HomeMy WebLinkAbout0175 MARSTON AVENUE - Health 175 MARSTON AVENUE, HYANNIS
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BUILDER OR O �t
PERMITDATEN COMPLIANCE DATE:
Separation Distance Between the:
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`eA�ofleac*hina,,l P Feet
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Commonwealth of Massachusetts 0?88'A8
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
175 Marston Ave.
Property Address
Okeefe
Owner Owner s Name
information is
required for every Hyannisport MA 02061 10/15/19
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
A. Inspector Information 64 ILIap�
Frank Nunes III
Name of Inspector
saa
Company Name
Box 841
Company Address
East Falmouth MA 02536
City/Town State Zip Code
508.272.6433 13010
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ® Passes
.2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
10/15/19
Inspector i natur 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 form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: 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.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
t, 175 Marston Ave.
Property Address
Okeefe
Owner Owner's Name
information is
required for every Hyannisport MA 02061 10/15/19
page. Citylrown State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) 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:
2) 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):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
.�e 175 Marston Ave.
Property Address
Okeefe
Owner Owner's Name
information is
required for every Hyannisport MA 02061 10/15/19
page. Cityfrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ 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):
3) 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.
a. 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:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
�. ,F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
•" 175 Marston Ave.
Property Address
Okeefe
Owner Owner's Name
information is
required for every Hyannisport MA 02061 10/15/19
page. CityrTown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ 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
b. 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.
c. Other:
4) 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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
le Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
175 Marston Ave.
Property Address
Okeefe
Owner Owner s Name
information is
required for every Hyannisport MA 02061 10/15/19
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1/day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the 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 water supply
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 2000 gpd-
10,000 gpd.
❑ ® 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.
5) 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 CA.
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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
." 175 Marston Ave.
Property Address
Okeefe
Owner Owner's Name
information is
required for every Hyannisport MA 02061 10/15/19
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered"yes"to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes"or"no"for each of the following for all inspections:
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?
❑ ® 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)]
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�a 175 Marston Ave.
Property Address
Okeefe
Owner Owner's Name
information is
required for every Hyannisport MA 02061 10/15/19
page. Cityrrown State Zip Code Date of Inspection
D. System Information
1. 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
Description:
4 bedroom permit on file
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
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: occupiedDate
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 7 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
175 Marston Ave.
Property Address '
Okeefe
Owner Owner's Name
information is
required for every Hyannisport MA 02061 10/15/19
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercia/ndust a I I ri 1 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
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: Pumped 2017 per owner
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�o 175 Marston Ave.
Property Address
Okeefe
Owner Owner's Name
information is
required for every Hyannisport MA 02061 10/15/19
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
4. 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):
No D-box
Approximate age of all components, date installed (if known) and source of information:
1975 per BOH record
Were sewage odors detected when arriving at the site? ❑ Yes ❑ No
5. Building Sewer(locate on site plan):
18"
Depth below grade: feet
Material of construction:
® cast iron ❑40 PVC ❑ other(explain):
>10'
Distance from private water supply well or suction line. feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
(o Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�e 175 Marston Ave.
Property Address
Okeefe
Owner Owner's Name
information is
required for every Hyannisport MA 02061 10/15/19
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 12"feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain)
H-10 tank appears to be structurally sound
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000g
Sludge depth:
10"
Distance from top of sludge to bottom of outlet tee or baffle >12
1
Scum thickness
Distance from top of scum to top of outlet tee or baffle
>2"
Distance from bottom of scum to bottom of outlet tee or baffle
>2
How were dimensions determined? measured
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pumping suggested every 3yrs to prolong the life of the system
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
- (P Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
175 Marston Ave.
Property Address
Okeefe
Owner Owner's Name
information is
required for every Hyannisport MA 02061 10/15/19
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
7. 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
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. 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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18
Commonwealth of Massachusetts
ro Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
t, 175 Marston Ave.
