HomeMy WebLinkAbout0044 ARBETA ROAD - Health F
44r Arbeta.Road
Hyannis
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LOCATION UCf �r�C�� l�y SEWAGE #
VELLAGE �A�C nCst S ASSESSOR'S MAP & LOT 11
INSTALLER'S NAME&PHONE NO. "22
SEPTIC TANK CAPACITY -Jo go '6X 1� J P +� l/
LEACHING FACILITY: (type) T7A I 5s (siz x d
NO.OF BEDROOMS
BUILDER OR OWNER_�pR'..� L
PERMITDATE: &Z20 � 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) 1" Feet
Edge of Wetland and Leaching Facility (If any wetlands exist
within 300 feet of leaching facility) Feet'
Furnished by
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SEWAGE #
VILLAGE ASSE SO MAP & LO
T�AME&PHONE NO.
SEPTIC TANK CAPACITY ZQX . C
LEACHING FACILITY: (type
NO. OF BED
BUILDER OR OWNER
PERMUDATE: COMPLIANCE DATE:
Separation Distance Between the:
j Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
- I
44 Arbeta Road
Property Address
Kevin Corcoran
Owner Owner's Name -j
information is --
required for every Hyannis '� Ma. 02601 09/29/2017
page., Cityrrown State Zip Code Date of Inspection
t°
r 7`9
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important: A. General Information �� �a�a�
filling out forms
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Michael T Bisienere
use the return Name of Inspector
key.
Cape Septic Inspections
Company Name
624 Old Barnstable Road
Company Address
Mashpee Ma. 02649
Cityrrown State Zip Code
508-280-3356 S13938
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
10/01/2017
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original should be sent to the system owner and copies sent to the
buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
' at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
l5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17'rc'
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 44 Arbeta Road
Property Address
Kevin Corcoran
Owner Owner's Name
information is Hyannis Ma. 02601 09/29/2017
required for every ,
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 1 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:
This 3 bedroom home has a H-10 1000 gallon septic tank and a H-10 D-Box feeding a leaching pit
and two sets of infiltrators. At the time of the inspection the leaching pit had appx. 2 feet of ponding
water and the infiltrators were dry. At the time of the inspection this system met all of the
requirements to pass Title 5 in The Town Barnstable and the State of Ma.
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by ,
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old-is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins.doc•rev.6/16' Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
44 Arbeta Road
Property Address
Kevin Corcoran
Owner Owner's Name
information is required for every Hyannis Ma. 02601 09/29/2017
page. City(rown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not.operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N . ❑ ND (Explain below):
❑ distribution box is leveled or.replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
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
tIins,doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
44 Arbeta Road
Property Address
Kevin Corcoran
Owner Owner's Name
information is required for every Hyannis Ma. 02601 09/29/2017
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
I
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
El ® 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 '/z day flow
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
44 Arbeta Road
Property Address
Kevin Corcoran
Owner Owner's Name
information is required for every Hyannis Ma. 02601 09/29/2017
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ Z The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
44 Arbeta Road
Property Address
Kevin Corcoran
Owner Owner's Name
information is required for every Hyannis Ma. 02601 09/29/2017
page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
El ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
❑ ® Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example,.a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): < 330 GPD
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
44 Arbeta Road
Property Address
Kevin Corcoran
Owner Owner's Name
information is required for every Hyannis Ma. 02601 09/29/2017
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):-
Detail:
In 2016 16,900 gallons were used and in 2015 17,400 gallons were used
Sump pump? ❑ Yes ® No
occupied
Last date of occupancy: Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
• Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ ,No,
Water meter readings, if available:
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
44 Arbeta Road
Property Address
Kevin Corcoran
Owner Owner's Name
information is Hyannis Ma. 02601 09/29/2017
required for every
page. City(rown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool .
❑ Privy
❑ - Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
l5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
44 Arbeta Road
Property Address
Kevin Corcoran
Owner Owner's Name
information is required for every Hyannis Ma. 02601 09/29/2017
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 36"feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade: 24"feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
ra• ..
If tank is metal, list age: i
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: Standard H-10 1000 gallon septic.
tank
Sludge depth:
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17,
1 ..
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M , r 44 Arbeta Road
Property Address
Kevin Corcoran
Owner Owner's Name
information is required for every Hyannis Ma. 02601 09/29/2017
page. CityrTown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
36"
Scum thickness 3
5"
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
12"
How were dimensions determined?
Sludge Judge
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
would recommend the new owner put the tank on a maint. plan with a local septic pumping co.The
Barnstable Health Dept. has a list of local septic pumping co.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
44 Arbeta Road
Property Address
Kevin Corcoran
Owner Owner's Name
information is required for every Hyannis Ma. 02601 09/29/2017
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No -
'i
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
44 Arbeta Road
Property Address
Kevin Corcoran
Owner Owner's Name
information is required for every Hyannis Ma. 02601 09/29/2017
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
0"
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.):
The H-10 D-Box had no visible signs of leakage or evidence of past hydraulic failure.
i
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No"
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
l5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
44 Arbeta Road
Property Address
Kevin Corcoran
Owner Owner's Name
information is required for every Hyannis Ma. 02601 09/29/2017
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: one
❑ leaching chambers number:
❑ leaching galleries number:
® leaching trenches number, length: Two with
infiltrators
❑ 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.):
At the time of the inspection the leaching pit had appx. 2 feet of ponding water and the infiltrators
were dry.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
` Indication of groundwater inflow ❑ Yes ❑ No
l5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
lugTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
44 Arbeta Road
Property Address
Kevin Corcoran
Owner Owner's Name
information is required for every Hyannis Ma. 02601 09/29/2017
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
r
' f
t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
44 Arbeta Road
Property Address
Kevin Corcoran
Owner Owner's Name
information is required for every Hyannis Ma. 02601 09/29/2017
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
3 = 3� "
�F 7 0
16 '
p A
3 .7 37 � N
y = ,2
Ffr03
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
44 Arbeta Road
Property Address
Kevin Corcoran
Owner Owner's Name
information is required for every Hyannis Ma. 02601 09/29/2017
page. City(rown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: 15 plus feet
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
I augered a hole to 15 feet.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
c
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
44 Arbeta Road
Property Address
Kevin Corcoran
Owner Owner's Name
information is Hyannis Ma. 02601 09/29/2017
required for every
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems).completed
® System Information- Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
13
v
J 1-%0^ o.F S A. .
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
No. - 0 7 Fee—5]2'
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
ZIpphratfon for �Dizpoga[ bpgtem Congtrurtton 30ermtt
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 419 A bf Gt a�N 15 Owner's Name,Address and Tel.No.
Assessor's Map/Parcel )vi
— 1 ��
Installer's Name,Address,and Tel.No. 1 Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms `� Lot Size sq.ft. Garbage Grinder rIUG�
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
» ` "Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Z006 Go�L Type of S.A.S.
r
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) ��� U �" . Z.-,.'tur-,s W y F74
� a around u -t
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been is VY
Atms
ealth. �.� [36
Signed Date
Application Approved by Date I t-30-
Application Disapproved for the ollowi g reasons
Permit No. ��FO 7 Date Issued
TOWN OF BARNSTABLE C,
LOCATION ArL>if A�+ U SEWAGE #
VILLAGE ASSESSOR'S MAP & LOTLj- LIT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY JC00 (ZL I 10)( (-;h I
i LEACHING FACIL=: (type) Cam /, (siz X d
NO. OF BEDROOMS r C.;�s
BUILDER OR OWNER j'n C
PERMITDATE: / JCJ� COMPLIANCE DATE: I� J 7 C/
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 1
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) A 1 r '' Feet
Furnished by
J �� l
No. O _ ^; `.. .Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
' Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
01pplication for ;DigposW *pgtem Construction Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 4Y 9 A Owner's Name,Address and Tel.No.
Assessor'sMap/Parcel i��.,jI�\ Co(,kr'vv-
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
SLOB --t,V�
Type of Building:
Dwelling No.of Bedrooms `� Lot Size sq. ft. Garbage Grinder(A(4
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons pe'r day. Calculated daily flow ' gallons.
Plan Date Number of sheets Revision Date
_ Title ti
Size of Septic Tank Zd0a GA L Type'of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) A,,) o C1I nPe.`A rz--1CUf S W U F4
Date last inspected: _
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been is d by t is ealth.
Signed Date
Application Approved by C) Date I i - _�n.
Application Disapproved for the ollowi g reasons
Permit No. - RD'7 Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certif irate of Compliance-- -
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired (�)Upgraded
\
Abandoned( )by -<t. I�
at (J r-r G f Ocn, 2 cJ 4u c.^t,S has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. n dated
Installer sr6t+ Designer
The issuance of this permit shall not be construed as a guarantee that the system will function as designed:`
Date_ f `�— 3 - �/ Inspector `�\
dab
Fee_
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
Mf 5poza[ *pgtem Conotructton Permit
Permission is hereby granted to Construct( )Repair( )Upgrade( )Abandon( )
System located at y A r- � 2� ►�.i�„n r�t 5
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this permit.
Date: !( r> - / Approved by
7J_
1/6i99
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only. -
CER=CATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLAYS)
L �k- C`1T-C, , hereby certify that the application for disposal works
construction permit signed by me dated 1[ 13 0 concerning the
property located at J meets all of the
following criteria:
• The failed system is connected to a-residential dwelling only. There are no commercial or business
uses associated with the dwelling.
• The soil is classified as CLASS I and the percolatioin rate is less than or equal to 5 minutes per inch.
1
• There are no wetlands within 100 feet of the pro
posead septic system
• There are no private wells within 150 feet of the proposed septic system
There is no increase in flow and/or change in use proposed
F
• There are no variances requested or needed.
• The bottom of the proposed leaching facility will not be located less than,five,feet above the
ma.-durum adjusted groundwater table elevation. (Adjust the groundwater table usin"-`the Frimntor
method,when applicable] ? a
• If the S.A.S. will be located with 250 feet of ar(y vegetated wetlands, the bottom of the"prop sed
leaching facility will not be located less than fourteen (14) feet above the maximum adjusted
groundwater table elevation,
Please complete the following: t ti
A) Top of Ground Surface Elevation(using<GIS:information)
B) G.W. Elevation =the MA,`C. High G.W. Adjustment .
DIFFERENCE BETWEEN A and B
SIGN DATE: I 6IC11
(Sketch proposed plan of system on back].
q:health folder cart
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BORTOLOTTI CONSTRUCTION,INC. j t
7G5 WAKEBY ROAD, MARSTONS MILLS,MA 02(►'48 �; -3
508-771-9399 508428-8926 FAX: 508-428-9399 , ;. '� 1•y � 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION'.FURM �q
PART A
CERTIFICATION g �.
Property Address: -Q
Date of Inspection: — Inspector's me:
c
Ow►er's N e an Address:
CERTIFICATION STATEMENT*
I certify that I have personally inspected the sewage disposal system at this address and that the informa-
tion reported below is true,.accurate and complete as of the time of inspection. The inspection was per-
formed based on my training and experience in the proper function and maintenance of on-site sewage
disposal stems. The System:
Passes
Conditionally Passes
Needs Further Eva ation By the ocal Aproving Authority
Fails
Inspector's Signature: ��'`� `"� Date: G
The System Inspector shall submit a opy of this inspection report to[lie Approving authority within thir-
ty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater, the inspector and the system owner shall submit'the report to the 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.
