HomeMy WebLinkAbout0185 MEGAN ROAD - Health 185 M-egan Road
Hyannis P
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
•' 185 Megan Road
Property Address
Megan Donaldson
Owner Owner's Name
information is required for Hyannis MA 02601 06/15/09
every page. Cityrrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.
Important: A. General Information
When filling out
formsthe
computer,
r,use 1. Inspector: J-
only the tab key
to move your Michael Kellett
cursor-do not Name of Inspector
use the return
key. Aardvark Environmental Inspection
Company Name
ffi P.O. Box 896
Company Address
East Dennis MA 02641
l'" Cityrrown State Zip Code
508-385-7608 S13742
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
f
!2�• / 06/16/09 CN
Inspector's Signature Date CS; Cn C
as
The system inspector shall submit a copy of this inspection report to the Appr"ving Atforitykpoard
of Health or DEP)within 30 days of completing this inspection. If the system i a shar&g Sys��or
has a design flow of 10,000 gpd or greater, the inspector and the system ow er shall' e
report to the appropriate regional office of the DEP. The original should,be s nt to th"ystem 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. `< '
J
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
185 Megan Road
Property Address
Megan Donaldson
Owner Owner's Name
information is required for Hyannis MA 02601 06/15/09
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Answer yes, no or not determined (Y, N, ND) in the❑for the following statements. If"not
determined," please explain.
❑ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent.
System will pass inspection if the existing tank is replaced with a complying septic tank as
approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate
of Compliance indicating that the tank is less than 20 years old is available.
ND Explain:
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced
❑ obstruction is removed
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
185 Megan Road
Property Address
Megan Donaldson
Owner Owner's Name
information is required for Hyannis MA 02601 06/15/09
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ distribution box is leveled or replaced
ND Explain:
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced
❑ obstruction is removed
ND Explain:
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier,if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
185 Megan Road
Property Address
Megan Donaldson
Owner Owner's Name
information is required for Hyannis MA 02601 06/15/09
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
C) Further Evaluation is Required by the Board of Health (cunt.):
❑ 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 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
El E Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
El ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than %day flow
El ® 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.
Commonwealth of Massachusetts
Title 5 Official Inspection Form _
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
t( 185 Megan Road
Property Address
Megan Donaldson
Owner Owner's Name
information is required for Hyannis MA 02601 06/15/09
every page. Citylrown State Zip Code Date of Inspection
B. Certification (cunt.)
D) System Failure Criteria Applicable to All Systems (cont.):
Yes No
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails.The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,.
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�t 185 Megan Road
Property Address
Megan Donaldson
Owner Owner's Name
information is required for Hyannis MA 02601 06/15/09
every page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® 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)]
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
185 Megan Road
Property Address
Megan Donaldson
Owner Owner's Name
information is required for Hyannis MA 02601 06/15/09
every page. Cityrrown State Zip Code Date of Inspection
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms(actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220
Number of current residents: 0
Does residence have a garbage grinder? ® Yes ❑ No
Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)):
Sump pump? ❑ Yes ® No
Last date of occupancy: 02/09
Date
Commercial/industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe):
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
s �< 185 Megan Road
Property Address
Megan Donaldson
Owner Owner's Name
information is required for Hyannis MA 02601 06/15/09
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system(yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known)and source of information:
10/07/97 per BOH
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
y( 185 Megan Road
Property Address
Megan Donaldson
Owner Owner's Name
information is required for Hyannis MA 02601 06/15/09
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan):
Depth below grade: 1.6
feet
Material of construction:
❑ cast iron ®40 PVC ❑other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade: 0.9feet
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: 1000 gal
Sludge depth:
2"
Distance from top of sludge to bottom of outlet tee or baffle
29"
21'
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
15"
How were dimensions determined? measured
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
'g( 185 Megan Road
Property Address
Megan Donaldson
Owner Owner's Name
information is required for Hyannis MA 02601 06/15/09
every page. City/Town state Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
The tank was sound and tight with tees in place and liquid at outlet invert.
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.):
Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
0 concrete 0 metal ❑ fiberglass ❑ polyethylene ❑other(explain):
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
yt 185 Megan Road
Property Address
Megan Donaldson
Owner Owner's Name
information is required for Hyannis MA 02601 06/15/09
every page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Tight or Holding Tank(cunt.)
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Commonwealth of Massachusetts
Title 5 Official . Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
s� 185 Megan Road _
Property Address
Megan Donaldson
Owner Owners Name
information is required for Hyannis MA 02601 06/15/09
every page. City/Town State Zip Code Date of Inspection
D. System Information (cunt.)
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
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: 4
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
The system has a 6'x6' precast pit surrounded by one foot of stone. The pit was dry with a stain line
at the outlet invert. The pit flowed into four flow defussors surrounded by three feet of stone. the
stones showed no sign of ponding or failure.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
185 Megan Road
Property Address
Megan Donaldson
Owner Owner's Name
information is required for Hyannis MA 02601 06/15/09
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
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.):
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.):
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
185 Megan Road
Property Address
' Megan Donaldson
Owner Owner's Name
information is required for Hyannis MA 02601 06/15/09
every page. Cdy town State Zip Code Date of Inspectlon
t
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties
to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet
Locate where public water supply enters the building-
ay
�B
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
185 Megan Road
Property Address
Megan Donaldson
Owner Owner's Name
information is required for Hyannis MA 02601 06/15/09
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
r
❑ Surface water
i
❑ Check cellar
❑ Shallow wells
20.0
Estimated depth to high ground water: feet I
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) I
® Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
USGS maps show an elevation of over 20.0 feet.
