HomeMy WebLinkAbout0041 FURLONG WAY - Health riir 4-1 10ng Way � t.
Cotuit
A= 022 — 079
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1 e
•'' 41 Furlong -
Property Address
Bunnie Stevens
Owner Owner's Name
information is COtUIt T
required for every Ma.- 02635 03/07/2014 .
page. Cityrrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of,the form..
Important:When filling out forms A. General Information
on the computer, Jtt
use only the tab 1. Inspector: I �X�
key to move your,
cursor-do not Michael T Bisienere .
use the return Name of Inspector
key.
Cape Septic Inspections
Company Name
624 Old Barnstable Road
Company Address
Mashpee Ma. 02649
City/Town State Zip Code
508-280-3356 S13938
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage,disposal system at this address and that the
information reported below is true, accurate and complete as,of the time of the inspection. The inspection
was performed based on my training and experience'in the proper function and maintenance of on site
sewage disposal systems. lam a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 16.000). The system:.,, F
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs`Further Evaluation by the Local Approving Authority
03/07/2013
spedor's Signature Date
r
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.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official p
{Ins ection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessmentse
41 Furlong r
Property Address
Bunnie Stevens
Owner Owner's Name
information is Cotuit Ma., 02635: 03/07/2014
required for every '
page. Cityrrown State Zip Code' Date of Inspection
B. Certification- (cont.)
Inspection Summary:'Check A,B,C,D or E 1 a/ways 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:
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 tan k'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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
i
r
Commonwealth of Massachusetts ,
F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
41 Furlong
Property Address
Bunnie Stevens
Owner Owner's Name
information is COtult
required for every Ma: 02635 03/07/2014
page. Citylrown 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 breakout 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):
El 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 saltmarsh
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 _
Commonwealth of Massachusetts'
W Title 5 Official Inspection Fou�m
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,•�'' 41 Furlong
Property Address a ';
Bunnie Stevens
Owner Owner's Name
information is required for every Cotuit Ma. 02635 03/07/2014
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. P
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
❑ Z 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 town overloaded
or clogged SAS or cesspool
0 ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y day flow
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
„w ' 41 Furlong _
Property Address
Bunnie Stevens
Owner Owner's Name
information is Cotuit Ma. 02635 03/07/2014
required for every
page. City/Town 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. R
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 16,000 gpd. _
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No ;
❑ ❑ the system is within 4.00 feet of a surface drinking water supply
❑f the system is within 200 feet of a tributary to a surface drinking water supply
0 ❑ the system is located in-a nitrogen'sensitive area (Interim Wellhead Protection
Area-IWPA)or a mapped Zone II of a public water supply well
if you have answered "yes"to any question in Section E the system is considered`a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3/13 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
41 Furlong
Property Address
Bunnie Stevens
Owner Owner's Name
information is
required for every Cotuit Ma. 02635 03/07/2014
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?
® ElWas the tSit
e 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
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments i
41 Furlong m
Property Address
Bunnie Stevens
Owner Owner's Name
informatifor every on is
required Cotuit Ma. ' 02635 03/01/2014
page. City/Town State Zip Code Date of Inspection
D. System Information
Description: _
Number of current residents: 1
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ❑ No
Seasonaluse? ® Yes ❑ No
Water meter readings, if available(last 2 years usage(gpd)):
>
Detail:
2013 77,000 gallons used 2011 '98,000 gallons used The water dept. said she had a meter
problem in 2011 and 2012 so the data is incorrect for 2011 and 2012
Sump pump? ❑ Yes ® No
Last date of occupancy: Nov. 2013
Date .
Commercial/Industrial Flow Conditions: `
Type of Establishment:
Design flow(based on 310 CMR 15.203):. 1 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-3A3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
r
L\ Commonwealth of Massachusetts .
