HomeMy WebLinkAbout0019 OAKVIEW TERRACE - Health 19 OAKVIEW TERRACE, HYANNIS
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TOWN OF BARNSTABLE ,
LOCATION Oak secj -re r-toaC e- SEWAGE #
VILLAG ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. W,chac L W e L L e tt
SEPTIC TANK CAPACITY 1000 4a.LLons
LEACHING FACILITY: (.type) (size)
NO. OF BEDROOMS J
1'nTrIT tBl✓R-9R OWNER
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PERMITDATE: 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
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TOWN OF BARNSTABLE
LOCATION SEWAGE #
VIL LAGE A,e-'Pi ASSESSOR'S MAP & LOT o
INSTALLER'S NAME &V14ONE NO.
.SEPTIC TANK CAPACITY
LEACEIING FACILITY: (type) (size)
NO. OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: 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
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Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r=
t„"
w�:+
19 Oakview Ter. i
iG^M
Property Address;;
Maria Altobelli
Owner Owner's Name «•
information is H annis Ma. 02601 07-02-2018 "-
required for every y
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 filling out forms A. General Information
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Michael T Bisienere
use the return Name of Inspector
key.
Cape Septic Inspections
r� Company Name
624 Old Barnstable Road
Company Address
Mashpee Ma. 02649
Cityrrown State Zip Code
508-280-3356 S13938
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
2 07-02-2018
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original should be sent to the system owner and copies sent to the
buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17
t ;
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 19 Oakview Ter.
Property Address
Maria Altobelli
Owner Owner's Name
information is required for every Hyannis Ma. 02601 07-02-2018
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
This 3 bedroom home has a H-10 1000 gallon septic tank and a H-10 D-Box feeding a leaching pit. At
the time of the inspection the leaching was dry.
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 FIND (Explain below):
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
r
i t
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
19 Oakview Ter.
1y
Property Address
Maria Altobelli
Owner Owner's Name
information is required for every Hyannis Ma. 02601 07-02-2018
-
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):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
r -
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
19 Oakview Ter.
Property Address
Maria Altobelli
Owner Owner's Name
information is required for every Hyannis Ma. 02601 07-02-2018
page. CitylTown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
-more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
El ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6 below invert or available volume is less
than Y2 day flow
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 19 Oakview Ter.
Property Address
Maria Altobelli
Owner Owner's Name
information is required for every Hyannis annis Ma. 02601 07-02-2018
page. Cityrrown 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
❑ 0 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
19 Clakview Ter.
�M
Property Address
Maria Altobelli
Owner Owner's Name
information is required for every Hyannis Ma. 02601 07-02-2018
page. City/Town 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): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 PLUS
gpd
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
19 Oakview Ter.
Property Address
Maria Altobelli
Owner Owner's Name
information is required for every Hyannis Ma. 02601 07-02-2018
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonaluse? ® Yes ❑ No
Water meter readings, if available (last 2 years usage(gpd)):
Detail:
Sump pump? d ❑ Yes ® No
Last date of occupancy: occupied
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
19 Oakview Ter.
Property Address
Maria Altobelli
Owner Owner's Name
information is required for every Hyannis Ma. 02601 07-02-2018
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: Inspector
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: 1000
gallons
How was quantity pumped determined? drivers est.
Reason for pumping: maint.
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):
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 19 Oakview Ter.
Property Address
Maria Altobelli
Owner Owner's Name
information is required for every Hyannis Ma. 02601 07-02-2018
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
"
Depth below grade: 21
feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: Standard H-10 1000 gallon septic
tank
Sludge depth:
1"
t5ins.doc-rev.6/16 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 19 Oakview Ter.
Property Address
Maria Altobelli
Owner Owner's Name
information is required for every �H annis Ma. 02601 07-02-2018
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank (cont.)
.Distance from top of sludge to bottom of outlet tee or baffle
36"
Scum thickness
1
Distance from top of scum to top of outlet tee or baffle
5"
Distance from bottom of scum to bottom of outlet tee or baffle
12"
How were dimensions determined? Sludge Judge
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
I would recommend the new owner put the tank on a maint. plan with a local septic pumping co.The
Barnstable Health Dept. has a list of local septic pumping co. Note the tank was pumped as part of
the inspection.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins.doc•rev.6/16 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
M 19 Oakview Ter.
Property Address
Maria Altobelli
Owner Owner's Name
information is required for every Hyannis Ma. 02601 07-02-2018
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.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
19 Oakview Ter.
Property Address
Maria Altobelli
Owner Owner's Name
information is required for every Hyannis Ma. 02601 07-02-2018
page. Citylfown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
0"
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
The H-10 D-Box had no visible signs of leakage or evidence of past hydraulic failure.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 19 Oakview Ter.
Property Address
Maria Altobelli
Owner Owner's Name
information is H annis Ma. 02601 07-02-2018
required for every - y
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number:
one
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
At the time of the inspection was dry.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
19 Oakview Ter.
Property Address
Maria Altobelli
Owner Owner's Name
information is required for every Hyannis Ma. 02601 07-02-2018
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
. Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 19 Oakview Ter.
Property Address
Maria Altobelli
Owner Owner's Name
information is required for every Hyannis Ma. 02601 07-02-2018
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
r �
2 .:
73
6
3 y�-6
= 65
f = 2
l5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 19 Oakview Ter.
Property Address
Maria Altobelli
Owner Owner's Name
information is required for every Hyannis Ma. 02601 07-02-2018
page. Cityrrown 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: 14 plus 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:
augered a hole at a lower elevation and I shot it witrh a transit.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
f
19 Oakview Ter.
M
Property Address
Maria Altobelli
Owner Owner's Name
information is required for every Hyannis Ma. 02601 07-02-2018
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
r
` COS vION 'EALTH OF SAC IL'SET'I S
ExECu-TIvE OFFICE OF ENwRoNwEwAL AFFAIRS .
F, Ell
DEPARTMENT OF ENVIRONMENTAL PROTECT5ION
J
H § I04V
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 0y wi ems)T4e f t'GX..Q.
Owner's Name:
-=—
Owner's Address: « �tLlt V tw Grt'ae�
l4����:` . mA oal&o( Sr Al
Date of Inspection:_ q 9L (per
Name of Inspector:1please print) MkkcA r elf
Company Name: a/A✓ar w i on_n%ewkA [vts?e0tovW
Mailing Address: .170 x ecu
D..6y.(
Telephone Number•
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15340 of Title 5(310 CMR 15.000). The system:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
t �Fails
Q
Inspector's Signature: fL�:ccc� � G� Rate: ,0S�
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 I0,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving
authority. °
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address flow the system will perform in the future under the same or different
conditions of use.
I
Title 5 Inspection Form 6/15/2000 page i
f
Page 2 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
. . PART A
CERTIFICATION(continued)
Property Address: 1ct y i s'u..> -F.e nra Q_
Owner.
Date of Inspection:
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:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"secti eed to be replaced or
repaired.The system,upon completion of the replacement or repair,as approved b e Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the follo statements.If`hot determined"please
explain.
The septic tank is metal and over 20 years old*or the se c tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or failure is imminent.System will pass inspection if the
existing tank is replaced with a complying septic tauuk as' roved by the Board of Health.
*A metal septic tank will pass inspection if it is situ y sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is a ble.
ND explain:
Observation of sewage backup or reek out or kigh static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken, led or uneven distribution box.System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruc fm is removed
distribution box is le sled or replaced
ND explain:
The syste equired pumping more than 4 times a year due to broken or obstructed pipe(s).The sysbem will
pass inspection' (with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
C
Page 3 of I 1
OFFICIAL INSPEC-1 ION FORM-NOT FOR VOLUNTARY ASSESSMEWS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORIM
PART A
CERTIFICATION(continued)
Property Address: (q Oa. k t�Yca7 1 e (�[,•e
Owner:
Date of inspection: q IQ I O3
i
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in/ne if the system
is failing to protect public health,safety or the environment.
L System will pass unless Board of Health determines in accordance with3(lXb)that the
system is not functioning in a manner which will protect public heal 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 vegetate etland or a salt marsh
2. System will fail unless the Board of Health(a Public Water Supplier,if any determines that the
system is functioning in a manner that protects a public health,safety and environment:
_ The system has a septic tank and soil sorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a s ce water supply.
The system has a septic tank SAS and the SAS is within a Zone I of a public water supply.
The system has a septic and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a septi and SAS and the SAS is Iess than 100 feet but 50 feet or more from a
private water supply well" .Method used to determine distance
*"This system passes. the well water analysis,performed at a DEP certified laboratory,for conform
bacteria and volatile rganic compounds indicates that the well is free from pollution from that facility and
the presence of onia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria triggered.A copy of the analysis must be attached to this form.
3. Other:
3
Page 4 of l I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE D19POML SYSTEM INSPECTION FORM Qz
PART_A-
CERTMCATION(continued)
Property Address: a.tc Vi eW --aetcG-e-
G1HK 4S
Owner:
Bate of Inspection.
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for aH inspections:
Yes No
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
Static liquid Ievel in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
-0(- Liquid depth in cesspool is less than 6"below invert or available volume is less than'/2 day flow
K Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
A-� 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 IDEP certified laboratory,for colfform bacteria and volatile organic-compowaids
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.]
,�
rV O (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 serves facility with a d 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 a above)
yes no
the system is within 400 feet of a surfs drinking water supply
_ the system is within 200 feet of butary to a surface drinking water supply
_ the system is located in a ' ogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped
Zone H of a public w supply well
If you have answered"yes" any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above a large system has failed.The owner or operator of any large system considered a.
significant threat ection E or failed under Section D shall upgrade the system in accordance with 310 CN 4R.
15.304.The system er should contact the appropriate regional office of the Department.
4
r
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B ,
CHECKLIST
Property Address:
I_ 3
Owner: i`(�
Date of Inspection:
Check if the followin have been done.You must indicate"yes"or"no"as to each of the followin
Yes No
K _ Pumping information was provided by the owner,occupant,or Board of Health
K 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
Of Have large volumes of water been introduced to the system recently or as part of this inspection?
X i 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?
0 _ 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
f the b oaffles 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:
Yes no
Existing information.For example,a plan at the Board of Health.
Determined in the field(if any of the failure criteria related to Part Cis at issue approximation of distance
is unacceptable)[310 CMR 15.302(3)(b))
5
Page 6 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE IDISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:_tjGt(C V j eu) lr/L'ccQ
Owner: h 1 _
Bate of Inspection:
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x# of bedrooms): 33C-)
Number of current residents:!—
Does residence have a garbage grinder(yes or no): NO
Is laundry on a separate sewage system(yes or no):gLO [if yes separate inspection required]
Laundry system inspected(Yes or no
_
AJO
Seasonal use:(yes or no):W
Water meter readings,if available(last 2 years usage Gopd)):
Sump pump(yes or no): A)O
Last date of occupancy: Ei rlie�
COMMERCIAIA"USTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/ tc.):
Grease trap present(yes or no):
Industrial waste holding tank p sent(yes or no):_
Non-sanitary waste dischar to the Title 5 system(yes or no)._
Water meter readings,if ailable:
Last date of occupan use:
OTHER(desc " ):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part of the inspection(yes or no):
If yes,volume pumped: gallons—How was quantity pumped determined?
Reason for pumping.
TYPE OF SYSTEM
Septic tank,distribution box,soil absorption system
_Single cesspool
_Overflow cesspool
_Privy
_Shared system(yes or no)(if yes,attach previous inspection records,if any)
_Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
_Tight tank _Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
SLOG e4kf5
Were sewage odors detected when arriving at the site(yes or no):
6
Page 7 of I I
OFASSESSMENTS.FICIAL INSPECTION FOR
M—NOT FOR VOLUNTARY
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address
1s
Owner:
Date of Inspection:
BUILDING SEWER(locate on site plan) .
Depth below grade: c�c(
Materials of construction:_cast iron __X 40 PVC_other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: 14 (locate on site plan)
tt
Depth below grade:1�
Material of construction: l�concrete_metal`fiberglass_poIyethy}ene
_other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of
certificate) /
Dimensions: (n oa q 4, J
Sludge depth: c2 a
Distance from top of sl ,W to bottom of outlet tee or baffle: 30 r,
Scum thickness: - 1
Distance from top of scum to top of outlet tee or baffle: [O t
Distance from bottom of scum to bottom of outlet tee or baffle:
How were dimensions determined: M.to's jC-C
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakagne,etc(At -):
c. �a .�u t, v'•o S La v�_ dr Coil dki odPit.
GREASE TRAP:_(locate on site plan)
Depth below grade:_
Material of construction:_concrete_metal r ass_polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to to of outlet tee or baffle.
Distance from bottom of scu to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumpin commendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet inv ,evidence of leakage,etc.):
7
Page 8 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ,
PART C
SYSTEM INFORMATION(continued)
Property Address: _t �r G
Owner:
Date of Inspection: �Q�° —
TIGHT or HOLDING TANK: (tank must be ped 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 or no .
Alarm level: arm in working order(yes or no):
Date of last pumpmi
Comments(condi ` n of alarm and float switches,etc.):
DISTR BUTION BOX:.C_(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: etWA
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.):
` ke 6 dx Guns �/16 CA c` t ro ln� O CGuty'c.otj!id'
PUMP CHAMBER: (locate on site an)
Pumps in working order(yes o}:.
Alarms in working order s or no):
Comments(note cond' 'on of pump chamber,condition of pumps and appurtenances,etc.):
8
• �rge9ofil
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT'S
SUBSUr ACE SE*AGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address o�tt:V a �t�yTt,r yL,e
Owner-
Date of Inspection: p�
SOIL ABSORPTION SYSTEM(SAS):_�(locate on site plan,excavation not required)
If SAS not Iocated explain why:
Type
_,,C leaching pits,number: t
teaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number-
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.): (nI
a� 6 K 6 rcot 6Ui'vbq%Je- (O
r b C-'-
CESSPOOLS: (cesspool must be pum ection)(locate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note conditio of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
PRIVY: (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
Page 10 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:_1 I Qa,L V i eW /ereCG-Q
Owner:
Date of Inspection p
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.
v I,
t� 38
36
r
• Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY:ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART"C
SYSTEM INFORMATION(continued)
Property Address Gt Vi lA erfr
Owner:
Date of Inspection:_ Cl��I QI
SITE EXAM
Slope w0 .
Surface waterr%p
Check cellar V-0
Shallow wells 00
Estimated depth to ground water ,d 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:
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
CelOftf t c7
I
li
h
is p '3"' •
-
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Department of moo co
Environmental Protection
g �
William F.Weld f 5
Governor
Trudy t'.oxe
ec 8rotery,EOEA
David B.Struhs
Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: (� d UlQ� T�Rn.q c le, Address of Owner:
Date of Inspection: lv— ��— 4 s- _ (If different)
'Name of Inspector:
Company Name, Address and Telephone Number:
CER3ICA IT iT Sphl)- f�T
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate 4.
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
L-'Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
F
Inspector's Signature: Date: 1D
16
:1
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this
inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit
the report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
Check A, B, C, or D:
A] SYSTEM PASSES:
l�l have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
B] SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,
passes inspection.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"mot determined", explain why not)
The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as
approved by the Board of Health.
(revised 8/15/95) 1
One Winter Street a Boston,Massachusetts 02108 a FAX(611)556-1049 a Telephone(611)292-5500
0 Printed on RecKkd Paper
n SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
r PART A
..�, CERTIFICATION (continued)
Property Address:
Owner: t. e
Date of Inspection:
B] SYSTEM.CONDITIONALLY PASSES (continued)
_ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the
Board of Health):
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
_ The system required pu ing more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approva of the Board of Health):
roken pipe(s) are replaced
o struction is removed
C] FURTHER EVALUATION IS REQUIRED BY THE B ARD OF HEALTH: ��I
Conditions exist which require further evaluatio by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH ETERMINES THAT HE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND AFETY AND T ENVIRONMENT:
_ Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetal wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND P19BLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PRO 9CT`THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT.
_ The cvstem has a septic tank and soil absorpti system and is thin 100 feet to a surface water supply or tributary to a
surface water supply.
_ The wstem ha! a septic tank and soil abs ption system and is withi a Zone I of a public water supply well.
_ The system has a septic tank and soil ab orption system and is within 0 feet of a private water supply well.
_ The system has a septic tank and soil sorption system and is less than 400 feet but 50 feet or more from a private water
supply well, unless a well water an ysis for coliform bacteria and volatile�prganic compounds indicates that the well is
free from pollution from that faci ' and the presence of ammonia nitrogen nitrate nitrogen is equal to or less than 5
ppm.
D] SYSTEM.FAILS:
I have determined that the syst violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is ide fied below. The Board of Health should be contacted.to determine what will be necessary to correct
the failure.
Backup of wage into facility or system component due town overloaded or dogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged AS or
cesspool.
(revised 8/15/95) 2
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: (Q Oo )c U IieLj 42 4tj•e �l..�lt/dt!!5
Owner: -��n �cao� 11
Date of Inspection: -
D]SYSTEM FAILS(continued):
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow.
Required ping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number f times pumped /;-
r
Any portion o t e Soil Absorption System, cesspool or privy i below the high groundwater elevation.
Any portion of a ces ool or privy is within 100 feet , aoY surface water supply or tributary to a surface water supply.
Any portion of a cesspoo or privy is within a one I of a public well.
Any portion of a cesspool or •rivy is w• in 50 feet of a private water supply well.
Any portion of a cesspool or pri is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality anal is. I he well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile ganic co ounds, ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
The following criteria ap y to large systems in addition to the criteria above:
The design flow of sy em is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety
and the environmen because one or more of the following conditions exist:
the sys m is within 400 feet of a surface drinking water supply
the ystem is within 200 feet of a tributary to a surface drinking water supply
e system is located in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone II of a
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 8/15/95) 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: C CSH U t e e 2 �-� iy7ifw All s
Owner: 2
Date of Inspection:
Check if the following have been done:
uPumping information was requested of the owner, occupant, and Board of Health.
`None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
during that period. Large volumes of water have not been introduced into the system recently or a5 part of this inspection.
built plans have been obtained and examined. Note if they are not available with N/A.
acility or dwelling was inspected for signs of sewage back-up.
e system does not receive non-sanitary or industrial waste flow
to was inspected for signs of breakout.
stem components, excluding the Soil Absorption System, have been located on the site.
:T e septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or
tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
e size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
l T e facility ov ner (and occupants, if different from o%%ner) were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 8/15/95) 4
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: l Ct. 04 k V l,-Csj l•ei2/2RL-,e 1,(,7vfw4Ic 5
Owner: �D
Date of Inspection:
qS
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 330_gallons
Number of bedrooms:-3--
Number of current residents:
Garbage grinder(yes or no):-AZ
Laundry connected to syste (yes or no):
Seasonal use (yes or no):
Water meter readings, if available:
9 /
Last date of occupancy: 64J0fteAff`
COMMERCIALINDUSTRIAL:
Type of establishment:
Design flow:_gallons/day --......__._
Grease trap present: or no)_
Industrial Waste Hol 'ng Tank present: (yes or no)_
Non-sanitary waste dis rged to the Title 5 system: (yes or no)_ bC�
Water meter readings, if ava le:
Last date of occupancy:
OTHER: (Describe)
Last date of occupan
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as part of inspection: (yes or no)>1Jp
If yes, volume pumped gallons
Reason for pumping:
TYPE OF SYST
eptic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
Other(explain)
APPROXIMATE AGE of all components, date installed (if known) and source of information:
--
Sewage odors detected when arriving at the site: (yes or no)
(revised 8/15/95) 5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
SEPTIC TANK:
(locate on site plan)
Depth below grade: `a
Material of construction: �crete _metal _FRP_other(expiain)
Dimensions: 5�'"— L ;F Lt1 x Z 7?
Sludge depth:fi_ i,.
Distance from top of sludge to bottom of outlet tee or baffler
Scum thickness: 0
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of I' ui level in relation to outle�invert, structur.44
integrity, evidence of leakage PtcJ & A _
GREASE TRAP:_
(locate on site plan)
Depth below grade:
Material of construction: _concrete _ al FRP_other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of ou tee or baffle:
Distance from bottom ni rilm t- . om of outlet tee or baffle:
Comments:
(recommendatio r pumping, condition of inlet and outlet tees or baffles, de of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.)
(revised 8;15/95) 6
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: tct OA-Ec(l Ile U) -T-e 9��
Owner:
Date of Inspection: (_b ` I G � S S—
TIGHT OR HOLDING TANK:_
(locate on site plan)
Depth below grade:
Material of construction: con ete_metal _FRP—other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm level:
Comments:
(condition of inlet tee, condit on alarm and float switches, etc.)
DISTRIBUTION BOX:_
(locate on site plan)
Depth of liquid level above outlet invert: ::�o
Comments:
(note vel and distribution is equa!, evi once of sohd� c r ver, evidence of leakage into or out of box, etc.)
o a
PUMP CHAMBER: '
(locate on site plan)
Pumps in working order:(yes or no)
Comments:
(note condition of pump chamber, condition o ps and appurtena s, etc.)
(revised 8/15/95) 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS):
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type: / `- l U o d
leaching pits, number.
leaching chambers, number:_
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number: _
level of in condition of ve etation,etc.)
Comments: (note co ition of soil, signs of hydraulic failure, p g, g �S�
CESSPOOLS: _
(locate on site plan)
Number and configuration:
_r
Depth-top of liquid to inlet invert:
Depth of solids layer
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow (cesspool must be pumped as part of inspecti
Comments: (note condition of soil, signs of draulic failure, level of ponding, c clition of vegetation, etc.)
PRIVY:_
(locate on site plan)
Materials of c struction: Dimensions:
Depth of ids:
Comme : (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised 8/15/95) 8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
,,((ccountinued)
Property Address: (� �'� - U t le W 2�4C C IsS
Owner: .%��
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
3(,I
Pa*2
13
-14
L
X7
C3 = 32-,
DEPTH TO GROUNDWATER
�7�
Depth to groundwater: / _feet /1�e,4,
met of dete urination or appProxima ion: �4
hd��s
(revised 8/15/95) 9
iv
aj -
r.
;
Commonweatfh of Massachusetts
Executive Office of Environmental Affairs
Department of
Environmental Protection
Wllllam F.Weld <
��
Trudy Core'
Ssc tw EOEA
David B.Struhs'
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
f. PART A ,
t F CERTIFICATION • i �'.
( q Grp k V;-cv T�, e �.� 44"en,4c Y �—
Property Address: � ' ' I Address of Owner:
Date of Inspection: f U &— S Of different) �.
Name of Inspector: T P r►o 'V—
Company Name,Address and Telephone Number:
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper f u rict ionNncl
maintenance of on-site sewage disposal systems. The system:
asses
_ Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
1rtspector's Signature: w Date: D
The System Inspector shall submit,.a copy of'this inspection report to the Approving Authority within thirty (30) days of completing this
inspection.' If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit
the report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the wstem owner and copies sent to the buyer, if applicable and the approving authority.
t
INSPECTION SUMMARY:
Check A, 9, C,or D:
A] SYSTEM PASSES:
C/1 have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below. "
Bj SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,
passes inspection.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"mot determined", explain why not)
_ The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is'
imminent. The system will pass inspection.if the existing septic tank is replaced with a conforming septic tank as
approved by the Board of Health. -...
(revised 8/15/95)
One Winter Street • Boston,Massachusetts 02108 • FAX(617)SS111-1049 • Telephone(617)292-55W
t � �
j
r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ,
PART A
CERTIFICATION (continued)
r
Property Address:-
Owner:
Date-of Inspection:
B) SYSTEM CONDITIONALLY PASSES (continued)
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the
Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is levelled or replaced
_ The system required pu in more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approv of the Board of Health):
'broken pipe(s) are replaced
obstruction is removed
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 the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT YHE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND T ENVIRONMENT:
_ Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetat wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT: \\t
The system has a septicion tank and soil absorpt system and is hin 100 feet to a surface water supply or tributary to a
surface water supply. j \
— The syste-•: ha, a septic tank and soil absorption system and is within.a Zone I of a public water supply well.
_ The system has a septic tank and soil absorption system and is within 5.0 feet of a private water supply well.
_ The system has a septic tank and soil,4sorption system and is less than 1,00 feet but 50 feet or more from a private water
supply well, unless a well water anafysis for coliform bacteria and volatile''prganic compounds indicates that the well is
free from pollution from that faci ' and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5
PPm•
D) SYSTEM FAILS:
I have determined that the syst violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is ide fied below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
Backup of,s'ewage into facility or system component due to an overloaded or dogged 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.
L(,,e-ised 8/15/95) 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: (Q C ► U+Eli T fe2R U e 14�t/V`Ui 5
Owner: ��>z 7
Date of Inspection:
D]SYSTEM FAILS(continued):
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow.
Required ping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number f times pumped
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of"a surface water supply or tributary to a surface water supply.
Any portion of a cesspool of privy is within a.,Zone I of a public well.
Any portion of a cesspool or privy is wilt;n 50 feet of a private water supply well.
r,
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. If•.ihe well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above:
The design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety
and the environmen)''because one or more of the following conditions exist:
the system is within 400 feet of a surface drinking water supply
i
the system is within 200 feet of a tributary to a surface drinking water supply
_Ihe system is located in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone II of a
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 8/15/95) 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: (� GR (C U t e U ) 22-4 'C-- t-1 vV 101 S.
Owner: �l�J
Date of Inspection:
Check if the following have been done:
vPumping information was requested of the owner, occupant, and Board of Health.
`None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
during that period. Large volumes of water have not been introduced into the system recently or a5 pan of this inspection.
f built plans have been obtained and examined. Note if they are not available with N/A.
L1 e'tacility or dwelling was inspected for signs of sewage back-up.
e system does not receive non-sanitary or industrial waste flow
site was inspected for signs of breakout.
�<lsystem components, excluding the Soil Absorption System, have been located on the site.
u(he septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or
tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
LJ-h6ize and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
l�fhe facility ovine; (and occupants, if different from o�%ner; \vere provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 8/15/95) 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: rz�
Owner: �cr�
Date of Inspection: JJ
(L- S
FLOW CONDITIONS
RESIDENTIAL:
Design flow: '33y ttalIons
Number of bedrooms:-3—
Number of current residents:—�--
Garbage grinder (yes or no):-4z
Laundry connected to syste (yes or no):
Seasonal use (yes or no):
,Water meter readings, if available:
Last date of occupancy: G 'f/Zr'r(�
COMMERCIAUINDUSTRIAL•
Type of establishment:
Design flow:_ allons/day
Grease trap present: or no)_
Industrial Waste,Hol ng Tank present: (yes or no)_
Non-sanitary waste dis rged to the Title 5 system: (yes or no)_ _
Water meter readings, if ava le:
last date of occupancy:
OTHER: (Describe)
Last date of occupan
GENERAL INFORMATION
PUMPING RECORDS and source of forrpa4onn:
System pumped as part of inspection: (yes or no)_
If yes, volume pumped Rallons
Reason for pumping:
TYPE OF SYS
ptic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
Other(explain)
APPROXIMATE AGE of all components, date installed (if known)and source of information:
Sewage odors detected when arriving at the site: (yes or no)
(revised 8/15/95). S
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:-
Date of Inspection:
SEPTIC TANK:
(locate on site plan)
r(
Depth below grade:
Material of construction: Leb"ncrete _metal _FRP —other(explain)
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle: . e;
Scum thickness:_
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle: —
s
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of I' ui lever in relation to outlet invert, structur
integri , evidence of leakage, etc.) U
GREASE TRAP:_
(locate on site plan)
j Depth belo\,\, grade: ��
Material of construction: concrete — al FRP _other(explainn)
Dimensions:
Scum thickness:
Distance from top of scum to top of ouslet tee or baffle:
Dista^ce from bottom ni cr r tot om of outlet tee or baffle:
Comments:
(recommendatio r pumping, condition of inlet and outlet tees or baffles, cl� of liquid level in relation to outlet invert, structural
integrity, evidence of leakage. etc.)
(revised 8/15/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: f ct OA-k v c-c(L) L17,4 AJiV 1 5
Owner:
Date of Inspection: l0 ` I G
TIGHT OR HOLDING TANK:_
(locate on site plan)
Depth below grade:
Material of construction: con ete_metal _FRP—other(explain)
Dimensions: _
Capacity: rtallons
Design flow: Qallons/day
Alarm level: �� t
Comments:
(condition of inlet tee, conditignof alarm and float switches, etc.)
DISTRIBUTION BOX:_
(locate on site plan)
Depth of liquid level above outlet invert: L:f�d
Comments:
(note e! and disc;iburor. eq a!, e�i ante of so!id< c •er, evidence of leakage into or ou of box, etc.)
e
PUMP CHAMBER:
(locate on site plan)
Pumps in working order:(yes or no)
Comments:
(note condition of pump chamber, condition ps and appurtena s, etc.)
(revised 6115195) 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS):
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type:
Teaching pits, number.
leaching chambers, number:_
leaching galleries, number:
I leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
Comments: (note co ition of soil, signs of hydraulic failure,level =ping, condition of vegetation,etc.)
J�
CESSPOOLS: _
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert: ,
Depth cf solids layer:
Depth of scum layer: /
Dimensions of cesspool: j
Materials of construction:
Indication of groundwater.
inflow (cesspool must be pumped as part of inspecti
Comments: (note condition of soil, signs of . draulic failure, level of ponding, c dition of vegetation, etc.)
0
PRIVY:
(locate on site plan)
Materials of c struction: Dimensions:
Depth of tds:
Comme : (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised-6/15/95) 8
t
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued
Property s:
Owner:
Date of Inspection: i
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
3JI h-c44
L
L �
- 7 a7
DEPTH TO GROUNDWATER
Depth to groundwater. _feet L4 Sv 2 U �� 41e e,Q,
met*of dete ination or approximation: r
/&_-
(revised 8/15/95) 9
w
f � •
i
h
x
L0CAT10 SEW GE PERMIT NO.
VILLAGE
I N S T A LLER'S NAME i ADDRESS
3UILDER OR OWN
DATE P RMIT ISSUED
DATE COMPLIANCE ISSUED
L-
9
A
s
Fss....... .p.../.
s �
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF- HEALTH
....._. ...o w..4)........OF.....ISAJZX�_!'Ahlam............................
Appliration for Dhiposal ,ark, Tomitrnrtinn �[ami#
Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal
System at
Locatio -Address J �� or Lot N --•-tot. `
01
Owne Addrr ss
a ` .... ........:...... ...............•---..._...............-•-•....-----------•......•-•- ---________..
In aller Address Q
d Type of Building 3 Size Lot__?e,�_7?..Sq. feet
V Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder (No)
Other—T e of Building No. of ersons._._....__ ._
a YP g P -. Showers (�) — Cafeteria ( )
04 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 t k ( ),4
'-' Percolation Test Results Performed by....... r � <,_.__. 1.C�, �/__��.t 5.._. Date.._._-��___��__._
1.4 a minutes per inch Depth of Test Pit.................... Depth to ground water........................
Test Pit No. l.f�............
LZ4 Test Pit No. 2.._ Zminutes per inch Depth of Test Pit____________________ Depth to ground water........................
a' ----__-- ........................................... ,y
crp 2---1-- � ..5 . 4,E{rf_----- �' ��f S - `.'fi 0 Description of Soil /
w
UNature of Repairs or Alterations—Answer when applicable................................................................................................
••------•--------------------------•••--•-------------------------------•---.....------...--••••...•----••-----------•-----------------------------------------------------------------------.......----
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITI Uj 5 of the State Sanitary Code— The undersigned f ther agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board th.
Signed /l;ej��^r--�--.6�->1..._ yI�CL=/ ...... Date
Application Approved BY ............
Date
' Application Disapproved for the following reasons:-:...........................................................................................................
Date
PermitNo......................................................... IssuedL.......................................................
Date
0�1
Ftc$...............3ONo... ......... ...............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Touj.A).......OF,.... /Z.4 ;!... Er............................
Appliraa#ion for Uiopooal Works Tonotrurtion throb#
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System
/mat:.Srrli.L•i-•••• G ..i...... iA�IY/.i Y .... ...................................Lo.N...X.
............ . . :..
LotoAdddr / 57Owner Address
-----------------•--............-••••-••...._............... .............••-•••............•_.... -•-...............••-•••......--•-----.....
Installer Address 1�
UType of Building Size Lot...�*.-j_______7 .Sq. f
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
'4 Other—Type T e of Building No. of persons __
W yP g ------•-•-----------•---•--- P �--------•---- Showers (' ) — Cafeteria ( )
P4 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 t
----� Percolation Test Results� Performed by....... �u=-�. 4� � �-- -------- Date--- --------- ...--------
a 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...................
..
..•-••••.•••.
Descri tion of Soil." l/' CCUis' - �' ... 1 �a �
v ...........` .. /..t, ° _L ,_�__C'Q '-' - -'" ' ----------------- - -------- -------- ----------------------------------
w
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
------------------------------------------------------------------------------------•-•••...........•--•••--•---•---•--==----•...-•---------•-------••••-•---•-•-•••---•--------•---......_..-••-••.••--
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewag Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code—The undersign d her agrees not to}place the system in
operation until a Certificate of Compliance has b t o rd o a
AM
g d..... •••• .............................................................
ApplicationApproved By......................................... .....-•••••••-••••-••••..............................
Date
Application Disapproved for the following reasons----------------•-------------------------------------...--------------------------=--•------•---•••••••-_...._
.................................................•-----------------------............•-•---•--••-••••••. ••.-••-•---------•-----•------•---•--••••--•---•-----••-•----••-- ----------------••..........:f Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
,a BOARD OF HEALTH
01-VA..J ...... ......X�"..
Trdif irFatr of TonapliFanrr
THIJ IS Tga CTIFY, That the Individual Sewage Disposal System constructed ( 1 or Repaired ( )
�¢j •-••---------------- •----•-• ---------•------- ------. ------.by = ----------------------------
t O • Inst 1
has been installed in accordance with the provisions of 14of The State Sanitary C/)d&A-4ff0scribed in the
application for Disposal Works Construction Permit No......................................... dated----............................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCT101H SATISFACTORY.
DATE............................_,......-l.--....---•...-••-------...----------. Inspector.....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEALTH
.....,.1 .W.. ........OF.......... 1✓ '�?�..� ............ �t�J
No......................... FEE........................
ElispooFal Z
Tons ra ion rrnti#
Permission is hereby granted.....�� .....----•--------------------•--•----...........................................................
to Construct ,cZrAR��epair ( Individual Sewag Dispo$�l step
Street
as shown on the application for Disposal Works Constructs !,,o----------- -- ---' .......................................
-
Board of Health
DATE................................................................................
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS
2
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P l }
IN
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RORERT G
,tom Pilo.22162 O Q I y M
" 90� CIS
AL
•r I { _ !`/ t7 V-r°
EXISTONG SPOT ELEVATION Otto 'CERTIFIED PLOT PLAN .r,
EXOSTOHD CONTOUR --- 0 - - - a
PBNISHEO SPOT ELEVATION O.0 �oT �.9 0,q vr,�vi! •TER.
FINISHED . CONTOUR O !� J"A,A!Ni5' ,
IN , .
APPROVEDt BOARD OF HEALTH
DATE AGENT SCALE: i " = 40' DATES
DREDGE ENGINEERING CO IhV
— CL=IENT C(r..2:�Ur�r�
I CERTIFY THAT THE PR®P®SE®;.
%EdISTERE REGISTERED Joe NO. 8,004`7 BUILDING SHORN ON THIS PLAN %,
CIVIL LAND
DR. 1J. �. CONFORMS TO THE ZONING Lkis",.
®OCJI:ER SURVEYOR OF BARNST ®
33 NO. MAIN ST. 712 MAIN .ST_ CM. ®Y= �a ' �' ��' �-a A
i
SO. YARM®UTH MASS. HYAfdPIIS+ MASS. 2 '
SHEET— OF • -DATE_ REG. LAND SURVEYOR,
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