HomeMy WebLinkAbout0137 GUNSTOCK ROAD - Health ,4
137 Gunstock Road
..T Osterville P
y A = 121 107
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COMMONWEALTH OF M.A.SSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
RECEIVE®
AUG 1 1 2003
TITLE 5 TOWN OF BARNSTABLE
HEALTH DEPT.
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A _
CERTIFICATION (SAP
Property Address: 137 Gunstock Road PARCEL
Osterville, MA toT
Owner's Name: Phil Larosa
Owner's Address:
Date of Inspection: r
Name of Inspector:(please print) Wi 1 1 i am _ • Robinson Sr.
CompanyName: William E. Robinson Septic Service
Mailing Address: P 0 Box 1 089
Centerville, MA
Telephone Number: (508) 775-8776
CERTIFICATION STATEMENT
1 certify that I have personally inspected the sewage disposal system at this address and that the information reported .
below is true,accurate and complete as of the time of 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:
t/Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: e,'v � ��— Dutei 0`3
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 die
DEP.The original should be sent to.the system owner and copies sent to the buyer,if applicable,and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page I
l ;
Page 2 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:_ 137 Gunstock Road
Osterville
Owner. Phil Laro a .
Date of Inspection:
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. Sy m 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:
B System Conditionally Passes: .
One or more system components as described in the"Conditional Pass"section need to be replaced or
repair d.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer y s,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please
explain.
The s tic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound,cxhrbits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the
existing tank A 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 a tank is less than 20 years old is available.
ND explain:
Observa ion of sewage backup or break out or high static water level in the distribution box due to-broken or
obstructed pipe(a)or due to a broken,settled or uneven distribution box.System will pass inspection if(with
approval of Bo d of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The ystem required pumping more than 4 times a year due to broken or obstruxted pipe(s).The system will
pass mspe ton if(with approval of the Board of Health):
broken pipe(s)are replaced _
obstruction is n=vcd
ND explain:
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 137 Gunstock Road
Osterville
Owner:
Date of Inspection:- —(j
C. F rther Evaluation is Required by the Board of Health.
C nditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing t rotect public health,safety or the environment.
1. Syste will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
syste is not functioning in a manner which will protect public health,safety and the environment:
_ C spool or privy is within 50 feet of a surface water
_ Cc spool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
r
2. System ill fail unless the Board of Health(and Public Water Supplier;if any)determines that the
system is fu ctioning 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 ater supply or tributary to a surface water supply.
system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
e system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ e system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
pri ate water supply well** Method used to determine distance
'This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
acteria and volatile organic compounds indicates that the well is free from pollution from that facility and
t e presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
fa ure criteria are triggered.A copy of the analysis must be attached to this form.
3. Othe
3
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 137 Gunstock Road
Osterville
Owner: Phil Lar sa
Date of Inspection:
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes 0
Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
Liquid depth in cesspool is less than 6"below invert or available volume is less than%day flow
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 f et from a private Rater
supply well with no acceptable water quality analysis.(This system passes if the well water analysis,
performed at a DEP certified laboratory.,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E: arge Systems:
To b considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd•
You ust indicate either"yes"or"no"to each of the following:
(The llowing criteria apply to large systems in addition to the criteria above)
yes 0
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a stuiace 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 y 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 err operator of arty large system considered a
signi cant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.30 .The system owner should contact the appropriate regional office of the Department.
4
y
Page 5 of l l
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 137 Minstoc-k Road
osterville
Owner: ---
Date of Inspection:
Check if the following have been done.You must indicate`yes"or"no"as to each of the following:
Yes o
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?
l�Have large volumes of water been introduced to the system recently or,as part of this inspection
41 Were as built plans of the system obtained and examined?(If they were not available note as N/A)
k'_ Was the facility or dwelling inspected for signs of sewage back up?
t/_ Was the site inspected for signs of break out?
III
—42/_ 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 baffleess ortees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? ^
_ 1,/Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:.
Yes .no /
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(3)(b)j
5
Page 6 of l 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 137 Gunstock Road
Ost rvill
Owner: Phi 1 Larnsa
Date of Inspection: --O 3
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):, Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): J G 0
Number of current residents:&Z
Does residence have a garbage grinder(yes or no):A-0
Is laundry on a separate sewage system(yes or no):A-G [if yes separate inspection required)
Laundry system inspected(yes or no): v
Seasonal use:(yes or no): O
Water meter readings,if available(last 2 years usage(gpd)):
Sump pump(yes or no): �a
Last date of occupancy:
COMMERCIAL/I USTRIAL
Type of establishme t:
Design flow(based c n 3I0 CMR 15.203): gpd
Basis of design flow seats/persons/sgft,etc.):
Grease trap present( es or no):_
Industrial waste hol ing tank present(yes or no):_
Non-sanitary waste ischarged to the Title 5 system(yes or no):_
Water meter read' gs,if available: 2001 52, 000 2002 50, 000
Last date of occu ancy/use:
OTHER(descri e):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part of the inspection(yes or no): A-U
If yes,volume pumped:_gallons--How was quantity pumped determined?
Reason for pumping:
TYPF,OF SYSTEM
eptic 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 contact(to be
obtained from system owner)
_Tight tank Attach a copy of the DEP approval
_Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Were sewage odors detected when arriving at the site(yes or no): i v
6
]'age 7 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 1 '17 r;,,nctnr�k Road
osterville
Owner: phi 1 T.a o a
Date of Inspectlon:
BUILDING SEVER locate on site.plan)
Depth below grade:
Materials of construct on:_cast iron _40 PVC other(explain):
Distance from privat water supply well or suction line:
Comments(on cond' ion of joints,venting,evidence of leakage,etc.):
SEPTIC TANK:--Oocate on site plan)
I
Depth below grade: / /
Material of construe tion: ,_/concrete_metal fiberglass_polyethylene
—other(explain)
If rani:is metal list age:-,is age confumed b
certificate) y a Certificate of Compliance(yes or no):—(attach a copy of,
� / � � r�
Dimensions:
Sludge depth: 9 y'
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness:
Distance from top of scum to top of outlet We or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle: ` I
How were dimensions detcrntmcd:
Comments(on pumping recommendations,inlet and outlet tee or baffle conditicn,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
GR SE TRAP:_(locate on site plan)
Depth b ow grade:—
Material f construction:_concrete metal fiberglass_polyethylene other
(explain):
Dimensio s:
Scum thic ess:
Distance om top of scum to top of outlet We or baffle:
Distance om bottom of scum to bottom of outlet tee or baffle:
Date of I st pumping:
Common s(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as relate, to outlet invert,evidence of leakage,etc.):
7
Page 8 of 1 I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 137 Gunstock Road
Osterville
Owner:
Date or Inspection:. —G 3
TIGHT or H DING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below gr de:
Material of con ruction: concrete metal fiberglass_pol,yethylene other(explain):
Dimensions:
Capacity: I allons
Design Flow. allons/day
Alarm presc (yes or no):
Alarm level: Alarm in working order(yes or no):
Date of las umping:
Comments ondition of alarm and float switches,etc.):
DISTRIBUTION BOX: "(if resent must be o ened locate on site plan)
P P )( P )
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.):
PUMP CHAMBER: (locate on site plan)
Pumps in wor•ing order(yes or no):
Alarms in wo king order(yes or no):
Comments(n to condition of pump chamber,condition of pumps and appurtenances,etc.):
8
Page 9 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 137 Gunstock Road
O Prvi11
owner:
Date of Inspection: '0 3
SOIL ABSORPTION SYSTEM(SAS): /(locate on site plan,excavation'not required)
If SAS not located explain why:
Type �.
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.):
J
CESSP OLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number a d configuration:
Depth—to of liquid to inlet invert:
Depth of s ids layer:
Depth of sc im layer:
Dimension of cesspool:
Materials o construction:
Indication f groundwater inflow(yes or no):
Comments ote condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
PRIVY: locate on site plan)
Materials of co struction:
Dimensions:
Depth of soli
Comments( to condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 137 Gunstock Road
Os _ ryi 1 1 _
Owner: Phil T,;;
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building.
c iL
l�
1
S3
10
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 137 ins c) -k Read
Osterville
Owner. Phil Larosa
Date of Inspection: Z:—`l —f�
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-if checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground wat e 471
11 -
f
a
r COMMONWEALTH OF MASSACHUSETTS ti 3
EXECUTIVE OFFICE OF ENVIRONMEN AIRS =
DEPARTMENT OF ENVIRONMENTAL C r 3
ONE WRITER STREET,BOSTON MA 02108 (617 -5500
MA 4 O
� �ECENE
WILLIAM F.WELD 167 TRUDY
Governor F MAR 1 1 1997 SK
ARGEO PAUL CELLUCCI B. S
Lt. Governor TOWN nr BADRNS S
HEALTH DEFT. o s4 r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Oj s
PART A
CERTIFICATION
Property Address: t3"1 oSMe-V1 \\L Address of Owner:TtT%c..p%� �' ��"' �' L`S
Date of Inspection: c4kOS\,jj t (If different) 1355 Srr��r t?xX 2c�
Name of Inspector: N C�r`�I.a��R -k..� 8c\e ]e�� F'\�.
Company Name, Address and Telephone Number:
341't
pTLANMAr , '�uti�\ .a t_ 1?p_t�,O& at16y I V-A A,. 02-e yg Csa$�
CERTIFICATION STATEMENT I
I certify that I have personally,inspected the sewage disposal system at this address and that the information reported be!ow is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
Passes
_ Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: Date: 0?1xr15-i
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this
inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit
the report to the appropriate regional office of the Department of Envircnmental Protection.
The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority.
INSPECTION SUMMARY:
Check A, B, C, or D:
A] SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
B] SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired..The system, upon completion of the replacement or repair,
passes inspection.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not.
The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as
approved by the Board of Health.
(revised it/o3/9s) 1
�� 1'nntni�n R•c�rlrA P,lcr•r
r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
I � PART
CERTIFICATION (continued)
. N
Property Address: 1,
Owner:
Date of Inspection:
'1-.J) .
B] SYSTEM CONDITIONALLY PASSES (continued)
box i due to broken or obstructed
tacit water level observed in the distribution
_ or breakout or high s
Sewage backup g
pipe(s) or due to a broken, settled or uneven distribution box. The system will pass ' spection if(with approval of the
Board of Health):
broken pipe(s) are replaced
•�; : obstruction is removed
distribution box is levelled or replaced
_ The system required pumping more than four times a year due to broke or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipes) are replaced
obstruction is removed
Cj FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board Health in order to determine if the system is failing to protect the
public health, safety and the environment.
i) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETE MINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND FETY AND THE ENVIRONMENT:
_ Cesspool or privy is within 50 feet of a su ace water
Cesspool or privy is within 50 feet of a� ordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF/HEALTH HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MA NER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tan and soil absorption system and is within 100 feet to a surface water supply or tributary to a
surface water supply.
_ The system has a septi ank and soil absorption system and is within a Zone I of a public water supply well.
_ The system has a sep c tank and soil absorption system and is within 50 feet of a private water supply well.
_ The system has a s tic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private wate
supply well, unle a well water analysis for coliform bacteria and volatile organic compounds indicates that the we!1 is
free from pollu 'on from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than
ppm•
3) OTHER
(revised 11/03/95) 2
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: --
Owner:
Date of Inspection:
DJ SYSTEM FAILS:
I have determined that the system violates one or more of the following failure crite a as defined in 310 CMR 15.303. The basis
for this determination is identified below. The Board of Health should be contact to determine what will be necessary to correct
the failure.
Backup of sewage into facility or system component due to an overl ded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or s ace waters due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution box above outlet invert d e to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or ava'able volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year N due to clogged or obstructed pipe(s).
Number of times pumped_
Any portion of the Soil Absorption System, cesspool /or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 et of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a one I of a public well.
Any portion of a cesspool or privy is withi 50 feet of a private water supply well.
Any portion of a cesspool or privy is le than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If tote we!I has been analyzed to be acceptable, attach copy of we!I water analysis for
coliform bacteria, volatile organic cgtounds, ammonia nitrogen and nitrate nitrogen.
Ej LARGE SYSTEM FAILS:
The following criteria apply to large s tems in addition to the criteria above:
The system serves a facility with a esign flow of 10,000 gpd or greater (Large System) and the system is a significant threat to
public health and safety and the nvironment because one or more of the following conditions exist:
the system is within 00 feet of a surface drinking water supply
the system is wit in 200 feet of a tributary to a surface drinking water supply
the system is I cated in a nitrogen sensitive area (Inte.rim Wellhead Protection Area (IWPA) or a mapped Zone 11 of a
public water upply well)
The owner or operator of an such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR .00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 11/03/95 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: \7-1 C-�U rJsTo�-X--
Owner: go V Y-ec L.t S
Date of Inspection:
Check if the following have been done:
Pumping information was requested of the owner, occupant, and Board of Health.
-4 None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
As built plans have been obtained and examined. Note if they are not available with N/A.
AThe facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow.
The site was inspected for signs of breakout.
All system components, excluding the Soil Absorption System, have been located on the site.
The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or
�(tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
\The size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-
-1_5urface Disposal System.
(revised 11/03/95) 4
N
SUBSURFACE 'SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:L7 31 (rjtlN��x.�_
Owner: ou V-PL�%
Date of Inspection:
l 'FLOW CONDITIONS
RESIDENTIAL:
Design flow: 330 gallons
Number of bedrooms:_Qa?
Number of current residents: 0
Garbage grinder(yes or no): NO
Laundry connected to system (yes or no):l
Seasonal use (yes or no): l�
Water meter readings, if available: uih
Last date of occupancy:
COMM ERCIAUINDUSTRIAL:
Type of establishment:
`Design flow:_gallons/day'
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non-sanitary waste discharged to the Title 5 system: (yes or no)_
Water meter readings, if available:
Last date of occupancy:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as part of inspection: (yes or no)_
If yes, volume pumped: eallons
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)
Other (explain)
APPROXIMATE AGE of all components, date installed (if known) and source of information: IS QS
Sewage odors detected when arriving at the site: (yes or no)
(revised 11/03/95) 5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 1"b7 EtUNS�c—V—
Owner: ��t�5
Date of Inspection:
SEPTIC TANK: S
(locate on site pl n)
Depth below grade: l2l
Material of construction: I.concrete _metal _FRP —other(explain)
Dimensions: la
Sludge depth: 0" u
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: t�_ It
Distance from top of scum to top of outlet tee or baffle:_ tl
Distance from bottom of scum to bottom of outlet tee or baffle:_I
Comments:
(recommendation for pumping, conditi n of isle nd outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.) �� � �S t►JTftS�-�L.1''"%d °-\sl
.LrjV K )N o
GREASE TRAP:_
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _FRP —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:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.)
(revised 11/03/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: k-bl �V"vTY—K--
Owner: b,k.fiLi s
Date of Inspection: a ICI.17
TIGHT OR HOLDING TANK: 00
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _FRP—other(explain)
Dimensions:
Capacity: eallons
Design flow: Rallons/day
Alarm level:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX: „
(locate on site plan)
Depth of liquid level above outlet invert:.it�w/OJ rJ�
Comments:
(note if level and distribution is a ual, eevidence of solids carryovecr, evidence ofleakage into or out of box, etc.)
PUMP CHXL tBER: NV
(locate on site plan)
Pumps in working order.(yes or no)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 11/03/9 1 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: %'51 G1dNST-00�
Owner: �)M>w+4 S
Date of Inspection: \2S\g7
SOIL ABSORPTION SYSTEM (SAS): 5
(locate on site plan, if possible; excav tion not required, but may be approximated by non intrusive methods)
If not determined to be present, explain:
Type:
leaching pits, number: Kt,
leaching chambers, number:_
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition `of veoetation,etc.)
\ -Shy—Igo Sl S
CESSPOOLS: LQ
(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 (cesspool must be pumped as part of inspection)
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised 11/03/95) $
1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 31 C-7vticTo`��
Owner:lbbo IG�tI\S
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
2,—(
R
63 - 17
DEPTH TO GROUNDWATER
Depth to groundwater: '1 2J) feet `
method of determination or approximation: v. oil0 Q \I \G
(revised 11/03/95) 9
COMMONWEALTH OF MASSACHUSETTS
x EXECUTIVE O.FFI,CE OF ENVIRONMENTAL.AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
t
TITLE 5.
OFFICIAL INSPECTION.FORM—NOT FOR VOLUNTARY:ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: d
Owner's Name
Owner's Address:
Date of Inspection:
Name of Inspector: (please print)
Company'Nam.
Mailing Address:
Telephone Number:
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 CMR 15.000). The system: -
Passes
Conditionally Passes
eeds Further Evaluation by the Local Approving,Authority
ai
ls
�.. Date:"
Inspector's,Signatu ',
w .
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.
Notes and.Comments .
****This report only describes conditions at:.the time of inspection and under the conditions of use at that
stem will perform in the future under the same or different.
time.This inspection does not address how the sy
conditions of use.
a
Title 5 Inspection Form 6/1.5/2000 page
v
Page 2 of lI e
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS .
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: r �
Owner:
Date of Inspectio : 3 //D/
Inspection Summary: Check A,R,C;D or E I ALWAYS complete all of Section D
VA. S stem Passes:
I have not found any information which indicates that any of the failure criteria described in 310 CMR
15. 03 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.
Answer yes,no or not determined(Y,N;ND)in the for the following statements. If"not determined".please
explain.
The septic tank is metal.and over 20.years old*or the septic tank(whether inetal or not)is structurally
unsound,exhibits.substantial infrltfation or exfiltration or.tank failure is imminent:I System'will pass insp'ection'if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed .
distribution box is`leveled or replaced
ND explain:
.The system required pumping more than'4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with approval•of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
Page 3.of 11:
s OFFICIAL INSPECTION FORM :.NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE.SEWAGEDISPOSAL SYSTEM INSPECTION FORM
`PART A
CERTIFICATION(continued)
Property Address: M 7
i
Owner
Date of Inspectio ) i 'le/
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'env iron ment:
— 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
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 pnvate.water supply well-
The system has a septic tank and SAS and the SAS.is less than.100.feet but 50 feet or more from_a.
private.water supply well".Method used to.detennine distance
"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.:
3
Page•4 of 11
P
OFFICIAL-INSPECTION FORM-NOT FOR.VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGT DISPOSAL SYSTEM INSPECTION FORM
PART A.
CERTIFICATION(continued)
Property Address: , 2eAy&zTW
Owner:
Date of Inspection-!-
D., System Failure Criteria applicable to all systems:
You must indicate"`yes"or"no:"to each of the following for all inspections:
Yes No
_,/B. ackup of sewage into facility onsystem component due to overloaded or clogged SAS or cesspool
;!/ Discharge or ponding'of effluent to the surface of the ground or-su�face 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 rcesspool
/Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2day flow
Required.pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped .
_ V 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
6.Any
water supply.
portion of a cesspool or privy
'is within a Zone 1 ofa public`well.
_ _LoAny 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 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
1; gto or less than ppm;provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.)
(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of
Health to determine what will be necessary to correctthe failure.
E. Large Systems:
To be:considered a large system the system must serve`a facility°with;a design flow of 10 000 gpd to 15,000
gpd.
You:must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
— 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 public water supply well
If you have answered"yes"to any questibn in' Section E the system is considered a significant threat,or an
"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.
4
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR YOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM'INSPECTION FORM
PART B j
CHECKLIST
Property Address:
Owner:
Date of Inspectio .J //
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 Boardoniealth
i/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?
— _LZ 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 inspec.ted.for signs of sewage back up?
— Was the site inspected for signs of break out?
I�— 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
�thbaffles
o or tees,material of construction,dimensions,depth.of.liquid,depth.of sludge.and.depth.of scum?
— Was.the facility owner(and occupants if different fromowner)provided with.information on the proper
maintenance of subsurface sewage disposal systems
The size and location of the Soil Absorption System`(SAS)on the site has been.determined based on:
Yes no
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(3)(b)]
.. 5
Page 6 of l l
' OFFICIAL INSPECTION FORM-NOT FOR VOL'UNTARY-ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL-SYSTEM INSPECTION FORM
PART C
SYSTEM JNFORMATION
Property Address:
Owner:
Date of inspection—
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): ;.3. Number of bedrooms(actual):: .
DESIGN flow based on 310;CMR 15:203 (for example: 110 gpd x#of bedrooms):3
Number of current residents: .
Does residence have a garbage grinder(yes or no):
Is laundry on a separate sewage system (yes or no lif yes separate inspection required]
Laundry system inspected(yes or no)-
Seasonal use:(yes or no) 14—
Water meter readings, if available(last 2 years usage(gpd)):
Sump pump(yes or no): n
Last date of occupancy: �
COMMERCIAL/INDUSTRIAL/"—
Type of establishment
Design flow(based on 310 CMR 1..5.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):_
Industrial waste holding tank present(yes or no):_
Non-sanitary waste discharged to the Title 5 system (yes or no):_
Water meter readings, if available;
Last date of occupancy/use: .
OTHER(describe):
GENERAL INFORMATION
Pumping Records _
Source of information: '` 17
Was system pumped as.part of the inspection(yes or no
If yes,volume pumped: gallons- I.ovr v as.quantity pumped determined?
Reason'for'pumping:
TY_AeP F SYSTEM
eptic 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 copyof the DEP approval
—Other'(describe):
A proximate a e of all components,date installed(if known)and source of information:
Were'sewage odors detected when arriving at the site(yes or no)
6.
Page 7 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM.INFORMATION(continued)
Property Address: )C7
Owner:
Date of Inspectio D
BUILDING SEWER(locate on site.plan)
Depth below grade:
Materials of construction: cast iron _40 PVC_other(explain):
Distance from private water supply well or suction line:.
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: Z/ (.locate on site plan)
Depth below grade: 1t�
Material of construction: .✓concrete_metal_fiberglass____polyethylene
_other(explain).
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate) , a
?(Dimensions:
Sludge depth:
Distance from top of sludge to bottom.of outlet tee.or baffle: a.
Scum thickness: /0 2
Distance from top of scum to top of outlet tee or baffle: a
Distance from bottom of scum to bottom of outlet te@ or baffle: z "
How were dimensions determined: Liilwt
Comments(on pumping recommen a�, Inlet and outlet tee or baffle condition,structural integrity, liquid levels
related to outlet invert,evidence of leakage,etc.):
� GL /GCS • i
GREASE TRAP (locate on site.plan)
Depth below grade:
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:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels,
as related to outlet invert,evidenced leakage,etc.):
7
I,
Page 8 of I I
OFFICIAL INSPECTION FORM=NOT FOR YOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTI'M INSPECTION FORM
PART•C .
SYSTEM INFORMATION(continued)
Property Address: 4X01
Owner:
Date of Inspectiod: 3// /0 1
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/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes'or no):
Date of last pumping:
Comments(condition of alarm and float switches, etc.):
DISTRIBUTION BOX: 1/(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
akage into or out of box,etc.):
PUMP CHAMBER/ ocate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments{note condition of pump chamber,condition of pumps and appurtenances,etc:):
8
4 4
,
Page 9 of 11 +r
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: ''
Owner: -
Date of Inspection: 1 f
SOIL ABSORPTION SYSTEM (SAS): 1/ (locate on site plan,excavation not required)'
If SAS not located explain why:
0/ leaching pits,number:
leaching chambers,number:
Leaching galleries,number: 1 a
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,
e c.):
11'
CESSP00% (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 or no)
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY%"(locate on site plan) w
Materials of construction:.
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
Page 10 of 11
OFFICIAL INSPECTION:FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE'SE WAGE DISPOSAL SYSTWINSPECTION FORM
PART:C.,
SYSTEM INFORMATION(continued)
Property Address:
4
Owner:
Date of Inspecti.ot : "Z�/I to
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or '
benchmarks. Locate all wells within-100 feet.Locate where public water supply enters the building.
r 1
4
10
Page l l of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)'
Property Address:
44,4
Owner
Date of Inspection: 5, , Jo
SITE EXAM
Slope' S
Surface water
Check cellar
Shallow wells
Estimated.depth to ground water_ 4 feet }
Please indicate(check).all methods used to determine the high groundwater elevation:..
Obtained from system design plans on record-If checked,date of design,plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with.local excavators, installers-(attach documentation) r
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Ze
' - 41
I1
L O C A T ION SEWAGE PERMIT NO.
r?
VILLAGE
i INSTA LLER'S NAME i ADDRESS
UU4LDE R OR OWNER
M. K
DATE PERMIT ISSUED 2 ��
DATE - COMPLIANCE ISSUED _,2 _ ve
i
LA
a
i
I
Fimz
THE COMMONWEALTH.OF MASSACHUSETTS
SOAR® OF 1-IEA1_Tt-1��
�.. /..................0 F.....13iPSI z l ....................................................
Appliration for Piopootal Works Tomitrnrtion Vernat
Application is hereby made for a Permit to Construct A or Repair ( ) an Individual Sewage Disposal
System
a� �v...... .. — 1 .:-- .- ........ ....
,. •" -----Location-Ad
r Lot No
caner Address
--____A ' r ....................
W
Inst er Address ��--
Type of Building Size Lot._. �..Sq. feet
Dwelling—No. of Bedrooms.......______...............................Expansio ttic.( ) Garbage Grinder ( )
`4 Other—T e of Building No. of persons____________________________ Showers — Cafeteria
a' Other.fixtures ---------------------------------------------- --------------------------------
•----..._._...-•-•-- .._____-------_----
W Design Flow............................................gallons per person per day. Total daily flow.._.._.______________________.__..__________gallons.
WSeptic Tank—Liquid capacity_:..........gallons 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 lank ( ) �j `
a
Percolation Test Results Performed b ..___ .. v vl�_ _____________________ Date._ _ ___,__ e ______.___....
a Test Pit No. 1__E_'__. __..minutes per inch Depth of Test Pit____________________ Depth to ground water.........................
44 Test Pit No. 2...!!�_.Z+.minutes per inch Depth of Test Pit____________________ Depth to ground water.........................
......
.. ---...---. ------ ---- Z�� --••r•-•....................•-----•-- --
O Description off Soilv.... . S. l.' :.... Y� -----------------� --._&.o 2
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 TLITLU 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has.been issued by the jg4rd f
ned_ ......... ......
Da
or
Application Approved ..... -------------------------------------- .. ..---L -...... ............
Date
Application Disapproved for the following reasons----------------------------------•--------------------•----•••--------------•--------•----••-•------•••_---•--
.............................•--•----••-----------------------•-----------•----------------•--------.....---------...---•-----------------------•------------------------------•------------------------
Permit No.................................••- Issued---••_. _._ ------------------
Date _
_ -----------•--- ----• e_
GV
Fns.... .li ._
THE COMMONWEALTH OF MASSACHUSETTS
/ BOAR OF HEA�TF-���
f...��,�lJ..............OF...... . 'r .f ........-----
ApplirFation for Uiipusaal arks Tumitrnrtion Vantit
Application is hereby made for a Permit to Construct,(A) or Repair ( ) an Individual Sewage Disposal
Sat:
... :. - - - __ .. ..� ........ ....... ................
ocation-
Add N
caner Address
•-•--------- ------ -•-•--q-•-••:....•------------------•-•.. .__...•••....-_•----•_-•- •--••--...__••••••-........_...---•--•-•--•---•-•--•--.
o.._...........---........-•---.....-•-•---•-
Address
d Type of Building { Size Lot___ _-.Sq.- feet F .
Dwelling—No. of.Bedrooms----
__....................................._Expansion-Attic ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons......... _ ............. Showers ( Z- — Cafeteria ( )
dOther fixtures ---------------------------------------•---•----- ---••••-•--••••--•-•••---••_•_. •---------• - .....:.....: .....
W Design Flow........................................____gallons per person per day. Total dailyflow___..._.________._____________.___________.. lons.
WSeptic Tank—Liquid capacity............gallons 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 a ( ) ra
Percolation Test Res lilts• Performed byc _. ,��?� '' Date /__-_� V---'�'`--
04 Test Pit No. I......... ___minutes per inch Depth of Test Pit____________________ Depth to ground water___................_.__.
(i Test Pit No. 2___�"__�G__''_minutes per inch Depth of Test Pit____________________ Depth to ground water...................
-
O D }ipt�n o Soil�'� .. _ � �t'.._.. _ / i`-� ..--• -•-
V ._...._ '�'--•--=�.�_..i ....................................................................................................................
-''•---------------------------------------------------•--------------------------.....------....---------
•--•------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•----•-•---••••-
U Nature of Repairs or Alterations—Answer when applicable................................................................................................
................-.................................................................••-•--•••-----•----•-....••-••••--------------•••-•--•••---•••------................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLZ 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance ha is ,4eei ued by the rd e
gned
y :-
Date
Application Approved By..-----,,,' -�.......!.�______, .. .
'Application
Disapproved for the following reasons: �/ ..............:.
-•------••----------•----------------•---•-----------------.....----•--------------._.........---------....--------------•--------------------------------------.-..-----------------------...••---••----
Date
PermitNo......................................................... Issued-.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Ik
!v..........OF...... �-/..�. �� 's" ...................
Tntifiratr of ToutpliFattrr
IS IS'TO CE IFY That the Individual Sewage Disposal System,constructed ( or Repaired ( )
Y--- ...e
4�t ......................;. .....5 ..........."---------
/ - Ins Pier
at................................. -_-------------------- ................
.................. ...../ ........................
has been installed in accordance with the provisions of T 1TLP, 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No... `____er____7,5......... dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.......f•_a..` .._ ... Inspector..
--------•---•..................................................
_
THE COMMONWEALTH 'OF MASSACHUSETTS
BOARD F HEALT
(No' �. 3.... OF.... - - '? FEE... ... .
-
uisvrr� 1 Works (ffn !r uaat pamit .y 1
Permission is hereby granted.._. 1'" � .."•' ,.
to Construct ( ) or Repair ( ) an Individual Sewage Disposal System '
atNo........................................................................................................... -----••--------•-••--•------•--------------•------•-••••••-••--•••-....---•-.......
Street
as shown on the application for Disposal Works Construction-Permit No..................... Dated..........................................
....
Board,,gf Aealth
DATE-----
�. -3 -
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS .. .. },
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No.22162'ONAL
'4 �,. LEGEND +
� - I$TINO SPOT ELEVATIO"N OXO CERTIF
EX IED PLOT•
. EXISTING CONTOUR --- p -- -
FINISHED SPOT ELEVATION 0.0 G v
,t FINISHED CONTOUR 0 5 7--t �'' ��- �' � ��f►ta,
APPROVED , BOARD OF HEALTH IN
DATE .,
AGENT SCALE: l — O'DATE`S
[,DREDGE ENGINEERING CO.
` CLIENT '
I CERTIFY : THAT , THE • PROPOSED`,E C`!VIL E LE( ERED JOB NO. Fe)0 �'9i BUILDING SHOWN ONTHIS PLAN
CIVILND CONFORMS TO THE ZONING LAWS
i, EP10'INEER YOR DR.BY= 0F'' BAt:N$:T LEA MA 9.
712 MAIN ST. CH. BY=
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SHEETL OF �` DATE REO. LAND . SURVEYOR
'XI "4 7 /VOTE;: %F E/TNeR TNESEPT/C TANK OR
/NG P T/ ARLa /y ORE THA/V /2"BELOW
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CO1vG4BTB iy/N• P/TCN s ti ,�` !''•EAVY C/1 ST /RO/Y GOV,&R SHALL 49E USE,
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2+LAYER
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PE U L� -'j/B
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WPER IT, TANfC BOX ° i i ° • • • • • :°o °
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IN•G -F-PISTR/el/T/ON BOX FT. SECT/ON OF
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SEJ�VAGE O/S�OSA L SYSTEM
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