HomeMy WebLinkAbout0071 MIDWAY DRIVE - Health 71 Midway Drive
Hyannis
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Commonwealth of Massachusetts
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Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
71 MIDWAY DRIVE
Property Address h+
QD
BANK OWNED
Owner Owner's Name
information is CENTERVECL� MA 02632 02/28/2016
required for every s �-+
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.
Important:When A. General Information c
filling out forms 11,411„� ,
on the computer, '
use only the tab 1. Inspector:
key to move your
cursor-do not JOHN P GRACI SR
use the return Name of Inspector
key.
GRACI SEPTIC INSPECTIONS LLC
Company Name
PO BOX 2119
Company Address
TEATICKET MA 02536
City/Town State Zip Code
508-641-6694 S1468
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 Evalu on by the Local Approving Authority
AL 02/28/2016
Inspector's Signature Date
The system inspector sh submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within days of completing this inspection. If the system is a shared system or
has a design flow of 10,0 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
-Page 1 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
71 MIDWAY DRIVE
Property Address
BANK OWNED
Owner Owner's Name
information is required for every CENTERVILLE MA 02632 02/28/2016
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:
® 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:
AT TIME OF INSPECTION SYSTEMS APPEARS TO BE STRUCTURALLY SOUND AND
FUNCTIONING PROPERLY.
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
NA
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 71 MIDWAY DRIVE
Property Address
BANK OWNED
Owner Owner's Name
information is required for every CENTERVILLE MA 02632 02/28/2016
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high 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):
NA
❑ 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):
NA
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
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 71 MIDWAY DRIVE
Property Address
BANK OWNED
Owner Owner's Name
information is required for every CENTERVILLE MA 02632 02/28/2016
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well
**
Method used to determine distance: NA
** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
NA
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/day flow
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
71 MIDWAY DRIVE
Property Address
BANK OWNED
Owner Owner's Name
information is required for every CENTERVILLE MA 02632 02/28/2016
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
4
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 71 MIDWAY DRIVE
Property Address
BANK OWNED
Owner Owner's Name
information is required for every CENTERVILLE MA 02632 02/28/2016
page. Cityfrown 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)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
(Sins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 71 MIDWAY DRIVE
Property Address
BANK OWNED
Owner Owner's Name
information is required for every CENTERVILLE MA 02632 02/28/2016
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
1000 GALLON SEPTIC TANK 1000 GALLON LEACH PIT WITH 2' OF STONE
Number of current residents: VACANT
Does residence have a garbage grinder? Yes N
9 9 9 ❑ ® o
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 ears usage TOWN
9 ( Y 9 (gpd))�
Detail:
2014 900 CUBIC FEET 2015 ZERO
Sump pump? ❑ Yes ® No
Last date of occupancy: VACANTDate
Commercial/Industrial Flow Conditions:
Type of Establishment: NA
Design flow(based on 310 CMR 15.203): NA
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.): NA
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: NA
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
71 MIDWAY DRIVE
Property Address
BANK OWNED
Owner Owner's Name
information is required for every CENTERVILLE MA 02632 02/28/2016
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: NA
Date
Other(describe below):
NA
General Information
Pumping Records:
Source of information: NA
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: NA
gallons
How was quantity pumped determined? NA
Reason for pumping: NA
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):
SEPTIC TANK LEACH PIT
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 71 MIDWAY DRIVE
Property Address
BANK OWNED
Owner Owner's Name
information is required for every CENTERVILLE MA 02632 02/28/2016
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
1989
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: (24 )TWENTY FOUR INCHES
feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line. 10+ FEET
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade: (18) EIGHTEEN INCHES
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
SEPTIC TANK APPEARS TO BE STRUCTURALLY SOUND AT TIME OF INSPECTION. UNABLE
TO INSPECT UNDER NORMAL USAGE SYSTEM WAS EMPTY AT TIME OF INSPECTION
If tank is metal, list age: NA
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
1000 GALLON
Sludge depth: EMPTY
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M s 71 MIDWAY DRIVE
Property Address
BANK OWNED
Owner Owner's Name
information is required for every CENTERVILLE MA 02632 02/28/2016
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle EMPTY
Scum thickness EMPTY
Distance from top of scum to top of outlet tee or baffle EMPTY
Distance from bottom of scum to bottom of outlet tee or baffle 0
How were dimensions determined? VISUAL
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
SEPTIC TANK APPEARS TO BE STRUCTUARLLY SOUND AT TIME OF INSPECTION .UNABLE
TO INSPECT UNDER NORMAL USEAGE RECOMMEND PUMPING EVERY TWO YEARS.
Grease Trap(locate on site plan):
Depth below grade: NA
feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
NA
Dimensions:
NA
Scum thickness NA
Distance from top of scum to top of outlet tee or baffle NA
Distance from bottom of scum to bottom of outlet tee or baffle NA
I
Date of last pumping: NA
Date
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
71 MIDWAY DRIVE
Property Address
BANK OWNED
Owner Owner's Name
information is required for every CENTERVILLE MA 02632 02/28/2016
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.):
NA
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade: NA
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions: NA
Capacity: NA
gallons
Design Flow: NAgallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: NA Alarm in working order: ❑ Yes ❑ No
Date of last pumping: NA
Date
Comments (condition of alarm and float switches, etc.):
NA
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
i
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 71 MIDWAY DRIVE
Property Address
BANK OWNED
Owner Owner's Name
information is required for every CENTERVILLE MA 02632 02/28/2016
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert NA
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.):
NA
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.):
NA
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
NA
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 71 MIDWAY DRIVE
Property Address
BANK OWNED
Owner Owner's Name
information is required for every CENTERVILLE MA 02632 02/28/2016
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: (1) ONE
❑ leaching chambers number: NA
❑ leaching galleries number: NA
❑ leaching trenches number, length: NA
❑ leaching fields number, dimensions:
NA
❑ overflow cesspool number: NA
❑ innovative/alternative system
Type/name of technology: NA
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
1-1000 GALLON LEACH PIT WITH (2)TWO FEET OF STONE APPEAR TO BE STRUCTUARLLY
SOUND AT TIME OF INSPECTION. UNABLE TO INSPECT UNDER NORMAL USEAGE. EMPTY
AT TIME OF INSPECTION. (1) ONE FOOT OF LEACHING LEFT. RECOMMEND RAISING
COVER
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration NA
Depth—top of liquid to inlet invert NA
Depth of solids layer NA
Depth of scum layer NA
Dimensions of cesspool NA
Materials of construction NA
Indication of groundwater inflow ❑ Yes ❑ No
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
f .
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
71 MIDWAY DRIVE
Property Address
BANK OWNED
Owner Owner's Name
information is required for every CENTERVILLE MA 02632 02/28/2016
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
NA
Privy(locate on site plan):
Materials of construction: NA
Dimensions NA
Depth of solids NA
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
NA
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
71 MIDWAY DRIVE
Property Address
BANK OWNED
Owner Owner's Name
information is required for every CENTERVILLE MA 02632 02/28/2016
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
OACL
PATID
1
0-
A V 1 b1 cn
A2cDb 62 5TI
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
r
e
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 71 MIDWAY DRIVE
Property Address
BANK OWNED
Owner Owner's Name
information is required for every CENTERVILLE MA 02632 02/28/2016
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: 12+FEET
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
HAND AUGER
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
H u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
71 MIDWAY DRIVE
Property Address
BANK OWNED
Owner Owner's Name
information is required for every CENTERVILLE MA 02632 02/28/2016
page. Citylrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
�OFTHE Tp DATE:
FEE:
• BARNSTABLE, "
y MASS.
1639. �0� REC. B ��
Town of Barnstable
SCHED. DATE: J,, ly
Board of Health zo?
200 Main Street, Hyannis MA 02601
Office: 508-862-4644 Wayne A.Miller,M.D.
FAX: 508-790-6304 - Paul J.Canniff,D.M.D.
�1.1�3�ofL�-Id�L �v I�tau
REQUEST FORM
LOCATION
L t Yoh lS
Property Address:
Assessor's Map and Parcel Number: (09 Size of Lot:
Wetlands Within 300 Ft. Yes Business Name:
No Subdivision Name:
APPLICANT'S NAME: j?D/,.� Phone 150 —7 LD -7 9 J
Did the owner of the property authorize you to represent him or her? Yes No
PROPERTY OWNER'S NAME CONTACT PERSON
Name: R_oe,, ,efz_,v in p e2,�-oiJ Name:
Address: SA 0-t 2 Address:
Phone: �j Q — 0 :79 431�_ Phone:
/-N JS,^tJN
VARIANCE FROM REGULATION(List Reg.) REASON FORE(May attach if more space needed)
40
NATURE OF WORK: House Addition ❑❑❑❑❑❑ House Renovation ❑ Repair of Failed Septic System
Checklist (to be completed by office staff-person receiving variance request application)
Please submit copies in 4 separate completed sets.
_ Four(4)copies of the completed variance request form
_ Four(4)copies of engineered plan submitted(e.g.septic system plans)
_ Four(4)copies of labeled dimensional floor plans submitted(e.g.house plans or restaurant kitchen plans)
_ Signed letter stating that the property owner authorized you to represent him/her for this request
_ Applicant understands that the abutters must be notified by certified mail at least ten days prior to meeting date at applicant's expense (for Title
V and/or local sewage regulation variances only)
_ Full menu submitted(for grease trap variance requests only)
_ Variance request application fee collected(no fee for lifeguard modification renewals,grease trap variance renewals[same owner/leasee only],
outside dining variance renewals[same owner/leasee only],and variances to repair failed sewage disposal systems [only if no expansion, to the
building proposed])
Variance request submitted at least 15 days prior to meeting date
VARIANCE APPROVED Wayne Miller,Chairman
NOT APPROVED Paul J.Canniff,D.M.D.
REASON FOR DISAPPROVAL
Q:\Application Forms\VARIREQ.DOC
1
MAIL-IN REQUESTS
Please mail the completed variance application form to the address below. Also include four
copies of engineering plans, house plans, authorization letter, etc (see check-list- below). In
addition, please include the required fee amount (see fees at bottom of this page). Make
$85.00 check payable to: Town of Barnstable. Our mailing address is:
Town of Barnstable
Public Health Division
200 Main Street
Hyannis, MA 02601
Checklist
_ Four(4)copies of the completed variance request form
_ Four(4)copies of engineered plan submitted(e.g.septic system plans)
_ Four(4)copies of labeled dimensional floor plans submitted(e.g.house plans or restaurant kitchen plans)
_ Signed letter stating that the property owner authorized you to represent him/her for this request
_ Applicant understands that the abutters must be notified by certified mail at least ten days prior to meeting date at applicant's expense (for Title
V and/or local sewage regulation variances only)
_ Full menu submitted(for grease trap variance requests only)
_ $85.00 variance request application fee (no fee for lifeguard modification renewals, grease trap variance renewals [same owner/leasee only],
outside dining variance renewals[same owner/leasee only],and variances to repair failed sewage disposal systems[only if no expansion to the
building proposed])
Variance request submitted at least 15 days prior to meeting date
FOR FAXED REQUESTS
Our fax number is (508) 790-6304. Please fax a completed application form.
Also, you must mail the required $85.00 fee. Please make the check payable to: Town of
Barnstable. The check must be mailed to the address listed above. In addition, please mail
four copies of engineered plans, house plans, authorization letter, etc. (see check-list below):
Checklist
Four(4)copies of engineered plan submitted(e.g.septic system plans)
_ Four(4)copies of labeled dimensional floor plans submitted(e.g.house plans or restaurant kitchen plans)
Signed letter stating that the property owner authorized you to represent him/her for this request
_ Applicant understands that the abutters must be notified by certified mail at least ten days prior to meeting date at applicant's expense (for Title
V and/or local sewage regulation variances only)
_ Full menu submitted(for grease trap variance requests only)
_ $85.00 variance request application fee(no fee for lifeguard modification renewals, grease trap variance renewals [same owner/leasee only],
outside dining variance renewals[same owner/leasee only],and variances to repair failed sewage disposal systems[only if no expansion to the
building proposed])
Variance request submitted at least 15 days prior to meeting date
For further assistance on any item above, call (508) 862-4644
Back to Main Public Health Division Page
EXCERPT FROM BOARD OF HEALTH MEETING MINUTES ON 7/14/09:
VI. INFORMAL REVIEW:
A. Robert Anderson, owner - 71 Midway Drive, Hyannis, Map/Parcel 252-
069, 0.26 acre parcel, installing a White Knight treatment system.
Robert Anderson was present and explained that his house was built in 1966 as a 2
bedroom with an unfinished upstairs. The septic was not increased at the time the
additional bedrooms were built in.
Dr. Miller stated there are issues to be resolve: 1) need a septic system designed for
four bedrooms provided they are not in a restricted zone, or if the property is limited
to expansion, Mr. Anderson will have to convince the Board of Health historically that
the bedrooms upstairs were put with proper permits even though the size of the
septic was an oversight by the town. With the small system, the owner is aware that
he will most.likely need to replace the whole system.
Mr. Anderson said the Building Division has the proper permit in their file. He also
mentioned that he is interested in using his property for the White Knight System
since he needs to change his entire system.
The Board stated that Mr. Anderson will have to have his engineer look into the MA
DEP's approvals for the White Knight. The MA DEP must approve it before the
product is permitted to be used in our town.
r
COMMONWEALTH OF MASSACHUSETTS 2� �—
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS .
DEPARTMENT OF ENVIRONMENTAL PROTECTION
RECEIVED
as
SEP 1 5 2004
TOWN OF BARNSTABLE
TITLES HEALTH DEPT.
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 71 Midway Drive
Centerville .
Owner's Name: Andre Nolin a�Ap
Owner's Address: ,� LRRCEL TJ-�-
Date of Inspection
Name of Inspector.(please print) W i 1 1 jam E_ •Robinson Sr.
Company Name: William E. Robinson Septic Service
Mailing Address: P O Box 1089
Centerville, MA
Telephone Number: (508) 775-8776
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP
approved system inspector pursuan7P"asses
tion 15340 of Title 5(310 CMR 15.000). The system:
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: /v., ltz-� Date: T-r V—o y
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Heatth 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 seat to the system owner and copies:sent to the.buyer,if applicable,and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1 .
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 71 Midway Drive
Centerville
Owner: Andre Nolin
Date of Inspection:
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. Sys in Passes:
I have not found any information which indicates that any of the failure criteria described in 310 CMR.
15.303 or in 310 CUR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments: {
dS C� Al kk-v
B. System Conditi nally Passes:
One or more iystcm 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 no determined(Y,N,ND)in the for the following statements.If"not determined"please
explain.
The septic is metal and over 20 years old' or the septic tank(whether metal or not)is structurally
unsound,exhibits sut stantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the
existing tank is repla Led with a complying septic tank as approved by the Board of Health.
•A metal septic tank ill pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the is less than 20 years old is available.
ND explain:
Observatio of sewage backup or break out or high static water level in the distribution box flue to-broken or
obstructed pipes) r due to a broken,settled or uneven distribution box.System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or mplaced
ND explain:
Th system required pumping more than 4 times a year due to broken or obswucted pipe(s).The system will
pass insp tion if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is rcmovod 4
ND explain:
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 71 Midway Drive
Centerville
Owner: Andre Nolin
Date of Inspection: .91/��
C. Fu her Evaluation is Required by the Board of Health:
C ditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing t protect public health,safety or the environment.
1. Sys( m will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
sysle is not functioning in a manner which will protect public health,safety and the environment:
sspool or privy is within 50 feet of a surface water
_ C sspool 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 fu ictioning 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 1 vater supply or tributary to a surface water supply.
system has a septic tank and SAS and the SAS is within a Zone l of a public water supply.
_ T e system has a septic tank and SAS and the SAS is within 50 feet of a private water supply.well.
e system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
priva a water supply well•• Method used to determine distance
"T is system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bac ena and volatile organic compounds indicates that the well is free from pollution from that facility and
the resence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
far ure criteria are triggered.A copy of the analysis must be attached to this form.
3. (her:
- 3
Page 4 of I l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 71 Midway Drive
Centerville
Owner: Andre Nolin
Date of aspection: —fit
D. Sysi m Failure Criteria applicable to all systems:
You mus indicate"yes"or"no"to each of the following for all inspections:
Yes No
_ ackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
_
ischarge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
ogged SAS or cesspool
tic liquid level in the distribution box above.outiet invert due to an overloaded or clogged SAS or
c spool
- _ Li uid depth in cesspool is less than 6"below invert or available volume is less than%day flow
_ Re uired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of imes pumped
An portion of the SAS,cesspool or privy is below high ground water elevation.
An portion of cesspool or privy is within 100.15eet of a surface water supply or tributary to a surface
wa er supply.
An portion of a cesspool or.privy is within a Zone 1 of a.public well.
_ .An r portion of a cesspool or privy is within 50 feet of a private water supply well.
An e portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private'A-Ater
su ply well with no acceptable water quality analysis.(This system passes if the well water analysis,
pe formed at a DEP certified laboratory.,for coliform bacteria and volatile organic compounds
in icates that(lie well is free.from pollution from(fiat facility and the presence of ammonia
n' rogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
a e triggered.A copy of the analysis must be attached to this form.)
(Yes o)The system fails. 1 have determined that one or more of-the above failure criteria exist as
escribed 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.
L La r a Systems:
To be onsidered a large system the system must serve a facility with a design now of 10,000 gpd to 15,000
gpd-
You ust indicate either"yes"or"no"to each of the following:
(The ollowing criteria apply to large systems in addition to the criteria above)
yes n
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 We Protection Area—1WPA)or a mapped
Zone 11 of a public water supply well
If you h e answered"yes"to any question in Section E the system is cocisidered a significant threat,or answered
"yes"i Section D above the large system bas failed.The owner or operator of any large system considered a
signifhc nt threat under Section E or failed[under Section D shall upgrade the system in accordance with 310 CMR
15.304.The system o%%wr should contact the appropriate regional office of the Department.
4
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 71 Midway Drive
Centerville
Owner:—Andre No in
Date of Inspection:
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
ZWere 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?,.
t/ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
v- Was the facility or dwelling inspected for signs of sewage back up?
Was the site inspected for signs of break out?
'V _ Were all system components,excluding the SAS,located on site?
L-®L4 14ie 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?
— __1_,,4as the facility owner(and occupants if different from owner)provided with information on the.proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes ilixiisting
_ 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(3)(b))
5
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 71 Midway Dr; vP
Centerville
Owner: n Centerville
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAI.
Number of bedrooms(design):;---3 Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): a a
Number of current residents: _
Does residence have a garbage grinder(yes or no):�L .
Is laundry on a separate sewage system(yes or no):,U[if yes separate inspection required]
Laundry system inspected(yes or no):L�
Seasonal use:(yes or no):/
Water meter readings,if available(last 2 years usage(gpd)): 2 0.0 3 — 7 4, 2 5 0
Sump pump(yes or no):;&^0 2002 — 65, 250
Last date of occupancy:
COMMf R L/INDUSTRIAL
Type of establi ent:
Design flow(ba ed on 310 CUR 15.203): Rpd
Basis of design I low(seats/persons/sgft,etc.):
Grease trap pres nt(yes or no):_
Industrial waste olding tank present(yes or no):_
Non-sanitary w ste discharged to the Title 5 system(yes or no):_
Water meter r dings,if available:
Last date of o cupancy/use:
OTHER(d scribe):
GENERAL INFORMATION
Pumping Records
Source of information: Al A
Was system pumped as paft of the inspection(yes or no):
If yes,volume pumped: allons-=How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
�Fvegrflow
'c tank,distribution box,soil absorption system
e cesspool
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:
Were sewage odors detected when arriving at the site(yes or no):
6
I'agc 7 of
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 71 Midway. Drive
Centerville
Owner: Andre Nolin
Date of Inspectlon: —Q y
BUILD SEWER(locate on site plan)
Depth bel w grade:
Materials f construction:_cast iron _40 PVC _other(explain):
Distance om private water supply well or suction line:
Common s(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK:_(locate on site plan)
Depth below grade:
Material of constru ion:_concrete metal fiberglass_polyethylene
_other(explain)
If tank is metal list ge:_ Is age confumed•by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions:
Sludge depth:
Distance from to of sludge to bottom of outlet tee or baMe:
Scum thickness:
Distance from t of scum to top of outlet tee or baffle:.
Distance from ottom of scum to bottom of outlet tee or baffle:
How were di nsions determincd:
Comments( pumping recommendations,inlet and outlet tee or battle conditicn,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
A-A
Lim
SE T P: (locate on site plan)
below ade:_
al of a nstruction:_concrete._metal fiberglass_polyethylene_other
n): _
sions:
hic ess:
ce fr m top of scum to top of outlet tee or baffle:
ce fr m bottom of scum to bottom of outlet tee or baMc:
f I t pumping:e s(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
d to outlet invert,evidence of leakage,etc.):
Page 8ofII
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 71 Midway Drive
r'entPr�; i i P
Owner:
Date of Inspection: �1✓m
TIGHT or HOLD G 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: allons/day
Alarm present(yes r no):
Alarm level: Alarm in working order(yes or no):
Date of last pump' g:
Comments(condi on of alarm and float switches,etc.):
j
DISTRIBUTION BOX: (i present must be opened)(locate on site plan)
Depth of liquid level above out] t invert:
Comments(note if box is level nd distribution to outlets any equal, evidence of solids ca over evidence of
q } rTY �any
leakage into or out of box,etc
PUMP CHAMBER: ( cate on site plan)
Pumps in working order( s or no):
Alarms in working order yes or no):
Comments(note condi on of pump chamber,condition 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: 71 Midway Drive
Centerville
Owner: Andre Nolin
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation'not required)
If SAS not located explain why:
Type
leaching pits,number:_
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
aching fields,number,dimensions:
overflow cesspool,number: 1
innovative/altemative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.):
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: �. w
Depth—top of liquid to inlet invert: '
Depth of solids layer: 4— (,s
Depth of scum layer: �...
Dimensions of cesspool: ar
Materials of construction: /eel -4
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,dens of hydraulic failure,level of ponding,condition of vegetation,etc.):
A- brIL
PRIVY: (locate on site Ian)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note conditi n of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
Page 10 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 71 Midway Drive
Centerville
Owner: Andre Nolin
Date of Inspection: -`" -
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.
IV
All
Y
10
Page 11 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: .71 Midway Drive
Centerville
Owner. Andre Nolln
Date of Inspection:
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
;hecked with local excavators,installers-(attach documentation)
'^Accessed USGS database-explain:
You must describe how ou established the high ground water elevation:
11
TOWN OF BA.RNSTABLE
LOCATE ION ")I T)rZ-. SEWAGE #
`JILLAGE ASSESSOR'S MAP & LOT
INSTALLER'S NAME PHONE NO. V*-
SEPTIC-,TANK CAPACITY < , C90
o
LEACHING FCId.ITY:(type) t'�$' i, b (size)
NO. OF,BEDROOMS PRIVATE EVE ;L 0'R UBLIC W®ATER
i BUILDER OR OWNER f' r*k)A2
DATE PERMIT ISSUED. ( hod�1
DATE COMPLIANCE ISSUED: I-77-7
VARIANCE GRANTED: ides Ida
.- _ \,
'i7
\�
��
_¢ i
•";rr
!�,
i J4 � �?��
r __...-_....-�_
Jw�
No....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
... ...................0 F... ................................................
Ap.pliration for Disposal Works Tonstrurtion Prrmit
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at: Y6
Location-Adaesff_y_ _Vm��........ ..................................................................................................
r Lot No.
........KA.0141
OwnerAddress
-------------------------------
Address
Type of Building Size Lot----------------------------Sq. feet
U
Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder
aOther—Type of Building ............................ No. of persons............................ Showers Cafeteria Other fixtures
<� ..........................
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
1:4 Septic Tank—Liquid capacity............gallons Length................ Width....._.......... Diameter......_..._..._. Depth._..._.......___
Disposal Trench—'\To..................... Wiclth.................... Total Length.
................... Total leaching area--------------------sq. f t.
Seepage Pit No..._-__--__--_____-. Diameter.................... Depth below inlet......_............. Total leaching area..................sq. f t.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by........................................................................* Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit......__............ Depth to ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit.__................. Depth to ground water-___._-____--.-..______
-------------------------------i........................ ....*--------------------------""......"----------*-------------------*--------------*---------------------------
0 Description of Soil.....cr�----------------!SL�44.... ..�2 .. -C.Atvl>
W .... ..... .............................................................
U ........................................................................................................................................................................................................
W
x ...............I........................................................................................................................................................................................
U Natum of Repairs or Alterations—Answer when applicable.._)AS-3.%mA&........ ......0-4.e!nLLXY.%_........................
........ ..........N.A) C-?\ E-
...I.....................................................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
`-T: `P�77
the provisions of 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by t board o' ealth.
'Signed.....!�_ ... ........... ...... ................... ................................
Application Approved By........... Date
Dale
Application Disapproved for the following reasons:..............................................................................................................
........................................................................................................................................................................................................
Date
/ /Q.. ....................
Permit No....... ....................... Issued-----
..
Date
No.--- rl � FEs..3.a........_
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......... 3?.L07-U...............OF.... ,vkCZWstI�►. .................................................
Applirtttion for Pispos al Works Tonstrnrtion t rruti#
Application is hereby made for a Permit to Construct ( ) or Repair { an Individual Sewage Disposal
System at:
......."1. ........ --..................................... ..................................................................................................
Location-Address or Lot No.
..^V n(�. - '.�.? -►. NZ•;1'1t4s2A 'fig.............•-•--• •----....•-----•-......---••-................ ir...------•"-•••--................._...........
Owner Address
a __Aic,.)jgj_�Y.....rs�. c. .sO.P_..-•------ C?...�anaC.. P_O . Cox ?zL e�w� +�v►�.�..
..... ...........................•--•--..----- --•-•-•......_......---•----...._.._......-------------
Installer Address
U Type of Building Size Lot----------------------------Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
a Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Other fixtures
w Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P4 .••-•••--•----•-•-••-•------•••••-•••---•......---•-----•-----•-_.......-•--------'-•. •-••....................
O Description of Soil......f�:-_2................•= - /'�t7...__S�ay`�- - -..._... - ...
x
w
U Nature of Repairs or Alterations—Answer when applicable_.....W_ 'r` ........ .S?a� �'-a LL??p_____________________
---
- , ............._i_9 u IF...••----'--•--•-•.......--•---••••--••••--•--•---•----•••----•---••-••-••--------•-•---•------------------••--....--
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by t,e board of IIIlth.
Signed c Sa--...... . �� -` `----- ?
A lication Approved B Dated
PP PP Y ~� ..................Z....�--P•_......
Date
Application Disapproved for the following reasons----------------------------•------•--------------------•------•--•------------..........-•-•--....----••-•--•---
.....................•----•--•---------.....Q.-----------•---.............----....•........-•------•-•-..._..--•--•--------------...------------------------. -.----------------------------------------
Permit No......... = c ................--- Issued--- Date '•
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
. ..........�.tZiW*J................OF......74 '-.AgNVr-.......6%*
Trriifirtt#r of. Toutplitturr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (1043
by--•--kAAe_4E:`t....S'r tiuIS--_._. O.:....- --------------- --- -----------.....----------------------------•••........-----••------
Installer
at......!j........... .......... .......--- V�`
has been installed in accordance with the provisions of TIT 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No......_ 1K��_--�G'--._?1....... dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FU TIOIJ SATISFACTORY.
DATE........... •..... ...............................
Inspector- `'. % .....•---- .
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
� ��................oF..` ?ew� -t�LC
No......A. - ,� �
FEE.....V................
Disposal Works Tons#rurtion rrutit
Permission is hereby granted....... •.•..... SIM....rd...............................................................................
to Construct ( ) or Repair ( !an Individual Sewage Disposal System
at No.......^k------•----�^` >.....`"�&!------•--4 g t I ..... Q-a1J I, V•1"-
-•-•--------------•---------------•-•-•---...••----
Street CJ
as shown on the application for Disposal Works Construction Permit No____ ��___________ Dated_.__..__...___.___....___.._._....._......
DATE...................�-�-".�..--��..................................
Board of Health
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS