HomeMy WebLinkAbout0022 JANICE LANE - Health 22 Janice Lane
Hyannis
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Commonwealth of Massachusetts
Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
,M 22 Janice Ln �p
Property Address fV
Ed Dewsnap y
Owner Owner's Name
information is
required for every Hyannis ` MA 02601 3-4-16
page. City/Town State Zip Code Date of Inspection ►y
Inspection results must be submitted on this form. Inspection forms may not be altered in anya
way. Please see completeness checklist at the end of the form.
A. General Information
1. Inspector:
Shawn Mcelroy
Name of Inspector
Upper Cape Septic Services
Company Name
P.O. Box 73
Company Address
E. Falmouth MA 02536
City/Town State Zip Code
1-508-495-0905 S 13971
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
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 is a shared system or
has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
System is in good working order with no sign of failure. Property is scheduled to be connected to town
sewer at some point in the future.
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17
OL�
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
22 Janice Ln
Property Address
Ed Dewsnap
Owner.
Owner's Name
information is H annis MA 02601 3-4-16
requited for every y
page,,,-, City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR-15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
System is in good working order with no sign of failure.
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-3113 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
22 Janice Ln
Property Address
Ed Dewsnap
Owner Owner's Name
information is Hyannis ! MA 02601 3-4-16
required for every H y -
page. City/Town 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 staticwater 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):
❑ br'oken 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
's ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5i6s-3/13' 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
22 Janice Ln
Property Address
Ed Dewsnap
Owner Owner's Name
information is required for every Hyannis MA 02601 3-4-16
page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment: . .
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
Supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ ,® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y2 day flow
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts s"
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
GM s.•�'' 22 Janice Ln
Property Address
Ed Dewsnap
Owner Owner's Name
information is Hyannis MA 02601 3-4-16 ,
required for every H y
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes' No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion•of the SAS, cesspool or privy is below high ground water elevation.
El ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® . Any portion of a cesspool or privy is within a Zone 1 of.a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® 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.]
❑, ® 7 The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
ET ® 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
s 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 ll'of a public water supply'well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under. Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
GM 22 Janice Ln
Property Address
Ed Dewsnap
Owner Owner's Name
information is required for every Hyannis MA 02601 3-4-16
page. City/Town state Zip Code Date of Inspection
C. Checklist 4 - -
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): 4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
}
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments -
` 22 Janice Ln
Property Address
Ed Dewsnap
Owner Owner's Name
information is required for every Hyannis MA 02601 3-4-16
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
Sump pump?. + ❑ Yes ® No
Last date of occupancy: ,E 2016
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gauons per day(gpd)
f Basis of,design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? F ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts ,
Title 5 Official Inspection form
Subsurface Sewage Disposal System Form-Not for Voluntary,Assessments
22 Janice Ln
Property Address
Ed Dewsna
p
Owner
Owner's Name
information is required for every Hyannis MA 02601 3-4-16 "
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: N/A
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
r
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract (to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under-contract .
❑ Tight tank.Attach a copy of the DEP approval. '
❑ Other(describe):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 117
Commonwealth of Massachusetts '
W Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments '
wM 22 Janice Ln
Property Address
Ed Dewsnap
Owner Owner's Name
information is Hyannis MA 02601 3-4-16
required for every y
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:
2003
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan): .
Depth below grade: • 24"feet
Material of construction:
❑ cast iron 040 PVC ❑ other(explain):
Distance from private water supply well or suction line:
feet
Comments (on condition of joints, venting,evidence of leakage, etc.):
Good condition.
Septic Tank(locate on site plan):
Depth below grade: 16"feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1500 gal
12"
Sludge depth:
t5ins•3/13 Titre 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
\ ..
