HomeMy WebLinkAbout0099 EAST OSTERVILLE ROAD - Health 99 East Osterville Road
Osterville
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No.
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THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
21pplicatlon for Disposal *pstrm Construction permit
Application for a Permit to Construct( ) Repair Grade( ) Abandon( ) ❑Complete System (L;�If ividual Components
Location Address or Lot No. C{C�, [— 0 �(�Vl\kf_ Owner's Name,Address,and,Tel.No. U,)p,,10t (�1Ca�Colrfl
Assessor's Map/Parcel f Ml Qq
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
Q%1A aP, w`!ca
6a -a
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building �� ���� No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S. _
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) O
° w )e q0,N
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not place the system in operation until a Certificate of
Compliance has been issued by this Board of Healt , /
Signe Date 5A, 41
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. 1 Date Issued
O�(� c TOWN OFBARNSTABLE
'LOCATION [ ` C' a STtry,I� ��•, SEWAGE#
VILLAGE O S i f ry,((L ASSESSOR'S MAP&PARCEL
INSTALLERS NAME&PHONE NO.
SEPTIC TANK CAPACITY /
LEACHING FACILITY:(type) P:7- (size) /
NO.OF BEDROOMS C —
OWNER b e ro r4
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
FURNISHED BY T-Ar gip^ �' For
A &(Jk
a
6
3 I�
i 3Y ay �
3 3c� 30
y y 3Y
77
LOCATION SEWAGE PERMIT NO.
lea
VILLAGE
� s'; Ile-
INSTALLER'S NAME & ADDRESS _
v �
JOS2 Old Stage Road
r!Fr..apvil e, Maas. 02632
B U I'L D E R OR OWNER
'e'L.•/,ve-- AEU-/
DATE TP ER MIT, ISSUED _/G_ 7T
DATE COMPLIANCE ISSUED 3_l✓�,. �
r-�
o
(� i
No. _ Q -i "r0� r Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes_�
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
0[pplication for VspoBaY'6pstem Construction J)Prmit
Application for a Permit to Construct( ) Repair(1--<Upgrade( ) Abandon( ) ❑Complete System tE;kITiidividual Components
Location Address or Lot No. qq Owner's Name,Address,and Tel.No. Uj0,jOC ftk_owr
Assessor's Map/Parcel r) q�
�w.� t
Installer's Name,Address,and Tel.No. t\ Designer's Name,Address,and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building \ �t ('C`�r C r.� No.of Persons Showers( ) Cafeteria(
)
f _
Other Fixtures
"- 'Desi"n'Flow irrm.re aired "`' x
d -_- Desi n flow-rovided . . .-- :_ - d.
g ( � 4 ) gp g.. P� . gp _.
Plan Date Number of sheets Revision Date
Title
Size of Septic"Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) P_i\ae � �C�i !,�'c�i(M� '1?�., yrgae
Date last inspected: `
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health ,
Signe 21116", Date
Application Approved by ,a Date / V
Application Disapproved by Date
for the following reasons
Permit No.2 pp�/ Date Issued
----------------------------------------------------------------------------------------------------------------------------------------
Th E COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
(Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired Upgraded( )
Abandoned( )by �.�C�:CZ�(1�5�(lf yy'n_- t, �ocx\e�-'
at V, V C�� ���1 has been constructed in accordance
`F with the provisions of Title 5 and the for Disposal System Construction Permit No. U Wdated
Installer Designer
#bedrooms a Approved design flow J / gpd
The issuance of this ermit shall not be 'o ed a guarantee that the system Il n"cf on as designed.
Date Inspector
._.,'
C/
No. / -d Fee �0
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Disposal *pstem Construction Permit
Permission is hereby granted to Construct( ) Repair( ) (�, Upgrade( ) Abandon( )
System located at GQ 0,A C\)0 k_ t^1
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must Ve completed within three years of the date of this permit. n
Date 3/ / L/ Approved by �_
R
Commonwealth of Massachusetts
-Nof 9.r.Vckutt" .
99 E Ostwvft rd
Property Aftess
W N181001 rt
Owner Ownwe true
intonnation is , Os bvvifle MA 02655 3-24-14 `
reauired.for every state zip code Data of Uspecdon_
pa". CityrfTown
Inspection,results must be.submitted on this form.Inspection forms"I"not be 81ho d in:any
way. Pfewe see(mripleftness checklist at the endof the fon".
kni,�men A. CNenmlInfonm—Ion
on"oorwftr,
use only the tab
1. Inspector: I
key to move your
cursor-do not Michael DiBuono
use the return Nam of inspector
key. NEIGHBORHOOD WASTE WATER SERVICES
Company Nam
.350 MAIN STREET
W.YARMOUTH MA73
CtiylTcwn Zp Code
508-775-2820 S113522
Telephone Plumber License Number
B. Ceon
t ::that.l have person ly inspected ft sewap diop�SYSWM at tttls ci that;the
belly is true,ac r e artd ,ae O tfo tM%l i-4 .
d based on my b.ainmg and m the p � '.
o frt sits
Sowgige di1 systems. i awa-DEP approve system irr POOP"
Titfe.5:t310 Cilia 1&900} The system:
❑ Passes Condffamlly Passes ❑` FOs
Further Evalva0vn by f#te Local APPwin9 Rat Weeds
0=412014
s Date
to shall submit a of this unction report tO the {#hoard
The system spe�or
of Health or DEP)within 30 days of .If:ttte a eye
has a.dssign flaw of 40,IX or gfealier,the-It�specor:2td tip s cif s
the
eft. oi ;of tip DEP.The 3�es tbltem
and s W.the buyer,d the OPP awl►
. :' is
6 /I
Two 5Pagel of,7
3113
Commonwealth of Massachusetts
Title 5 Off c al I , #�O Form
S ,
99 E Osterville rd
PmpaAyAddress
Malcolm
Owner Ownees Who
iniomut ri is o�rvu� MA 02I 55 3-24-14
everymgwred for every y� ap� take. of Irspedon
Pap. Citown
a. Celt ice'tion (cunt.)
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:
The system consists of a one thousand gallon concrete septic tank.a concrete distribution box that is
Rotted and no loner working properly The system will pass on the condition the D Box and lines
exitinq the tank are replaced with new pvc. as the Ift weight pipe is crushed•
B) System CondWanaliy Passes:
® one or more,system components as described in the"CondiftrH t loss"section need to be
replaced or repaired.The system, upon completion of the replacement orrepair,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. tf"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 infikration or exftation or tank failm.is.kmmiftent.System witi
PM
inspection if the existing.tank is replaced.with a complyling s tic `by of
Health:
*A metal septic tank will pass inspection if it is structurally sound, not Waking.and if a Cerfafjcate of
Compliance indicating that the tank is less than 20 years old is available.
below):
El Y ❑ N ❑ ND(Explain )
The system consists of a one thousand gallon concrete septic tank.a concrete diction lox.that is
Rotted and no loner working properly The system VAR pass on the condition the I)Box and lines
exiting the tank are replaced with new pvc as the lite.weight pipe is:crushed•
Title 5 oftal kgwcbm Form:SWmWft*Sewage Dwposal Systern•Page 2 of 17
t5ins•W 3
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
99 E Osterville rd
Property Address
Wayne Malcolm
Owner Owner's Name
information is MA 02655 3-24-14 .
required for every Ostervllle state LP Code Dale of Inspeciion
per• -cityfTown
B. Cettifiil+aftn (Cunt.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes(cunt.):
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 C3 ND(Explain below):
distribution'box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
The system consists of a one thousand gallon concrete septic tank. a concrete distribution box that is
Rotted and no loner working properly The system will pass on the condition the D Box and lines
exiting the tank are replaced with new pvc as the life weight pipe is crushed.
❑ The system required pumping more than 4 times a year due to broken or° ppe{s}:Theobstructed
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ 0 ❑ ND(Explalin below):
❑ obstruction is removed ❑ Y ❑ N 0 NO(E)pain below
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in or?der to determine if
the system is failing to protect public health,safety or the environment:
1. System wW pass unless Board of Heath deb.nm0nes in,arm 3"-CMR
15.393(1)(b).*A`the system is not tuned In a t o public beabh,
sa y and�a�tvkomwelt:
❑ Cesspool or privy is within 50 feet of a sur bm Water
❑ Cesspool or privy is within W feet of I borderirq or a salt marsh
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Commonwealth of Massachusetts
Title 5 Official- Inspection' ,Form Y
Subsurface Sewage Deposal System Form-.Not for Voluntary Assessments
99 E Osterville rd
property Address
Wayne Malcolm
Owner owner's Name .
information is Osterville MA C=5 3-24-14.
required for every stagy Z Coda Date of ir�pecWn
page- City/Town
B. Certification (cont.) a
Yes . . No a
Required pumping more than 4 times in the.last year NOT due to dogged or
i E] ®` 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 pri ry 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.
0 , ® Any portion of a cesspool or privy is lessthan,100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
,7 system pauses if the wag water analysis,performed at a DEP certified
laboratory,for fecal colg'orm.bacteria indicates absent and the presence
of ammonia nitrogen and nftrate nitrogen Is earl 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-1
O ® The system is a cesspool senvin9 a facility with a design flow of 2000gpd-
10,000gpd.
. ® The system fg' .1 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.
To be considered a large system.the"SUM MAW;gem a facf�l`via a
E) LargeSfFstetw: ,
design am of 10,000 gpd to 1S,W 9P&
For large systems,you must indicate either"yes".or."no"to.each of the fat wing,in addition to the
questions in Section D:
Yes No r
r ❑ the system is within 400 feet of a surface.drinking.water supply
❑ Elthe system is within 200 feet of a tributary to,a surface drinking,water supply
.the system is located in a nitrogen sensitive area(interim.WeRie d Protection
h _ Area-IWPA)or a mapped'Zone 11 of a.public water supply well
0 you have answered"yes"to any question in gr►�can#Section E the system is considered a s't threat,
or answered"yes'in Section D above the large sys n.has hood.The owner or operalor,of any age
system considered a soocant.threat under Section E or hood wWerSecWn D shalt upgrade the
system in.accordance with 310 CMR 15.304.The system ouorcer sib the Wit.
regional offrce of the D
�..y{3
7t5a 5 U1BFje1 ti5pecdon 4rtn$uCe+feo® Q •�.5 of 17
Commonwealth of Massachusetts
Title 5 Official. Inspection Form
Sttbswfam Sewage Sysom Foy-Not for Vokmtary Assessments
99 E Osferville rd
Property Address
Wayne Malcolm
Owner owner's Narne
inforrnstion is O MA 02665 3-24-14
required for every Ctyrrown State ZIP Code Date of loon
page.
C. Checklist
Check if the following have been done.You must indicate"yes"or"no'as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner,occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ Has the system received normal flows in the previous two week period?
Have large volumes of water been introduced to the system ray or as part of
❑ this inspection?-
Were as built plans.of the system obtained and examined?(If they were not
® ❑ available note as NSA)
® ❑ Was the faality 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 she?
® ❑ 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 soon?
❑ Was the faciiity.o r(and occupants if deferent ft owner).provided with
information on the proper maintenance of subsurface sewage.dual systems?
The size a"kick Of 019.301t AbsOrPUM Systerri`# ) n;the site.has
been determhied based on:
® ❑ Existing information. For example, a plan.at.the Board of Health.
❑ ❑ Determined:in the field(if any of the fa ce.c,ail3ena h**ed to Part C is at issue
apprownabon.of die is amble)1.3f0 CMR't5 302(5)j
D. System lnf nnatian
Reeklential Flow Condidom:
2 2
Number of bedrooms(design): Number of.bedrooms(actual):
DESIGN flow based on 310 CHAR 15.203(for example: 1%gpd x#of bedrooms):
220
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c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsuftce Sewage Disposal systern Form Not for voluntary dents
99 E OsWvflla rd
PmperlY Addran
Wayne MaWm
Owner owner's Marry
information is Ostenrille MA 02655 3-24-14
requited for every page- Cityfrown State Zip Code Daleof Inspection
D. System Information (cont.)
Occupied
Last data of occupancyluse: .
ONtar(describe below):
The system consists of a one thousand gallon concrete septic tank,a cone distribution
box that is Rotted and no loner working properly The system will pass on the condition the D
Box and lines exiting the tank are replaced with new pvc as the lite weight pipe is crushed.
General Information .
Pumping Records:
Sauce of information:
Was system pumped as part of the inspection? ❑ Yes ® No
if yes,volume pumped: SaW=
How was quantity pumped determined?
Reason for pumping: .
Type of System:
® Septic tank, distribution cox;soil absorption system
❑ single cesspool
❑ Overriow cesspool
❑ Privy
❑ shared system(yes or no)(if yes,attach previousDinspeCtion records, if any)
❑ lnnovative/Altemative technology.Attach a copy of the c urent operation and
maintenance contract(W be Wined from system ow*):a-War War copy of latest
inspection of the UAc system by system qm*v under
❑ Tom#tank.Attach a copy of the M:P iral.
❑ Other(describe):
tSetis•3f13 To 5 oftW kWpgCWn Faux&bad— System•Pqp 8 d 17
Commonwealth of Massachusetts
Title 5 official kn: on Fob
Subsurface Sewage Disposal Systein Form-Not for Volunthry Asset
99 E Osterville rd
W Malcolm
owner owners Name
Wortnation is Osterville MA 02655 3-24-14
required for every city/rown State Zip Code DaW of krapection
page
D. System information (cost.)
Approximate age of all components,date installed(if known)and source of information:
38 years
Were sewage odors detected when arriving at the site? ❑ Yes 0 No
Building Sewer(locate on site plan):
.24"
Depth below grade:
Material,of construction-,
Q cast iron 40 PVC O'other(explain): r
10+
well r suction line: -
to water sup
ply we o
' a
Distance from PP y
private
Comments(on condition of joints,venting,evidence of leakage,etc.):
The system consists of a one thousand<galbn.OXWOW tw a OWX=W. .disb*utlon box that-is
Rotted and no loner working.proPerty'The sum wi �the the D Box and lines
exitim.the tank are
with new pWas the tee: is
Septic Tank(locate on site plan):
Depth below grade:
Material of construction:
Opolyeqv 0 other(explain).
If tank is metal,list,age
Is age contid# ►a of Compere?'( avy ? Fes [# tic
1fl�kt '+
Dimensions:
Sludge.depth
Title 5o MaN",edm Faa:S os Sam ^FegB 9 d 17
twm•W3
commonwealth of Massachusetts
'Title 5 Official Ina ctio n Form
u� e F -Not for Vokm ry Assessor tts
99 E Osterville rd
h¢ "a
Jayne Malcolm =
Owner Oates Nta<rts
n is tViA tY2655 3-2414
age- C�RownOsterville
State Zip Code Pate of inspection
D. System tnfofmation (com.)
Seic Tank(cont),
Distance from top of sludge to bottom of outlet*--.or baff
Vt
Scum thickness 4
Distance from top of scum to top of outlet tee or baffle .
- J
' Distance from bottom of scum
to bottom of outlet tee or baffle
How.were diimenslm detemdrod?
Comments(on pumping ,iniet an d outlet tse bafe.pmWition, structural integrity,
liquid levels as reiaW to outlet invert,evklenceof Vie,etc.): R
The system consists of a one thousand.gallon.�septic tank a dish box that is
Robed and no loner working properly'Elie system will.pass..on the zonNon the D Box and line
exiting the tank are replaced with new pvc as tare tree pipe is crushed:
e Timp'(ke on
a Eft below 9ra +� feet
Material of construction:
a
y
Dry from boftm of Scum to baftm of OuWA":.orI.beft
d.
t5*-3H3 €7N6.Ei IB RE 8S�6 990.11, Pap- 09f t7
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface gewage Oftposal System Foan-Not for Voluntary Assessments
99 E Owe ni
Pmp&V Add
Wayne Malcolm
owner Orbs Narrie
informations le MA 02655 3-24-14
required for every
Pa9®• cKyrrown
State Zip code Date of inspection
D. System Information (cons.)
Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity,
liquid gels as related to outlet invert,evidence of.leakage,etc.):
The system consists of a one thousand gallon concrete septic tank.a concrete distribution box that is
Rotted and no loner working properly The system will pass on the condition the D Box and lines
exiting the tank are replaced with new pvc as the life weight pipe is crushed.
Tight or Holding Tank(tank must be pumped at time,of insPection)(locate on site plan):
Depth below grader
Material of construction:
❑concrete ❑metal ❑fiberglass ❑polyethylene ❑other(explain):
Dimensions:
Capacity: yaaons
Design Flow.
gallorss per day
Alarm present ❑ Yes ❑ No
Alarm level: Alarm in waiang.or+da: ❑ Yes. ❑ No
Date of fast pumping: Daft
Comments(condition of alarm and fiat qwitches,etc.):
•Attach copy of current pumping contract(required). Is copy a >ed? ❑ Yes ❑ No
TINS oadd kmacd=Fam s6.reoa.SmW DW=d sotsm-POW»or 17
65he•3H3
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface sewage Disposal System Fob-Plot.fbr Voluntary Assessments
99 E Osterville rd
PmpertyAddrew
Wayne Malcoh
Owner OwrWe Name
inrormation Is Osterville AAA 02655 3-24-14
required for every State Zip Code Date of insp�ion
Pa"_
Citylrown
D. system information (cunt.)
Distribution Box(if present must be opened)(lode on site plan):
Depth of liquid level above outlet invert
Rotted and needs racing
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.):
The system consists of a.one thousand gallon concrete septic tank.a concrete.distribution box that is
Rotted and no loner working.properly The system will pass on the condition the D Box and lines
exiting the tank are replaced with new pvc as the lite weight pipe is crushed.
Pump Chamber(lode on site plan):
Pumps in working order. ❑ Yes ❑ Pam*
Alarms in working order. ❑ Yes ❑ W
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.
Soh Absorption System(SAS)(knate on site plan,excavation not required):
If SAS not located,explain why:
T00 5 WcJel; Fan¢S*WJ� 8W Sew.Dhp"d Sydm•Pap 12 OW
On•9M8
Commonwealth of Massachuset#s
Title .5 Official inspection Form
gate gem Dispoe w sy rt ft m-Not for Voluntary Assessmeift
99E .stervillerd
Wayne MOWM
owner owners Name
infomation is AAA 02655 3-24-14
required for every CiiyO State Zip Code Date of tnspe�On
per-
frown
D. Systwn lnformation (cunt)
TYe:
0 Ong Pits
number: 1
11 leaching chambers number.
hiching galleries number.
❑ leaching trenches number, length:
overflow CWSPOOI number
Q innovative/ ve system
Typeinameof technology.
Cutts,.(note condition of soil,sue.of h rc; ,: .
vegetation,etc.):
:(cesopool must be.purnpW as.PQd..
Depth-"of N,Wjd to.4M. invert
Depth,ofedids layer,
Depthetscumlaw
crf g nd rice► 0 vim. C-
,�„•aMa
Commonwealth of Massachusetts
Title 5 Official Inspection. Form
8ubmfbm Swr- a D".SYSWM Fwm-W for voluntary asses
99 f 0sWville rd
ProperV.A*Tess
Wayne Malcolm
Owner Owner's Name
information is MA �Z6,55 3-24-14
required for every 1e dityrrownS3afe Zip code Date orinspecUon
PW-
D. System Information (cunt.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of motion,
The system consists of a one thousand gallon concrete Septle tank a concrete di on box,that is
Rotted and no loner working Property The system will pass on the condition the D lox and lines
exiting the tank are replaced with new pvc as the Cite weight pipe is crushed.
Privy(locate on site plan)..
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic f;kik.x%Orel of.pon.0_g, c v lion,
.. . . _
7WSoffi" epeeYas£W=abbvita=Sorege. $�►`peP 4
f5trm•3H3
Commonwealth of Massachusetts
Title 5 Official IMspection Form
Su*mwfte UwW Disposal Syeftm Form-Not for Voluntary Assessments
99 E Osterville rd
Propedy Adi s
VVayne Malcolm
owler s Name
inforrnadonis MA 02655 3-24-14
required for every COsbNllle
page- Smote Zip Code Date of Impaction
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at lest two permanent reference landmarks or benchmarks. Locate @A 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
a
t5bu•913 Tkle 5 I Y pn Forstt SybarIfeoe 3arage.0ispoaeYSysOen•R sqe 15 d 17
> ill
i
J
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-:mumps
-vrmoo tE
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Commonwealth of Massachusetts
Title 5. Official inspection Form .
Sub surbee;S +.Fom-Not for Voluntary Assessments
99 E Osterville rd
PMpft
Wayne Malcolm
owner Owner's tie
Mmmadon is MA 02M5 3-24-14
mquired for wary 4 state zlo code came of
D. System Infomation (cunt.)
Ske mot:
® Crack Slope
® Surface wader
Check cellar
® Shallots►Wells
27
dp�tp high grounds
the h h d water elevation:
Please indicate all methods Used-to determine cg 9roun
. Obtained from system design pins on record
If checked,date of design plan reviewed: Date
Q Observed site(abMng property/ We within 1.50 t of SAS)
Checked with:local Board of HeaNh-explain:
0 Checked with local excavators, installers-(attach docurr n)
Q Accessed tJSCS database-a x am:
You.aluM Abe how you established the:hio VowW,water
Lumbert pond is at elevation 23 g922Eft to uses maQ 1978 E Oil rod 9 4 `40
uft Please us ` 'evk page.
rwse►r :r«� ,.,,,.... .as ea•o+�sr�•Peos.+aat�
N Commonwealth of Massachusetts
Title 5 Official inSCO- FQ
SuFa - WV
88 E der ift rd.
Property►Adams
MalcolmWavne
owner Owners Name
information is Ostervilie NIA 02655 3-24-14
required for every t
/Town State Zip Code Date ofnapecdon
POW
E. Report CoMpleWnOSS Checkist
® Inspection Summary:A, B, C, D,or E checked
® Inspection Summary D(System Failure Criteria Applicable to AA Systems}completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
Tile s oPww*q*cYon Fwm StOWzft=-GOMWVApQsetSyftn'Pao 17 of 17
Isms•3M3
' COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIROhIMENTAL PROTECTION
TITLE-5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE,SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
_ Property
p y Address: 99 East Osterville Road
Osterville. MA 02655
Owners Name os
: Karen DeRa
Owners Address:. 460 Main Street
Charlestown tYIA 02129 c�—�i '
'7
Date of Inspection October 26 2007 e
Name of Inspector:(Please Print) James M. Ford. ','
Company Name: James M.Ford
Mailing Address: P.O.Box 49
CD
0stervi11e.11MA 02655;0049
Telephone Number: & 0 862-9400
CERTIFICATION STATEMENT
L certify that T 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 theproper.,function and maintenance of on site sew
age'disposal systgms. I am a DEP
approvedaystem inspector pursuant to Section,15.340 of Title 5(310 CMR 15:0.00): The system:
Pass
Go di ionally.P.asses-
Ne ds Further Evaluation by the Local Approving Authority
Fai s
Inspector's Signature:
Date: November 2. 2007
The system inspector shall sub a copy of this inspection_report to.the Approving Authority(Board of Health or,
DEP).within 30 days of completingahis inspection. If the system is asharedaystem 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
DER The original should be sent`to the system owner and copies sent to the buyer,if applicable;andahe approving
authority:
Notes and Cotmnents
****This report.only.describes conditions:at the time of inspection and under the conditions of use at that
U9
time. This inspection does not address how the system`wll perform in the future under the same or different
conditions of use.:`
Title 5 Inspection Form 611.5/2000 ' page I
Page 2 of 11 .
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued):
Property Address: 99 East Osterville Road
Osterville MA "
Owner's.Name: Karen DeRosa
Date of Inspection: October 26 2007
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 in310 CMR.15.304.exist. Any failure criteria not evaluated are indicated below.
Comments
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.
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:
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:
2
,
Page 3 of 11
OFFICIAL.INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE`SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 99 East Osterville Road
Osterville MA
Owner's Name: Karen DeRosa
Date of.Inspection:. October 26.2007
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 aseptic 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..
tank
The system has a.se tic
— p- 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
**Thin system passes,if the.viwell water analysis,performed at a DEP certified laboratory, for coliform
bacteria-and volatile organic compounds indicates that the well is free 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 farm:
3. Other:
3
Page 4.of 11
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM
'PART A
CERTIFICATION (continued) .
Property Address• 99 Easi Osterville Road
Osterville MA
Owner's Name; Karen DeRosa
Date of.Inspection: ._ October 26 2007
D. System Failure Criteria applicable to alLsystems:
You must indicate either"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 in or available'volume is less than''/Z day flow
✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).: Number
of times pumped_
✓ Any portion of the SAS,cesspool or privy is below high groundwater elevation.
✓ Any portion of cesspool or.privy is within.100 feet of a surface water supply or tributary to a surface
water supply:
✓ Any portion of a cesspool or.privy is within a Zone 1 of a.public.well. .
°✓ Any,pbrtion of a cesspool or privy is within'50 feet of a private water supply well.
✓ Any portion of a cesspool or privy is Iess than 100 feet but greater than SO 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 farm.]
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 System:.
To be considered a large system the system musbserve a facility witha 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
_ 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 pitrogen 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.
Page 5`of 11
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
T~ SUBSURFACE SEWAGE DISPOSAL''SYSTEM INSPECTION FORM'
PART B
CHECKLIST '
Property Address: 99 East'Osterville Road`'
Ostvr ille ILIA'
Owner's Name: Karen be Rosa
Date of Inspection: October 26.2007`
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
r.
✓ Were any of the system components pumped out in the previous two weeks
Has the system received normalMflows in the previous two week period
✓ Have;iarge volumes of water been introduced to the system recently or as part of this inspection
Were as built pldns 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, .A
;'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 7
Was the'facility owner,(and.oecupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems? '
The size and location of the Soil Absorpnon_System(SAS)on the.site has been determined based on:
Yes w No f
t
Existing information. For example,a plan at the Board of Health.
= ,Determined in the field(if any of-the failure criteria related to Part{Cis at issue approzitnation of distance
is unacceptable)[310 C*.15.3b2(3)(b)]. `
5
Page 6`of 11 :
OFFICIAL INSPECTION FORM-.NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIONFORM
Y.
PART C
SYSTEM INFORMATION
Property Address: . 99 East Osterville Road
Osterville MA
Owner's Name: 'Karen DeRosa
Date of Inspection: October 26 2007
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual): 2
DESIGN:flow based on 310 C1VIR 1.5;203_(for example: 1410 gpd x#Hof bedrooms): ' 330
Number of current residents: 0
Does residence have a garbage grinder,{yes or`no): n/a 4,
Is laundry on a separate sewage system(yes or-no): n/a [if yes separate 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)):` Unavailable
Sump Pump(yes or no): No
Last date of occupancy: Unknown
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203) apd
Basis of design flow(seats/persons/sgft;etc.);
Grease trap present(yes or no); g`
Industrial waste holding tank.present(yes or no)
�.
Non-sariitary.waste discharged to the,Title 5 systerri(yes or no):
Water meter readings-,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL':INFORMATION
Pumping'.Records
Source of information: Unavailable `
Was system pumped as part of the inspection(yes or no): No
If yes;volume pumped: gallons--How was quantity pumped determined
Reason for pumping:
TYPE.:OF SYSTEM
Septic tank,distribution box,soil absoiptiori system
Single,cesspooL
rOverflow cesspool '
Privy, n.
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'(io be
J`~ obtained from system owner),
Tight Tank Attach a copy of the DEP approval`'
Other(describdd
e):
..
Approximate age'of all components, date installed(if known)and source of information:
Installed on 3115178-Per as built card
Were sewage odors detected when arriving at the site(yes or no):, No
- l
6
Page 7 of 11
OFFICIAL INSPECTION FORM-NOT FOR"VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL" SYSTEM`INSPECTION FORM' '
PART C '
SYSTEM INFORMATION.(continued)
Property Address: 99 East Osterville Road
Osterville MA
Owner's Name: Karen&Posa
Date,of.Inspection:. October 26 2607 "
BUILDING SEWER(locate on.site plan)
Depth below grade:
Materials of construction: _cast iron _4o PVC _other(explain):
Distance-from private water-supply well oiwction line:
Comrrients(on condition of joints,venting,evidence of.leakage,,etc.): _.
SEPTIC-TANK: ✓ (locate on site plan)`-
Depth below grade: Ig„
material°of construction: ✓ concrete __2netal_fiberglass _polyethylene
_other;(explain)
If tank is metal list age: Is age-con fined by a'Certificate'of Compliance(yes or no):" (attach a copy of
certificate)
Dimensions: IOOO Qal.
Sludge depth: 2„
Distance from top of sludge to bottom of outlet fee or baffle:
Scum thickness: 1"
Distance from top of scum to:top of outlet tee or baffle: 6"
Distance r,om bottom of scum to"bottom of outlet tee or baffle:` 1011
How were dimensions determined: Measuring stick
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to.outlet invert, evidence of leakage,etc:): .
Cement tees were L7reseht. The li uid level was.even with the outlet invert. There did not a ear to be an si ns o leaka'e. .
GREASE TRAP. None (locate on site plan).
Depth below grade:
Material of construction: _concrete _metal _fiber`glass =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:
Comments(on'pumping recommendations,inlet and outlet tee or baffle condition,structural,integrity,.iiquid levels
as related to outlet invert;:evidence of leakage,etc.):
Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 99 East Osterville Road
Osterville MA
Owner's Name: :Karen DeRosa
Date of Inspection: October 25-2007
TIGHT'or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on ite plan)
Depth below grade:
Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain):
Dimensions:
Capacity: aallons
Design Flow: allons/day.
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.);
DISTRIBUTION BOX:.. ✓ (if present must be opened)(locate on site plan)
Depth of liquid level above outlet.invert: ..Level
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.): "
The'D-box was in normal condition. No solids were 12resent
PUMP CHAMBER: 'None locate on site plan'
( p )
Pumps in working.order(yes or no):
Alarms in working order(yes or no)
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): .
fi...
8
Page 9 of 11
OFFICIAL INSPECTION•FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
.PART C
SYSTEM INFORMATION(continued)
Property Address: .99 East Osterville Road
Osterville MA
Owner's Name: Karen DeRosa
Date of Inspections October 26 2007 fl
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
✓ leaching pits,number: I -6'x 6;(1000 gal.).
leaching chambers,number:
leaching`galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions: ...
overflow:cesspool,number:
Innovative/alternative system Type/name:of technology:
Comments(note condition of soil,signs of.hy
etc.). draulic.failure;level of ponding;damp soil,condition of vegetation,
The pit was. ry, The scum line was 1'un-from the bottom. The cover was 3'6"below rade. The bottom to grade was 10'6".
There did not a ear to be any si ns o ;ailure.>Recommend installin risers.
CESSPOOLS: None (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;. k .
Indication of groundwater inflow
`(yes or no):
Comments (note`condition ofsoil, signs of hydraulic failure; level ofponding, condition of vegetation,etc.):
PRIVY: None` (locateon'siteplan)
Materials of construction:
Dimensions;
Depth of solids:
Continents(note:condition of soil signs of hydraulic failure,level of pondirig,condition-of vegetation,etc.):
9
• Page 10 of.1 l
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
x SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECT I0
N FORM
PART C
SYSTEM INFORMATION(continued)
Property Addressc: 99 East Osterville`Road
Osterville.. LIA:
.,Owner's.Name: Karen L)8osa
-Date-of Inspection: . . October 26. 2007
` SKE ,TCROF 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.
�4 1�3A�.,1� a •
y
a 3� ag
y y 3y -
io
. . Page 11 of, l l
OFFICIAL INSPECTION.FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE'DISPOSAL.SYSTEM INSPECTION FORM
PART C '
SYSTEM INFORMATION(continued)
Property Address: 99 East Osterville Road
Osterville,`MA
Owner's Name: Karen DeRosa
Date.of Inspection: October 26, 2007
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water. 40+Y feet'
Please indicate(check)all methods used to determine the high ground water elevation:. .
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain: Topographic and water contours maps
Checked with local excavators,:installers-.(attach documentation)'.
Accessed USGS database-explain,:
'You must describe how you established the.high ground water elevation: .
Using Barnstable topographic and water'contours'niatis the maps were showing approximately 40'+/ to groundwater at this
site.
y
G
This report.has been prepared only for the septic system and components described herein. 'This septic system has been
inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will
function properly in the future. There.have been no warranties or guarantees,either expressed,written or implied,
relating to the septic system, the' inspection, this report and/or any components of the septic system which have not
been located and inspected:
x
11
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ridrl�( FLOW = Itb -4 3 = 330 6.p.D. /p0
330,e 15c % - 4-95 6.P.D.
USte- 1000 GALL .
.,7 MGU/ALL AV-EA = (50 S.P.
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD Off'.. H�E�AT.
_L%,Vk . .......OF....... .................. -- --------------------------------------------
Aliptiration for Dig pasal Works Tonstrurtion Famit
Application is hereby made for a Permit to Construct (4-1--or Repair an Individual Sewage 'Disposal
Sys!29 a$/
�1
..X.7.11.1.......................... . ...... . ....e .............. ......................................
....... .......................................
L:t' ddress or Lot
....... - ............................................................ ..... . ...........-
.............. N,
j,
,
-- -- .....
.0A-1-------------------------------- ---------- A..
............
AW;res;
... ......... ..........................................
Installer Address
.Type o g of Size Lot... ......Sq. feet
U
Dwelling—No. of Bedrooms.........1,
.................................Expansion Attic Garbage Grinder
Other—Type of Building ............................ No. of persons._.___.____.___.._._..____.. Showers Cafeteria
Otherfixtures ------- .............................................................................................................................
Design Flow..........-�7_0........................gallons per person per day. Total daily flow.................A.A.0................gallons.
04 Septic Tank—Liquid capacity/ g-allons Length________________ Width___________.____ Diameter________________ Depth____________....
Disposal Trench—No_ .................... idth.................... T_ptal Length._____._____./__ T4al leaching area--------------------sq. f t.
Seepage Pit No..__. ............._a4"ewf otal leaching area.....30.2_sq. ft.
Z Other Distribution boxDosing tank ( ) .01R, le/,;-&- 12- f- 7 7
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I......4!7__.minutes per inch Depth of Test Pit____________________ Depth to ground water..___.____________...__.
r3, Test Pit No. 2................minutes per inch Depth of Test Pit__-____.___-________ Depth to ground water...___..._..__.__._._...
..........- --- ------------------- ---------------------- 7-------- ............7.............*... . .... ..7
CS . .......
0 Description of Soil---___ -�- ----- . ........ A..........
x _j"141
U ........................................................................................................................................................................................................
........................................................................................................................................................................................................
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 TJIT�U 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the hoard of health.
igne .
Ag ....... ..... ... ............... ..... .4�
ate
Application Approved By ..... . ................ ...... -------Z.Z.
Date
Application Disapproved for the following reasons:...............................................................................................................
.........................................................................................................................................................................................................
as 7
PermitNo......................................................... Issued........................................Date............
O Date
Fmc...1.1�7..................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF H
........OF.......t....................... ..............................
Appliration for Disposal Works Totwuurtiott rprmit
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
S.y.'.s.Lo....,
_gy-
. .. .... I
- - ----- -•-- .........................
LocatW 0- ddress 0or or Lot No.
. ...... .......
A ...... -r IV Addres&
................ --------- ----------------------- .........." ................................
..................*'*'**.......
............
............ ..... -------------------------------------------- ...................... .............................................................
0��Address
Installer 'Address
Type of Building Size Lot.../J/' ......Sq. feet
U Bedrooms.....Dwelling—No. of .......................................Expansion Attic Garbage Grinder ( )
'_l
P4 Other—Type of Building ............................ No. of persons............................ Showers Cafeteria ( )
04 Other fixtures ...etll.-A-711-4-—---------------------------------------------------------------------------------------------------------------------------
ell Design Flow..........5.1.0.........................gallons per person per day. Total daily flow................9_0.a...............gallons.
1:4 Septic Tank—Liquid capacit/ Ions Length................ Width__............._ Diameter-----------_--- Depth................
Disposal Trench—No................ eidth....................;V4,Dtal Length............../... 'Vtal leaching area....................sq. f t.
Seepage Pit No.. ............... �I" j41q?f otal leaching area....:39.9..sq. f t.
-- ----- "I A �'4�%� /;?1. Y'- �7 7
Z Other Distribution box Dosing tank 0 1 /-C
Percolation Test Results Performed by.......................................................................... Date.........................................
Test Pit No. I... minutesperinch Depth of Test Pit.................... Depth to ground water......._...._...........
Test Pit No. 2................minutes.per inch Depth of Test Pit............._..._.. Depth to ground water____._.............._...
...........
................... ..............
0 --- ------------------ ----------7K------------1-7....
.............. ... ..........0Z. ....lam.
........Description of Soil...... 410-ilri,14
--------------- -------- ------- -----------------------------*-------------------------"*------------------------------*----------------------------------------*"--------------
.......................................................................................................................................................................................................
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 provisionsbf,TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a'Certificate of Compliance has been issued by the Ward of health.
7igne ..... ........ ........................... ....
-- -----------------
F Date
. . . .......:.1..........Application Approved By. . . .....
Date
Application Disapproved for the following reasons:_--7.777� .................7........................... ............................................,............
....................................................................................................------ ---------------------------------7--------------------------------------------------------
Date
PermitNo..................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OFHEALT
0 F......0� !........ .. A .......................
Titrtifirate of Toutpliaurr
'Individual Sewage Disposal System constructed ( )
THIS TO CERTIFY, at t /--**"'Or Repaired
by........... ....... ...................... . ........................t......................... ... .........................*--------1"1-1-1-------
in
. ................. . . .. .... ............................. ...........................................................at........... ... ......... . ......
has been installed in accordance with the provisions,,U-r,�I,;�,_,�E `5 of,,The State Sanitary Code as described in the
application for Disposal Works Construction Perinit"N' 7-f--------_---------- dated_./7_-___/G'---7-7
...............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. .2
DATE...--- .................................... Inspector.....---:.... i.................. .................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD ,$>f HEALTJH
.. - /.
................J.aw........OF............. ..................... .... ... ....................7
No.--.. f........ FEE.! ..............
Disposal Works Toustr tan Vrrmit
s 66� granted------9'o�rufo. .....
Permission. ... ................................. ............
-----------------
to Constru t or Repair Z'....n'd'ivi jual 4_ 39wage D D' 0 sal S
at .......... .................
SWt*.re-t.- ----------
as shown on the application for Disposal Works Construction P t N Dated... . _4 ...... ..................
..........................
7 — 7 dc-, Board of Healtri
DATE.......... .................................................................
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS