HomeMy WebLinkAbout0070 HOLLINGSWORTH ROAD - Health 70 HOLLINGWORTH Rhl��D
_ x OSTERVILLE
A = 140 076
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Commonwealth of Massachusetts 3 f,l U• , ;>�� t , e +; ;µ ,�.:.
Title 5 Official Inspection.-Fdr" i w '
Subsurface Sewage Disposal System Form-'Not for Voluntary Assessments,t. '+ .d-:T-
'4
70 Hollingsworth
Property Address !0,4A _V-
HOLLANDER, RONALD S &TOBY S ' .` ,t 't .v �' 1'' "+ . + s .. _'•,i
Owner Owner's Name r=-t,a
information is r i
required for every Osterville'� Ay'! MA 02655 7/7/2Wi f f
page. City/Town` ^'Y State Zip Code - Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the;end of the form.
Important:When filling out forms A. Inspector Informations {(.!-�(�
on the computer,
use only the tab Michael DiBu0n0 •-
key to move your Name of Inspector •-
cursor-donot `� r �r, ..�* =' , ' t �?t t• t ?y ;., �rkl r;,
use the return DiBuono Sewer And Drain
key. Company Name
35 Content Ln ..r_t .�
r� Company Address
Cotuit •^Ma -1► . f ,i.V"i+ Y t = 02635
Cityrrown State Zip Code
508-364-9587 S113522-
Telephone Number License Number
B. Certification- -
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposalsystem at the property address.
_ listed above; the information reported below is true, accurate and complete as of.the time of my
inspection, and the inspection was performed based on my training and:experience in the proper function
and maintenance of on-site sewage disposal systerris.•.After, conductingthis.inspection I have determined
that I!'
system: y
''I.jt ®' Passes 3.ir I, i:.• F �'; dr� '�I' .Piq;:'.is M!, i•..P.rt '1'4'r fc 1.`,%L+
+:r iV t '✓� ',.�.it.' iw+o% << ail .
r,12. ; ❑. Condltlonally.,Passes.-�
t1 if A.tr y».�3 rr �4i a.. 7 C4 � Q� . l;i' t y�.} I i',.,t"�t.!� �.�:�.� 111 ' i
3.. +D;Needs Further,Evaluation by the:Local Approving!Authority x i' ,
4. ❑ Fails < ..tit �;t•I
0"r !_li l !) .'oi 7. fI 4:.•, t'+Mti V+".' .t-, } 7 •+:'•'... '•1 a1+tF f� G'Jf:.i",fr^• ��.
.It'.., .1" ' ..•%�'. .—Ii�,1:. 'r! �`'�iT�M�,i i a�+�Uaf'�.,s�l'r�t.h;.i��,.,r}�; .
r i ,7/8/20 ;A, ;--,
Inspector's Signature " Date 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 has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
9Y p
the buyer, if applicable, and the approving authority:
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time.This inspection does not address how the system will perform
' in the future under the same or different conditions of use.
t5insp.doc•rev.7/26/2018+ . .+ t Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of.18:. :y
Commonwealth of Massachusetts f141 ,':1, ,' t `U
Title 5 OfficialsInspectionsF.ormy
Subsurface Sewage Disposal System Form,INot for Voluntary Assessments .,• : J%,'
70 Hollingsworth
Property Address
HOLLANDER, RONALD S &TOBY S `,'� " '. ;,.r .art y-a'►. . ' +
Owner Owner's Name
information is required for every Osterville` !;. c f. a'.!l MA 02655 7/7/20
' - k
page. City/Town,� 1 46 State Zip Code Date of Inspection
C. Inspection Summary
^$ t �._ �'.. ` "t ,i i,s' 'F_ < k' ` *) r�i.,;•.,. c..� s- r" ri: ' ' . t.`11 ::a
r�'eC.� 1t [ 'a . C11.'.•!,•!r
Inspection Summary: omplete 1, 2,--3;or 5 and all'of 4`and 6.
1) ^System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria,not evaluated are
indicated below.
Comments: ;J r'
System is functioning as designed
2), System`Condtionalljf'Passes: ''' " `' ''' �' }E
'❑ One or more system components as described In the"Conditional Pass" section heed to be
replacetl or;repaieed..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(Wheth6ir 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 wiWa 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):
I-
1 ._
I,J[ ..+ 1 at s. - a• '1 , + ,. - a .. - ,i yFli ..-.{.s: ... .7 ..7r 9
10{J!! i"ar+ Zif " ,.'riT"_"1� `i.�Y .+'. F' % !a
t5ins .doc•rev.7126/2018 Title 5 Official Inspection form:Subsurface Sewage Disposal System Page 2 of 18
Commonwealth of Massachusetts ,f,j,-Jy
Title 5 Official Inspection-.-Four
Y
Subsurface Sewage Disposal System Form,*-Not forVoluntary Assessments`•,:,.,iu-.,*.tf.
70 Hollingsworth
Property Address s sbti'1•.,,gnr,j5r
HOLLANDER, RONALD S &TOBY S :3' T rs c.i ,'-,y0r ;;fir}" ,4;_`t,,,,
Owner Owner's Name -,f U,3loll +
information i e
required for every Osterville MA 02655 7/7/20
- }'•• '• '
page. Cityrrown State Zip Code Date of Inspecticin ,
C. Inspection Summary (cont.)
2) System Conditionally Passes'(contr): t tj
❑, Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms'are repaired' -
` b.+ '. . t". . P ,.if. , 's..� 1,t`c t ,.1•� �'.1:: _..•I"ry. 4-�.�y Ir ,«."•Aa ti 1.,1 fi.'l,r ! �t A -
,,:1✓ if !V. 01; r ;s
❑ Observation of sewage backup or breakout or high static wate�level in the distribution box due
to.broken or obstructed pipe(s) or,due to a broken, settled or uneven distribution box. System will
Ipass inspection If(with approval of Board-of Health), r
. . . a#a . y'•. { s''. .. .i._4t.t, "ai•�S « .'....t[la '`�si, + �+{;,
t` ❑ broken pipes) are replaced t'` ❑'Y "❑ N `�❑� ND (Explain below):
" El f•"obst ruction' V.
'is"removed 'r'� `'�' ❑ Y"�❑ N ❑; ND (Explain below):
. {. ^� ,jU !• r, r".� . .... ;-,•.� 'i .'�e'', y.'r t � a`r t tx r•:r�T .," } �,�-' ;r�r' •1:;��> . .,i'i +...
` distribution box is leveled or replac.ed '❑ Y �4^❑ rN f :❑ ,ND}(Explain below):
e + rl 'y - M•., :+:}i,. � _.:.�.[ �i°�I� ri..1. wi�ti�r� }' ��."F .`uru'ti i'���>N'++1 :,'}#t�i�rr..tl'.fY..,}.'tt'j
{
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y , ❑ 'N. ❑ ND (Explain below):
3) Further Evaluation is Requiredby the Board'bf Health:, `,
❑ Conditions exist which require`further.evaluation,by,the,Board,of Health in order to determine if
the system is failing to protect`public health,safety`or'the environment.` `.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning,in_a manner which will protect public health,
safety and the environment: ,
. .'-'. . .1E'i':.1 ' '(!. �. �t i . ..- "F.. ,. r,; '1 , t j •y .;t• .�t: +4a t, ... (:- r,, '
t5insp.doo•rev.7/26/2018 r i « Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18
Commonwealth of Massachusetts +'rI+ -.:0
Title 5 Official Inspection Form : -
Subsurface Sewage,Disposal System Form -Not for Volunta :Assessments
9 P Y F ry {
70 Hollingsworth
Property Address
HOLLANDER, RONALD S &TOBY S
Owner Owner's Name ,>
information is ter OSville " ;' "a
required for every MA 02655 7/7/20
page. Cityrrown r _ ,: State Zip Code Date of Inspection
C. Inspection Summary (cont.) ; �i � , l.�fx (' �:�. - I,' -"
❑ Cesspool or privy is within 50 feet of a surface water.,°' .sw, ,:
li is r'..> •.,v - , i - '. .• r ., i}r. .,. ' , t : aF .. r�
"❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
afety andYenvironment:
❑ 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.
1 ❑. The system has a septic tank and SAS and the SAS is,within.50 feet of a private water
supply well.
r� ❑ 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.
c. ,Other:., r , ,
4) System Failure Criteria Applicable to•'All Systems:.,,),.,• : < <;. t-' Y',°r' °z,,,a
You must indicate"iYes" or"No"fo ea&o'i the'following for all inspections:
Yes., ;,No. f ._ .�`k1 e. •.� '�E: a. :r .* 14,:;. - ` :i .•` �._; +41-, >.Y' J °4-• ,{°
.ri��• , .} �' 1 t?.y :. :'r .{ r.O` •i sr�®�?i,.. .. . ., ,.,«, f�„;1. 0 ,.wF ,.., , }4-
Backup ofsewage Into facility or system component due to overloaded or
clogged SAS or cesspool td
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/26/2018 a Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18,
c Commonwealth of Massachusetts
Title 5 Official �1 i ' , ' �� nspec#ion FO�r� m° `} 4�1
Subsurface.Sewage,Disposal.System Form,- Not for,Voluntary Assessments it t.wLu
til
70 Hollingsworth f#Ft,.kT?t•'' ,F! L
Property Address
HOLLANDER, RONALD S &TOBY S �'` : u �j rs 31,!;
Owner Owner's Name +! -Y,
information is ,� '
required for every Osterville �: MA 02655 717/20• • .'".'�
page. tY p .
Ci /Town': •��: �*,�: State Zip Code Date of inspection
C. Inspection Summary (cont.) .1 ,;-tire
4),,System Failure Criteria Applicable.to All Systems: (cont j)x,;,,%-•*;�; Azf' . •t, i
.•�i�,.. t? a ]h :! .k .r�Jk... i -in, ;I ze'l '1t;y�='i'T.F',. ]�. .sro.•"^f�i
.•,,. .Yes , No. t, _:r r: r ,;;; .:.�,� �, • .;,-_ ,.,^10 < ,.:,'. u.�c , ,,
mod"' _ ":;1. 1rr ,� �' ` x ;x, tS �,. ..t.7 rl. .: `" •r; { i4, • ";,, fri � r• ,
❑ ® Static liquid level.in the distribution box above outlet invert duetl to an overloaded
'`` or clogged SAS or cesspool "'
�, AEl
Liquid depth in cesspool is less,thanr6°,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:
1.❑,z:� Z;, ---Any portion of the SAS,`cesspool i or.privy is below high`;,ground water elevation.
Any portion of cesspool or privy,is within 100 feet of a surface water supply or
Z.
ttrib6tary"to'a surface water"supply.
,❑ ..1 .® i .S', Any portion of a,cesspool or privy,is within a Zone 1 of a ipublic water supply
well.
'� „'. '- '�-• •� ~ �y "- .` .3: `� ,..t..'. .' t � '3� `.n .ter .ni .'.�V .-•.}! 1.�.�. ,. ..
El' Any portion of a cesspool,or privy is within 50 feet of a private water supply well.
lot
t_n y `t_p,•.: .-
.1 r • ;❑ ® 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
4 -' '• ! ,"' system passes if the well water analysis, performed at a DEP certified
•laboratory,for fecal coliform bacteria indicates absent and the presence
z xof 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:],
}�, �,. •D]'s t. ® o The system is a cesspool servinga facility withf a design.flow of 2000 gpd-
! �n •� ]l 1 •tRd
.•, , FThe,system fails. I have,determined•that one or more of the above failure
❑ q ® L criteria exist as described in 310 CM 15.303, therefore the system fails. The
u r ,0 t 1 ItTa;,'system owner should contact the Board of Health to determine what will be
r i necessary-to correct thd1failure.•t" <H,
- ,�.i! � •, ���:�i i}t'%,'.q,.:y Yf�`.!'riiL' � ..ii't s .fit ,. ,�U"§�'? n+, 1;tt1<_,,. .�...`;:si•,.�.�
5). .Large Systems:. To,be considered a large system the,system must serve a facility with a
design flow 6f'10,000 gpd t6'15,000'gpd: '�' ' "'' ,.a
ft_ For large systems, you must indicate either"yes"or?:no",to'each of the,following, in addition to the
aquestions in Section C.4 .•,,,r`,; � g;- ,,t 1,JU .>. +.._.
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
t5insp.doc•rev.7/2 612 01 8 r Title 5 Official Inspection Form:Subsurface Sewage Disposal System,-Page 5 of 18 0 ?
Commonwealth of Massachusetts =;z;;
Title 5 Offi,cial :I � " r.
� nspe:ction Form'
Subsurface•Sewage Disposal System Form- Not for.Vol u ntary Assessments pi I
70 Hollingsworth
Property Address <
HOLLANDER, RONALD S &TOBY S
Owner Owner's Name w
information is Osterville . ` +�^ MA 02655 7/7/20
required for every '
page. City/Town. State Zip Code Date of Inspection
C. Inspection Summary (cont.) "'
If you have answered "yes';to any.question inSection C.5 the system is considered" significant
threat, or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat underSection C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should'contact the•appropriate regional office of the`Department.
You^must*indicate"yes"'or"no"foe'each of the following for all-inspections:
Yes No
❑ .. ®,,+' Pumping information was provided by;the owner, occupant, or Board of Health
,
El' ® Were any,of the, ..syste�m 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
°`�� `` • ' � - n�' '❑ �'`�-' available note'as N/A)
® , ❑;. -Was the.facility ordwelling inspected for signs of sewage back up?
1 ®' ❑;. I,Was the site inspected for signs of,breakout?
,•
l {: = ❑, { - :.f*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?
••a•_ ®..:• 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:
t e1 i Y 1 . Health.'
.
® ❑ a Ezisting information. For example•, a plani at the Board of Health..
c 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)]
. + .. ,1J .�; r. . it .. 3 ..` +• _ � '
t5insp.doc!rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts �; Fi+it . ..7: �r �::.� . p.•srn�T ":
Title 5 Official..Inspection Form,
h� Subsurface Sewage Disposal,System Form, Not-foryoluntary A'ssessments`.
4
M 70 Hollingsworth C .
Property Address
HOLLANDER, RONALD S&TOBY S r' 4'';i. '� " r tuwt{ `';:�"{ •;���:.try 't-i
Owner Owner's Name rt c
information is lll Sterve �' ~';as4. `'
required for every O MA 02655 7/7/20 :0
page. Cityfrown State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions: �c r.v r 'o.; Wx
Number of bedrooms(design): 3 Number of bedrooms'(actual): 3
DESIGN flow based,on 310 CMR 15.203 (for kafHple: 110 gpd x#of bedrooms): 330
Description: rl
IT
Number of current residents: +t' 2
Does residence have a garbage'grinder?.f` x.`" ►� ,'1,'f .�ih w � 4 f.�s04 1 J'I ❑ .Yes ® No
Does residence have a water treatment unit? L-W ❑ Yes ® No
- If yes, discharges to:
t- x'—`•
Is laundry on a separate sewage system? (Include laundry system inspection, /� 0 Yes ® No
information in this report.)
Laundry system inspected? t ® ,Yes ❑, No
Seasonal use? - - ® Yes ❑ No
Water meter readings, if available last 2 ears usage d 236 GPD Est
g ( Y g (gp ))� `
Detail
OU
-tx
v' �,!& y'.. •,�t r ��lei,. � " �,;t t`'+'�j,4 s:.w,`3ftiS.:`"•t!p y'.7,. ; ' j rif'" `+
Sump pump? - r •t.,, 4i,;,�,•p� r, s, ,; :ti ❑ Yes ❑ No
Last date of occupancy: Date
t5insp.doc rev.7/26l2018> , - - • Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18.�`•!
Commonwealth of Massachusettsf
p Title 5 Offi:ciall. lnspection--Form ° J "
Subsurface Sewage Disposal System form -'Not for voluntary.Assessments t .i; - ,.
70 Hollingsworth
Property Address
HOLLANDER, RONALD S &TOBY S '.
Owner Owner's Name
information is r
required for every Osterville'',. 1: .A MA 02655 7/7/20`t,-
page. City/Town' '," State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:,
Design;flow(based o91310 CMR,15.203):., Gallons per day(gpd) j
Basis of design flow(seats/persons/sq.ft., etc.): ' ~
Grease trap present? w ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ;' F - i. , . ,,, ❑ Yes ❑ No
r ' Water meter readings, if available:
Last date of occupancy/use: t pate
.1
OtherF,..(desc•, ribe[,below): k
3. Pumping Records:
Source of information: Not Provided
Was system pumped as part of the inspection? ❑ Yes ® No
V M If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc rev.7126/2018 ^^•. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of.18 "
Commonwealth of Massachusetts -=t.' *rJ,. , �y 'i '►: F'Viz, � , t ^•
Title 5 Officialklnt,spection
Subsurface Sewage Disposal System Form Not for�,Voluntary Assessmentg::,,60f d .
70 Hollingsworth lr .,a .fl �4i:* s `
Property Address ate"t v oo 4:
HOLLANDER, RONALD S'&TOBY S `" '" _ Z4,AV r I Q`,r.�- #°
Owner Owner's Name Mst"4 iv,,
information is 1 -Z A: MA 02655 ,7/7/20• f:--18 '�
required for every Osternlle� "�" _ c�;� �.. - _; _..��•� ,
page. City/Town ", 7.n ut State Zip Code Date of Inspection
D. System Information (cont.) r jj. ) { la -- : C 1 ;iu�t` :o
4. Type of System: . k} '7+ to>I ''., �` .._ .t
-' ♦f.. _
® Septic tank, distribution box, soil absorption systems
❑ Single cesspool ro
_ ,� F,�, �r - ❑ ,�v I ,�tk�Overflow cesspool
El Privy d; '
❑ Shared system(yes or no)�(ifyes, 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 operato(underecontractr N ,
? ❑'f ; 'Tight•tarik�Attach a.copy of.the-DEP approval.
Other(describe)--
Approximate age of all components;date installed'(if known),6ndlsource ofinformation:
Installed 2000
Were sewage odors detected when.arriving at the site?:�;t* eF r,_� ,t Yes No
5. Building Sewer(locate onlsite plati):,, tK N11,40 1qixst,,iJ
Depth bWWg ade: t, L.str, , t',ark.it"`2#
`feet
h ::;t., z .;3s`K �I#�'# '41
{kr.,�'i ',S"'4�'k`3 e fX t 3ewr#�Rt4.4 w.1 „4'=+ 1•s;y`S �'S:i!+ :t°I tl +m. ..
Material of construction: . F
' -S #� s_tt�'Pw t$'e���"ra.;,•N#��f{tit rn.,,� -
'®'cast iron ,•, ®40 PVC ❑ other(explain):
y Distance from private water supply well or suction•fne: ;
feet
Comments(on condition of joints, venting, evidence of leakage, etc.)-.'., .;
F
t5insp.doc•rev.7/26/2018: -" �• Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of,16
, i
Commonwealth of Massachusetts
Title 5 Official lnspection,,r,Form+
i Subsurface Sewage,Disposal System-Form,--Notfo,r.V.oluntary,.Assessments
M ,e 70 Hollingsworth
Property Address
HOLLANDER, RONALD S &TOBY S 6
Owner Owner's Nameinformation
t
required forlevery Osterville ," ' MA 02655 7/7/20
page. Cityffown =>t! " r: State Zip Code Date of Inspection
D. System Information (cant.) :*•¢�. , , . '
6. Septic Tank(locate on site plan): ' �_, • . ., a
Depth below grade' 1.5 T.
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass-, ❑,polyethylene ❑ other(explain)
1500
:�''1 ,..- ••s r .l'« .. i a. .. a ..
If tank.is metal, list age::., } y
years
Is age confirmed by a,Certificate of.C-ompliance?:(attach a,copy of certificate) ❑ Yes ❑ No
Dimensions: ;, l ,., 1500
Sludge depth: 3
24"
j,r Distance from top of sludge to bottom of outlet tee or baffle.
Scum thickness
"4
Distance from top of scum to top of outlet tee,or.baffie ;
301,
Distance from bottom of scum to bottom of outlet4ee,or baffle
How were dimensions determined? Tape Measure/Data On File
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage,'etc),
Tees in place at time of inspection;
t5insp.doc•,rev.7/26/2018- ! Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
r
Commonwealth of Massachusetts ,.4',` :. .,:.' , i• �°.# . . � a f,g=
Title 5 Official. Inspection_Form d 4, �
e
Subsurface Sewage-:Disposal System Form -'Not for_Voluntary,Assessments:,,Il x-,a, "' s
{
70 Hollingsworth
Property Address s, ',r•a,... .. ;,
HOLLANDER; RONALD S TOBY S. ='± 3 _' � `till
Owner Owner's Name er 4 s
Information Is
required for every Osterville ' -E '_: „MA. '02655` 7/7/20l-'!:a'-
page. Cityrrown State Zip Code• Date of Inspection
D. System Information'(coat.) 7 .._C
7. Grease'Trap (locate on site plan):
Depth below grade: feet ; v
r' Material of construction
❑concrete - ❑ metal `. ❑5fiberglass poly�ethgi 64LT❑ other(explain):
Dimensions: ; "r
Scum thickness
Distance from top of scum to'top of outlet tee or baffle `~
a
Distance from-bottom of scum to.,bottom of outlet tee or baffle -
.t° Date of last pumping ,, ,,1 i%1;f :i ,c b."o o ,t: , ',�: Jw,'
fir Date
Comments(on pumping recommendations, inlet and outlet tee or`baffle condition, structural,integrity,y
liquid levels as related to outlet invert, evidence of leakage;etc.):
jqs t+�'i'j2,;, ,'j4 .1s.k *.1
i
-~-8. Tight or,Holding Iank`(tank must be pumped at time of inspection):(locate on site plan): .
Depth below grade:
T
Material of construction. µ ,
❑•concrete-, ❑ metalb; ❑,fiberglass ❑ polyethylene ❑ other(explain):
.: g,
r ' 'e r _,Fd ' 3 w.t J• s � 1• ..;� 1 - ' J, `
Dimensions: 4.
Capacity: ,
_ gallons
Design Flow:
gallons per day i
t5insp.doc•rev.7/26/2018 n ,;& Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of18•t.v&$'
Commonwealth of Massachusetts
x Title 5 Official. Inspection .Former .y
Subsurface Sewage.Disposal System Form 7 Not for Voluntary Assessments ,M1
70 Hollingsworth
Property Address =z 4
HOLLANDER, RONALD S &TOBY S r ' •'' . ,.'
Owner Owner's Name L:
information is r ,
required for every Osterville c" MA 02655 - 7/7/20
page. City/Town +t State Zip Code Date of Inspection
D. System Information (cont.) i "Co
8. ' Tight or Holding Tank(cont.), x<
Alarm present: ❑ Yes Eli,No
Alarm level: Alarm:inworking order: ❑ Yes ❑ No
a Date of last pumping: ' Date
Comments(condition of alarm and float switches, etc.):
' Attach copy of current pumping contract(required). Is copy attached? c❑ Yes ❑ No
9. Distribution Box(if present must tie opened) (locate on site plan):
Depth of liquid level above outlet invert Level with no signs of failure
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.):
t r.
a
A
t5insp.doc•rev:7/26/2018 Y Title 5 Official Inspection Forth:Subsurrace Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
F Title 5 Official . Inspection-Forr�i, -
i Subsurface Sewage Disposal:System Form-"Not for,Voluntary•Assessments :'
70 Hollingsworth � tl.
Property Address sjt;,.}r•
HOLLANDER, RONALD S &TOBY S ` 5 rt?€
Owner Owner's Name
information is Osterville ' c `�`'. i+-a MA 02655• 7/7/20, <' u' '
required for every
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.) Yr-v ►t -v t$`s01P ' '=I ,-r;t *,. ' =_
10. Pump Chamber(locate on site plan): t `.,`' ,,r ^,:e. "s� �`� +~t� ��J�' i i: t
_t� "' _ :. f.,,.I•, . t. �- �i• � ,�tt�i;..�.�, ."�n 7�..11 r �ya...f.....
Pumps in working'order: ❑ .Yes. ❑ No*
Alarms in working order: "` ji ❑ Yes ❑ No
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a,conditional pass:-Id ftEF
11. Soil Absorption System (SAS) (locate on site plan, excavation not required) 141
If SAS not located, explain why:
�;' _• Type: . :''aY�i7;�'J7 ' Oar
j 1'li t}`�1• ` `'1 `7' T 1 �s iflrr pit },�s't..r,a: ik tt,:i,:!"
leaching pits ' ftT'1 `F'"t
n umber:
❑ leaching chambers number:
® —leaching galleries, number: 2 dry Wells
- 0 leaching trenches • ll number, length: .
- leaching fields number,•dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system '
q
p.
Type/name of technology:
t5insp.doc-rev.7/26/2018 ' * i '• Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 °:t `
Commonwealth of Massachusetts U)
Title 5 Offici:al-� insp.e�ction Formw
Subsurface Sewage Disposal System Form_- Not,fortV.oluntary,Assessments$
70 Hollingsworth
Property Address
HOLLANDER, RONALD S &TOBY S c
Owner Owner's Name
information is Osteryille MA 02655 7/7/20
required for every
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.) f vi "4"'. . _r
11. Soil Absorption System (SAS) (cont.) r '": r 1^h
Comments(note condition of soil, signs of hydraulic failurejevel of ponding, damp soil, condition of
vegetation, etc.):
,.- No break out no ponding
e 1
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth.--.top of liquid to inlet-invert
Depth of solids layer x ,
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes r ❑ No
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.): ;,a, } - lj :t
,
t5insp.doc-'rev.7/26/2018 .. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts vC 1
Title 5 Official. Inspection 'Form.
Subsurface Sewage.Disposal.System,form-Not for.Voluntary^Assessments,,',ijL PA, _
70 Hollingsworth
Property Address , r 1:F•,',: 'zY�
HOLLANDER, RONALD S &TOBY S.. r
Owner Owner's Name
information is r .,
required for every Osteryille •�: :)+ .Q.g MA 02655 4' 7/7/20+ 1•
page. City/Town .:. A a State Zip Code Date of Inspection
D. System Information (cont.) • ,rt(, # ::;; € ; ;
13. Privy (locate on site plan): ^'`':.•' • p{c' 11 tG'4'wf'%?
�,.y �•r. A:. S.'F .. { } { '_,�'tT tt•+-ga4:4.'7 if3'.; +"�` .+!?
of construc� p,•.�r •;�; r �;� ,�.i< "=t • ►t� �a : k�,f .�, :�r+ar:c .`� �:•.�t..,�,,,r
Materials tion: d, r, ; i } t .: � .'i;'• �,•,.t.t�.°1 -��
Dimensions ..tF. ;
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
f
• 1 f
j
t5insp.doc•rev.7/26/2018 '. ^i.'+ ', Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 15 of 18^ ,^e
s
Commonwealth-of Massachusetts ,o413 z ��I;
x Title 5 Offi,1'1- InspectionrFormx =M:
Subsurface Sewage:Disposal System Form;-Not for#Voluntary Assessments F
70 Hollingsworth
Property Address
HOLLANDER, RONALD S &TOBY S . ".> ' __ :,:,'•. .. s
Owner Owner's Name t
information is required for every Osterville 1; xr' " MA 02655 7/7/20, =•, 1 r +'rv=
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) ,. i,
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties tout 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
' ,.. f' �. ... '3 , ;4f�r ".� +5t,✓ w� ;"'�v: - ,; .. .. ra i:` ;:'� ire .aJ+. - r ^,:• , ,. ,^`. Y,;..7
t5insp.doc•rev.7126/2018`t. -•- r , - Title 5 Official Inspection Form:Subsurface Sewage Disposal System,Page 16 of 18, -
Assessing As-Built Cards https://www.townofbamstable.us/Departments/Assessing/Propert7 ...
TOWN OF BARNSTABLFJ t j
LOCATION -10 l�o�S t_1o2'F� Rc O-V SEWAGE M 0,30-!06
VILLAGE. �4Er3R.ut C- ASSESSOR'S MAP&LOT
INSTALLER'S NAME&PHONE NO. '7 7 S-Y-7 7 L
SEPTIC TANK CAPACfI'y--A oO
LEACHING FACU Ty:(type)-61 -DQt *1(S (size) i 21 2•x, '1
NO.OF BEDROOMS_
t•
BUILDER OR OWNER' R-Ot-1P `
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(if any wetlands exist
within 300 feet of leaching facility) * Feet'
Furnished by
° e R
• 1 Shara�
0 3�
19
t
y
Jr
1 of 1 7/8/2020,8:39 AM
Commonwealth of Massachusetts
Title 5 Officia1slnspe-ction- .Fd'r6 ,-. . Y
Subsurface Sewage Disposal System form Not.for;Voluntary,Assessments"N'.�"`
70 Hollingsworthy
Property Address
HOLLANDER, RONALD S &TOBY S '`"• �n':i. '" ar :1? t +F' .` ' ,r +
Owner Owner's Namep�,
information is _- K NP
required for every
Osterville $4 a' : " MA 02655 7/7/20'_" �'"
page. City/Town' ) State Zip Code Date of Inspection
D. System Information (cost.) ha -gib°
15. Site Exam: ;ir, "y 1+ie 3 li a 's, ,, (L 3:'-3',4 li-x .0-rt+111. , :,J',77 f,.s <
❑ Check Slope .=r+ ;I �•,�tg,: .i `r ,t• . �i, ' �+ ..: ��}a .„G�:,I-iP
❑ Surface watercr.'fn,
❑ Check cellar 1If,,-Vitt, "I'w3,.;
❑ Shallow wells . apt,`,f`f: ? o: 'i`r V ,. 1�
Estimated depth to high ground water: feet
, .
Please indicate all methods used to determine the high ground water elevatidw. ;
® Obtained from system design plans on record;Y
If checked;date of design reviewed: 10/24/20.00
Date
❑ IObserved,site'(abutting property/observatiomhole with in.150'feet of SAS)
❑ Checked with local Board of Health -explain,
❑ Checked with local excavators, installers-(attach documentation)
01 Accessed USGS.,database-explain:
You must describe how you established the high ground water elevation:
Test hole data
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
i t5insp.doc-rev.7I26/2018 Title 5 Official Inspection Fonn:Subsurface Sewage Disposal System Page 17 of 18
Commonwealth of Massachusetts
? Title 5 Official; Inoection -Form ra �
� Subsurface Sewage Disposal:System Form -Not forVoluntary Assessments ,.-,)
70 Hollingsworth '
Property Address
HOLLANDER, RONALD S &TOBY S
Owner Owner's Name n ,
information is required for every Osterville_ + �' ,: MA 02655 7/7/20
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist.-,. t .•,� .a }: , . .
Complete all applicable sections of this form inclusive of:
❑ A. Inspector Information: Complete all fields in this section. , y
❑ B. Certification: Signed & Dated and 1, 2, 3, or 4 checked .,•
❑ C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate '
4(Failure Criteria)and 6(Checklist)completed
[3 ,D:System Information:• .•1 ,I ,, . , , , .
For 8: Tight/Holding.Tank—Pumping contract attached r+
For 14: Sketch of,Sewage Disposal System drawn on.pg. 16.or attached
-For 15: Explanation of,estimated depth.to high groundwater included
.`+ l'l -�. ! �.. x_.,i y4a " ! •.' 7i ciol r „ �..1. ,"1 r � ..�1 . y + ..`. 't t u r/A i'
t5insp.doc•rev.7/26/2018:� + Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
TOWN OF BARNSTABLE
� G �
t� r•i'.ir-qzl. �-
LOCATION 70 i4c f C i NA'� t—)Ofe�il D SEWAGE # a OeO a laG
VILLAGE 0 ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. 9JO("54N Sc.,fa 6G,
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) OL D94 W&I t$ (size) i Z 7 2�`f
'i NO.OF BEDROOMS
BUILDER OR OWNER RLOL-%5P i
PERMIT DATE: 16 ® COMPLIANCE DATE: 10 1Q 130 b
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
De6c
y,
+
c
LOCATION SEWAGE PERMIT NO.
VILLAGE
INSTA/L�LER'S NAME & ADDRESS
B UILDE R OR OWNER
DATE PERMIT ISSUED / 7
y
DATE. COMPLIANCE ISSUED - 7
wa er-/-1 ZOAD
.� 7
0
No. �(/� \ �e\ Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVIS104-; TOWN OF BARNSTABLE., MASSACHUSETTS
Zippficatiou for Migozar *potem Cow6tructiou Permit
Application for a Permit to Construct( . )Repair(g )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. Owner's Name,Address and Tel.No.
As2JQ0r'HQkUBgsworth Rd. , Osterville Maggie Rowe
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Wm. E. Robinson Septic Service
P O Box 1089, Centerville
Type of Building:
- Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil Sand
Nature of Repairs or Alterations(Answer when applicable) Tttle-5 Septic system consisting
tank,of a -
sterie all around.
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by th' B Hof He�
Signed ob L Date
Application Approved by Date
Application Disapproved for the following reasons
Permit No. _C-d l—4 Date Issued
!fit% � .^V•.r. - ... ., pF'�i��,,,r ,y.,,... ...,. ._. ,_... i'1l .��`.`t: .`o
V V
No. / Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS
ZIpphration for Oigogar bpotem Congtructi.un Permit
Application for a Permit to Construct( . )Repair(X )Upgrade( )Abandon( ) ❑Complete System El Individual Components
Location Address or Lot No. Owner's Name,Address and Tel.No.
Ass7sQr' W&9sworth Rd. , Osterville Maggie Rowe
/ O- D76
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Wm. E. Robinson Septic Service r
P 0 Box 10989 Centerville
Type of Building:
Dwelling No.of Bedrooms 3 — Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
` Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
`Title
_`Siie of Septic Tank Type of S.A.S.
Description of Soil Sand
Nature of Repairs or Alterations(Answer when applicable) Septic 3ysterj s
c}-nnA all 3r�n�7r
Date.last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issu d b t ' B d of He _
p 6 t r �! Date
Signed
Application Approved by Date
Application Disapproved for the following reasons
Permit No. �D d� Date Issued
--------5---(--- -----------------------
THE COMMONWEALTH OF MASSACHUSETTS
Rowe . BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( X )Upgraded( )
Abandoned( )by gym. E. Robinson Septic Service
at 70 Holling,�o tad. , Osteryille has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. 6 dated l I-- ��
t Installer Wm. E. Robinson Sr. Designer n t?
The issuance of this emut hall n e o s e as a uarantee that the(s,'ktem,will:func'tiori as�de�si nee �
Date p � � g Inspector
'. — -- ---- —
6 CJ l Fe450
Rowe THE COMMONWEALTH OF MASSACHUSETTS
�yUR 0?(,0PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
lwiopogar Opotem Construction Permit
Permission khereby granted to Construct( )Repair( X)Upgrade( )Abandon( )
System located at70 Hn1 I i ngaumri-h RA, Osterai 1 1 e
and as described in the above Application for Disposal System Construction Permit.The applicant recognizeifiis/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction ust a completed within three years of the date of this p it.
Date: /C� Zd-r�D Approved by
w �
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
CER YWICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS)
1, William E. Robinson,S�ereby certify that the application for disposal works
construction permit signed by me dated �(�'��� , , concerning the
property located at 70 Hollingsworth Rd_ f osterville' meets all ofthe
following criteria:
• The failed is connected to a residential dwelling only. There are no commercial or business
uses associated th the dwelling.
The soil is ct ed as CLASS I and the percolation Late is less than or squat to 5 minutes per inch.
There are no ands within 100 feet of the proposed c s stem
P P
There;tie no rivatt;well,within 150 feet of the proposed septic system
There is no ncrease inflow and/or change in use proposed
• There are variances requested or needed.
• The bouom of the proposed leaching facility will ngt be located less than five feet above the
maxi um adjusted groundwater table elevation: [Adjust the groundwater table using the Frimptor
m Z when applicablel
• the'.A-S.will be located with 250 feet of any vegetated wetlands,the bottom of the proposed
caching facility will not be located less than fourteen(141 feet above the maximum adjusted
groundwater table elevation,
Please complete the following.
?►) Top of Ground Surface Elevation(using GIS information)
B) G.W.Elevation +the MAX. High G.W_ Adjustment
DIFFERENCE.BETWEEN A and B
SIGNED : 1/y L ✓ L' ,��y�'`�
DATE.
[Sketch proposed plan of system on backl.
y:b=M folds cat
f
}; _ ,�
.. _ /�/
' � ���,
� 1 ! _
.�
r J
..-�
�'�A�
V�/
. �
)7/
No.... .......... F s..: ..... ........
THE COMMONWEALTH.OF MASSACHUSETTS
L4boo
�-
BOARD F HEALTH
_.... ..... . . .. _... ....OF........... .....
Appliration -fur Bitip aiitt1 Vorkg Towitrurtiutt Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
S stem at
- - .. .� -
Luc t' d re; ort No.
..
.. • >� . : ----.---•-- ...•.......--'............ ..•--....---•••. .----.'-.--
wner -- --------- --P---'-"'. Add Ss
Installer. Address
Q Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms..-3-----------------•----•--___-------_-._-_Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
QOther 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. it.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by------- ---------•-------..._...--------------------------------------•--- Date........................................
Test Pit No. 1................minutes per inch Depth of "Pest Pit.................... Depth to ground water.._._-_----_-_._-.------
r-L4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water......-..-_-__----------
O Description of Soil-----------
------------------------------------------ _
x
W -------------------- ----------------------------------------------------------------------------------------------------------- -------------------- .....
Nature of Repairs or Alterations—Answer when applicable---------- __-------� Zt
-•------•--•-�:_: ---- -
. . --- •-----•----------
Agreement:
The undersigned agrees to install the. aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has e issued by the bowl of e th.
/—�
Signed.. __ _
-------------------------�eo�-------------- jD 7, _�
ApplicationApproved By-....................................................................................------------- ----------------.._.._------ -----------
Date -
Application Disapproved for the following reasons------------------------------------------------------------------------------------------------------------•---
-•-------•-•-----------•--------•-----------------------•------'---••-------•---•••...-----•-•--'---•---.-----•----•----........-•------......--•-------------•------------------•-•-----•----••--•-•-•-
Date
Permit No.---- Issued...... 3- 7 7.
Date
No..... ......... F!
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
. .... .............OF........................................................................-.......--------
Appliratinn -for 15iipniitt1 Workii Tonf#rurtion Vrruid
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: _")
..
1LocationA"ddre or Lot No.
y J 6wner (' fJ �j Address
.W1 .............................................fit J �+'�C.?!n�-h. ti.. .1 .i Z........ t I f3i
..... •... ..........................................................•-----
Installer Address
UType of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms---_j_�--------------------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ---------------------------- No. of persons............................ Showers ( ) — Cafeteria ( )
v�
Q 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 tank ( )
aPercolation Test Results Performed by--------------------------------------------------------------------------- Date---------..---..-----------------------.
a Test Pit No. 1----------------minutes per inch Depth of Test Pit..------------------ Depth to ground water...--..-.-._...-.-_---
L14 Test Pit No. 2________________minutes per inch Depth of Test Pit-------------------- Depth to ground water.-.-_._.._-.____.___-. -
W ......!................ ---------- ------------^.......................................................................................................
O Description of Soil-------------A.44 J---- '------�
U --------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------
W __ ___
U Nature of Repairs or Alterations—Answer when applicable..._---_.--4__.:..._.�_I ..�.:._.;>` ._.____. .-�+_ c .---!
U P"
----------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------- ------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Dispos�.l System in accordance with
the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b'nissued by the bovo of e lfth.
Signed- ................................................. .---------• ••--•-----•---------- �/_�_ ---__1 7 4
r / Date
ApplicationApproved By-------_----- ------------------------------------------------------------------------------ ---- ----------------------------------------
Date
Application Disapproved for the following reasons-----------------------------------------------------------------------------------------------••---- -•-•--
••••--•-•--------•----------•-----------------------------•------------••--•-----•-••••••••-••--•-•••••-•..-•--•-•----------•----•-••-- -•------•-.._...------------------------------------------------
Date
PermitNo------G.�d.......---•-----•-•.................. Issued............................................Date.......
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
r OF..
Qrrttf iratr of fI'nmphaurr
THIS IS TO CERTIE,Y, /That the Individual Sewage Disposal System construct?d ( ) or Repaired
..c�*-:r- / .. �11i .. t131n r� (•#� vt L- , c
by....... ----..---- - ------- ---- ------------------------------------------------•---•----- ..................•`••--
Installer
at....... 7. r 'M-'-=- _ (, G '- � fC? �Lr GL J .� 4�tn G l fcii 1 c L,Cl �
-•------------------•-------------•--- ----------- --
has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No_________________________________________ dated-----
_-----_--_--__-.---------------------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
7 ............DATE.
J-3 ..--7-` - Inspector, ... 1��
' v
THE COMMONWEALTH OF MASSACHUSETTS ,
BOARD OF HEALTH
..........................................OF.............. ..... .........--•-•-.............
No. "••. FEE_�................
Di-sp rgal Norkii � tr rti> it drrmit
Permission is hereby granted-----------------------------------------------------------------
to Construct ( ) or Repair (.>') an Individual Sewage Disposal System
q � �
at No._1 '-----1 ---- - - .tJ 1 �C� � ="-.,
Street
as shown on the application for Disposal Works Construction Permit- No---- 0a------ Dated---
_
and of Heal.
DATE..... �� ` P._77�---
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS