HomeMy WebLinkAbout0113 OAK HILL ROAD - Health 113 Oak Hill Road
Hyannis P
A = 248 068
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TOWN OF BARN STABLE
LOCATION `\� �,\`� —o� SEWAGE #
VILLAGE� ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO--;:,
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SEPTIC TANK CAPACITY C���
LEACHING FACIIMITY: (type) (size)
NO,OF BEDROOMS__ `
BUILDER OR OWNER
PERMTTDATE: 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
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
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TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION Q'
Property Address: 113 OAK HILL RD HYANNIS 02601 D l�
Owner's Name: TOM MAHEDY
Owner's Address: 113 OAK HILL RD HYANNIS 02601
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Date of Inspection: 1/14/04 z
Name of Inspector: (please print) JOHN GRACI,INC. FEBCompany Name: SEPTIC INSPECTIONS PolyMailing Address: P.O. BOX 2119 TEATICKET,MA.02536 hFq�t3
Telephone Number: 508-564-6813 FAX 508-564-7270
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is
true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and
experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system
inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
X Passes
_ Conditionally, ses
_ Needs Furth valuation by the Local Approving Authority
Fails
Inspector's Signature: , '' Date: 1/14/04
The system inspector shall submit a py of this inspection report to the Approving Authority(Board of Health or DEP)within
30 days of completing this inspectoo . If the system is a shared system or has a design flow of 10,000 gpd or greater,the
inspector and the system owner shal 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
SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE
SYSTEM'S USEFUL LIFE.
****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 IncnPr.tinn Fnrm (,/i 5/?nnn 1
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Page 2 of I'1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 113 OAK HILL RD HYANNIS 02601
Owner: TOM MAHEDY
Date of Inspection: 1/14/04
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310
CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
SYSTEM PASSED TITLE V INSPECTION.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE
SYSTEM'S USEFUL LIFE.
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.
n/a 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: n/a
n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed
pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of
Health):
_ broken pipe(s)are replaced
_ obstruction is removed
_ distribution box is leveled or replaced
ND explain: n/a
n/a 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: n/a
Page 3 of 1�1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 113 OAK HILL RD HYANNIS 02601
Owner: TOM MAHEDY
Date of Inspection: 1/14/04
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.
_ 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 n/a
"This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and
volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5.ppm, provided that no other failure criteria are triggered. A copy
of the analysis must be attached to this form.
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3. Other:
n/a
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Page 4 of I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 113 OAK HILL RD HYANNIS 02601
Owner: TOM MAHEDY
Date of Inspection: 1/14/04
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all-inspections:
Yes No
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
_ X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged
SAS or cesspool
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool
_ X Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow
_ X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times
pumped NOT IN THE LAST TWO YR. PER OWNER.
X Any portion of the SAS, cesspool or privy is below high ground water elevation.
_ X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
X Any portion of a cesspool or privy is within a Zone 1 of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
X 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 must be
attached to this form.]
NO (Yes/No)The system fails. I have detennined 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.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
X the system is within 400 feet of a surface drinking water supply
X the system is within 200 feet of a tributary to a surface drinking water supply
X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone It 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.
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Page 5 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 113 OAK HILL RD HYANNIS 02601
Owner: TOM MAHEDY
Date of Inspection: 1/14/04
Check if the following have been done. You must indicate "yes" or"no" as to each of the following:
Yes No
X _ Pumping information was provided by the owner, occupant, or Board of Health
X Were any of the system components pumped out in the previous two weeks
X _ Has the system received normal flows in the previous two week period?
X Have large volumes of water been introduced to the system recently or as part of this inspection ?
X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
X _ Was the facility or dwelling inspected for signs of sewage back up ?
X _ Was the site inspected for signs of break out?
X _ Were all system components, excluding the SAS, located on site?
X _ 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?
X _ 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:
Yes no
X _ Existing information. For example,a plan at the Board of Health.
X _ 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)]
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Page 6 of 41
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 113 OAK HILL RD HYANNIS 02601
Owner: TOM MAHEDY
Date of Inspection: 1/14/04
FLOW CONDITIONS
RESIDENTIAL
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): 330
Number of current residents: 2
Does residence have a garbage grinder(yes or no): NO
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or no): NO
Seasonal use: (yes or no): NO
Water meter readings, if available(last 2 years usage(gpd)):
Sump pump(yes or no): NO
Last date of occupancy: n/a
COMMERCIAL/INDUSTRIAL
Type of establishment: n/a
Design flow(based on 310 CMR 15.203): n/agpd
Basis of design flow(seats/persons/sgft,etc.): n/a
Grease trap present(yes or no): NO
Industrial waste holding tank present(yes or no): NO
Non-sanitary waste discharged to the Title 5 system(yes or no): NO
Water meter readings, if available: n/a
Last date of occupancy/use: n/a
OTHER(describe): n/a
GENERAL INFORMATION
Pumping Records
Source of information: NOT IN THE LAST TWO YR. PER OWNER
Was system pumped as part of the inspection (yes or no): YES
If yes,volume pumped: 1000gallons-- How was quantity pumped determined? n/a
Reason for pumping: MAINTENANCE
TYPE OF SYSTEM
_Septic tank,distribution box, soil absorption system
X Single cesspool
X 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): n/a
Approximate age of all components, date installed (if known)and source of information:
1980 PER ASBUILT
Were sewage odors detected when arriving at the site(yes or no): NO
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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: 113 OAK HILL RD HYANNIS 02601
Owner: TOM MAHEDY
Date of Inspection: 1/14/04
BUILDING SEWER(locate on site plan)
Depth below grade: 16"
Materials of constriction: _cast iron _40 PVC Xother(explain): ORANGEBURG
Distance from private water supply well or suction line: n/a
Comments(on condition of joints, venting,evidence of leakage, etc.):
TOWN WATER
SEPTIC TANK: (locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_rnetal_fiberglass_polyethylene other(explain)n/a
If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate)
Dimensions: n/a
Sludge depth: n/a
Distance frorn top of sludge to bottom of outlet tee or baffle: n/a
Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
How were dimensions determined: n/a
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.):
n/a
GREASE TRAP: _(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
Date of last pumping: n/a
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related
to outlet invert, evidence of leakage, etc.):
n/a
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Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 113 OAK HILL RD HYANNIS 02601
Owner: TOM MAHEDY
Date of Inspection: 1/14/04
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: n/a
Material of construction: _concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Capacity: n/a gallons
Design Flow: n/a gallons/day
Alarm present(yes or no): N/A
Alarm level: N/A Alarm in working order(yes or no): NO
Date of last pumping: n/a
Comments(condition of alarm and float switches, etc.):
n/a
DISTRIBUTION BOX: _(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: n/a
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into
or out of box,etc.):
NONE PRESENT
PUMP CHAMBER: _(locate on site plan)
Pumps in working order(yes or no): NO
Alarms in working order(yes or no):NO
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
n/a
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Page 9 of+l I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 113 OAK HILL RD HYANNIS 02601
Owner: TOM MAHEDY
Date of Inspection: 1/14/04
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
n/a
Type
1000 GAL 6' X 6' leaching pits, number: 1
n/a leaching chambers, number: n/a
n/a leaching galleries, number: n/a
n/a leaching trenches, number, length: n/a
n/a leaching fields, number: n/a
n/a overflow cesspool, number: n/a
n/a innovative/alternative system
Type/name of technology: n/a
Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.):
THE LEACH PIT IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.THE PIT HAD 3' IN IT AT
TIME OF INSPECTION WITH STAIN LINES AT 3' -BOTTOM OF PIT AT 8' 6" -PIT APPEARS TO BE IN
GOOD WORKING ORDER.
CESSPOOLS: X(cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: 1
Depth—top of liquid to inlet invert: I"
Depth of solids layer: 4"
Depth of scum layer: 4"
Dimensions of cesspool: 6' X6"'
Materials of construction: BLOCK
Indication of groundwater inflow(yes or no): NO
Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.):
MAIN CESSPOOL AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING
PROPERLY. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE.
HOMEOWNER SAID THERE WAS NO GARBAGE DISPOSAL.
PRIVY: (locate on site plan)
Materials of construction: n/a
Dimensions: n/a
Depth of solids: n/a
Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a
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Page 10 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 113 OAK HILL RD HYANNIS 02601
Owner: TOM MAHEDY
Date of Inspection: 1/14/04
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.
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Page I 1 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 113 OAK HILL RD HYANNIS 02601
Owner: TOM MAHEDY
Date of Inspection: 1/14/04
SITE EXAM
_Slope
_Surface water
_Check cellar
Shallow wells
Estimated depth to ground water 50 feet
Please indicate(check)all methods used to determine the high ground water elevation:
NO Obtained from system design plans on record- If checked,date of design plan reviewed: n/a
NO Observed site(abutting property/observation hole within 150 feet of SAS)
YES Checked with local Board of Health-explain: SEPTIC REPORT
NO Checked with local excavators, installers-(attach documentation)
NO Accessed USGS database-explain: n/a
You must describe how you established the high ground water elevation:
GROUNDWATER INFORMATION DETERMINED FROM PREVIOUS SEPTIC REPORT BY J B MACOMBER-
REPORT STATES GRW AT 50' SOURCES USED: GAHRETY& MILLER MODEL,GROUND WATER ABOVE
SEA LEVEL- USGS 92-001 PLATE 92-USGS OBSERVATION WELL DATE JUNE 1992
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JAN-2,9-2004 10:29 BARNSTABLE WATER COMPANY 508 790 131.3 P.02/02
From Date. • • ... ,
Mahedy Thomas Status
Serial Number. •
Service Address. 101172 113 Oak Hill Rd
Meter Position
Account ID • -
Work Order • •
0 Read Mtr Meter fill R R E S Account
P Date L. Reading Cqn.sumptigj2 U I I B. T ID
12/01/03 1 291 1,M FC 1 N 1 00141457
09/02/03 1 274 2,600 FC 1 N 1 00149957
_ 06/02/03 1 248 2,500 FC 1 N 1 00149 157
03/10/03 1 223 1000 FC 1 N 1 00149957
11/09/02 1 E06 21100 FC 1 N 1 00149957
_ 09/11/02 1 185 4,900 FC 1 N 1 00149957
06/07/02 1 136 1,900 FC 1 N 1 00149457
03/04/02 1 117 1400 FC 1 N 1 00149957
12/05/01 1 107 0 FC 1 N 1 00149957
_ 11/28/01 1 107 600 FC 5 N 1 00149957
_ 09/20/01 1 101 800 FC 1 1 N 1 00149957
,O,P,t,:, , 1,=,R,Q.a,ds. . .6,®,T,e,x,t. , ,F,4=D,t,l,s. , ,F,8,=AAA0, Se,4. . .F,1,2,=,D,is,R1a,Y; ,T,Q,9,9,1,v. . . ,24=,M,o,r,e, ,
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TOTAL P.02
LOCA-TION _ SWAGE PERMIT N� ✓I
1-3
VILLAGE o
INSTA LLER'S NAME i ADORES
r-4- �yn
IUILDER OR . OWNER
CooI�
DATE PERMIT ISSUED_
DATE COMPLIANCE ISSUED �1( -
D o
0 A9,
DATE: 10/23/01
PROPERTY ADDRESS: 113 Oakhill Road
Hyannis,Mass.
------------------------
02601
------------------------
On the above date, I inspected the septic system at the above address.
This system consists of the following:
1 . 1 -6 'X8 ' block cesspool
2. 1 -1000 gallon precast leaching pit packed in stone. 6 'X10 '
Based on my inspection, 1 certify the following conditions:
3 . This is not a title fiv septic system.
4 . This is a sewage system' as had a overflow leaching pit
added to it.There fore the cesspool acts as a septic tank.
Contains solid waste in place.Effluent passes to the leaching pit.
5. The leaching pit is presently dry.
6 . The sewage system is *in proper working order at the present time.
-
SIGNATURE:
Name:-J . P. Macomber Jr .
---------------------
Company: Jose_ph_P. Macomber_& Son , Inc .
Address: Box 66
Centerville , Ma . 02632-0066
--------------------
Phone: 508-775-3338
---------------------
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
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JOSEPH P. MACOMBER & SON, INC.
Tan
Pumpedo&I elds
Installed
oF0?�,p`� Town Sewer Connections
P.O. Box 66 Centerville, MA 02632-0066
775-3338 775-6412
1\0
4
�--\ COMMONWEALTH OF MASSACHUArs
t EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
i
TITLE 5
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address:113 Oakhill Road
Hyannis,Mass.
Owner's Name: Doris Walsh
Owner's Address: Same
Date of Inspection: of 2-i.()1
Name of Inspector: (please print) J.P. Macomber Jr.
Company Name:Joseph P. Macomber & Son Inc
Mailing Address: P=O= Box _ Ef
rpn}pr_zi1le Ma 02632
Telephone Number: 508-775-3338
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is True, accurate and complete as of the time of 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
_ Needs Further Evaluation by the Local Approving Authoriry
ails
fV'
Inspector's Signature: ?,4 t Date:
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. if the system is a shared system or has a design flow of 10,000
gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving
authoriry.
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 I
Page 2 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address-1 13 Oakhi l l Road
Hyannis,Mass.
Owner: Doris Walsh
Date of Inspection: 10 2 3 01
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A'. System Passes:
Alt I have not found anv information hich indicates that any of the failure criteria described in 310 CMR
15.30 or in 310 CMR 15.304 exist. ny failure criteria not evaluated are indicated below.
Comments: -
The sewage system is in proper working order at the
present time.
B. System Conditionally Passes:
.410 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.
410 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:
W4,CObservation of sewage backup or break out or high static water level in th distribution boy ue to broken or
stru Lobcted pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is 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:
2
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Page 3 of 1 1 ,4
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A ,
CERTIFICATION(continued)
Property Address: 1 1 3 Oak Hill Road
Hyannis,Mass.
Owner: Doris Walsh
Date of Inspection: 10/2 3/01
C. Further Evaluation is Required by the Board of Health:
,V6 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.
I. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(l)(b) that the
system is not functioning in a manner which will protect public health,safety and the environment:
I! 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:
/VO 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.
V The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
Nl�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 froth a
private water supply well". Method used to determine distance
—This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other: '
This is a sewage sytsem, It has one cesspool with
a 1000 gallon leac ing pit as an overflow. The cesspool
acts a septic tank. Contains solid waste inplace and
allows the effluent to pass over the leaching pit.
3
r
Page 4 of 1 1
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address1 1 3 Oakhill Road
Hyannis,Mass.
Owner-Doris Walsh
Date of Inspection: 1 0 23 01
D. System Failure Criteria applicable to all systems:
You must 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
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
.(J� Static liquid level in th distribution box bove outlet invert due to an overloaded or clogged SAS or
cesspool
iquid depth in cesspool is less than 6"below invert or available volume is less than 'h day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
/ of times pumped
y 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.
�/_ Arty portion of a cesspool or privy is within a Zone 1 of a public well.
_ // y 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 coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
,(f (Yes/No)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•
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
_./the system is within 400 feet of a surface drinking water supply
v e 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 11 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.
4
i
s
Page 5 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 1 1 3 Oakhill Road
Hyannis,Mass.
Owner: Doris Walsh
Date of Inspection: 10 23 01
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
zwereany 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 pan 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,eluding the SAS, located on site?
t �i'pr/e Were the se tic anholes 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 ?
2— 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:
Yes no
Existing information. For example, a plan at the Board of Health.
y — Determined in the field (if any of the failure criteria related to Pan 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: 1 1 3 Oak Hill Road
Hyannis,Mass.
Owner: Doris Walsh
Date of Inspection: 10/2 3/01
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 6 Number of bedrooms(actual): .Z
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):!& "X;V 611V
Number of current residents:
Does residence have a garbage grinder(yes or no): Yd'S
Is laundry on a separate sewage system (yes or no):M [if yes separate inspection required]
Laundry system inspected(yes or no):
Seasonal use: (yes g no):available
� ����� dt1��"
Water meter readings, if available(last 2 years usage(gpd)): /e'�fJ d �'����
Sump pump(yes or no): A��
Last date of occupancy:
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): W11 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(yes or no): &Y
Water meter readings, if available: JXl
Last date of occupancy/use:
OTHER(describe): /Jf
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part of the inspection(yes or no):"
If yes, volume pumped: O gallons-- How was quantity pumped determined?
Reason for pumping: 140
TYPE OF SYSTEM
_
eptic tank,distribution box,soil absorption system ingle cesspool I 1e�
tOverflow•cesspoe} ARAOJZ?Ay
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)
a Tight tankAttach a copy of the DEP approval
4 Other(describe): )A
ApproxL'mWe age of 411 components,date installed (if known)and source of information:
49
Were sewage odors detected when arriving at the site(yes or no):
6
f
i
Page 7 of I 1 ,
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 1 1 3 Oakhill Road
Hyannis,Mass.
Owner: Doris Walsh
Date of Inspection: 1 0 23/01
BUILDING SEWER(locate on site plan)
N
Depth below grade: _ -�
Materials of construction: cast iron V6 40 PVC her(explain):
Distance from private water supply well or suction line:,e
Comments(on condition of joinu, venting, evidence of leakage, etc.):
Joints appear tight. No evidence of leakage ThP yy�t�m
is vented through the house vents.
SEPTIC TANWV4.(locate on site plan)
Depth below grade: /¢
Material of construction: concrete / metaWAftberglass A olyethylene
'(�/P other(explain) AM
If tank is metal list age:X119 Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions: AZ4
Sludge depth:
Distance from top of s e to bottom of outlet tee or baffle: A)h—
Scum thickness:
Distance from top of scum to top of outlet tee or baffle: �s4
Distance from bottom of scum to bottom of outlet tee or baffle:04
How were dimensions determined: W'/W
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 is not present The main cesspool shc)iilcl hp
bumped annually- C'arhagP di spnGal i Sp resent
GREASE TRAP"S(locate on site plan)
Depth below grade:Z2,?�
Material of constructionAW concrete 11!4meta IV#fiberglass41!±polyethyleneZ�4_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle: If/W
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:_
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
Grease trap is not present-
7
1
Page 8 of 1 I
',;
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 1 1 3 Oakhill Road
Hyannis,Mass.
Owner: Doris Walsh
Date of Inspection: 10/2 3/01
TIGHT or HOLDING TANK(tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: 4M
Material of construction: W concrete44±_metal j/,�fiberglass,eZ4—polyethylene gg&other(explain):
AM
1 Dimensions: ,4
Capacity: _ allons
Design Flow: &1P gallons/day - ' J, '
Alarm present(yes or no): A W
Alarm level: xM Alarm in working order(yes or no):
Date of last pumping:�1A
Comments (condition of alarm and float switches, etc.):
Tight or holding- tanks are no pr sent
DISTRIBUTION BOXY//� (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.): }
Distribution box is not present-
PUMP CHAMBERdWg(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 of pumps and appurtenances, etc.):
Pump chamber is not present
m
8
I
Page 9 of 1 1 A KW
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 1 1 3 Oakhill Road
Hyannis,Mass.
Owner: Doris Walsh
Date of Inspection: 10/2 3/01
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required)
1 -6 ' X8 ' bloc cesspool with 1 -1000 gallon leaching pit in
series.
If SAS not located explain why:
cr, J6'
Type
__Teaching pits,number:
,VC leaching chambers, number: O
.,VP leaching galleries,number: p
.4)Ll leaching trenches,number,length: 0
leaching fields,number,dimensions: Q
)Z overflow cesspool,number: 0 n __ � -''
� innovative/altemative system Type/name of technology:/Tl1�CJLJ� y`'� 4�*-77 '117
Comments(note condition of soil, signs of hydraulic failure, level fo ponding,damp soil, condition of vegetation,
etc.):
Loamy sand to medium fine sand.No signs of hydraulic failure
or ponding.Soils are dry.Vegetation is normal The leaching pit is
presently dry.
CESSPOOLY: Zcesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: f �—
Depth—top of liquid to inl t invert:
Depth of solids layer: _
Depth of scum laver:
Dimensions of cesspool:: ; 7
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
Same as above
PRIVYAI&&(locate on site plan)
Materials of construction: �Ji9
Dimensions: y�9
Depth of solids:
Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
Privy is not present.
9
i
Page 10 of 1 I
OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:1 13 Oakhill Road
Hyannis,Mass.
Owner: Doris Walsh
Date of Inspection: 1 0/23/01
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 \
►i3 0� �1 III w^
10
Page I I of 1 I to
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 1 1 3 Oak Hill Road
Hyannis,Mass.
Owner: Doris Walsh
Date of Inspection: 1 0 23 01
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
t
Estimated depth to ground water feet
Please indicate (check) all methods used to determine the high groundwater 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:
Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Used; Gahrety & Miller Model.Ground water above sea level
USGS 92-0001 Plate #2.
USGS Observation w 11 Data JtinP 1992
Top of Ground
Leaching o
Pit :eet
Groundwater: Feet Below Bottom of Pit High Groundwater Adjustment
Therefore, the vertical separation distance between the bottom
of the leaching pit and the adjusted groundwater table is
feet.
11
f
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1 TOWN OF Barnstable BOARD OF IIEALTII
SUI)SURFACR SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D .- CERTIFICATION
^•Tt1�T•'.':: -T.tI1.��Tr'ITT.111'II.T►1 T!I1►JfTTf T1T'r•!.•f r11RR!7 1.'-TTR�r/R1�A 7 I n ..�I•T'T•1• •�..�
-TYPO OR PRINT CI.EARLY-
PIlOPERTY INSPECTED
STREET ADDRESS113 Oak Hill Road Hyannis,Mass. '
ASSESSORS MAP , BLOCK AND PARCEL # 248-068
OWNER' s NAME Doris Walsh
PART D - CERTIFICATION
NAME OF INSPECTOR Joseph P. Macomber Jr.
COMPANY NAME Joseph P. Macomber & Svn Inc
COMPANY ADDRESS P.O. Box 66 Centerville Ma 02632
Street Town or City State iI
COMPANY TELEPIiONE (508 ) 775 - 3338 FAX ( 508 ) 790 - 1 578
R
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal, system at
this address and that the information reported is true , accurate , and
omplete as of the time of ,inspection , The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems .
Check one :
System PASSED
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
health or the environment as defined in 310 CMR 16 , 303 . Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form ,
System FAILED* \
The inspection w)licll I have con tacted has found that the system fails to
protect the j)ublic health and the environment in accordance with Title
5 , 310 CMR 15 , 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form .
r , [�
Inspector Signature Date ".7f2�4/
copy of this certification must be provided to the OWNER, the BUYER
One
where applicable ) and the BOARD OF HEALTH.
* If the inspection FAILED, the owner or."operator shall u d
within one ,year of the date of the inspection , unless allowed ortrequiredm
otherwise as provided in 3.10 ChiR 15 . 305 ,
partd . doc
Al
F60-
�r
�r3 ooJS I� f4 m s
No........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
7R __r j ...
Appliratinn fat DhOus al Workri Tnnitrurtinn ramit
Application is hereby made for a Permit to,fConstruct ( ) or Repair ( ) an Individual Sewage Disposal
System
a - U� . ----------------- .........................................
L ion-Addre s or Lot No.
- . ' 1a
_ ..... --•-••-•--••:_•---. ...............................
.. y
W �.!..:.. �Zl d .. �................. .. if.i��¢-re�-••.-•-•--............................---
Installer Address
Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
'4 Other—T e of Building No. of persons____________________________ Showers — Cafeteria
P4Other 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.......................................
aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a
Descriptionof Soil---_•_ �,7- --• .. f. ....-•---••------------------------------------------------------------•-------------..............__.
x
. ....................................
. .W ••••-•-----•---------••-----•------•--•-•••----•-•-----------------•-•--------------.....•--•-•----•-----•-. ------------ ---
UNature of Repairs or Alterations—Answer when applicable_.._..;_ 6.:�.. ....... ....... ..................................
..-••-•-•-------•--•••••.•--•--•••.......--•......_..••••••••--••••-•..............................•••-•----....-•-••-----•-••-•---••-•-••----••------••••••---•............_............._..--••.---•••
Agreement
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iiTLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has ben issued by the board of ealth.
Sig .....P..MutesI.A............. ,
Dat
Application Approved By------ /✓-- 4v
,7 -------_---------------
Date
Application Disapproved for the following reasons--------------------------------•---------------------------------------------- ...........................
................•---•----------------.............-----------.....------.....----•-----------••--•--------•--•••-•-----•--•-----•••--------•-----•--•-•-------------------------------------------------
Date
a
... Issued.... ....__.Permit No..........................................•-•----•--• � . .................-...-...-..
Date
N.
No........�_9_4
,THE COMMONWEALTH OF MASSACHUSETTS
%BOARD OF HEALTH
J. ..........................
............. . ..OF..... ............................
b;
Appliration for M.0"V' aaal Worko Tongtrurtion ramit
Application is hereby made for 'a Permit to Construct, or Repair an Individual Sewage Disposal
System at:
.......... -----------
Location-Address or Lot
............................ ..................... _................................................
Owner I Address
....
Installer r Address
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder
Other—Type of Building ............................ No. of persons............................ Showers Cafeteria
Otherfixtures ......................................................................................................................................................
Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
9 Septic Tank—Liquid capacity............gallons Length.......�i....... Width________________ Diameter_____._._____.__ Depth___.________._-_
Disposal Trench—No_.................... Width_..._._._.._._..__.. Total Length______.____.________ Total leaching area....................sq. ft.
Seepage Pit No_____________________ ameter.................... !Depth Di below inlet.__..___.._____._.__ Total leaching area..................sq. f t.
- f,
Z Other Distribution box-(' -Dosing tarik
Percolation Test Results Performed by....... Date........................................
......................... .......................................
Test Pit No. I................rpinutes per inch Depth of Test Pit_.__.___._.__.______ Depth to ground water........................
Test Pit No. 2...............mmutes per inch Depth of Test Pit__.____...__________ Depth to ground water._____.________.___.___.
.................................... .....................................................................................................................
0 Description of Soil.___.__.:_. ...../........ ; -/
. . .. . . .. .. ......................................................................................................................
.................................................................................................................................................. ...... .....................................
------------------------------------------------------------------------ --------------------------------------i.................... ...... . . ........ .................................
Nature of Repairs or Alterations—Answe& when applicable............ZLII...... ---- .. ...�--•--•-----••-••---------•--•----
Agreement .................................
U
...............................................................................................................................................................
>.N,,.
The undersigned agrees to install e aforedescribed Individual Sewage Disposal System in.accordance with
njstal'l*'th Sz
the provisions o0*L*!TLE_ 5xif,the Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certiff-alt"e' of Compliance has been issued by the board of health.
V
S 41
........................................ ...............................
D t
�a- _4...........
Application Approved By...... .... ........................ 7 ..... ...
Date
Application Disapproved-for the following reasons:............................== -------------------------------------------------------------------------------
..........11K....................................................................................................... ...............................................................................
Date
'Permit No.........................I..................
.............. Issued_....------
'.
Date
THE COMMONWEALTH OF MASSACHUSETTS
A�
BOARD OF H,EA1jH
........... I V' �
...........J.........;......... ..... ...... . .............I........................................
(9prfifirate`of4 (&impItaurr
4
THIS-IS.-TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired
b J-...1....j....�...�../..j../..,/..,....,/.....�...,..!-I)--,-------*------,- ` ----- /;/------I '......................................................y----------4....... --
/ / / / / Inetaller .........................
at................................................................................................................. ------------------------------------*......................
I / t ...........
has been installed in accordance with the provisions of�,T" 5 of The,State Sanitary Code as describ d in the
application for Disposal Works Construction ... .... J' V Permit N, . . ........ dated.......7--.Z: .................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTIr Amn,
SATISFACTORY.
I . 4 *...................................................
DATE.... :Inspector. ---e�Z/
............-----------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
F 0.... ..................................... 0 ............................................................................
N ..... FEE.... :'_........
Ehiposal,Marko TDonottudiall rrrud�_
Permission is hereby granted......2... ....I,))/-//,/J,)/h?",1�- -i I/ ..)) ;?1�
.............r................................�n.......�--7 .........................................
to Construct or Repair (X) an Individual Sewage Disposal System
at No... r)
Street
as shown on the application for Disposal Works Construction Per Ot"'go----------Z d.... ...............
.......................
...... 2A 44
DATE... ........................................... ... Board of Health ::4
.. -------------
............
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS