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Home My WebLink About0035 FOX HOLLOW LANE - Health `35 Fox Hollow. Lane Osterville P A 145 006009 ,I I a Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 35 Fox Hollow Lane Z Property Address Peter Crosson & Melissa Caughey Owner Owner's Name information is required for every Osterville Ma 02655 5-25-16 z page. City/Town State Zip Code Date of Inspection C7'1 Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms on the computer, use only the tab 1. Inspector: . key to move your cursor-do not Matthew Gilfoy use the return Name of Inspector key. B&B Excavation r� Company Name 374 Route"130 Company Address Sandwich Ma 02563 City/Town State Zip Code (508)477-0653 S113640 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation.by the Local Approving Authority 5-25-16 Inspector'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 is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 35 Fox Hollow Lane Property Address Peter Crosson & Melissa Caughey Owner Owner's Name information is required for every Osterville Ma 02655 5-25-16 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete-all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System was in working order at time of inspection. 13) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System°Page 2 of 17 f Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 35 Fox Hollow Lane Property Address Peter Crosson & Melissa Caughey Owner Owner's Name information is required for every Osterville Ma 02655 5-25-16 page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 35 Fox Hollow Lane Property Address Peter Crosson & Melissa Caughey Owner Owner's Name information is required for every Osterville Ma 02655 5-25-16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: *" This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 'h day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments CGM , 35 Fox Hollow Lane Property Address Peter Crosson & Melissa Caughey Owner Owner's Name information is required for every Osterville Ma 02655 5-25-16 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) - Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 35 Fox Hollow Lane Property Address Peter Crosson & Melissa Caughey Owner Owner's Name information is required for every Osterville Ma 02655 5-25-16 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ 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 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)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (Actual) 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 35 Fox Hollow Lane Property Address Peter Crosson & Melissa Caughey Owner Owner's Name information is required for every Osterville Ma 02655 5-25-16 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 4 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) . Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d See below 9 ( Y 9 (gP ))� Detail: 2015-69,000gallons 2014-60,000gallons Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: NA Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection,Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments ^M 35 Fox Hollow Lane Property Address Peter Crosson & Melissa Caughey Owner Owner's Name information is required for every Osterville Ma 02655 5-25-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Owner- pumped one year ago Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form.- Not for Voluntary Assessments ^M 35 Fox Hollow Lane Property Address Peter Crosson & Melissa Caughey Owner Owner's Name information is required for every Osterville Ma 02655 5-25-16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1988 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 22 feet Material of construction: ❑ cast iron . ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 16" feet Material of 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: 1000gallons Sludge depth: 5 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 35 Fox Hollow Lane Property Address Peter Crosson & Melissa Caugghey Owner Owner's Name information is required for every Osterville Ma 02655 5-25-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 31" Scum thickness 2 Distance from top of scum to top of outlet tee or baffle 6 Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? Measured Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank was in working order at time of inspection with liquid level equal to outlet invert. Tank is not in need of pumping at this time but should be pumped every two years for maintenance. Grease Trap (locate on site plan): Depth below grade: NA feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 35 Fox Hollow Lane Property Address Peter Crosson & Melissa Caughey Owner Owner's Name information is required for every Osterville Ma 02655 5-25-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: NA Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 35 Fox Hollow Lane Property Address Peter Crosson & Melissa Caughey Owner Owner's Name information is required for every Osterville Ma 02655 5-25-16 page. CityTTown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 11 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-box is in working order at time of inspection with liquid level equal to outlet invert. D-box did not show signs of back up or carry over. 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.): NA * If pumps or alarms are not in working order, system is a conditional pass.. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c,M 35 Fox Hollow Lane Property Address Peter Crosson & Melissa Caughey Owner Owner's Name information is required for every Osterville Ma 02655 5-25-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: (1) 6'x6' ❑ 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.): Leaching was in working order at time of inspection with no sign of hydraulic failure. Water level was 2'4" below invert at time of inspection. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration NA Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 35 Fox Hollow Lane Property Address Peter Crosson & Melissa Caughey Owner Owner's Name information is required for every Osterville Ma 02655 5-25-16 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: NA Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 35 Fox Hollow Lane Property Address Peter Crosson & Melissa Caughey Owner Owner's Name information is required for every Osterville Ma 02655 5-25-16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately VARMor ON '0t 0 - ' ® 4 . y� 0° " t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 35 Fox Hollow Lane Property Address Peter Crosson & Melissa Caughey Owner Owner's Name information is required for every Osterville Ma 02655 5-25-16 page. City[Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: No GW 12' 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: Aug-9-84Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Plan on file with BOH. Before filing this Inspection Report, please see Report Completeness Checklist on next page. l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 k Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 35 Fox Hollow Lane Property Address Peter Crosson & Melissa Caughey Owner Owner's Name information is Osterville Ma 02655 5-25-16 required for every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information- Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System—Page 17 of 17 CONTRACT Customer Name `, Sales Representative Signature SKETCH Contract Date (. .�� ` ( 2 ' , -c' . � Contract Price ATTACHMENT Customer Phone 39 40 41 42 43 44 45 43 47 48 49 SO 5, 72 S] 54 9s BB Ol 58 59 W 1<.� 9 ,o 11 12 13 14 is to 17 It, 1B 20 21 22 x7 24 25 2E 27 1 B 2E 29 30 31 37 3J N 35 3B 3 3B 2 pc - it �. Ci11 to to 20 It 21 J, 22 23 24 25 4�M1' - /Ai,I.,, 26 27 28 29 I c 4 �j 30 ,r 31 32 33 34 1 y^tiA. A IV 35 'Each box equals one foot unless otherwise noted.This sketch Is a good faith ../" NOTES: representation of the work to be done, It is understood that all dimensions derived from this sketch are approximate,and that all locations of outlets,light fixtures,plugs,lacks and/or switches are subject to change it necessary. t, 1 J" 4 i u, ��o� ��t� r T f COMMONWEALTH OF MASSACHUSETTS RECEIVED XECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONV"MENTAL PROTECTIO SEP 2 3 2003 Z I w d TOWN OF BARNSTABLE l y. HEALTH DEPT. p .. c oW TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION F roperty Address: 35 FOX HOLLOW LANE OSTERVILLE, MA 02655 9wner's Name: KATZ wner's Address: 35 FOX HOLLOW LANE OSTERVILLE,MA 02655 ate of Inspection:8/22/03 'Cory Dame of Inspector. (please print) JOHN GRACI,INC. ompany Name: SEPTIC INSPECTIONS flailing Address: P.O. BOX 2119 TEATICKET,MA. 02536 MAP elephone Number: 508-564-6813 FAX 508-564-7270 PARCEL, (0 SJ® ' LOT CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310.CNIR 15.000). The,system: 4 X Passes Conditionally Pas 's _ Needs Further Ev L ation by the Local Approving Authority _ Fails I spector's Signature: Date: 8/22/03 �he system inspector shall submit a copy oft �nspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the s tem is a shared system or has a design flow of 10,000 gpd or greater, the i spector and the system owner shall submit th 'report to the appropriate regional office of the DEP. The original should be s nt to the system owner and copies sent to the buyer, if applicable, and the approving authority.; ` otes and Comments SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. *'**This report only describes conditions at the time of inspection and under the conditions of use at that time.This n spection does not address how the system will perform in the future under the same or different conditions of use. itle 5 Incnertinn Fnrrn 6/1 5/?M(1 1 Page12 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY 1.ASSESSMENTS.. SUBSURFACE SEWAGE-DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) roperty Address: 35 FOX HOLLOW LANE OSTERVILLE,MA 02655 Owner: KATZ pate of Inspection: 8/22/03 , nspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D k. System Passes: , I have not found any information which indicates that any of the failure criteria described in 3I0 CMR 15.303 or in 310. MR 15.304 exist. Any failure criteria not evaluated are indicated below.. Comments: �YSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE YSTEM'S USEFUL LIFE. C • 4 System Conditionally Passes: _ One or more system components as described in the",Conditional,Pass'section need to be replaced or repaired.The system, pon completion of the replacement or repair, as approved by the Board of Health,will pass. �nswer yes, no or not determined (Y,N,ND) in the foi the-following statements. If"not determined" please explain. s/a The septic tank is metal and over 20 years old* or,the septic tank(whether metal or not) is structurally unsound,exhibits ubstantial infiltration or exfiltration or tank failure is imminent. Systern will.pass inspection if the existing tank is replaced �rth 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 at the tank is less than 20 years old is available. - ,r D explain: n/a 1/a Observation of sewage backup or break out or high static water level in-'the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of II ealth): _ broken pipe(s)are replaced' _ obstruction is removed _ distribution box is leveled or replaced ~`- ND explain: n/a r �/a The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass i spection if(with approval of the Board of Health): f _broken pipe(s)are replaced _obstruction is removed D explain: n/a F _ - 4 „ a i age3 of 1 I c OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) ;roperty Address: 35 FOX HOLLOW LANE OSTERVILLE, MA 02655 wner: KATZ ate of Inspection: 8/22/03 C. 4 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 rotect public health, safety or the enviromment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(I)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption,system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 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. A. �. _ 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 n/a - x "This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: n/a Pagc 4 of 1 1 s , OFFICIAL INSPECTION FORM—NOT•FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 35 FOX HOLLOW LANE OSTERVILLE, MA 02655 Owner: KATZ Date of Inspection: 8/22/03D. .,., System Failure Criteria applicable to all systems: �ou must indicate"yes"or"no"to each of the following for all-inspections: es No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool i X Static liquid level in the distribution box above outlet invert due to'an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow i1 X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s) Number of t7 times pumped NT IN THE LAST YR PER OWNER. , X Any portion of the SAS, cesspool or privy'is below_ high ground water elevation. i X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. ry" X Any portion of a cesspool or privy is within 50 feet of a private water supply well. `- X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and.nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must'be attached to this forma NO (Yes/No)The system fails. 1 have determined that one or more of the above failure criteria'exist as described in 10 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be i ecessary to correct the failure. Large Systems: �o be considered a large system the system must serve a facility with a design flow of 10,000 gpd'to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: The following criteria apply to large systems in addition to the criteria above) es no X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 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 nder 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:, A Page,5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST �roperty Address: 35 FOX HOLLOW LANE OSTERVILLE,MA 02655 caner: KATZ ate of Inspection: 8/22/03 Check if the following have been done. You must indicate "yes" or"no" as to each of the following: , Wes No ± Pumping information was provided by the owner, occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks X Has the system received normal flows in the previous two week period "? X Have large volumes of water been introduced to the system recently or,as part of this inspection 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 X _ 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 affles 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 f subsurface sewage disposal systems The size and location of the Soil Absorption System (SAS)on,the site has been determined based on.- Yes no _ 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 acceptable) [310 CMR 15.302(3)(b)] Page-6 of 1 I ' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION �roperty Address: 35 FOX HOLLOW LANE OSTERVILLE, MA 02655 Qwner: KATZ A Date of Inspection: 8/22/03 FLOW CONDITIONS , (RESIDENTIAL 1�Jumber of bedrooms(design): 3 Number of bedrooms(actual): 3 11�ESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x #of bedrooms): 330 Number of current residents: 2 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system (yes or no):NO [if yes separate inspection required] aundry system inspected (yes or no): NO easonal use: (yes or no): YES 6 , Water meter readings, if available(last 2 years usage(gpd)): W& urnp pump(yes or no): NO ast date of occupancy: n/a s " OMMERCIALANDUSTRIAL ype of establishment: n/a ° Tesign flow(based on 310 CMR 15.203): n/agpd " asis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO a Non-sanitary waste discharged to the Title 5 system(yes or no): NO , )Vater meter readings, if available: n/a , irast date of occupancy/use: n/a THER(describe): n/a GENERAL INFORMATION' . x Pumping Records ; Source of information: NOT IN THE LAST YR PER OWNER { as system pumped as part of the inspection (yes or no): NO If yes, volume pumped: n/agallons-- How was quantity pumped determined? n/a eason for pumping: n/a 4 YPE OF SYSTEM Septic tank, distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no)(if yes, attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank Attach a copy of the DEP approval r ther(describe): n/a Approximate age of all components, date installed(if known)and source of information: 1988I PER AGENT/ASBUILT ' ere sewage odors detected when arriving at the site(yes or no): NO Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) • h Property Address: 35 FOX HOLLOW LANE OSTERVILLE,MA 02655 Owner: KATZ Date of Inspection: 8/22/03 BUILDING SEWER(locate on site plan) Depth below grade: 22" Materials of construction:_cast iron =40 PVC other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on condition of joints, venting, evidence of leakage, etc.): OWN WATER EPTIC TANK: X(locate on site plan) Depth below grade: 16" aterial of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a f tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: L 8' 6" H 5' 7" W 4' 1011" Judge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 32" cum thickness: 1" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 17 How were dimensions determined: MEASURED Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related �o outlet invert,evidence of leakage,etc.): EPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. ECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. GREASE TRAP:_(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass : polyethylene_other(explain): n/a Dimensions: n/a cum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations, inlet and outlet tee or baffle condition;structural integrity, liquid levels as related o outlet invert,evidence of leakage, etc.): /a r 7 lage 8ofII 3 OFFICIAL INSPECTION FORM'-NOT FOR VOLUNTARY ASSESSMENTS... SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ' SYSTEM INFORMATION(continued) } Troperty Address: 35 FOX HOLLOW LANE OSTERVILLE, MA 02655 " Owner: KATZ ate of Inspection: 8/22/03 �IGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)21 ; Pepth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a imensions: n/a apacity: n/a gallons esign Flow: n/a gallons/day " Alarm present(yes or no): N/A �larm level: N/A Alarm in working order(yes or no): NO ate of last pumping: n/a - omments(condition of alarm and float switches,etc:): /a d'Y DISTRIBUTION BOX: X(if present must be opened)(locate of site plan)' Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE omments(note if box is level and distribution to outlets equal;any evidence of solids carryover, any evidenceof leakage into• pr out of box,etc.): -BOX IS STRUCTURALLY SOUND.- BOX IS HI0 ` UMP CHAMBER: _(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO - Comments(note condition of pump chamber, condition of pumps and appurtenances;etc.): /a i .,.' ... R .. f S.. age 9 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) property Address: 35 FOX HOLLOW LANE OSTERVILLE, MA 02655 Owner: KATZ ate of Inspection: 8/22/03 OIL ABSORPTION SYSTEM (SAS): X (locate on site plan,excavation not required) y If SAS not located explain why: ype 000 GAL 6' X 6' H-10 leaching pits, number: 1 /a leaching chambers, number: n/a /a leaching galleries, number: n/a 11/a leaching trenches, number, length: 'A/a i/a leaching fields, number: n/a /a overflow cesspool, number: n/a /a innovative/alternative system , Type/name of technology: n/a omments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): LEACH PIT IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. SYSTEM SHOWS NO SIGNS OF 1HAILURE. BOTTOM IS AT 8'6". _"ESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) ' Number and configuration: n/a Depth—top of liquid to inlet invert: n/a. �epth of solids layer: n/a epth of scum layer: n/a Dimensions of cesspool: n/a inaterials of construction: n/a dication of groundwater inflow(yes or no): NO omments(note condition of soil,signs of hydraulic failure,.level of ponding;condition of vegetation,etc.): /a RIVY: (locate on site plan) aterials of construction: n/a imensions: n/a epth of solids: n/a omments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a ., Page 10 of 1 1 • ;w OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C r SYSTEM INFORMATION(continued) l roperty Address: 35 FOX HOLLOW LANE OSTERVILLE, MA 02655 Qwner: KATZ Jute of Inspection: 8/22/03 KETCH OF SEWAGE DISPOSAL SYSTEM '. i rovide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. ocate all wells within 100 feet. Locate where public water supply enters the building. Ah !l0`° At r3 F Ac lU 32 �A�3D Poo et et 23 r _ Page II of II OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ` SYSTEM INFORMATION(continued) �roperty Address: 35 FOX HOLLOW LANE OSTERVILLE, MA 02655 wner: KATZ >�ate of Inspection: 8/22/03 r ITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 12+feet Please indicate(check)all methods used to determine the high ground water elevation: . O Obtained from system design plans on record- If checked,date of design plan reviewed: n/a ES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) O Accessed USGS database-explain: n/a ou must describe how you established the high ground water elevation: AND AUGER- 12+FT. it � l D►"r /a� WN OF BARNSTABLE 9'S 9 00 LOCATION�/ �� SEWAGE #� VILLAGE JL ASSESS R'S MAP Cz LOT INSTALLER'S NAME .PHONE NO f� t� t (� SEPTIC TANK CAPACITY LEACHING FACILITY:(type)_` (size) 14571W NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATE BUILDER OR OWNER �C�2 DATE PERMIT ISSUED: G DATE COMPLIANCE ISSUED: _ �S VARIANCE GRANTED: Yes No L � �� t/�T t r � .� i .�. No3l lz 'LC-' G-9 Fps...... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH 6'%.ct rU........ ......OF.._ . 1.6.- .. 3 Appliration fur Disposal Murky Tonstrudiun anti# Application is hereby made for a Permit to Construct X or Repair ( ) an Individual Sewage Disposal System t: ---------------1- . �� ocation-Address 5 n No. ... ...... ....: ........... (`''�- tic.... r c Owner ress Installer Address Type of Building 22 Size Lot._. j ---Sq. t V Dwelling—No. of Bedrooms_.�.d.....:......:.........................Expansion Attic Garbage Grinder46, '4 Other—T e of Building No. of persons............................ Showers — Cafeteria a' Other fixtures ............................ . W Design Flow.......t? ..........................gallons per person per day. Total daily flow--------3-3O........-. ............ s. WSeptic Tank—Liquid capacity.l�gallons Length�'�.... Width-A-10_ Diameter----___-.------- Depth.----... x Disposal Trench—No. .................... Width........-........... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.__.___.k-_.__-__ .. Diameter...._.......... Dep h below inlet...�2........... Total leaching area-Z �__sq. ft. Other Distribution box `7�5 Dosin�.#ank A P _ Percolation Test Results Performed by..'� AX-TET __.. _ C .......•. Date.. /i Lam• e.......__. as Test Pit No. 1-_4.�....minutes per inch Depth of Test Pit....y2-......... Depth to ground water_ -j0-T' CXX)kt Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ �+ -------- --- g LL .. ............ ...._.......--........................-...................................... O Description of Soil---Q^29C....S�l?. . !. ..._..2..-� 1_ .� x w x •--•••••-•-•.............•--•--•--------•••-•-•••-•••--•••••--------•••-••••----••••-••...•••-••--••----•-••••••••-•--•--••••----•-•--•-••••--•••--••----•••----•••--••••-•......-•••-•......--•-•----•- 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 iIHE 5 of the State Sanitary Code—The undersigned Art er agrees not to place the system in operation until a Certificate of Compliance has an issued by he b rd o � �' Brie • •--•----•• . . . .. . • ---•••-•••......-----• .. •• .... Application Approved By--...... ••.... -----Il� �k-7------- Date Application Disapproved for the following reasons---------------------------------------------------------------•----------------•-------------------------•••.. .............•--•-••--•-•-.........••---......_....•-••••-••-..............---•----•••••••-•---•---•••••.•--•---------••------••-----••-------•-------•---•••••-•••••••••-••••••-••-•-••••••---•--...... Permit No.... -- Issued........................ y�-•--•7c;*. ---------------- ----•----..........Date------ `/ Date y � � . / � % NoCam-� Fss.--•-•-------•--_....... 1-� ......,+:=--.._....._.....�: THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..................................t rlt ...........OF..... t}.t��N .. �- ............................... Appliration for Disposal VWorks Tonstrurtion Frrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal S stem t: l Cox- O Lt✓O\r,� d Ac N L LIB i i f(C.0 T . ..................................................•-•---•--•--.._...._..._...------_. ...---•--•---•-----•------..._•---.......-----...--•----�....-•---•�•--•------•---•----••---••- ' Addresof-Mt o. ( � S � �z1'. •---�-- ---� l-:�•t QU��..Y.`.`.� Owner dress a � Installer Address Type of Building Size Lot...zqj_ A...Sq. feet ., Dwelling—No. of Bedrooms............................................Expansion Attic ( Cb Garbage Grinder 4 Other—Type T e of Building No. of persons............................ Showers — Cafeteria P� YP g P ( ) ( ) PL4 Other fixtures .---•••...............••---••••• . ....-----•-•--......---•----- W Design Flow.._.._6...................................gallons per person per day. Total daily flow...... . ........................gallons. WSeptic Tank—Liquid*capacity` gallons Lengthe'�w"�..._. Width'- 3.0.. Diameter----..--....... DepthS•"_.5�... x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No._--.__�......_ _.. Diameter............... Depth below inlet...?............ Total leaching area.7�?_0..sq. ft. z Other Distribution box (`Js Dosin ank '-'. Percolation Test Results Performed by. •- --.... ..1!�:�!�f=-- �`-<<-----.----• Date..�-t.57/9.!S-__-...__.. 1a Test Pit No. 1.47�`'__.__minutes per inch Depth of Test Pit.__1Zc.......... Depth to ground water.NnT.C_tzr ccukA i�eZ:r Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ --•••--- ----• - -••-----•-----•- ...............•-----------......................................................... O Description of Soil ^2 ...OA wt.'.`�L. u 1�? !�'--•--� -s Z.....k � N. ....................................... ----------- -•......... •--••----------------- -------------- •............... -------••-••••-••-•••------------ --•------------------------------------------ -•----------------------------------•---. W ._.•-•••--••--------------•••---••••••••-••--•-•-•-...•••••••-•---•••-•••••••---•---•-•••--•-•._..--•••--••--•--••••••--•-••----••••----••••--•-••••-•---•••-....-•-•-----•••••-...........•••--•_----•- UNature 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 T I TLE 5 of the State Sanitary Code—The undersigne rt er agrees not to place the system in operation until a Certificate of Compliance has 9, en issued b the Vard e t lgrie�-- ------•-- f g - ` ---•••----•- . .�(... .....--••-- ate Application Approved B �1__.___ '_ _ :_�%.._... . . 2- , PP PP Y --- •. •-••--•-- ----�� _ Y "� Date Application Disapproved for the following reasons---------------••-----•-----...••------------•-•---------------•-----------.....----.....-•--••------._......-•- ____•-----•-••••-•-----....•----••-••-----------------••------•-•----------------....._.....•----....-•••••--------•••-•------•-----••-•-•----•------•••-•-•••---•-•••-••-••••--••-••••••--•..........._ Date PermitNo� .- `�-- ...... Issued....................................................... ttt Date Y THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........OF +K /.. `.,/...f�. .( ............................... TrrtifirFate of TotnpliFana TH IWO CERTIFY, That the Individual Sewage Disposal System constructed ) or RepairedbY---...... � .�/F �:.N. �. .............•--•----...----...._...... Installer y;- � 1` j..- has been installed in accordance with the provisions of IE 5 of Th State SanitaryCode as escribed in the application for Disposal Works Construction Permit No •°--"i°-_'t' dated . PP P I----•••-- -- _ a THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. �/_..... .......... Inspector...----•................. --__-_-•-•---.._------------_--_-...----- DATE._.......... -'=-.c._..�_� _1.D THE COMMONWEALTH OF MASSACHUSETTS ll � ))11 x BOARD OF HEALTH � -0F... PdQ ................. N 1 FEE.. _ ................. %Vos al Works Tontrurtion rrmit Permission is hereby grante-Ge._ b r.._..r .�� - .1................................................................ ._._.__._�. x X, / to Construct ) or Repair (' ) an Individual Sewage Disposal ystem o at No. _ -----•-••-••--- •-- ------------•_-_-__--___-__ l Strut- as shown on the ap cation f r Disposal Works Construction a dnit i7,rl. .. D t -1 3.l,r_ �a T� �, �_......... Board of Health DATE.......... f/!.{ ............./----------------------------------------------- FORM 1255 HOBBS & WARREN, INC., PUBLISHERS -7777 ZJ S � 6 dd �" ys 12J� o clz S — /9 , 1 �LIZ -5q e f• �.a .. -, Lam. _t - ._. \ '(A/../ G 0 , i t j in +W-CHARD t� - D 4V, 404yrz� 1 t BAXT�S_ Fin, ST7. D b 124�•/ nib of Myss PeA�✓ ! F -7 �A/4 ' ��.�. U ,..49 r' r� I