HomeMy WebLinkAbout0195 MARINER CIRCLE - Health 195 MARINER CIRCLE, COTUIT `
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Commonwealth of Massachusetts d�
W Tile 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
. a
,M 195 Mariner Circle
Property Address �-►
t-+
Maureen Raymond
Owner Owner's Name G?
information is x
req u i red fo r eve ry Cotuit: Nfa, 02635 3/7/16
page. City/Town State Zip Code Date.of Inspection f..�
W
�]_
7 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:out forms -:vVhen
filling
A. Genera I Information
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Michael.DiBuono
use the return
key. Name of_Inspector
DiBuono Sewer and Drain
rab Company-Name
8 Johns'path
Company Address
iewn
S Yarmouth Ma 02664
City/Town State Zip Code
508-364-9587 S103522
Telephone Number License Number
B. Certification
I.certify that I have-personallyinspected the sewage disposal'syste'm at1his 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 Evaluation by.the Local Approving Authority
3/7/16
3
Irfspector'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.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts -_
W Title 5 Official Inspection Form
Subsurface Sewage~bisposal System Form'-Not for Voluntary Assessments
r<
W
yc^M 195 Mariner Circle
Property Address
Maureen Raymond
Owner Owners Name
information is COtUIt
required for every Ma 02635 3/7/16
pa/ge. 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:
• :. ,;r ... _..— ,,._ ;;�.:. _:-_:r „_ .- __ :,,-; , . ;-,�. ,.,- s +tea ,.`-•,;a,.- -. .�,w , .h
® I have not found any information which indicates that anyof 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:
t The system contains a 1,000 gl septic tank as well'as a 1 000 gl Leach pit. Pit had only 4" of water in
the bottom of it at time of inspection. Stain line indicates level has been within 18' of pipe
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired.The system;upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for".yes",�"no" or"not determined" (Y, N, ND) for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health,
"A metal septic tank will pass inspection if it is structurally sound,.not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N !❑ ND (Explain below):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
wM 195 Mariner Circle
Property Address
Maureen Raymond
Owner Owner's Name
information is
required for every Cotuit Ma 02635 317/16'
page. CitylTown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N :❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken.pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of.Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title '5 Official Inspection Form
y
Subsurface'Sewage"Disposal System Form -Not for Voluntary Assessments
c°M ,•e'y 195 Mariner Circle
Property Address
Maureen Raymond
Owner Owners Name
information is
required for every Cotuit Ma 02635 3/7/16
page.— -- -- --- Cityfrown State Zip Code Date of Inspection
B. Certification (coot.) ,
2. System will fall 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 s(5il 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.
a ❑ The:system has a septic tankand-SAS and'the SAS is less than 100 feet'but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of-ammonia nitrogen and nitrate nitrogen is equal
.to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form. " '}
3. Other:
i.
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No Y
® Backup of sewage Into faculty or.system component due to overloaded or
clogged SAS or'cesspool
0 ® 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 '/z day flow
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection E®rrn
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
195 Mariner Circle
Property Address
Maureen Raymond
Owner Owner's Name
information is.required for every Cotuit Ma 02635 3/7/16
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
El ® •'Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
..- ® ; ; Any portioniof the SAS;<cesspool.or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or.privy is within a Zone 1 of a public well.
❑ ® Any portion.of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure. -
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
El 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
W Title 5 Official Inspection" ®rrn
Subsurface Sewage Disposal System Form - Not for V_ 6luntary Assessments
195 O� Mariner Circle
- .. M yr• ... ..
Property Address
Maureen Raymond
Owner Owners Name
information.is
required for every Cotuit Ma 02635 3/7/16
page. City/Town -. State --Zip Code Date of Inspection
C. Checklist
_ Check if the following have been done. You mustindicate"yes" or"no"as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes'of water been introduced to the system recently or as part of
this inspection?
❑ ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and-the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
-dimensions, depth of liquid, depth of sludge and depth of scum?
❑ ® Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
®o System I formation
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 2
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
Title S. Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
195 Mariner Circle
Property Address
Maureen Raymond
Owner Owner's Name
information is required for every Cotuit Ma 02635 3%7/1'6
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
The system contains a 1,000 gl septic tank as well as a 1,000 gl Leach pit. Pit had only 4" of water in
the bottom of it at time of inspection. Stain line indicates level has been within 18' of pipe.
Number of current residents: Vacant
Does residence have a garbage grinder? ❑ Yes Z 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 readin s, if available last 2 ears usage d 189 GPD
9 ( Y 9 (gp ))�
Detail:
Sump pump? ❑ Yes ® No
'Last date of occupancy: Dec 2015Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Common
wealth of Massachusetts
W Title 5 official Inspecti®n F�orM
Subsurface Sewage Disposal System FoPrn - Not for Voluntary Assessments
�M 195 Mariner Circle -
Property Address
Maureen Raymond
Owner Owner's Name
information is
required for every Cotuit Ma 02635 3/7/16
page. _ _.. -Cityl.Tbwn State Zip Code Date-of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: Pumped'June of 2016
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:.
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑. Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
No Dbox
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
W Title--5 Official Inspection Form
Subsurface Sewage Disposal System Foram--.Not for Voluntary Assessments
195 Mariner Circle
Property Address
Maureen Raymond
Owner Owner's Name
information ie required for every Cotuit Ma 02635 3/7/16
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
System was installed in 1983
Were sewage odors detected when arriving at the site? ❑ Yes ❑ No
Building Sewer(locate on site plan):
Depth below grade: 2feet
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: 1feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
11000
-'If tank is metal, list age: I
.years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
Sludge depth:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Offi-cial1h,spedtion F®rr�
- Subsurface Sewage Disposal Systern'Form - Not for Voluntary Assessments
195 Mariner Circle -
Property Address
Maureen Raymond
Owner. Owners Name
information is
required for every Cotuit Ma 02635 3/7/16
page. City/Town _. ._-.._State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cone) .
---- --_ Distance from top of sludge to bottom of outlet tee or baffle 24
11
-Scum thickness
Distance from top of scum to top of outle4211--
t tee or baffle
--- ^- - -- -- - Distance from bottom of scum to bottom of outlet tee or baffle V Sludge stick
H'ow were'dimensions determined? ` ' ' Tape Measure
-Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of.leakage, etc.):
No evidence of Ieaking,Tees and or baffles in place at time of inspection'
Grease Trap (locate on site plan)
Depth below grade: feet
Material of construction:-
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene' El other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
Date .
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
W Title 5. Official Inspection. Form
Subsurface Sewage Disposal System Form.- Not for Voluntary Assessments. .
195 Mariner Circle
Property Address .
Maureen Raymond
Owner Owner's Name
information is required for every Cotuit Ma 02635 3/7/16
page. CitylTown State Zip Code Date of Inspection
D. System n oB"Gll'6ation'(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.):
Tees are in place and levels are normal.
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 7.
Title Official In p `_ tin ®r
Subsurface Sewage Disposal System Fortin - Not for Voluntary Assessments
-
195 Mariner-Circle
Property Address
Maureen Raymond -
Owner Owner's Name
information is Cotuit Ma 02635 3/7/16
required for every ,
page. Cltyrrown- _"-:_._ 'State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert Na
- Comments (noterif box-is level and distribution to'outlets egiaal-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
W Title, 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
° M •''y 195 Mariner Circle
Property Address.
Maureen Raymond
Owner Owner's Name
information is required for every Cotuit Ma 02635 3/7/16
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont)
Type:
® leaching pits number-
El , leaching;chambers ;�. e. ; number. •- - =;
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
No signs of ponding or break out.
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of (Massachusetts
Title 5. Official -Insp�ecti®n-'F®rrn h
w h.
Subsurface Sewage'Disposal System Form- Not for Voluntary Assessments
195 Mariner Circle
Property Address
Maureen Raymond
Owner Owners Name
information is
required for every Cotuit Ma 02635 3/7/16
page. City/Town _ _ -----State ----- Zip Code Date of Inspection
D. System Information (cont.) v ;
Comments(note'condition of soil, signs of hydraulic failure, level of pondin I g condition of vegetation,
etc.):
No ponding no'break out
i
I
I
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,
1 etc.):
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection For
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments.
195 Mariner Circle
Property Address
Maureen Raymond
Owner Owner's Name
information is required for every Cotuit Ma 02635' 3/7/16
page. City/Town State Zip Code Date of Inspection
D, System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
❑ hand-sketch in the area below
®.drawing attached separately...-
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
CommonweaKh of Massachusetts
W Title 5 Official inspection F irm
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 195 Mariner Circle
Property Address
Maureen Raymond
Owner Owners Name _
information is
required for every COtUIt Ma 02635 3/7/16 _
page. Cityfrown State Zip Code Date of Inspection
D. System _information (cont) =
Site Exam:
El -ChecK Slope :r
❑ -Surface water_
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 10+ ft
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
0 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:
Property sits high above nearest water venue.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
Assessing As-Built Cards
Page l of 2
r TOWN OF BARNSTABI.E
LOCATION l> 0, ( Ctrc wA E#,c VILLAGE As As ESSO S &LOUT'
INSTALLER'S NAME PHONE NO.
SEPTIC TANK CAPACrrY LEACHING FACR=.(type), (size)
NO.OF BEDROOMS
BUILDER OR OWNER_ ► P 1 f
PERMITDATE COMPLIANCE DAM- —
Sguntion Distance Between the:
Maxiinitm Adjusted Ctnundwater Table to the Bottom ofLeaching 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 weWds exist
within 300 feet of leaching facility) v-.
Furnished by ��
5,4
Ae +oS
http://wwwtowno#barnstable,us/Assessing//` IH ldisulAv.asD?mann;ir=094141,P�,cP„=1 1)1AMAIr
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
195 Mariner Circle
Property Address
Maureen Raymond
Owner Owner's Name
information is required for every Cotuit Ma 02635 3/7/16
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
❑ Inspection Summary: A, B, C, D, or E checked
❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
❑ System Information—Estimated depth to high groundwater
❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
_y
XX
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS John Graci
DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector
ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119
TeaTicket,Ma.
(508)564-6813
TRUDY CORE
Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ���m 8
PART A
CERTIFICATION
Property Address: 195 MARINER CIRCLE COTUIT MAP 024 PAR 143 ,rf'"���E �+
Name of Owner MR.SILVA �~ D
Address of Owner: 52 SCHOOL ST.SOMMERVILLE MA.02143 Sep 2 1„
Date of Inspection: 8/30/99
Name of Inspector:(Please Print)JOHN GRACI
I am a DEP approved system inspector pursuant to Section 15.340 of Tide 5(310 CMR 15.000) i
Company Name: n/a ,y
Mailing Address: n/a
Telephone Number: n/a
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 inspection.The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems.The system:
X Passes The Inpection Is based on criteria defined In Title V
_ Conditionally Passes code 310 CMR 15.303.My findings are of how the system Is
Needs Further Ev lu 'on By the Local Approving Authority performing at the time of the inspection.My inspection does
Fails not imply any warranty or guarantee of the longgevity of the
septic system and any of its components useful life.
Inspector's Signature: Date:9/13/99
The System Inspector sh submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(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 Department of Environmental Protection.The original should be sent to the
system owner and copies sent to the buyer,if applicable,and the approving authority.
NOTES AND COMMENTS
THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING SYSTEM EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL
LIFE.
revised 9/2/98 Page 1 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 196 MARINER CIRCLE COTUIT MAP 024 PAR 143
Owner: MR.SILVA
Date of Inspection:8/30199
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated
are indicated below.