Property Address
P
Okeefe
Owner Owner's Name
information is
required for every Hyannisport MA 02061 10/15/19
page. Citylrown State Zip Code Date of inspection
D. System Information (cost.)
8. Tight or Holding Tank(cont.)
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
9. Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert n/a
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Probing gives no indication of a D-box
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
Commonwealth of Massachusetts
,F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
175 Marston Ave.
Property Address
Okeefe
Owner Owner's Name
information is
required for every Hyannisport MA 02061 10/15/19
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
10. 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.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
® leaching pits number: 1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
175 Marston Ave.
Property Address
Okeefe
Owner Owner's Name
information is
required for every Hyannisport MA 02061 10/15/19
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System(SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leach pit is 12" below grade, there is 3'6"of effluent in it at this time, there is light staining of the
sidewall to the very last row of weep holes, no high staining, no indication of past hydraulic failure
12. 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
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
175 Marston Ave.
Property Address
Okeefe
Owner Owner's Name
information is
requited for every ry H annis ort MA 02061 10/15/19
page. City[rown State Zip Code Date of Inspection
D. System Information (cont.)
13. 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.):
t5insp.doc-rev.7/26/2018 TRIe 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18
Commonwealth of Masshnsetts
,: (o Title 5 Official 'lnspection Form
a
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
175 Marston Ave.
Property Address
Okeefe
Owner Owner's Name
information is
required for every Hyannisport MA 02061 10/15/19
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
14. 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
j✓t..�sraNs ��
U�
�ci s�lV
t5insp.doc-rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
175 Marston Ave.
Property Address
Okeefe
Owner Owner's Name
information is
required for every Hyannisport MA 02061 10/15/19
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
® Surface water
® Check cellar
❑ Shallow wells
Estimated depth to high ground water: 15
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: n/a
Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
4'seperation per compliance on file
❑ Checked with local excavators, installers-(attach documentation)
® Accessed USGS database-explain:
TOPO mapping put the site at 16'msl and nearby surface water is at 1'msl
You must describe how you established the high ground water elevation:
See above
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
175 Marston Ave.
Property Address
Okeefe
Owner Owner's Name
information is
required for every Hyannisport MA 02061 10/15/19
page. Cityfrown State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria)and 6(Checklist)completed
® D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 18 of 18
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Separation Dixtance Between the:
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Private Water Supply Well end leaching Facility(If any wells exist
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Edge of Wetland and leaching Facility(If any wellatdx exist
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DATE: 2/23/9�6
PROPERTY ADDRESS:_"175 Marstonf Ave.
Hyannisport,
tMass . 902647
On the above date, 1 Inspected the septic system at the above address.
This system consists of the following:
1 . 1 -1000 .gallon septic tank.
•2. 1 -1000 gallon leaching pit.
Based on my Ins �ectlon, I certify the following conditions: 414i� g
1 . This is' a title five septic s'y 'tetra-. ( 78 Code ) 8
2.Tie•` $sptic' system is in proper working order`-
at the- present time . �`' ;w
3 The abandoned ces_spool was not fille'd 'in.This shoa.ii'; e done
fdr "safet r. • Eventually thiso cesspool will :&Ve .ii . &
�i
SIGNATURE: G`�(
Name: J.P.M-acomber Jr...
i
Company: J.P_MacoMber. & Son,_Inc ;
Address:
__Cente!rvi1l,e LMass__0.2.632 '
Phone:--, `11
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
LP. MACO�RBER & SON, INC.nks-CesApool&-LeschfIelds
Pumpsd & Installed
own Sewer Connections
6' Centerville, MA 02632-0066
775-3338 77"412 _A(
II
L
• D
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Department of
Environmental Protection
William F.Weld Trudy Coxe
Govemor 8w9tary
A��Pfaul Cellucci • David S.Struhs
•
comrtJulor»r
•
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 175 Marstons Ave Hyannisport Mass Address of Owner.
Date of Inspection: 2/2 3/9 6 (If different)
Name of Inspector. Joseph P. Macomber Jr.
Company Name,Address and Telephone Number.
J.P.Macomber & Son Inc Box 66 Centerville ,Mass . 02632 508-775-3338
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
Passes •
_ Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: � a /%/lLG-GAG (/_ Date:
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspection. If the system is a shared system.or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the
report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority.