Commonwealth of Massachusetts {
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
22.Janice Ln
Property Address
Ed Dewsnap
Owner Owner's Name
information is required for every Hyannis MA 02601 3-4-16
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
20"
2"
Scum thickness
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
14"
How were dimensions determined? Tape
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank is in good condition with baffles installed and no sign of leakage.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 22 Janice Ln '
Property Address
Ed Dewsnap
Owner Owner's Name
information is required for every Hyannis MA 02601 3-4-16
page. City/Town State Zip Code Date of Inspection
D.-System Information (cunt.)
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 1
Alarm level: Alarm in worldng order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3113 Title 5 Official Inspecbon Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
w u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
wM 22 Janice Ln
Property Address
Ed Dewsnap
Owner Owner's Name
information is required for every Hyannis MA 02601 3-4-16
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Good condition with water at working level and no sign of back-up from field.
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.):
Tested and found to be in good working order.
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•3113 Tide 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
M 22 Janice Ln
Property Address
Ed Dewsnap
Owner Owner's Name
information is Hyannis MA 02601 3-4-16'
required for every y '
page. City/Town State Zip Code Date of Inspection ,
D. System Information (cont.)
Type.
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
® leaching fields number, dimensions: 1-25x25
❑ overflow cesspool number.
❑ innovative/alternative system
Type/name of technology:
L Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leach field in good working order with no sign of back-up into d-box or surrounding stone.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•3113 Title 5 Official Inspection form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts -
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 22 Janice Ln
Property Address
Ed Dewsnap
Owner Owner's Name
information is required for every Hyannis MA 02601 3-4-16
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official. Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments%
M 22 Janice Ln
Property Address
Ed Dewsnap
Owner Owner's Name
information is required for every Hyannis MA 02601 3-4-16
page. City/Town _ State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building.Check one of the boxes below:
® hand-sketch in the area below
El drawing attached separately
6 0 0
� - r
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form'
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
22 Janice Ln
Property Address
Ed
Dewsna
P
Owner Owner's Name
information is required for every Hyannis MA 02601 3-4-16
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 10,
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:
Original design plans show groundwater at 10'.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 22 Janice Ln
Property Address
Ed Dewsnap
Owner Owner's Name
information is required for every Hyannis MA 02601 3-4-16
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary:A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins-W3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
COMMONWEALTH OF MASSACHUSETTS
i�
EXECUTIVE OFFICE OF EN"vTRONmENT_A�L=AFFAIRS
' d DEPARTMENT OF ENVIRONMENTAL PROTECTION
F�
o,N SV Y
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: o vr'ce Z e- -0f
cviH's
Owner's Name:
Owner's Address: (, tqu� G�
r s
Asti � ,¢ oar�� � �q � ; •'-
Date of Inspection:
Name of Inspector1pleasg print)
Company Name: O--- Q7
Mailing Address: O 16,
Telephone Number: SO ^I =��jcctf
5
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 15340 of Title 5(310 CMR e disposal
The system:
c Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature- - ._ Date:_?7
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000
gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable.and the approving
authority.
Notes and Comments
****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.
Title 5 Inspection Form 611 512000
page 1
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUT TARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM N- -SPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: C�°Z �1-0 N t CQ Gi(/
cc��av�y��f /f�.F} Ord-601
Owner: s l p fo V-
Date of Insp cti in: 3
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. Syst Passes:
I have not found any information which indicates that any of the failure criteria described in 310 C'NZR
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below:
Comments:
B.. System Conditionally Passes:
/C(Z 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.
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 exfiitration or tank failure is imminent.System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level_in the.. distribution box due to broken or
obstructed pipe(s) or due to a broken,settled or uneven distribution box. System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is Ieveled or replaced
ND explain:
The system required pumping more than 4 times a year dune system ,ill
pass inspection if(with approval of the Board of Health): e to broken or obstructed pipe(s). T
broken pipe(s)are replaced
obstruction is removed
ND explain:
Title-G inanortinn
2
Page.3 of 11
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SLTBSLTRFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: J G ki t ce L/
Owner:
Date of Inspection: S 3/ O
C. Further Evaluation is Required by the Board of Health:
/V 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 C_�M 15303(l)(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
"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:
Taco nrm 9n v�nnn 3
: Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSvIENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: C�C�- JGnr!
Owner: ems,
Date of Inspection: ?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/
_ Hackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
�/ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
ogged SAS or cesspool
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
_ "esspool "
squid depth in cesspool is less than 6"below invert or available volume is less than'/2 day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
-,,,-Of times pumped
rAny 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 56 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.]
(Yes/No) The system fails.I have determined that one or more of the above failure criteria exist as
described in 310 Cif 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)
Ays 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-TWTPA)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 Cl1P 15.304. The system owner should contact the appropriate regional office of the Department.
4
r
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNT-ARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
l CHECKLIST
Property Address: �oC G✓llc-e L�
Owner•
Date of Inspection: S
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes o
Pumping information was provided by the owner,occupant,or Board of Health
Were any of the system components pumped out in the previous two weeks?
✓ — Has the system received normal flows in the previous two week period?
Have large volumes of water been introduced to the system recently or as part of this inspection?
Were as built plans of the system obtained and examined?(If they were not available note as N/A)
TWas 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,AS,located on site .
_ Were the septic tank manholes uncovered opened,and the interior of the tank inspected for the condition
of the b foes or tees, material of construction,dimensions, depth of liquid,depth of sludge and depth of.scum?
Was the f `acility 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 determinedbased on:.
Ye�no
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 CMI R 15.302(3)(b))
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 6Lc)_41
Owner:
Date of Inspection:
RESIDENTUI, FLOW CONDITIONS
Number of bedrooms(design): Number of bedrooms(actual): `/
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x of bedrooms): 7 z{o
Number of current residents: -7
Does residence have a garbage grinder(yes or no):/V0
Is laundry on a separate sewage systemSyes or no :
Laundry system inspected(yes or no):/V O ) (if yes separate inspection required)
Seasonal use: (yes or no):,"
Water meter readings, if available(Iast 2 years usage(gpd)):
Sump pump(yes or no): &0
Last date of occupancy: (I/if"�
C O MM ERC LAL/IND US TRIAL
Type of establishment:
Design flow(based on 310 CIMR 15.203): gpd
Basis of design flow(seats/persons/sgfft etc.):
Grease trap present(yes or no):_
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: C2 005— p L✓vr.P,�
Was system pumped as part of the inspection(yes or no):y0
If yes, volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
TYP"1i 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 b
obtained from system owner) e
—Tight tank _Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if know)and source of information:
00.3 o!� G�,o 02 oo-7- 6a�
Were sewage odors detected when arriving at the site(yes or no):/�D
- Titia G In cnartinn �n rTn�i/I4/7nM
6
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUTNT_ARY ASSESSMENITS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORIAI
PART C
SYSTEM INFORMATION(continued)
Property Address: GIA/( /—/r/
Cit�dlr iJt OVIC0
Owner: �Gi Sr' V.
Date of Inspection:
BUILDING SEWER(locate on site plan)
Depth below grade: o�6
Materials of construction:_cast iron 40 PVC_other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK:-(` locate on site plan)
Depth below grade:
Material of construction: .concrete_metal—fiberglass_polyethylene
—other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions: xy
Sludge depth: 02
Distance from top of sludge to bottom of outlet tee or baffle: 3�
Scum thickness: ,s1
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or bale:
How were dimensions determined: t'o/e Rer5 �I ce
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as�lated to outlet invert,evidence of leakag ,etc.):
110/
/ Grn r h 7`_'
4,
GREASE-TRAP:�Iocate 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.):
1
7
Page 8 of i l
OFFICIAL INSPECTION FORM—NOT FOR VOLL`V TARP ASS SSE-SS I S
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 0��
4,�Hdt�t /Iil�� Od-6-O/
Owner:Date of of Inspection:
TIGHT or HOLDING TANK:/V(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.):
DISTRIBUT Z(if
ION BOX. present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: 00/r/"4 L
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of
leakage F* to or out of b x, etc.):
/�S O J(
PUMP CHAMBER: Z (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or
Comments(note condition of pump chambei condition bfP...__ s andaPP urfenances,etc.):
AP
8
Page 9 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C ,
SYSTEM INFORMATION(continued)
1 �
Property Address: o� o ✓1/Ce- G-4
Owner: cl'Sl
Date of Inspection: fa fa
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits, number:_
leaching chambers,number:
leaching galleries, number:
hing trenches,number, length:
leaching fields,number, dimensions: oZ X .2 Z
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.): /
✓ O`
CESSPOOLS: cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil, signs ofhydraulic failure, IeveI ofponding,condition ofvegetation,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
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: p2cZ ,TGi n lc e.- Z-41"
Owner: Dc4f,' �i�
N' Doi-GO/
Date of Inspection: 3 ��
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 buflding.
Z.
A3 _ a 91 L
/Sd y .
r
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLL'NT_44,RY ASSESSMENTS
.SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: o2,) G
Owner:
Date of Inspection: �j Q
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:
Obtaine from system design plans on record-If checked,date of design plan reviewed:
O rved site(abutting property/observation hole within 150 feet of SAS)
hecked with local Board of Health-explain: %olc, v,
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe ow you established the�jh ound w ter elevation):
D
4i7 ci,)nnn 11
r.
TOWN OF BARNSTAI
LOCATION •`� 2 t/ 1hic!^ ��'�� SEWAGE # 201
VILLAGE ASSESSOR'S MAP & LOT-12T-�
INSTALLER'S NAME,&PHONE NO.'Sa S y24
i SEPTIC TANK CAPACITY ..vim
S.X 2'
LEACHING FACILITY: (type) � ��/ (size)
NO.OF BEDROOMS rr��
EUILDER OR OWNER
PERMITDATE: IQ-17-OS COMPLIANCE DATE: LZ-If -D 3
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 Feet
on site or within 200 feet of leaching facility)
Edge of Wetland and Leaching Facility (If any wetlands exist Feet
within 300 feet of leac 'ng facility)
Furnished by
G
I.
II .
s`
''$
J
� o
7NO.
4� TOWN OF BARNSTABLE
TION `� �/ `rlcl- L�9VT" SEWAGE # 20�3 -G22
GE flGll4y/�'J/S ASSESSOR'S MAP & LOT 4 — 7
LLER'S NAME]&PHONE NO. f0 -y2D/—�1738
C TANK CAPACITY, 0d Rv
HING FACILITY: (type) (size) g X
F BEDROOMS �f
i7UILDER OR OWNER 5'
PERMITDATE: 'COMPLIANCE DATE: /% —0 3
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet--. p
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 leac 'ng facility) Feet
Furnished by
ALA y� u
o
v
v
vo
n
o?
No. U fr Fee 5
r ,
THE COMMONWEALTH OF MASSACHUSETTS' Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
01pplication for Miopooal bpotem Construction Permit
Application for a Permit to Construct pair( )Upgrade( )Abandon( ) 0 Complete System Individual Components
Location Address or Lot No.A Z Owner's Name,Address and Tel.No.
o��Ps ii&rTob,5 y
Assessor's Map/Parcel y
Installer's Name,Address,and Tel.No.S,og' zl X a—C/'138" Designer's Name,Address�`d Tel.No.
,1os_epn1 0 l3,ezd�� /� I
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
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 Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) O
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 issued by thi5 Boargd of H alth.
Signed Date
Application Approved by - Date I a
Application Disapproved for a following reasons
Permit No. 266 3 Date Issued b 3
No. Fee
THEICOMMONWEALTH OF.MASSACHl3ShT7S Entered in computer: ✓ t/
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS , Yes
Zfppricattou for Otoogar *pztem Conztructiou Permit `
Application for a Permit to Construct( air( .)Upgrade( )Abandon( ) ❑Complete System O Individual Components
Location Address or Lot No.,�2 L� Owner's Name,Address and Tel.No.
Assessor's Map/Parcely'`��l/!iS �03���i
307-� 2 7 5
Installer's Name,Address,and Tel.No. I/ Designer's Name,Address d Tel.No.
Josr/�ti U-� 13,�``vs � (,.�a•9 Yc -V/C/-5
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
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 Type of S.A.S.
Description of Soil,
Nature of Repairs or Alterations(Answer when applicable) T % DD6AgVl
go X
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 issued by this Board of Health.
Signed �r i�#/L�rL Date
Application Approved by _ P�, I s-- Date /
Application Disapproved for the following reasons
1
Permit No. Date Issued / !, 0 3
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of (Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( <-)-Repaired( )Upgraded{ )
Abandoned( )by. As,, vu5
at i i has been constructe in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. U o -ti�� dated I �/7 U
Installer � �- v`, r� 4 Designer
The issuance of thiss permit shall not be construed as a guarantee that the Sys • will function' " esigne
Date �-1 rn-Z Inspector Aj 1 S
— --l�D - 6 -----.——-----.-- —.----------- — -
Fee —
_S
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
D gpogar 6pgtem Con5tructton Permit
Permission is hereby granted to Construct( >Repatr�" ('j Upgrade( )Abandon( )
System located at 4 2
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:Cons • ction.must be completed within three years of the date of d6s'pernut.
Date: ( Z') Approved• b �L
PP Y
TU
CAMAN 4C L' L c� .: SEWA�G R'.
L'ACs �!�—�-----
5TR .l. 'S NAB 1i�&?It3IdE I�[0
spli Ica' NK(:� �-
er5 x
,. „..._ ( sae)
PISF.MPTP�AdTE
aep etotr fi�asttanac;Between tX�e
Maxisnuml d'JtWd ;qt! ciwa6t;Tableld dj6 96ttogt Ldoching Pocility.
� 1va4c W tuj;Saplal Ulaal as cu(�e�rfi ng ac Uty W 01y Rio- cxlst
an.e�tu ar v�i�tktin Atf feet a�laaoEu�t Cctci)itY) ._.;. . col
pctg�s cy�"�'Vet�ant1 aalctLGnclttt}tt�apt�tty(�'�riy wetlanci5 ext&4
iyiQ..{�9ia._3�O duet., t�4aa�ung keI
but aihad by `� C
Nf� m o n
tl�l
® o
tz�
S �
• � ' TOWN OF BAYNSTABLE
LGCATION o0%a 0,0 ti te W SEWAGE #33-3 / 8 _
VILLAGE �� e. AIS SESSOR'S "MAP &
INSTALLER'S NAME & PHONE NO."fo �I�fic_Kl. ��
SEPTIC TANK CAPACITY_,o0
LEACHING FACILITY:(type) �bW �:VtK tg-5 (size) 'y-�g
NO. OF BEDROOMS PRIVATE WELL O1? PUBLIC WATER
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED: / I q'o T _.
VARIANCE GRANTED: Yes No ✓_
t
36-7
No. --..����
THE COMMONWEALTH OF MASSACHU TTS
BOAR H EALT
a _
------. --...� :+�.a.------..OF.............. .........-..
Appliration for Uigpusal Works Tomitrnrtinn lirrutit
Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal
System at:
.................. ........................
1 cation yAddress Lot No.S;L i
1 �Q
.lea=�. ........ -o...... ----------. .. - ;
1 Own Address
.......................................vV � 1�`..-i-•-•-'-_�?o ......•..•........._......... ....... .............r�•
Installer Address
UType of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............_............... Showers ( ) — Cafeteria ( )
Otherfixtures --------------------------------------------•------------•--...-•--•----••--•-------------•--••-•----•...•-•-----••---•---•-•-.....-••-••----•-----
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth........._......
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water-___-----_--_-_-_______-
fi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-------_................
--- -------- - --------
O Description of Soil................
x
---------- - - ------------- --------------------- .. --. . ----- ------. �1
Nature of Repairs terations er w pp] ._._ `�' ' \
U P PP - -------------- ...Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of'TILE 5 of the State Sanit ode— The undersigned further rees not to place the system in
operation until a Certificate of Compliance ha be issue by the and of ealth.
--
I
Application Approved B ................................. +� Hate
PP PP Y I ct
Date
Application Disapproved for the following reasons-----------------------••------------•-------•---------------•---------------•-------------------••••--.....-----
...........•------•--------•--•-•------•-....---•-•-•----•----•--•-••-•--.....•--•-------------•••-•---....•••-•-•---•-----•-----•--------•-•------•--------••----•------••-----•----••----••---•-------.
— -—�� Date
t
Permit No.. � �� Issued -------- ------------------
Dste
No..-.,.................
THE COMMONWEALTH OF MASSACHU TTS
BOAR H SALT '
............... ......0 't` ............. ---- ----------- --------
ApplirFa#ion for Diupuual Workii Towitrur#ion Prrmit
Application is hereby made for a Permit to Construct ( ) or Repair r an Individual Sewage Disposal
System at:
........:...:....... ..................••-••--..... .-�----------
_", ation Address or Lot No.
-V
Own Address
Installer Address
QType of Building Size Lot----------------------------Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( }
04 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Pa Other fixtures -------------------------------- .
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
9 Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
W Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
. x
Seepage Pit No-_----------------- Diameter_______--___.___.-__ Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by..-....................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water-._________-_-_--__-___.
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-_._-______-____.._____-
x ------ -
Descriptionor Soil..................'Y'N =-------.`.---...--•--.......-•------•-----------------------------------------------------------------------....----•----- ----
V ----•--•••-------••---•-----••---•---•---•---•---•--•-•---•------------------------••---...-----•---------•-----------•--•-------•._.._......------............................................
W
--------------------------------------------
UNature of Repairs Alterations�r w pplicable....- - --- ---- - ---- ------------ {
5 �
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of IT TIE
-,�..y: of the State Stitrbe&Al.
ode— The undersigned furti:er agrees not to place the system in
operation until a Certificate of Complianceissued by the oard of ealth,
. ned ...........................
Date
Application Approved B i............................................................ .:`� ..�
Date
Application Disapproved for the following reasons:-------•----------------------------------------------------•------------------•-------------------------------
.....................................••------•-•...--••------------------......_..•-•-•-•-----.......----•--------------•---•......-----•-----•-•-•--•-•-•-•-----•-•-•----•----•---------•-----•-------
Date
111�-�
Permit No. - :......_... .........-_. Issued. ---•------------------------IS --------------------
THE COMMONWEALTH OF MASSACHUS TTS
ti
. -�-, BOARD OF HEALTH
t 0 w _ y v� �
...................................O F.......... .................................................._._..............
(In ifiratr of TompliFaure
THIS IS-4TO CERTIFY, That the Individual S,ewage Disposal System constructed ( ) or Repaired (�
by------------------ -----------` ' �_` a c�- = �� .............----.........----..............-----.....------...........---•--
P1, Installer
has been installed in accordance with the provisions of TIT i E 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.__LL's" _ =__.__.._.. .?_ �-- dated p/_ `:I ......................•.....
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. ��
DATE..........................�-.` u v Inspector -------------- }
THE COMMONWEALTH OF MASSACH USl
BOARD OF HEALT
� .h- .O F..... ..ice•t� °+^........................................................
No............... `.._..:� E........ ..............
P �iuvr qal• ork�up TM
`r ion ierutit
Permission is hereby granted ------------------- '----------------------•---•--....................-••------
to Construct ( ) or Repair �Q an Its i al Sed age Disposal Systerq
at No. `�' .m •-- . ' kv
Street
as shown on the application for Disposal `Forks Construction Permit No..................... Dated.................... .......a........
Board of health
10
DATE---- .......•---•-®- -------•--------
FORM•J2.55 HOBBS & WARREN, INC., PUBLISHERS
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� . INVERT EL . . . I . H-j_Q_ PUMP 2011.3j, . I I . . . � I F 1- - , J_/6&4� � . . I ,i THIS PROPERTY . BSORPTION SIST&M 11 I I . � .
. I . . H-10 I- . I , . � OR WITHIN 100' OF THE PROPOSED SOIL A I I � . I �
I I � I � . I - , I .. � 6 I � INVERT EL � I . 11 . .7,- i, , C�- . I ! .. � � . � I 11 . . 1� I I 1.I �
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I . 1. I I I . I - ! �INVERT EL I I C)Q0. z/ , �,�.- t I . . I � 6) ALL COVERS OF SYSTEM CoMpONEN.TS SHALL BE BROUGHT To 47TB7N 12 OF FINISHED GRADE, W7TH ONE C0 VER OF THE I I I.,
: I I . . . . . � I � � � I .. . 1 . .. . . I � I�, I .I I 8-L, . . . . . .. � . . ..I I . . : i 1. � 0�- e .1 I � � � . . . . . I . . - . I . . . ,
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I I I I I I .1 2 . I � � i . I I INVERT EL � I I C-l"_�_��Z_. I . . . . . SEPTIC TANK BROUGHT, #7THIN 6" OF�GRADE I . . I . . I . I I . 11
,� I . I �. ..� 6' Crushed Stone.-t'-A Proposed _/4_:�A�L Cal. ! . , . i � I I . � 1 � . � . . I I . I I I . . . . . . . . . � I I I . . . . � . � . � . I 1� � �� :� I
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. .1 . I . I . I I I � I I I . . I I . EL . I �) ALL SYSTEM . .1 I . I � , � :"�
. I . . . . . . . . . ') I ' , I . . � . I � . . I . �, .. . . . 1. . . . ESTIMATED HIGH ,GROUND WATER - ,, COMPOAENT5 SMLL REMAIN ACCESSIBLE FOR INSPECTION. NOSTRUCTURES SHALL BE LOCATED . I I. 1, � 4, ,�/
- ptic ,Tank 'H-IL ; � . . . I I . � �
I � . I . . I . . Se . -1 I � I � . I . I . I . . . I I . I I I. �11 11 I I . . . . I I . . .I.-I I � DIRECTLY I I I., I .
� I . . . I I . . . I � . �. . I . I ,� - I � I . �� ,.. . I . "� Proposed /A>0 �Gal I . , . I I 111 . � I . 1 I � � � � � I I . � I I � I . � . . GROUNDWATER� EL J�_J' 5 . � . . I UPON OR ABOVE TWE COMPONENT ACCESS LOCAT?OAS . � I . . . � . . . .1 . 11 ,, - .1 � � ��21:1;
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I . I � . . - � . I 10* . I �� 1 �3 , , I ' . I - I . . I .1 . . � I I 36. . . . . � . .WHICH [FOULD INTERFERE #77H THE PERFORMANCE, ACCESS, ,INSPECTION L �'
I I I 11 . . . . . � . � . . I . I I .1 Pump Cb�6mber . I I I I . . . . 11 � . � I . . .. I 1. . I � I . I . . . I . . I I - I'll 1. I , i
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i I . I I . .. . I . . - I I . I . I I I . ... . I . .1 �� . I . . I . I _� I I il I . - . � , 8)' NO DRIVENA ,, PARffING OR TURNING AREA OR OTHER LVPERHOUS AREA SRALL .:BE LOCATED ABOVE A SOIL ABSORPYYON , . � I . .- �
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