COMMENTS:
System passes Title V inspection
B. SYSTEM CONDITIONALLY PASSES:
n1a 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.
Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not.
n1a The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or
structural) unsound shows substantial infiltration or exfiltration,or tank
the septic tank,whether or not metal,is cracked, y ,
failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
n& Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health).
broken pipe(s)are replaced
obstruction is removed
distribution box is levelled or replaced
n1a The system required pumping more than four 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
revised 9/2/98 Page 2 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 195 MARINER CIRCLE COTUIT MAP 024 PAR 143
Owner: MR.SILVA
Date of Inspection:8/30/99
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 the public health,safety
and 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 ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
_ Cesspool or privy is within 50 feet of 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 ANY AND PUBLIC WATER SUPPLIER.IF DETERMINES THAT THE SYSTEM IS
( 1
FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well,
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well,unless a well water analysis 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,Method used to determine distance !>La-(approximation not valid).
3) OTHER
n/a
revised 9/2/98 Page 3 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 195 MARINER CIRCLE COTUIT MAP 024 PAR 143
Owner: MR.SILVA
Date of Inspection:8/30/99
D. SYSTEM FAILS:
You must indicate either"Yes"or"No"to each of the following:
I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is
identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
X Backup of sewage into facility or system component due to an 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 1/2 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 nta.
X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
X Any portion of a 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 I of a public well.
Y p P P vY
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.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic ompounds,
ammonia nitrogen and nitrate nitrogen.
X The liquid level in the SAS is over the invert pipe,is in Hydraulic Failure.
E. LARGE SYSTEM FAILS:
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:
_ The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and
safety and the environment because one or more of the following conditions exist:
Yes No
X the system is within 400 feet of a surface drinking water supply
X the system is within 200 feet of a tributary to a surface drinking water supply
X 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)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the
Department for further information.
revised 9/2198 Page 4 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 196 MARINER CIRCLE COTUIT MAP 024 PAR 143
Owner: MR.SILVA
Date of Inspection:8/30/99
Check if the following have been done:You must indicate either"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 None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates
during that period.Large volumes of water have not been introduced into the system recently or as part of this inspection.
X As built plans have been obtained and examined.Note if they are not available with N/A,
X The facility or dwelling was inspected for signs of sewage back-up.
X The system does not receive non-sanitary or industrial waste flow.
X The site was inspected for signs of breakout,
X All system components,excluding the Soil Absorption System,have been located on the site.
X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles
or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption
System on the site has been determined based on:
X Existing information,For example,Plan at B4O,H,
X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)
[1 5.302(3)(b)]
X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of
Subsurface Disposal Systems.
revised 9/2/98 Page 5 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 196 MARINER CIRCLE COTUIT MAP 024 PAR 143
Owner: MR.SILVA
Date of Inspection:8130/99
FLOW CONDITIONS
RESIDENTIAL:
Design flow:_=g.p.d./bedroom
Number of bedrooms(design): 2 Number of bedrooms(actual):2
Total DESIGN flow: 22Q
Number of current residents:Q
Garbage grinder(yes or no):NQ
Laundry(separate system)(yes or no): NO If yes,separate inspection required
Laundry system inspected(yes or no):M
Seasonal use(yes or no): YES
Water meter readings,if available(last two year's usage(gpd): nta
Sump Pump(yes or no): NO
Last date of occupancy: nLa
COMMERCIAL/INDUSTRIAL
Type of establishment: n&
Design flow: nLa gpd(Based on 15.203)
Basis of design flow: nLa
Grease trap present:(yes or no):JLQ
Industrial Waste Holding Tank present:(yes or no): NQ
Non-sanitary waste discharged to the Title 5 system:(yes or no):NQ
Water meter readings.if available:Wit
Last date of occupancy: n&
OTHER: (Describe)
nLa
Last date of occupancy: n&
GENERAL INFORMATION
PUMPING RECORDS and source of information:
nLa
System pumped as part of inspection:(yes or no):NQ
If yes,volume pumped nLa- gallons
Reason for pumping: n&
TYPE OF SYSTEM
XSeptic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no)(if yes.attach previous inspection records,if any)
I/A Technology etc.Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other: n&
APPROXIMATE AGE of all components,date installed(if known)and source of information:
1980
Sewage odors detected when arriving at the site:(yes or no) NQ
revised 9/2/98 Page 6 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 195 MARINER CIRCLE COTUIT MAP 024 PAR 143
Owner: MR.SILVA
Date of Inspection:8/30/99
TIGHT OR HOLDING TANK: NO (Tank must be pumped prior to,or at time of,inspection)
(locate on site plan)
Depth below grade: nLa
Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain)
nLa
Dimensions: nta
Capacity: nLa gallons
Design flow: nLa gallons/day
Alarm present: 111Q
Alarm level:-nt& Alarm in working order:Yes_No_ DLO
Date of previous pumping: nLa
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
nta
DISTRIBUTION BOX: _
(locate on site plan)
Depth of liquid level above outlet invert:nLa
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.)
ilia
PUMP CHAMBER: NQ
(locate on site plan)
Pumps in working order:(Yes or No): NQ
Alarms in working order(Yes or No): WQ
Comments:
(note condition of pump chamber,condition of pumps and appurtenances.etc.)
nta
revised 9/2/98 Page 8 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 195 MARINER CIRCLE COTUIT MAP 024 PAR 143
Owner: MR.SILVA
Date of Inspection:8/30/99
BUILDING SEWER:
(Locate on site plan)
Depth below grade: V
Material of construction:_ cast iron X 40 PVC _ other(explain)
Distance from private water supply well or suction line: TOWN
Diameter: nLa
Comments: (condition of joints,venting,evidence of leakage,etc.)
nLa
SEPTIC TANK: X
(locate on site plan)
Depth below grade: !>'•'
Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain)
nLa
If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): MQ
nla
Dimensions: L 8'6"H 5'7"W 4'10"
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle:
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: 17"
How dimensions were determined: MEASURED
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,
etc.)
SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND RECOMMEND PUMPING EVERY TWO YEARS
GREASE TRAP:
(locate on site plan)
Depth below grade:
Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain)
WA
Dimensions: n&
Scum thickness: nLa
Distance from top of scum to top of outlet tee or baffle:l7la
Distance from bottom of scum to bottom of outlet tee or baffle n/A
Date of last pumping: Wit
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,
etc.)
nLa
revised 9/2/98 Page 7 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 195 MARINER CIRCLE COTUIT MAP 024 PAR 143
Owner: MR.SILVA
Date of Inspection:8130/99
SOIL ABSORPTION SYSTEM(SAS): X
(locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods)
If not located,explain:
nLa
Type:
leaching pits,number: 1000 GALLON LEACH PIT
leaching chambers,number: _nLa
leaching galleries,number: -n&
leaching trenches,number,length: n&
leaching fields,number,dimensions: nta
overflow cesspool,number: nLa
Alternative system: WA
Name of Technology: _n&
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.)
THE LEACH PIT IS STRUCTURALL SOUND AND FUNTIONING PROPERLY.THE PIT HAS NOT HAD MORE THAN V OF WATER IN IT.
CESSPOOLS: _
(locate on site plan)
Number and configuration: n&
Depth-top of liquid to inlet invert: n&
Depth of solids layer: n&
Depth of scum layer. nla
Dimensions of cesspool: nla
Materials of construction: n&
Indication of groundwater: n1a inflow(cesspool must be pumped as part of inspection)n&
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
D&
PRIVY: _
(locate on site plan)
Materials of construction:Wa Dimensions:n/a
Depth of solids: n&
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
Wa
revised 9/2/98 Page 9 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 196 MARINER CIRCLE COTUIT MAP 024 PAR 143
Owner: MR.SILVA
Date of Inspection:8/30/99
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes into house)
n/a
I
nA
AA 5a
B� 10
revised 9/2198 Page 10 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 195 MARINER CIRCLE COTUIT MAP 024 PAR 143
Owner: MR.SILVA
Date of Inspection:8/30/99
NRCS Report name: n&
Soil Type: n&
Typical depth to groundwater: n&
USGS Date website visited: n/a
Observation Wells checked: NO
Groundwater depth:Shallow _ Moderate _ Deep _
SITE EXAM _ Slope
_ Surface water
_ Check Cellar
_ Shallow wells
Estimated Depth to Groundwater 12 Feet
Please indicate all the methods used to determine High Groundwater Elevation:
_ Obtained from Design Plans on record
_ Observed Site(Abutting property,observation hole,basement sump etc.)
Determined from local conditions
Checked with local Board of health
Checked FEMA Maps
_ Checked pumping records
_ Checked local excavators,installers
X Used USGS Data
Describe how you established the High Groundwater Elevation.(Must be completed)
USGS MAPS AND CHARTS
revised 9/2/98 Page 11 of 11,
(�TCWN OF BARNSTABLE
LOCATION I ► 1 d ctrc - WAGE #
VILLAGE ASSESSOR'S all,
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size) l.-
NO. OF BEDROOMS �n Q
BUILDER OR OWNER ( I ✓ ���
PERMITDATE: - COMPLIANCE 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
MA
'°J
Ac
gc
��
LOCATION SEWAGE PE MIT NO.
1�4c= C % C =
VILLAGE e
c� -T61
1NST LLER'S NAME i ADD ESS
BUILDER /OR OWNER
e --
DATE PERMIT ISSUED LZ
DATE COMPLIANCE ISSUED / �
o ,Ai�i�
a.
THE COMMONWEALTH.OF MASSACHUSETTS
BOAR® OF HFAiTH
R................OF...,�� ........ -----•----------------------------.
L Applira#ion for Disposal Works Tonstrnr#ion rumit
Application is hereby made for a Permit to Construct C>o:0 or Repair ( ) an Individual Sewage Disposal
Sys ....at •. ---------------------------
or
s /) Lot No.
... .. ..... ..... ... ._._•.............................. ••........ ...... ............
Ow er
Installer Address
Type of Building Size Lot..c).�t ®....Sq. feet
V DwellingNo. of Bedrooms. .......... . ... .Ex Expansion Attic Garba e Grinder
aOther—Type of Building _ ...... ..... .. .. No. of persons....................... Showers ( ) — Cafeteria ( )
dOther fixtures ... .........•..... ---•-•.........................•-••---•-•-••-----------•----------------------------•--•---•••••.
Design Flow...........,.��-------------- gallons per person per day. Total da.1 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.Y.............. Total leaching area..................sq. ft.
Z Other Distribution box (0 ) DosinVt4n,
Percolation Test Results Performed b ..... ................................... Date .....Y 7
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water..-... .. .
fX Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water. _ -_...•.......---
N . .
O Description of Soil...... ."--
W ------------------------- �/ - - - --- - - -
------------------------------ � �y7--•-•---...41,106.1e----- ----------------•--•--------------------------•--------••-•---•-•----------•------•---------------------•---.
UNature of Repairs or Alterations—Answer when applicable...............................................................................................
..------••-•----------••--------...-•---•-•-----•-•-----------------------------------------------------•-------------------------------------------------------.......................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been ' sued by the boa f heal .
Si
Date
Application Approved BY---..----. � � .....�-- 1......
Date
Application Disapproved for the following reasons______________________ ___._..___...-_..._...__..---.____........._._____.__._._...._ .-............
_
•-•-------•----------•-----•-•---•------•---•---------------•-------------•------.......---•---------•--------------•-•-•--•-••••----••-••--------•--•-----------------...-----•--••---•-------•--------
Date
PermitNo......................................................... IssuedL-------------------------------------------------------
Date
No...........
::.... Fss L1. ..
THE COMMONWEALTH OF MASSACHUSETTS
BOA RD�OF H EALTI-�
a�v ------......OF...../..,).��:LT `.'.:
Appliration for Disposal Works Tonstritrtion Primit
Application is hereby made for a Permit to Construct X) or Repair ( ) an Individual Sewage Disposal
System at•, �.. .... ..........................................................� /OIwlnie>r.� L .L(' ............. ` ...............
...... 4tkN..
--. -..
Lto -AdTess
d ..... --- ......._
Installer Address
U Type of Building Size Lot..r_)0,4Q00....Sq. feet
Dwelling—No. of Bedrooms.......................r..._._._.._.-------Expansion Attic ( ) Garbage Grinder ( )
`k Other—T e of Building .k�� ... -.. No. of persons........................................... Showers — Cafeteria
Otherfixtures ..- '�-------------.................................................... ••-••••-•--...............................................................
W Design Flow.............5.7.`�_..........._____._ gallons per person per day. Total?cda,*,..,. flow..................._....._..................gallons.
WSeptic Tank—Liquid capacity, gallons Length�/_�'�...... Width.. .... Diameter................ Depth...... :...._.
x Disposal Trench—No. .................... Width.................... Total� Length..................... Total leaching area.
r ./............. Total leaching area__._..............Sq. ft.Seepage Pit No.____.___._.✓_____.. Diameter..... .......... Depth below inlet.
Z Other Distribution box (/ ) Dosing tank ( )
aPercolation Test Results Performed ............. . :}Xl � Date.. .....
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water ,.._. .
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water. C.�
'.......................................................................................................................................
O Description of Soil...... ....r�..._.��Ct � ...---•-•-------------------------------------------•----------------------------.......................•--•-
v =:.--•------------------------------------------------------------------------------------
U! Nature of Repairs or Alterations—Answer when applicable................................................................................................
t
---------------------------------------------------------------•-----------------------..............---•-----------------....--------•----•--.....------------------------------------------.......-•--
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
G the provisions of TITLE 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.
._... .
� Si ate
ApplicationApproved By......... ........... ---•• •-•-..... ...--•-•...................... .......................... ........................................
i Date
'f Application Disapproved for the following reasons:................................................................................................................
r
---------------•------------------------- = f---•-•-•-•••••••n Date
PermitNo......................................................... Issued-.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD jOF HEALTH
..........OF..... / :2 :: .0 �.... � .......
s _�..
(9rdifirate of Tontpliattrr
THIS IS TO CERTI'FY;�That the Individual Sewage Disposal System constructed A/) or Repaired ( )
by..._...... ..� ......••... ----------------------------------------------•--
- nstaller `J /141
at.......�-,�... > ?._���l.�r,� t,�r (',le �Ci / �---t,--""" �--/t ---------
has been installed in accordance with the provisions of T 1�Sttate Sanitary C UASer in the
application for Disposal Works Construction Permit No......................................... dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
s �� �
DATE..............••............. ,:. Inspector............. .
THE COMMONWEALTH OF MASSACHUSETTS
-
/� BOARD OF HEALTH,
.............................OF................................................_.................................... �3 .
No.......................:. FEE......:................
Disposal Works Tonstrudions rrmit
Permission is hereby granted..., �� a. ? ✓E ...?. _._._.. ._,...........................................
to Construct, (Y) or Repair ( ) an Individual Sewage,Dispogal .System
��...,�� rlrfj l�r 1c✓
at No. ?` ---------------• •-•--•-•-•--•.
as shown on the application for Disposal Works Construction /�o.---0_ _� ted.
------•........1--------------------------••••-......-••--•.......f�.' ...........................
/ Board of Health /
DATE....... -- --•. ... ............. ..
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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