ground or.surface waters due to an overloaded or
X clogged SAS or cesspool
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'h•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 wafer 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 aprivatelwater supply well. .
7F 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 mom.'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 101000 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
X the system is within 400 feet of a surface drinking water supply
X the system is within 200 feet of a tributary.to a surface drinking water supply
X 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
"yes"in Section D above the large system has failed.The owner or operator of any large system considered a .,.
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304,The system owner should contact the appropriate regional.office of the Department.
4
Page 5ofII
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL-SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 3 Washington Bursley Way.
Centerville MA 02632
Owner: Victor Barossi
Date of Inspection: 3/16 0 6
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 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 syste;n obtained and examined?(If they were not available note as N/A)
y
X _ Was the facility or dwelling inspected for signs of sewage back up.?5
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
OFFI:CIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE.DISPOSAL:SYSTEM.1NSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 3 Washington Bursley Way
Centerville MA 02632
Owner: Victor Barossi
Date of Inspection: 3/1 6/0 6
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330
Number of current residents: 1
Does residence have a garbage grinder(yes or no): n oo
Is laundry on a separate sewage system(yes or no):2 oo [if,yes separate inspection required]
Laundry system inspected(yes or no): n o
Seasonal use! (yes or no): a o 2 0 0 4_8 7, 0 0 0 .ga i e o n z G%D_2 3 8., 3 5
Water.meter readings,if available(last 2 years usage(gpd)):2 0 0 5=119, 0 0 0 gae i o a z G 10 D 3 2 6 0 2
Sump pump(yes or-no): a 0
Last date of occupancy: unknown
COMMERCIAL/lr4bUSTRIAL NSA
Type of estabo ont:
Design flow 6li6 ed on 310 CMR 15.203): gpd s,
Basis of desigd'flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no):_ v;
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: unknown
Was system pumped as part of the inspection(yes or no): no
If yes,volume pumped:_gallons--How was quantity pumped determined?
Reason for pumping:
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:
unknown
`k.
Were sewage odors detected when arriving at.the site(yes or no): ILO -y
6
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 3 Washington Bursley Way
Centerville MA 02632
Owner: Victor Barossi
Date of Inspection: 3./16/_0 6
BUILDING SEWER(locate on site plan)
Depth below grade: 18"
Materials of construction:_cast iron X 40 PVC_other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
aoiatz a/2/aea/t right no zignz o,e eekage.i Vented thaouuh hOuZe vent.
SEPTIC TANKq X S (locate on site.plan) 1000 ga.tPon s
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()es or no):_(attach a copy of
certificate)
'-` Dimensions$' 6"X5 ' 81IX4' 10"
Sludge depth: ... #.n a r o. .
Distance from top of sludge to bottom of outlet tee.or baffle: t a a c e
Scum thickness:no 6 cum
Distance from top of scum to top of outlet tee or baffle: no -3 cum
Distance from bottom of scum to bottom of outlet tee or baffle:no rs cu m
How were dimensions determined: m e a z a a e d
Comments(on pumping recommendations,inlet and outlet.tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
/ umP I a n k euo�y/ 7 Uprin.t inLaL R. ead-f- tops ate nLace
7nnk jA AlIzur/'uariffu .tnunr/ ,
GREASE TRAP: n 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.):
Gaea.6e t2ap not /zaezenl
7
Page 8 of 11
.OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 3 Washington Bursley Way
Centerville MA 02632
Owner: Victor Barossi
Date of Inspection: 3/1 6/0 6
TIGHT or HOLDING TANK:NO (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.):
7.ight o2 hodi,ing tanks aae not /zaezent
DISTRIBUTION BOX:NO (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.):
lD.izt2zi&ut.ion &ox .is not 121tezen.t
PUMP CHAMBER:n o (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.):
Pump nhnmPva 1A nni p17v.ton1
8
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 3 Washington Bursley Way
Centerville MA 02632
Owner: Victor Barossi
Date of Inspection: 3/1 6/0 6
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Located Zee /gage 10o
Type
X 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,
�toam to medium .sand. No
.� y 99nz o� �a.i$u2e.';;.;,.So.i.gs ate d2y.,
No gorzding., Vnyofnfinn is neZmag
CESSPOOLS:n o (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.):
ce.6b/200.L.6 ate not /22e..6en.L
PRIVY: no (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.):
PlI iV y .gib not /22ehent
9
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION,FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: •3 Washinaton Bursley .Way
Centerville MA 02632
Owner: victor BaroGsi
Date of Inspection: _/16!o r
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water feet
Please indicate(check)all methods used to determine the high ground water elevation:
•N 0 Obtained from system design plans on record-If checked,date of design plan reviewed:
u P"Observed site(abutting property/observation hole within 1 So,feet of SAS) h
n,.with.in
�Checked with local Board of Health-explain: r and
n o Checked:with local excavators,installers-(attach documentation)
®ccessedUSGSdatabase=explain /� own.��aan�sta8.�e -,mG,,u!s
.a
�-.. You must describe how you established the high ground water elevation:
11hed. : Ca pa Cod Comm.izion 1datea 7a8..2e199 itouls And Puktic &)atea SuPN.t?y
Ide.2.e head Roteet.ion aaeaZ ma Se t
Glatea aahouaeez o ice cape cod comm.ihione'
Leaching 1'
Pit 'eet
Groundwater: feet Below Bottom-of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method (�
Therefore,the.vertical.separation distance between the bottom 1
of the leaching pit and the adjusted groundwater table is
feet: J
11 ..
Page 10 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL;SYSTEM INSPECTION FORM i
PART C
SYSTEM INFORMATION(continued)
Property Address: 3 Washington Bursley Way
Centerville MA 02632
Owner: victor Barossi
Date of Inspection: - 16 n 6
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.
- i
C
10
•rn:nnr.-Ere+.-,w•,r+nr+nrrr+w►s+nn �� +wrnn`]rer..-••�;
TOWN OF BARNSTABLE 330ARD QF 1I3;A'LTII
_SUBSURFACE SFWA08 DISPOSAL SYSTEM IIISPECTION FdRH — PART D CERTIFICATION
...•rr,-.•.-,:.-.,,nw•u,-in+.nn•w,r....e+.s..+n�.nrxw war r.•a,
-TYPE OR PRINT MARLY-
P170PERTY INSPEOTED
STREET ADDRESS 3 Washington Burslev Wav Qentpgyi1 1 e ' 02632
ASSESSORS MAP, DLWK AND 'PARCE•L II
OWNER's NAME Victor Barossi'
PART' D 0ERTIFI0AT30N '
NAME 'OF 'INSPECTOR • Ro Ae et Pa.okln i
COMPANY NAME Iozaph. :P.- Nacomlea'''k Son Inc "
COMPANY ADDAR SS pox 66 ': -Cent tvi a ea Oa.6.6 026.32
Strut- Town-or city. Sta • LIP
COMPANY TELEPHONE ( 508. 1 7.5 - 3338 .FAX (' 508 JI90 f 578 .
0 ZRTTFI CATION. STATEMENT A.
I. certify that I -have persohal-IY .ins-pected.-:.this mewage 'diliposill. system at
this adJress and that. tird' information reported J- true#. a.0cUra•te•, acid
omplete as of the time .qf�inspectiony The Im9pectio.•n was per-Formed and any
recommendations regarding. upgrade., .ma-intenance,' abd repair .are• eon$is•tent
with my training and exP.erience in the proper function' and maintenance of on-
site sewage disposal systems,
.•Check one:
Systec PASSED
The inspection which -I have .•conducted has .,n•at' 'fou•nd any information .
which indicates that the system' .falls to • adequately. protect .public
health or the enviropment as defined in- .310 CMR. 15';30.3•► -Any failure
criteria Clot evaluated are as stated in the FAILURE' CRITLRIA .section o•f
this form.
System FAILED*
The inspection which I have ao'n ted 'has •found that the System fails to
protect the public health and the eny.ronm' en•t ' in a000rd•anee with Title
61 310 CMR 15 , 308 , and as- specifically noted on .PA'RT- C FAILURE
CRITERIA of this inspec'ti .form.
Inspector' $i nature Date
Yn copy of this eei7Wicat•i:ch must •be grrovi'ded 'to the .9WNSR•It BUYER
re appli•.aable) and the DPARD OV HZA TII,
* If the inspection FAIL•Ebj th'e .6wneV.ox*9' Poxator e.hall, . upgansle'•the evatem.
within one year of the date of the inspection, unless. al;'lowed ar requi;red
n h.hnrw48e as. Provided in �JO CMR 15 ,305 ,.
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTA FFAIRS
Z
DEPARTMENT OF ENVI VRO ECTION
d
� d
APR 2 $ 2�04
� W
Cl�'7M SJO VV RIV.71!'D�E
TOwH EARTH DEPT
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 3 WASHINGTON BURSLEY WAY CENTERVILLE,MA 02632 MCP k")a. �)Cr
Owner's Name: MRS.DOWLING
Owner's Address: 3 WASHINGTON BURSLEY WAY CENTERVILLE,MA 02632
Date of Inspection: 4/6/04 VIpR
Name of Inspector: (please print) JOHN GRACI,INC. PARCEL '*
Company Name: SEPTIC INSPECTIONS ,-OT
Mailing Address: P.O. BOX 2119 TEATICKET,MA.02536 - � -
Telephone Number: 508-564-6813 FAX 508-564-7270
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
_ Conditional] es
_ Needs Furth aluation by the Local Approving Authority
Fails
Inspector's Signature: Date: 4/6/04
The system inspector shall submit a opy of this inspection report to the Approving Authority(Board of Health or DEP)within
30 days of completing this inspecti . If the system is a shared system or has a design flow of 10,000 gpd or greater,the .
inspector and the system owner shal 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
SYSTEM PASSED TITLE V INSPECTION.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE
SYSTEM'S USEFUL LIFE.
****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.
Titip 5 Incnartinn Fnrm 6/1'VInnn 1
page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 3 WASHINGTON BURSLEY WAY CENTERVILLE,MA 02632
Owner: MRS.DOWLING
Date of Inspection: 4/6/04
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 which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310
CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE
SYSTEM'S USEFUL LIFE.
B. System Conditionally Passes:
_ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,
upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain.
n/a 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: n/a
n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed
pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of
Health):
_ broken pipe(s)are replaced
_ obstruction is removed
_ distribution box is leveled or replaced
ND explain: n/a
n/a The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass
inspection if(with approval of the Board of Health):
_broken pipe(s)are replaced
_obstruction is removed
ND explain: n/a
Page 3 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 3 WASHINGTON BURSLEY WAY CENTERVILLE,MA 02632
Owner: MRS.DOWLING
Date of Inspection: 4/6/04
C. Further Evaluation is Required by the Board of Health:
_ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to
protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is
not functioning in a manner which will protect public health,safety and the environment:
_ Cesspool or privy is within 50 feet of a surface water
_ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water
supply or tributary to a surface water supply.
_ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
_ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ 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 n/a
"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:
n/a
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 3 WASHINGTON BURSLEY WAY CENTERVILLE,MA 02632
Owner: MRS.DOWLING
Date of Inspection: 4/6/04
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 ''/z 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 nLa.
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
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.
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
_ X the system is within 400 feet of a surface drinking water supply
X the system is within 200 feet of a tributary to a surface drinking water supply
X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat
under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner
should contact the appropriate regional office of the Department.
4
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 3 WASHINGTON BURSLEY WAY CENTERVILLE,MA 02632
Owner: MRS.DOWLING
Date of Inspection: 4/6/04
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)]
S
Page 6 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 3 WASHINGTON BURSLEY WAY CENTERVILLE,MA 02632
Owner: MRS.DOWLING
Date of Inspection: 4/6/04
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):330
Number of current residents: 2
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): NO
Seasonal use: (yes or no): NO
Water meter readings, if available(last 2 years usage(gpd)):
Sump pump(yes or no): NO
Last date of occupancy: n/a 03
COMMERCIAL/INDUSTRIAL
Type of establishment: n/a
Design flow(based on 310 CMR 15.203): n/agpd
Basis of design flow(seats/persons/sgft,etc.): n/a
Grease trap present(yes or no): NO
Industrial waste holding tank present(yes or no): NO
Non-sanitary waste discharged to the Title 5 system(yes or no): NO
Water meter readings, if available: n/a
Last date of occupancy/use: n/a
OTHER(describe): n/a
GENERAL INFORMATION
Pumping Records
Source of information: n/a
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: n/agallons--How was quantity pumped determined?n/a
Reason for pumping: n/a
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): n/a
Approximate age of all components,date installed(if known)and source of information:
1976 PER PERMIT#76-580
Were sewage odors detected when arriving at the site(yes or no): NO
F
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 3 WASHINGTON BURSLEY WAY CENTERVILLE,MA 02632
Owner: MRS.DOWLING
Date of Inspection: 4/6/04
BUILDING SEWER(locate on site plan)
Depth below grade: 22"
Materials of construction:_cast iron _40 PVC Xother(explain): 20 PVC
Distance from private water supply well or suction line: n/a
Comments(on condition of joints,venting,evidence of leakage,etc.):
TOWN WATER
SEPTIC TANK: X(locate on site plan)
Depth below grade: 16"
Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a
If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy,of certificate)
Dimensions: L 8' 6" H 5' 7" W 4' 10""
Sludge depth: 1"
Distance from top of sludge to bottom of outlet tee or baffle: 33"
Scum thickness: 0"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: 18"
How were dimensions determined: MEASURED
Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.):
SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.
RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE.
GREASE TRAP:_(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
Date of last pumping: n/a
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.):
n/a
7
Page 8 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 3 WASHINGTON BURSLEY WAY CENTERVILLE,MA 02632
Owner: MRS.DOWLING
Date of Inspection: 4/6/04
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Capacity: n/a gallons
Design Flow: n/a gallons/day
Alarm present(yes or no): N/A
Alarm level: N/A Alarm in working order(yes or no): NO
Date of last pumping: n/a
Comments(condition of alarm and float switches,etc.):
n/a
DISTRIBUTION BOX:_(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: n/a
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into
or out of box,etc.):
n/a
PUMP CHAMBER:_(locate on site plan)
Pumps in working order(yes or no): NO
Alarms in working order(yes or no):NO
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
n/a
R
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 3 WASHINGTON BURSLEY WAY CENTERVILLE,MA 02632
Owner: MRS.DOWLING
Date of Inspection: 4/6/04
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
n/a
Type
1000 GAL 6'X 6' leaching pits, number: 1
n/a leaching chambers, number: n/a
n/a leaching galleries, number: n/a
n/a leaching trenches, number, length: n/a
n/a leaching fields, number: n/a
n/a overflow cesspool, number: n/a
n/a innovative/alternative system
Type/name of technology: n/a
Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.):
LEACH PIT IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. SYSTEM SHOWS NO SIGNS OF
FAILURE.PIT HAD I' OF LIQUID IN IT AT TIME OF INSPECTION.STAIN LINES INDICATE PIT HAS
NEVER HAD MORE THAN P OF LIQUID IN IT.BOTTOM IS AT 8 FT.
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: n/a
Depth—top of liquid to inlet invert: n/a
Depth of solids layer: n/a
Depth of scum layer: n/a
Dimensions of cesspool: n/a
Materials of construction: n/a
Indication of groundwater inflow(yes or no): NO
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.):
n/a
PRIVY: (locate on site plan)
Materials of construction: n/a
Dimensions: n/a
Depth of solids: n/a
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a
q
v
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 3 WASHINGTON BURSLEY WAY CENTERVILLE,MA 02632
Owner: MRS.DOWLING
Date of Inspection: 4/6/04
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.•L,ocate where public water supply enters the building.
W
p
J �
in
iPage 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 3 WASHINGTON BURSLEY WAY CENTERVILLE,MA 02632
Owner: MRS.DOWLING
Date of Inspection: 4/6/04
SITE EXAM
_Slope
_Surface water
_Check cellar
Shallow wells
Estimated depth to ground water 12 feet
Please indicate(check)all methods used to determine the high ground water elevation:
NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a
YES Observed site(abutting property/observation hole within 150 feet of SAS)
NO Checked with local Board of Health-explain: n/a
NO Checked with local excavators, installers-(attach documentation)
NO Accessed USGS database-explain: n/a
You must describe how you established the high ground water elevation:
HAND AUGER- 12 FT.
tt
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEA' T"
Application is hereby*made for a Permit to Construct or Repair an Individual Sewage Disposal
System at:
Y -"_ .............................................................
Location-,&
owner Address
ot
installer Address
Z Other Distribution box Dosing tank
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code— The undersigneTfurther agrees not to place the system in
ope�ration until a Certificate of Compliance has been * ue by the board offhealth.
Date
71 Date
Date
PermitNo......................................................... Ioeoe6_—_------.--_-_--_-__
. Date
No........................ Flu?.....1.6...............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD, OF HEALTH
............OF......... .............................................
Appliralion -for Bri-qvniiat Works Toastrnrlion 13muft
Application is hereby:made for a Permit to Construct or Repair an Individual Sewage Disposal
System at: ff
.................................................................................................. ;-------------------------------------------------------------------------------------------------
dd 1�ocation-Aress il No.
� r V
..........7.1........................;7............................................................ ..................................................................................................
Owner_- Address
.................................................................................................. ................. .........................=....................... .............................
Installer Address
<11 Type of Building Size Lot_./-_c.,.... .....Sq. feet
L)
Dwelling—No. of Bedrooms..-------�.?............._.:.._..._.Expansion Attic Garbage Grinder
pa Other—Type of Building ------------------_:...... No. of persons------ --------------------- Showers Cafeteria
44 Other fixtures ---------- -------------------------------------------- ............................................... ----------------------------------------------
Design Flow---------------- •--------•----.gallons per person per.day. Total daily flow------------------------------------_,.....gallons.
T, ��gallons Length---------•...... Width................ Diameter._.._._..__....- Depth................
P4 Septic Tank capacity 6
Disposal Trench—No- --------- --- width_---.._.....__.._. Total Length....._.............. Total leaching area..... ..............sq. ft.
Seepage Pit Depth-below inlet...... ---- Total leaching area.------ ----sq. f t.
Other Distribution box D' 'J"14- / '4—27, 76.
osingtank (. ) -
Percolation Test Results Performed by------- ------------------------------------------------------------------- Date........................................
Test Pit No. 1.----------------minutes per inch Depth of Test Pit.__.-._---.--.-.-... Depth to ground water.__._...__....--........
Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........_.._......-___....... ..9 ......;--. /. i.... ...... . ...4�f"- .........
------ -----
Description of Soil-------- 40 _4_
------------------------ ---------
......................---------------------
...................... ......------------------------------------------------------------------------------------------------------------------------------------------------------------------
U Nature.ofRepairs or Alterations—Answer when applicable......... ............ -------------------------- ----------------- ---------------------
-------------------- .........................................------------------------------------------------ ------------------------------------------------------- ----------------------=------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code— The undersigned(further agrees not to place the system ill
* J
operation until a Certificate of Compliance has been issued.by the board of health.
igne).
.7....... ........................................................... --------------------------------
Date
Application Approved By.
L4_MT i 7Z--------
lvt------------------ ------ Date
Application Disapproved for the following reasons:---------- ............... -------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------7-------------
Date
PermitNo.-_.... ............................ Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
. .......... ..........
.............OF....... ............
%L11rdifiratr of TIontVIiaurr
THIS-IS T610ERiPIFY, That the Individual Sewage Disposal System constructed or Repaired
T,
by cf ..................------------------------------------------------------ ------------------------------------------------------------------------------------------
I' Installer
at-. ............
---------------- --------------- --------------------------------------------------------- ......
has been installed in accordance with the provision/of Article X1 of The State Sanitary Code as described in the
'application for Disposal Works Construction Permit No--...-- -------------------6-------------- dated......../-/--------- ..............
THE ISSUANCE OF THIS CERTIOI.CATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE-,
.SYSTEM WILL FUNCTION SATISFACTORY A.
DATE--- .......... ...... Yn t------------------------------------ --------- ..... . .,,.,nspec or------------7---- ------- ................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
-M. ......... C) . . .......................F-- ----
No.......... FEE-----......--------
t.
Permission i-s granted -------6.21 /11. -------
togrant ----------- ------- ------- ------- -------------------------
to Construc A or Repair an IndividtyJ Sewage Disposal System,
at .......... ............------ .............-------- ...................... ---------- -----------
f
Street
as shown on the application for Disposal Works Construction Permit No Dated_/f--------- ------- ..................
--- ----- ---
......... .. .. .................................. .........................
V Board of Health
DATE... - -
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
r
i
7.1
5oj41
dJ 96
e
k 0
m
} 1N
1 �-UPo�''� S6t,v�Rl�loA
1- 1000 Vic.. 56;mc. TnNK ��
{ - I ooCU C.�L. L.GAa.1 PiT ''LD,�L-Z.� S F .
wiria too°,o exPAOjlo4 ,
� t1i
1 �
�L
I
�L Ut:..�T•�v�.t �E�i'�ZV I t..l...� 1
i G` -k•T 1 t: / ;E-i A-r T l-1 t
e E `t�:t{c�. : f :a v': : �v', .t.T-5 vcz r F:t^ oT qq PC. B I<. 306 P6 74
THI1 , SJLAQ 1,-. "10r E'„to;t 'G 0ti-j 4%W U:,TE—r—\./lLLL'- Vt/>i`i
.F.,�!`j,., t+ 4_l,"1' r'ii:�l�:f � 7F-;C.. c� C_F �;E.'t'•> ��•n( ' '.. Y'�4�L...I G:�'�.��.lT
r TOWN OF BARNSTABLE
LOC4T.ON GJ S WAGE #
VII I.AGE ASSESSO ' MAP & LOT 7.7
INSTALLER'S NAME&PHONE NO. rT `
SEPTIC TANK CAPACITY �pD
LEACHING FACILITY: (type) laoo (size)
NO.OF BEDROOMS _
BUILDER OR OWNER 0 5
PERMTTDATE: — COMPLIANCE DATE: /L 0
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 Feet
13
lj3'Nu _
o°l$�
,1
t4a'sitn
C
I
ry TOWN OF BARNSTABLE
LOCATION , i SEWAGE #
VILLAGE ASSESSOR'S MAP & LOT rKNS.
INSTALLER'S NAME&PHONE NO.
SIEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS
BUILDER OR 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 y l��
�hh� e
vv
gbh �b' Flo
°'fill
r
L.,O, �10 W P R M T NO.
CAT SE AGE E
V-I.L L A GG E
L]24�62
i�-y�fly
INSTALLER'S NA: E & ADDRESS
1 -
B U I'L D E R OR OWNER
V
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED
',
�:
��C
r
��
;