HomeMy WebLinkAbout0026 DONNA AVENUE - Health 26 DONNA AVENUE, OSTERVILLE
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Commonwealth of Massachusetts �ya' �°� y Q t�✓ i1
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,.
26 Donna Ave
Property Address I'\?
Virginia Gould Kelly ,
Owner Owner's Name
information is /
required for every Osterville V MA 02655 10-11-15
page. City[Town State Zip Code Date of Inspection '
fXi
Inspection results must be submitted on this form. Inspection forms may not be altered in any
p Y Y
way. Please see completeness checklist at the end of the form.
A. General Information
1. Inspector. 1, _ . ;. , . ,, r• ..
Shawn Mcelroy '. . , f'_.
Name of Inspector
Upper
ppe Cape Septic Services
Company Name
P.O. Box 73 : v ,• ,
Company Address
E. Falmouth MA 02536
City/Town State Zip Code
1-508-495-0905 S13971
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000).The system:
® Passes, ❑ Conditionally Passes ❑ Fails
❑ -Needs Further Evaluation,by the Local Approving Authority, , f
10-11-15 .
•Inspector's Signature J 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•3113
Title 5 Official Inspection Form:Subsurface Sewage Disposal System e1f17V
Commonwealth of Massachusetts '
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments '
26 Donna Ave
Property Address
Virginia Gould Kelly '
Owner Owner's Name
information is Osterville MA 02655 10-11-15
required for every
page. Cdy/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
1
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 ❑ N ❑ ND (Explain below):
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts
= Title 5 Official. Inspection Form
Subsurface.Sewage Disposal System Form -Not for Voluntary Assessments,, ,
26 Donna Ave
Property Address
Virginia Gould Kelly
Owner Owner's Name
information is required for every Osterville• MA' 02655 10-11,=15t
*^r'
page. Cityrrown 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.):
El 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 Healthj:
M. a . . ,.fy„c• �t .
'❑ {broken pipes) are replaced _ '❑ Y ` ❑'N ❑ ND (Explain below):
❑ !obstruction is removed , ` `' ❑ Y ❑'N r`❑ ND(Explain below):
- , $ i1
❑ distribution box is leveled or replaced ❑ `Y``❑'N� ❑ ND (Explain below):
+M Y L
❑ 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:,,,,;o)r it, .ul, 3,; ;
❑ 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,
t
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
W Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form 'Not for Voluntary Assessments
26 Donna Ave
Property Address
Virginia Gould Kelly
Owner Owner's Name
information is required for every Osterville MA 02655 10-11-15
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 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
r to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes 'No
Backup of sewage into facility or system component due to overloaded or
❑ ® clogged SAS or cesspool
® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
El ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
El ® Liquid depth in cesspool is less than 6" be_low.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.--. •� ? .
26 Donna Ave
t.4
Property Address
Virginia Gould Kelly
Owner Owner's Name
information is Osterville .i MA 02655 10-11=15
required for every
page. Cityrrown ,, State Zip Code Date of Inspection
B. Certification (cunt.)
Yes No Ir. ", +a..•
® Required pumping more than 4 times in the la_s t,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
❑'• ' ® r tributary to`a surface water supply.' -
❑ ® k Any.portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ®`" ' Any portion of a cesspool orprivy 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
, I and�chain of custody must be attached to this form.]
The system is a cesspool serving a-facility with a design flow of 2000gpd-
❑ ® t 10.000gpdf' r..
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
,6 'system owner should contact the Board of Health to determine what will be
necessary to correct the failure. _ r..� '
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd. r
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
N Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
y 26 Donna Ave
Property Address
Virginia Gould Kelly
Owner Owner's Name
information is required for every Cistefville MA 02655 10-11-15
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
❑ ® r 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?
❑ Z . 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?
El ® Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based'on:
❑ ® Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any.of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
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•3M 3 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts ' -
Title 5 Official, Inspection. Form .
Subsurface Sewage Disposal.System Form -Not for Voluntary Assessments
M 26 Donna Ave r•
Property Address a
Virginia Gould Kelly
Owner Owner's Name
information is
required for every Osterville i .3 MA 02655 10-11-15
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 0
Does residence have a garbage grinder?i ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection. El Yes ® No
information in this report.)
Laundry system inspected? El Yes ® No
Seasonal use? r s. 'E .r -ITS" ❑ Yes Z. No
Water meter readings, if available (last 2 years usage (gpd)):a
Detail
Sump pump?r - , a. _ _ v tz °. ❑ Yes ® No
Last date of occupancy: '�J}• -`' �', i �• � Unknown
. Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): +�t r T .�' Gallons per day(god)
,Basis of design flow(seats/persons/sq.ft.; etc.): ,
Grease trap present? ,.;� : x,• ;t" ,:.•`rr ► fw ��,. 6 ❑ Yes ❑ No
Industrial waste holding tank present?., s ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available: -
t5ins•3/13 Tide 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 5vey�t 26 Donna Ave
Property Address
Virginia Gould Kelly
Owner Owner's Name
information is required for every Osterville MA 02655 10-11-15
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:
. r
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 i
❑ 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 1/A system by system operator under contract
❑, Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3113 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 ,t.e1,
26 Donna Ave {+
Property Address ,•wd t
Virginia Gould Kelly
Owner Owner's Name +. ,
information is Osterville MA 02655 10-11.15
required for every -
page. CityTTown State Zip Code Date of Inspection ry• .
D. System Information (cont.) � �,. . , t;.; •{ � ;
Approximate age of all components, date installed (if known) and source of information:
1985
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan): ; ,t r
Depth below grader .z , �.:{- +.. A i r. � +
18"
- feet
Material of construction: -,P 1, ':e
' ❑cast iron "; ®40 PVC ❑ other(explain)'`
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.): .
Good condition.
Septic Tank(locate on site plan):
1211
Depth below grade: '` d; + '` feet
Material of construction:
® concrete ❑ metal ❑ fiberglass %1❑ polyethylene , ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a�copy of certificate) -01 ❑ Yes ❑ No
Dimensions: 1500 gal
Sludge depth: 12
t5ins•3f13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection, Form
Subsurface.Sewage Disposal System Form -Not for Voluntary Assessments
wM 26 Donna Ave
Property Address
Virginia Gould Kelly
Owner Owner's Name
information is required for every Osterville MA 02655 10-11-15
-
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" '
Scum thickness
1"
Distance from top of scum to top of outlet tee or baffle
6"
Distance from bottom of scum to bottom of outlet tee or baffle 15".
How were dimensions determined? Tape
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 a
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
f
Commonwealth of Massachusetts , -
Title 5 Official Insp ection .Form
Subsurface Sewage Disposal System Form =Not for.Voluntary Assessments • ,
26 Donna Ave
Property Address
Virginia Gould Kelly
Owner Owner's Name
information is required for every Ostervllle MA 02655 10-11-15 '
page. City/Town 'State` Zip Code Date of Inspection
D. System Information (cont.) , ;- , . -x'. • -
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.) '
- - r'.•l if, t 'fir..' rf 1 •', 1:4•"-•r "- > ?. • 11t+} i
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 r ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow: ,t
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.):
...#i t 1. -J. - a i ._ 4f +!' .r • .t' - _.. 1'. xR s 5'Lf i ..,y ... • ,. •
"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
M 26 Donna Ave r
Property Address
Virginia Gould Kelly
Owner Owner's Name
information is required for every Cisterville r MA 02655 10-11*-15
page. Cityfrown 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 with water at wonting level and no sign of back-up from pit.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspectionfdrft
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments, 'Fs,
M 5aey`9r 26 Donna Ave ' .•F . A;f^
Property Address s
Virginia Gould Kelly
Owner Owner's Name
information is required for every Osterville MA 02655 10-11-15, ,.
`
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1-1000 gal
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields i ,number,,dimensions:
❑ overflow cesspool number:
El innovative/alternative system
Type/name of technology:
' Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leach pit in good condition and empty at inspection with stain lines at 24" 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts -
w Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 26 Donna Ave
Property Address
Virginia Gould Kelly
Owner Owner's Name
information is required for every Osterville MA 02655 10-11-15
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) i
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.):
e
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts ;,r - • } ,-
Title 5 Official Inspection Form t
Subsurface Sewage.Disposal System Form -Not for Voluntary Assessments k� • ,
M 26 Donna Ave
Property Address
Virginia Gould Kelly ;., • ,,,
Owner Owner's Name ,
information is
required for every Osterville - RI MA 02655 10-11-15
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) t• • _ ,.+. ;; . . _ .�
d
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
•z
_ q , 3 1..Y1;. .1 ,• :# it it t . - F
F •
.... , • ry rl rR- 1K:�.' 3i- ! 1 rr t • 1"4' ''
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( frJ � r � � n.,. • •
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■+enrn�..•wnw�nrin.nan �r�wr��rn.n�awwi�ni���nn -."_. ______. �.
t5ins•3f13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts j
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
26 Donna Ave
Property Address
Virginia Gould Kelly
Owner Owner's Name
information is required for every Osterville MA 02655 10-11-15
page. City/Town - 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: 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-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
26 Donna Ave
Property Address
Virginia Gould Kelly
Owner Owner's Name
information is required for every Osterville MA 02655 10-11-15
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 AII.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
p
]':XI,('[ITIVI; OIL VWI-; OI ENVIi NME;N IAL A.FI`AIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500
TRUDY CORE
Secretary
ARGEO PAUL CELLUCCI 3�P ' DAVID.B.STRUHS
Governor Commissioner
�SUBS.URFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
fj PART A
oZ /✓®h i1 A /'-Ve CERTIFICATION
Property Address: S/�R ufa 1" Name of Owner ¢
Date of Inspection: /
D��_ ��� Address of Owner: �j5 fidV`rr 1 l
Name of Inspector:(Please Print)ce)q/rre
1 am a DEP ap.roved system inspector pursuant to Section 15.340 of TFde 5(310 CMR 15.000)
an Compy Name: � W " G
MaTing.Address:
Telephone Number: V"
CERTIFICATION STATEMENT t`
1 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 sew a disposal systems. The system:
Passes
—
Conditionally Passes
..� _ Needs Further.Evaluation By the Local Approving Authority
Fails
Inspectors Signature: v i `�J Date
c;
The System Inspector shall submit a copy of this inspection report to the Approving uthority (Board of Health or DEP)within thirty(30)days of
completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner
shall submit the report to the appropriate regional office of the Department of-Environmental Protection. The original should'be senttovmk
system owner.and copies sent to the buyer, if applicable, and the approving authority.
NOTES AND COMMENTS
'A
E� R ?I
� lgg9
a�� a
revised 9/2/98 page Iof11
i� Printed on Recycled paper 1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
a
CERTIFICATION (continued)
Property Address: .
Owner: f3 u r+5°'Z
Date of Inspection:
/ ? U r
INSPECTION SUMMARY: C �A, C, or D:
A. SYS PASSES:
have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure
criteria not evaluated are indicated belo 1 /
COMMENTS: _ S'y ��°/Y� — I�6�lpG/9�!/ �r i9 D v
B. SYSTEM CONDITIOIN ALLYPASSES:
One or more system components as described in the "Conditional Pass" sectio need to be replaced or repaired. The system,upon
completion of the replacement or repair, as approved by the Board of Health ill pass.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determiner n in all instances. If "not determined", explain why not: )
` Th tank is metal,unless the owner•or operator�ha provided the system inspector with a copy of a Certificate of l
ompliance ched)indicating th the tank was•n stalled within:twenty(20)years prior to the date of the inspection;or,
the septic tank, w ther t met , is cracke , structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. e s s em wi pass i action if the existing septic tank is replaced with a complying septic tank,as
\proved by the Board f alth.