INSPECTION SUMMARY*
A)!1�7
PASSES:
have not found any information which indicates that(he.system violates any of the failure
criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated
below.
B)SYSTEM CONDITIONALLY PASSES;
One or more system components need to be replaced or repaired. The system,upon comple-
tion of the replacement or repair, passes inspection.
Indicate yes,nor,or not determined(Y,N,OR ND). Describe basis of determination in all instances. If
"not determined",explain why not.
The septic tank is metal,cracked, structurally unsound, shows substantial infiltration or
exf ltration,or tank failure is imminent. The system will pass inspection if the existing sep-
tic tank is replaced with a conforming septic tank as approved by The Board of Health.
Sewage backkup or breakout or high static water level observed in the distribution box is due
to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. The
system will pass inspection if(with approval of The Board of Health):
-1 -
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Broken pipe(s)replaced
Obstruction is removed
Distribution Box is levelled or replaced
The System required pumping more than four times a year due to broken or obstructed pipe(s).
The system will pass inspection if(with approval of The.Board of licalth):
Broken pipe(s)are replaced
Obstruction is removed
C)FURTHER EVALUATION IS REQUIRED BY'1'H E 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 the public health, safety and the environment.
1)SYSTEM WILL PASS UNLESS BOARD OF HEALTH UE'.1'ERMINES THAT THE
SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE
PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 Feet of a surface water
Cesspool or privy is within 50 Feet of a bordering vegetated wetland or a salt marsh.
2)SYSTEM W1LL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER
SUPPLIER,IF APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTION-
ING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 Feet to a surface
water supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and is with a Zone I of a public
water supply well.
The system has a septic tank and soil absorption system and is within 50 Feet of a private
water supply well.
The system has a septic tank and soil absorption system and is less than 100 Feet but 50
Feet or more from a private water supply well,unless a well water analysis for colifortn
bacteria and volatile organic compounds indicates that the well is free from pollution from
the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm.
D)SYSTEM FAILS:
I have determined that the system violates one or more of the following failure criteria as defined
in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health
should be contacted to determine what will be necessary to correct the failure.
Backup of sewage into facility or system component due to an overloaded or clogged SAS
or cesspool.
Discharge or ponding of efluent to the surface of the ground or 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 clog-
ged SAS or cesspool.
Liquid depth in cesspool is less than G"below invert or available volume is less than 1/2
day flow.
Required pumping more than 4 times in the lass.year NOT due to clogged or obstructed
pipe(s). Number of times pumped
-2-
i`
is SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (conlinuc(l)
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 l of a public well.
Any portion of a cesspool or privy is within 50 Feel 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 colil'or►u bacteria, volatile organic
compounds,ammonia nitrogen and nitrate nitrogen.
E)LARGE SYSTEM FAILS:
The following criteria apply to a large system in addition to the criteria above:
The design flow of a system is 10,000 gpd or greater(Large System)and the system is a significant
threat to public health and safety and the environment because one or more of the following
conditions exist:
The system is within 400 Fcct 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 Il of a public water supply well.
The owner or operator of any such system shall bring the system and facility into full compliance with the
groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local
regional office of the Department for further information.
�. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CIIECKLIS'I.'
Check if the following have been done:
//Pu►riping information was requested of the owner,occupant, and Board of Health.'
l' None of the system components have been pumped for aticast 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.
As-built plans have been obtained and examined. Note if they are not available with N/A.
_pThe,facility or dwelling was inspected for signs of sewage back-up.
_ The systeni 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 site.
The septic tank manholes were uncovered,opened,and the interior of the septic tank was in-
spected for condition of banes or tees, material of construction,dimensions,depth of liquid,
depth of sludge,depth of scum.
L�The size and location of the Soil Absorption System on the site has been determined based on
existing information or approximated by non-intrusive methods.