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form"-Not for Voluntary Assessments
w 41 Furlong
Property Address
Bunnie Stevens
Owner Owner's Name
information is required for every Cotuit Ma. 02635 03/07/2014
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
- P g
Source of information: `
Was system pumped as part of the inspection? ❑' Yes ® No i
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.(yesfor 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
' r ,
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments`
41 Furlong
Property Address
Bunnie Stevens
Owner Owner's Name
information is
required for every Cotuit Ma: 02635 03/07/2014
page. Citylrown State - Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
•Depth below grade: 30"feet
Material of construction:
❑ cast iron ®40 PVC []'other(explain):
Distance from private water supply well or suction line:, feet
Comments(on condition of joints, venting,'evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade: 261
feet
Material of construction:
I
® concrete ❑ metal ❑ fiberglass ❑polyethylene ❑ other(explain)
If tank is metal', list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: Standard 1000 gallon-
Sludge depth:
t5ins•3113 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
41 Furlong
Property Address
Bunnie Stevens
Owner
Owner's Name
information is required for every Cotuit Ma. 02635 03/07/2014
page. Cityrrown 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 39"
Scum thickness
i
4"
Distance from top of scum to,top of outlet tee oi=baffle
Distance from bottom of scum to bottom of outlet tee or baffle
lilt .
How were dimensions determined? field instruments '
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage,'etc.):
The system should be put on a maint. plan to extend the life of the leaching pit.
sA
f
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
t
Distance from bottom of scum to bottom of outlet tee or baffle
' L
Date of last pumping: Date
t5ins-3/13 Title 5 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
,• 41 Furlong
Property Address
Bunnie Stevens
Owner Owner's Name
information is required for every Cotuit Ma. 02635 03/07/2014
page. Cityrrown 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
. Title 5 Official Inspection Form a
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
41 Furlong
Property Address
Bunnie Stevens
Owner Owner's Name
information is required for every Cotuit Ma. 02635 03/07/2014
page. City/Town State Zip Code Daespection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert N/A
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection. Form = .
Subsurface Sewage Disposal'System Form -,Not for Voluntary Assessments
41 Furlong
Property Address
Bunnie Stevens
Owner
Owner's Name
information is
E.
required for every Cotuit Ma: 02635 03/07/2014.
page. City/Town State Zip Code Date of Inspection
D. System Information (cont:)
Type:
® leaching pits• number: one
❑ leaching chambers. number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
The leaching pit had over one foot free of stain'lines.
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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
s
Commonwealth of Massachusetts
Title 5 OfficialInspection Form
Subsurface Sewage Disposal System Form -Not for.Voluntary Assessments
41 Furlong
Property Address
Bunnie Stevens
Owner Owner's Name
information is required for every Cotuit Ma. 02635 03/07/2014
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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
•° 41 Furlong
Property Address
Bunnie Stevens
Owner Owner's Name
information is otuit Ma. 02635 03/07/2014
required for every C '
page. Citylrown 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
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ot
"%M AaM
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
41 Furlong
Property Address
Bunnie Stevens
Owner Owner's Name
information is
required for every Cotuit Ma. 02635 03/07/2014
page. City/Town State Zip Code Date of Inspection
D. System Information(cost.)
Site Exam:
® Check Slope
f
® Surface'water.
® Check cellar
® Shallow'wells }
Estimated'depth to high ground water: 15 plus feet -
• feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design,plan reviewed: Date
® Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators,,installers-(attach documentation)
❑ Accessed USGS database-explain`:
e
You must describe how you established the high ground water elevation:
I augared a hole at a lower elevation and shot it with a transit. '
i
Before filing this Inspection Report, please see Report Completeness Checklist on next page. .
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
f
Commonwealth of Massachusetts
4 - Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
41 Furlong
Property Address .
Bunnie Stevens
Owner Owners Name
information is required for every Cotuit Ma. 02635 03/07/2014
page. Cityfrown 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
,• A f
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
TOWN OF BARNSTABLE L+CATION U✓1 C)'J SEWAGE# �_
7>
VILLAGE- TU1 - ASSESSOR'S MAP&PARCEL
1N�S NAME&PHONE NO. 'F rick (X,'oo vac l I
SEPTIC TANK CAPACITY LOB
LEACHING FACILITY:(type)' (size) &A0
NO.OF BEDROOMS
OWNER —Tr-2d"Z-
PERMIT DATE: C0@A4k9VV1=E DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge,of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
FURNISHED BY
Furlong Way
Water Service
31
15
30 45
y COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF.ENVIRONMENTAL AFFAIRS
d DEPARTMENT OF ENVIRONMENTAL PROTECTION
e�
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSA_ L SYSTEM FORM
PART A
CERTIFICATION
Property Address: 41 Furlong Way (�
Cotuit MA
Owner's Name: Irene Peterson
Owner's Address: Same L r }
Date of Inspection: May 16,2007 Job#07-105 N
Name of Inspector: PATRICK M.O'CONNELL
Company Name: SEPTIC INSPECTION SERVICES CO. '. L' t f
Mailing Address: 189 CAMMETT ROAD
MARSTONS MILLS MA 02648
Telephone Number: 508-428-1779 co
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
X_ Passes
Conditionally Passes
__ Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature `;, l/ Date: 5/16/07 '
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. '
Notes and Comments: Leaching pit has 8-10"of effective leaching,tank is not in need of pumping at this time.
****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.
Page 2 of 1 I
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 41 Furlong Way,Cotuit
Owner: Irene Peterson
Date of Inspection: May 16,2007
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D {
A. System Passes:
_XX_ 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:
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:
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:
Page 3 of I 1
OFFICIAL, INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A '
CERTIFICATION(continued)
Property Address: 4.1 Furlong Way,Cotuit
Owner: Irene Peterson
Date of Inspection: May 16,2007
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
_ Cesspool or privy is within 50 feet of a surface water ,
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
_ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a t
private water supply well". Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered.A copy of the analysis must be attached to this form.
t
3. Other:
Page 4 of I i
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 411 Furlong Way,Cotuit
Owner: Irene Peterson
Date of Inspection: May 16,2007
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
_X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
—X— Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
—X— Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
X Liquid depth in cesspool is less than 6"below invert or available volume is less than_day flow
—X— Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
_X_ Any portion of the SAS,cesspool or privy is below high ground water elevation.
—X— Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
X Any portion of a cesspool or privy is within a Zone 1 of a public well.
_X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
—X— Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this forma
_No_(Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with"a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
_ the system is within 400 feet of a surface drinking water supply
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.
Page 5 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 4.1 Furlong Way,Cotuit
Owner: Irene Peterson
Date of Inspection: May 16,2607
Check if the following,have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
_X_ _ Pumping information was provided by the owner,occupant,or Board of Health
_X_ Were any of the system components pumped out in the previous two weeks`?
_X_ _ Has the system received normal flows in the previous two week period ?
_X_ Have large:volumes of water been introduced to the system recently or as part of this inspection'?
_X_ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
_X_ _ Was the facility or dwelling inspected for signs of sewage back up?
_X_ _ Was the site inspected,for signs of break out
_X_ _ Were all system components,excluding the SAS, located on site'?
_X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the
condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of
scum?
_X _ Was the facility owner.(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
t
The size and location of the Soil Absorption System (SAS)on the site has been determined based on:
Yes no
_X_ _ Existing information. For example,a.plan at the Board of Health.
X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of
distance is unacceptable) [310 CMR 15.302(3)(b)]
Page 6 of I I
OFFICIAL, INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 411 Furlong Way,Cotuit
Owner: Irene Peterson
Date of Inspection: May 16,2007
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):330
Number of current residents: l
Does residence have a:garbage grinder(yes or no): No
Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required]
Laundry system inspected(yes or.no):
Seasonal use:(yes or no): No
Water meter readings, if available(last 2 years usage(gpd)): Two years total: 113,000 gal.= 154 gpd.
Sump pump(yes or no): No
Last date of occupancy: Currently Occupied
COMMERCIAL/INIDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no):_
Non-sanitary waste discharged to the Title 5 system(yes or no):_
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records:' Tank pumped 8/05
Source of information: Owner
Was system pumped as part of the inspection(yes or no): No
If yes,volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
_X_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) j
_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:
1976
Were sewage odors detected when arriving at the site(yes or no): No
f
Page 7 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 41 Furlong Way,Cotuit
Owner: Irene Peterson
Date of Inspection: May 16,2007
BUILDING SEWER.: XX (locate on site plan)
Depth below grade: 2'
Materials of construction:_cast iron _X_40 PVC other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: XX (locate on site plan)
Depth below grade: 2'
Material of construction:_X_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: 8.5'long:x 5.2'wide—1000 gal.
Sludge depth: 3"
Distance from top of sludge to bottom of outlet tee or baffle: 27"
Scum thickness: 2"
Distance from top of scum to top of outlet tee or baffle:6"
Distance from bottom of scum to bottom of outlet tee or baffle: 12"
How were dimensions determined: STICK WITH HINGE FLAP.
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
Baffles are intact and clear,liquid level at bottom of outlet invert.Tank is not in need of pumping at
this time.
GREASE TRAP: No (locate'on site plan)
Depth below grade:
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:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity; liquid levels
as related to outlet invert,evidence of leakage,etc.):
Page 8 of 1 I .
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 41 Furlong Way,Cotuit
Owner: Irene Peterson
Date of Inspection: May 16,2007 ,
TIGHT or HOLDING TANK: No (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/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: No (if present must be opened) (locate on site plan)
Depth of liquid level above outlet invert:
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
PUMP CHAMBER: No (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no): r
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
Page 9 of 11 f
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM_INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 411 Furlong Way,Cotuit
Owner: Irene Peterson
Date of Inspection: May 16,2007
SOIL ABSORPTION SYSTEM(SAS): XX (locate on site plan,excavation not required)
If SAS not located explain why:
Type
_X_leaching pits,number: One 6x6 pit.
_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.): Liquid level in pit was 2' below inlet pipe at time of inspection,high stains indicate liquid level had
previously been 8-10"below inlet pipe.
CESSPOOLS: No (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 or no):
Comments(note condition of soil,.signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
PRIVY: No (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.):
Page 10 of 1 I
OFFICIAL, INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 411 Furlong Way,Cotuit
Owner: Irene Peterson
Date of Inspection: ;May 16,2007
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.
Furlong
o g Way
Water Service
....... ....V .....................
31
15
30 45
•
Page I 1 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE:SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 411 Furlong Way,Cotuit
Owner: Irene Peterson j
Date of Inspection: May 16,2007
SITE EXAM
Slope None
Surface water None
Check cellar Dry
Shallow wells None
Estimated depth to ground water More than 20 feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record- If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators, installers-(attach documentation)
_X_Accessed USGS database-explain: USGS topo map and town GIS.
You must describe how you established the high ground water elevation:
Town groundwater contour map shows water below el. 15 and topo map shows property above el.50.
y:. LOCATION : 4.oT ZZ tJO._
C .�
VILLAGE -- — — �
—BUILDER
---
---DATE-P--ERW T. 1.5SUED� �-�� --
-- D ATE--COMPLI &DICE ISSUE
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"Rep"Rep �O� �d U 5G
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ik
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' THE COMMONWEALTH OF MASSACHUSETTS
BOARD O HEALTH
i
._.OF............
..............
�- ',� Itrtttiun -fur Uiipu,iat Works Tomitrurtiutt Vaniit
Application is hereb made for a Permit to Construct or Repair an Individual Sewage Disposal
PP Y ( ) P ( ) a P
System at:
a2.2
�Ls o io -Address or Lot No.
Owner Address
Installer Address
UType of Building 3 Size Lot............................Sq. feet
Dwelling—No. of Bedrooms..._- r...................................Expansion Attic ( ) Garbage Grinder (�B)•
aOther—Type of Building&1AC _ __________________ No. of persons............................ Showers ( ) — Cafeteria ( )
dOther fixtures ----------------------------------------------------------------------------------------------------------------------------------------------------
W Design Flow----------S-0---------------------- gallons per person per day. Total daily flow......... . -_-__-.-_-.....gallons.
WSeptic Tank Liquid capacity gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No..................... Width-------- T en ------------
SeepageTotal leaching area_--_.._-__---__--_sq. ft.
Pit No"_-----. ---___ Diameter . ..___ _ e t elow let............... Total leachin area.---- _........ sc ft.
z Other Distribution box ( ) Dosing tank ( ) O� �� 7_4,V_
Percolation Test Results Performed by-------------------------------------------------------------------------- Date..---------------------------------....
Test Pit No. 1................minutes per Inch Depth of Test Pit-------------------- Depth to ground water...._.---._..__---.-----
G4 Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground water........................
O Description of Soil----- .P...... �__
x
x --------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------
V Nature of Repairs or Alterations—Answer when applicable................................................................................................
- _---------------------
L5�
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issu by the bi
d of health.
---------------------------— Date
Application Approved BY .... / � - ------ ---L_::A J-7 _4-------
/ 7' Date
Application Disapproved for the following reasons-------------------------------------------------------------------------------- ................................
.........................................................................................................................................................................................................
Date
PermitNo. Issued........................................................
Date
- .-.. --- ----- -----------
7NoP ��..........
THE COMMONWEALTH OF MASSACHUSETTS Finc
BOARD O HEAL/�t��
Appliration -for 'Uiipouttl Works Totuarurtion Vrrnift
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
-�' J7- �yocati_ory•Address or Lot No.
� E /�
i Owner Address
------- --------------•--------•---.................
-y
Installer Address
Q Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms_____ ____________________________________Expansion Attic ( ) Garbage Grinder (wo
aOther—Type of Building M/r�--�________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
QOther fixtures ---------•-•---____--•-•---------------------------•--------------------------------------------------
-a-Desi n Flow_...-.__.._� _ ____.___ Mons per person per day. Total daily flow__________ _��_
g -�---�.............. �g� P P P Y• Y --------------gallons.
WSeptic Tank I Liquid capacity-�l/__�__gallons Length................ Width.-_ ............ Diameter.......--------- Depth...............
x Disposal Trench—No. .................... Width..........._._j�_•.- t n- Total leaching area...__-__.__.-____...Sq. ft.
Seepage Pit No- --------�--------- Diameter. ��v._� eL)� elow i let_�_��_ Total leacl�I area sq. it.
z Other Distribution box ( ) Dosing tank ( ) O
aPercolation Test Results Performed bY-------- -----••---- --------------------•----•-••--- •---'----'----- Date----_____-•---------•--•------------
,� Test Pit No. 1----------------minutes per inch Depth of "Pest Pit.................... Depth to ground water---______-___-___-_--_--
I� Test Pit No. 2................minutes per inch Depth of Test Pit-_______..__________ Depth to ground
water__-__-________-__-__
- - -- -----------h------- --- - - ------•------------------------------------------.-.-_-
G _ -- `
-------------------Description of Soil �
�
f---------------------------- --- --------- l�„U W
Z ------------ ----------------------------------------------------------------------------------------------------------------------------------------------------------
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 Article \I of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issu d by the bo d of health.
_ t
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Application Approved B n -•-r)-- '/� - - 3- 7-7 Dat �
PP PP Y
/� Date
Application Disapproved for the following reasons:--•------------------------•-------•----_-•___-___----••----------------•------............. •------------_--
.............•-------._..___.....---._.._.._.._.._....---------•-•-•----------•-•------__...--•-•------•--•---...-•-----•--•----•-•--•----------•-----=--_...---•----------------___.__...--------------
Date
PermitNo......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD HEALTH
.�'L-..7
Trrtif irate of 1,01.1ompliaurr
TH S ISO CF IFI t e Individual Sewage Disposal System constructed ( ) or Repaired ( )
by.... __.. '•-• • ...........................---- -- --------------------------------------
Inst 11er
at =Tl` _ Z 2 '� �/ - ---------- -------------------------____-----------------------•-•---------------
d LL(/
has been installed in accordance with e provisions Art•etleX of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No----- -._..._l_�/ ............ dated.... _______________
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE 7
SYSTEM WILL FUNCTION SATISFACTORY.
DATEw / � � --------•---'•--'--•-- Inspector------- _�_____ ...._............................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD HEALTH
/ 6
(rU of.......... .... ..... z' .....................................:
No......................... FEE....Id...........
�i� u tti o tIo " rurtion Vamif -
Permission Vreby granted r4 .__--------_ OF------_
1. to Cons" tic ( or airan In ividual Se�e(+Jy o '1 System
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at No. ��-.- fin !
St et
as shown on the application for Disposal W ks Construction P �rr t No. __;c__ ..... -_ ated..........................................
--------- ----- - ------ - - -- -- -- of Health-- -
DATE............................................------------------------------------ Board
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