INSPECTION SUMMARY:
Check A, B, C,or D:
AJ SYSTEM PASSES:
_..�I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
BI SYSTEM CONDITIONALLY PASSES:
yD One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes
inspection.
Indicate yes,no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain why not)
The septic tank is metal,cracked,structurally unsound,shows substantial infiltration or exMtration,.or tank failure is
immineat. The system will pass inspection if the existing septic tank is replaced with a ponforming septic tank as approved
by the Board of Health.
(revised 11/03/95) 1
One Winter Street 0 Boston,Massachusetts 02108 • FAX(617)556-1049 9 Telephone(617)292-5=
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(oontinued)
Property Address: 175 Marstons Ave Hyannisport,Mass .
Owner. . Nutter McClennen & Fish
Date of Inspeotton: 2/2 3/9 6
BI SYSTEM CONDITIONALLY PASSES (continued)
e
�A Sewage backup or breakout or h ji static water level observed in the distr1ution box is due to broken or obstructed pipe(s)
or due to a broken,settlod or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is levelled or replaced
1/Q The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
Cl FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Al 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 DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A
MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
AL4 Cesspool or privy is within 50 feet of a surface water
A" 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 APPROPRIATE)
DETERMINES THAT THE SYSTEM IS FUNCTIONING 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.
j The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water
supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free
from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 6 ppm.
3) OTHER
(revised 11/03/95) 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(oontinued)
Property Address: 175 Marstons Ave Hyanni sport,Mass .
Owner. Nutter McClennen & Fish
Date of Inspection:2/2 3/9 6
D] SYSTEM FAILS: e
ALb 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.
d� Backup of sewage into facility or system component due to an 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.
,V01, Static liquid level in the • tribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in oeaepcel is less than 6"below invert or available volume is less than IJ2 day flow.
Ab Required pumping more than 4 times in the last year NOT due to dogged or obstructed pipe(s).
Number of times pumped—_
Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
P Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 60 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
ooliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen.
EJ LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above:
_426 The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a slpi&ant threat to public
health and safety and the environment because one or more of the following conditions exist:
Ag the system is within 400 feet of a surface drinking water supply
the system is within 200 fast of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone II of a public
water supply well)
The owner or operator of any such system shall bring the system and facility into 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..
(revised 11/03/95) 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
PropertyAddrom 175 Marstons Ave Hyannisport,Mass .
owner. Nutter McClennbn & Fish
Date of Inspection: 2/2 3/9 6 e
Check if the following have been done:
,Pumping information was requested of the owner,occupant,and Board of Health.
,None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
-de"s built plans have been obtained and examined. Note if they are not available with N/A
, The facility or dwelling was inspected for signs of sewage back-up.
2The system does not receive non-sanitary or industrial waste flow
, The site was inspected for signs of breakout.
ZAll system components,L-cluding the Soil Absorption System,have been located on the site.
, The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of battles or
tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.
, Ths size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
/The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub.
Surface Disposal System.
(revised 11/03/95) 4
PART C
SYSTEM INFORMATION I
Property Address: 175 Marstons Ave Hyannisport,Mass .
Owner. Nutter McClennen & Fish
Date of Inspection:2/2 3/9 6
FLOW CONDITIONS.
RESIDENTIAL,
Design now per
Number of bedrooms:
Number of current residents
Garbage grinder(yes or no): s
Laundry connected to sy (yes or no):"L
Seasonal use(yes or no): $
Water meter readings,if available: JyAfl��%L'-
Last date of occupancy:
COMMERCIAL/INDUSTRIAL,
Type of establishment: V jq
Design flow: L1q gal1ons/day
Grease trap present: (yes or no)IQ14
Industrial Waste Holding Tank present: (yes or no)O-d
Non-sanitary waste discharged to the Title 5 system: (yes or no)&
Water meter readings, if available: AM
Last data of occupancy:_
OTHER(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPINGrORBSand so of informatiA
System pumped as part of inspection: (yes or no)&lO
If yes,volume pumped: Q ons
Reason for pumping: _
TYPE F SYSTEM
Septic tank/dislribat3va-bas/soil absorption system
i/h Single cesspool
4 Overflow cesspool
AIQ Privy
Shared system(yes or no) (if yes, attach previous inspection records, if any)
Other(explain)
APPRO MAT]q AGE of all co ponen ,date ed(if kn wn)and source of reformation: (�^f�—7
)Ajd S 47 /1-41e ' a�i Zidw D e
Sewage odors detected when arriving at the site: (yes or no)A ,
(revised 11/03/95) 6
02!27,96 15:42 &;R.doTABLE !dATER� CUIPANY 001
CUSTOMER CONSUMPTION Hl-,TORY
jCCOUNT NUMBER 298 119
;USTOMER NAME JOHN P -.ORISCOLL- .j'R READING
;ERVICE LOCATION HYANNIS AVENUE DATES READINGS USAGE
PERIOD (MMDDYY) (CCF) (CCF)7
FIRST 01 18 96 833 A
il._LOWANCE BALANCE SECOND 10 10 95 626 A 119
AVERAGE WATER USE 31 THIRD 07 11 95 708 A 14
FOURTH 04 03 95 694 A
(EAR TO DATE WATER USE FIFTH 01 06 95 690_A _ 10
- -.. 1Q .o,�_...� 68o A 42
SIXTH ..
4ON SEWER'USE SEVENTH 07 08 94 638 A 26
)rHER USE EIGHTH _ 04_06 94 _ 612 A
N I NNi'K.. d 1 !0 �4 597 A 9—
.TENTH 10 07 93 597 A 11
ELEVENTH 07 08 93 485 A
LION SEWER FIRST READING -- TILF�'CH _— Q -QS�'3
-$E�1ER SECCSRD 9A[ NG — THIRTEENTH O1 06 93 457 A 7
NON SEWER METER NO. FOURTEENTH 10 07 92 4S0 A
ENTER FIRST SCREEN PFKEY 14 = PRINT SCREEN
b .
SUBSURFACE SEWAGE DI9IP^9:+:1 SYSTEM INSPECTION FORM
C
SYSTEM INFO1-, i.,%.'riON (oontinued)
propertyAddesa: 175 Marstons Ave Hyannisport,Mass .
Owner. Nutter McClennen & Fish
Date of Inspection: 2/2 3/9 6
e
SEPTIGTVM-., 1-1000 gallon 4tic tank.
(locate on site plan)
Depth below grade: I L
Material of construction:2concrete_metal_FRP_othar(eirl:,:^)
Dimensions 1 /;
Sludge depth: tc
Distance from top of shidga to bottom of outlet tee or baffle: 15
Scum thickness: D _
Distance from top of scum to top of outlet tee or baille: 0
Distance from bottom of scum to bottom of outlet tee or baffle:
Comments:
(recommendation for pumping,condition of inlet and outlet tees or batY!ea, depth of liquid level in relation to outlet invert,structural integrity,
evidence ofleaka2e,etc.)• Pump septic tank annua, ly; (_srbnge chi slinsnI lracart.
Inlet & out let tees are present: liquid level is 5111 in rPlatinn to
v� outlet invert;,Tank llrid and ehn�ac nn SlariS—c�,f leakag
No repairs are needed at this time .
GREASE TRAP:
(locate on site plan)
Depth below grade:,
Material of construction. ) concrete_metal_FRP_other(e:pb;.n)
ANA
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:
Comments:
(recommendation for pumping,condition of inlet and outlet tees or b,, depth of liquid level is relation to outlet invert,structural integrity,
evidence of leakage,etc.) A)f5 CP N"16Nr%
(revised 11/03/95) 6
SUBSURFACE SEWAGE DIQPCFAL SYSTEM INSPECTION FORM .
SYSTEM II:: �)N (oontinued)
Propertymdma 175 Marstons Ave Hyanni sport,Mass .
Owner. Nutter McClennen & Fish
Date of Inspeotlon: 2/2 3/9 6
TIGHT OR HOLDING TANK: kWe •
(locate on site plaa) • .a ,;,
Depth below grade: ' ..... :. .. .. .
Material of construction:lAmoncrets_►stal_JBP other(-.'.,.-)
A
Dimensions:
�p�tY R'�A sallons \
Design flow ons/day
Alarm level
Comments: _
(condition of inlet too,-condition of alarm and float switches,etc.)
h;t C0AlMQ40Tg
DISTRIBUTION BOX:L)0/0,1
(locate on site plan) ..
jDepth of liquid level above outlet invert: )!�
Comments:
(note if and distfl1ution is RUA f solids cam,-,,-- leakage into or out of box'etc.)
;I
PUMP CHAMBER:,�,/(��
Cocats on site plan)
i
Pumps in working order:(ves or no)__42 .
Comments:
(note coudigqnofpu=p chamber,coalition of pumps and ap^
(revised•11/03/95)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(oontinued)
propO1tyAddem 175 Marstons Ave Hyanni sport ,Mass .
Owner.. Nutter McClennen & Fish
Inspee 2/23/96
Date of tics: •;, •tia'� .
SOIL ABSORPTION SYSTEM(SA3)-Z e
(locate on site plan,if possible;excavation not requir*,but may be approximated by non-intrusive methods)
If not determined to be present,explain:
I
leaching Pits,number.1.
Ileaching chambers,number a
leaching galleries numbar._a
leaching trenches,number,lengtlu
caching fields,number,dimensions:
overflow cesspool,iumber._L
Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
• All ve etation normal.
I oamy sana to- medium san •No re eded at the present time .
CESSPOOLS:&�641c'•
(locate on site plan)
i
Number and configuration:
Depth-top of liquid to inlet invert.
Depth of solids layer.
Depth of scum layer.
j Dimensions of cesspool:
Materials of construction:
Indication*of groundwater.
. . . inflow(oeespool must be pumped as part of inspection)
Co nta.(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.).
i
PRIVY:VO4
(locate on site plan)
Materials of construction: X Dimensions: 11'�
j Depth of solids:.
j Commants54note ooaditioa of soil,signs of hydraulic failure,level of pondiag,condition of vegetation,etc.) lG)/�
/I;'r d vet rti"P...A)1'S
i
i
i
(revised 11/03/.95)• 8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(oontinued)
PropertyAddrem 175 Marstons Ave Hyanni sport,Mass .
Owner. Nutter McClennen & Fish
Date of Inspection: 2/2 3/9 6
SKETCH OF SEWAGE DISPOSAL SYSTEM: Su��sJ n(,UL 1
include ties to a _
locate all wells within 100' /dt6�iV Llfi¢
i
40
i
I
i
o � �
s
DEPTH TO GROUNDWATER
` Depth to gioundwater._�feet
Imethod,pf or a p tion: GJ 47e-,vId 716-
!`i C
(revised 11/03/95) 9
TOWN OF Barnstable BOARD OF HEALTH
SUBSORFACE SEWAGE DISPOSAL .SYSTEM INSPECTION FORM - PART D .- CEiITIFICATION
-TYPE OR PRINT CLEARLY-
PROPERTY INSPECTED
STREET ADDRESS 175 marstans Ave 4anni spor-t D4ass
ASSESSORS MAP , BLOCK ANJ) PARCEL * 288-118
OWNER' s NAME Nutter Mcnennei2 & Fish
PART D - CERTIFICATION
NAME OF INSPECTOR Joseph P. Macomber Jr.
COMPAN7 NAME J.P.Macomber & Son Inc .
COMPANY ADDRESS Box 66 Centerville ,Mass . 02632
Street Town or City State LIP
COMPANY TELEPHONE 508 5 3338 FAX (508 790 1578
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at
this address and that the information reported is true , accurate , and
complete as of the time of .-inspection . The inspection was Performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems .
Check one:
XXX= Systeai PASSED
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
heal Lh or Lhe environment as defined in 310 CHR 15 . 303 . Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form.
System FAILED
The inspection which I have conducted has found that the system fails to
Protect the public health and the environment in accordance with Title
5 , 310 CHR 15 , 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form .
Inspector 8ignatur i Z Date 2/27/96
One copy of this certification must be provided to the OWNER, the BUYER
( where applicable ) and the DOAnD or HEALI'll.
