HomeMy WebLinkAbout0021 CAP'N ISIAH'S ROAD - Health Cap`n Wah's Road
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
M 21 Cap'n Isiah's Road Assessor's Map: 38 Parcel: 67 I
Property Address Q�
Edward M. and Sally Vetstein,Trs
Owner Owner's Nam X
information is 0required for every Cotuit MA 02635 May 1 Q7f2017
page. City/Town State Zip Code Date of tt pection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. General Information ,5 f l y
filling out forms � Jc3
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not David D. Coughanowr
use the return Name of Inspector
key.
Eco-Tech Rapid Response
% Company Name
155 George Ryder Road South
Company Address
Chatham MA 02633-1621
City/Town State Zip Code
508 364-0894 1328
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection.The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000). The system:
® Passes �SHoan ❑ Conditionally Passes ❑ Fails
DAVID. Qti
ElNeeds er Ev uatlon e Local Approving Authority
COUGHANO R N
No.i 8
Epp May 10, 2017
Inspector's Signa u l�jy INsp* Date
The system inspector s all 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.
l5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
t ,
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
T�19,
21 Cap'n Isiah's Road Assessor's Map: 38 Parcel: 67
Property Address
Edward M. and Sally Vetstein, Trs
Owner Owner's Name
information is Cotuit MA 02635 May 10, 2017
required for every y
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or EJ always complete all of Section D
A) System Passes:
® 1 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:
Inspector's Notes==> The septic system described herein is deemed to pass this Real Estate
Transfer Inspection if it does not meet any of the failure criteria enumerated in Section D on pages 4-
5, or specified by local regulations. The scope of this inspection is limited to health and environmental
compliance and the septic system has been evaluated according to the conditions observed on the
day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing
determination.
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*orYthe'septic tarik,(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltr-atlon�or;itank fail-.1 is imminent. System will pass
inspection if the existing tank is replaced with a;co.mplyinsepticitank as approved by the Board of
F , ,
Health. Ai lu a�btl+. !�tiC ig ?'
*A metal septic tank will pass inspection if it iAtruc4bra11y sou, d;,an!i t leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years oldrisiavaflable:.
❑ 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
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 21 Cap'n Isiah's Road Assessor's Map: 38 Parcel: 67
Property Address
Edward M. and Sally Vetstein,Trs
Owner Owner's Name
information is Cotuit MA 02635 May 10, 2017
required for every Y
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if (with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The
system will pass inspection if (with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
wM 21 Cap'n Isiah's Road, Assessor's Map: 38 Parcel: 67
Property Address
Edward M. and Sally Vetstein, Trs
Owner Owner's Name
information is Cotuit MA 02635 May 10, 2017
required for every y
page. City/Town 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
❑ ® 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 1/2 day flow
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
21 Cap'n Isiah's Road Assessor's Map:38 Parcel: 67
Property Address
Edward M. and Sally Vetstein,Trs
Owner Owner's Name
information is Cotuit MA 02635 May 10, 2017
required for every Y
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303,therefore the system fails.The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304.The system owner should contact the appropriate
regional office of the Department.
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
M 21 Cap'n Isiah's Road Assessor's Map:38 Parcel: 67
Property Address
Edward M. and Sally Vetstein, Trs
Owner Owner's Name
information is Cotuit MA 02635 May 10, 2017
required for every Y
page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
_. ® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
M 21 Cap'n Isiah's Road Assessor's Map:38 Parcel: 67
Property Address
Edward M. and Sally Vetstein,Trs
Owner Owner's Name
information is Cotuit MA 02635 May 10, 2017
required for every Y
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ❑ No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d 255 gpd
9 ( Y 9 (gpd)):
Detail:
2015: 83,000 gallons 2016: 103,000 gallons
Sump pump? ❑ Yes ® No
Last date of occupancy: 1 week ago
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
M 21 Cap'n Isiah's Road Assessor's Map: 38 Parcel: 67
Property Address
Edward M. and Sally Vetstein, Trs
Owner Owner's Name
information is Cotuit MA 02635 May 10, 2017
required for every y
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
i
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: owner's agent
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
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
M 21 Cap'n Isiah's Road Assessor's Map:38 Parcel: 67
Property Address
Edward M. and Sally Vetstein, Trs
Owner Owner's Name
information is Cotuit MA 02635 May 10, 2017
required for every Y
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
Age: 36 years. System installed at time of dwelling's construction in 1981.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 7 ft+-
feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: 10+
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Sewer line appears structurally sound with no evidence of leakage or backup into dwelling.
Septic Tank(locate on site plan):
Depth below grade: 2
feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 8.5'x 5'x 6'-1000 gallon
Sludge depth: 6 inches
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official .Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
M 21 Cap'n Isiah's Road Assessor's Map: 38 Parcel: 67
Property Address
Edward M. and Sally Vetstein, Trs
Owner Owner's Name
information is Cotuit MA 02635 May 10, 2017
required for every y
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
28 inches
Scum thickness 1 inches
Distance from top of scum to top of outlet tee or baffle 10 inches
Distance from bottom of scum to bottom of outlet tee or baffle 13 inches
How were dimensions determined?
Previous inspection report
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pumping not required at this time. Maintenance pumping is recommended within 2 years and every
2-4 years thereafter with year round occupation. Tank and tees appear structurally sound and
functioning as intended. No evidence of leakage in or out was observed.
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
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
21 Cap'n Isiah's Road Assessor's Map: 38 Parcel: 67
Property Address
Edward M. and Sally Vetstein,Trs
Owner Owner's Name
information is y
required for every Cotuit MA 02635 May 10, 2017
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
l
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
21 Cap'n Isiah Road Assessor's Map:38 Parcel: 67
Property Address
Edward M. and Sally Vetstein,Trs
Owner Owner's Name
information is y required for every Cotuit MA 02635 May 10, 2017
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 at 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.):
No adverse conditions observed.
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
l
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
M 21 Cap'n Isiah's Road Assessor's Map:38 Parcel: 67
Property Address
Edward M. and Sally Vetstein, Trs
Owner Owner's Name
information is Cotuit MA 02635 May 10, 2017
required for every Y
page. City/Town State Zip Code Date of Inspection
D. System Information (Cont.)
Type:
® leaching pits number: 1
❑ 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.):
No evidence of surface ponding, breakout, lush vegetation, or other evidence of hydraulic failure was
observed. No staining due to effluent backup was observed in the system.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
21 Cap'n Isiah's Road Assessor's Map:38 Parcel: 67
Property Address
Edward M. and Sally Vetstein, Trs
Owner Owner's Name
information is Cotuit MA 02635 May 10, 2017
required for every Y
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.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
l
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 21 Cap'n Isiah's Road Assessor's Map:38 Parcel: 67
Property Address
Edward M. and Sally Vetstein,Trs
Owner Owner's Name
information is Cotuit MA 02635 May 10, 2017
required for every Y
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
_ SEPTIC INFO AT THIS SKETCH IS
EC®_TECWUS BEST VIEWED IN
COLOR FORMAT
— '
—OF SEPTIC COMPONENTS
EX IS TING —DISTANCES IN DECIMAL FEET
D ►V�01L G UNG A e
l 39 47.5
021 2 44.5 52.5
B 3 49 57.5
A
1
100E GALLON /
SEPTIC TANKLU
3
j
LEACH
PIT ��80+2 cr
NOT
3 j TO
a SCALE
CApW MAWS ROAD 508 364-0894
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
M 21 Cap'n Isiah's Road Assessor's Map:38 Parcel: 67
Property Address
Edward M. and Sally Vetstein, Trs
Owner Owner's Name
information is Cotuit MA 02635 May 10, 2017
required for every y
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: 18+
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:
Town of Barnstable GIS maps
You must describe how you established the high ground water elevation:
Town of Barnstable GIS Department records indicate that the property is over 18 feet above nearby
surface water.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
l5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 21 Cap'n Isiah's Road Assessor's Map:38 Parcel: 67
Property Address
Edward M. and Sally Vetstein,Trs
Owner Owner's Name
information is Cotuit MA 02635 May 10, 2017
required for every y
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
GEOHYDROLOGICAL PROFILE
NOT TO SCALE
PRECASTS
g
LEACH
PIT
41
4-
6=
� 8
BOTTOM
OF
LEACHING
PIT
LEACHING 1S
ABOVE HIGH
GROUNDWATER;
GROUNDWATER ELEVATION
PER GIS MAPS
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF,ENVIRONMENTAL AFF IRS
DEPARTMENT OF-ENVIRONMENTAL PRO,TECTIONY`'
,IqN 2 22
Tow
N OF 8q p
HFgLTy. AB1E
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL.SYSTEM FORM
PART A
CERTIFICATION
Property Address: 21 C'a pt T G i a h.-, R d MAP 0 3
r'.nt ui t
Owner's Name: aabeth Kennedy PARCEL
Owner's Address: LOro.,,,
.."",.r,.+... .
Date of Inspection: b —G
Name of Inspector:(please print)_Wi 11 i am E Robi nson Sr.
Company Name: . William E. Robinson Septic Service
Mailing Address: P 'O'-Box 1089
_Centerville, MA
Telephone Number: (5081 775-8776
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and.that the information reported
below is true,accurate and.complete as of the time of the inspection.The inspection was performed based on my
training and experience,in the proper function and maintenance of on site sewage disposal systems.I am.a DEP
approved system inspector.pursuant�to Section 15.340 of Title 5(310 CMR 15.000). The system:
(/Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
t -
Inspector's Signiature:,_�U 4 - .,,.... Date:
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health
DEP)within 30 days of completing this inspection.If the system is a shared system or bas 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 appro.ving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page I
Page2ofIl
OFFICIAL INSPECTION FORM' NOT FOR VOLUNTARY ASS FO SS RM S
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTI ,
PART A
CERTIFICATION (continued):
Property Address: 21 Ca t Isi =,Cotuit
Elizabeth Kennedy
Owner.
Date of Inspection:
Inspection Summary:,Check A,B,C,D or E/ALWAYS complete all of Section D
A. S tem Passes:
1 have not found any information which indicates that any of the failure criteria described in 310 CMK
15303 or in 310 CMR 15.304-exist.Any failure criteria not evaluated are indicated below.
;J.
Comments: t; .
B. ystem Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
wil
repa d.The system,upon completion of the replacement or repair,as approved by.the Board of Health, l pass:
the for the following statements.If"not determined"please
Answ r yes,no or not determined(Y,N m,ND)i
expla' .
e septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unso d,exhibits substantial infiltration or.exfiltration or tank failttre-is unmment:System will pass inspection if the
exist. tank is replaced with a complying septic tank as approved by the Board`of Health:
•A m tal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indic 'ng that the tank is less than 20 years old is available.
ND plain:
Observation of sewage backup or break out or high static water level in the distribution box due Wbroken or
Ob
obs cted
Ob pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with
app oval of Board of Health):.
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND xplain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass spection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is rcmovcd
NDexIi
Page 3 of I 1
OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAt.SYSTEM INSPECTION FORM
PART'A Y
CERTIFICATION(continued)
Property Address 21 CAPT Isiahs. Rd
Cotuit
Owner: R1 i 7.AhRth Kennedy
Date of Inspection: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 fa ling to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in-A- ordaoce with'310 CMR 15.303(1)(b)that the-
system.is not functioning in.a manner which will protect public health,safety.and the environment:
Cesspool or privy is within 50 feet of a surface water -
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh .
2. S tem will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is.fui a oning 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
rP Y (SAS) _...
sur ace water supply or tr►bytary 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
p ivate water supply well".Method used to determine distance
'This system passes if the well water analysis,performed at DEP certified laboratory,for coliform
acteria 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
ilure criteria are triggered.A copy of the analysis must be attached to this form.
3. Ot er:
3
Page 4 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS =
SUBSURFACE SEWAGE DISPOSAL SYSTEM..INSPECTION FORM
CERTIFICATION(continued)
Property Address:
21 Capt Isiahs Rd
o uit
E izabeth Kennedy
Owner: _.. _..- .
Date of Inspection: �6 O
D System Failure Criteria applicable to all systems:.
You must indicate—yes'or"no"to each of the following for all inspections:
Yea No due to overloaded or clogged SAS or cesspool
Backup of sewage into facility or system component d
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 volum..e is lessthan'/: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 vrater 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 an_.d volatile organic compounds
indicates that the well is free from pollution from that facility and the presence otammonia
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 fortn:j
(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To a considered a large system the system must serve a.facility with a design flow of 10 000 gpd to l5,000
gpd-
You ust indicate either"yes"or"no"to each of the following:
(The ollowing criteria apply to large systems in addition to the criteria above)
yes ° .
_ 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 11 of a public water supply well .
If yo have answered"yes"to any question in Section E the system is considered a significant threat,id answered
"yes" in Section D above the large system has failed.The owner or operator°f any large system considered a
signi cant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.30 The system owner should contact the appropriate regional office of the Department.
4
Page 5 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 21 Capt I s iahs Rd
Cotuit
Owner: R1 ; Zabeth Kennedy
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 penod;?,
t/ Have large volumes of water been introduced to the system recently or as part of this inspection?_
v — Were as built plans of the system obtained and examined?(If they were not available note az N/A)
Y — 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
Yes no
�/ Existing information.For example,a plan at the Board of Health.
Determined in the field if an of the failure criteria related to Part C is at issue approximation of distance
( Y PP
is unacceptable)(310 CUR 15.302(3)(b))
f
5
L
Page 6ofII
OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Isiahs Rd t
Property Address: 21 Ca P Cotult
iza a ennedy
Owner: •.,
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL .. -
Number of bedrooms(design): 5 Number of bedrooms(actual):,3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x a of bedrooms):3L b
Number of current residents:
Does residence have a garbage grinder(yes or no):1 U
Is laundry on a separate sewage system(yes or no):A 0 [if yes separate inspection required)
Laundry system inspected(yes or no):ti '
Seasonal use:(yes or no): /i U
Water meter readings,if available(last 2 years usage(gpd)): :` 2 0 01 77,000 gals:
Sump pump(yes or no): Al v 2002 75,000 gals
Last date of
occupancy: — 3 0 3
COMM RCIAL/INDUSTRIAL
Type of a tablishment:
Design flo (based on 310 CUR 15.203): Rpd'
Basis of d ign flow(seats/persons/sgft,etc.):
Grease tra resent es or no):
_
P Y
Industrial aste holding tank present(yes or no):—
Non-sani waste discharged to the Title 5 system es or -
g (
no _
y y )
Water m er readings,if available:
Last dat of occupancy/user
OTH (describe):
GENERAL INFORMATION
Pumping Records
Source of information: ,/ 4
Was system pumped as part of the inspection(yes or no) 2g
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/Altemative 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,d installed(if known)and source of information:
Were sewage odors detected when arriving at the site(yes or no):A0
6
• Page 7 of 11
OFFICIAL INSPECTI,ON FORM NOT-FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL,SYSTEM.INSPECTIQN FORM
PART C
SYSTEM INFORMATION(continued)::
Property Address: 21 Cap t I s i ah s Rd
Cotuit
Owner: Elizabeth Kennedy
Date of Inspection:
BUILDING SEWER cite on site plan)
Depth below grade:
Materials of constru ion:_cast iron _40 PV.0 ._other(explain):
Distance from priv a water supply well or suction line:
Comments(on co dition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: " locate
_( on site plan)
Depth below grade: 'g-
Material of construction:concrete_metal_fiberglass_polyethylene
other(explain)
If tank is metal list age:— Is age confirmed-by a Certificate of Compliance(yes or no):_.(attach a copy of
certificate) >
Dimensions
Sludge depth:
Distance from top of sludge 4 o bottom of outlet tee or battle: ,,—
Scum thickness:
, L
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:L
How were dimensions determined:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural_integrity,liquid levels
as related to outlet invert,evidence of-leakage,etc.):
ze
GRE SE TRAP:_(locate on site plan)
Depth low grade:_
Materia of construction:_concrete_metal_fiberglass_polyethylene_other.=
(explain
Dimensi ns:
Scum thi kness:
Distance om top of scum to top of outlet tee or baffle:
Distance om bottom of scum to bottom of outlet tee or baffle:
Date of I t pumping:
Comment (on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related o outlet invert,evidence of leakage,etc.):
7
Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DI5POSAL SYSTEM INSPECTION.FORM'
PART C
SYSTEM INFORMATION(continued):.
Property Address: 2 1 Cant T G i a1,S Rd
COtni t _ _
One Kennedy
Owner: _
Y
Date P
of Inspection:
TIGHT or HO DING TANK: (tank must be pumped at time of inspection)(locate on.site plan)
th below e:
- ain Dep s of eth lene other(expl )
concrete. metal fiberglass_p. y Y
Material of cons coon:
Dimensions:
Capacity. allons
Capacity. -
Design Flow: allons/day
Alarm present( es or no):
Alarm level: Alarm in working order(yes or no
Date of last pu ping:
Comments(c dition of alarm and float switches,etc.):
/Cif ust be o ened (locateon site plan)
DISTRIBUTION BOX: resent mu P )
Depth of liquid level above outlet invert: V `' • '
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.): )
PUMP CHAM ER: (locate on site plan)
Pumps in work• g order(yes or no):
Alarms in wor• ng order(yes or no):
Comments(no a condition of pump chamber,condition of pumps and appurtenances,etc.):
8
Page 9 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:_ 21 Capt Isiahs Rd
Cotuit
Owner: Elizabeth Kennedy
Date of Inspection:,f r 0—o-3 Zoocate
SOIL'ABSORPTION SYSTEM(SAS): on site plan,ezcavation*not required)
If SAS not located explain why:
Type
Z/leaching pits,number: 7
leaching chambers,number:
leaching galleries,number:
leaching trenches,number, length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/altemative system .Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.):
CESSPOOLS: cesspool must be pumped as part of inspection)(locate on site plan)
Number and configura'on:
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction
Indication of groundwate inflow(yes or no):
Comments(note conditio of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: (locate o site plan)
Materials of construct' n:
Dimensions:
Depth of solids:
Comments(note c- dition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
0-1
Page 10 of l l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASS ESS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION SSMENTS
PART C
FORM
SYSTEM INFORMATION(continued)
Property Address: 21 Capt Isiahs Rd
co it
Owner: Eliza e edy
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.
g
r
)Z a
a cJ�
10
r
Page I l of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 21 Capt Isiahs Rd
Cotuit -
Owner: Elizabeth Kennedy
Date of Inspection: I--<3--o 3
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
/ x
Estimated depth to ground water /p feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hol with' 150 feet of SAS)
i/Checked with local Board of Health-explain:_J T
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe" �how you established the high ground water elevation:
6 6 06 b Sp
� I
i!
r
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
. Z74&117------------------OF.. ...: � -�1.5.!GL.Il._� .......................................
Appliration for i f�. >axk C ��c r r iu rrutit
Application is hereby made for a Permit to Construct (V/) or Repair ( } an Individual Sewage Disposal
System at
Location-A dress Lot NQ.,
Ow er Address
-----------------------------
Ins er Address
Type of Building Size Lot___fSq. feet '
a Dwelling—No. of Bedr000ms_____. ___________________________P_Expansi Attic ( ) (Gajbag
Other—T e of Building ............. _ _. No. of ersons.... Showers Cafeteria
dOther fixtures .�_..T�'<Y�� _6? ----------------- -------------....----------------------------------------------.....--------
Design Flow...............: - o.......... -- :......•..._...___galIons per person per day. Total daily flow______--- ....................gallons.
W
WSeptic Tank—Liquid capacity_ p _gallons Length___0...... Width_4__.________ Diameter________________ Depth_-_:-__••---___-
x Disposal Trench—No ......... Width...... Total Length___.....~—'_....... Total leaching area...... ---sq. ft.
Seepage Pit No..................... Diameter-----C!-------- Depth below inlet.................... Total leaching area....C�RO_sq. ft.
z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by._-�J�x� .Q _ ./��l __._1....................... Date.."ive....lat.
,a Test Pit No. 1....4---------minutes per inch Depth of Test Pit---/a ........... Depth to ground water____
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-_..•-____--_-__-______
O Description of Soil.........46_�'l V h
x
U ----•-••-------••••---•-•••-•----•----.....•---•-•-••••••--••--•-••••••-•-•-•••......----••......--••••.....-----••••••••-•----•••••---•-•--•-------------............................................
...................................................----------------------------------------------------------------------------------------------------------------------------------------------------
UNature of Repairs or Alterations—Answer when applicable----------------_--------------_................................................................
----------------•••-----••-•-----------•----•-•••-•--••--•••--•---•-••-•--•-•-••-•-••-••-••-••••......----------------•••-•-••--•---•--------•---------------------••-••-••--•......-•..•--••-
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of'TTLI
p 5 of the State Sanitary Code--The undersigned further agrees not to place the system in
operation until a Certificate.of Compliance has been issued bby the board of health.
Signed •• •. - -_----------->.... �'h
7
Date
ApplicationApproved By-•-••••-•••-•-••••••--•--•••••••-•--•-•••••••••-••-•---•-••••-••-••---•......•-••-•......••••-_.. .......................
'Date
Application Disapproved for the following reasons-................-------------------------------------------------------------------------------------=•--------
--•••-•••••••••••-•••--•.....-•-•....••••••••••••••-•--•••••......--••...................•••••.................................------------------------------------...............-------------- ---
Date
PermitNo......................................................... Issued.......................................................
Date
No....`..�.. %. «` FE$.3�1._.............
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
Appliratiou for Uiiplugal Workfi Tomitrurfiuu lirrutit
Application is hereby made for a Permit to Construct ( V�or Repair ( ) an Individual Sewage Disposal
System at
l
f _..e.r,/i f ....._.r �.'�_ ....=_-- ti..�..:::�`. ^.. i_•I �:..._. ..___�=..�1.-...�Y yf,a...:=r-
Location Address J or Lot No
Own r Address
$m
Inste er AddressPQ /
d Type g '` `, Sq. feet
T, e of Building
Size Lot__.._t '_ :__.'.__'
Dwelling—No. of Bedrooms........... ................................Expansion Attic ( ) Garbage Grinder ( )
..........._ No. of persons __________________ Showers — Cafeteria
p`�, Other—Type of Building _____________ p ( ) ( )
Other fixtures ':,,. :, .f ---- ----------- ----------
,'4 5- Ions.
W Design Flow_____________________c'......._____._..___.gallons per person per day. Total daily flow__.__......... ..._, gal
W Septic Tank—Liquid capacity-1 41 . .;:'^-
---------- Diameter________________ Depth................
x Disposal Trench—No. ------...
......... Width-------------------- Total Length.................... Total leaching area........::_---------sq. ft.
Seepage Pit No--------------------- Diameter._...t...°....... Depth below inlet.................... Total leaching area____.-r..!r >sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
'~ Percolation Test Results Performed by__-h.:-`°-'`-r '---''-/ '", 'i- ------------------------------ Date..-'-``==--'--__f-= --1
Test Pit No. I.... .........minutes per inch Depth of Test Pit...._-___:.......... Depth to ground water.......... :._.........
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
•-•-------•-----------------•...--•-•-•---••--•-•-•----••--•-•--•------------•-------------•----------..__.........._......--••._..............._•----__----
O f
Descriptionof Soil----------�-�--=-----=--------=-•-------=--•-•--------------------------------•----------------------•-----.._..-------------------------------------------------------
x
V --•---••-------•---•------------••----------•--••-•-------••-•-------•-•----•-•••---------•---------••--------------------•------•-•------•------•-•--•-----•-•-•-•---•-•-•--•--------------•----•--•--
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 TT T L
p 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been.issued by
the board of health. i
Signed = = ---•--• •-•••--- ---- ---------•------ •-- ................................
Date
ApplicationApproved �y-------------------------------------------------------------------------------------------------- .........-------------------------------
Date
Application Disapproved for the following reasons--------------------------------------------------------------•-----------------...-------••---•-••--•-----•---
-------------------------- -••-----------------------------------------•-----------------------••------------
a1,. Date
PermitNo......................................................... "Issue(L.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETT
BOARD ,,OHEALTH
,....le., ........................t, ...O F...........
t -
, TTrrt firatr of Tumpliaurr
T1YI ^ IS TO CERTIFY, ` tie Individual Se Fe is osal S stem constructed G_'or Repaired
P )
- ..
,.
tallW �� r
at ' f 1 _---/, _ ��z- --•--•---• , .�, �.G�c '' J
./
has been installed n accordance ' h the provisions of T ' IZ j of The State Sanitary Code,as,deFc ibe in the
application for Disposal Works Construction Permit No.__1�_.�_'__ ��. ............ da.ted_-�_/i�_ _._€ ....._.__._...
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A C�IARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
�Q 6--
DATE................................................................................ Inspector-------....................1 ` i,� ----------------------________---
r .^THE COMMONWEAJ-TRH OF MASSACHUSETT� t
BOARf1D•-OF HEALTH - /j
No. .. ... ........ FEE._:=•:.«_.............
i tl orkii Tu fit tr _ `tau Vr it
1 d / r
Permission is hereby grad" . = - ----- ' �
V _r
to Constfuc�( ) ,Rep >�,( ),,at}°Indi�tid-ual SevtTage isp S��stem__ -
GG-�� G /! -, f
at No. ` � ---=----�/ .........._.1� <a.. :............----------
Street ,f
as shown on the application for'Disposal Works Construction Permit No,i�'.3-�' Dated. '/7_ G�_.....
••---_-•---
•--------- ...-•--••••----. ------------------------
DATE _
. Board of Health
.. / �- t/9,4,
�f "'� tFORM 1255 HOBBS & WARREN, INC., PUBLISHERS eux I/
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