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• COMMONWEALTH OF MASSACHUSETT3
ExECU'I'IVE OFFICE OF ENVIRO
DEPARTMENT OF ENVIRONMENTAL
AFFAIRS
NVIRONMENT
AL PROTECTION
OFFICIAL INSPECTION FORM TITLE 5
SUBSURFACES WAGE D NOT Sp VOLUNTARY
OSAL SYSTEM Fps MESS
PART A
CERTIFICATION.
Property Address; /�
Owner's Na..;
Owner's Address; r q/s o 6 O/ ,
Date of Inspection: G Coo
S= '
Name
Of Inspector:
Company Name: ��y print) G1✓�i /"o/se-��' �'
ase
Mailing Address: V O C
Telephone Number: 3 _ �v�b%
CERTIFICATION STATEMENT P,,
I certify that I have personally Inspected the sewage
below is true,accurate and complete to t the .
'mining and a tJme of the ••sal system at this address and that the '
experience in the proper function and Inspection The�nspcctiOn Onnation reported
approved system inspector pursuant to S maintenance of on site sewagewas
�O�based on my
oa 15.340 otTitle s(310 CMR IS.disposal. sYsems•I am a DEP
Passes
The system:
—
Conditionally passes
Needs Further Evaluation by
YtheLocal Approving Authority
Inspector's Signature:
4�L Date: 9 �6 p The system inspector shall submit a co DEP)within 30 days of co PY of
�Inspection
gPd or greater,the mpleting this inspection If s report to the Approving Authority
DEP. I'>sPector and the system owner shall a systembmit i r shared system or has a e�°ard of Health or
The ongina!should be.sent to the system owner design l of 10,000
authority, and copies sent to to the buyer, regional office of the
the buyer,Notes and Commentsif applicable,and the approving
`*"This report o
time.T pp my describes conditions at the time of ins
This Inspection does not address how the system will
conditions of use. inspection and under the conditions of use at that
Perform in the future under the same or different
Title S Inspection Form 6/15/2000
page 1
Page 2 of 11
OFFICIAL INSPECTION FORM
SUBSURFACE SEWAGE ppOT FOR VOL�.ARY
SAL SYSTEM INSPECT MENTS
PART A ON FORM
Property Address:
CERTIFICATION(continued)
l �S /JP
ii
Owner: h 4-7 /
Date of Inspection:
Inspection Summary-' Check q,B,C,D or E/A&WAYS complete all of Section D
A. Syst asses:
I have not found any information which '
15.303 or in 310 CMR 15.304 exist.An f indicates that an of aaure
Y allure criteria Y the f ' teria described in 310 C11,
feria not evaluated are indicated below.
Comment:
3 SY tem Conditionally Passes:
Z�7r
i— or more system components as�cr•�in
ePaued•The systerq upon completion of the �e"Conditional Pass"section need to be replaced or
replacement or repair,as approves by the Board of Health,Will pass.
explain.Answer Yes,no or not determined(y,N�)�the
for the following statement.If"not determined"please
__The septic tank is metal and over 20 e *
unsound,exhibits substantial ' years old or�s
existing tank a comp- or exfilfiation or tank�l�isis (whether
��or not)is structurs�
*A metal septic tank will Pas a complying septic tank as approved b imminent System wiU pis y
indicating that respecdoa if it is structurall Y the Board of Health, inspection if the
tank is less than 20 years old is available.sow'not leaking and if a C
emt"rcate of CompliaIICe
ND explain:
Observation of sewage backup or break out or hi
obstructed
Board Or of due to broken,settled or static water level is the
uneven distribution box.System
ys distribution box due to broken or
Pass inspection if(with
— broken Pipe(s)are replaced
obstruction is removed
ND explain: distribution box is leveled or replaced
The system required pumpin
Pass inspection if g more than 4 times a i
( �approv
al of the Board of Health); year due to broken or obstructed
P PKS)•The system will
broken pipe(s)are replaced
____obstruction is removed
ND explain:
Titlo 1^Q►+�tinn Fnrm 4/1 inAnn
2 -
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR
S1JBSURFACE SEWAGE DISPOSAL SYSTEM IN VOLUNTARY ASSESSMENTS
PART A
SPEC77ON FORM
Property Address:
CERTIFICATION(continued)
��
Owner:
Date of Inspection:
C• her Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation b
is fig to protect public health,safety or the environment the Board of Health in order to det
ermine if the system
1• System will pass unless Board of Health determines in
system is not functioning in a manner which will pro accordance with tect public health,safe an
310 CAM 15.303(1)(b)that the
Cesspool or privy is within 50 feet of a surface water d the environment:
— Cesspool or Privy is within SO feet of a bordering vegetated wetland or a salt
marsh
2. System win fall unless the Board of Health(and Public Water Su
system is functioningin a manner that protects
the Public heal
p Supplier,if Any)determines that the
P th,safety and environment:The system has a s mnent:
surface water supply tri tank and son absorption system SAS
PP Y or tributary to a surface water apply, (SAS) the SAS is within 100 feet of a
_ 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 t�and SAS and the SAS is within 50 feet of a private
The system has a Septic P ate water supply well.
private water supply well+ tank and SAS and the SAS is less than 100 feet but 50 feet or mo1C from a
.Method used to determine distance
"`This system passes if the well water �bacteria and volatile organic a analysis,performed at a DEP Certified�borato
the presence of �°��indicates that the well is free from rY,for coliform
O nitrogen
and nitrate nitrogen is equal to or less Pollution fMZ2
failure criteria are triggered.A co that facility and
PY of the analysis must be attached to thus form m'pro that no other
3• Other:
T;0. i fno^i•rtinn Fnrn, G/1 /�nnn
I
I
Page 4 of 11
OFFICIAL INSPECTION FORM_NOTF
SUBSURFACE SEWAGE DISPOSAL
VOLUNTARY
ASSESSMENTS
�SYSTEM INSPECTION FORM
CERTI PART A
FICATION(continued)
PropertoAddren:
14Owner:Date of I
/ 6
D• System Failure Criteria a
You EN indicate"yes"or�boppRcable to all systems:
to each of the following for alinapections:
Yes Nokup of
D* al' a orpondinto
to f or system component
0ggg g of effluent to the s due to overloaded or clo
ed SAS or cesspool urface of the ground orb SAS or cesspool
S tic liquid level in the distribution box above out
invert surface waters due to as overloaded or
cesspool
fl-�R,
epth in cesspool to
an°Vmloaded or clo spool i8 less than 6" gged SAS or
�f times pad g more
than 4 times in the 11 Ye Of
tdue to volume is less than%day now
—�Y Portion of the SAS,ces clogged or obstructed pipe(,).Number
--- — AnY portion of cesspool or n cesspool or priin 1 flow high ground wa
titer supply. privy
is
within 100 feet of a s elevation.
Y portion of a cesspoolsurf
��Supply or tributary to a surface
or privy is within a Zone Wy Portion of a cesspool or ne 1 of a public wed
�Y Portion of a cesspool or privy
>9 SO feet of a private
PP1Y well with no acc vY is less�aa 100 feet but water Supply well.
performed at a DEP c eptabl0 water quality analysis. �greater rhea SO feet from a
indicates that the well"Wed laboratory, system passes If the Wen Private water
nitrogen and nitrate nitrogen r equal to for collform bacteria and volatile o water analysis,
Pollution from that tactll organic comp°undo
are triggered.A co or less than S and the presence of a PY of the analysis must be attached toPM,thisprovided that no other nun nia
n'�o)The system fail .AR I I form.] ore criteria
described in 310 � have determined that one or
Health to determine what.303,therefore the s re of the above failure cri
system
f ' feria exist will be necessary to correct the as
aflumsystem owner should contact the Board of
E. Large Systems:
p 6e considered a large system the system must serve a
You must indicate either` •• ,� facility with a desI slow of 10,000
(The followin PP
or s to each of the following; >0d to 1S,000 g criteria alargesystems in addition to the:s feria above)
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet ofa tnbutary to a surface drinlan
the system is located 8 water supply
Zone II of a rn a nitrogen sensitive area(Interim Wellhead Protection
public water supply well
If you have ". Area—IWPq)or a mapped
answered yeS.,to an
"Yes"in Section D above the large question in Section E the system is
significant threat ge system has failed Theo considered a significant
15.304. under Section E or failed under Section D shall uwner pgrade o large
system
threat,or answered
The system owner should contact the a Operator of any large system considered a
appropriate
regional
e 01fice the system in accordance with 310 CMR
gronal office of the.Department.
rihln C l"o.'o„tin" Rnrm G/��MAAA
A
Page S of l l
OFFICIAL INSPECTION FORM—NOT FOR VOL SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR ASSESSMENTS
PART B N FORM
CHECKLIST
Property Address: / ��P
r9�Ji Gt Ul
Owner: e,11 Sa"? r¢ as C 9/
Date of Inspection: G
Check if the followine have been done.You must indicate as,or ho
` "as to each of the folio wing:
Yes N,o�
— _ in8 Formation was provided
c� by the owner,occupant,or Board of Health
re any of the system components Pub out in the previous two weeks?
_ Has the sy
stem 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 7
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,lo
cated on site?
Were the septic tank manholes uncovered,opened,and the interior of the tank
of the bath or tees,material of construction,dimensions,depth of liquid,d depth o
inspected for the condition
Was the facility owner f sludge and depth of scum?
maintenance of subsurface sewage dis occupants if different from owner)Provided with information on the proper
8 disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has determined b
Yes no based on;
�_ Existing information.For example,a pLm at the Board of Health.
Detennjned in the field(if any of the
is unacceptable)[310 CMR 15.302 3 failure criteria related to Part C is at issue approximation( )(b)) PP xlmation of distance
Titin.i incnnnrinw Pl—Oil ciinnn
5
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: j/ 0 7e )(IC/Owner:,: P
Date of Inspe on:
RESIDENTIAL OW ONDITION3 /:142
Number of bedrooms(design): NQ
DESIGN flow based on 310 umber of bedrooms(actual):
Number of current residents: 15.203(for example: 110 gpd x#of bedrooms): 3�p
Does residence have a garbage grinder(yes or no):le o
Is laundry on a s�ce s wa a or System or no):�t'V [if yes separate inspection required)
Laundry system
Seasonal use.(yes or no):�v
Water meter readings,if available(last 2 years usage(gpd)):
Sump Pump(yes or no): /GO
Last date of occupancy.
COIt+&MCDAUINDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15-2—03).
Basis of design floc,(sea epd
Grease trap �P�On�sgftetc.):
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):
Pumping Records GENERAL,INFORMATION
Source of information:
Was system pumped as part of the inspection(ye or no):If yes,volume pumped:_gallons_Ho
Reason for pumping; w was quantity Pumped determined?
------------------------------------------
TYP 91+SYSTEM
Septic tank,distribution box,soil absorption system
—Single cesspool
_Overflow cesspool
—ivy
—Shared system(yes or no)(if yes,attach previous
_Innovative/Altemative technology.Attach a c oinspectionftherr records,if any)
obtained from system owner) copy of the current operation and maintenance contract(to be
_Tight tank _Attach a copy of the DEP approval
_Other(describe):
Approximate � components,date installed(if known)and source of information:
Were sewage odors detected when arriving at the site(yes or no): /C-'O
T:tlo i rn0r%a+ tinn P^rm b/1CNAAA
Page 7 of l l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY
ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION
FORM
PART C
r SYSTEM INFORMATION(continued)
Property Address: �J �/
Owner: !�p 0 ei
Date of Inspection: i O>
BLUDING SEWER(locateM site plan)
Depth below grade:
Materials of construction:_cast iron 40_ PVC_other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc,):.
SEPTIC TANK:
(loc
ate_( to on site plan)
Depth below grade: �f/ -
Material construction
._.other(axplaia) : concrete,_metal_fiberglass_polyethylene
If
e tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):—(attach a c of
certificate)
Dimensions: Jr � � oPY
Sludge depth: of
Distance from top of sludge to bott
Scum thickness: )m of outlet tee or baffle:
, �Ls —
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to botto f outlet tee baffle;
How were dimensions determined; /�f� �e
Comments on L� c-
( PPmB commendations,inlet and outl tee or baffle conditio
ashelated to outlet invert;evidee of leakage,aI—V structural integrity,liquid levels
ea �
GREASE TRAP:&(10cate on site plan)
Depth below grade:_
Material of construction;_concrete
(explain): _metal_fiberglass_polyethylene_other
Dimensions:
Scum thickness:
Distance from top of scum o top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,
as related to outlet invert,evidence of leakage,etc.): gnty,liquid levels
Titlo C TnanAM;e%n Vn "4/1,qtinnn
7
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: /1�r
0
Owner: q✓t �, f
Date of Inspection:
TIGHT or HOLDING TANK:/I/ (tam must be pumped at time of inspecdon)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiber y y
_fiberglass---.Polyethylene lene other(explsia):
Dimensions:
Capacity: Rations
Design Flow: Rallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of boa,etc.):
PUMP CHAMBER: locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition ofpumps and appurtenances,etc.):
Title 4C (ncnnntinw C....L/t eitnnn R
` Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: Y3
Owner: 0 d/ y74.1
Date of Inspection;
SOII,SORPTION SYSTEM(SASj:
(locate on site plan,excavation not required)
If SAS not located explain why:
T� �eachin /
$Pits,,number:/ 1*, l/e
leaching chambers,number
leaching galleries,number
leaching trenches,number,length: `L"' f 141, ✓
leaching field "
s,number,dimensions: 1S itv ,,
overflow cesspool,number;_ y.a 4 vt d
innovative/alternative system Type/name of technology: y h C p Comments(note condition of soil,signs of hydraulic failure,level of ondin
-----
etc.): P B, "soil,condition of vegetation,
r
i
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:
ladication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs ofhydmulic failure,level :f condition ofponding, o vegetation,etc.
r )
Tola 4 inonantinn Rn..,.L/t eH+nnn p
' Page 10 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE
SEWAGE DISPO
SAL SYSTEM INSP• ECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: r /!"/��j C /(V
—_�
Owner. OD,
Date of Inspection: TLI p!j
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. ate all wells within 100 feet Locate where public water supply enters a building.
V
r0
Title 9 rnan rtinn perm Al g1,)Ann 10
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORT NTS
PART C
SYSTEM INFORMATION(continued)
Property Address: o J� .
Owner: i10
Date of Inspection:
SITE EXAM
Slope
Surface water 5 I�
Check cellar
Shallow wells
Estimated depth to ground water a y Meet ('0 V,
Please indicate(check)all methods used to determine the high ground water elevation:
%or
Obtained fiom system design plane on record-If checked,date of design
rued site(abutting pro 8n P�reviewed:
party/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain; �'t
Checked with local excavators,installers- attach
Accessed USGS database-explain: ( documentat►on)
You must describe how
you established the high ground water elevation:
_'-- -- 9 2
r
C VVvv
Titi&i Tnono�.t�nw l�nnr,F�1 /7AAn
11
Installer�' Name Address,�and Tel.No.
_(GL�'"'"`�' � Designer's Name,Address and Tel.No.
1vock
N S A- o Zbo
Type of Building:
Dwelling No.of Bedrooms _ Lot Size S9.ft. arbage Grinder( )
Other Type of Building No.of Persons Sh wers( i Cafeteria( )
Other Fixtures
Design Flow "33c� gallons per day. Calculated daily flaw y gallons.
Plan Date Number of sheets
Title Revision Date
Size of Septic Tank Type of S.A.S.
Description of Soile�
Nature of Re airs or Alterations(Answer when applicable) �t e 1�� � �[ /oJY�f�j �LT•A>�✓�
Gc. ll) CZ-r.,o ors it�-c -t-��<<�►.�...r�..t-K
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 Co cate of Compliance has been issued by B and not to place the system in operation until a Certifi-
of Health.
S' ned J Date 47
Application Approved b Dated
Application Disapproved for ollowing reasons
Permit No. Date Issued
---------_ -----._.�._.�_...._.._�_#--,--_.�------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewa a Disposal System Constructed( )Repaired( )Upgraded(X)
Abandoned( )b i cs- t' `
at � .Q -.
with the provisions of Title and a for Disposal Syste Construction Permit No. has been constructed in accordance
Installer LC ;C_; dated
Designer
The issuance of this permit shall not be cons ed as a guarantee that the system will nction as designed.
Date `' _ �—Inspector
-------------
_
_.------------._---- --
�
No. 2 ,.
THE COMMONWEALTH OF MASSACHUSETTS Fee
PUBLIC HEALTH DIVISION - BARNSTABLE,MASSACHUSETTS
�igpogal $pOtem ongtruction hermit
Permission is hereby granted to Construct( )Repair( Upgrade( )Abandon( )
System located at t
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction us be completed within three years of the da e' it.
Date: /� Approved bKyty
TROY WILLIAMS 6
L- 2
SEPTIC INSPECTIONS
Certified by MA Department of Environmental Protection (508) 385-1300
19 Hummel Drive RECEIVED
South Dennis, MA 02660 a t\
COMMONWEALTH OF MASSACHUSETTS OCT 9 ZOOZ
EXECUTIVE. OFFICE OF ENVIRONMENTAL,AFFAIRS
I TOWN OF BARNSTABLE
DEPARTMF,NT OF ENVIRONMENTAL PROTFsCT O 'LLTHDEPT.
'rI,rLE 5
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Propert% Address: 185 Megan Road
Hyannis,MA
Owner's Name: Erica Donalson
Owner's Addres,: 185 Megan Road
Hyannis, MA 02601 O v
Date of Inspection: October 3,2002 y
Name of Inspector: TroyM. Williams
Company Name: Troy Williams Septic Inspections
Mailing Address: 19 Hummel Drive
South Dennis,MA 02660
Telephone Number: (508)385-1300
CERTIFICATION STATEMEN"r
1 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. 1 am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The systcm
,/ Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authow)
Fails
Inspector's Signature: 2J,�� Date: /0 /3/o A
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of I lealth 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
Although system meets the minimum requirements set forth by the Massachusetts Department of
Environmental Protection,certification is not to be construed as a guarantee of future working condition
of system,piping or components. This Inspection represents the conditions of the system on the Date of
Inspection noted above.
""This report only describes conditions at the time of inspection and under the conditions of use at that
time. I his inspection does not address how the system will perform in the future under the saute or different
conditions of use.
Title 5 Inspection Form 6/15/2000 pace 1
' Page 2 of I l
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
185 Megan Road
Owner: Hyannis,MA
Date of Inspection: Erica Donalson
October 3,2002
luspection 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 CN4R
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need t be eplaced or
repaired. The system, upon completion of the replacement or repair,as approved by the Boardo tlealth,will pass.
Answer yes.no or not determined(Y,N,ND)in the_ for the following statements f"not determined"please
explain.
The septic tank is metal and over 20 years old* or the septic tank(w ther metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is ' minent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by a Board of Health.
•A metal septic tank will pass inspection if it is structurally sound of 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 o or high static water level in the distribution box due to broken or
obstructed piP4(s)or due to a broken,settled o even distribution box. System will pass inspection if(with
approval of Board of Health):
br en pipe(s)are replaced
struction is removed
distribution box is leveled or replaced
ND explain:
The system quired pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspection ' with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
Page 3 of 1 l
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
185 Megan Road
Owner: Hyannis,MA
Date of frt5pection: Erica Donalson
October 3,2002
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health ui order to determine if the system
is failing to protect public health, safety or the environment.
1. System Hill pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) at the
system is not functioning in a manner which will protect public health,safety and the envir ment:
_ 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 mar
2. System will fail unless the Board of Health(and Public Water upplier,if any)determines that the
system is functioning in a manner that protects the public heal ,safety and environment:
_ The system has a septic tank and soil absorption s em(SAS)and the SAS is within 100 feet of a
surface +eater supply or tributary to a surface water - pp1y.
The system has a septic tank and SAS the SAS is within a Zone 1 of a public water supply.
The system has a septic tank an AS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic • k 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 pas if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria and v ile organic compounds indicates that the well is free from pollution from that facility and
the presen of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure tteria are triggered.A copy of the analysis must be attached to this form.
3. Other:
.3
i
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 185 Megan Road
Hyannis,MA
Owner: Erica Donalson
Date of Inspection: October 3,2002
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 clog, ed 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
_ � i 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%2 day flow
Required pumping more than 4 times in the Iasi year N T 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.
LR 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.
NA Any portion of a cesspool or privy is within 50 feet of a private water supply well.
IvI4 Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. (This system passes if the well water analysis,
performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered. A copy of the analysis niubt be attached to this form.)
/N0 (Yes/No)The system fails. 1 have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303. therefore the s\-stem 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 ad ign 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 crite a above)
yes no
— _ the system is within 400 feet of a surface drinkin ater supply
the system is within 200 feet of a tributary a surface drinking water supply
the system is located in a nitrogen s itive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone 11 of a public water supply 11
if you have answered"yes"to any q tion in Section E the system is considered a significant threat,or answered
"yes"in Section D above the Iarg ystem has'failed.The owner or operator of any large systegt considered a
significant ttleat under Sectio or failed unc}er Section D shelf upgrade the system in accordance with 310 CMR
15.304.The system owner uld contact the appropriate regional office of the Department. ,
ep
4 �
Page 5 of 1 I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
185 Megan Road
Owner: Hyannis,MA
Date of Inspection: Erica Donalson
October 3,2002
Check if the following have been done. You trust indicate"yes"or"no"as to each of the followine•
Yes No
P:;npinu information was provided by the owner. occupant,or Board of I lcaltl�
__... _✓ 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)providers 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:
Y� 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)f 310 CMR 15.302(3)(b))
5
Page 6 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
185 Megan Road
Owner: Hyannis,MA
Date of inspection: Erica Donalson
October 3,2002FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): ,3 Number of bedrooms(actual): .
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): -33 0
Number of current residents: d
Does residence have a garbage grinder(yes or no): Yp S (ti/of ,A )
Is laundn on a separate sewage system(yes or no):Ny (if yes separate inspection required
Laundry system inspected(yes or no): yi/ti
Seasonal use:(yes or no):
Water meter readings,if available(last 2 years usage(gpd)):0/-o 7- = 34,,v a j 4/i..., uo-o►
Sump pump(yes or no): No
Last date of occupancy:
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): ^gpd
Basis of design flow(seats/persons/sgft,etc.): •
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no):—
Non-sanitary waste discharged to the Title 5 system (ye or no):_
Water meter readings, if available: _
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: _ ; 7 ILL
Was system pumped as pan of the inspection(yes or no): _,k/„
If yes, volume pumped: gallons-- How was quantity pumped determined?
Reason for pumping: —
TYPE OF SYSTEM
Septic tank,d tif'. eac,soil absorption system
_Single cesspool
_Overflow cesspool
_Privy
_Shared system(yes or no)(if yes,attach previous inspection records, if any)
_Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be .
obtained from system owner)
Tight tank _Attach a copy of the DEP approval
—Other(describe):.
Approximate age of all components. date installed(if known)and source of information:
/�(�+tti -.t.t iD -}' G.r U✓• S h 1 !�J< < �-h T7 '�,n.J•�✓c wo J dlo� o In /d/ 7 /y 7
Were sewage odors detected when arriving at the site(yes or no):6La
6
Page 7 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
185 Megan Road
Owner: Hyannis,MA
Date of Inspection: Erica Donalson
October 3,2002
BUILDING SEWER(locate on site plan)
Depth belu%k grade: /S" 4-
Materials of construction: _Zcast iron ,,/40 PVC ,-'other(explain):h J,, f`
Dkianc;• fron• private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
ur r hT Y f�•'..L„�
SEPTIC TANK:v/ (locate on site plan)
Depth below grade: /p"
Material of construction: concrete metal_fiberglass_polyethylene
—other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliattce(yes or no)'_(attach a copy of
certificate)
Dimensions:
Sludge depth fir'
Distance from top of sludge to bottom of outlet tee or baffle: a '8
Scum thickness: 1/1
Distance from top of scum to top of outlet tee or baffle: L'f
Distance from bottom of scum to bottom of outlet tee or baffle: /3,,
Ilow were dimensions determined:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
+!L.c c_. L.•I SI.a_ i . W.a. �t i •.y Ur.•l/<r• ___L._`7 t-V.i.[ ,_�.• c ,�__.o3'C.L'I�.fi�C.�+.J_(:t
•l J✓.L /G4 �a�A 0 �w M St / _.). 7^t]J L.✓�
GREASE TRAP:_(locate on site plan)
Depth below grade:_
Material of construction:_concrete_metal_fiberglass__polye ene_other
(explain): _
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or bafl`le:
Distance from bottom of scum to bottom of outlet tee or b e:
Date of last pumping:
Comments(on pumping recommendations,inlet and flee tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,et :
7
Page 8 of l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
185 Megan Road
Owner: Hyannis,MA
Date of Inspection: Erica Donalson
October 3,2002
TIGHT or HOLDING TANK: (tank must be pumped at time o spection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiber g ss__polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flo%%. _ gallons/day
Alarm present(yes or no):
Alarm level:_ Alarm in working or r(yes or no):
Date of last pumping:
Comments(condition of alarm and fl t switches,etc.):
DISTRIBUTION BOX: • (if present must bZopened)(1 n site plan)
Depth of liquid level above outlet invert:
Comments(note if box is level and distribution to evidence of solids carryover. any evidence of
leakage into or out of box,etc.):
PUMP CHAMBER: __(locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,Condit' n of pumps and appurtenances,etc.):
8
Page 9 of I 1
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
185 Megan Road
Owner: Hyannis,MA
Date of inspection: Erica Donalson
October 3,2002
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits, number: L ,j- w; t ' S fv.,l ,
leaching chambers,number: y— T;. A 1� , �,:-� (t, y 's�h� ti n;.,�A �.� � /�/"✓tia.r.
leaching galleries,number:
leaching trenches;number, length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/altemative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure, level of ponding, damp soil,londition of vegetation,
etc.).
lbw+.i �t,i. �c•-� 4 1�."M ya `
InE
CESSPOOLS: (cesspool must be pumped as part of inspectio 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 n�draulic
Comments(note condition of soil,signs of 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 ilure, level of ponding,condition of vegetation,etc.):
9 _
i
• Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 185 Megan Road
Hyannis,MA
Owner: Erica Donalson
Date of Inspection: October 3,2002
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
1
n c ZO 13 L - 2-0
0
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O fir . 3h f3r ' y6
G'kb' Lt4vt-�/ r
t �titi.
>% w fl, S
�0
Page I 1 of 1
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
185 Megan Road
Owner: Hyannis,MA
Date of Inspection: Erica Donalson
October 3,2002
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to groundwater ay_rj feet Adjusted high ground water elevation/7- X'feet
Please indicate(check)all methods used to determine the high ground %%ater elevation:
Obtained from system design plans on record- If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within I50 feet of SAS) —
Checked with local Board of Health-explain: „
Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:,3„_� t 3„ O 2 . 3 7. ?
You must describe how you established the high ground water elevation:
.Car
2-1
1 H 5�p-a��'� N /s i+ r-fs c-►. O!C r/cti._4, .H S p-"f' �. 7 ../c�S 5�6.wL��k o •1�-L f"U
A/ -f tv G t/Wct.r�j V h c, l /"7 T7✓y .�
U o d +
5,4410
_ dw.
7 ,
This report has been prepared and the system inspected as of the date of inspection. This report is not a
warranty or guarantee that the system will function properly in the future. There have been no warranties or
guarantees,either expressed,written or implied,relating to the system,the inspection and/or this report.
11
TOWN OF BARNSTABLE
1011"?11ON O-YL SEWAGE #
;�"Y% . ,AGE 1 r14rt�c.��✓ ASSESSOR'S MAP & LOTC� / 0;?-5V
IN NAME&PHONE NO. f�..1.�.G(.c_. c�.. �el
SEPTIC TANK CAPACITY
LEACHING FACIL=: (type) (size)
NO.OF BEDROOMS
81M ID OR OWNER
PERMUDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
j
oe
off-
0
h ,,d
ItMP g Addm—*nand gory*aeoo7 IM OOI URYWA m—m v4mmwe2q
m 1°aam°3a meaemrad om+l7eeal N a—&W-gmq ma+rte P-dgp all—app qxW a"wa
PZ31SAS 7VSOMU HOVAUM HO IS[=3XS
�O mopaadeol�oaeQ
O 9 PO f " 7p7:+eerp
(PeeDP°0e)NOLLtlNRI03AII LNaZS1[S
• �,tuva
Mo3 NOLLOaasha waisas modsia asv bas 3Dvmmsans
SZNZKSSaS AdVLNR'IOA Milo LON—PMOA NOI.13aaSN1'M M&O
�n TOWN OF BARNSTABLE
L6c;zION h_ SEWAGE# ,1
VILLAGE !J-/ wvAJ ASSESSOR'S MAP & LOT L
INSTALLER'S NAME&PHONE NO. `��
SEPTIC TANK CAPACITY .` 5v [C 9
LEACHING FACILrTY: (type) Hb��r�Csar�c=�� t�(size)
NO.OF BEDROOMS
BUILDER OR OWNERS
PERMIT DATE: 142 — 7 COMPLIANCE DATE:. o ''7
Separation Distance Between the: e T
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and'Leaching Facility (If any wells exist
on'site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
C
cli
O Q �
SIC, '
r
en
No. �. '� Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
es
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
01pprication for Migozar *p!tem Con6truction permit
Application for a Permit to Construct( )Repair(/Upgrade( )Abandon( ) X Complete System ❑Individual Components
Location Address or Lot No. 1$: kw �Ab �-�c�k Owner's Name,Address and Tel.No.
Assessor's Map/Parcel
Installer' Name Address,and Tel.No. Designer's Name,Address and Tel.No.
A- o 24o
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. %? Garbage Grinder( )
Other Type of Building No.of Persons Sh wers( ) Cafeteria( )
Other Fixtures
Design Flow "33C7 gallons per day. Calculated daily flow �cJ ` 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) �_ jkl l �C�c, r�a�,G L ►'�
c,t)r5.JQM.2dS�r
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 Cod and not to place the system in operation until a Certifi-
cate of Compliance has been issued b this B of Health.
S' ned Date ,0-47
Application Approved b Dated
Application Disapproved for ollowing reasons
Permit No. Date Issued
... 4,
No. .?,�►...tz � —�� . 'Fee
r _T
' THE COMMONWEALTH.OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS
2pprication for Migogal *pgtem Congtruction Permit ._
_Application for a Permit to Construct( )Repair(1/)Upgrade( )Abandon( ) (Complete System ❑Individual Components x„
.F�yE
Location Address or Lot No. 1$.S 1"p ", ,K) �c,a Owner's Name,Address and Tel.No.
�.• rE
Assessor's Map/Parcel
d. J Installer's Name Address,and Tel.No. '7���()��7 Designer's Name,Address and Tel.No.
h Type of Building:
h t
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 33 y gallons per day. Calculated daily flow 31Ac1 gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S. `
Description of Soil Ih�e S MF v�
Nature of Rep irs or Alterations(Answer when applicable) n3 51 A �{ ' C� ra.,/k r r a—�tom,<<LT G��✓t
C.C. r O t� St C —1-\� ` .,1 s�;�-4.�f1
J
Date last inspected:
1
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 Cdand not to place the system in operation until a Certifi-
cate of Compliance has been issued bx,th B2atrbf ealth.
S' ned DateQ7
Application Approved b Datel
Application Disapproved fa':t e oolowing `reasons
Permit No. Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewa a Disposal System Constructed( )Repaired ( )Upgraded(ev\)
Abandoned( )by
at UN-Q_ wn o c c, u i, r has been constructed in accordance
with the provisions of Title and a for Disposal IsystAi Construction Permit No. dated
Installer �1 -Cc..�t < ice.% Designer
The issuance of this permit shall not be construed as a guarantee that the system will function� as designed.
Date r - t Inspector
----------------------------------------
6,
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
Migw5al 6pgtem ongtruction Permit
Permission is hereby granted to Construct( )RXC>
ir( Upgrade( )Abandon( )
System located at -!
and as described in the above Application for Disposal System Construction Permit.
t.The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:ConstructionAnusl be completed within three years of the date-of
--tX. ermit.Date: /(� Approved by F
NOTICE: This Form isytu lie used,for tiff-Repair of Failed • • '�'�
Septic Systems Only
r
CI:R'1'IfICA'I'ION Uf SKETCH AND APPLICATION FORE D1LAO3AL
1VUIthS (.UNS`I ItUC 110N rl-Itt\f11'(1Y1'171UU 1 UESIGN
hereby certify,that the application for disposal works
construction permit signed by me dated 1� —�9 •
concerning the
property located at
meets aU of the
following criteria:
V. There are no wetlands within Soo fret of the proposed septic system
V� Thcre are no private wells within 1 So kct or the proposed septic system
Tlic observed groundwater rabic is 14 feet or greater below the bottom of the teaching facility
v 'There is no Increase in now and/or change In use proposed
There are no variances requested or needed.
DATE:
SIGNED:
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
IA(lach a sketch plan or the proposed system. Also If the licensed installer posesses a certified plot plan,
Ibis plan should be submitted).
a
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{ ,
,�
l
� �
1
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1
{ r
� �
,(
-� - 1
.,
TOWN OF,BARNSTABLE
LOCATION ;/1�S4 SEWAGE #
VILLAGE ` '1� �^-'�w� "' .ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY G�
• (type)LEACHING:FACII.ITY:
ab��,Cs a� (size) a-� Y`C l-
NO.OF BEDROOMS 3 .
BUILDER OR.OWNER
PERMTTUTE: I/� — Ga 7 COMPLIANCE DATE:
Separation Distance Between the: Feet
Ivlaximum:Adjusted Groundwater Table and Bottom of Leaching Facility
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 leaching facility)
Furnishedby:
i
o
0
J2.
i
ci
1
rJ/LL g d - rG�ZaO i�
B - - ----- Gam- .�• - -- --Ma ------
_ yS� X-rua
r ��
�, ��
_ �
s
i.
- _
��
�'m-'-----
THE ooMmomWsAcrn 'OF MAaaAc*uscTrs
�& �� �
"°" ~
�����----.OF--'
���. �
x . ��/� �~�� %��oO����� ��rrmit _
Application is hereby made for u Permit to Construct Repair ( ) an Individual Sewage Disposal
` System
Own Address
` ---° ................................ _-----'---------_--'-'-'-'----...------------'-'-_'---
Inst"lle, Address
Iyorof'Buildino Size fee
)
o~
Other ` -
Design Flow............ ......................gal ooa per person per day. Total daily flow-.--'�e.. Z)..................gallons. '
u� ~~'. a^ ^^~~^ .. Width
c� S Po �v �acuo�gvcra--. �^e�'-�g o.
�� Other D�t��ot��o 6�� �, T ^�- osing too� ( ) �
~~ ' Percolation Test Results Performed bv.......................................................................... Date....................................
Teat Pit No. '1a:..............minutes per inch Depth of Test Pit.................... Depth to gc0006 water........................
Test Pit No. 2................minutes per inch Depth of Test Pit--..------ Depth to cc000d water......................... -�
--_---.._.-.-_--'--__'-__'---...-_-__--'---'-'---___''-_-------------------- `~
v Description of S 'I
-------.-----'------------'-----------_-.---'-_-----.----_-----_------------_.-------_--------_ |
" _-- - `
Agreement:. ~
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with '
C
No.----k.. ---•---• .. ...................
THE COMMONNWEAL--T^'y�H OFg�_ B
MASSACHUSETTS
BOAR
F .
&I -le,
.
ppliration for R-sp ,sal Works To' nil rurtion Frrutit t;
Application is hereby made for a Permit to Construct ( . or Repair an Individual Sewage Disposal
System at
16
............ Altz . ........I................................................................
ionte or Lot No.
... .. ................................... .......__.................................. .
.......... •-----........------------------.
l�Own Address
W ......... .r . ... .................................
Installer Address j
d Type of Building Size Lot.__>- .+ ... ...Sq. feet
Dwelling—No. of Bedrooms___._ ........... ________________Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No. of ersons___________________________ Showers
a g •--------------------------- P - ( ) — Cafeteria ( )
Otherres -------------------.......................................---•--•----------'------•-----•---------- ----- ------------•---
W
Design Flow_____-___- , � ____________________gallons per-.person per day. Total daily flow..,...... _--- ___.gallons.
W Septic Tank—Liquid capa ' cllons Length............... Width.__ .___.._. Diameter................ Depth------,.........
"4 _
x Disposal Trench—No. ..........._�Width _ otal Le Total leaching area.._.. sq. ft.
Seepage Pit No.___----___ r el _ _ -__..__. Total leaching area___ .._. sq. ft.
Other Distribution lfox ) ng tank'( )
Percolation Test Results Performed by...... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
(� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water......_.................
-----------------------------=---------------------•----•--•---•-------..-----------•-•--....-----..........................................................
Descriptionof Soil...... ................... ----- ............. -•------------------------ ------------------------------------------•-•-------•----
I ..
V ----------------------------------------------------•------------------•-----------..__._...........
-=------------------------------------------------------------- -.............................................................................................................................
U Nature of.Repairs or Alterations—Answer when applicable................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed .Individual Sewage Disposal System in accordance with
`the provisions of Article XI of the State Sanitary Code_ The • ersigned further agrees not to place the system in
operation until a Certificate of Compliance has is d #,'boardof lt�Sign _ _eApplication Approved BY --- .---_ -----• --- .. :I.
-
Date
Application Disapproved for the following reasons:................................................... ............................................................
Date
PermitNo......................................................... Issued........................................................
Date
r
THE COMMONWEALTH OF MASSACHUSETTS 5,..
~ BOAR OF HEA
' � r
t
..........................................OF.... ....
Trdifiratr of Toutpliuttrr If, f .J
THIS I CERTIFY, hat the I dividual ewage Disposal System constructed ( or Repaired
P )
by :-- ---=- .........�
"' �I ""�""�"
at -----••. -•---- •----- .. Installer
-., -----------
has been installed in accordance with the pr ' lsions of Article XI f T State Sanitary Code describe in the
` application for Disposal Works Construction Permit No-----_.--------- dated.__._A, _.._/._ 7__. _ __
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONST E® A 'GUARANTEE THAT THE
SYSTEM WILL FUN IONS SATISFACTORY.
DATE._.... ..{t_.. ....-/..... ......... Inspector---- _--•. ... ......
THE COMMONWEALTH OF MASSACHUSETTS +t
BOAR F HEALAll T
. .-. .....OF...... ... ...
No......................... F E .. .......w
Permission is hereb:granted---•--_... Ic- -- •. -•-•--
to Cons uct or R air ( ) an Individ 1 Sewag Di pos System °t
at No/. -- .0... ........
.................... --• _-----
` = II��
Street r1�N ! 7A`
as shown on the application for Disposal Works Construction Perm', _::.__. ... d_______ ________ ________
Board of Health
DATE...................•--••.....---•-__...:
i•FORM 1255 HOBBS & WARREN, INC., PUBLISHERS - - -
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