If the inspection FAILED, the owner or""�'Pe-rator shall upgrade - the system
within one year of the date of the inspection , unless allowed or required
otherwise as provided in 310 CHR 15 . 305 .
vY
Z
V/ N
THE COMMONWEALTH OF M.A.SSA.0 USETTS
DEPARTMENT OF E ONYIENTAL PROTECTION
BE IT KNOWN THAT
Joseph P. Macomber, Jr.
Has satisfied the Department's qualifications as required and is hereby
authorized to use the title
CERTIFIED TITLE 5 SYSTEM INSPECTOR
as provided in 310 CMR 15.340 and Section 13 of Chapter 21A of the
General Laws. Issued by The Department of Environmental Protection.
June 8. 1995
r Acting Director of the ion of.Water Pollution Control
LOCQTLON SEW�,C,E PERMIT MO.
OL
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VILLAGE (- - — - — —
`•. 1t�J ALL R
BUILDER DDRE SS
jo
Dt�,TE PERtA1T ISSUED ' �l ya: _ —
COMPLI WA CE ISSUED ;
Y,y
y
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Fiziic
THE COMMONWEALTH OF MASSACHUSETTS
ROAD® OF I-Br-ALT'H'
OF..... ........�;Yq.�.......�..-...... .......................................-.....-................-...---....................
Applirativ or Ii,4pusal Workii ( onfi#rur#ion Vrrnift
Application is hereby made for a Permit to Construct ( .) or Repair an Individual Sewage Disposal
System at:
----------•-c7
Locatio Address or Lot No.
Owner Address
a W c�6S G�12 i C
-- .......... -----------------------------------------
Installer Address
d Type of Building Size Lot..................----------Sq. feet
U Dwelling—No. of Bedrooms-------- -.-_----..--_--_.Expansion Attic ( ) Garbage Grinder ( )
�+
a4 Other—Type of Building ---------------------------- No. of persons........... -----.._ Showers ( ) — Cafeteria ( )
GaOther fixtures ------------------------------------------------------
W Design Flow--------------------------------------------gallons per person per day. Total daily flow--------------------------------------------gallons.
9 Septic Tank—Liquid capacity------------gallons Length........:....... Width..........- Diameter.-..-----__-_ Depth----------------
xDisposal Trench—No--------------------- Width-------------------- Total Length.................... Total leaching area--------------------sq. ft.
Seepage Pit No--------------------- Diameter_._--_-_-----_--.-.- Depth below inlet.................... Total leaching area..--._..-----__.-sq. it.
z Other Distribution box ( ) Dosing tank ( )
'-, Percolation Test Results Performed by------ -------•-----------.-----•----------------------------------------- Date----------------------------------------
Test Pit No. 1----------------minutes per inch Depth of "Pest Pit.................... Depth to ground water...........--. -----.
G14 Test Pit No. ,2................minutes per inch Depth of Test Pit-------------------- Depth to ground water-............. ....
P+ ••--------••-----------------------------------------••-•-•-•-•--•--•-----•---•--•--•--•----•--------•------••-------•---•--..--•-----------------------------
ODescription of Soil---------------------------------------•-•------•---------------•-------•----•---------------------------------•--------------------------------------------------------
x
V ---------------------------•--------------•-- -•-----•...--•-------•------•------•-------------••---------•---------•---------------------•-•-•--•------•--•------•.-.-----•-•---•--•....-----•----
W --•--------•------------------------- --------------------------------------------•---•--------•---•---------•--•-----------•---------------•-••-----------------------•------• -------•---------------
VNature of Repairs or Alterat' ns—Ans r when applicable----OA�_-----14q'q------- X----------- .....ow.
---------- / nl-------- --------- !-�--------------------------------------------- ----------------------------------------------------------------------.
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 een issue�jdl.bb the-boardd of health.,
d`'Ll ��`d .�.'1 Signe - --------------------------------
Date
---- ---- ----- �
Application Approved BY ...-..... '�� -- -•--------------•--•---•--..-....--•------...-----------•--• ---•--------- !r.. .....G...75
Date
Application Disapproved for the ollowing reasons:--•-••---•-•-----------•-•------•----••-----------------------•----------------------- -----•-------•----- ----
------------------••------•----•-•••--•---•--------------------•••--•------•-•--•------------•---••---------•-••--••----•---• -••---• -----------•-•----...._.._........_.-....--.•...---••-------•-----
Date
PermitNo........./-3-y................................... Issued-_-----------------------..........................
Date
No......................... Fiziic............................
;THE COMMONWEALTH OF MASSACHUSETTS UCJ
BOARD OF HEALTH
.. .........OF._............................ ----------- ...........
Appliration -for DiaVotial Works Towitrurtion Vrruift
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System'1114t,I
...........J001
.7- .......h- �i--_-------- -4 ...............................................................................................
L t' eddress or Lot No.
. ............................................... .......... --------------------------------------------------
Owner Address
..........jo '000........................ ........------------- ...........................
Installer Address
Type of Building Size Lot_-------------------------Sq. feet
Dwelling—No. of Bedrooms-_.__ Expansion Attic Garbage Grinder
43V---------- --------------
Other—Type of Building ----------------------------_No. of persons..----_--43�---------- Showers Cafeteria
Otherfixtures -------------m------------------------- .............------------------------- ---------------------------------------------------------------
Design Flow.....................................:--__--gallons per person per day. Total daily flow------------------------------------------.-gallons.
Septic Tank—Liquid capacity-----:......gallons Length________________---------------- Width.._--.___._--.------------- Diameter........._...._ Depth ------ ----------
.
Disposal Trench—No_ -------------------- Width-------------------- Total Length._..........___..._. Total leaching area--_------ -------sq. f t.
Seepage Pit No..................... Diameter________-_______---- Depth below inlet____-__________-_-_. Total leaching area------- ......sq. ft.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by---------- ......................................................... Date---------------------------- ----------
Test Pit No. I----------------niinutes 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--_-_._-__-.-_----__---.
•----------------------------------------------------------•-----------------------------------------------------------------.............. .................
0 Description of Soil........................................................................................................................................................................
U ------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------
--------------------------------------- ------------------ -------------------------------------------------------------------------------------------------------- .........................
U Nature of RepqL'rs or AlteraUqns—Ans when appficable_lalwe--------/0 --------�.A?----------
0 - RVOAle e# - -
------ -------—----------------- -------- z-------------------------------------------------------------------------------------------------------------------------
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 f he; .
Signe -- ------
ApplicationApproved BY------------ //.......................................................................... --------------
Date
Application Disapproved f( 4-01-11-o-wing reasons:-----------------------------------------------------------------------------------------------------------------
..........................................................................................................................................................................................................
Date
Permit No.
f_41------------------------------------- Issued...................... .................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
%
BOARD OF HEALTH
.............. ........ti.....� OF .........................................
..... ...... ...............
....
"Yyk"v rtifira
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired
b .......... ................................................
y ........................................................................................ .............................
Installer
at-------- ......... -----_------------- --------------'*u't-_r..................
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..___ l dated-,......
-------------
THE ISSUANCE OF THI-S ,C-ERTIFICATE�,-S'JH,AI I CONSTRUED AS A G � TEE 1 FIAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE__.,`_
T-----------------------------------------------------..........- Inspector....................................................................................
'Z--4 4'6 iEALTH OF MASSAC
HUSETTS
XA*3 THE COM SETTS
BOARD OF4 _5 V
^1,�ALTH
.......... ................OF............ 4......................................
No.......
Dinpotial Workii Qla.mitrurtion Prrmit
Permission is hereby granted------------ey- ......... ................................................ .....................
to Construct*��
'Ke ir ok Individ*D�,Kg&Mposal System
...........
at No............................................................................. ------------------------------------- ........
Street /$-�
as shownon the applicdifanfforj)isposal Works Go4aTurztion..Bermit No_____________ ______
-----------------
---------- -------------- ....... ..........
----------J,!" Board of HeaA
DATE.._ -------------------------------------------------
FORM 1255 Hoess &"'Iw.Aj� C.. PUBL-tP_jq&RS,";_