- f
_ Sewage backup or brea t or h t is ater level observed in the distribution box is due to broken or obstructed pipe(s) 'i
or due to a broken, s led or une istribution box. The system will pass inspection if(with approval of the Board.of
Health)•
broken pipe(s) are repla d
obstruction is removed - -
distribution box is levelled or rep d
_ - e system r quired pumping more than four times a yeardue to ken or obstructed pipe(s). The system wilt peal
inspection if with approval of the Board of Health): -'
broken pipe(s) are replaced
obstruction is removed
,x
l
t_
revised 9/2/98 Pagc2of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: , 00"?/? /a Ave o t, 1
Owner: C)ur'1 tS on
Date of Inspection: jz
la _ 30 -- /9
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: " .
Condition s.exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment. //
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH IO CMR 15.303(1)(b)THAT THE`SYSTEM,r• •`'
IS NOT FUNCTIONING IN A MANNER WHICH.WILL.PR(ITECT THE PUBLIC HEALTH.AN SAFETY AND THE ENVIBONMEhLT:.
`r
Cesspool or privy is w hin 50 feet of surface water
Cesspool or privy is wit in 50 feet of a bordering vegetated wetland or salt marsh.
<4
2) SYSTEM WILL FAIL UNLESS THE BOARD OF H (AND PUBLIC WATER SUPPLIER IF ANY)DETERMINES THAT THE.SYSTEM IS
FUNCTIONING IN A MANNER THAT PROTECTS PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
The system has a septic tank an soil absor lion system (SAS)and the SAS is within 100 feet of a surface water supply or
tributary to a surface water su ly.
The system has a septic to and soil absorptio system and the SAS is within a Zone I of a public water supply well.
The system has a septic nk and soil absorption ystem and the SAS is within 50 feet of a private water supply well.
The system has a sep 'd tank and soil absorption stem and the SAS is less than 100 feet but 50 feet or more from a
private water suppl well, unless a well water analy is for coliform bacteria and volatile organic compounds indicates,.that the,'t'
lution from that facility and the p esence of ammonia nitrogen and nitrate nitrogen is equal to 0r1ess
well is free from/01
than 5 ppm. ethod used to determine distance (approximation not valid). `
3) OTHER
revised 9/2/98 Page 3of11 ':QR
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner: I-1C.'5
Date of Inspection:
D. SYSTEM FAILS:
You must indicate either "Yes" or "No" to each of the following:
I have determined that one qr 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 N
Backup of sewage irrto4ecihty-or-system component-due1to 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 in the distribution box above outleYin rt due to an overloaded or clogged SAS or cesspool.
ILiquid depth in cesspool is less than 6" belo i ert • available volume is less than 1l2 day flow. r
Required pumping more than 4 ti es in the ast year NOT due t clogged or obstructed pipe(s).
Number of times pumped_.
Any portion of the Soil Absorption S tem, cesspool or rivy is below the high groundwater elevation.
I Any portion of a cesspool or privy is wi hin 100 f t of a s t ce water supply or tributary to a surface water supply. .
�_ Any portion of a cesspool or privy ' -wit a l o public well.
1 Any portion of a cesspool or priv is 1 0 feet f a private water supply well.
_ Any portion of a cesspool or privy_ le s•han 0 feet but greater than 50 feet from a private water supply well with no_
acceptable water quality analysi . If the well s een analyzed to be acceptable, attach copy of well water analysis for
-coliform bacteria, volatile or nic-compounds, a mo is nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAILS:
Y4 u must indicate either "Yes" or "No" to each of the following:
The following criteria apply to large systems in addition to the riteria 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:
Y s No
the system is within 400 feet of a surface drinking water supply
the system is-within 200 feet ofe tritiutary-toe surtaoe�►inkir�g•water supply _ • _._...:
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or-a mapped-Zoneill of a public
water supply well).
j
Th 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 4of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 00-InA A V S
a�1 Owner: E vl
V�
Date of Inspection:
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Y,eyr/ No .
V _ Pumping information was provided by the owner, occupant, or Board of Health.
None of the system cornpo"nts.6aa&.boen pumpedaor-atJoast two weeks a &the aYetem 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.
f _ The system does not receive non-sanitary or industrial waste flow.
The site was inspected for signs of breakout.
U All system components, excluding 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 on the site has been determined based on:-
Existing information. For example, Plan at B.O.H.
_ Determined 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))
The facility owner land.occupants.if different from-awaad,,wn re.provide d.with iafnunatioann t o mnPrzaWRtaqanc.&4f-
SubSurface Disposal Systems.
rF
revised 9/2/98 Page 5of11
SUBSURFACI SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
c� SYSTEM INFORMATION %Y
• Property Address: -
Owner: BO r-�ESOa1
Date of Inspection:
O _ FLOW CONDITIONS
RESIDENTIAL—,
Design f1owg•p•d.lbedroom.
Number of bedrooms(design): Number of bedrooms (actual):
Total DESIGN flow__
Number of current residents:_
Garbage grinder(yes or no):_� NO
Laundry(separate system) lies or no): f yes, separate inspection required C�, / f�
Laundry system inspected ( es-emTTO �io� / 7 -7, Y
Seasonal use(yes org
Water meter readings,if available(last two year's usage(gpd): 1�0
Sump Pump.(yes or no):Av o
Last date of occupancy: 5�"?
COMMERCIAUINDUSTRIAL:
Type of establishment:
Design flow: qpd ( Based on 1 .203)
Basis of design flow i
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non sanitary waste discharged to the Title 5 system: or no)_ _
Water meter readings,if available:
Last date of occupancy:
OTHER:(Describe)
Last date of occupancy:
GENERAL INFORMATION
i
PUMPING RECORDS and source of info rmatnt o
System pumped as part of inspection: (yes or no)_
If yes, volume pumped: 2 G"� g(l61 /oPVXCV,-
Reason for pumping:
TYP I STEM
Septic tankldistribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records,if any)
I/A Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of f all components, date installed4if known)-and source of-Wormation:
Sews"odors detected when arriving at the site: (yes or no) _
/I
l-
f _
revised 9/2/98 Page 6of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
operty Address: �j ®a� A14 5
Owner:
Date of Inspection:
BUILDING SEWER:
(Locate on site plan)
Depth below grade:_
Material of construction:—cast iron_40 PVC other (explain)
Distance from private water supply well or suction line
Diameter
Comments: (condition of joints, venting, evidence of kage,-etc.)
SEPTIC TANK:
(locate on site plan)
Depth below grade:
Material of construction: concrete—metal—Fiberglass _Polyethylene—other(explain)
Jf tank is(petal,list age_ Js-age-confirmed by Certificate of Compliance_ (Yes/No) .
Dimensions:
Sludge depth: S —
Distance from top f udge to ottrti of outlet tee or baffle:
} 1
Scum thickness: etiPP.*I
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 dimensions were determined:
Comments:
(recommendation for pumping condition f inlet and outlet to of s�gpth of quid I relation to o �trt, strut r tegrity,
evidence o leakage, etc.) �` t
/
GREASE TRAP:
(locate on site plan)
Depth below grade:_
Material of construction:—concrete—metal— iberglass Polyethylene er plain)
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 ba e:
Date of last pumping:
Comments:
(recommendation for pumping, condition of inle and outlet tees or baffles, de of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, etc.)
r
revised 9/2/98 Page 7of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner:
Date of Inspection:
TIGHT OR HOLDING TANK: an must be pumped prior to, or at time of, inspection)
(locate on site plan)
Depth below grade:_
Material of co struction: _concrete_metal_Fiberglass_Polyethylene_other(explain)
Dimensions: `+
Capacity: gallons
Design flow: allons/day
Alarm present
Alarm level: Alar in working order:Yes_ No_
Date of previous pumping:
Comments: _
(condition of inlet tee, condition o alarm and float switc s,
DISTRIBUTION BOX:_
(locate on site plan)
Depth of liquid level above outlet invert:
--\
Comments:
(note if level and distribution is equal, evidence of s7evidenceinto or out of box, etc.)
;a
PUMP CHAMBER:_
(locate on site plan)
Pumps in working order: (Yes/ No)
Alarms in working order (Ye,S or No)
Comments:
(note condition of pun chamber, condition of pumps and appurtenances, a .)
revised 9/2/98 I'age8of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
�! ,n SY TEM INFORMATION((c'ontinued)
Property Address: �6P6��7 � r
Owner: �U o
Date of Inspection:
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: l!/ �� f�00 All
leaching chambers, number:_
leaching galleries, number:_
leaching trenches, number, length:
leaching fields, number, dimensions:
overflow cesspool, number:_
Alternative system:
Name of Technol y:
Comments:
(note condition of soil, signs of hydrauic failure, level of ponding, damp soil, condition of vegetat/1-tc.,
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 cesspool:
Materials of construction:
Indication of groundwater: 7
inflow (cesspool b pu ed a art o inspection)
IZ
Comments.
(note condition of soil, signs ofh rauhc failure, level of\_ 1
ng,.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, condit n of vegetation, etc.) }.
revised 9/2/98 Page 9ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART
SYSTF INFORMATION (continued)
Property Address:
Owner:
Date of Inspection: 1J UY'l C'S j
v - 9
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (t,ocate where public water supply comes into house)
v9 r
I
A�CO.d Al
t,
revised 9/2/98 Page 10ofII
............
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
)x PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner; /e do
`
Date of Inspection:
NRCS Report name
Soil Type_ —,— —
Typical depth to groundwater _
USGS Date website visited '
` I
Observation
Wel
ls
s checked
,e Groundwater depth: Shallo
w
ow
Moderate.
Deep
SITE EXAM Slope fi --
Surface water
Check Cellar j
Shallow wells
Estimated Depth to Groundwate eet >. .
ti
Please indicate all the methods used to determine High GroundwaterlElevation: A
Obtained from Design Plans on record j
Observed Site (Abutting property, observation hole, basement sump etc:) ,
Determined from local conditions
7 CI Cnec'ked with local Board of health
Checked FEMA Maps
Cocked pumping records
—7/hecked local excavators, installers
Used USGS Data
• r
Describe how you established the High Groundwater Elevation. (Must be completed) ;,• t
p .
revised 9/2/98 v
1011
f
TOWN OF BARNSTABLE �
J G SEWAGE#
LOGMIION
A SSe"on N OT -
VILLAGE
INSTj;J LER'S NAl+ L P1It1NE iD.
SEPTIC TANK CAI'AC£f'Y SO
O
5 r v 00 , f
LEAMMG`:PACi t+.t ) ', t ize)
NO.OF'BMROOMS 3
PERmrrDATE:
- Ct�NlPLIAidc�DA'1�: -
Separation Distance Between fbe Feet
MaximumAdjustcclGroundwaterTabieto the Bpttom of l,eachtttgFacility
pnYatc water Supply Well gad Lac-hiag any iijiIls exist wt
on site or witiun 2QQ fact¢f leach►$faailiiy)
Edge of Wetland w Leaching CY AY;cvetlands exist11
t
within y)O feet of leaching..
Furnished by _--
a
A �
D D
D �
a3 '6 I.
d
a
LOCATION SEWAGE PERMIT NO.
VILLAGE
!¢Z 12-+
INSTALLER'S NAME & ADDRESS
B U I L D E R 16 WV
DATE PERMIT ISSUED
D A T E COMPLIANCE ISSUED
-------------------------
i
TE) -OF'BARNSTABLE
LQC'AA'TLLOFd �'�n,� f'f SEWAGE
�il,t;AOE ASSESSORSri.
II�STAi.L�R'S Ply�P�flNE ivC) - -
SEPrT[C TAN7777777777-
K CAPACITX LTb
LEAG� NG FACB.1'I' 'ttypr} �
NO f FBEBI MOM �
Itl OFA O OWNER
�Rll�T1DA�. CC3h�€PLIANC� DATE`-
SCpaIAtiODAlsmc ctwe a'Effie
ivfaxt uan_Uus. . GroundwatdT 16tothe$ottomofLeacleugFaeilI Feet.
PsYvato stater:Supply Well ai8 Leaching Facility { �Y�r�ls.exist
on site ar wu�in Z�feet of leurinisg fac�a�J Wit':
Edge of Wetland and 3.eactuzsg i"aal�ty(hf any wetia� ds exisf
wjthtn 34fl€eet n£teaefuag
Furiushed by..: a T� Jai
0
�1 a
O
Qb
o �-
� � s
n
LOCATION SEWAGE PERMIT NO.
5 2r-z
VILLAGE _
INSTA, LLER'S NAME A ADDRESS
�Q.liS%
d U 1 L D E R 1kE-1E-.
DATE PERMIT ISSUED �7
DAT E COIMPLIANCE ISSUED
I
i
�;
� � '
�� � � ,
i
i
_ � ��
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J
�;
�:
No.... ...............��; FIMs......... . �. . .
-
.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..... ...........OF.................................. --------...... ......_..........................
r°I -Jon for Bhgpoii al Works 'tlowitrurt, rrmt# 1Z1"?_t
Application is hereby"made for a Permit to Construct ( ) or Repair { an Individual Sewage Disposal
System at:
.�s�.......AvE..........®srF..t.Y------------- ----------------------------------------------------------•-------....-•-•------...............---
Location-Address --•--- --••--•-•---------------or.
Lot No.
..............T E..D....---. 12�. .t{`. _N__..__....----•---•---...._._.... . ---.............---•----...-•--•--•--.:.---.........
/� Oyfier Address
a ............... �o ti T C_o .......................................... •--•-•------•-•..----..__..... --------------_-_-
Installer " Address
Type of Building Size Lot................ Sq. feet
U Dwelling—No. of Bedrooms.............. .......................Expansion Attic ( ) Garbage Grinder ( )
PL4Other—T e of Building No. of persons____________________________ Showers' — Cafeteria
a, Other fixtures -----•--•---•-••••-••---•---•-_...
�� gallons per person per day. Total daily flow_____________ .................
W Design Flow........................ g P P P Y• Ygallons.
1:4 Septic Tank—Liquid capacity.. allons Length................ Width................ Diameter................ Depth................
Disposal Trench—No_ ____________________ Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No----------/........ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( l) Dosing tank ( ) M
aPercolation Test Results Performed bY.......................................................... ..--------•-•-• Date........................................
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.........................
x --••••••-•--. •---••...... ..................•-..._._.................-----------............................................................
0 Description of Soil........-•�••1•-�- ----•- �``�`' ----...-•---•------------•------------------------•---.....-•--•-----------------------....._.......---•-----••••-•-
----------
U -••••-•-•-•-•---•------••••----••••••-•-----•••--•--••••-•-•----•••---•-•---•-•••••-•--.....---•----•-._.....---•-•••••--•...-••--•--•----•••---
UW •••-•-•--------- __...-••••-••-•--•-••---•---•--
Nature of Repairs or Alterations—Answer when applicable__.._ ,__ __l _w_!`? __._. __l._.._:...o_m o Z_��rr
-------------------•---•------•-----•--•---..-•-•-•----....................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System.in accordance with
the provisions of iI'LU 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in
operation until a Certificate of Co pliance has been issued by the b a, of heal .
Signeif.•----• - ---_----• -------•-•-•-•................•••_.... /� dry
ate
ApplicationApproved By........... - ......-•-•-•-•-•-_... . . ... ........................ ---• -....... •-••--
Date
Application Disapproved for the f l wing reasons:_:..
--•---------------•-----•---••-------.....---•--------•-------------....-------•-----------•---------•-•-'•---------------------------•••-----•••...•----•-••-•-••--••----•--•---•-'• -•-•------•--
Date
PermitNo.........2 ..q_........--•----•--. Issued.......................................................
Date
Z
No................_....... F$s_........._...
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..._.... --.............................OF............................-..........----......---.._.--.:_.__..-_._.._..........-._._..
Appliration for Disposal Works Tons#rur#ion Permit
Application is hereby made for a Permit to Construct ( ) or Repair (v) an Individual Sewage Disposal
System at:
/ vo.Div y f•'/!/-, 0 S i—,; 1 // /�
-Location-Address or Lot No.
................_ED_. Q.v G.i:l:!. .1 ......................••---•--_.. . .......--•••._... ..._•--•••••-___-_---•. -•-----.......................................
Ow er Address
M Installer Address
U Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms.............. ............... Attic ( ) Garbage Grinder ( )
a'4 Other—T e of Building No. of ersons____________________________ Showers
YP g --------•-•--•-•-•-•---....- P ( ) — Cafeteria ( )
Other fixtures ----•----- -- -------•-------•-----------
Design Flow.......................1....: '... ____gallons per person per day. Total daily flow..............f.:$.v_................gallons.
iL,,
Septic Tank—Liquld capacity._:.:_.____�gallons Length................ Width................ Diameter...... Dept h................
W Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area...................sq. ft.
x
Seepage Pit No.........../....... Diameter____________________ Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( /) Dosing tank ( )
� Percolation Test Results Performed bY.......................................................................... Date.................................••---•
Test Pit No. 1________________minutes per inch Depth of Test Pit.................... Depth to ground water...................
f1r, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
PG . .............................................................-•---••----._......----•--..._.....•--......__-----_.....
0 Description of Soil........__/_t/Z ...� -�
U -----------------------------------•--•--...---•---•••••-•-----••--•-••-----•-----••-•----•-•.....--•---••--••-••-----•------...._..._.._---•- ..__...••••--•...........•••----....••••..._•••-•••-
W
---------------------------------•---...-•----------------------------......---------••-•-••_---••----••••----.._._..-------------------•-••----••------•----.........._._...•••------•-•----........_
U Nature of Repairs or Alterations—Answer when applicable___.__!. _S _v._7 r'_ / :'2 _ ��H
/ i / ._.......
--------------------------------•---..-•--------....----.._._._........_.__.._......._...•••••••••-••----•-•••••-------------•-----__-•_..__........---•••••------=----•••••_--•--•----•------.........-
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 Co pliance has been issued by the board of health.
G __
?• , Date
Application Approved By....
- _ • .. . ....•••---. ....-•-•••--- --•••---------------•--•••.. ........ ---1-7 5-----
Date
Application Disapproved for the f ll •ng reasons:--•---•-------•---------•--•................•----._.......----•----•-------•----•---••...-•-••••--••---•-----
........-•----•---------------------------•--....-•------------........----..........._.......---._.........-----... .Date
PermitNo......................................................._ Issued......................................................_
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....................................OF.....................................................................................
(Intifiratr of Tontpliattrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired )
by--------- .....-•- - .......•---- - .. ..... ...........................................:_
Installer
at..... /)mot.............................s r .
--.......... .... ..... ..........
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No....... ....... dated...... -..[,D__-.Rs...................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CO STRUED AS�GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.................. .'.U. ............................... Inspector........_. .... --..........--••--
THE COMMONWEALTH OF MASSAC SETTS
BOARD OF HEALTH
� ...........................................OF........-......---_...-...._.................._................-._..._...............
No.--C FEE.......
1 DC7
-.. may
Disposal Works Tons#rurtion Errant
Permission is hereby granted....... f� .......................................
to Construct ( ) or Repair (ei�n Individual Sewage D* sal System
at No....... .K--•-� ,41� �� �-�`'= -CU S %=-2 cam/
.... ....- .............1.....__..............................................................
street
as shown on the application for Disposal Works Construction Permit No.?_-c__-Jpl;k_.C(Dated........... - ........
DATE.......... 1.7--.:_?5.._..•-•......... •......... oar o ealth
FORM 1255 A. M. SULKIN, INC., BOSTON