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HomeMy WebLinkAbout0582 MAIN STREET (COTUIT) - Health '582 Main Street Cotuit - A= 036 — 024 i 1 1 t j Yl Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 582 Main St Property Address Franz & Ruth Cahoon Owner Owner's Name information is required for every Cotuit MA 02635 10-1-10 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form.Inspection forms may not be altered in any way. A. General Information , 1. Inspector: Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name 29 Atwater Dr Company Address E. Falmouth MA 02536 City/Town State Zip Code 508-495-0905 S13971 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Se%O' n jg.340 of Title 5 (310 CMR 15.000).The system: o r ©- z_ ® Passes El Conditionally Passes ❑ Fails -n: ,L CO ❑ Needs Further valuation by the Local Approving Authority 10-7-10 O Inspector's Signature Date C:) r'1 C:) The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd'or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP-The original should be sent to the system,owner and copies sent to the buyer,.if applicable, and the approving authority. ****This report only describes conditions at the'time`of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Property has title V system in front that is in good working order, and two cesspools in back that are very small with no sign of failure. t5insp official document•03/08 _ Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 r Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 582 Main St Property Address Franz & Ruth Cahoon Owner Owner's Name information is required for every Cotuit MA 02635 10-1-10 page_ City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: Systems are in good working order with no sign of failure. B System Conditional) Passes: Y Y ❑ 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 t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 582 Main St Property Address Franz& Ruth Cahoon Owner Owner's Name information is required for every Cotuit MA 02635 10-1-10 page. City/Town State Zip Code Date of Inspection B. Certification (cont.} B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced y t 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: 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. t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 582 Main St Property Address Franz & Ruth Cahoon Cwner Owner's Name information is required for every Cotuit MA 02635 10-1-10 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 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 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. t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form:Not for Voluntary Assessments 582 Main St Property Address Franz& Ruth Cahoon Owner Owner's Name information is required for every Cotuit MA 02635 10-1-10 page. City/Town State zip Code Date of Inspection B. Certification cont. D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® 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.] El ® 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 ❑ Elthe 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. t5insp official document•03/08 * Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 582 Main St Property Address Franz & Ruth Cahoon Owner Owner's Name information is required for every Cotuit MA 02635 10-1-10 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding AS y p g the SAS, 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 pp oximation of distance is unacceptable) [310 CM 15.302(5)] t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 16 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 582 Main St - Property Address Franz& Ruth Cahoon Owner Owner's Name information is Cotuit ^� MA 02635 10-1-10 required for every page. City/Town state Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms(design): 2 Number of bedrooms (actual): 2 - DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x #of bedrooms): 220 Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: Date 0 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM 15.203): Gallons per day(gpd) Basis of design flow(seats/persofis/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste.holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: - Last date of occupancy/use: Date Other(describe): t5insp official document-03/08 c, Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7.of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 582 Main St Property Address Franz & Ruth Cahoon Cwner Owner's Name information is required for every Cotuit MA 02635 10-1-10 page. City/Town State Zip Code Date of Inspection D. System Information (coot.) General Information Pumping Records: Source of information: Owner--pumped 10-2010 Was system pumped as part of the inspection? ® Yes ❑ No If yes,volume pumped: 300 gallons How was quantity pumped determined? Reciept Reason for pumping: Required for cesspool. I� 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): Approximate age of all components, date installed (if known) and source of information: 1978 front system 1960's back system Were sewage odors detected when arriving at the site? ❑ Yes ® No t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 582 Main St Property Address Franz& Ruth Cahoon Owner Owner's Name information is required for every Cotuit MA 02635 10-1-10 ' page. City/Town T State Zip Code Date.of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade:, 36"feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain):. Distance from private water supply well or suction line: . ,feet Comments (on condition of joints,venting, evidence of leakage, etc.): Good condition. Septic Tank(locate on site plan): ; 30" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: 1000 gal - _ Sludge depth: 12" Distance from top of sludge to bottom of outlet tee or baffle. 20 Scum thickness 1 6" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? Tape t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of,15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 582 Main St Property Address Franz & Ruth Cahoon Owner Owner's Name information is required for every Cotuit MA 02635 10-1-10 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.): Tank is in good condition with baffles installed and no sign of leakage. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene- ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date 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): t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 582 Main St Property Address Franz & Ruth Cahoon Owner Owner's Name information is required for every Cotuit MA 02635 10-1-10 - page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.). Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present:' ❑ Yes ❑ No. Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? r ❑ Yes ❑ No 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 t5insp official document-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °wM 582 Main St Property Address Franz & Ruth Cahoon Owner Owner's Name information is required for every Cotuit MA 02635 10-1-10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System(SAS) (locate on site plan, excavation not required): - If SAS not located, explain why: Type: ® leaching pits number: 1000 gal ❑ leaching chambers number: ❑ leaching galleries number: ❑ leashing trenches number, length: ❑ leaching fields numbei, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding,.damp soil, condition of vegetation, etc.): Leach pit is in good condition with no sign of failure and stain line at 20"from bottom of pit. t5insp official document•03108 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 582 Main St Property Address Franz & Ruth Cahoon Owner Owner's Name information is required for every Cotuit MA 02635 10-1-10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) _ Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration `. 2-inline Depth —top of liquid to inlet invert 18 Depth of solids layer 0 Depth of scum layer 0 Dimensions of cesspool 4x3 Materials of construction Block Indication of groundwater inflow ❑ Yes ® No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Cesspools are very small with no sign of back-up or failure. 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.): t5insp official document-03/08 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 582 Main St Property Address Franz & Ruth Cahoon Owner Owner's Name information is required for every Cotuit MA 02635 10-1-10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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. s I fh 1 r, t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 15 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 582 Main St - Property Address Franz & Ruth Cahoon Owner Owner's Name information is required for every Cotuit MA 02635 10-1-10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: f ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 20' feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: ® Checked with local excavators, installers- (attach documentation) ® Accessed USGS database- explain: You must describe how you established the high ground water elevation: USGS maps show groundwater at greater than 20'. t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 /0/ _ Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 582 Main St - Property Address Franz & Ruth Cahoon Owner Owner's Name information is required for every Cotuit . MA 02635 9-14-10 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. A. General Information 1. Inspector: l �/ v zp Fnl , Shawn Mcelroy _U Name of Inspector I SEf 1 7 Upper Cape Septic Services Company Name 29 Atwater Dr -- Company Address E. Falmouth MA 02536 City/Town State Zip Code 508-495-0905 S13971 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: ❑ Passes ❑ Conditionally Passes �® Fails ❑ Needs Further Evalua ' In by the Local Approving Authority 9-14-10 t Inspector's.Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall.submit the report to the appropriate regional office of the 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. Failure is because of single cesspool in rear of property. Tank and pit in front of property is in good working order. j t5insp official document•03/08, Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 7M 582 Main St Property Address Franz & Ruth Cahoon Owner Owner's Name information is required for every Cotuit MA 02635 9-14-10 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: 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 t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15 e Commonwealth of Massachusetts W Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 582 Main St Property Address Franz &Ruth Cahoon Owner Owner's Name information is required for every Cotuit MA 02635 9-14-10 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced �' t 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: 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 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. t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 3 of 15 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 582 Main St Property Address Franz & Ruth Cahoon Owner Owner's Name information is required for every Cotuit MA 02635 9-14-10 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has aseptic 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 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 '/2 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. t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15 Commonwealth of Massachusetts , Title 5 Official Inspection form Subsurface Sewage Disposal System Form.-Not for Voluntary Assessments 582 Main St Property Address Franz & Ruth Cahoon Owner Owner's Name information is Cotuit MA 02635 9-14-10 required for every , page. City/Town State Zip Code Date of Inspection B. Certification (cont.) - D) System Failure Criteria Applicable to All Systems (cont.):- ' .'Yes ,;I• No . ❑ , ® 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 CM 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be ` necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 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 1 ❑ ❑ 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 El ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA),or a,mapped Zone Il,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. t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•,Page 5 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 582 Main St Property Address Franz & Ruth Cahoon Owner Owner's Name information is required for every Cotuit MA 02635 9-14-10 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes"or"no"as to each of the following: Yes No S .; ® ❑ 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? El ® 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 CM 15.302(5)] t5insp official document-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °7M 582 Main St Property Address Franz & Ruth Cahoon Owner Owner's Name information is required for every Cotuit MA 02635 9-14-10 page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 2 , Number of bedrooms (actual)- 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x #of bedrooms): 220 Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected?• ❑ Yes ® No Seasonal use? - ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: 9-2010 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/perso.ns/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? • ❑ Yes ❑ No Non-sanitary-waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings,.if available: Last date of occupancy/use: Date Other(describe): t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 582 Main St Property Address Franz & Ruth Cahoon Owner Owner's Name information is required for every Cotuit MA 02635 9-14-10 page. City/Town State Zip Code Date of Inspection D. System information (cont.) General Information Pumping Records: Source of information: Owner--15 yrs ago Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Maintenance 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): Approximate age of all components, date installed (if known)and source of information: 1978 Were sewage odors detected when arriving at the site? ❑ Yes ® No t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments . M 582 Main St Property Address Franz & Ruth Cahoon Owner Owner's Name information is Cotuit MA . 02635 9-14-10 required for every � - page. City/Town state Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): t Depth below grade: i t 36" feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): . Good condition. Septic Tank(locate on site plan): T Depth below grade 30" r 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)A ❑ Yes ❑ No ------------------------------------------------------------------------------------------------------------------------- Dimensions: 1000 gal Sludge depth 12" Distance from top of sludge to bottom of outlet tee or baffle 20 Scum thickness ,. Distance::from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee.or baffle 15 How were dimensions determined? Tape t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 582 Main St Property Address Franz & Ruth Cahoon Owner Owner's Name information is required for every Cotuit ' MA 02635 9-14-10 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.): Tank is in good condition with baffles installed and no sign of leakage. Grease Traplocate on site plan): ( p ) Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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): t5insp official document•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System.Form -Not for Voluntary Assessments 582 Main St Property Address Franz & Ruth Cahoon Owner Owner's Name information is required for every Cotuit MA 02635 9-14-10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.), Dimensions: Capacity: gallons Design,Flow: . gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date - Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 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.): t Pump Chamber(locate on site plan): y Pumps in working order: ❑ Yes.,, ❑ No Alarms in working order: ❑ Yes ❑ No t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °tea 582 Main St Property Address Franz & Ruth Cahoon Owner Owner's Name information is require or every Cotuit MA 02635 9-14-10 d f page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: 1-1000 gal ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach it is in good condition with no sign of failure and stain line at 20"from bottom of pit. t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r 582 Main St Property Address Franz& Ruth Cahoon 3. ,• Owner Owner's Name information is required for every Cotuit MA 02635 9-14-10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration 1 Depth —top of liquid to inlet invert Empty Depth of solids layer 0 Depth of scum layer 0 Dimensions of cesspool 4x4 Materials of construction Block Indication of groundwater inflow ❑ Yes, ® No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Cesspool in good working order with no sign of failure. 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.): t5insp official document-03108 Title 5`Official'inspection Form:-Subsurface-Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 582 GSM Main St ' Property Address Franz & Ruth Cahoon Owner Owner's Name information is required for every Cotuit MA 02635 9-14-10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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. 30 r r .' PT 3 t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 16 41 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .. a 582 Main St Property Address Franz & Ruth Cahoon Owner Owner's Name information is required for every Cotuit MA 02635 9-14-10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope f ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 20 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: pate ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with.local Board of Health -explain: ® Checked with local excavators, installers- (attach documentation) ® Accessed USGS database - explain: You must describe how you established the high ground water elevation: USGS maps show groundwater at 20'. t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 1 TOWN OF BARNSTABL,E . LOCATION ��02 /��cc;� 5�_ SEWAGE VILLAGE Cv � ASSESSOR'S 1b1A1'& LOT _..., INS'TALI.ER.'S NAME&PHONE NO. SEP'I1C TAM{ CAPACITY I LEACI LINO FACILITY: (type) �� (size) ! NO,OF'BE®ItCtOMS..._a j BUILDER OR OWNER, PERM1TOA'IE:_,.,_,.,,,._...,.A,..,.,..-- C0KPL1ANCE DATE: (� Separadon DiWXare Between the: I Maximum Adju9t d Groundwater Table to tlac Bottom of Leaching Pacility e—c i Private plater Supply Well and Leaching Facility (If any wells exist on site ov witlhia 200 feet of leaching facility) Edge of Wetland and Leaching Facility(if any we ds exist within 3 feet leaching arili eel A/Jn Furnlshed by� ` �er C 0 07 �� � O 6'F � J� W . -.C� OJ � � � `,� T �1 c rt . trJ .� l0C-AT10 SEWAGE PERMIT NO.. z23� -tea 4 VI-LLAGE INST "LL 'S NAME i ADDRESS T B OR OWNER ro DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED -� 1� 1 ��T �. � ;, TOWN OF BARNSTABLE LOCATIONS / /�/� C�y�/�j SEWAGE # 78 - ,3 (, J VILLAGE r ASSESSOR'S MAP & LOTeI3 —e2- L INSTALLER'S NAME & PHONE NO.'' P SEPTIC TANK CAPACITY /6®67 LEACHING FACILITY:(type) (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER !/ G BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No ��vN����� �iTc�✓/��s?�a�Sr/�f��F/t� i J � 7D e r ry1 � t U Fims... f........ - THE COMMONWEALTH OF MASSACHUSETTS BOARD O� 1-1 A T I-I /.. .............OF..ff .. . . ----------------- Applira#ion for Uhipati al 10orkti Totwitrurtion Permit Application is hereby made for a Permit to Construct ( ),or Repair ( ) an Individual Sewage Disposal System at: ..:�.......l,..o.�.u.�.j ----•------- •--...---••-•-•-•---•... . .......................................... .. ...... . ... Location-Address or Lot Ao. Owner Address d• - ,�- . 1'SJ_A-1-_1�...[ 4� ` `'i---L--.Ran �....� ..�!4Lu. r".s-6:1-5 .....................••----- Installer Address Type of BuildinY, ; Size Lot............................Sq. feet Dwelling—No. of Bedrooms..........2 ............................Expansion Attic ( ) Garbage Grinder. ( ) p., Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a Other fixtures .......................................... W Design Flow.._......•..................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................. Diameter---------------- Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) ~' Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water_____-_____.----__--._.- G%, Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ P4 -----------------------------------------------------------•--------...................---•---_...--........................................................ 0 Description of Soil........................................................................................................................................................................ ----------------- ----------------------------------------------------------------- ---------------=--- --------- ------------------------------------------------•-----------------------------------. U Nature of Repairs or Alterations—Answer when ....__ ......W. -IR ...J.!A c.------�.i-O&c P_t�-------------------------------------------------•----.......---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITi:;. 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. ` igned/ Date . � .......Approved BY .... ..... ... Date Application Disapproved for the following reasons------------ --------------------•• . . . ---•---------•----------•--••-......•--•-----•--......•-•--- ..............•-----•--•---•-•-......-------••-•-----•--•---•---•••---•--------........---...---•--•-------•-••-••--•-•---•-------•---------•--••-•-•--•--------•-•-------------------------------•---•- f Date PermitNo......................................................... Issued----- l 7 ........ Date 0—! i4b l .r✓ No.......... �I� FEB ................. . THE COMMONWEALTH OF MASSACHUSETTS .y�' ,fr BOARD OF H A 9 I-I .......... .. OF..` .. .................................. AV'Pftrdtiou for Dispati al Works C� at xttr intt ea`atti . Application is hereby made for a Permit to Construct ( )..or Repair ( ) an Individual Sewage Disposal System at • -.... Z _. .... ... _......--••- � � 6d ss ' 6 IL �.+ r I of 1 V ..Fi-. __qqy�` ...... ....... -----------......---------------... . . ..---------....... r. ..... . --........................... -•-.'-- -._"_......... . . ......._ 2 'i...."t �►r+��1 l A t? t..t�1 �+4=i•C... Installer ' Address dType of Buildin� Size Lot............................Sq. feet U Dwelling—No. of Bedrooms........... ................................Expansion Attic ( ) Garbage Grinder ( ) ►� PL, Other—T e of Building No. of persons____________________________ Showers — Cafeteria a Other fixtures -----------------------------------------•--•- . WDesign Flow___________________________................gallons..per_person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter_.-_____________ Depth................ Disposal Trench—No_______________._____ Width.__..................... Total Length.................... Total leaching area_____ .........sq. ft. Seepage Pit No :<_-____="."Diameter .:::........... Depth below inlet.................... Total leaching area........^W......aq. ft. z Other Distribution box ( ) Dosing tank ( ) Percolation Test:Results Performed by--------------_------_.............................................. Date-- ••-••- --•------------------- aTest 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........................ ODescription of Soil------------------------•----------._...-------------•--...........-•--•-----•-=-=--------------------------------------•-------------................................. x . W _______________________ ________________________________________________________________ ____ ____ 4_________..____ 4 ._.._.____ V Nature of Repairs or Alterations—Answer when applicable " - �bAic'!4G�t __._........................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT . 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. fined ............................. •-- ................................ Application Approved By_________ _ _____ _ Date Application Disapproved for the following reasons: ...........;'_____________________________________ _____ _ _ ___________________________________ Date PermitNo.........................................1` .._. Issued.----..._•... •-----••---••••-••••-•--•-•--•----•- Date THE COMMONWEALTH OF MASS.AC'HUSETTS BOARD OF EALTH :..O F.......... .... . ............................... v . Crrfif iratr of TontliiiFatt.rr THI VIFO TI at the, Individual Sewage Disposal System constructed ( ) or Repaired ( ) tal ------------------------------------ �/F atat. `. p-4�j •- -1- -.. �`'~h_ a!__A- .... --- -------.-`---------••--------------------------------- ------ ------ •--- has been installe m accordance' with the provisions of !�of T State Sanitary CQ ass de d in the application for Disposal Works Construction Permit No..._ ----•- ••--- ;.... dated_- --------------------------------------------- THE <F ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A:GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. .................. Inspector :=---- DATE..........--•--------------•------...............__.....:... ---------•--------•-•----.....-......................... HE COMMONWEALTH OF MASSACHUSETTS BOARD OF EALTH ®F..--.�! ............ ...1�G ...... ............ . ca.�. :_...._.... .' F '"..... No....................... FEE........... .......... 'Dispolla t be ion amii Permission 2ktfereby fir me _ .------- -•= ....................................... --- ----- - to Constru� ) or Re >< ( an Individual a rage osal•Sys t... ` -`j --•-- F i wu •. Street as shown on the application for Disposal,Works=Construction Permi .___.___ � ..._.__ .... r � . �� Board of.,Health DATE------- --•••• ..................................... FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS