HomeMy WebLinkAbout0180 MOORING DRIVE - Health 180 Mooring Drive; Cotuit
- -
i
c Commonwealth of Massachusetts
Title 5 Official' Inspection Forin .
N Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�" �5•y
180 Mooring Dr , �•y
Property Addressv
t-.
Pauline O'Brien f _- 71 s.;
Owner Owner's Na e +
information is
required for every Cotuit '✓ s _ 3 -:�". �; MA 02635 6-14-18 U_
page. City/Town . ps _ State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
A. General Information
;.. o, 1., Inspector:
.� !_• " � i' r. :^{9cil r . '4.B ' - .+ ',Z •'tip
Shawn Mcelroy'
Name of Inspector
Upper Cape Septic Services r. , .•
Company Name
P.O. Box73
Company Address
E. Falmouth MA 02536
City/Town State Zip Code
1-508-495-0905 S13971
Telephone Number License Number
B. Certification
a r , I certify that I have personally inspected the-sewage disposal system at this address and that the
• ,t = _ 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.O06).The system:
Passes r.,,,t ;_. t Conditionally Passes, ; ,i❑ Fails
Ire. --a r. ' ,,,tti�., .- t.
Needs Further,Evaluation by the Local Approving Authority „ r
+ r 6-14-18 t
r ,
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 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17
IO lied
VV
Commonwealth of Massachusetts
r3� Title 5 Official Inspection Form
wa
I'll Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
180 Mooring Dr
Property Address
Pauline O'Brien
Owner Owner's Name
information is It COtU r
required for every MA 02635 6-14-18
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
i t '
Inspection Summary: Check A,B,C,D or E%always complete all of Section D
A) System Passes:.
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
System is in good working order with no sign of failure.
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND) for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a�complying`septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y El ❑ ND (Explain,below):
� r
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
r� Title 5 Official Inspection Form
,,ISM Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
180 Mooring Dr r
Property Address r
Pauline O'Brien
Owner Owner's Name
information is
required for every Cotuit s• ; S MA 02635 6-14-18 , .
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.' `'
..�_ a .1- It 'j w
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break ou't or high static water level in.the distribution box due
to broken or obstructed pipes) or due to a broken, settled or uneven distribution box. System will
.A pass inspection if(with approval of Board of Health): t'
❑ broken pipe(s)'are'replaced ❑"Y ❑N :.41- ND (Explain below):
°' `❑' obstruction is removed" `` '3 ,' `❑ Y ' ON ❑ ND'(Explain below):
❑ distribution box is leveled or replaced` ❑Y ❑ N Y ❑ ND (Explain below):
( .t.l, • i r i .•.(T.'-• 1 i.. T^., (•s rr 'rl iTi f' -S, - ,
• Tt f '+ .a t�' v .. `- a ,� r+ ?• .r- { •^ rF. JR' .. .1 •1 i ,
❑ 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.
System will pass unless Boa`rdof Health determines in accordance with 310 CMR
15.303(1)(b)that the system is'not'functioning in a mannerwhich will protect public health,
safety and the environment:
❑` "besspool or privy is within 50 feet of a surface water
J " "❑" °Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
3 Title 5 Official p
cial Inspection Form
r
;, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
r� ,r
180 Mooring Dr
Property Address
Pauline O'Brien
Owner Owner's Name
information is required for every Cotuit MA 02635 6-14-18
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of? surface water,supply or tributary to a surface water supply.
❑The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The,system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
O'
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes"or"No"to each of the following for all-inspections:
Yes No '
El ® Backup ofFsewage into facility or system component due to overloaded or
clogged SAS or cesspool '
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y2 day flow
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
i
Commonwealth of Massachusetts
w.,
Title 5 Official . Inspection' Form . .
Ki.1 Subsurface Sewage Disposal System Form -'Not for Voluntary Assessments
180 Mooring Dr _
Property Address
Pauline O'Brien •�;: �'
Owner Owner's Name
information is
required for every Cotuit f '- ;`' MA 02635 6-14-18 ,
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
-Yes,. -No,)
❑ E Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
„�a ❑; :® t ..Any portion of the SAS, cesspoolr 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: `
❑ r ®,, t ,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.
(04 ❑ ® - 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
L 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
rt. . ❑ t_ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 3'10 CMR 15.303,therefore the system fails. The
.4 f,: . _ ,t, system owner should contact the Board of Health to determine what will be
,• - • .,, G 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 dunking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen.sensitive area (Interim Wellhead Protection
"❑ ' ` El Area- IWPA) or a mapped Zone'II of a public water'supply well
IL If you have answered "yes"to any question ih Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed.The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
Commonwealth of Massachusetts
r� Title 5 Official Inspection Form
ili Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
180 Mooring Dr
Property Address
Pauline O'Brien
Owner Owner's Name
information is required for every Cotuit MA 02635 6-14-18
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 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?
® . Wasthe facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:.
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of,the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information ,
Residential Flow Conditions:
Number of bedrooms (design): 3f F 'Number of bedrooms (actual): 3
DESIGN flowbased on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
c Commonwealth of Massachusetts -
�/ Title 5 Official Inspection Form
(l
M Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
180 Mooring Dr
J Property Address
Pauline O'Brien
Owner Owner's Name ,
information is
required for every Cotuit r MA 02635 6-14-18 f
page. City/Town . State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 1
Does residence have a garbage grinder?,, ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
• Seasonal use? t yi _ , „ , . ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):•
Detail:
Sump pump? tc r:. t. �,.r,,� :_ r t. _-`i , El Yes ® No
6-2018
Last date of occupancy: 4 ,, ; ;- Date
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow (based on,31 0I CMR 15.203):. L Gallons per day(gpd)
Basis of design flow,(seats/persons/sq.ft:,.etc.): f r R, •',
Grease trap present?- ❑ Yes ❑ No
Industrial waste holding tank present?, >. t,• ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
r� Title 5 Official Inspection Form
Ili Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
180 Mooring Dr
Property Address
Pauline O'Brien
Owner Owner's Name
information is required for every Cotuit MA 02635 6-14-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: N/A
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract (to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
r Commonwealth of Massachusetts
r� 3, Title 5 Official Inspection Form
i ii Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
180 Mooring Dr
Property Address
Pauline O'Brien r ,
Owner Owner's Name t
information is required for every Cotuit MA 02635 6-14-18. .:
page. City/Town State Zip Code Date of Inspection a
D. System Information (cont.) . .
Approximate age of all components, date installed (if known) and source of information:
1980 '
Were sewage odors detected when arriving at the site? ;y ❑ Yes ® No
Building Sewer(locate on site plan): , i*�,
Depth below'grade: 24"
�, . �- �„ t >: •'feet
Material of construction: �.;,', y.• „ _
❑•cast iron' n 40 PVC' ` ` ❑'other(expWn' j� ` ' "
Distance from private"vvate�"stapplywell or suction line: r. feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Good condition.
Septic Tank(locate on site plan):
Depth below grade: 18"feet '
Material of construction: a,. _ :_'►
® 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: ^- + _ � _. ,1, ;- �r;. . ' r►�,:,, � ,
1000 gal
Sludge depth: , ,
12"
t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts f
3 Title 5 Official Inspection Form w
0 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�<1l_ 180 Mooring Dr
Property Address
Pauline O'Brien
Owner Owner's Name
information is required for every Cotuit L MA 02635 6-14-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.),
Distance from top of sludge to bottom of outlet tee or baffle
20" .
litScum thickness
Distance from top of scum to top of outlet tee or baffle 611
Distance from bottom of scum to bottom of outlet tee or baffle
15'
How were dimensions determined? Tape
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank is in good condition with baffles installed and no sign of leakage.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
-'G Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
K�
r`jyf
180 Mooring Dr
J1'
Property Address -•
Pauline O'Brien
Owner Owner's Name
information is required for every Cotuit MA 02635 6-14-18 .
,.
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) 4 k, - ' • ,
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage; etc:):
� J . . �". dJ1•,` .r q.. - i r .Y f�.4t f. •1. 'i„ .! s _ .1
Tight or Holding Tank (tank must be pumped at time of.inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal. ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
6e� Commonwealth of Massachusetts
Title 5 official Inspection Form
�i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
`!`1 180 Mooring Dr
Property Address
Pauline O'Brien
Owner Owner's Name
information is required for every Cotuit MA 02635 6-14-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must'be opened)(locate on site plan): •
Depth of liquid level above outlet invert 0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Good condition.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ -Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:.
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
r� 3 Title 5 Official Inspection Form
ai Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
180 Mooring Dr
Property Address
Pauline O'Brien
Owner Owner's Name
information is MA 02635 6-14-18
required for every Cotuit .,� >�'t� r
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4
® 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: _
J Comments (note condition'of soil, signs of.hydraulic failure,Jevel of ponding, damp soil, condition of
vegetation, etc.):
Octagonal leach pit in good condition and holding 24"of water with stain line at 30" below inlet invert.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
3 Title 5 Official Inspection Form
i�i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
180 Mooring Dr
Property Address
Pauline O'Brien
Owner Owner's Name
information is required for every Cotuit MA 02635 6-14-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.): ,
w ,
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
c Commonwealth of Massachusetts
r� y Title 5 Official Inspection Form
hA
01 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
180 Mooring Dr
Property Address
Pauline O'Brien
Owner Owner's Name -
information is MA 02635 6-14-18
required for every Cotuit . i
page. City/Town• x 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
L
IL
t ' F
4
I.
ti
+( �
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts
y Title 5 Official Inspection Form f
t�l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
180 Mooring Dr
Property Address
Pauline O'Brien
Owner Owner's Name
information is required for every Cotuit - MA 02635 6-14-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam: `
❑ Check Slope
❑ Surface water 4
❑ 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 and town maps show groundwater at greater than 20'.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
of Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
180 Mooring Dr
Property Address
Pauline O'Brien
Owner Owner's Name
information is required for every Cotuit MA 02635 6-14-18
page. City1rown 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
Commonwealth of Massachusetts
Executive Office of Enviromnental Affairs
Dept. of Environmental Protection
One winter Street, Boston,Ma. 02108 Jolm Grad
y D.E.P..Title V Septic hispector
P.O. Box 2119
Teaticket,MA 02536
WILLIAM F.WELD (508) 564-6813
Governor
s
ARGEO PAUL CELLUCCI
Lt.Governor
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM fCEIV�'®
PART A
CERTIFICATION T 8
1997
WNOFgA N
Property Address: 180 Mooring Dr.Cotuit Lot 93 Address of Owner: df� N�(TNp pTT�Lf
Date of Inspection:8112197 (If different)
Name of Inspector:John Grad Margeret Kinney A
I am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000) y
Company Name,Address and Telephone Number:
CERTIFICATION STATEMENT'
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of 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 This inspection is based on criteria defined in Title V
Conditionally Passes code 310 CMR 15.303.My findings are of how the system is
Needs Fu her aluation B the Local A rovin Authori performing at the time of the inspection.My inspection does
Y pP 9 ty not imply any warranty or quarantee of the longevity of the
Falls septic system and any of its components useful life.
Inspector's Signature: Date: 8113/97
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspections. 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.
INSPECTION SUMMARY:
Check A. B.C, or D:
A] SYSTEM PASSES: -
X I have not found any information which indicates that the system violates any of the failure criteria
defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below.
COMMENTS:
B] SYSTEM CONDITIONALLY PASSES:
_One or more system components need to be replaced or repaired. The system, upon completion
of the replacement or repair, passes inspection.
Indicate yes, no,or not determined(Y, N,or ND). Describe basis of determination in all instances. If "not determined", explain why not.
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
the septic tank,whether or not metal, is cracked,structurally unsound, shows substantial infiltration or exfiltration,or tank
failure is imminent.The system will pass inspection if the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
(revised 04127/97)
One Winter Street 9 Boston,Massachusetts 02108 9 FAX(617)556-1049 9 Telephone(617)292-5500
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 100 Mooring Dr.Cotuit Lot 93
Owner: Margeret Kinney
Date of Inspection:9/12/97
_ Sewaae backup or.breakout.or. hiah.static water level observed.in.the distribution box is due to a broken.
or obstructed pipe(s)or due to broken, settled or uneven distribution box.The system will pass inspection if
(with approval of the Board of Health). Describe observations:
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
—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): i
broken pipe(s)are replaced ,
obstruction is removed
Cl 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 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 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 APPROPRIATE) DETERMINES
THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 feet to a
surface of water supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private watersupply 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 presense of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method used to determine distance (approximation not valid)
3)Other
DJ SYSTEM FAILS:
You must indicate either"Yes"or"No"as to each of the following:
I have determined that the system violates one or more of the following failure criteria as defined 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
Backup of sewage in facility or system component due to an overloaded or clogged SAS or
cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an ownrlonrlPd or r,loggr:d
cesspool.
SAS is in hydraulic failure.
(revised 04127/97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 180 Mooring Dr.Cotuit Lot 93
Owner: MergeretKinney
Date of Inspection:8/12/97
D] SYSTEM FAILS(continued)
Yes No
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or.obstructed pipe(s).
Numbers of times pumped
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
You must indicate either"Yes"or"No"as to each of the following:
The following criteria apply to large systems in addition to the criteria:
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
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area (IWPA)or a mapped Zone II of a
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 04127/97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECLIST
Property Address: 180 Mooring Dr.Cotuit Lot 93
Owner: Margeret Kinney
Date of Inspection:8112/97
Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following:
_X_ _ Pumping information was requested of the owner,occupant, and Board of Health.
X None of the system components have been pumped for at least two weeks and the 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 NIA.
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.
X _ The size and location of the Soil Absorption System on the site has been determined based on
The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of
Sub-Surface Disposal Systens.
X Existing information. Ex. Plan at B.O.H.
X Determined in the field(if any failure criteria related to Part C is at issue, approximation of distance is
unacceptable)115.302(3)(b)J
(revised 04f27/97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 180 Mooring Dr.Cotuit Lot 93
Owner: Margeret Kinney ,
Date of Inspection:8/12/97
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 330 g.p•d./bedroom for S.A.S.
F
Number of bedrooms. 3
Number of current residents: t
Garbage grinder(yes or no): No
Laundry connected to system(yes or no): Yes
Seasonal use(yes or no): No
Water meter readings,if available:(Iast two(2)year usage(gpd):
nla
Sump Pump(yes or no): No
Last date of occupancy: n/a
COMMERCIAL/INDUSTRIAL:
Type of establishment: n/a
Design flow:0 gallons/day
Grease trap present:(yes or no) No
Industrial Waste Holding Tank present:(yes or no) No
Non-sanitary waste discharged to the Title 5 system: (yes or no) No
Water meter readings,if available: n/a
Last date of occupancy: n/a
OTHER: (Describe) n/a
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System has not been pumped in the last year.
System pumped as part of inspection: (yes or no)No
If yes,volume pumped: 0 gallons
Reason for pumping: n/a
TYPE OF SYSTEM
X Septic tank/distribution box/soil absorptions system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) ( if yes,attach previous inspection records,if any)
I/A Technology etc.Copy of up to date contract?
Other:
APPROXIMATE AGE of all components,date installed(if known)and source information:
1980
Sewage odors detected when arriving at the site:(yes or no) No
(revised 04127/97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 180 Mooring Dr.Cotuit Lot 93
Owner: Margeret Kinney
Date of Inspection:8/12/97
SEPTIC TANK: X
(locate on site plan)
Depth below grade: 2'
Material of construction:X concreate metal FRP_Polyethylene_other(explain)
If tank is metal, list age 17 . Is age confirmed by Certificate of Compliance Yes (Yes/No)
Dimensions: L 8'6'H 5'7'W 4'10'
Sludge depth:1"
Distance from top of sludge to bottom of outlet tee or baffle: 26"
Scum thickness:1"
Distance from top of scum to top of outlet tee or baffle:6"
Distance form 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 septic system every two years for maintenance.
GREASE TRAP:
(locate on site plan)
Depth below grade: n/a
Material of construction: concrete_metal_FRP_Polyethylene_other(explain)
Dimensions: n/a
Scum thickness:n/a
Distance from top of scum to top of outlet tee or baffle:We
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
Date of last pumping„/,•
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.)
n/a
BUILDING SEWER:
(Locate on site plan)
Depth below grade: 26•
Material of construction:_cast'iron_40 PVC_other(explain)
Distance from private water supply well or suction Iinel—
Diameter: 4•
G,iamments:(conditions of joints,venting, evidence of leakage,etc.)
(revised 04127/97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 180 Mooring Dr.Cotuit Lot 93
Owner: Margeret Kinney
Date of Inspection:8/1V97
TIGHT OR HOLDING TANK:
(locate on site plan)
Depth below grade: We
Material of construction:_concrete_metal_FRP_Polyethylene_other(expiain)
Dimensions: nla
Capacity: n/a gallons
Design flow: n/a gallons/day
Alarm level:_nla Alarm in working order?_Yes_No
Date of previous pumping'.
Comments:
(condition of inlet tee,condition of alarm and float switches, etc.)
n/a
r
DISTRIBUTION BOX: X
(locate on site plan)
Depth of liquid(eve(above outlet invert: Liquid level with bottom of pipe.
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box etc.)
D•box is structurally sound.
PUMP CHAMBER:
(locate on site plan)
Pumps in working order.(yes or no)No
Alarms in working order(yes or no)_Yes
Comments:
(note condition of pump chamber,condition of pumps and appurtenances, etc.)
n/a
(revised 04127197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 180 Mooring Dr.Cotuit Lot 93 .g
Owner: Margaret Kinney
Date of Inspection:8112/97
SOIL ABSORPTION SYSTEM (SAS):Y
(locate on site plan,if possible; excavation not required,but may be approximated by non-intrusive methods)
If not determined to be present, explain:
n/a
Type:
leaching pits,number: 1,000 octagon gallon leach pit
leaching chambers,number:n/a
leaching galleries, number: n/a
leaching trenches,number,length: n/a
leaching fields, number, dimensions:nla
overflow cesspool, number:n/a
Alternate system: n/a Name of Technology:_nla
Comments:(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) .
The overflow is structurally sound and functioning properly.lt has not had more than 2'of water in it.
CESSPOOLS:
(locate on site plan)
Number and configuration: n/a
Depth-top of liquid to inlet invert: n/a
Depth of solids layer: nla
Depth of scum layer: n/a
Dimensions of cesspool: n/a
Materials of construction: n/a
Indication of groundwater: n/a
inflow(cesspool must be pumped as part of inspection)
n/a
Comments:(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
We
PRIVY:_
(locate on site plan)
Materials of construction: ma Dimensions: n/a
Depth of solids: n/a
Comments:(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
We
(revised 04127/97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
180 Mooring Dr.Cotuit Lot 93
Margeret Kinney
8/12/97
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references, landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes into house)
LPJ�
c I'38
b C #4 g.
IR C
(revised 04/27/97) PlkQ• 9 Of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
180 Mooring Dr.Cotuit Lot 93
Margeret Kinney
8/12/97 w
Depth of groundwater 1z+
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from design plans on record.
Observation of Site(Abutting property, observation hole, basement sump etc.) '
Determine it from local conditions "
Check with local Board of Health
Check FEMA Maps "
Check pumping records
Check local excavators, installers
x Use USGS Data
Describe in your own words how you established the High Groundwater Elevation.(MUST be completed)
USGS Maps and Charts
a e.
(revised 04/27/97) Fay 10 of 10
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF.... ...... .............................
L/.................... .........Appliration for Disposal Works Tomotrurtion ramit
Application is hereby made for a Permit to Construct X or Repair an Individual Sewage Disposal
System '4
77LIOL'
•
............ ....... ........... ... ....................,
-----------......
. ....... ....
................ .
.........................................................................
r Lot No.
--- ---------------------------------to) er Address
.... .... ............................................... ............................................................
FWD
Pq Installer Address
Type of Building Size Lot.00.MV.........Sq. feet
U Expansion ttic Garbage Grinder ( )
Dwelling—No. of Bedroom
P4 Other—Type of Building ..... No. of persons__..______ -------------- Showers Cafeteria ( )
Other fixt ..................................................................................... ...................................
PL4 PLC's -------;.a
Design Flow......... .....................gallons per person per day. Total da)y flow...........jU' X _._.___...........gallons.
1:4 Septic Tank—Liquid capacity/gallons LengthXY�... Width.--'/' Z----- Diameter________________ Depth................
Disposal Trench—N�- -------------------- Width ....... Total Length................... Total leaching area......;,.
7....... ...�sq. ft.
Seepage Pit No......./........... Diameter.....i.......... Depth below inlet..7�_?...... Total eaching area.%J.0,1....sq. ft.
Z Other Distribution box (/) Dosing t ( ) V 7
Percolation Test Results Performed by......Vlt'&V ......... .�J'
................................ ....................................Test Pit No. L. Depth of Test Pit-------------------- Depth to ground water.Wd--- 4....
_A�----minutes per inch &0;
Test Pit No. 2................minutes per inch Depth of Test Pit..__._..._._._____.. Depth to ground waterAg...Z'ig �
P4 .............................................................................................................................................................
0 Description of Soil ...............r.......0----------------------- ........#*
17, ...... ------- -----
---------*--------------------- �kf .................."').4 .......
-------------------- ..................................................................................................................... ---- -- ------------I..........................
U Nature of Repairs or Alterations—Answer when applicable______________________
.......................................................................................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TL Ili LE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been ued by th and ff hea.l.th,
V6 ."
Sign ......... ........................ .. ......*****--------
ti Date
Application Approved By--..--- --- ... .. ...................... ......-----........... ...
Date
Application Disapproved for the following reasons:.........................../--------------------------.................................................
.........................................................................................................................................................................................................
Date
PermitNo......................................................... Issued.......................................................
Date
No................... ..........
a THE COMMONWEALTH OF MASSACHUSETTS
BOARD�OF HEALTH
/./...........................................OF....../;L? t11t4/_ ............................. ;
Apli ir-Fa#ion for Disposal Works Tonstrnrtion Prrmit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at:
44 � .
................ ....-•--.-fa=------------------------•--------................---------.... -!---- .--.-•-•- .....-------
Locatio'n'-/address / or Lot No.
w....................../CGt. ����'t� . /l.`r ,/; .ta� . 1r'� .........................................................
Ow..er Address
ll f nr
a .........--•-•-•---...----•-•----•.................................. .............,........................... ......................................................
I+ Installer Address
Type of Building Size Lot._--��-.'_ t-!f........Sq. feet
U Dwelling—No. of B'edrooms___...... ..........................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building 4t":.... No. of persons..........(0............. Showers — Cafeteria
Otherfixtur --------------------------------------------------•---------•-••---••--•---------.---------...
W Design Flow.........:_�5........................gallons per person per day. Total daily flow__._........ - .................gallons.
t
WSeptic Tank—Liquid*capacityZf7%?��.gallons Length...�"... Wldth.._�r�___.. Diameter________________ Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No....... ............ Diameter......_--....... Depth below inlet..7...a......... Total eaching area.jG.�7sq. ft.
Z Other Distribution box Dosing tank ( ) f• 7g
Percolation Test Results Performed by-- /e ...................... � t`
1.4 Test Pit No. I...A.?!-._-_minutes per inch Depth of Test Pit.................... Depth to ground water..462—(I W4,•,.1-
(i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water....
O Description of Soil .. ................... ••---------------- .............. ' -
p �� 5-;:
:_... ✓ttr,�`l� tt tr......... .... !L. /-.....1.? 'fr�irf' Ll{ 'c1.P..._. ..
UW ----------• ------ -- ---------------------------•• -•---•....--•----• ........................................
Nature of Repairs or Alterations—Answer when applicable...............................................................................................
:-----------•......---•--•--••.................•----•-----•-•---•--•-•-----•--•-----•----........---•-••-------------------------•--------.....-------••-••------•---•-•---•--•--•-•--.................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been
,issued by the boa_rdd of health.
Sign. ,'c✓1J`'' ! /X 1!if I/
��'+�I� ..... ��' " "
------
Date
Application Disapproved for the following reasons: :............................................. .........................................................
..........................................................................................................................................................................
Date
PermitNo......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
M
.......................... ............. i
O F........... j� '.` :. ..........
CIrr#ifiratr of Tomplianrr
THI IS TO�CRRTIFY, That the Individual Sewage-,Disposal System constructed (�) or Repaired ( )
by -r --- ----•--•.......................•---•-•--• -
nstal es / 1
at......... �r�- _.�- zGr. s ----................................. ........................................` .................................
has been installed in accordanke witla.,the provisions of TITLE J5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No--------------------------------------- dated_--." ...............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector .--- :.
-- ----- -•--------------------•---.---
,,YY non .=-
, - .. ..hf•1'�: - ..
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
a71)
30
No....::.................. FEE.......................,
Disposal Works %'_1=otrwffou_jJrr
Permission4is hereby granted_.../..t ...f.!.�."�...� .N f..._•_ !u! ? ......... ........................
to Construct ) or Repair ( ) an Individual Sewage Disposal/System��
at No. ......c:---_..r.
r. .. reet
as shown on the application for Disposal Works"C:onstruction Permit _._ a ............................
..................:..
<.:.
Board of Health ""
9 y
DATE -- ..j_._.. � -------------• , ,,,
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