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Home My WebLink About0050 EAST OSTERVILLE ROAD - Health 5O�East Osterville 'Road � � ' Osterville P P A 122 :053 o ° o � i y et C a e e o - K a ° , 0 n a Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary.Assessments 50 East Osterville RD ' Property Address Erin'Warren Owner Owner's Name information is required for every, Osterville Ma. 02655- 3-19-12 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 A. General Information out forms l e on the computer, I use only the tab 1. Inspector. �.. 4 �` keyto move our p Y cursor-do not David J Burnie use the return Name of Inspector key. d-i David J Burnie Mgmt, Inc ITV Company Name 3 Perry's way Company Address Harwich Ma. 02645 City/Town State Zip Code 1-866-980-1440 SI 386 Telephone Number License Number r B. Certification c I certify that I have personally inspected the sewage disposal system at this addressand that the information reported below is true, accurate and complete as of the time of the inspection. The mspe' ion was performed based on my training and experience.in-the proper function and maintenance gLpn sit sewage disposal systems. I am a DEP approved system inspector pursuant to Sol 15 340 of- Title 5(310 CMR 15.000).The system: ( Q_ Z Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority pectors Signa!u0 2� 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 101000 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. �� IZ t5ins•11/10 Title 5 Official Inspection Fo l S surface Sewage Disposal S stem•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 50 East Osterville RD Property Address ^• ° Erin Warren , Owner Owner's Name information is required for every Osterville Ma. 02655 3-19-12 page. Cityrrown 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: System was missing an outlet tee and some Sludge had move into the leaching pit. The leaching pit level was 12 inches below the invert. The leaching pit has T of stone around it, this exceeds the requirement of having to have a 1/2 a days flow space available. The tee was replaced during the inspection, both the septic tank and leaching pit were pumped and all covers were raised to within 6 inches of grade. a filter was also installed at the outlet of the septic tank. 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•11110 Title 5 Official Inspection Form:Sut:surface Sewage Disposal System-Page 2 of 17 f^ Commonwealth of Massachusetts Title 5 Official Inspection Form [ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 50 East Osterville RD Property Address Erin Warren W . " Owner Owner's Name information is required for every Osterville Ma. 02655 3-19-12 ' page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled_ or uneven distribution box.. System will pass inspection if(with approval of Board of Health): ❑ , broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): - obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ . broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ 'Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is.within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-11/10 r Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 5 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 50 East Osterville RD Property Address Erin Warren Owner Owner's Name a information is Osterville Ma. 02655 3-19-12 required for every - page. Cityrrown 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 aseptic 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. 0 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 ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged,SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑- ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5ins•11/10 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 50 East Osterville RD Property Address Erin Warren Owner ., Owner's Name information o n e Osterville Ma. 02655 3-19-12 required for every ' page. City/Town 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: E Any portion of the SAS, cesspool or privy is below high ground water elevation. El ® 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. El 0 Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] The system is a cesspool serving a facility with a design flow of 2000gpd- ❑ ® 10,000gpd. The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ® the system is within 400 feet of a surface drinking water supply ❑ ®' the system is within 200 feet of a tributary to a surface drinking water supply ❑ ® 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•11/10 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 b � 50 East Osterville RD , Property Address Erin Warren Owner Owner's Name information is Osterville Ma. 02655 3-19-12 required for every page. Cityrrown 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 El ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ® Have large volumes of water been introduced to the system recently or as part of this inspection? 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. t ® 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): no plan unknown Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example:-110 gpd x#of bedrooms): 3 t5ins•11/10 Title 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 . 50 East Osterville RD Property Address c Erin Warren Owner Owner's Name information is required for every Osterville . Ma. 02655 1 3-19-12 page. Citylfown State Zip Code Date of Inspection' D. System Information Description: 1000 gallon septic tank, no distribution box and 1 leaching pit with 3'of stone Number of current residents: 5 Does residence have a garbage grinder?, ❑ Yes ® No Js laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected?. a ® Yes ❑ No d Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): yes Detail: 2011= 75.000 gallons=205 gpd..............2010 107.000=294gpd Sump pump? ❑ Yes ® No Last date of occupancy: Current •. Date H 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-1 Ill 0 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 50 East Osterville RD Property Address m Erin Warren Owner Owner's Name' information is required for every Osterville r Ma. 02655 3-19-12 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): ; General Information Pumping Records: Source of information: 2009 per owner Was system pumped as part of the inspection? ® Yes ❑ No 1800 If yes, volume pumped: gauons How was quantity pumped determined? site glass on truck ' Reason for pumping: Type of System: ❑ Septic tank, distribution box, soil absorption system ❑ - Single cesspool ' ❑ Overflow cesspool ❑ F Privy s ❑ 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 ti inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. Z, Other(describe): _. Septic tankl and leaching pit, no distribution box . - - t5ins•11/10 + Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 F of Massachusetts Commonwealth . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ' 50 East Osterville RD Property Address Erin Warren y Owner Owner's Name information is required for every Osterville Ma: 62655 3-19-12 L. 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: 25+ estimated Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: r. 24 inches feet - Material of construction: cast iron Z 40JPVC El other(explain): f Distance from private water supply well or suction line: 1 feet Comments(on condition of joints, venting, evidence of leakage, etc.): Ok Septic Tank(locate on site plan): 1811 Depth below grade: feet Material of construction: ` ® concrete ❑ metal El fiberglass ❑ polyethylene ❑ other(explain) t - R If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No - Dimensions: Sludge depth: f t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal Syszem•Page 9 of 17 w 1 Commonwealth of Massachusetts Title 5 Official Inspection Forme Subsurface Sewage Disposal System Form-Not for Voluntary Assessments N 50 East Osterville RD Property Address Erin Warren Owner Owner's Name M information is required for every Osterville Ma. 02655 . 3-19-12 - page. Cityrrown 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 No tee in tank • 611 Scum thickness Distance from top of scum to top of outlet tee or baffle No Tee Distance from bottom of scum to bottom of outlet tee or baffle No tee 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.): No tee, installed at time of inspection. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑.fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle, Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•11/10 r 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 50 East Osterville RD Property Address Erin Warren Owner Owner's Name information is Osterville Ma. 02655 3-19-12 required for every , page. Cityfrown - State Zip Code Date of Inspection D. System Information (cont.) , Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank should be service every year. 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.): r *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts ILI Title 5 Official Inspection Form ri Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 50 East Osterville RD Property Address Erin Warren Owner Owner's Name information is required for every Osterville Ma. 02655 3-19-12 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 None 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.): Soil Absorption System (SAS) (locateon site plan, excavation not required): If SAS not located, explain why: locaated, opened, pumped and cover raise to within 6" t5ins-11/10 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 50 East Osterville RD Property Address Erin Warren Owner Owner's Name information is Osterville Ma. 02655 3-19-12 " - required for every , page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) F Type: Z leaching pits number: ❑; t leaching chambers number: j ❑ leaching galleries number: " ❑ leaching trenches number, length: r ❑ 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.): None, leaching dry and clean. s 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 f Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments . s 50 East Osterville RD i Property Address Erin Warren Owner Owner's Name y information is required for every Osterville Ma.� 02655 3-19-12 page. Citylrown 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.): Leaching pit was up to 12 inches below the invert.. 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.): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 50 East Osterville RD Property Address Erin Warren s Owner Owner's Name t 7 information is required for every Osterville Ma. 02655 3-19-12 page. City/Town - State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 ' f �J u. �F r 7n Y Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 50 East Osterville RD Property Address Erin Warren z R Owner Owner's Name information is Osterville Ma. 02655 3-19-12 required for 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: 12' per prior report dated 3-4-04, hand auger found dry to 12 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: prior report ❑ Checked with local excavators, installers-(attach documentation) ❑ .Accessed USGS database-explain: You must describe c e how you established the high ground water elevation: Prior report 3-4-04 hand auger no water at 12' Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-11110 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 50 East Osterville RD - Property Address •Erin Warren t' ' Owner Owner's Name information is required for every Osterville Ma.- 02655 "3-19-12 page. Cityfrown 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 , W t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 :a COMMONWEALTH OF MASSACHUSETTS -" EXECUTIVE OFFICE OF ENVIRONMENTAL AF Z DEPARTMENT OF ENVIRONMENTAL PROTECTION MAP , 4 � W PARCEL F 5 o^M SVev LOP .._... TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A - CERTIFICATION iVED Property Address: 50 EAST OSTERVILLE ROAD OSTERVILLE,MA 02655 M122 P053 MAR 2 ?_.004 Owner's Name: PRENDERVILLE-YETMAN Owner's Address: 50 EAST OSTERVILLE ROAD OSTERVILLE,MA 02655 TOWN _oFABLE DEPT. Date of Inspection: 3/4/04 Name of Inspector: (please print) JOHN GRACI,INC. Company Name: SEPTIC INSPECTIONS Mailing Address: P.O. BOX 2119 TEATICKET,MA.02536 Telephone Number: 508-564-6813 FAX$08-564-7270 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 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 o, Title 5(310 CMR 15.000). The system: X Passes Conditionally Isses _ Needs Further aluation by the Local Approving Authority _ Fails 3 Inspector's Signature: ? �t Date: 3/4/04 The system inspector shall submit a copy this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If th 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. Notes and Comments SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. ****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. Title. 5 1ncnertinn Fnrm rill v?nnn 1 X. _�Pagd 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 50 EAST OSTERVILLE ROAD OSTERVILLE,MA 02655 M122 P053 Owner: PRENDERVILLE-YETMAN Date of Inspection: 3/4/04 r Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X 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: SYSTEM PASSED TITLE V INSPECTION.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. B. System Conditionally Passes: _ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined"please explain. n/a The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: n/a n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health):. broken pipe(s)are replaced _ obstruction is removed _ distribution box is leveled or replaced ND explain: n/a n/a The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): _broken pipe(s)are replaced _obstruction is removed ND explain: n/a Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 50 EAST OSTERVILLE ROAD OSTERVILLE,MA 02655 M122 P053 Owner: PRENDERVILLE-YETMAN Date of Inspection: 3/4/04 C. Further Evaluation is Required by the Board of Health: _ Conditions exist which require further evaluation by the.Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone I 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 detennine distance n/a "This system passes if the well water analysis,performed at a DEP certified laboratory, 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,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: n/a -Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 50 EAST OSTERVILLE ROAD OSTERVILLE,MA 02655 M122 P053 Owner: PRENDERVILLE-YETMAN Date of Inspection: 3/4/04 D. System Failure Criteria applicable to all systems: You miW indicate"yes"or"no"to each of the following for all-inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped Wa. X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,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,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] NO (Yes/No)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. 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) yes no X the system is within 400 feet of a surface drinking water supply _ X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well 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. d Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 50 EAST OSTERVILLE ROAD OSTERVILLE,MA 02655 M122 P053 Owner: PRENDERVILLE-YETMAN Date of Inspection: 3/4/04 Check if the followinghave been done.You "o must indicate yes or no as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health _ X Were any of the system components pumped out in the previous two weeks X _ Has the system received normal flows in the previous two week period ? _ X Have large volumes of water been introduced to the system recently or as part of this inspection? X Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out? X _ Were all system components,excluding the SAS, located on site? X _ 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? X _ 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: Yes no X _ Existing information. For example,a plan at the Board of Health. X _ 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(3)(b)] S f —Pa�e6ofII OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 50 EAST OSTERVILLE ROAD OSTERVILLE,MA 02655 M122 P053 Owner: PRENDERVILLE-YETMAN Date of Inspection: 3/4/04 RESIDENTIAL FLOW CONDITIONS Number of bedrooms(design): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):220 Number of current residents: 1 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if v-e zenarate inspection required] Laundry system inspected(yes or no): NO Seasonal use: (yes or no): NO Water meter readings, if available(last 2 years usage(gpd) Sump pump(yes or no): NO Last date of occupancy: n/a COMMERCIAL/INDUSTRIAL . Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or i Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a Pumping Records GENERAL INFORMATION Source of information: n/a Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: n/agallons--How was quantity pumped determined? n/a Reason for pumping: n/a TYPE OF SYSTEM X 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) _Tight tank Attach a copy of the DEP approval Other(describe): n/a Approximate age of all components,date installed(if known)and source of information: 1977 PER AGENT Were sewage odors detected when arriving at the site(yes or no): NO - � Page7ofII OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 50 EAST OSTERVILLE ROAD OSTERVILLE,MA 02655 M122 P053 Owner: PRENDERVILLE-YETMAN Date of Inspection: 314/04 BUILDING SEWER(locate on site plan) Depth below grade: 0" Materials of construction:_cast iron =40 PVC other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting,evidence of leakage,etc.): TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade:30" Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: L 8' 6" H 5' 7" W 4' 10"" Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 32" Scum thickness: 2" 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: n/a How were dimensions determined: MEASURED Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. GREASE TRAP:_(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): n/a 7 f `Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 50 EAST OSTERVILLE ROAD OSTERVILLE,MA 02655 M122 P053 Owner: PRENDERVILLE-YETMAN Date of Inspection: 3/4/04 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX:-(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: n/a Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): NO D-BOX PER AS.BUILT AT TOWN HALL. PUMP CHAMBER:_(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a R • `Pag'e*9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 50 EAST OSTERVILLE ROAD OSTERVILLE,MA 02655 M122 P053 Owner: PRENDERVILLE-YETMAN Date of Inspection: 3/4/04 SOIL ABSORPTION SYSTEM(SAS): X locate on site plan,excavation not required)( p � q ) If SAS not located explain why: n/a Type 1000 GAL 6' X 6' leaching pits, number: n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a innovative/alternative system Type/name of technology: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): LEACH PIT IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.SYSTEM SHOWS NO SIGNS OF FAILURE. BOTTOM IS AT 10 FT.THERE IS T OF LEACHING LEFT IN PIT. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer:n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a 4 Page 10 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 50 EAST OSTERVILLE ROAD OSTERVILLE,MA 02655 M122 P053 Owner: PRENDERVILLE-YETMAN - Date of Inspection: 3/4/04 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. . W _ J�l c in Page 11 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 50 EAST OSTERVILLE ROAD OSTERVILLE,MA 02655 M122 P053 Owner: PRENDERVILLE-YETMAN Date of Inspection: 3/4/04 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 12+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) NO Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: GROUNDWATER WAS DETERMINED BY HAND AUGER-NO WATER AT 12' t fi DATE ; 10/3/02 PROPERTY ADDRESS: 50 East Osterville Road --- Osterville ----------- Mass 02655 ------------------------ On the above date, I inspected the septic -system at the a ve ra Ed)es'VED This system consists of the following: 1 . 1 -1 000 ,gallon septic tank. OCT 10 2002 2 . 1 -1000 gallon precast leaching pit. ( 6 'X101.) TOWN OF BARNSTABLE HEALTH DEPT. Based on my inspection, I certify the following conditions: Z 3. This is a title five -septic system. ( 78 Code) 4 . The septic systems in proper working order at- the ' present time. ` 5. The leaching pit is presently dry. 6 . Very. little useage for the past two years. :SIGNATUR Name : J . P . Macomber Jr . Corhpa'ny: Joseeh _P,_ Macomber _& Son , . Inc . Address :--BQx-6�------------ _22 632-0.066 Phone 508- 775- 3338 THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY � I!I JOSEPH P. MACOMBER & SON, INC. Tanks-Cesspools-Leachflelds Pumped & Installed Town Sewer Connections P.O. Box Centerville, MA 02632-0066 775.3338 775.6412 , COMMONWEALTH OF "SACHUSE`I`TS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:50 East Osterville Road Osterville Ma 02655 Owner's Name: Shaun Pandit Owner's Address: samP Date of Inspection: 1 0 3 02 s Name of Inspector: (please print) Joseph P. Macomber Jr. Company Name: J.P. Macomber & Sons Inc Mailml; Address: BOX 66 . Cpntprvillp Ma 02632 . Telephone Number: 508-7.75-3338 . CERTIFICATION STATEMENT I certilj 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 Tatntng and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP approved system inspector pursuant to$eciion 15.340 of Title 5 (310 CMR 15.000). The system: asses YConditionallY Passes Needs Funher Evaluation by the Local Approving Authoriry Fails Inspector's Signature; r Date: �d O^dam The system inspector shall mit a copy of(his 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 now 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 authoriry. { Notes and Comments This report only describes conditions at the time of inspection and under the conditions of use at that G' time. This inspection does not address how the system will perform in. the future under.tbe same or different � conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 1 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 50 East Osterville Road Osteryille Ownershal Date of Inspection: 10 3 02 Inspection Summary; Check A,B,C,D or E/ALWAYS complete all of Sectioa D tfA. System Passes: l have not found any information which indicates that any of the failure criteria des cribed in 3 10 C 15.303 MR 3 3 or m 310 CMR 15.304„exist. Any failure criteria not evaluated are indicated below. Comments: —--u--F _�-- - -� `, .'`The septic system is in proper •working order-- at the present time B. System Conditionally Passes:' One or more system components as`described in the "Conditional Pass"section need to be replaced or repaired. The system,•u on completion P p of there lacement p or repair, as approved ed by the Bo ard of Health, will pass.. Answer yes, no or not determined (Y,N,ND) in the for the following statements. If"not determined"please explain. . A 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.inetal septic tank will pass inspection if it is Structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is-available. ND explain; ` Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board'of Health): broken pipe(s)are replaced obstruction is removed ND explain: 7. Page 3 of l l r OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:50 East Osterville Road Osterville owner: Shaun Pandit Date of inspection, 1 0/3/02 C, Further Evaluatio❑ is Required by the Board of Health: Conditions exist which require.funher evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. Svstem will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or,privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering,vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: �D 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. /(fQ The system has a septic tank and SAS and the SAS is within a Zone I of a public water supple. !�! >The system has aseptic tank and SAS and the SAS is within 50 feet of a private water supply well. Nv The.system'has.a septic tank and SAS and the SAS is less than 190 feet bul 50 feet or more from a private water suppl% well•': Method used to determine distance —This s\,stem passes if the well water analysis, performed at a DEP certified laboratory, 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, provided that no other failure criteria are rriggered. A copy of.the analysis must be attached to this form. 3. Other. ti ry 3 Page 4 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Addiress:50 •East Osterville Road Osterville _ . Owner: Shaun PAnrli t Date of Inspection:l 0/3/02 D. System Failure Criteria applicable to all systems;`' You must indicate "yes" or "no" to each of the following for all inspections: Yes �No ackup of sewage•inlo facility or system component due to overloaded or clogged SAS or cesspool i,1 Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static..liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool f >—xAlem) Aly iquid depth in-eesspeel is less than 6" below inven or available volume is less than '/, day now Reiquved pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _Q. .Any portion of the SAS, cesspool or privy is below high ground water elevation. Any ponion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. y portion of a cesspool or privy is within a Zone I of a public well // �n� portion of a cesspool or privy is within 50 feet of a private water supply well. _ - Any ponion of a cesspool or privy is Less than 100 feet but greater than 50 feet Erom a private water supply well with no acceptable water quality analysis. jTbis system passes if the well water analysts, pert,rmed at a DEP cenified laboratory, 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, provided that no other failure criteria aa are triggered. A copy of the analysis must be attached to this forma �U (Yes'No) The system fails.'I have determined that one or more of the above failure criteria exist as described in 310 CMR '1 5,303. 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 now of io,000 gpd to 15,000 Bpd•' 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) yes no _ e system is within 400 feet of a surface drinking'water supply system is within 200 feet of a tributary to a surface drinking water supply _ he system.is located in a nitrogen sensitive area (Interim Wellhead Protection Area - IV/?A) or a mapped Zone I I 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 i 5 304 The system owner should contact the appropriate regional office of the Department. q. ,page S of I . OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Properry Address: Road 0 Owner: Shaun Pa i t Date of Iospectioo: 1 0 Check if the following, have been done. You must indicate s" or-no" as to each of the following: Yes ant or Board of Health � the owner. occupant, -• _ �' Pumping tn(ormation was provided by P _Xere"ahv of the system components pumped out in the previous two weeks Has the system received normal flows in the previous two week period ? aye large volumes of water been introduced to the system recently or as part of this inspection Were as built plans of the system obtained and examined? (If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? _ was the site inspected for signs of break out Were all system componentsf 4cluding the SAS,,o ated 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 Yes n t/ Existing information. For example, a plan at the-Board of Health. _Y Determined in the field (if any of the failure criteria related to Pan C is at issue approximation of dis=cc is unacceptable) (310 CMR 15.302(3)(b)( Y 5 Page 6 of 1 1 . r OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM.INFORMATION Property Address:50 East Osterville Road Osterville rt , Owner: Shaun Pandit Date of Inspection: 1 0/3/0 2 FLOW CONDITIONS RESIDENTIAL, Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x'# of bedrooms)-& l)A = ,*xa eev Number of current residents: Does residence have a garbage grinder"(yes or no): 1 Is laundry on a separate sewage system ves or no):.W [if yes separate inspection required) Laundry system inspected(yes or no): Seasonal use: (yes or no): Water meter readings, if available (last 2 years usage (gpd))2 0 0 0-2 3 , 000 gallons=63 . 02 GPD Sump pump (yes or no): U_ 2001 —1 6, 000 gallons=43 . 