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Home My WebLink About0145 PINEY ROAD - Health 145 PINEY ROP`-� I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M y< 145 PINEY RD Property Address ZIMBLE Owner Owner's Name information is required for COTUIT MA 2-5-14 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out A. General Information forms on the computer,use 1. Inspector: only the tab key to move your DOUGLAS A BROWN cursor-do not Name of Inspector use the return key. DOUGLAS A BROWN INC Company Name P.O. BOX 145 Company Address CENTERVILLE MA 02632. Cityrrown State Zip Code 508-420-4534 S14297 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and thaf�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 andmaintenance iof o mite sewage disposal systems. I am a DEP approved system inspector pursuanCWSection`ib4&of Title 5(310 CMR 15.000).The system: �r: ® Passes ❑ Conditionally Passes ❑ Fails r ❑ Needs Further Evaluation by the Local Approving Authority 2-5-14 41nto�rSignature 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 145 PINEY RD Property Address ZIMBLE Owner Owner's Name information is COTUIT MA 2-5-14 required for - every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) . Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 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 APPEARS TO BE QUITE OLD BUT MET PASSING REQUIREMENTS AT TIME OF INSPECTION, POSSIBLY ORIGINAL. CAN NOT PREDICT FUTURE PERFORMANCE UNDER THE SAME OR INCREASED USE 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 T . Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 5 145 PINEY RD Property Address ZIMBLE Owner Owner's Name information is COTUIT required for MA 2-5-14 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass_ with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑'Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced ❑ Y ❑ N ❑. ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N FIND(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 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments. 145 PINEY RD Property Address ZIMBLE Owner Owner's Name information is required for COTUIT MA 2-5-14 every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ 0 Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool El ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool El ❑ 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 3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments GM ,. 145 PINEY RD + Property Address ZIMBLE Owner Owner's Name information is required for COTUIT MA 2-5-14 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any,portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria'are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 1 0,000g pd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection` Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins°3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System°Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GSM , 145 PINEY RD Property Address ZIMBLE Owner Owner's Name information is required for COTUIT MA 2-5-14 every page. CityrTown 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? El ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® El available as built plans of the system obtained and examined? (if they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ❑ ® Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank • inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided�with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M ,•'' 145 PINEY RD Property Address ZIMBLE Owner Owner's Name information is required for COTUIT MA 2-5-14 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: A 1000 GALLON TANK WAS FOUND AND A LEACH PIT WAS VIEWED BY CAMERA Number of current residents: Does residence have a garbage grinder? ❑ Yes ❑ No Is laundry on a separate sewage system? (Include laundry system inspection El Yes ❑ No information in this report.) Laundry system inspected? ❑ Yes"❑ No Seasonal use? ❑ Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): Detail: 2013 AND 2012 WATER USAGE WAS ONLY 3000 GALLONS EACH YEAR WHICH EQUALS 8.2 GALLONS PER DAY Sump pump? ❑ Yes ❑ No Last date of occupancy: , Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ .No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 ' Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 145 PINEY RD Property Address ZIMBLE Owner Owner's Name information is required for COTUIT MA 2-5-14 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: JUDGING BY WATER USAGE HOUSE APPEARS TO BE SEASONAL Other(describe below): General Information Pumping Records: Source of information: 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): TANK AND PIT t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 145 PINEY RD Property Address ZIMBLE Owner Owner's Name information is required for COTUIT MA 2-5-14 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: POSSIBLY ORIGINAL FROM 1975 Were sewage odors detected when arriving at the site?. ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ❑ 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence'of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 3 If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: APPEARS TO BE 1000 GALLON Sludge depth: LIGHT t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments GSM s•a'y< 145 PINEY RD ' Property Address ZIMBLE Owner Owner's Name information is required for COTUIT MA 2-5-14 every page. CitylTown 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 Scum thickness TTRACE Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? WOODEN POLE 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 APPEARS TO BE ORIGINAL AND SHOWS SIGNS TYPICAL OF ITS AGE WITH SOME EXPOSED AGGREGATE AT AND ABOVE THE WATER LINE Grease Trap (locate on site plan): Depth below grader 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 5 145 PINEY RD Property Address ZIMBLE Owner Owner's Name information is required for COTUIT MA 2-5-14 every page. Cityrrown State Zip Code- Date of Inspection D. System Information (coot.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): .Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments I �M 145 PINEY RD Property Address ZIMBLE Owner Owner's Name information is required for COTUIT MA- 2-5-14 every page. Cityrrown 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(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required) If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 145 PINEY RD Property Address ZIMBLE Owner Owner's Name information is required for COTUIT MA 2-5-14 every page. Cityrrown State Zip Code -Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.).- PIT WAS VIEWED BY CAMERA AND WAS'DRY WITH SOME ROOT INTRUSION. NO EVIDENT SIGNS OF FAILURE. PIT APPEARS TO BE ORIGINAL. WATER USAGE APPEARS TO BE VERY LOW. CAN NOT PREDICT THE FUTURE PERFORMANCE UNDER THE SAME OR INCREASED USE 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 E Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System•Page 13 of 17 w ' Commonwealth of Massachusetts Title 5 Official Inspection.Form' ' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments, 145 PINEY RD Property Address ZIMBLE Owner Owner's Name information is required for COTUIT' MA 2-5-14 every 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.): s t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 e Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 145 PINEY RD Property Address ZIMBLE Owner Owner's Name information is required for COTUIT MA 2-5-14 4 every 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 i t5ins•3/13 Title 5 Official Inspection Form Subsu face Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 145 PINEY RD Property Address ZIMBLE Owner Owner's Name information is required for COTUIT MA 2-5-14 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.), Site Exam: ® Check Slope ® Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: AT LEAST 5 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: HAND AUGER 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 4 M 145 PINEY RD ` Property Address ZIMBLE Owner Owner's Name information is required for COTUIT MA 2-5-14 every 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 -- I Assessing As-Built Cards Page 1 of 2 2,0 3 LOC&TIQI�I 5EW&4f PERMIT UO /yam, e 3- IWST&L,LER 5 U&ME ADDRESS 1%.D0RE SS" — — — — DOTE PERM VT ISSUED -- — — — DD.TE COMPLIb6K10E- ISSUED : ' T Q 1 http://www.townofbamstable.us/Assessing/HMdisplay.asp?mappat=020084&seq=1 2/11/2014 Rd Cep„+ Re:3 of � o� George Paton 145 Piney Road Cotuit,Mass. h 02635 System Consists of; 1 -1000 gallon septic tank. 1 -Distribution box. 1 -1000 gallon precast leaching pit. aAT E' ----- 0 --- PROPERTY ADDRESS:—1,4.5 Piney Road________ G1ii. ,llass_---------- 02635 --- ---------------- On the above date, I Inspected the septic system at the above address. This system consists of the following; 1 . 1 -1000 gallon septic tank. a 2O 2 . 1 -Distribution box. 3 . 1 -1000 gallon precast leaching ,ppit. Based on my Inspectlon, I certify the following condltlons: 4 . This is a title Five Septic System. ( 78 Code ) 5. The septic system is in proper working order at the present time.- 6. Pumped septic tank at time of inspection. 7 . Waste water is 64" below the inert pipe of the laeching ppit. SIGNATURE: f jMwat?+- N N a m e:_1,_P.�11i c.2 attr--L --_--- Company: Joae.Rh_P_ Macomber_& Son, Inc . Address Box_66 ____ ___ Centerville Ha_ 02632-0066 -Phone:--- THIS CERTIFICATION ODES NOT CONSTITVTE A GUARANTY OR WARRANTY J6SEPH P. MACOMBER & SON, INC. - Tinks•Cisspools•Leichflolds Pumped 0 Installed Town sewer Connectlons P.O. Box 66 Contervllll, MA 026320066 775.3336 775.6412 4 5 2000 � i Ap R 2 = ` R(WI Iq TM�D�Col. COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 292.6500 TRUDY COKE Secretary ARGEO PAUL CELLUCCI DAVID B. STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECTION FORM PART A CERTIFICATION Property Addres,: 145 Piney Road Nameofowner George Paton C o t ul' t Mass 0 2 3 5 Address of Owner: Date oflns eca a/20g00 Joseph P.Macomber Jr. Name of Inspector:(Please Print) A I sm a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 16.000) Company Nam �. Rgcoeneer& $Qn Mass. 02632 Mang Address: Telepfaone Number: —7 7 5—3 3 3 8 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: � Passes Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: � Date: — The System Inspect shall 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 cKinvironmental Protection. The original should'be sent touts System owner and copies sent to the buyer,If applicable, and the approving authority. NOTES AND COMMENTS revised 9/2/98 Page Iof11 q,Printed on Recycled Paper SUBSURFACE SEWA09 DISPOSAL SYSTEM INSPECTION FORM PART A , CERTIFICATION (oondnw*d) PropwtyAddresa: 145 Piney Road Cotuit,Mass. Owr►w: George Paton Deae 01 In'p"tl°":4/2 0/0 0 WPEC.'TION SUMMARY: Check A. B, C, of D. _.A. SYSTEM PASSES: �s I have not found any Information which Indlcatss that any of the failure condh'lons descr(bsd In 310 CMR 14.303 exist. Any failu; criteria not evaluated us Indicated below. COMMENTS: B. SYSTEM CONDITIONALLY PASSES: ` VI), One or more system components as described In the 'Condltfonal Pass'section need to be rsplaoed or repaked. The syst#n. upo completion of the replacement or repair,as approved by the Board of Health, will peas. Indcste yes, no, or not determined(Y. N,or NO). Dsaer(be baals of detarmination In all klatanees. If'not detern"W,explain why rwt. 4,0 The septic unk is metal,unless the owner or ops otw has provided the system Inspector whh a copy of a Certmcate of Compliance(attached)Indicating that the tank was Installed within twenty(20)years prior to the date of the Uwpection: the septic tank• whether or not metal,Is cracked, structurally unsound, shows substantial Infiltration or exfjUstion. w to failure is Imminent. The system will pass Inapsctlon If the existing septic tank Is replaced with a complying septic t" a approved by the Board of Health. Sewage backup or breakout or high static water level observed In the distribution box Is due to broken or obstructed plp4 or due to a broken, settled or uneven distribution box. The system will pass Inspection If(with approval of the Board of Health)• broken pipes) are replaced obstruction Is removed distribution box Is levelled or replaced At • The eynsm squired pumplrtgmmm than-RKw-dmss t+•y+ardus to broken or obstraated pipe(►). The•yrtrm wfl VCPW-- Inspection If(with approval of the Board of Health): broken pips(s)are replaced obstruction Is removed revised 9/2/98 Psge2ofIt f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (contirvued) ProportyAddre": 145 Piney Road Cotuit,Mass. Owner: George Paton Data of k%spection:4/2 0/0 0 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: _A�o Conditions exist which require further evaluation by the Board of Health In order to determine if the system is falling to protect the public health, safety and the environment. 11 SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES W ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH.WILL.PRQIECT THE PUBLIC HEALTH AND SAFETY AND THE E WHONMEhfT 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(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS 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 then 100 feet but 60 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 ot� (approximation not vaUd).- 3) OTHER All revised 9/2/98 Page 3ofII I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 145 Piney Point Road Cotuit,Mass. Owner: George Paton Date of Inspection: 4/2 0/0 0 D. SYSTEM FAILS: u Yo 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 Backup of-sewage into4acifi " usratem component,duetto an overloaded orclegged-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,-irkthe die ribution,4ox,above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in eesepeof 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). Number of times pumped,-2., fF I/ 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 I 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" 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 _ !// the system is within 400 feet of a surface drinking water supply the system is-within 200 feet e ourfaoadrwaciwg-water•aupPly, - • --•• - _ _ 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 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 145 Piney Road Cotuit,Mass. Owner: George Paton Data of Inspection:4/2 0/0 0 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. None of the system•compoaanis ha►&Jbean paRmnd4oF4stJeast Iwo-weals andthe'rystem hasAmeaasceiwwgemsmal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note If they are not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or Industrial waste flow. _ The site was Inspected for signs of breakout. _ All system components?eluding the Soil Absorption System,.have been located on the site. _ 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 orr the site has been determined based on:- Existing information. For example, Plan at B.O.H. _✓ _ Date jmined.in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) 115.302(3)(b)1 _ The facility owner(and.^^.___pa.ol Af differani Informal onion thA p npar jMAj'AtaAAQrA Qf SubSurface Disposal Systems. i revised 9/2/98 Page sof11 i SUBSURFACE SEWAGE DISPOSAL SYSTEM,WSPECTION FORM PART C SYSTEM INFORMATION PmWWAddress:145 Piney Road Cotuit,Mass. owner: George Paton Data of Inspection: 4/2 0/0 0 FLOW CONDITIONS RESIDENTIAL: Design flow: A _g.p.d./bedro m. Number of bedrooms(desi n Number of bedrooms(actual): Total DESIGN flow Number of current residents: Y Garbage grinder(yes or no):_( e Laundry(separate system) s orl�r �o):_; If yes, separate Impaction required Laundry system inspected, e or no) Seasonal use(yes or no►: , l� �� Water meter readings,if available(last two year's usage(gpd): 6 Sump Pump(yes or no) A/D Last date of occupancy: M COM MERCIAUINDUSTRIAL Type of establishment: Design flow: d ( Based on 15.203) Basis of design flow gp Grease trap present: (yes or no)A Industrial Waste Holding Tank present:(yes or no)-.42 Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings,if available: Last date of occupancy: A,, OTHER:(Describe) Last date of occupancy: 1 GENERAL INFORMATION PUMPING R OQD��so of' forma System pumped as part of inspection: (yes or no) If yes, volume pumped: allons p0 �sf Reason for pumping: TYPE OF SYSTEM _t-,'o" Septic tank/distribution box/soil absorption system .416 Single cesspool )_ Overflow cesspool )b 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 �D APPROXIMATE AGE of all components, date installediif known)-and source of4nformation: d when•arrivin at the site:(yes or no) Sew odors detects 9 i i i l F revised 9/2/98 Page 6ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORMA PART C SYSTEM INFORMATION(cordmbed) Prop"Addre": 145 Piney Road Cotuit,Mass. Owrw: George Paton Dote of inspection: 4/2 0/0 0 BUILDING SEWER: (Locate on alte plan) Depth below grade: Material of construction:2cast Iron Z40 PVC40 other(explain) Distance from private water supply well or auction line 144 Diameter_V _ Comments: (condition of Joints, venting, evidence of ieak"e,-otc,) Join System is vented- through SEPTIC TANK: ,GLl; (locate on site iplan) /t Depth below grade- �/ Material of construction:Zoncrets,f�mstal,(JdFiberglass,(DPolyethyleno4&other(explaln) If tank Is fnetal,list age Js.age co�nfumed by Certificate of Compliances (Yes/No) Dimensions: �6/'� , 411/01111& ?G Sludge depth: Distance from top of sludge to bottom of outlet tee orbafflr.Q Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bolt of outlet tee or baffle Q How dimensions were determined: „�o Comments: (recommendation for pumpin , condition'of Inlet and cutlit`tess ofbifflos, depth of liquid level In rel+do to outlet invert, structuraHntegrity. avid co of • age,• C.) ump the- septic tank eves years Inlet anOf ou `et ees-arep ace.. e a•n c is structurallysound an s ows no evidence of leakage_ GREASE TRAP: (locate on site plan) Depth below grade: — 2—R Material of construction.A/concrete4Amet&140Fiberyless4'A PolyethylensV4Other(*xpi&In) 7 — Dimensions: Scum thickness: 4119 Distance from top of scum to top of outlet tee or baffle: ICU Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping, condition of Inlet and outlst tees or baffles, depth of liquid level In relation to outlet Invert, structural Integrity, evidence of leakage,etc.) Grease trap is not nrPGPnt revised 9/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(contirwad) Property Address: 145 Piney Road Cotuit,Mass. Owner: George Paton Dat'of Insp�ort:4/2 0/0 0 TIGHT OR HOLDING TANX: 1s,(Tank must be pumped prior to, or at time of, Inspection) (locate on site plan) Depth below grade: V1 Material of consuuttion;l/�concreteA/tnetal.✓�Flberglas&WAPolyethylona&Anther(explain) 4)4 Dimensions: l Capacity: AN gallons Design flow:4),4 gallons/day Alarm present VA Alarm level: V& Alarm In working order:Yes,4A) Nojol Date of previous pumping: AM Commenu: (condition of inlet tee, condition of alarm and float switches,etc.) Tight or hn1 di ng tanks are QQt Fr—eseet, DISTRIBUTION BOX:v (locate on site plan) Dspth of liquid level above outlet Invert: .L/0 Comments: (note if level and distribution Is equal, evidence of solids carryover, evidence of leakage Into or out of box, etc.) — - Dist No evidence of solids carry over-No evidence of ieakage into or nut of thA hnx PUMP CHAMBER:-4),Wre, ilocate on site plan) Pumps In working�ordsr:(Yes or No)_." Alarms in working order(Yes or No)_� Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) Pump chamber is not a raccanf- revised 9/2/98 page 0orI1 SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPE(MON FORM PART C SYSTEM INFORMATION(continued) Property Address: 145 Piney Road Cotuit,Mass. Owner: George Paton Data of Inspecoon:4/2 0/0 0 SOIL ABSORPTION SYSTEM(SAS)-_/ (locate on site plan,If possible;excavation not required,location may be approximated by non-Intrusive methods) If not located, explain: Type: ! leaching pits, number: leaching chambers,number. a leaching galleries, number: LIT leaching trenches,number, length: 6 leaching fields, number, dimensions:► overflow cesspool,number:0 Alternative system: ifl7__ Name of Technology: - 1 e lve ( 78 Code ) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.) Loamy sand Solis are dry.Veaetation is normal _ Waste water ; s �4 ' halnw the invert--pipe. CESSPOOLS: (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspo& Jr Materials of construction: Indication of groundwater: inflow(cesspool must be pumped as part of inspection) 0 C'-essp ool s are not present. Comments: (note condition of soil, signs of hydraulic failure, level of pending,condition of,vegetation, etc.) Cesspools are not Present PRIVY:A4 ' (locate on site plan) Materjals of construction: sjJ� Dimensions: yl9 Depth of solids: 4 Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation;etc.) Privy is not present - revised 9/2/98 Page 9of11 3U83VRFACE SEWAGE 013POSAL SYSTVA INSPECTION FORM PART C SYSToA INFORjAAT10N(eon*%"") P„a1yACk,.a,;145 Piney Road Cotuit,Mass. Owner: George Paton 4/2 0/0 0 SKF'C71 OF SEWAGE DISPOSAL SYSTEM: Include des to at Isast two permanent reference landmarks or benchmarks locals all wells w1thln 100' (Locate when publlo water supply comes Into house) � I O N 9 "fir°i revised 9/2/98 . Pig#10of11 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTBA INFORMATION lcwWrmuod) PropertyAddre": 145 Piney Road Cotuit,Mass. own«: George Paton Dau of Insp.ct$w:4/2 0/0 0 NRCS Report name Soil Type_ Typical depth to groundwater USGS Date websits visited Observation Wells checked Groundwater depth: Shallow Moderate Deep _ SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to GroundwateV Feet Please Indicate all the methods used to determine High Groundwater Elevation: Drained hom Design Plans on record Observed Site (Abutting proper)l observation hole, basemeat sump etc.) Determined from local conditions Checked with local Board of health _Checked FEMA Maps Checked pumping records hecked local excavators, Installers:C Used USGS Data Describe how you established the High Groundwater Elevation. (Myd be completed) Used water contours map. Gahrety & Miller Model 12/16/94 revised 9/2/98 Page II of II i ' ]•i+I.rat'w a—Rta7i'—'rr—aen:mr•nl�RrsTnrtrrr7r1r:7r+talfrrtTT�.nm f.erR1Y 11�'�n�t1.T TT•►'.•l�.s*tr.—..�..r•t. TOWN OP Barnstable UOARD OF HEALTH + SUDSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION I •••T!•11•••.•a—�.tIT.�.�TTITTII'R.TIITT1CCat7R�tTt'T1�41TR7i.7rOf—'7"�aIVO��T�lt�7R7 twit ..�I`T'T'1.�..w -TYPE OR PRINT CI.EARLY- PROPERTY INSPECTED STREET ADDRESS 145 Piney Road Cotuit,Mass. ' ASSESSORS ;MAP, BLOCK AND PARCEL # OWNER' s NAME George Paton PART D - CERTIFICATION NAME OF INSPECTOR Joseph P.Macomber Jr. COMPANY NAMEJ.P.Macomber & Sen' Inc. COMPANY ADDRESS, Box 66 Centerville,Mass. 02632 street Town or City State LIP COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX ( 508 ) 790 - 1 578 >R R CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at ®rlecommendat' ions' his address and that the information reported is true , accurate , and omplete as of the time of .inspection . The inspection was performed and any regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one : Systevi yPASSED ~� The inspection which I. have conducted has not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form . ' System FAILED* The inspection which I have con Mcted has found that the system fails to Protect the j-)ublic health and the environment in accordance with Title 5 , 310 CMR115t303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . r r - Inspector Signature*fZ) /6e,1�1 Date a( n6 copy of this certification must be provided to the OWNER, the BUYER here applicable ) and the BOARD OP' HEAL11114 .ip t... * If the inspection FAILED, the owner or operator shall upgrade ' the system within one year of the date of the inspection , unless allowed or required otherwise as provided in 3.10 CMR 15 . 305 , partd .doc 0 0,03 --\- _ LOCAT_IQN-_ _SEW&C., PERMIT MO. TC tJ-A E. __ ,�. .A D D R E SS OLP L`x DATE COMPLI &KICE ISSUED ; ?� -i ' �. �� ,� �'�� I `_ J THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Application is hereby made for a Permit to Construct or Repair ( 10P)0,an Individual Sewage Disposal SY7 at Loct�n-Address or Lot No. 00,C Owner Address Other Distribution box ( ) Dosing tank ( ) Agreement: ova The undersigned agrees to install the aforedescribed Individual Sewage I5isposal System in accordance with the provisions of Article %Iof the State Sanitary Code—Theundersigoed further agrees not mplace the system in operation until u Certificate of Compliance issued by the board o health. ' Si 7/ — —_~—~.-'==_------- � o*" � Application Approved D]c---.------__—.--.-_-----_'.------------------------------- ........................................ ` � . DateApplication Disapproved ' for the following reasons:------------------------------------------ .............. ..................................................... � - --_'._.—'----.—_-----._'-------'--------'---_-_--.—'-----_.---.-------.---._--.__- ~^~ . ^ o"* U 3 Fsa.... J.`�...._ THE COMMONWEALTH OF MASSACHUSETTS _ BOARD OF HEALTH .............. ... .. . . Appliratiuu -fur DiiVuuttl lurks Tomitrurtiuu Urruiit Application is hereby made for a Permit to Construct ( ) or Repair ( /) an Individual Sewage Disposal System at T / _ < •-----•---------------------------------------------- Lo / / c�tion-Address or Lot No.. rf ' Owner Address ................................ � irtaller Address d Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building __ ------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) a' Other fixtures ------------------------------- - - W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons. WSeptic Tank—Liquid 'capacity------------gallons Length................ Width-____.-..-__._ Diameter.........-...... Depth---------------- x Disposal Trench—No- --------------------- Width.................... Total Length-------------------- Total leaching area--------------------sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area-------.----------Sq. It. Z Other Distribution box ( ) Dosing tank ( ) ►-' Percolation Test Results Performed by.......................................................................... Date-----------------••--------------------- a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water---------------------... Test Pit No. 2................minutes per inch Depth of Test Pit__________._..------ Depth to ground water---------------------. -------------------- -------------------------------------------------------------------------------•--...-------------•--------------------------------- 0 Description of Soil---------------------------------------------------------------------------------------------------------------------------------------------•........................ x U -----------•----------------------------- ------- ----------------------•----•--•-•--------------•-•••••-•••--•----••--•.....--••----•-•-•-•-•---------------•--•----•.........._........_---------- ------------------------------------------------------------------------------------------------------------------------------------------------7------------------------------------------------------- U Nature of Repairs or Alterations—Answer when applicable.-._.._....___________________________________•_•.-I....._...-_...__._...___..._...._______....I ^� �J ----�- `------•• L S j ``�`?----- 5 `C.1 z.�._..._.j'_r l^. �0 Q , t` --- �—i / - Agreement: 1 j - The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board o health. 7 Signed=='�Z-y-"`- � - c' -G �_ --••------•--•-•-_ ----•-•---•-----_- -• -� --------- �-� 7 Date ApplicationApproved By.................................................................................................. ---•------------------------------------ Date Application Disapproved for the following reasons----------------------------------------------------------•----------------..............-•-•--......---•------- -•----------------•-------••-••••----------------••-----•-•-••--••••-•-•------•--•------•---•------•---•-•--•-------------•-------••-•------------------•------------------------•-•-------...--•---•-- / Date PermitNo......................................................... Issued..... I_- ..-5.......................... / Date t„ —� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......''`'`..i~'..............OF..... ..'... ``.."� -�"4-•........................ (WErdifiraIr of 01umpliaurr THIS IS TO CE,RTIFY That the Individual Sewage Disposal System constructed ( ) or Repaired by = = -- -----------------------------------------------------------------------------------------------------------•--- Inster -----�-�-�----=---------- `••d��--- -----�--_---�s--- _/c'..: at.............................. has been installed irS accordance with the provisions of Article I of The State Sanitary Code as described in the application for Disposal Works Construction Permit No______________________��:......_._._. dated_-_.__.........r�.-.......�.�.............. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. {------------- . ..... -•---- -- ........DATE ? .•..--------•----------- Inspector.__ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...f.....................................OF...f..�.a(......._................... No...�..._.7-_'-------- � .�--�--�,._��.•�,�--�.�.............................. FEE........................ Di-rupufitt1 Warka C-uui#rurtion Prrmif Permissionis hereby granted-----r -------------.......................... ---------------------•-------------•----------.._..---------------------------------....... to Construct ( ) or Repair �1-an In�ii'vidu j-Sewa e Disposal System —'/ �J fit;.,, K_,I, . .,_'C`y— atNo. ------------------------------•------- ------••------•-•---•-----........--•••-••--•-...--••- ....... .................... Street as shown on the application for Disposal Works Construction P rTlt No. _/.'_�/,-- _ Dated_._..1 _ ....................... ✓ 1,i 7_ _ 76' Board of Healt DATE... ---• ...--- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS