HomeMy WebLinkAbout0026 EVANS STREET - Health 26 EVANS- STREET
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-c� Title 5 official Inspection Form f
a
� � 1 Subsurface Sewage Disposal System Form Not for Voluntary
untar Ass
essments
sessments
Property Address F 'Eva vts
_g r L. ;
Owner Owner's Name /r / - - - Q !'/ --0-V?-- / �7
information fo is every
D �//e ✓ - D�L`� 6 ` C2_
required for eve �''��Y V f r ✓✓ ,
page. City/Town State Zip Code Date of Ins ctio
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: A.When A Inspector In atlon `—
fillingg out forms p
on the computer, �� Is
use only the tab 0_ f/` �
key to move your Name of Inspector
cursor- not —� ! t 0
use the return �(/ 1/
key. Company Name
Company Address (/J/ /�
City/To - -- - oa IO`G L
_ State YOV Zip Code
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined
that the syst
1. asses
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fail
Lao
Inspecto's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer,if applicable, and the approving authority.
Please note: 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.
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Commonwealth of Massachusetts
e Title 5 Official Inspection Form
Ic Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
4
Property Address
Owner G1,WS 0✓�
Owner's Name Os �` AA
��/
information is f0 �^
required for every __ w
page. City/Town state Zip Code Date of In pe Ion
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) Z�e asses:
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:
2) 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): "
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I
Commonwealth of Massachusetts
: Title 5 Official Inspection Form
i
f Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
Owner
Owners Namev,/j� 0� I I /O l
information is 'r/'G„1'� l �LJi -(+5_required for every
page. City/Town State Zip Code Date of In pec on
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ 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):
I
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
3) 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.
a. 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:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
�. Title 5 Official Inspection Form
+' �= Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
L
Property Address
Owner Owner's Name DS 1 Oo6 /
information is v
required for every
page. City/Town State Zip Code Date of I spe tion
C. Inspection Summary (cont.)
❑ 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
b. System will fail unless the Board of Health(and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
❑ Y P
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 160 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.
c. Other:
4) 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
I� clogged SAS or cesspool
❑ Discharge or ponding of effluent to the surface of the ground or surface waters
p due to an overloaded or clogged SAS or cesspool
t5insp.doc-rev.7t26l2018 Tide 5 oKiciai Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
<b Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
Owner Owner's Name �
information is /V/ / /4 411,
required for every
page. City/Town State Zip Code Date of section
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ _UV/ Liquid depth in cesspool is less than 6" below invert 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: .
❑ {-1_(// Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ zlo� Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ 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.
i
5) 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 C.4.
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
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• f
Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
Subsurface Sewage Disposal System For -Not for Voluntary Assessments
Property Address
Owner owner's Name
information is Ox �r�`1� 4 a.)(ass /Q 1
required for every l� , d �/0
page. City/Town State Zip Code Date of Uspediion
C. Inspection Summary (cont.)
If you have answered"yes"to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed.The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304.The system owner
should contact the appropriate regional office of the Department.
6. You must indicate "yes or"no" for each of the following for aH inspections:
Yes o
❑ mping information was provided by the owner, occupant, or Board of Health
❑ ere any of the system components pumped out in the previous two weeks?
❑ as the system received normal flows in the previous two week period?
Have large volumes of water been introduced to the system recently or as part of
❑ this inspection?
Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
Was the facility or dwelling inspected for signs of sewage back up?
Was the site inspected for signs of break out?
❑ Were all system components, excluding the SAS, located on site?
❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
Was the facility owner(and occupants if different from owner) provided with
❑ information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
❑ Existing information. For example, a plan at the Board of Health.
Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)[310 CMR 15.302(5)1
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Commonwealth of Massachusetts
�- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
GvL✓So
Owner Owner's Name
information is
required for every
page. City/Town State Zip Code Date of Insbectfort
D. System Information
1. Residential Flow Conditions: J
Number of bedrooms (design): Number of bedrooms(actual).
3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):
Description: / /Poo �� 1 G .'►
A,17"e:s
o
Number of current residents:
Does residence have a garbage grinder? ❑ Yes No
Does residence have a water treatment unit? ❑ Yes Er5o
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes No
information in this report.) ,.._,
Laundry system inspected? ❑ Yes �No
Seasonaluse? ❑ Yes No
Water meter readings, if available (last 2 years usage(gpd)): --
Detail:
Sump pump? ❑ Y o
Last date of occupancy: /D
D e
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f
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
i�-�i L✓�O� -
Owner Owners Name ��
information is I At. A14 �� /o /
required for every o��
page. Cityrrown State Zip Code Date of I spe6on
D. System Information (cont.) `
2. Commerciallindustrial 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
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to: — --
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
3
Source of information:
Was system pumped as part of the inspection? ❑ Yes ❑ No
If 1.yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc•rev.7l2612018 Title 5 Official Inspection Form:Subsurface sev age Disposal System•Page 8 of 18
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
Owner Owner's Name
information is 0yvt A CJ [� /O +�^
required for every Ol V_ ) k J
page. CitylTown State Zip Code Date of Ins ctio
D. System Information (cont.)
4. Type of S em:
Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of II components, date installed (if know )and source of information:
Were sewage odors detected when arriving at the site? ❑ Yes No
5. Building Sewer(locate on site plan):
Depth below grade: �
feet
Material of constructi;40
❑cast iron I PVC ❑other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
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f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
1= Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
54-
Property Address
Owner Owner's Name information is
required for every �Os- 4Vv i At A4-- /c) �
t/p� ..CJ
page. City/Town State Zip Code Date of Insp ctio
D. System Information (cont.)
6. Septic Tank (locate on site plan):
Depth below grader ..
feet
Material construction:
concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 5 '4 9
. �L .3 'f
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle 3,( y
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 /
How were dimensions determined? Coe
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
OR
01
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f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
.le Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
L
Property Address
Owner Owner's Name /
information is � 1/Ok
required for every 0
5 • b / y V�
page. City/Town State Zip Code Date of I spe tion
D. System Information (cont.)
7. 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
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. 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
l5insp.doc,rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Oisposal System-Page 11 of 18
r
Commonwealth of Massachusetts
�. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
.,�gwso
Owner Owner's Name
information is yJ U required for every
page. City/Town State Zip Code Date of Inoecy6n
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box (if present must be opened) (locate on site plan): 1�
Depth of liquid level above outlet invert �VT - f
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.):
D
-- 11412
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
4 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
OLW o
Owner Owner's Name information is ✓j�� n.)6s' /0
required for every ly/
page. City/Town State Zip Code Date of I pe ion
D. System Information (cont.)
10. Pump Chamber(locate on site.plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type.
. `f
rf I�
❑ leaching pits number: t
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology: --
tSinsp.doc•rev.7/26/2018 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
;p Title 5 Official Inspection Form
I. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
C2 A✓I,S
Property Address
Owner ] Sra
Owner's Name eq
information is 05 v` /O
required for every
page. City/Town State Zip Code Date of Ins ecti n
D. System Information (cont.)
11. Soil Absorption System (SAS)(cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
�4o4e-
�. T
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer ---
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.): .
t5insp.doc•rev.712612018 Tide.5 Of6ciad Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
33 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address /
Owner Owners Name
information is
required for every V ef-fO
page. City/Town State Zip Code Date of lnsptctiol
D. System Information (cont.)
13. 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.):
t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal SystemnFgrm -Not for Voluntary Assessments
Property Address
Owner Owner's Name
4
information is / /'SO/16 Lr to li-o
I� required for every V_
page. City/I own State Zip Code Date of Irfspettion
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks enchmarks. Locate all wells within 100 feet. Locate where public water supply enters
t�buindg. Check one of the boxes below:sketch in the area below
❑ drawing attached separately
c
Sot,,r� -(000 (A/
i,I N 0(
� r I�� 1__
3 Cove+ r
� otT
f
G
A 3
t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface sewage Disposal system•Page 16 of 18
f
Commonwealth of Massachusetts
�_ P Title 5 Official Inspection Form
i_ p
Subsurface Sewage Dis osal System Fo Not for Voluntary Assessments
-
� -
Property Address
. . -L
a-WSo
Owner Owner's Name ,
information is
uired for every ry 005
V1 -- oa 6 r
V
page. City/Town State Zip Code Date of Insp tion
D. System Information (cont.)
15. Site Exam:
❑ Check Slope
j
❑ Surface water
❑ Check cellar
❑ Shallow wells /10
Estimated depth to high ground water: feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health- explain:
❑ Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database -explain: .