84 GPD Last date of occupancy: - COMMERCIAL/WDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank- present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): /� Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: ye. Was system pumped as part of the inspection (yes or no): y If yes, volume pumped: gallons- How was quantity pumped determined? �(J� Reason for pumping: TYPg OF SYSTEM Septic tank, d+s��, soil absorption system eVSingle cesspool . /! Overflow cesspool ALO Privy, /QbShared system(yes or no)(if yes, attach previous-inspection records, if any) A�2 Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Linfight tank ADAttach a copy of the DEP approval Wither(describe): A��l App xim t aae of all cgrpponen date installed (if known).and,source of information: 2071) Were sewage odors detected when arriving at the site(yes or no): t� 6 Page 7 of 1 1 . OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:50 East Osterville Road Ost:erville Owner: Shaun Pandit Date of Inspection:J 0/3/02 ' BUILDING SEWER(locate on site plan) Depth below grade; /7 Materials of construction:,LJ cast iron IZ40 PVC,�j other(explain); d,1� Distance from private water supply well or suction line:/d Comments(on condition of joints, venting, evidence of leakage, etc.): Joints appear tight No evidence Of leakage Th.-_we_ sTcteM is vented througp the house vents. SEPTIC TANK; (locate on site plan) tl vo '9-* . . d' Depth below grade:. Material of construction: Y—concrete,e,�l meta LV�fberglass polyethylene ,JDther(explain) /J,h If tank is metal list age: D Is age confirmed by a Certificate of Compliance (yes or no): (attach a copy of certificate) Dimensions: ef � ;& Sludge dept ��J ' Distance from top�of. .lod,ge to bottom of outlet tee or baffle: �� Scum thickness; f Distance from top of scum to top of outlet tee or baffle: Distanee from bottom of scum to bottom oofputlet tee or baffle: How;were dimensions determined: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels ,as related-to outlet invert, evidence of.leakage, etc.): f Pump the -,Ppti n tank PyPry 2-3 Par—:77Tn1 Pt R niitl Pt tpps are in p l ace 'bhp tank is tuctur- I I sound. GREASE TRAP%h41 locate on site plan) Depth below grader Material of construction:A1 4concrete„ metalAfiberglassd&polyethylene.0�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' Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease trap is not present. 7 Page 8 of I I OFFICIAL. INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWACE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Propert1 Address:50 ast Ostervlle •Road Ostervi e Owner: Shaun Pandit Date of`lospectioo: j OZ3/02 a TICHT or `HOLDING TAN ,!�, (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of const-mc ion:Y14—concretc j�Lmet'al4/zLfiberglass&9 Polyethylene,&#other(explain) A1A Dimensions Capacity gallons Desien Floe- 164 gallons/day Alarm•preseht (yes or no): AI - arm level, Al arm �A arm in working order(yes or no): �/ , Date of last pumpin : g A4_ Comments (condition of alarm and float switches, etc.): Ticrht 'or holding tanks are not present. DISTRJBUTION BOX (if present must be opened)( ovate on site plan) Deptnrof liquid level above outlet invert: 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.): Distribution box is not present. Pl.''vtP CHAY8ER (loca(e on site plan) Pumps in working order (yes or.no): 4M Alarms in working order(yes or no):.-AA Comments (note condition of pump chamber, condition of pumps and appunenances, etc.): Pump chamber is no present,. 8 N S Page 9 of 1 1 I, OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 50 East Osterville Road Osterville Y Owner: Shaun Pandit Date of Inspection: 10/3/0 2 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required) 1 -1 nnn dal 1 nn p rPnact 1 Pal-hi ng pit „( A ' X1 n" ) if SAS not located explain why: Located See page 10 Typ leaching pits, number:� leaching chambers, number: leaching galleries;number: . leaching trenches,number, length: leaching fields, number, dimensions: overflow cesspool, number: ojV innovative/aliemative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation, etc.): ' Loamy sand to medium fin; sand-No -signs Qf hydraulic failure gr_pondi ng.Soi 1 s are dry. Vegetation iS nnrma1 The 1earhJ n l i t is presently �;dry at this time. 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: F Depth of scum laver: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or,no): Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): Q-sc;pnn1q arP not DrPSPnt PRIVY M:' _(locate on site plan) Materials of construction: Dimensions: Depth of solids: 111, Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy is not present. . • � Prdr Io or�I OFFICLAL INSPECTION FORM~ NOT FOR VOLLlNT SUBS URFnCE SSMF SEWACE DISPOSAL SYSTEM INSPECMONEFOFZ/.-1�,TS PART C SYSTEM INFORMATION (contlnvcd) a o9 rT) c 1 1 50 East Osterville Road O-off.Shaun Ya`n i 1 1 P �fic of lnlp,u oo:1 0737T2 S>C�TCN OP SCwnCE DISPO�nL SYSTEM P.o:,oc I ILtich of Inc Icwtic oilpolcl lyttfm Inclvding,ilcl l0 11 Itt71 fWp ' Qtn(r v /n1i:, L0 1,( III r�lll .run,n Ipp (tfl. L,Ccflf whflf public wfl(r toP p'rmtncm rcrcrcncc lLjc/nlIxI 0 P y cnlcfl'lhc bwiloinj 01 1 os. .2utpllnq ayi siawa Alddns iaiem otlgnd ajogm alm-1 Laaj 001 ul4ilm sham Ile mno-j -gnLULiouaq 10 s�{IMPLel aoualopi luouLmuQd oma Iseal IL, of saleBLnpnlaui WOISXs lesodsro aBemas ataL 10 uolaxs e aorAo1 r • Irk Page I I of I I 4/ OFFICIAL, FORM — NOT FOR VOLUNTARY ASSESSMENTS - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM.INFORMATION (continued) Property Address:50 East Osterville Road Osterville Owner: Shaun. Pandit. Date of Inspectional 0 L-3 02 - SITE EXAM Slope Surface water ' Check cellar Shallow wells Estimated depth to ground water feet Please indicate (check)all methods used to determine the high ground water elevation: NO • Obtained from system design plans on record - if checked, date of design plan reviewed: NA YRS Observed site(abutting property/observation hole within 15.0 feet of SAS) N.o—Checked with local Board of Health-explain: NA YES Checked with local excavators, installers- (attach documentation)- Accessed USGS database-explain: http: //town.barnstable,ma.us. You must describe,how you established the high ground water elevation: Jsed: Gahrety & Miller model. 12/16/94 Ground water elevations above sea level. Jsed; USES; Observation well data June 1992 Jesed;USG,qLTerhnJcAJ bulletin 92-0001 Plate #2 Annual ranges of ground water elevations. January 1992 Leaching Pit :eet Groundwater, Feet Below Bottom of Pit, High Crroundwater Adjustment 1.8 J ft per Fnmpter Method Therefore, the vertical separation distance between the bottom of the leaching pit and the adjusted groundwater table is J� feet. t`e w ► ti• -�a ' ` T'f'i— T'.t. .•ram, T�f.T'r'.Ti.T♦"'.T 1T:'TT\:.f�l �1i n'LT.Tc+..i" . . .. �.. _.TTTT'T� To' tl OF BARNSTABLE ilOARU OF HEALTH -- - SIl(fS�UItFACF 9EHA(,-E OIS(')S L SYSTEM IN�gf'FCTION FORM - PART D^- CEIZTIFICATIONr � - -TYPE OR PRINT CLEARLY- PROPERTY INSPECTED w STREET ADDRESS 50 East Osterville Road ASSESSORS MAP , BLOCK AND PARCEL # 122- 053 OWNER ' 9. NAME Shaun Pandit r PART D - CERTIFICATION NAME OF INSPECTORt Joseph P. Macomber Jr . COMPANY NAME Joseph P . Macomber vt6n. Inc COMPANY ADDRESS,, Box 66 Centerville Mass 02632 • Street Town or C1ty State t I P COMPANY TELEPHONE ( 508 ) 775-33-38 FAX ( 508 ) 790-1578 CERTIFICATION STATEMENT I certify that I have personall.y . inspected the sewage disposal system nt ff inthis nddress and '. that the information reported is true , accurate , and omplete as of the time of . inspection The inspection was performed and any % recommendations 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 ne System PASSED? The inspection which I '.have conducted .has not found any information which indicates that the system fails to adequately protect public heal01 or the environment as defined in 310 CMR 16 , 303 , Any failure criteria 'not•..,. evaluated are as stated .in the- -FAILURE CRITERIA section of this form, System FAILED# The inspection which I have c 'acted has found that the system fails to Protect Lhe public health and the. environment in accordance with Title 5 , 3.10 CMR• 15 - 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection f rm , Inspector 'Signature Date 11:94 � o7nbcQPY of th'i c t.ification must be . provided to the OWNER , the BUYER re appl-icab and the 130ARD OF 112ALT1{. * If the inspection FAILED , th'e, owner or `oparator shall upgrade the eyetem within one year oC the date of the inspection , unless allowed or required otherwise as provided in 310 CHR 15 , 305 , partd . doc TOWN OF BARNSTABLE I.00A_TTON�Jd �711 SEWAGE # VILLAGE 415/4^ti e iq25� ASSESSOR'S MAP & LOTOZ2. O53 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type), ` s (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: M1 Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and hing Facility If wetlands exist within 300 fe cili Feet Furnished b ii �wa livid ,.. �, -�:s._ iZ.ta✓ s� `��. �� i � l �3� �. l .z . _ .� . � --r` _ M�T V No..---.... lC.. Fps. ............... THE COMMONWEALTH OF MASSACHUSETTS BOARD Qf HEA OF.... ........................ ... .......... e:..------------. Appliratinn -fur Uhiv oat Norkii Tonitritrtion Vrrntit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System a J — .. xz - ..� 6-1��..................... .' - ----•• �------.......................__ 'Cocation-� % ss or Lot No. r '--^. .------'-------1- ��.L/......._1 --.......................... ............................ !C!�`.J.1 `?._- am :............................................ •-• ----- Owner Address ..._.t__.._..�/.-w............................sC_-_ ..................__ __..._.._.....__. .....__..._._.._.__........__. ...Vic -........... Installer / Address d Type of Building / Size Lot............................Sq. fe t U Dwelling—No. of Bedrooms.............. .._..._._ _ Expansion Attic ( ) Garbage Grinder ) �- ---------- aOther—Type of Building ............................ No. of persons.--------------------------- Showers ( ) — Cafeteria ( ) Otherfixtures ----• ___......--•----•.................•-------•---•----------•----......----------_-------•--------------------•--•... W Design Flow............... _........_....._.__ dions per person per day. Total daily flow.................. U._.�-..--.---gallons. WSeptic Tank—Liquid capacity?Ilons Length................ Width................ Diameter_..... Depth.-..-_--_.-.._.. x Disposal Trench—No_____________________ W• h.................... �° -ength-----------------_. To 'leaching area...... ft. Seepage Pit No. lam' D z l t J � � Tiat l=1e hin area--------- -------sc it. I e l c�t�l ij I Z Other Distribution box ( ) Dosing tank Percolation Test Results Performed by------- ---------------------------------------------------•---•-•-•••... Date.-------------------------- ------- Test Pit No. 1................minutes per inch Depth of "Pest Pit.................... Depth to ground water..-._.__-_--.--.--.--._. (_ Test Pit No. 2.__-_____-__-_minutes per inch Depth of Test Pit.................... Depth to ground water-_.----..--.--------.--- 04 ..... __ .. -----------------•-_.._-__--_-_--__--_---.---- 9 Description of Soil--- d!. �-.---_o... l - -- - ! x f � = - ' � U -- ----------- ----- --.........._..-. �' W ---------------------------------------------------------------------- ------------------------------------------ ------------------------------------------------------------------------------------- VNature of Repairs or Alterations—Answer when applicable------------------------------------.--------------------.-------------------------------------- ------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article NI 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 bo�aa,;d of health. Signe Al Date Application Approved By---- ` '' E� �E<� ------------------ -- --------•-- Date Application Disapproved for the following reasons:-------•-----------------------------------•----------------•---------------------•----------------------------- -----------••------------•------•----------------•--•----------------------------------------------------•--------------•-----------•----------------------------------------------------------------- Date \ Permit No......................................................... Issued...................... ................................. Date Jr kg � 4 P 'F } 1 o q •.`V.E ,� e?.r'., a r fit}. v. �t < r 9 �. k , ,t� ,� p►^ ,.5,//p r imp�,�.may /��ry It •9G. p7-/ T.+Q A!RWAIO&A.ICO: Ail .57 71E Q•t1 7'L!E = r :t" op a `LJp+�.��ayP9�6Rrv��-e�0 q,. 71i�V&�sp7 yDWA1 OAr��/ZnJS7/��C p`g91.QF° �•{ f��R�'A48'iA�7 er1�iM lin 7•��Yr/ b:w b,/. �(,p` ��^^Y r� {,��rppf�`' '� � i Of .. ®✓� �l�„f� P+ h. I•� 19�IYY� �.�A� -fir z. I No..........Z!l°-Z .............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OAF HEAL/T ........OF....../,)..... .............. .................... Apphration -for Elfitipofial Workii Tomarurtiou Vrruift Application is hereby made for a Permit to Construct ( ®r Repair an Individual Sewage Disposal System at, ............ ............. ... . ....... .......... . ......................... ... ....................... .................. .................................. ',-Location-A V11 or Lot No. r�,F .... ............................... nee-< ...... ................ ............................ ............../.......... ....Owner ddress ------_-------- ............................. ............................ --- ......... ............. ................................ ............ ....................... Installer Address PQ /,� Type of Building Size Lot-------------------- Sq. fee J Dwelling—No. of Bedrooms---------------e!5 X_..----------------------Expansion Attic Garbage Grinder ( ;14 Other—Type of Building ---------------------------- No. of persons.._......................._. Showers Cafeteria ( Other fixtures ------_,'J-7 -------------------------------------- ----------------------------------------------------------------------------- Design Flow................4_7 0 --------------gallons per person per day. Total daily flow_ .........gallons. ------------- 1:4 Septic Tank—Liquid capacity/6:7qallons Length_______________ Width............._.. Diameter........._:---._ Depth......_._._.... Disposal Trench—No. ................ ... W',d ---------------- Tgj.,;:�LLength........... Tot eaching area.......3.j��_.sq. ft. TO, ea ea -----------De, fbW,Seepage Pit No. 14�a �51iiiig Brea------------------sq. ft. Other Distribution box Dosino, tank Percolation Test Results Performed by.------------------------------------------------------------------------- Date............................. ---------- Test Pit No. I................minutes per inch Depth of Test Pit.-._--_-_-__-.____-. Depth to ground water.._._.-_-_-._.._-._.___- (_, Test Pit No. 2................minutes per inch Depth of Test Pit.__-----____.__---_. Depth to ground water--------------------_- ---------------- _1.........................----------------------------------------------------- /I...... Y------------------ 01 Description of S 'I--_----------- ----- .. - ------------------ Z ( ... ............................. -------------11 _-4-2------------- �.4� k --- U --- ---------------------7---------------------------------------------- W �r I -------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------- ....................... U Nature of Repairs or Alterations—Answer when applicable--------------------------------------------------------------- -------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------.......... ........... .............. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in �4 operation until a Certificate of Compliance has been issued by the board of health. Signe ------------ ................................ Date Application Approved By------- �e --------------- �/47_7/------------ Date Application Disapproved for the following reasons:e.'1_ ............................................................. .............................................. --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Date PermitNo.--------"'""'------------'-"------'.............•--""-_. Issued.----------------------- ............................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........ . ... OF.... ................... w.wrtifirate of OUNIntphattre- THI�, TO CERTIFY ThattWlndividual Sewage Disposal System constructed —_-)A�®r Repaired by..........f<1.... ............... ..................�;, ......................................................................................... ............................................................................. at------- ........ has been installed in accordance with the provisions of Articf-a XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit No---. ......... dated.-JC........ ............. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. . ..... ----- DIALTE..............71----------- --- -----/;��---------------- Inspector.C�HD \ .......................... THE COMMONWEALTH OF MASSACHUSETTS BOARD 017�y�i(/li..%� i'�/L"�. �HEALT 0 F.............. ................. ................................................. No... FEE... .......... ......... ........... Permission ish b ted---------- -------------------------------------------------9pre y gran 7-------------------------------------------------------------- to Construct or Repair an IndividTaff-Sew W-ISP050 gV, -y tem at No. i, L-- --------------------_---- . ... .......T",_----------------- ----------------------------------- ......................... Street as shown on the application for Disposal Works Construction Permi,'No._.__ ... -----------Dated----- 7e�............. ;--- ---------------- . . --------------- • ................... DATE........ 6_) — _74' e Board of Health' I/ ----------------------------------------------------------- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS