HomeMy WebLinkAbout0050 SKATING RINK ROAD - Health 50 Skating Rink Road
Hyannis
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LOCAI"lON Sy c��a=T'7' �t '� SEWAGE # -- ---
VMaGE l(�ci�^ti �� ASSESSOR'S &LOT
INSTALLER'S NAME PHONE NO.
SEPTIC TANK CAPACITY /6
LEACPiING PACILTI`Y:(type) �� '' (size) c�
No.OF BEDROOMS 3
B(JILIiMER OR OWNER
PERMITDATE: COMPLIANCE DA'I`t<:
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 caching f )� Feet
Furnished by Jl 4G✓v, —�!� .S/
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
50 Skating Rink Rd
Property Address
Steven Gemborys
Owner Owner's Name
information is required for every Hyannis MA 02601 7-26-11
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 i4
1. Inspector: �z .s
Shawn Mcelroy
Name of Inspector
Upper Cape Septic Service
Company Name
29 Atwater Dr
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 15.340 of
Title 5(310 CM 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
7-26A 1
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 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 DER.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.
/ I I
t5ins•11/10 Tiffe 5 Official Inspection Form:Subsurface Sewage D osal System•Page 1 of 17
T
Commonwealth of Massachusetts
u W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments,
b' M 50 Skating Rink Rd
Property Address
Steven Gemborys
Owner Owner's Name
information is
required for every Hyannis MA. 02601 7-26-11
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:j
® 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-11/10 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts ,
W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
50 Skating Rink Rd
Property Address
Steven Gemborys
Owner Owner's Name
information is required for every Hyannis MA 02601 7-26-11
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
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):
AV
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.`,
P 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
l
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments,
50 Skating Rink Rd
Property Address
Steven Gemborys
Owner Owner's Name
information is required for every Hyannis MA 02601 7-26-11
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ ... :The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**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 '
0 ® 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 '/2 day flow
t5ins.11/10 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,
50 Skating Rink Rd
Property Address
Steven Gemborys
Owner Owner's Name
information is required for every Hyannis MA 02601 7-26-11
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:
' '` u ❑ ` ® '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`fifes" 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•11/10 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 50 Skating Rink.Rd
Property Address
Steven Gemborys z
Owner Owner's Name
information is required for every Hyannis MA 02601 7-26-11
page. CitylTown 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 (f 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
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal,System Form -Not for Voluntary Assessments r
M 50 Skating Rink Rd
Property Address
Steven Gemborys
Owner Owner's Name
information is Hyannis MA 02601 7-26-11
required for every y '
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
r
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
.Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water.meter.readings, if available (last 2 years usage (gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: 6-2011Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203): Gauons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? El El
Industrial waste holding tank present?_ ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
^M 50 Skating Rink Rd
Property Address
Steven Gemborys
Owner Owner's Name
information is required for every Hyannis MA 02601 7-26-11
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:
. - 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) (f 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
50 Skating Rink Rd f, ;
Property Address
Steven Gemborys
Owner Owner's Name
information is required for every Hyannis MA 02601 7-26-11
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:
1986
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 r
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 ❑ other(explain)
t ' If tank is metal.list age:
- I years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 gal
Sludge depth:
16"
t5ins-11/10 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'
50 Skating Rink Rd `
Property Address
Steven Gemborys t'
Owner Owner's Name
information is required for every Hyannis MA 02601 7-26-11
page. CitylTown 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
16"
Scum thickness 6
Distance from top of scum to top of outlet tee or baffle
4"
Distance from bottom of scum to bottom of outlet tee or baffle 13'
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-11/10 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form.-Not,for Voluntary,Assessments_
�M 50 Skating Rink Rd
Property Address
Steven Gemborys
Owner Owner's Name
information is required for every Hyannis MA 02601 7-26-11
page. Cityfrown 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-.-
El 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
I Subsurface Sewage'Disposal System Form -Not for Voluntary Assessments
50 Skating Rink Rd
Property Address
Steven Gemborys
Owner Owner's Name
iequired for
is Hyannis MA 02601 7-26-11
required for every y
page. Cityrrown 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.
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.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•11110 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
f
Commonwealth of Massachusetts
F Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not,for Voluntary Assessments
�M 50 Skating Rink Rd
Property Address
Steven Gemborys
Owner Owner's Name
information is required for every Hyannis MA 02601 7-26-11
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1-1000 gal
?` a. ❑ leaching chambers i 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 with 12"of water in bottom. Stain line at 24" below inlet invert.
I
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer r
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•11/10 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
M 50 Skating Rink Rd
Property Address
Steven Gemborys
Owner Owner's Name
information is required for every Hyannis MA 02601 7-26-11
page. Cityfrown 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•11/10 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 -Notfor Voluntary Assessments
50 Skating 4„M Rink Rd
Property Address
Steven Gemborys
Owner Owner's Name
information is required for every Hyannis MA 02601 7-26-11
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
rt
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 50 Skating Rink Rd
Property Address
Steven Gemborys
Owner Owner's Name
information is required for every Hyannis MA 02601 7-26-11
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam: ,
❑ Check Slope
❑ Surface water' ,, r i J::r
❑ 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:
Original design plans show no groundwater at 12'.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-11110 Title 6 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
M 50 Skating Rink Rd
Property Address
Steven Gemborys
Owner Owner's Name
information is required for every Hyannis MA 02601 7-26-11
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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
Commonwealth of Massachusetts
. Tithe 5 Official Inspection Form
° Not.for Voluntary Assessments
Subsurface Sewage Disposal System Form p�
Inspection results must be submitted on this form or on the official Title 5 Inspection Form dated
611512000.Inspection forms may not be altered in any way.
A. Certification
Important:
When filling out 1. Property Information:
forms on the c
computer,use 50 Skating Rink Rd Hyannis
only the tab key Property Address
to move your G,frald Magid
cursor-do not
use the return Owner's Name
key. 26 Fallon Rd
Owner's Address
Eastham MA. 02601
Cityrrown State Zip Code
Date of Inspection: Date06
Date
2. Inspector:
N. Timothy White
Name of Inspector
HomePro Northshore
Company Name
P.O. Box 101
Company Address
Rowley Ma 01969
City/Town State Zip Code
1-978-948-8428
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 io,sectionl 5.340r of
Title 5(310 CMR 15.000).The system: ' -
® Passes ❑ Conditionally Passes ❑ Fails a
❑ Needs Further Evaluation by the Local Approving Authority
8-4-06
Inspector's Sign ture Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving 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.
TITLE V.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 1 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
M
A. Certification (cont.)
50 Skating Rink Rd
Property Address
Hyannis Ma 02601
Cityrrown State Zip Code
Gerald Magid 8-4-06
Owner's Name 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" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Answer yes, no or not determined (Y, N, ND) in the ❑for the following statements. If"not
determined," please explain.
❑ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent.
System will pass inspection if the existing tank is replaced with a complying septic tank as
approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate
of Compliance indicating that the tank is less than 20 years old is available.
ND Explain:
na
TITLE V.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 2 of 16
• Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
` Subsurface Sewage Disposal System Form
M
A. Certification (cont.)
50 Skating Rink Rd
Property Address
Hyannis Ma 02601
City/Town State Zip Code
Gerald Magid 8-4-06
Owner's Name Date of Inspection
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
❑ obstruction is removed.
❑ distribution box is leveled or replaced
ND Explain:
Ka.
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced
❑ obstruction is removed
ND Explain:
NA
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR.
15.303(1)(b)that the system is not functioning in a manner which will protect public health;
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
TITLE V.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 3 of 16
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont.)
50 Skating Rink Rd
Property Address
Hyannis Ma 02601
City/Town State Zip Code
Gerald Magid 8-4-06
Owner's Name Date of Inspection
C) Further Evaluation is Required by the Board of Health(cont.):
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well"*.
Method used to determine distance: NA
"*This system passes if the well water analysis, performed at a DEP certified laboratory, for
coliform bacteria and volatile organic compounds indicates that the well is free from pollution from
that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5
ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached
to this form.
3. Other:
I
TITLE V.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 4 of 16
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont.)
50 Skating Rink Rd
Property Address
Hyannis Ma 02601
City/Town State ZipCode
Gerald Magid 8-4-06
Owner's Name Date of Inspection
D)System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y2 day flow
❑ ® 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 coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the
presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm, provided that no other failure criteria are triggered. A copy of
the analysis must be attached to this form.]
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.
TITLE V.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 5 of 16
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont.)
50 Skating Rink Rd
Property Address
Hyannis Ma 02601
Cityrrown State Zip Code
Gerald Magid 8-4-06
Owner's Name Date of Inspection
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
YES NO
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
I
TITLE V.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 6 of 16
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
B. Checklist
50 Skating Rink Rd
Property Address
Hyannis Ma. 02601
City/Town State Zip Code
Gerald Magid 8-4-06
Owner's Name Date of Inspection
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
YES NO
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® 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(3)(b)]
TITLE V.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 7 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information
50 Skating Rink Rd
Property Address
Hyannis Ma 02601
Cityrrown State Zip Code
Gerald Magid 8-4-06
Owner's Name Date of Inspection
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): 330gpd
Number of current residents: 4
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 ears usage d 04&05 72000
g ( Y 9 (gpd)): gal =99 gpd
Sump pump? ❑ Yes ® No
Last date of occupancy: still 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:
Last date of occupancy/use: Date
Other(describe):
TITLE V.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 8 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
M Vim`
C. System Information (cont.)
50 Skating Rink Rd
Property Address
Hyannis Ma 02601
Cityrrown State Zip Code
Gerald Magid 8-4-06
Owner's Name Date of Inspection
General Information
Pumping Records:
Source of information:
last pumped 10 year Information from owner
I
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: 1500 gal
gallons
How was quantity pumped determined? size of tank
Reason for pumping: length of time since last pumping-thick scum
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:
20 years old information from owner& plans
Were sewage odors detected when arriving at the site? ❑ Yes ® No
TITLE V.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 9 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
50 Skating Rink Rd
Property Address
Hyannis Ma 02601
City/Town State Zip Code
Gerald Magid 8-4-06
Owner's Name Date of Inspection
Building Sewer(locate on site plan):
Depth below grade: 31 in
feet
Material of construction:
®cast iron ❑40 PVC ❑ other(explain):
Distance from private water supply well or suction line: 39 ft from incoming water line to
outgoing sewer line in basement
Comments(on condition of joints, venting, evidence of leakage, etc.):
joints&venting good condition no evidence of leakage
Septic Tank(locate on site plan):
Depth below grade: 25in
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 ❑ Yes ❑ No
certificate)
Dimensions: 8ft long -53in wide-5ft deep
1000gal
Sludge depth: 2in
Distance from top of sludge to bottom of outlet tee or baffle 31 in
Scum thickness 8in
Distance from top of scum to top of outlet tee or baffle 10in
Distance from bottom of scum to bottom of outlet tee or baffle 14in
How were dimensions determined? rulers- Measuring rod
TITLE V.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 10 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
N
C. System Information (cont.)
50 Skating Rink Rd
Property Address
Hyannis Ma 02601
City/Town State Zip Code
Gerald Magid 8-4-06
Owner's Name Date of Inspection
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 was pumped-inlet baffle&outlet baffle in good condition-liquid at bottom of outlet invert-no
sign of leakage in or out of tank
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
na
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade: NA
Material of construction:
❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain):
TITLE V.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 11 of 16
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.).
50 Skating Rink Rd
Property Address
Hyannis 'Ma 02601
City/Town State Zip Code
Gerald Magid 8-4-06
Owner's Name Date of Inspection
Tight or Holding Tank(cont.)
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.):
na
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.):
d-box was level-distribution was equal-no evidence of any solids carryover- no sign of leakage in
or out of d-box-d-box was 43in in below grade-size of d-box 13x22in inside depth15in
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
TITLE V.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 12 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
M
C. System Information (cont.)
50 Skating Rink Rd
Property Address
Hyannis Ma 02601
City/Town State Zip Code
Gerald Magid 8-4-06
Owner's Name Date of Inspection
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
na
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
® leaching pits number: 1 pit-235 sq ftleaching
❑ 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.):
dry sand soil-no hydraulic failure- no ponding-system was under back lawn depth below grade to
chimney 30 in 50 in to tank 6ft round 7ft deep 3ft gin liquid- pit 1000 gal
TITLE V.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 13 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
50 Skating Rink Rd
Property Address
Hyannis Ma 02601
Cityrrown State Zip Code
Gerald Magid 8-4-06
Owner's Name Date of Inspection
Cesspools(cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
na
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.):
NA
TITLE V.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 14 of 116
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cunt.)
50 Skating'Rink Rd
Property Address
Hyannis Ma 02601
cdy/rown State
Zip Code
Gerald Magid 8-4-06
Owner's Name Date of Inspection
Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties
to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet
Locate where public water supply enters the building. 40
C>
� p
o
—C— c rj
TITLE V.doc.1 W004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 15 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
50 Skating Rink Rd
Property Address
Hyannis Ma 02601
City/Town State Zip Code
Gerald Magid 8-4-06
Owner's Name Date of Inspection
Site Exam:
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water:
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:
From plans test pit#1 144in on water
I
TITLE V.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.
Page 16 of 16
ASSESSOR'S MAP NO. o10- 116 PARCEL Oro — I S7
LOCATION® SEWAGE PERMIT NO.
V11LAGE
141y w,%�,
i
IN A LLER'S NAME A ADDRESS
3
� I U I L D E R OR OWNER
A
DATE PERMIT ISSUED �P ' .
DAT E COMPLIANCE . ISSUED ��
V �- � �
`� �� �
� �� �
.., �, s ,�
o � °� a
® ,
,�.
. ,:
O
'� �
!Y
E � - i
a.- '
e w.r�• r a_.y
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF , HEALTH,,
ww. .... .......oF..:: ��� =� � ......................................
Ap rtttiiall for Uiupuu d Works Tunitrur#'tun Frrutit
Application is hereby made for a Permit to Construct (6() or Repair ( ' ) an Individual Sewage Disposal
System at:
... .......... ........................-----LG%
- Location-Address or Lot No.
...lt!✓`�: %!�T� .. f/eA? ,.j �`3..........................
O Address
a .. z �} £ zs2�*?r,4.�� eg�e.)V,d � -•..:.................................................
Installer Address
Type of Building .,. Size ......Sq. feet
Dwelling—No. of Bedrooms.......e...............................Expansion Attic (V/) Garbage Grinder ( )
Other—Type T e of Building ............................ No. of ersons...._..--.........--........ Showers p., yp g p ( ) — Cafeteria ( )
f1rOther fixtures ...--•--•---------------------------------------•-•• ..'.. .._
W Design Flow..............33b....................gallons per person per day. Total daily flow.............3_a.A.....................gallons.
WSeptic Tank—Liquid capacity evrm?..gallons Length....a........ Width.... Diameter.... ...... Depth.................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
3 Seepage Pit No----------- ------ Diameter....<i ...... Depth below inlet....S........... Total leaching area•.0.30:-4.sq. ft.
Z Other Distribution box (%/) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
F1.4j Test Pit No. 1-.--<Z...minutes per inch Depth of Test Pit./�!_....... Depth to ground water........................
�rq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........---.............
a --•-------------------------•------------••-•-------------...---...------------.....------...................------------------...._....-------------••--•••.
O Description of Soil_.0r?_V y-.......... � �Z. �s o Cc.�-rs -,i'°' L 4 -
x ...............
V .................•_..... `1_ y!9......Cc ...2_......S2.............---................------------------•-------•-----------------
W
VNature 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 TITIU 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in
operatio u til a Cer 'ficate of Compliance has been issued by-the boar of health.
V
/Date
A plication Approved By.... :_: _.............I/ -------==--------------------------- ( -
Date
Application Disapproved for the following reason
-------------•---••.........---••------------•••----•••.,......---------••----••----•-•-•-•-•---.....•--•••--•-•--•-•-•---•-•-•...-•-•••-•-•-•-----••-----••--•--•---•-•-•••---•------•-••-•--••-------
Date
PermitNo.......... ............ Issued........................................................
Date
No..... ......_.... ............._....._.....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....... ............... ...............OF........................................
ApVftration for Disposal Works Tunstnution Prrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
....:..........._........_...................................................................... ----...--•-•-----•-•--------•-•----......------•------•-----------.................---_......••••-
Location-Address or Lot No.
......-•---•....................•--•-------....._........----...-•- ...........................---•
W�„� ,,....� ....... Owl Address
0��..............................� .... .........................................•-•--•-•--•----•--•-••-•---------•----..........---......
Installer Address
Type of Building Size Lot............................Sq. feet
U Dwelling No. of Bedrooms............................................Ex ansion Attic�-. g— p ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures ------•---------------------------------•---...---------••••-•--••-•-••----•-••_..-••-•-•---•-••-
W Design Flow............................................gallons per person per day. Total daily flow......___.__.-_._...__.______.._............gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No_____________________ Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
a
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a ••••-•--••••-•------•...••-••••..............••-••••-•-•-•.......---••••--•••-•-•----•------•-----••.........................................................
0 Description of Soil.........................................................................................................................................................................
x
V •---•••-•...••-•••.............•--•-•-•-•-...._......._.....--•..._..•••---•••-•••••-•--•---•-...-••••••••-••---•-••--•--••-•-•-...-•••-•-•-••-••-•--••••••--._._._......••-•-••....---••-•.._-•••-_----
W
---•-----------------------------------------------•------------------------------------------------------•----------------------•------------•---------------------------..._---•---•••-••--•--......
U Nature of Repairs or Alterations—Answer when applicable.
-•-•--•----------------•------•----------------------------------•----------------------------.._..__.._......_._.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in
operatio u til Cert•ficate of Compliance has been issued by the board of health.
...................•--•-•-•-•-•-----------------.........._.....-------.._...._...---- ..........................
A plication Approved BY-•-•-•-- ..............`--..... ___� `.. =--•-•.................................. -•--•-•••-•- �D1e ......
-=
Date
Application Disapproved for the following reasons-------------------------------------------------------------------•-------------------------------....-••._..._
--------------------------------------------•-------•--•------------.....--•-•••-........__.........._...._•-•-••-••••-•-•-•-••••------------•---------•------------------•--•-••••-•-••--••-•-••---•--•-
'r Date
Permit No........... r: �rz......_Z._/1 Issued.............•-•-•---••--••••--•-•-•
--- ��. ...._...... Date -------------•-•---
THE COMMONWEALTH OF MASSACHUSETTS
BOAR OF HEALTH
/..(.".!�.....................O F.. .........................-........-.......................................
(Irrtif ira of Tontpliattrr
THIS IS TO CERTIFY, That the Individual Sewage Ispos Yst m con ucted ( ) or Repaired ( )
. .. 77
by �_ ^.. ••,�. __.. .....-- .,....... -•-• --•----• ----•----------------------------------••---
Installer
at----••---••--•-••.............••-••-•-•••-••--....•••••••••••-----....-••-•••••••...•----------••••••------------.._.....---------------------•--------•-•--................••-•-------•••------•_...
has been installed in accordance with the provisions of TITLE, 5 of The State Sanitary Cod as des ibed in the
7application for Disposal Works Construction Permit No..... __1..`..j:�.�.. dated-`- '_ ! _____________
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED A GUARANTEE THAT THE
SYSTEM WW
NC�N SATISFACTORY.
DATE.-_-_-•-- 3 ........................................ , Inspector.------.. ../......i'----------------------•-----•----•-------••-•-----•----------
THE COMMONWEALTH OF MASSACHUSETTS
BOA HEALTH
........ ....( .......OF............. - Z"..----.......----
No.......................... > FEE... ........
Disposal Works Ton#to wtt Prrutit
Permission is.hereby granted............. �!.__t N� --- '
= ...:.......:............._....
to Construct L✓)or Repair ( _) an Individual Sewage Disposal System
atNo............. .......='------------- ". .... k ...........................
✓ _Street
as shown on the application for Disposal Works Construction Permit No..._ '_._:_._ _ Dated...................................
.�.
Board of Health
5;xWarATE.--•--• ...................................
FORM 1255 A. M. SULKIN, INC., BOSTON
v.
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j PST i � �Qj„CSE7LV[7 /
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war�uz—
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V J
N
34 _ /i J/, 2 ► F
90�`D
57/7 ZF
LOCATION . /Y- 5 s... . ..
SCALE . ��=30.�. . . . DATE .
/VoV. S
PLAN REFERENCE -7NG T
COv T
2-
a 'DU�RD G,
o� E.
KE€LL.EY u
' No. �6;GJ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Ma�s�s�EGf �`a
CERTIFY THAT THE
0" ... ...... . ...... ....... .. ......
,� -- SHOWN ON THIS PLAN IS LOCATED ON THE GROUND
AS SHOWN HEREON AND THAT IT CONFORMS TO THE
SETBACK REQUIREMENTS OF THE TOWN OF
WHEN CONSTRUCTED.
n DATE . . . . . . . . . ..
REGISTERED LAND SURVEYOR
4 s
z of Z. Sf�EZsTS
L. 38 S.', . ...
TOP OF FOUNDATION
CONCRETE COVER
CONCRETE COVERS
4'1 CAST IRON II X MAX 12�rnsmr .
OR SCHEDULE 402 MAX.
PVC PIPE 4"SCHEDULE 40 PV.C.(ONLY)
PER. PIPE- MIN. LEACH
PITCH 1/4-PER.FT. PIT PRECAST
LEACHING
•' NVERT :.�'�
`•• EL..3c;o,7.. INVERT INVERT : . ; PIT OR
,•, SEPTIC TANK EL.3sGs.. DIST. EL�s4� ; >_ EQUIV.
..• INVERT
ox .. -�, o• ,I.
L. 3SBG , "�� GAL. INVERT/ INVERT •�� o ,�' 3/W 2•WASHED
STONE
.• I �'--Ito, DIAr--q 78'
PROM LE OF GROUND WATER TARE--
SEWAGE &z. zz.� o� nor"L DISPOSAL SYSTEM g¢
NO SCALE N�cN C/jeyND wA7"d72
•9 wills ry�r=de'
439s Fz. Zs.4n
SOIL LOG WITNESSED' BY :
DATE TIME. '�%. . A. . .� -!ems, ,LvNLo�! , BOARD OF HEALTH
TEST HOLE 1 TEST HOLE 2 cAJ✓9?�O 1 ,AC67GZ;/, ENGINEER
ELEV.. 3B•AA ELEV. .... . . . . . .
WoapCe/fisy
z4" -Sue sole-
DESIGN DATA :
JC.zo NUMBER OF BEDROOMS `3
TOTAL ESTIMATED FLOW . . . GALLONS/DAY
7i' ez 32Zo BOTTOM .LEACHING AREA 7�':So . SQ.FT./PIT/Z/0,D,
84t r
SIDE LEACHING AREA . . .�' . . . . . SO.FT./ PIT13147coo
GARBAGE DISPOSAL .^!n^!�`"..(50% AREA INCREASE)
os»2s,' z3S�
s'4wD TOTAL LEACHING AREA . . . . . . . . . SO.FT
PERCOLATION RATE �c-3s 7?14,v, 7?`!n MIN/INCH
LEACHING AREA PER PERCOLATION RATE SQ.FT./.-.RD,
Z .WATER ENCOUNTERED 1
oMEr R1 T A117;V . .
NUMBER OF LEACHING PITS . . . . . . . . . . . .
APPROVED . .. . . . . . . . . . . BOARD OF HEALTH �• of .Syv�✓e� oN A!� S/r,�. • . . .
DATE. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
AGENT OR INSPECTOR
N Of 'NaSo� H CP P,�ass�c
o` EDVV,^R
LOT #iS v, STETS
���LEY � R "
... . . .
AN/V/l5 • M�95S �'Ai L�?EO`'�'/ sanrtaafta�
PETITIONER