HomeMy WebLinkAbout0962 MAIN STREET (OST.) - Health 962 MAIN STA�OSTERVILLE
A = 117 160
a
0
t _ -
�P
COMMONWEALTH OF•MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET, BOSTON MA 02108 (617)292-5500
TRUDY COXE
Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
4 PART A
CERTIFICATION,
Property Address: 962 Main Street, Osterville, MA Name of Owner: Jonathan&Amy Conway
Address of Owner: same -
Date of Inspection: March 11, 1999
Name of Inspector: (Please Print) James M. Ford
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: James M. Foal -
Mailing Address: P.O. Box 49, Osterville, MA 02655-0049 Map: 117
Telephone Number: (S08)862-9400 Parcel: 160
Lot:
CERTIFICATION STATEMENT x '
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 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 aluatio y the Local Approving Authority
ails
Inspector's Signature: LZ Date% March.15, 1999
The System Inspector shall sub t copy of this inspection report to the Approving Authority(Board of Health or DEP)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 If
regional office of the Department of Environmental Protection. The original should be sent to the
system owner and copies sent to the-buyer, if applicable, and the approving authority.
NOTES AND COMMENTS
ro
199
4*0
A 4
revised 9/2/98 Page IofII
Primed on Recycled Paper
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 962 Main Street, Osterville, MA
Owner: Jonathan&Amy Conway
Date of Inspection: March 11, 1999
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
✓ I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 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.
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, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or
the septic tank, whether or not metal, is 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 complying septic tank as
approved by the Board of Health.
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken, settled or uneven distribution box. The system will pass inspection 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 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
-1
revised 9/2/98+ Page 2of11
f
E
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM',
PART A
CERTIFICATION (continued)
Property Address: 962 Main Street, Osterville, MA
Owner: Jonathan&Amy Conway
Date of Inspection: March 11, 1999
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 the
public health, safety and 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 THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
,
4 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 AND SAFETY AND
'4 THE ENVIRONMENT:
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet to a surface water supply or
tributary to a surface water supply.
The system has a septic tank and soil absorption system and the SAS is within a Zone 1 of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis 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. Method used to determine distance (approximation not valid).
3) OTHER
a .
5
revised 9/2/98 Page 3ofII
, Y
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 962 Main Street, Osterville, MA
Owner: Jonathan&Amy Conway
Date of Inspection: March 11, 1999
D. SYSTEM FAILS:
You must indicate either "Yes" or "No" as to each of the following:
I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this
determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
Backup of sewage into facility or system component due to an 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 1/2 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
PP Y arY
Any portion of a cesspool or privy is within a Zone 1 of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAILS:
You must indicate either "Yes" or "No" as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public
health and safety and the environment because one or more of the following conditions exist:
Yes No
the system is within 400 feet of a surface drinking water supply
I
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
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Department for further information.
revised 9/2/98 Page 4ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 962 Main Street, Osterviiie, MA
Owner: Jonathan&Amy Conway
Date of Inspection: March 11, 1999
Check if the following have been done: You must indicate either "Yes" or"No" as to each of the following:
Yes No y
✓ _ Pumping information was provided by the owner, occupant, or Board of Health.
✓ _ 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.
The 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 conditions 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. For example, Plan at B.O.H.
✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable)
[15.302(3)(b)].
✓ _ The facility owner(and occupants,if different from owner) were provided with information on the proper maintenance of
SubSurface Disposal Systems. f
revised 9/2/98 Page 5ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 962 Main Street, Osterville, MA
Owner: Jonathan&Amy Conway
Date of Inspection: March 11, 1999
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 110 g.p.d./bedroom.
Number of bedrooms(design): 4 Number of bedrooms(actual): 4
Total DESIGN flow n/a
Number of current residents: 2
Garbage grinder(yes or no): No
Laundry(separate system) (yes or no): No If yes, separate inspection required
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings, if available(last two yearg;usage(gpd): 1998-54,000.eals.; 1997-31,000ltals.
Sump Pump(yes or no): No
Last date of occupancy: Currently occupied.
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow: gpd(Based on 15.203)
Basis of design flow
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:
None on file
System pumped as part of inspection(yes or no): No
If yes, volume pumped: gallons
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)
I/A Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
.APPROXIMATE AGE of all components, date installed(if known)and source of information: 1996- per as built card.
Sewage odors detected when arriving at the site: (yes or no) No
revised 9/2/98 Page 6of11
Y
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION,(continued) .
Property Address: 962 Main Street, Osterville, MA
Owner: Jonathan&Amy Conway
Date of Inspection: March 11. 1999
BUILDING SEWER: _
(Locate on site plan)
Depth below grade:
Material of construction: _cast iron _40 PVC other(explain)
Distance from private water supply well or suction line
Diameter - }
Comments: (condition of joints, venting, evidence of leakage,etc.)
SEPTIC TANK: ✓
(locate on site plan)
f
Depth below grade: 28"
Material of construction: ✓concrete metal Fiberglass _Polyethylene _other(explain)
If tank is metal, list age_ Is age confirmed by Certificate of Compliance_(Yes/No)
Dimensions: 10'6" x 5'8" x 5'8" (1500gal.)
Sludge depth: 1"
Distance from top of sludge to bottom of outlet tee or baffle: 31" ,
Scum thickness: 2"
Distance from top of scum to top of outlet tee or baffle: 6
Distance from bottom of scum to bottom of outlet tee or baffle: 13
How dimensions were determined: Measuring stick
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.) The tees were present. The liquid level was even with the outlet invert. There were no signs of leakage.
GREASE TRAP: None
(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:
(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 9/2/98 Page 7of11
I `
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 962 Main Street, Osterville, MA
Owner: Jonathan&Amy Conway
Date of Inspection: March 11, 1999
TIGHT OR HOLDING TANK: None (Tank must be pumped prior to, or at time, of inspection)
(locate on site plan)
Depth below grade:
Material of construction: _concrete,_rnetal _Fiberglass _Polyethylene _other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm present:
Alarm level: Alarm in working order: Yes_ No_
Date of previous pumping:
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: 0" (even)
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) The box was level and there
were no signs of solids or leakage.
PUMP CHAMBER: None
(locate 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.)
revised 9/2/98 Page 8ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C '
SYSTEM INFORMATION (continued)
Property Address: 962 Main Street, Osterville, MA
Owner: Jonathan&Amy Conway
Date of Inspection: March 11, 1999
SOIL ABSORPTION SYSTEM(SAS): ✓
(locate on site plan, if possible; excavation not required, location may be approximated by non-intrusive methods)
If not located, explain:
Type:
leaching pits,number:
leaching chambers,number:
leaching galleries,number:
leaching trenches,number, length: 2-40'x 4'x 2'
leaching fields,number, dimensions:
overflow cesspool, number:
Alternative system:
Name of Technology:
Comments: -
(note condition of soil, signs of hydraulic failure, level of ponding,,damp soil, condition of vegetation,etc.)
The trench was approx. 32"down and was not dug up. There were no signs of failure in the D-box
CESSPOOLS: None
(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)
Continents: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
•
PRIVY: None
(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.)
4
revised 9/2/98 Page 9ofII
j • v
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 962 Main Street, Osterville, MA
Owner: Jonathan&Amy Conway
Date of Inspection: March 11, 1999
Map: 117
Parcel: 160
Lot:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
PY1 A i n ST
A
a
0
y r lei
yg' ovrle r
'- ° Sy' D. 80k yy '
Sy' 7Ten c—
i
revised 9/2/98 Page 10ofII
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 962 Main Street, Osterville, MA Y
Owner: Jonathan&Amy Conway
Date of Inspection: March 11, 1999
NRCS Report name
Soil Type
Typical depth to groundwater
. p
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep
SITE EXAM Slope -
Surface water
Check Cellar
Shallow wells
Estimated Depth to Groundwater Feet N
Please indicate all the methods used to determine High Groundwater Elevation: ,
Obtained from Design Plans on record
Observed Site(Abutting property,observation hole, basement sump etc.)
Determined from local conditions
✓ Checked with local Board of Health '
Checked FEMA Maps
Checked pumping records
Check local excavators,installers -
✓ Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
Using the Barnstable water contours and topographic maps, the maps were showing approximately 25: +/- to groundwater at
this site.
t
This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty
or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed,
written or implied, relating to the system, the inspection and/or this report: .
revised 9/2/98 Page 11of11
f'
TOWN 01O BARNSTABLE
i000w
LOCATION~ SEWAGE # 45;
V�iLAGE c��s�1,�t�,A SS ASSESSOR'S MAP& LOT
`�/� J1l—f��
INSTALLER'S NAME&PHONE NO. I*10? f� ,, ��►
SEPTIC TANK CAPACITY D e
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS_
BUII.DER OR OWNER
.PERMIT DATE: 47 '94� COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and 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) v Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 fSjLpf leachi g ci ' ) Feet
Furnished by
i
ag 0 D,
6
TOWN OF BARNSTABLE
LOCATION �b� h S�'= SEWAGE#
IA�LAGE Cis � .�tl� ASSESSOR'S MAP&LOT �U
INSTALLER'S NAME&PHONE NO. G t,vn u J
SEPTIC TANK CAPACITY /,5-00 GA-1-
LEACHING FACILITY: (type) leAC I // �c�i (size) a
NO.OF BEDROOMS
BUILDER OR OWNER S Yt e:\ TTS
PERMIT DATE: a COMPLIANCE DATE: C
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Waver 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 leac 'ng facility) Feet
Furnished by 7 2"gW ey—o "
1
y/
-�to Ica
i 'I
ASSESSORS MAPNO' �
� -
No.
'PARCEL -.....N., Fee �
THE COMMONWEALTH OF MASSAMMMTTS
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
f 0[pprtcatton for Mtgponl bpgtem Congtructton permit
Application is hereby made for a Permit to Construct( )or Repair(VI)'an On-site Sewage Disposal System at:
Location Address or Lot No. Owner's Name,Address and Tel.No.
Q e--
� s1e � I�e
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
t
Type of Building:
Dwelling No.of Bedrooms 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
Description of Soil
Nature of Repairs or Alterations Answer when a 1'cable U -T r 4 61�1- 5 T
P ( � tom--, PP j� ) I
�/f r lax yo x 5' )(� I �2ertc S L", I t/a `5T6rr
/�� �%.L/- rev ;!
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 issue by this d of t .
Signed Date
Application Approved by
Application Disapproved for the following reasons
Permit No. 9 n y f`% Date Issued
No. 9 < // Fee j
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
0(opricatton for Mtzpaar *r5tem Construction Permit --
Application is hereby made for a Permit to Construct( )'or Repair(If)an On-site Sewage Disposal System at: "?
{F Location Address or Lot No. Owner's Name,Address and Tel.No.
q
` Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building:
1 Dwelling No. of Bedrooms Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
'. Other Fixtures
6
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date,.
5
Title
Description of Soil
Nature of Repairs or Alterations Answer~when appl'cable)^ �r GF � - oo 6t� ^ 3- T 1
�/�� t PS1u'1
Date last inspected:
Agreement:
Y
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 issue by this Bo d�oft
r Signed �� Date. f
Application Approved by d
Application Disapproved for the following reasons
f
Permit No. -" Date Issued `
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO C RTIFY,that the On-site Sewage Disposal System instal d( )or repaired/replaced(k<on
by 6 Yi3�erg l /i'12 fi v� for y< f:Lw
as �G? -�"'TT G has been constructed in accordance t
with the provisions of Title 5 and the for Disposal System Construction Permit N=5 dated ->5-- �. �
f
Use of this system is conditioned on compliance with the provisions set forth below:
k
.. 7 ,e
No. �~ /°� r` Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Miopont W`p!5tem Construction Permit
Permission is hereby granted to 6 2D4 IQ y j _
to construct( )repair(1,4an On-site Sewage System focated at . A/Af 57 05%<'t,' C
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to
` comply with Title 5 and the following local provisions or special conditions.
All construction must be completed within two years of the date below.
f Date: PP' v A roved
Y
1
i
'. Soo
t
t
P
f
0
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT,(WITHOUT DESIGNED PLANS)
hereby certify that the application for disposal works
construction permit signed by me dated concerning the
property located at C u MR(In�I- �lei t��P meets all of the
following criteria:
• There are no wetlands within 300 feet of the proposed septic system `.
• There are no private wells within 150 feet of the proposed septic system
• The observed groundwater table is 14 feet or greater below the bottom of the leaching facility
• There is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
SIGNED: DATE:.
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER 3 o
[Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan,
this plan should be submitted].
5/13/96
4. f ;
DATE:_ -
PROPERTY ADDRESS:(a.z_maj _"t-___-_-_ �fcEIvEO
MAY 1 '
Osterville Mass. 1�9b ;
02655 ►, 44
------------------------
t D
On the above date, 1 inspected the septic system at the above address.
This system consists of the following:
1 . 1-1000 gallon leaching pit packed in stone. ( 61x7l )
ASSESSORSM1�pN -
Based on my inspection, I certify the following conditions: PARCEL 40--
1 . This is not a title five septic system.
2. The system was filled to capacity.
3. The system is in failure.
4. The system must be upgraded to a title five septic system.
SIGNATURE:---------------------
Name:_ Joseph P.Macomber Jr. _
Com an J.P.Macomber' & Soh Inc.
Py:----------------
Address:_ Box S�-0nn-tarxillei.Mass . 02632
Phone: 5 os-775=3333----------
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
JOSEPH P. MACOMBER & SON, INC.
Tanks-Cesspools-Leachflelds
Pumped & Installed
Town Sewer Connections
P.O. Box 66 Centerville, MA 02632-0066
775-3338 775-6412
•
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Department of
Environmental Protection
William F.Weld Trudy Cox*
Governor a_VWy
Arp*o Paul Celluccl David B.Struhs
tL Gowmor Comrnb+brrr
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
PropertyAddresa: 962 Main Street Osterville,Mass. Address of Owner.
Date of Inspection: 5/6/96 (If different)
Name of Inspector. Joseph P. Macomber Jr.
Company Name,Address and Telephone Number.
J.P.Macomber & Son Inc. Box 66 Centerville,Mass . 02632 508-775-3338
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 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
-rNeeds Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: 1, 00el� Date: J f/^7�
l�
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 Environmental 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:
NO I have not found any information which in 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)
/ N&I The septic tank is metal,cra ked,structurally unsound, shows substantial infiltration or exilltration,.or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a ponforming septic tank as approved
_ ar the soma sd mgmi1Lh
(revised 11/03/95) 1
One.Winter Street * Boston,Massachusetts 02108 * FAX(617)556-1049 a Telephone(617)292-5500
Printed on Recycled Paper
V•
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (oontinued)
PropertyAddtroaa: 962 Main Street Osterville,Mass. 02655
Owner. Sheila Thomas
Date of Inspection: 5/6/96
B]SYSTEM CONDITIONALLY PASSES (continued)
,,Vgg?e—� Sewage backup or breakout or huh static water level observed in the distribution bar is due to broken or obstructed pipe(s)
or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is levelled or replaced
A,O The system required pumping more than four 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
C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
_Q_ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A
MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
aCesspool or privy is within 50 feet of a surface water
AZO 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 APPROPRIATE)
DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT:
The system has a septic tank 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 septic tank and soil absorption system and is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and is within 60 feet of a private water supply well.
The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water
supply well,unless a well water analysis 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.
3) OTHER
T110 a.ra+c,n nonQ; gfQ of an 11100- gallon leachl �p t-paokad
in stone, Tns .a 1 1 Pd in 197I _ :r�P_M,-Camhe- &-Son-!no -
(revised 11/03/95) 2
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(oontlnuod)
proportyAddre.ssr 962 Main Street Osterville,Mass . 02655
Owner. Sheila Thomas
Data of Inspootiotu 5/6/96
D) SYSTEM FAILSt •
I haw determined that the system violates one or more of the following failure criteria as dalusad in 310 CMR 15.303. 'I'ha bails for
this datarmination is identified below. The Board of Health should be contacted to datormtn•what will be aocwsary to eorroct the
failure.'.
,} Backup of"wag into facility or system comPonont duo to an overloaded or clogged SAS or carpool.
Discharge or ponding of oPluent to the surfaca of the ground or surface waters duo to an overloaded or clogged SAS or
cos,pooL '
/,aVG Static liquid level in� distribution box above outlet invert due to an overloadod or clogged SAS or catspool.
Liquid depth in ecsrpoot k less than 6'below invert or available volume is leas than 111 day flow.
Nb Roquirod pumping more tlmn 4 tunas is the last year NOT duo to clogged or obstructed plpa(s).
Humber of times pumped
Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
Any portion of a cats' I or privy is within 100 foot of a surface water supply or tributary to a surface water supply.
POO
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 60 feet of a private water supply well.
Any portion of a cosspool or privy is lass than 100 foet but greater than 60 foot from a private water supply well with no
aoceptabls water quality analysis. If the well has boon analyzed to be acceptablo,attach copy of well water analyst for
ooliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogwL
E)LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above:
The system servos a facility with a dW41 flow of 10,000 gpd or greater(Large System)and the system is a slgniflcaat threat to public
health and safety and ths•onviroament bocause one or more of the following conditions exist:
the system is within 400 fast of a surface drinking water supply
tha system is within 200 tat,of a tributary to a surfaco druilciug water supply
the system is located in a nitrogen sensitive area (interim Wellhead Protection Aron(IWPA)or a mapped Zone II of a public
water supply well)
The owmar or operator of az1Y such system sha.l bring the system and facility into hill oompllasia with the Vvuudwater traatmont VOVIM
roquuwments of 314 CMR 5.00 and 6.00. Plow:9 consult the local regional office of the Department for further information.,
u
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 962 Main Street Osterville,Mass . 02655
Owner. Sheila Thomas
Date of Inspection: 5/6/9 6 e.
Check if the fo wing have been done:
Pumping information was requested of the owner,occupant,and Board of Health.
—4ons 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.
2Ax built plans have been obtained and examined. Note if they are not available with N/A
-/The 641ty or dwelling was inspected for signs of sewage back-up.
, The system does not receive non�sanitary or industrial waste flow
ZThe site was inspected for signs of breakout.
- All system components,.e:tcluding the Soil Absorption System,have been located on the site.
,)0-VL The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baines or
tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.
f/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.
eThe facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub.
Surface Disposal System.
(revised 11/03/95) 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
PropertyAddresa: 962 Main Street Osterville,Mass . 02655
Owner. Sheila Thomas
Date of Inspection: 5/6/9 6
FLOW CONDITIONS
RESIDENTIAL.
Design flow: Mons per�� •
Number of bedrooms:
Number of current residents:02
Garbage grinder(yes or no):�Q -
Laundry connected to system(yes or no):j5
Seasonal use(yes or no): A L �'( OD(�' �J"d• /9,lld
Water meter readings, if available:
Last date of oocupancy:A2e4°iWTZje
COMMERCIALIINDUSTRIAU
Type of establishment: Asli
Design flow:-AA gallons/day
Grease trap present: (yes or no).9ft
Industrial Waste Holding Tank present: (yea or no).Al 14
Non-sanitary waste discharged to the Title 5 system: (yes or no)_
Water meter readings,if available: &A
Last date of occupancy:
OTHER:(Descn'be)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as part of ins ion: (yes or no) S
If yes,volume pumped: 1 Dv' ales
Reason for pumping:
TYPE OF SYSTEM }
A16_ Septic tank/distribution box/soil absorption system
.4JD Single cesspool
0 Overflow cesspool
Privy
Shared system(yes or no) (if yes, at�t,afy h previoV�inn ion ,;, if an
Other(explain) lQ' q/¢!,![OA') /46W /�
XI TE AGE J�f�all cam nents, date installed(if known)and source of information: 06 "e1,1e5
Sewage odors detected when arriving at the site: (yes or no)/f�(
(revised 11/03/95) 6
• b
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(oontinued)
Property Address: 962 Main Street Osterville,Mass . 02655
Owner. Sheila Thomas .
Date of Inspection: 5/6/9 6
SEPTIC TANK e s
(locate on site plan)
Depth below grader
Material of construction.looncrete_metal_FRP_other(esplain)
Dimensions: AM
Dludge depth---At—
istance from top of sludge to bottom of outlet tee or baffle:-&&
Scum thicknesa: b Ar _
Distance from top of scum to top of outlet tee or bafIIe:_JL�Of
Distance from bottom of scum to bottom of outlet tee or bafile: AA�A
�i
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.)
Ne Ger�t.rr1Q�T
GREASE TRAP: oNP.-
(locate on site plan)
Depth below grader
Material of construction:466ncrete_metal_FRP�otleu{explain)
AJA
Dimensions:
Scum t&JMess: Al A
Distance from top of scum to top of outlet tee or baffle:—ad
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.)
Ale r!��x�ar✓yTS
I
. r
(revised 11/03/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(oontinued)
PropertyAddresa: 962 Main Street Osterville,Mass . 02655
Owner. Sheila Thomas
Date of Inspection: 5/6/9 6
TIGHT OR HOLDING TANli{:,/�pl4!,
(locate on site plan) •
Depth below grade:,
Material of construction:/concrete_metal_._FRP—.other(explain)
04
Dimensions:
Capacity: uA gallons
Design flow: ons/day
Alarm level:t
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
119n C��s^�s�.y17's
DISTRIBUTION BOX:A&V,-
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if and distribution is equal, evidence of solids carryover,evidence of leakage into or out of bar,etc.)
�o Ca.✓?yr�1v.�/T� _
s
PUMP CHAMBERj/a&j;;,'
(locate on site plan)
Pumps in working order.(yes or no)AI .
Comments:
(n�ote condition of purr chamber;condition of pumps and appurtenances,etc.)
(revised 11/03/95) 7
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(oontinued)
Property Address: 962 Main Street .0sterville,Mass. 02655
Owner. Sheila Thomas
Date of Inspeotion:5/6/96
SOIL ABSORPTION SYSTEM (SAS):_2
(locate on site plan, if possible;excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type: leaching pits, number: t
leaching chambers, number
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, ions: to
overflow cesspool, number:r.
-Comments: (note t on f so' s of hydralc fV re,e;el of pondir4,condition of
Loamy8�g S) O y rau 1C
oamy sanc` i ;Stand grave 77 ; ine sanC1 I t
—Tailure or pon ing;Al e e a ion is normall Leachingit was filled to
_ the pit cover; en pit cover was pulled sewage filled the hole.
The system is in failure; Must be upgraded to a title five septic system.
CESSPOOLS:
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer: AIR
Dimensions of cesspool:
Materials of construction: AM
Indication of groundwater: A A
inflow(cesspool must be pumped as part of inspection) All#
Commen�4{: (note condition f soil signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:
(locate on site plan) '
Materials of construction: �� 1 Dimensions: V4
Depth of solids: All
ats: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) 1
Co77
(revised 11/03/95) 8
PropervAddreaw 962 Main Street Osterville,Mass . 02b55'
Owner. Sheila Thomas
Date of Inspection: 5/6/9 6
SKETCH OF SEWAGE DISPOSAL SYSTEM: •
include ties to at least two permanent references landmarks or benchmarks
locate all swells within 100'
Centerville- Osterville Marstons' Mills
Water Company
428-6691
F 09
0 � O
DEPTH TO GROUNDWATER
Depth to groundwater.2 5!t feet
method of
9 y„ AA A �.✓ s T
JTp-Mannmber Rr Son Inc. Installed system in o water was e -
at 14'
(revised 11/03/95) 8
\� oidlli i1%-• J
V
b
I
THE COMMONWEALTH OF MASSACHUSETTS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BE IT KNOWN THAT
Joseph P. Macomber, Jr.
r .
Has satisfied the Department's_qualification& as-required.-and is.hereby
authorized to use the title
CERTIFIED TITLE 5 SYSTEM INSPECTOR
as provided in 310 CMR 15.340 and Section 13 of Chapter* 21lA of the
General Laws. Issued by The Department of Environmental Protection.
June 8, 1995
Acting Director of the 90ion of Water Pollution Control
n•nnnrnr'sra--rr':rn-mrnsrnrrnrtasrrrnr::-errs+•mrl�+rrarrm•ns�-esnsr:Terasn .rsrrx�r�.urr. `.:tr.r—•�F .
TOWN OF Barnstable BOARD OF HEALTH
�J ••4tM.,•:.;;,_T„�_.SUIISURFACF: SEWAGE DISPOSAL SYSTEM INSPECTION ION FORM - PART D^- CERTIFICATION -' M
-TYPE OR PRINT CLEARLY- A
PROPERTY INSPECTED
STREET ADDRESS 962 Main Street Og•. rville,Mass . 02655
ASSESSORS MAP, BLOCK AND PARCEL # 117-160
OWNER' s NAME ,Shell ` Thomas _
PART D - CERTIFICATION
NAME OF INSPECTOR Joseph P. Macomber Jr. .
COMPANY NAME J.P.Macomber & Son Inc.
COMPANY ADDRESS Box 66Centerville,Mass. 02632
Street Town or City State LIP
COMPANY TELEPHONE ( 508 ' 775 3338 FAX ( 508 790 - 1578
m R
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposa-1 system at
this address and that the information reported is true, accurate, and
complete as of the time of ,inspection . The inspection was performed and any
recommendations regarding. upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of o-n-
site sewage disposal systems .
Check one: ;
Systeui PASSED
The inspection Iahich` I have conducted has not found any information
which indicates that� the system fails to adequately protect public
health or the environment as defined in 310 CMR 15. 303 . Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form. ,
XXXXXXXXXSystem FAILED*The inspection wklich `I have conducted has found that the system fails to
Protect th.e •public health and the environment in accordance with Title
5 , 310 CMR 15 . 30.3, and as. specifically noted on PART C - FAILURE
CRITERIA of this inspection form ,
Inspector Signature i Date 5/13/96
/ One copy of this certification must be provided to the OWNER, the BUYER
( where applicable ) and the. DOARD OF HEALTH.
* If the inspection FAILED, the owner or operator shall upgrade ' the system
within one year of the date of the inspection, unless allowed or required
otherwise as provided in 310 CMR !15 . 305 .
. ..!A.-2 -2
- f
ell
�,
1
a.• � `�
(, ,
0
\�
t
^ V �� y_
� �� � _ =
1
No..., ......... Fsa. . ...... 1..
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® HEALT
AVVIira inn -for I -4poii l Workii Tunfitrurtion Urrulit
Application is hereby made for a Permit to Construct ( ) or Repair (dam ) -an Individual Sewage Disposal
System at:
............ -- •---•---••----•-------------••-•---.. ......... .. ................... .......... ._.-- -------• -------- --------------
Loca ion-A e �. t----•---. No
------------- //}� .... .... ............
WI/1e7g7,/ .... AddTesS
Installer Address
Q Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms________________________________ _Expansion Attic ( ) Garbage Grinder ( )
per, Other—Type of Building p .._.__ Showers ( ) — Cafeteria ( )
....---- No, of ersons-------•--.....--••---
a' Other fixtures ...
Q
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...__._--_--_--._..-----
r%, Test Pit No. 2..........------minutes per inch Depth of Test Pit.................... Depth to ground water_-.__._____-___._____--.
O ............. ------ ....................... � ------........................... .. _ze t Description of Soil " G!'.
x - --- --
U .................................... . - ----- -------
--------------------------------------- -- ------- -- - - - -------- -- --
W ------------------------------------------------------------------------------------------------- -------------------------------------- --•-•----------• ............................................
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 Article \I of the State Sanitar ode— The undersigned rther agrees not to place the system in
operation until a Certificate of Compliance ha e su d y th oar of ealth.
- .
-
Dati
Application Approved By.............. . -- -- -=---- . ---- 1
ate
Application Disapproved for the following reasons----------------------------------------- ---- -----------------------------------------------------------
------------------------------------------------------------------------------• ------------------
Date
PermitNo.......................................y.................. Issued........................................................
Date
--------------------- - --
THE FOLLOWING
IS/ARE THE BEST
IMAGES FROM POOR
QUALITY ORIGINAL (S)
I A ,
m / �C(�J IL
DATA
a
- ace
_ a
4
t.
f
re � �•mod -
�p - r Y
No.._.3- ......-•• Fss.,,�e�..................._
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O HEALT `
.....OF._....... .. :. ..
, ppliration InT lhsp real Workii Cnutuarur ion.. Vrrmft
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System af:
-- ---- ----------- --- '--- ------------------- -- ---•-- --------------
oc n-A e --•. t No5
ner Address
W
nstaller Address
UType of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms_:--------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—.Type of Building --- "-:"----------------"- No. of persons---------------------------- Showers ( ) — Cafeteria ( )
dOther fixtures ----------------- ----------------------------------------------------------------------------------------------------------------------------------
Wj Design Flow..."........................................gallons per person per day. Total daily flow............................................gallons.
P4 Septic Tank-Liquid capacity,,----------gallons Length................ Width........._..... Diameter...----..------- Depth................
xDisposal Trench—No----- ."--"--_.-.- Width-------------------- Total Length.................... Total leaching area-------------------_sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..."..._..-..-..-Sq. ft.
Z Other Distribution box ( ) Dosing tank ( ) • . •
Percolation Test Results . Performed bY--------------------------------------------------------------------------- Date---------------------------------------
,� Test Pit No. 1----------------minutes per inch' Depth of Test Pit""................." Depth to ground water-----------------.......
�14 Test Pit No. 2................minutes per inch Depth of Test Pit..................... Depth to ground water------------- ----- .
------------ =
Description of Soil ' -- ---- ---- - ----. -_-.
U ...............•-----------•-----------•-------------------------•---- — ------i------------
W
x .: ---------•--------------------------------
U Nature of Repairs or Alterations—Answer when applicable...."...................."-..-.-....."._....................."....".....".----------------------
Agreement:
The undersigned agrees..to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitar, de—The undersigned f'rther`agrees not to place the system in
operation until a Certificate of Compliance ha e sue y_th jar of alth.
ned. -"X.............................
_ / j �p----0-
Application Approved BY ......... r �` ''� �+ •Z-�"—
- ate
Application Disapproved for the following reasons:............................................ =--•--•--•- -----------------------------------
�:
............................................ ----•---...---•-•-"-------- --••--------
Date
Permit No......................................................... Issued_._
Date
rt .....................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF EALTH E
.... ....
%Lk.. fir tle f f�nut Ii nrr
IS I 04E -Y, That t e'Indi dal Sew Dis al stem constructed '( ) or Repaired
P )
by ._. ,..._:_ R. -------- --------- ----- -•• r•-•-•---
at
has been installed in accordance with t e rovisions of:Artrcie��+X��I of T� e tate Sanitar Cod as descr ed in the
application for Dtsp al Works Construction Permit N#1.1o... ti,e.._ .................. dated_4.. _ ...� ..... ... . _.._.
THE ISSUANCE OF THIS CERTIF,E4Tk�SHAL!"`NOT BE CONST ED.,AS A G A NTEEE THAT THE
SYSTEM NAIL
-..s.+•a ray r,M-a:� ..r..v+. -,;r.:n 7 r. - SAT[5FA6Trg R-Y , ,s r nfs,p
tec ..................... ..D �
Y
.A.�_ _..ene•.,..:r2�t;:r..'v-rx. ...tvs•...e-d'4���:Y^s i+c=��hs�-i�y.'+.r:a: ,e- ..'kik. _..._ _- � .�..... •._ ... .. ..._ � � .. �.. ,,. r... ... � _a
i• - C Y f l
THE COMMONWEALTH OF MASSACHUSETTS jtir
BOARD f\OF ALTH
...... .... ... . O F..... � ...... .......
No...._13Z...... FsE-•a'..............
k nlitrurtion rmit
�-
Permission is hereby grante ___. �_.. .....A..._.._ ._ Lti'Cv ,Lam.-s -
to ConstrucVy ) or air n ' i al S Disposal Syste
at No.__Ae . -- �'? ---
--_._... -------- ----- -- --- --- --------
Street
as shown on the •pplication for Dispos Works Construction P m N :... ...... .. . ed-.:
r•"
DATE. �. t � '- � ---
oa d of ealth
FORM 1255 ORBS & WARREN. INC.. PUBLISHERS r
_ �
� ��
s)
— - -
- �
�. �
-- - o '��
�' ,
_ e
-- 1• _ _
� . .