.-3 -
N
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART R
CIIECKLIST(conlinued)
� The facility owner(and occupants, if different fromowner) were provided with information on
the proper maintenance of Subsurface Disposal Syslem
SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPEC'1I'1ON FORM
PART C
SYSTEM INFORMATION .'
FLAW CON DVFIONS
RESIDE MAI.:
Design Flow: gallons Numbcr of 13cdrooms:_a_ Nun)bcr of Current Rcsidcnts:6AeG/J-e,
Garbage Grinder: Laundry Connected To System:_ 71�S Seasonal Use: yPs
Water Meter Readings, if available-
Last
Last Date of Occupancy:�y — w CU>'7�
C'OMMERCIALLINDUSTRIALi (/
Type of Establishment: _ —
Design Flow: gallons/day Grease Trap Present: (yes or no)__
Industrial Waste Holding Tank Present:
Non-Sanitary,Waste Discharged To The Title itle V Systcn►:____..___
Water Meter Readings, If Available: Last Dale of Occupancy:
OTHER: Describe)
Last Date of Occupancy:
/2
GENER NFORMATION
PUMPING RECORDS and source of mfurmat' n: /,�
System Pumped as part of inspection:l 'lJ If cs, vo nine pumped: gallons
Reason for pumping:
TYPE YSTEM:
Septic Tank/Distribution Box/Soil Absorption System
Single Cesspool
Overflow Cesspool
Privy
Shared System(If yes, attach previous inspection records, if any)
Other(explain): _
APP OXIMATE AGE of all components,date install (i nown)and source of information:
ewage odois detected when arriving aL the site:
-4-
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART(:
GENERAL INFORMATION (continued)
SEPTIC TANK:
Depth below grade: Material of Construction: �icrete metal FRP Other
(explain) —
Dimisions: r s�X �'�'s ' Sludge llepth: Scuin Thickness:IYO�I>
Distance from top of sludge to bottom of outlet Ice or baffle: —_3
Distance from bottom of scum to bottom.of outlet tec o_r baMc: �t/n*e_
Comments: (recommendation for pumping,condition of inlet and outlet tees.or baffles,depth of li uid
level in relation t utle .invert,structural irate city vidence of leaky ,ctc.�' S / nei �GY7
Z�?/lK Cam.
�C GSA � 0/( �S Q-
f
GREASE TRAP: /V
Depth Below Grade: Material of Construction: concrete metal FRP Other
(explain) -- — — —
Dimensions: Scum Thickness:
Distance from top of scum to top of outlet tee or baffle:
Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles, depth of liquid
level in relation to outlet invert,structural integrity,evidence of leakage,etc.)
TIGHT OR HOLDING TANK:A
Depth Below Grade: Material of Construciion:_concrcic—n►ctal—FRP—Other(explain)
Dimensions: Capacity`. gallons Design.Flow; gallons/day
Alarm Level:
Comments: (condition of inlet tee,condition of alarm and float switches,etc.)
DISTRIBUTION BOX: (/, ------.-_—_.-
Depth of liquid level above outlet invert:
Comments: (not.9-if4cvel and.di tribu ion is a il, evi race of solids car over, a idence f leaky info
or out of box,et 0'�(' � �� ��0� ��
PUMP CHAMBER:
Pump is in working or r:
Comments: (note condition of pump chamber,condition of pun►ps and appurtenances, etc.)
_5
i
w
i
SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM .INFORMATION (continued)
SOIL ABSORPTION SYSTEM(SAS):
(Locate on site plan, if possible;excavation tiol required, but may be approximated by non-intrusive
methods) If not determined to be present,
Type'
Leaching pits, number:Leaching chambers, number: (_.caching galleries,nuinber:
Leaching trenches, number, length:
Leaching fields, number,dimensions:
Overflow cesspool, number:__ _
Conunenls:.(note condition of soil, signs of Hydraulic failure level of punding, condition of vegetation
i
e, � �%�: -- � �o.�� 0- -V% V�1_ ..�,
CESSPOOLS: -----------------------
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(cesspool must be pumped as part of inspection)__—___— —_
Comments: (note condition of soilk, signs of hydraulic failure, level of punding, condition of vegetation,
etc.) — — ---
PRIVY:
Materials of construction: Dimensions:__
Depth of Solids:
Comments:.(uote condition of soil, signs o_-hydraulic failure, level of punding,condition of vegetation,
etc.) — -- — — -
-G -
SUBSURI:ACK SEWAGF, DISPOSAL SYS'1'E M INSPECTION NORM
PART C
SYSTEM INFORMATION (continual)
SKETCH Or SEWAGE DISPOSAL SYSTEM:
Include ties to alleast two permanent references, landmarks or benchmarks.
Locate all wells within 100 Feel.
o
- ;T
DEPTH TO GROUNDWATER: f
Depth to groundwater:
MethM of Determination or Approxima'on: Lj //y9Q /'G9 ✓. �:°
- 7-
S:a•'
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Appliration -fur Uhipuuttl Works Tomit urtion Vrruiit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: 4V
Loc _Address or Lot No.
........0�_ ""� _._..... ... ........... - '�..... ra .. ------------_--------
Owner dd ss �
L�-1 ..T....... -••-•-----------•---•-
Installer Address
UType of Building Size Lot....e367..5�'_........Sq. feet
Dwelling No. of Bedrooms.............. ------------------------- Attic ( ) Garbage Grinder (,1VV
a Other—Type, of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtt s --------•_____________________________________••---•--------------------___--••---.._-----____-_______________._...___-••-•---•-••-•--•-•---•••-••--
w Design Flow................__._.__.__.._:__..gallons per person per day. Total daily flow.........
WSeptic Tank—Liquid capacity./.O".gallons Length---------------- Width................ Diameter................. Depth................
x Disposal Trench—No. _.._ Width..... .............. Total Length------------_----- Tota leacl area.._...__.._... sq. ft.
Seepage Pit No--------------------- Diameter_.j��.,._ Depth below inlet----f,11_C�$ al lea 1�'e�--------__sq. ft.
Z Other Distribution box ( ) Dosing tank 2, ;2
a Percolation Test Results Performed by.......................................................................... Date.......................................
Test Pit No. 1----------------minutes per inch Depth of "Pest Pit.................... Depth to ground water........................
rZ4 Test Pit No. 2----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water......................
P4 ------------•-•-•••••------•-•--------- ------•--••-•-•--•-----•-•------------------------••-----.........................................................
O Description of Soil___ . . ___.
---------- ---- -.... ..
w
U Nature of Repairs or Alterations—Answer when applicable.............................................:.................................................
----•..............................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article \I of the State Sanitary'Code—The undersigned further agrees not to place the system in
operation,until a Certificate of Compliance has been - sued by the board of heal
✓ ` Date /
Application Approved By..........
.d 7C
Date
Application Disapproved for the following reasons::......::......:.
...........................••-------•-------•-------•---•---••----•------•-----------••••-=-•--------..._._-•--------------------------•------------------•--•--•----------•------•__•--••••-------------
Date
PermitNo......................................................... Issued........................................................
I Date
• _ e
��.
o...... . -------•--. F$a..�. ...�
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
c�z✓ ------------
�/.........OF.......pp . t. }�r
A lirFation -for M o,itt1iorkseV/t"1.54`/udK1jan
Vrrmit
�� �
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
R.16 /------- , �------------------------•--•----------
/ Loc Address or Lot No.
t = 6. �.� .......- '� , a 7-'�l------------------------
Owner Akrc;K
y /'� /
••----•--•--........r-'�i�.---L.✓-..y6 �`---•--•--••-E:+�` i t F G t!7•-----------------------
Installer Ass p
UType of Building Size Lot....b7�,?i2_3__._.._.Sq. feet
Dwelling -No. of Bedrooms.............. ..........................Expansion Attic ( ) Garbage Grinder (;�0(0
pi Other--.Type of Building ____________________________ No. of persons----------------------------- Showers ( ) — Cafeteria ( )
QIOther fiat s ------------------------------------------- - - - - - - ---
W Design Flow.............____.5..0________________gallons per person per day. Total daily flow......... ......................gallons.
9 Septic Tank—Liquid capacity_W—gallons L ngth................ Width................ Diameter................ Depth................
Disposal Trench—No. .... V lidth I..._ .. .....::.:.. Total Length......... ...-_---.-.Totalleacl • area--------------------sq. ft.
Seepage Pit No..................... Diameter-.(... Depth-below inlet..../]#. al le 1 .. .............sq. ft.
z Other Distribution box ( ) Dosing tank
aPercolation Test Results Performed by.........;---------:................................. ................ .Date----------------------------------.-....
Test Pit No. 1----------------minutes per inch Depth of "Pest Pit--:'............:.__'kD epth to ground water........................
(sI Test Pit No. 2................minutes per inch Depth of Test Pit.___-___-----__-___- Depth to ground 'water............-...........
-----------------------------•-..................-•--•-----•------•---•............._.........ti....._......_........._..--•--_............_....--••••••----.
O Description of Soil_... •..... /.. ...........................................................
�-- ----------------------------•------
------------------------- -`!� n . =
x ------------------------------------------------------------------------------------------------- --- .................... ---------- ----------------------
U Nature of Repairs or Alterations—Answerrwhen applicable................................................................................................
-----•-•...........................................•----......_._......................................................................................................................................
Agreement: �(` '
The undersigned agrees to'install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been i tied by the board of healt}►. '
Signed...... ... ----•-----•----•-----------•--
/_ '...--•----- --� ............
- Date
ApplicationApproved By--------- !-. •.. •-• • -•••-•--•--••.._...•-•....-•--•--•--••...... ------------------- _.._..._...
Date
Application Disapproved for i.e'f of oft" re `..- ..../ r ------•---¢ _; --------
..............................................................
Date
PermitNo......................................................... Issued.........................................................
Date
I
- I
THE COMMONWEALTH OF MASSACHUSETTS'
BOARD OF HEALTH
..........................................OF........................ ........... .......................
(Irrtifiratr a1f 105jompliFarare
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by -•••••-•--••......-••-••-----------
Installer
at....................................................................................................................................................................................................
has been installed in accordance with the provisions of Article XI 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. ��� '= ------• .. Inspector•--.��. _�-ems.�.��' - .,._' _ ----------------------
THE COMMONWEALTH OF MASSACHUSETTS;"•-
BOARD/)OF HEALTH. .-'
7�' a_
......................................: OF ' ...•....
.
FEE_...No../.L ......
�i��o�ttt. �aTrk,� non�trazrtio,a �rrmit � �• •
Permission is hereby granted..............:...� '":_�.._' �*!!_.._�-�4..
to ConstruEy(� or Rep�a'r ( ) an ��Sewage Disposal System
atNo------------ � (N-.........` .�._--.....--•-----•---- ..........�........ ...................••----._........-•-•-----•--------......-----.....-------•--......
Street
as shown on the application for Disposal Works Construction Permit No.. �' j-- Dated............. �-'?3 ��
-----------•-•-------••-•--•-- • --/.._._
76 ...........
-Board of;Health �
DATE................................................................................
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS -
LO'Cl��"ION 5EW&C-4E PERMIT UO.
0 1.0- Is R
IMST&LLER 5 U'WE ADDRESS
BUILDERS Q &MF- QDORE SS
i - -z� - - - - - - - - - - -
Dl� E PERMIT ISSUED =a 3`
DATE COMPLI &&ICE ISSUED ; 7-'6
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