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q.• ,° Commonwealth of Massachusetts
ffia ;i-p Title 5 Official Inspection Form 4
rf Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�v •;> 130 Regatta Dr
Property Address w _,z N
Steven Youwen Lug
Owner Owner's Name '
information is r.
required for every CiFle MA 02632 5-2-18
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
A. General Information �1# 13003
1. Inspector:
Shawn Mcelroy
Name of Inspector
Upper Cape Septic Services
Company Name
P.O. Box 73
Company Address
E. Falmouth MA 02536
City/Town State Zip Code
1-508-495-0905 S13971
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 16.340 of
Title 5 (310 CMR 15.000).The system:
® Passes - ❑ Conditionally Passes ❑ Fails
❑ Needs Further Ev ati by the Local Approving Authority
5-2-18 .
I spector'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.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Pag/e/1 of 17
Ij��tdI&
Commonwealth of Massachusetts
Title 5 Official Inspection Form
hi Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4
130 Regatta Dr
Property Address
Steven Youwen Lu
Owner Owner's Name
information is Centerville MA 02632 5-2-18
required for every
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:
System is in good working order with no sign of failure.
B) System Conditionally Passes:
❑ One or more system components as described.in the "Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND) for the following statements. If"not
determined," please explain. "
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑N ❑ ND (Explain below):
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
,�F Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
130 Regatta Dr
Property Address
Steven Youwen Lu _
Owner Owner's Name
information is required for every Centerville MA 02632 5-2-18
page. Cityfrown 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/alarm's 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 ON ❑ 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 El ❑ ND (Explain below):
❑ obstruction is removed El ON ❑ 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.
i! 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
Commonwealth of Massachusetts
3 Title 5 Official Inspection Form
N Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�..• ,�Ci
130 Regatta Dr '
Property Address
Steven Youwen Lu
Owner Owner's Name
information is Centerville MA 02632 5-2-18
required for every
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
E
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
Backup of sewage into facility or system component due to overloaded or
' ❑ ® clogged,SAS or cesspool
❑ ® Disdharge 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
❑ Z.
than %day flow
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage DisposRl System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
N Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
:. ? 130 Regatta Dr
Property Address
Steven Youwen Lu
Owner Owner's Name
information is required for every Centerville MA 02632 5-2-18
page. City/Town State Zip Code Date of Inspection
B: Certification (cont.)
Yes No I -
❑ ® 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-
❑ 2 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
F 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.
` r
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply-
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen,sensitive area (Interim Wellhead Protection
❑' ❑ Area— IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
ram' Commonwealth of Massachusetts y
�-r
Title 5 Official Inspection Form
iA +ws
i;l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
130 Regatta Dr
Property Address
Steven Youwen Lu
Owner Owner's Name
information is required for every Centerville MA 02632 5-2-18
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 b the owner,❑ ® p g p y occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ . t 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?
® 0 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?
® ElWere 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?
®' ❑ Wasthe 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 Feld (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 flowbased on 310 CMR 15:203 (for example: 110 gpd x#of bedrooms): 330
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form .
raF Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
•;_ >''
130 Regatta Dr
Property Address
Steven Youwen Lu
Owner Owner's Name
information is required for every Centerville MA 02632 5-2-18
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
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: 5-2-18
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 •
I� Title 5 Official, Inspection Form
w
r ip-`► Subsurface Sewage Disposal System Form -'Not for Voluntary Assessments
130 Regatta Dr f
Property Address
Steven Youwen Lu
Owner Owner's Name
information is required for every Centerville MA 02632 5-2-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) A ,
Last date of occupancy/use: Date
Other(describe below):
General Information -
Pumping Records:
Source of information: N/A
Was system pumped as part of the inspection? .❑ Yes ® No
If yes, volume pumped: . ; - gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ • Shared system (yes or no) (if yes,-attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract (to be obtained from system owner) 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
Title 5 Official Inspection Form
hi Subsurface Sewage Disposal System Form -Not for Voluntary Assessments.
130 Regatta Dr
Property Address
Steven Youwen Lu
Owner Owner's Name
information is required for every Centerville MA 02632 5-2-18 .
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) '
Approximate age of all components, date installed (if known) and source of information:
1995
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 24
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.):
Good condition.
Septic Tank(locate on site plan):
Depth below grade: 18"feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene t ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 gal
Sludge depth:
12"
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
�1ai Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�C:
130 Regatta Dr t
Property Address
Steven Youwen Lu
Owner Owner's Name
information is Centerville MA 02632 5-2-18
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank (cont.)
Distance from to of slu
dge a to bottom o
20"
p g of outlet tee or baffle
Scum thickness
1"
Distance from top of scum to top of outlet tee or baffle
6"
Distance-from bottom of scum to bottom of outlet tee or baffle
15"
How were dimensions determined? Tape
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank is in good condition with baffles installed and no sign of leakage.
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
r� ; Title 5 official Inspection Form
i�i Subsurface Sewage Disposal System Form -Not for Vol untary,Assessments
130 Regatta Dr
Property Address
Steven Youwen Lu
Owner Owner's Name
information is required for every Centerville MA 02632 5-2-18
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
c Commonwealth of Massachusetts
Title 5 Official. Inspection Form
i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments.
V.
,> 130 Regatta Dr
Property Address
Steven Youwen Lu + .
Owner Owner's Name
information is required for every Centerville MA 02632 5-2-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened)(locate on site plan): '
Depth of liquid level above outlet invert 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.):
Good condition with water at working level and no sign of back-up from pit.
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
Title 5 Official Inspection Form
114 Subsurface Sewager Disposal System Form -Not for Voluntary Assessments
�4•
130 Regatta Dr _
Property Address
Steven Youwen Lu
Owner Owner's Name
information is required for every Centerville MA 02632 5-2-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1-1000 gal
❑ 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.): ,
Leach pit in good condition and holding 12" of water at inspection with stain line at 24" of bottom of
pit.
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.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17`
Commonwealth of Massachusetts
Title 5 Official Inspection Form
� wa
NI Subsurface Sewage Disposal System Form Not for Voluntary Assessments
130 Regatta Dr
Property Address
Steven Youwen Lu
Owner Owner's Name
information is required for every Centerville - MA 02632 5-2-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) ,
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
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.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
.� Title 5 Official Inspection Form
w:
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
130 Regatta Dr
Property Address
Steven Youwen Lu
Owner Owner's Name
information is required for every Centerville MA 02632 5-2-18
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
J
13
/ 3
r ref.
e:
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
s Commonwealth of Massachusetts = r
,w Title 5 Official Inspection Form
! ibi Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
130 Regatta Dr -
Property Address
Steven Youwen Lu
Owner Owner's Name
information is required for every Centerville MA 02632 5-2-18
`
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope+
❑ Surface water
❑ Check cellar
❑ Shallow wells ,
Estimated depth to high ground water: 12
feet
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:
USGS and towri maps show groundwater at greater than 12'.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
':5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
f ` Commonwealth of Massachusetts
,l Title 5 Official Inspection Form
p Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
130 Regatta Dr
Property Address
Steven Youwen Lu
Owner Owner's Name
information is required for every Centerville MA 02632 5-2-18
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
f -
• Commonwealth of Massachusetts
M EMU Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
\V�tzj I_? O gegic, a O/, v-C
Property Address
i�f ��l � i^'1 � f ✓`'►rM�✓
Cw ner ON ner's NameInformation Is
I�
required for every r
A.?
page. City/Town Qn� State Zip Code Date of Ifispeallon
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.
Irnngoutf rms A. General Information
filling out forms .
on the computer,
use only the tab 1. Inspector. voy'kkey to move your cursor-do not
use the return Name of Inspector
key. -
IV IvI n
ad:
Company Name
Company Address �AS T N A✓'� Od A Toi(
GtylTown State Zip Code
(so?) g0--�7 D qo -Y
Telephone tuber 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
r. j -.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 16.340 of
!�Tltle 6(310 R 16.000). The system:
arr� C ,
rme
ff-
A' PL sses El Conditionally Passes ❑ Fails
`V Ne❑ Further Evaluation by the Local Approving Authority
Inspectoliern
Signature Date
The sy 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 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.
Ors•3113 Title 5Officid Inspection F orm Subsurface Sewage Disposal System•Page t of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
/-?0 ✓
operty Address
2 ( v✓1�'l.er
ON ner Owner's Name
In required
for
isevery � H ✓1 / ov
345-le>
page. Citylrown State Zip Code Date of I spec ion"
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/a/wayscomplete all of Section D
A) Syste asses:
7I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
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
Healt h.
A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
dam'Y13 TI1105Offlelel InspectlonForm Subuurface Sewage Disposal System-Page 20117
f,
Commonwealth of Massachusetts
19 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
/ o e t�ti D�
Property Address
z,rh r��r
ON ner ON ner's Name AState
1Information Is (�N�C✓f1 I C oarequired for everyllC..///��� �page. Cityfrown Zip Code Date of Jhsptfctlon
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 mannerwhich 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
One.W13 Title 5 Ofecid Inspection F orm Subsurface Sewage Dleposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form •Not for Voluntary Assessments
13(9 lee.j07Lj-A, A�r-
Property Address
f yv�1M�y'
Ory ner ON ner's Name le— ,� ! ^
information is Nt/✓! / �'��L. D��required for every
page. CitylTown State Zip Code Date of Inspbction
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 welt".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
co01orm bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must Indicate "Yes" or"No" to each of the following for all,inspections:
Yes No
❑ Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ a Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ Ga/ Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ c/ Liquid depth in cesspool is less than 6"below Invert or available volume is less
than'/2 day flow
t9m 3M3 Title601fldelIrepeotlonFormSuba NOSewage0lepoeatSptw•Pepe4of17
J
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form •Not for Voluntary Assessments
/30 15,4tlox 2r
Property Address
1 ✓1��✓
ON ner Ow ner's Name w ` / /
information is �j4!0 4 ✓l` 'od 6 3a 5 '/
required for every
page. 5 /Town State Zip Code Date of lAspeclion
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:
❑ B Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ 0/ Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ L7 Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ I�f 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 collform bacteria Indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen Is equal to or less than 6 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-
10,000g pd.
❑ The system&fiq. I have determined that one or more of the above failure
criteria exist as described in 310 CM 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 16,000 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
Cl ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered "yes"in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
One W13 Tile 60ffidsi Irspection Form Suburfac;o Sewage Dispose!System-Pogo Sof 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
V
Subsurface Sewage Disposal System,/Form •Not for Voluntary Assessments
Property Address do
e�40411� a
0r✓ti V-0K
Ow ner ON ner's Name I �,�
information is C�N�eKy614e 1—' 4 o,2 6 ?off l" �3
required for every —S —
page. City/rown State Zip Code Date of kispeetion
C. Checklist
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes
/ No
2 ❑ 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 NIA)
L7 ❑ Was the facility or dwelling inspected for signs of sewage back up?
❑ Was the site inspected for signs of break out?
L�7 ❑ Were all system components, excluding the SAS, located on site?
OR ❑ 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: J
Number of bedrooms (design): Number of bedrooms (actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x #of bedrooms):
151ns 3H3 Tile 5 Official InspectlofFormSubsurface Sewage DisposalSystem•page aof17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
ON ner ON ner's Name ,�f �
information Is ceo�✓vl 1 1,4 olC 6 0�-
page. Ciry/Town
required for every State Zip Code Date of Inipectibn
D. System In ation
Description: / Moo Ga ��p✓1 JP �IG l� ti/
/ !s4/1 coh 0
Number of current residents: ..,
Does residence have a garbage grinder? ❑ Yes Ly' No
Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes Ly' No
information in this report.) —/
Laundry system inspected? ❑ Yes L�' No
Seasonal use? ❑ Yes l No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
Sump pump? Yes 0
Last date of occupancy: Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CM R 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:
t5ris 3113 Tide 5Official Inspection Form Subsurlace SewapeDisposel System•Pepe 70f 17
s
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
L?
n ael
Property Address
07t vi rMe�
Cw ner Cw ner's Name l
information is K�evi• vvi /A f�a ,'�d 7 j
required for everyState Zip Code Date o Ins ction
page. Cilyffown P
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: � ��'f O��✓
Was system pumped as part of the inspection? ❑ Yes No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of stem:
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/Altemative 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 VA system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other (describe):
tSns-W13 TIOe B Offfdel Ins pecdon F orm Subsulace Sewage Disposal System-Pape 0 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
/3 0
Property Address
2 i v^1
Cw nor ON ner's Name /�Q 1/� ✓�! �- O�6 ��
information is
required for every page. g crown State Zip Code Date of lr4pectbin
D. System Information (cont.)
Approximate age of all components, date installed(if known) and source of information:
Ms ` o
Were sewage odors detected when arriving at the site? ❑ Yes No
Building Sewer(locate on site plan): r�
Depth below grade: feet �L
Material of construction:
❑ cast iron 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet O
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade: feet
;eri"f
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: y
Sludge depth:
Ons 3M3 Tito 50f11clalInepectonF arm Subsurface Sewage DispeadSystemPagogof17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Roperty Address -
ON ner Owner's Name
information is
required for every eN ✓v e111,14 0'�6j-oL ,-
page. Cltylrown State Zip Code Date of nspe tion
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle 7
Scum thickness
Distance from top of scum to top of outlet tee or baffle
it
Distance from bottom of scum to bottom of outlet tee or baffle �p /
How were dimensions determined? �a C-Ey/Ge-,
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
(A V" t✓1 Y10 1 ee Q c- c�7- -i4j' -�l mv-e,
I Au, AH S I&,I �L-Ooc
Cove J r�1419 1.1 , -_
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
t9ins•3I13 T10050FACUI MSPOCUanFann SubSt"S 8"ODlepasg System-Pape 100117
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
13o i2e5 �. � �✓
Property Address
ON nor Cw ner's Name
information is h y�� ,� Oo)
required for every CC �----l.
(o Z2 o5-11>h-7
page. City/Town State Zip Code Date of In pact
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
We•3M 3 Title 5 orAdal Inspection F orm Subsurteee Sewage Disposal System•Page 11 d V
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
/3: i�&
Property Address
✓mil✓�11�'1�' t /�
In is Osner s me /tee✓►�/V j I 0
required for every („�
page. City/Town State Zip Code We of Ins ct
D. System Information (cont.)
Distribution Box (if present must be opened)(locate on site Ilan
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.):
so
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:
t5ris,3113 Title 5Official Inspection Form Subsurface Sewageolepow System Page 12 d V
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary
�Assessments
-IV /�'o
Property Address
Cw ner
information is Ovv ner s Name �Q 6" ✓ / MI&
required for every `
page City/Town State Zip Code Date of InsiJection
D. System Information (cont.) (,�
Type: 6 X`�/ / a` r 54o,,
leaching pits / number:
❑ 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.):
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
tSn,3113 T10e5010dal InspecOon F orra Subsurface Sewage Disposal System-Pape 130117
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form •Not for Voluntary Assessments
Property Address
2 t il/h wl.e✓
Owner Owner's Name Cev-#�'W 1// /i� Q.)c d b1l.?
Information is
required for every
page. Cityrrown State Zip Code Date of Ins t'
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.):
tfts-W3 Tide50fAcid Inspection Form Subm0ace Sewage DlsposW System•Pape 14d 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form --Not for Voluntary Assessments
Property Address
wrrti.e,-
0N nor ON nor's Name
information is
required for every ---
page, CityNown State Zip Code Date of Intpection
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 lic water supply enters the building. Check one of the boxes below.
hand-sketch In the area below
❑ drawing attached separately
70
I
1
reins•3113 Me50(flOd InspecOon Form Subsurlaw SewepeDisposal S)etem-Page 15 d V
Commonwealth of Massachusetts
Title 5 Official Inspection Form
t Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
2� ✓h IM-QY
Owner rn- Owner's Name Ce N-ky 7 Ile
l � /7
information Is f QO'er6 3D_ S
required for every
page. Ckylrown State Zip Code Date of In pecti n
D. System Information (cost.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells 42 K
Estimated depth to high ground water: 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
11
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked wit al Board of Health-explai^
/�!C ylJ-es f- 14ole
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
!l C/ Ape h
ts
�S !3/gtiHC/�r
I
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
Mns 3113 McSO(AdellnspeCdonForm SubsurfeceSewegeDlsposal System-Page 15d 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
/_?0 1�!.e 5 ,,� �A--- -1 -
Property Address
2f Vn
Ow ner QYv ner's Name
information is CeN� 4V
V-$ `le od 6
required for every !.___L �.—
page, Cdy/Town State Zip Code Date of Inspectl6n
E. Report Completeness Checklist
inspection Summary: A, B, C, D, or E checked
Inspection Summary D(System Failure Criteria Applicable to All Systems)completed
N System Information—Estimated depth to high groundwater
Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
One•3M3 Tito 6Official InspeclanF"SubsuAece Sewage Disposal System-Page 17 d 17
Yi5�0000 SARNSTABLE
LOCATION 0W 37 ZrQ41TA SEWAGE # lD
VILLAGE CAOA11'60,V/I-LZ ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY Ila-Le azlL
LEACHING FACILITY: (type) (size) X S-d 'J13 i �
NO.OF BEDROOMS
BUILDER OR OWNER AAY S/AE AVI& M!!
PERMIT DATE:k!5�,-', V e �t;E::COMPLIANCE DATE: 3 24J T��
Separation Distance.Between the:
Maximum Adjusted Groundwater Table and Bottom-of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist -�-'
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by 9- /ml"'-
W
3-1 y
e
v
0
1
a
G�
No.... = � 9' Fss.........� ?n?.......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliration for Di-ripoml Worlm
(foutitrurtion ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
•� aJo 4. ...1 1..�"`t,-► 3?) ...... ......."'.................................................................
o ti i-:\dd ss or Lot No.
--------------- ........................... ...............•••--••--. .•••--••..---------•-------.......---••--
'.._._.-------
Address
wn T i���,p, -....... Address
Installer /� /'��
d Type of Building Size Lot..._...-_-- LV--•.--•--.....Sq. feet
Dwelling— No. of Bedrooms..__.__..__ -- .. --_----- ---._.__Expansion Attic ( ) Garbage Grinder ( )
P-4 Other—Type of Building 4 `6 o. of persons............................ Showers ( ) — Cafeteria ( )
a' Other fixtures ................ .................
W Design Flow.............................�.l.U.......gallons per pin per day.
WSeptic Tank—Liquid capacitytW _-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 anlk
a Percolation Test Result Performed by... ......_ -------------------------•- Date........-...............................
04 Test Pit No. 1._ __......_.minutes per inch Depth of Test Pit-------------------- Depth to ground water---V-6 ....
fi Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
IY4 .
0 Description of Soil.• - -----�......-•-------... •--------------------------------------------------------------------------------------------------•••----
"�
W
VNature of Repairs or Alterations—Answer when applicable.-.-_._......................................................................................... b'
..-•---•---•------------------------••-•••-•••--•-•--------•-•---•------------•----•-•--••--•••••--•-----•---------...------...-----•-•-•----•-•---------........•----•---•----••--•-•-•................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compjiance has bee issued e board f health.
Signed __...... ... .... ........... .... ..✓ � Ji�
A Itcation.Approved B c� '
PP PP Y .Dare 1 S
......._.......-- ----........---'---.................... Dace
Application Disapproved for the following reasons- -------------- ---------------------------------------------------------------------------------------------------------
---------------------------------------------------------------------------------------------------------- ---------- ------------------------ -
Dare
Permit No. ---- car... �q.._------- --------- Issued ---------------------------- ----2 3.....:.�7, .1s,
Dare
No.._. ?`y-.._ FEB ......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE '•
Appliratiun for Uiupuial Wurl Tomitrnr#inn rantit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System37)..
at: '
Vian- 1dd s or Lot No.
. ----•-
„-I caner --)e/1 ")4� Address
� Installer Address � P.
Q Type of Building Size Lot......../_?.t...........��....Sq. feet
Dwelling—No. of Bedrooms---------... __________________________Expansion Attic ( ) Garbage Grinder ( )
04 Other—Type of Building '� . ✓t:L�.No. of persons---------------------------- Showers ( ) — Cafeteria ( )
44 Other fixtures ...................... ........ ... �
Q ------------------------ •--•-•-------.---------•----------••------------.------------
W Design Flow----.........................11�......gallons per p64�sen per day. Total daily flow-------.3_ _/...______._---_--__-___--gallons.
WSeptic Tank—Liquid capacity!_)U-gallons Length--- ------------ Width-- ------------- Diameter._---._--._-_._- Depth................
x Disposal Trench—No_ ____________________ Width.................... Total Length;------------------- Total leaching area....................sq. ft.
3 Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
z Other Distribution box ( ) Dosing
W Percolation Test Results Performed by-------- --------------•--•--•---.. ----------.---------------- Date........................................
Test Pit No. I................minutes per Inch Depth of Test Pit.................... Depth to ground water.._V- _._.....----
(4 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
p^
D 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
y the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has been,,issued by `"he board health.
Signe [ y�../........,. .a.-.:�f.�-�, - -` ` T
............... ..� Dace I
*eA lication Approved B ... - � .__... 1-
,, � PP PP Y .... -- � ..........- ..... -....- ..... ....
Application Disapproved for the following rearonr: .............. - ............. . .....................................___......... --
Permit No. - �'?�.. ..a...?.......
,..... ........ .. ..... Issued ......................�...... -
Dace
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Tertifirate of Tomplianre
X. -IS TO CERTIFY' That the IRdK dual ew e Disposal System constructed ( �) or Repaired ( )
by " � l - ...........-...... .............._ - ............_...... ...............................
Installer r
installed in a accordance with the provisions of TITLE 5 of The State Environmental Code as described in
has beencc p
the application for Disposal Works Construction Permit No. .._.'�,5-,�.,6 r... dated .......-),-.)-,-,3-"_9' ....
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
K
... � ,R— � .r, �: C / is
DATE -- - _.... _...-- _............. Inspector.---- _ -
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
No. r ..: U FEE........IG�.C3...
�in�nu�tl nr�u �nnntrttr#' n �rrntit
Permissionis hereby granted.............................................................. ----� 0----•.......................................................
to Construct (�) or Repair_(� ) act Individual Sewage Disposal System
at No. 3 �,�C -.•... �1_ `---------------
Street �• �
as shown on the application for Disposal Works Construction Permit No.f��,�____�9__ Dated.....
..........................----•------•--------••-----------------•••••••-------•-------••---...---••---
Board of Health
DATE--------------------------------------------------------------------------------
FORM 36508 HOBBS&WARREN.INC..PUBLISHERS
TJ�s 16 N -PATA; ...��.
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APPL-ICA NT 0' 13AySIt)E $VILE► Go . INC.,