You must deso how you est blished the high ground water elevation:
(A 410
a-1.4 C/ 3V40'e—
moo il�
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7f2612018 Title.E.Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 19
I
Commonwealth of Massachusetts
:. p Title 5 Official Inspection Form
�1'. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
Owner
Owners Name0:510w,
/information is �� O�(�j�� /0
required for every
page. City/Town State Zip Code Date of 4sp4tion
E. Report Completeness Checklist
complete a applicable sections of this form inclusive of:
A. Inspector Information: Complete all fields in this section.
Certification: Signed& Dated and 1, 2, 3, or 4 checked
C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (F ure Criteria)and 6 (Checklist)completed
D. System Information: 7
For 8:Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
N I
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014
Commonwealth of Massachusetts
L Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments :3>
Property Address �
Owner a ^�7
Owner's Name
information is
required for every
page. City/Town / '
State Zip Code Date of Insp tion
Inspection results must be submitted on this form. Inspection forms may not be altered in any,;, t
way. Please see completeness checklist at the end of the form.
Important:When
filling out forms A. General Information
on the computer,
use only the tab
key to move your 1 Inspector:
cursor-do not
use the return Gc
key. Name of Inspector
reb Company Name
Company Address�— /
Ctty/I own
(:�2 go _ j/y nD State , Zip Code
T 1760
elephone umber // %
License Number
B. Certification
i certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. Ilan, a DEP approved system inspector pursuant to Sectioi,, 15.340 of
Title 5(310 C R 15.000). The system:
Passes ❑ Conditionally Passes
❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
Inspect s Signature /
Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original should be sent to the system owner and copies sent to the
I buyer, if applicable, and the approving authority.
"*"*This report only describes conditions at the time of inspection and under the conditions of use
at'that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins.doc-rev.6116
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17
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r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
Owner Owner's Name SO 4
information is
required for every $7 ✓�/ d/e / � Or� � �.
page. Clty/Town -
State Zip Code Date of Ins p ctio
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) stem Sy sses:
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:
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.doc•rev.6/16
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
M Property Address G N
Owner S�
information is Owner's Name required for every 0S l e v-v1 e va 6�`j page• City/Iown /
State Zip Code Date of Insp ction
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
Pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced f-1 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.
I. 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, y.
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.doc•rev.6/16
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M Property Address �N
Owner Owner's Name
information is l
required for every s'T e�(�/ 1 / Qa 6�js c�- �6 O
page. City/Town State
Zip Code Date of Insp ctio
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS.and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes, No
' ❑ Backup of sewage into facility or system component due to overloaded or�' v
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
❑ i,/� 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.doc-rev.6/16
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
.� ���s
Property J 6 S,y Address /
Owner Owner's Name
information is /
required for every (/S t env, Ile T /�� �� 6
page. City/Town 0 /
State Zip Code Date of I spect' n
B. Certification (cont.)
Yes No
❑ Evr'-,—Required pumping more than 4 times in the last year NOT due to clogged
obstructed pipe(s). Number of times pumped: or
❑ Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ Any portion of cesspool or privy is within 100 feet of a surface
ributary to a surface water supply.
water supply or
❑ Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ � ny portion of a cesspool or privy is within 50 feet of a predate water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
Of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
nd chain of custody must be attached to this form.]
❑ e system is a cesspool serving a facility with a design flow of 2000gpd-
101000gpd.
❑ 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.doc-rev.6/16
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
Commonwealth of Massachusetts
a Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
a M ,a �G✓
Property Address 6 L—
t f
Owner Owner's Name
information is
required for every �s 7''t°►/(/!`/,� t�a 6,S�j
page. City/Town l
State Zip Code Date of Ins coon
C. Checklist
Check if the following have been done. You must indicate"yes"or"no" as to each of the followin :
g
Limping information was provided by the owner, occupant,or Board of Health
El re any of the system components pumped out in the previous two weeks?
El the system received normal flows in the previous two week period?
Have large volumes of water H
❑ been introduced to the system recently or as part of
this inspection?
Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
Was the facility or dwelling inspected for signs of sewage back up?
Was the site inspected for signs of break out?
Were all system components, excluding the SAS, located on site?
❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
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
en determined based on:
❑ Existing information. For example, a plan at the Board of Health.
❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): Number o" of bedrooms (actual): ..
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):
t5ins.doc•rev.6116
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address �j
Owner Owner's Name �` ,0 1-1
information is P
required for every
page. City/Town (/ t- / e ��
State
Zip Code Date of Ins ectio
D. System Information
Description:
&C,/47,1
/11
Number of current residents: O
Does residence have a garbage grinder?
❑ Yes No
Is laundry on a separate sewage system? (Include laundry system inspection
information in this report.) ❑ Yes No
Laundry system inspected?
❑ Yes No
Seasonaluse?
❑ Yes No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
Sump pump?
❑ Yes No
Last date of occupancy:
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of,design flow.(seats/persons/sq.ft., etc.):
Grease trap present? t ❑ Yes
❑ No
Industrial waste holding tank present? El Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins.doc-rev.6116
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
Property Address
Owner 4 ws p
information is Owner's Name -/
required for every n V S Te f/j l e /' 111 o(� 6 S
page. City/Tow
State Zip Code Date of Insp tion
D. System Information (cons.)
Last date of occupancy/use:
Date
Other(describe below):
General Information
Pumping Records: A
Source of information: . ®„S_
Was system pumped as part of the inspection?
❑ Yes No
If yes, volume pumped:
gallons
Hovr was quantity pumped determined? —
Reason for pumping:
Type
Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system(yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest _
inspection of the I/A system by system operator under contract
❑ +Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
t5ins.doc•rev.6/16
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection F
Subsurface Sewage Disposal System Form - Not for Voluntary ry ssessments
4 M Property Address
Owner Owner's Name
information is required for every o S 1l /l
Te �� l�/0—
page. City/Town
State Zip Code Date of In ecti
D. System Information (cont.)
on
Approximate age of all components, date installe (if kn n) and source of information:
Were sewage odors detected when arriving at the site?
❑ Yes
Building Sewer(locate on site plan):
Depth below grade:
feet
Material onstructio;-40
cast iron PVC
❑ other(explain):
Distance from private water supply well or suction line:
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below gr
feet
Mated of construction:
concrete ❑ metal
❑ fiberglass El polyethylene ❑other(explain)
If tank is metal,.list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes
❑ No
Dimensions:
Sludge depth:
l5ins.doc-rev.6/16
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Property Address \J_' ✓/ (J
Owner WSp v/
Owner's Name
information is /�/� Da�, j
required for everyZ
page. City/I own State ZipCode /
Date of Insp ction
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness �G vl�V7
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined?
Comments(on pumping recommendations, inlet and outlet tee or baffle condition
liquid levels as related to outlet invert, evidence of leakage, etc.): structural integrity,
aH 4,, 7 4-ees o
CO117Ci/ J/o✓/ .
N0 /G
Grease Trap (locate on site plan):
Depth below grade:
feet
Material of construction:
❑concrete ❑ metal ❑fiber lass
. 9 ❑ polyethylene ❑other(explain):
'Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
Date
t5ins.doc•rev.6/16
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection For
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,,, Property Address �� � s ��
Owner Owner's Name �S
information is / [-�required for everyS 7'�,�1// e jV:
(�� IoJ JPage. Cty/Town Zi Code
P Date of In ectio
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.):
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 El 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.):
• I
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�v
" Property Address
Owner Owners Name z
information is required for every — OS p✓l/l >° /'"�/f
//JT Qp�6 sJP" 6
page. Clty/Town
State Zip Code Date of In ection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of 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.):
/,-
/Vp so/ s
A/O 4eq__J
Pump Chamber(locate on site plan):
Pumps i��working order:
❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
ti
If SAS not located, explain why:
t5ins.doc•rev.6/16
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Property Address
Owner �✓r0 of
Owners Name
information is /
required for every
page. City/Town State Zi Code
P Date of Ins ction
D. System Information (cont.)
Type: (J�'
v►Y���- ,z��f wSTO�1 a r
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions: --- ---
❑ overflow cesspool number: '
❑ innovative/alternative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
ovle a0cl SO/�
Cj d�
O �1 HS O �/G /t C t �Gt✓�
n
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer `
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins.doc•rev.6/16
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
H Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Property Address /
Owner Owner's Name �
information is
required for every DS /!/�//Q 61-11— )
page. CityrTown State ZipCode 9
Date of In pection
D. System Information (cont.) -
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions i
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
I
l5ins.doc-rev.6/16
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M Z' �f
Property Address
Owner Owner's Name �`rO
information is s 1��v1 /�� O or l �5S
required for every 't
page. Cityt I own State Zi Code
P Date of Ins ection
D. System Information (cont.)
Sketch Of Sewag a Disposal System: Provide a view of the sewage disposal system, including ties to
at least tw ermanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where lic water supply enters the building. Check one of the boxes below:
hand-sketch in the area below
❑ drawing attached separately
Q
R 6®
—t000
CG-R/lot
sep,lt' p�tv
T�Ll
�.
< �D
coYQr .
�s
6Qf0�.
Shc Il
15ins.doc•rev.6/16
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts
W Title 5 Official. lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Property Address
Owner Owner's Name �✓SO (/! /�
information is
required for every �S Q✓V /�11,e7
page. City/Town
State Zip Code Date of In pectin
Do System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water '
❑ Check cellar
❑ Shallow wells "�—
Estimated depth to high ground water:
feet — --
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record -
If checked, date of design plan reviewed:
Date
❑ bserved site (abutting property/observation hole within 150 feet of SAS)
Checked with al Board of Health -2�x'_ lain:
s
❑ Checked with local excavators, installers -(attach documentation)
❑ Accessed USGS database-explain:
You must desen how you esta ished the high ground water elevation: i
4ht~G1y4 40 /2,s
ro
d-e \.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins.tloc-rev.6/16
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M Property Address N�
Owner Owner s Name Q L"-S70 ✓J
information is �/J
required for every OS �,/(/( /-� //''✓ Dd 6
page. City/Town State -ZipCode
Date of Inspec on
E. Report ompleteness Checklist
Inspe tion Summary:A, B, C, D, or E checked
In ion
p Summary D(System Failure Criteria Applicable to All Systems)completed
Sy m Information—Estimated depth to high groundwater
Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
s
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
THE COMMONWEALTH OF MASSACHUSETTb" .
BOAR® OF HEALT
TOWN OF BARNSTABLE �
Appliration for Biipnaa1 Works Tomitrnrtinn ramit
Application is hereby made for a Permit to Construct ( ) or Repair (IX an Individual Sewage Disposal
System at
c �'7r4
. �... ................................ --.....---- .. .........----............-•----------•--------•••......------
Locatio -Address -vim'� or � N
,4 Z l�&s i c«
.............. .................................•-----.. . ----- ..._.....--•-••••---•----•-...•---•----------------•--.............
a �G�a�dGC�7 o<f6/J.S7 �O In�`s4�lL-C�5 y �� Address _ ^ / u
--------------------••-- ...-•--•-...•••-••---•••---••-•-•••-...........•••• -• ----••--•••---•-•••••......•••---.....-------••-••......--•••--••.........................--••--
Installer Address
Type of Building Size Lot............................Sq. feet
�-, Dwelling—No. of Bedrooms...................�.�. .........._.......Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons............................ Showers — Cafeteria
Other fixtures ................................ . '
W Design Flow....................5sJ............. per person per day. Total daily flow----- _��.__��_.�---._..____...._..gallons.
WSeptic Tank—Liquid capacity/Adv-..gallons Length................ Width................ Diameter---------------- Depth................
x Disposal Trench—No. ..........1....... Width.......7........ Total Length..... .... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed bY...............-................-----------------------
------------------- Date........................................
Test Pit. No. I................mmutes per inch Depth of Test Pit.................... Depth to ground water--_-__--_____•__----__-.
Test Pit No. 2................minutes per inch Depth of.Test Pit.................... Depth to ground water........................
------------------------------------------------------------------------------------------------••-•.........................................................
0 Description of Soil....................................................................................................---------------------------------------------------......--••--•---
x
W
------------------------------------•-----------•----------------------------------------------------------------------------------------------------------------•... •••-••--••-•......-•-••-•••......
U Nature of Repairs or Alterations—Answer when applicable------ ....... -___1....... ...!9'1GU
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Complianc as sue b e board f alth.
Signed .....7 ........................................................... r ... ..... .
Application Approved BY --------------------- U...Is:)- --------- e
....................................................................... Dale
Application Disapproved for the following reasons: -- ............................................................. .............................................................
..............----------- ----------------------------------------------------------------------- - --------------------------------------------------------------------------------------------------- ---------------------------------
Date
PermitNo. ..--.1_3------- ----------------------_-_ Issued .............------------...............---- -....------------..
Date
No..23`.5-�.-- r / ' U�11 Fxs...............
a;
THE COMMONWEALTH OF M'ASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliration for Dhipvii tl Workii Tomitrurthitt ramit
Application is hereby made for a Permit to Construct ( ) or Repair (X) an Individual Sewage Disposal
System at:
....................................................LoOcat�ioln-Address or Iw No. ^- .............
........ ......... �=---•---------•---------•--•---•- --- ......---•-- .. . C.
—� Owner 2 Address
W UP4C � v'�7 L'UNs%. 7 � w� J/��Q�/ / /1/� l�/LCS
,-� - ..............
Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No. of persons............................ Showers — Cafeteria
Pa Other fixtures -----------------------------••• .
W Design Flow.................... .. .___._.___..gallons per person per day. Total daily flow._.....__._.... `. ..................gallons.
W Septic Tank—Liquid"capacity M'.v..gallons Length................ Width......•_...... Diameter................ Depth................
10
x Disposal Trench—No.---------/_...... Width.......7........ Total Length-____c`� .--- Total leaching area...................sq. ft.
Seepage Pit No-_--_------------- Diameter--__.___--_-.-_•.-._ Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
aTest Pit No. 1................minutes per inch Depth of Test Pit...................• Depth to ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a -•---••-•-•----------------•••-•-•••-------•---••-••---••••-••••-•--•---•........_......---•.--•••-.........................................................
ODescription of Soil...............................................................................--------------------------------------`------------------............................
x
W
----------------------------•------------... ; .......--------...-----------------------..........--------------------.........----------
Nature of Re aIr or Alterations—Answer when a licable._.__�__________________ �pU a i u ..•.......•.._..
Agreement: 4
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System im'accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance iaVeen sue by�the b and of ealt � S3
Sign d e ...... � -t .. :
Application Approved By ....................C .- A ---s a-^ 3-93
Date
Application Disapproved for the following reasons- ...................................................................................... -----------------_--...........----------
..... ............................................................................................................................... .................. ....................................... .............. ........................
�j Date
PermitNo. .... ...' ------------------- ---- Issued ...................------------------------------------..
Date
t�
THE COMMONWEALTH OF MASSACHUSE17S
BOARD OF HEALTH
TOWN OF BARNSTABLE
C�e>r#iftctt#E � C�oz>��ltttr><�e -
THIS IS TO CERTIFY, That the,lndividual Sewage Disposal System constructed ( ) or Repaired ( fN>,f)t
1_5'6 L t O C 67Y 7 �'6Jr�1�Ta�c!(f-i/U-1
by---------............................................................------------ --- ------------------------- ---------------------- ---------------- - - -------..............................................---------
Instaaer
at .........................------------------------------------ - -- --------------
has been installed in accordance with the provisions of TITLE 5 of The Stat nvironmental Code as described in
the application for Disposal Works Construction Permit No. ...........T3......... d dated ..................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE............... --- -(. ...�.! ` ................................................... Inspector ....................... -- ----f7 ... ............................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
qq '-xx --
No...... TOWN OF BARNSTABLE FEE...1..J. ..�v .....................
d, io� v G.a tirs7-,
PermissionIs hereby granted..............................................................................................................................................
to Construct ( ) or Repair (`,) an Individual Sewage Disposal System 5?���I/!L
atNo. -•-••---•----•--•-••.........................•------•-.
Street ��
as shown on the application for Disposal Works Construction Permit No_______________ Dated..........................................
`�
oard of Health
r DATE................................................................................
FORM 36508 HOBBS&WARREN.INC..PUBLISHERS
TOWN OF BARNSTABLE �--
LOCATION dA6 c17ZJA?,Jr' `Si r- SEWAGE #
VILLAGE 6:5'-'QtU/&ct ASSESSOR'S MAP & LOT /V/ 0310
INSTALLER'S NAME & PHONE NO. 4'Q�O�i7 ( -Jd/ yam info
SEPTIC TANK CAPACITY /OU6 i�-nfi�
LEACHING FACILITY:(type) (size) :Z;X c;)9
NO. OF BEDROOMS PRIVATE WELL O PUBLIC WAT�ER ..
I
BUILDER.OR OWNERLr�}`J
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED: b
VARIANCE GRANTED: Yes No
� �� ` _ it
a� 1
��
d
i
r
cc�J d�
No.....3®_�----- Fizla...,�✓e................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD HEALTH
Appliratioll for Bii u,ittl Worse Towitrnrtinn Prrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) 'an Individual Sewage Disposal
System at:
r
Lo tion- ddress or Lot No.
----- _q�1--•••-'�=-._..._. W_Sssr►---_._r..--••............. -••••-----••--•...._....----
M Owner Address
W1 --•------- -�3---•-•-•- f S /----J�,"A e.------. --•---•---------•--------------•---------
nstaller Address
d Type of Building Size Lot..................... ......Sq. feet
U Dwelling—No. of Bedrooms---------- ___________________________Expansion Attic ( ) Garbage Grinder (►/j
aOther—Type of Building ______ ___________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
QOther fixtures -------------------------------•----------------------------------------------------------------------------------------------------------------------
W Design Flow............................................gallons per person per day. Total daily flow__.____-_.__________.._____-_---------------gallons.
R; Septic Tank—Liquid capacity------------gallons Length................ Width................ Diameter----------...... Deptll____--___-_---
Disposal Trench—No_ ____________________ Width-------------------- Total Length.................... Total leaching area.--------_...-------sq. ft.
� Seepage Pit No---_----------_---- Diameter.................... Depth below inlet.................... Total leaching area------------------sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by-------- -------------------------------------------------------- ------ Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water------------------------
Test Pit No. 2................minutes per inch Depth of Test Pit____________________ Depth to ground water-------------------
---------------------------------------------------------------------------------------------------------------------------------------------------------------•-------------------------------------------------------------------------------------------------
P4
0 Description of Soil...............................................-----------------------
JA
----------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------
___________________________________________________________________________________________________________________________ __-_______-__._.ureof Pe s•rs r Alterations— nswer when a cable- ____ _ _.greem ntThe undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
e provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in
eration until a Certificate of Compliance has bee sued by the rd o heaz,Signed.- . - --• --- ---- ------•----------_--------•_---•- ----•--- �_._� . -•!•--7-
Dapplication Approved By--------- . ... ---- - •----- ---- -- --- - ---• ......... -•-- -••-- -_ .. --- - - .. _7�a
Application Disapproved for the following reasons------------------------------------- ------------ --•-----------------------------••-----•••-•------•---••-•-
.........................................................................................................................................................................................................
Date
PermitNo.......................................................... Issued........................................................
Date
s THE COMMONWEALTH OF MASSACHUSETTS
' BOARD OF HEALTH
1J.. .............OF.......... ......-----------------:.........
...
Q�'TH;_c�,IS 0 C TIF That the I dividual age Disposal System constructed ( ) or Repaired
by..
I a e
at.... -•.�_-`--•---- -�• ---- . -- ...................................
has been installed in accordance with the provisions of Article XI of Th State Sanitary Code a describe In th
application for Disposal Works Construction Permit No.___, •®___ .......... dated...... e_. --_ __.__.7_.. ....
TIE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GU RANTEE THAT HE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector.------------------------------------------------------------......---.....---...---
•���••����!1����1�1•��•���••A�w��r •���••��•.•••••���••.��• ••'�t•���•••�����•••���1•��.}••O!••�•••�•�•�f•••A•••fa��A•••n�N•!w•foo•
THE COMMONWEALTH OF MASSACHUSETTS
Rn BOARD HEALTH
J �' •�/"1....;.OF.:...._ - ---c� ----------------------------------------
0.... - FEEoyr
]a at orkii rr t'
Permission is hereby grante •- -- ......
t onstr ct ) o epair ( an Indiv' Sewa spos stem
a o..... - � �--- a• ...
Street
s s non the application for Disposal Works Construction P a No. d___ .�j'__ -----------
----- -- ..............
rd� of alth
DA ------------------•----•-------...... ........................................
ORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
I
THE COMMONWEALTH OF MASSACHUSETTS
BOARD QJF HEALTH
.... OF....._.. .... .4 .. ..................
App ration -for Iiapoottl Works Tanstrurtion Vrrnift
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
------------------------- ---
''"" Lo tion-Add ss o. Lot No.
Owner rl ' Address
W _ ' C? stagy
nstaller Address
dType of Building Size Lot------.--..-•_______________Sq. feet
U Dwelling—No. of Bedrooms---------- ----------------------------Expansion Attic ( ) Garbage Grinder (VOY'
aOther—Type of Building ---------------------------- No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Other fixtures .............. --------------------------------------
W Design Flow............................................gallons per person per day. Total daily flow_._......................................---gallons.
WSeptic Tank—Liquid capacity._....__...gall.ons Length................ Width-----........... Diameter................ Depth...--.--_.------
x Disposal Trench—No..................... Width-------------------- Total Length•.__-_--__-__--_-. Total leaching area..............------Sq. ft.
Seepage Pit No..................... Diameter-------------------- Depth below inlet.................... Total leaching area-------.__.__.----sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date------------------------------------- '
Test Pit No. 1________________minutes per inch Depth of Test Pit-------------------- Depth to ground water-..-__-_"--_-.---_.-_-
G%, Test Pit No. 2................minutes per inch Depth of Test Pit_.............._.... Depth to ground water---------------------
P P P
a' -------------=-----------•-•--.......---•---•--•--------•---••••••-••---•--------••-........•----......................................................
0 Description of Soil------------_------ ------------•--•-------•••------•••-•-•-•---..:-----......•--..........-•----•-•-•--•--•---••••--- .............................................
•-
x ------------------------------------------------------------------------------------------------------- -------------------- .
V *lure of Rep' rs r AlX
tions— nswer when ble j-. . . __ __�_____________ _.._... . .
--- -- - --------- -- -- ---
Agreement:
h r "Individuala Dis Disposal stem in accordance with
The undersigned agrees to install the afo edescrtbed Sewage p Sy
the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee ' sued by the ` rd o he
g - '
Application Approved By--_..... --- • .-••••-- -•----• - --Da �
Application Disapproved for the following reasons:................................... -------------- ............................................................
-----••--•-•----------------•---•--•••-•--•--- -••--•------•----•-••••-----••-•-•-........-••-•••-•...---•-----•••--•--•-••••---•--••--•--------•--------------•--------•----•------•......-----------•.
Date
PermitNo. Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O HEALTH
II..QG i T..............OF......... ....... ...-......................
�rrtifiratr of'f�ompliaurr.
THJ.9,IS TO TI That the ndividual age Disposal System constructed ( ) or Repaired
by..,,.: ----- --- ------........ -- ---------- ---- ........................
st le
at. AL-4-------- - -f-------- ----- -----------....--------------------------------------....-----.......------------------
has been installed in accordance with the provisions of Article.XI of k
State Sanitary Cocle describ in th
application for Disposal Works Construction Permit No._. t ___ ----------- dated..... .. .:. . _._---- .__..
THE ISSUANCE `OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A RANTEE THAT FIE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector....................................................................................
TH•E COMMONWEALTH OF MASSACHUSETTS
BOARD HEALTH
r
H_�- ........................................ P-`;�'��. .
No.._�.4�.. FEE ........... `-'.
Rio oottl o k1i n ru i it rr
is hereby grante ; -- --- ---- -•--•--- - ---- --- ----•-. ------.....--------..------------------.....;
to Const, ct ) epair ( an Indi 1 Sew ispos stem
��
at No.A -- -•-•-•-- •--•-•--•---...-- -•P-•-- -, ......1...... .- - --- = .......................................
;- .--•• .-•--- •--... - --- •--• -----...._
as shown on the application for Dis osal Works Construction N1 " .. e",_. •i' __._._._....
oar of ealth
DATE................................................................................
F.o M--l2sg HOBBS•& WARREN. INC.. PUBLISHERS ' Y