HomeMy WebLinkAbout0716 MAIN STREET (OST.) - Health (2) 716 Main Street, Osterville
VILLAGE at COTACHESET CONDOS
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Commonwealth of Massachusetts
U v Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
716 Main Street Building A
Property Address
First Property Management
Owner Owner's Name
information is required for Osteryille Ma. 02655 4/10/2009
every page. City/Town 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 A. General Information
forms the ^ I
computer,
r, use 1. Inspector: `J Z
only the tab key �4
to move your Robert Paolini
cursor-do not Name of Inspector
use the return
key. Capewide Enterprises LLC.'
Company Name
r� P.O.Box 763
Company Address
Centerville Ma. 02632
City/Town State Zip Code
(508)428-4028 S14454
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310_CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
4/10/2009
Insp or's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17
Commonwealth of Massachusetts
u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
716 Main Street Building A
Property Address
First Property Management
Owner Owner's Name
information is required for Osterville Ma. 02655 4/10/2009
every page. CityrFown State , Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 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:
The septic system is in proper working order at the present time.
13) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltrationn-or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 716 Main Street Building A
Property Address
First Property Management
Owner Owner's Name
information is required for Osterville Ma. 02655 4/10/2009
every page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N . ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
wM 716 Main Street Building A
Property Address
First Property Management
Owner Owners Name
information is required for Osterville Ma. 02655 4/10/2009
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/2 day flow
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
�L
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
^M 716 Main Street Building A
Property Address
First Property Management
Owner Owner's Name
information is required for Osterville Ma. 02655 4/10/2009
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply
well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ❑ The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ❑ The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
GSM , 716 Main Street Building A
Property Address
First Property Management
Owner Owner's Name
information is required for Osterville Ma. 02655 4/10/2009
every page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (if they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the'SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ElWas the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
El ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 18 Number of bedrooms (actual): 18
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 2970gpd
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 716 Main Street Building A
Property Address
First Property Management
Owner Owner's Name
information is required for Osterville Ma. 02655 4/10/2009
every page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
The septic system consists of a 5000 gallon septic tank,distribution box and three leaching pits.
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ® Yes ❑ No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d seperate meters
9 ( Y 9 (gp ))�
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: 4/10/2009
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
t
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
wM 716 Main Street Building A
Property Address
First Property Management
Owner Owner's Name
information is required for Osterville Ma. 02655 4/10/2009
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 716 Main Street Building A
Property Address
First Property Management
Owner Owner's Name
information is required for Osterville Ma. 02655 4/10/2009
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
1985
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 38"feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line. 10+
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Joints appear tight.No evidence of Ieakage.System vented through the building vents.
Septic Tank(locate on site plan):
Depth below grade: 40"feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 5000 gallons
Sludge depth:
6"
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
716 Main Street Building A
Property Address
First Property Management
Owner Owner's Name
information is required for Osteryille. Ma. 02655 4/10/2009
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle
29"
Scum thickness
Distance from top of scum to top of outlet tee or baffle
5"
Distance from bottom of scum to bottom of outlet tee or baffle
13"
How were dimensions determined? measured
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pump septic tank yearly.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears to be
structurally sound.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
716 Main Street Building A
Property Address
First Property Management
Owner Owner's Name
information is required for Osterville Ma. 02655 4/10/2009
every page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
716 Main Street Building A
Property Address
First Property Management
Owner Owner's Name
information is required for Cisterville Ma. 02655 4/10/2009
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert No
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.):
Box is Ievel.Box has three outlet laterals with equal distribution.No evidence of solids carryover.No
evidence of leakage into or out of box.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
w 716 Main Street Building A
Property Address
First Property Management
Owner Owner's Name
information is required for Osterville Ma. 02655 4/10/2009
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 3-6'x8'
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Sandy dry soil.No signs of hydraulic failure.Leachng pits are in very good condition.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M s 716 Main Street Building A
Property Address
First Property Management
Owner Owner's Name
information is required for Osterville Ma. 02655 4/10/2009
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
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Commonwealth of Massachusetts
W Title 5 Official Inspection Fora,
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 716 Main Street Building A
Property Address
First Property Management
Owner Owner's Name
information is required for Osterville Ma. 02655 4/10/2009
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
❑ Shallow wells
Estimated depth to high ground water: Bottom of leaching 10.4'
feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed: July 1985
Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
As-Built Card
❑ Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
USED:USGS Observation Well Data.USED:Technical Bulletin 92-000-01 plate#2 annual ranges of
groundwater elevations.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 716 Main Street Building A
Property Address
First Property Management
Owner Owner's Name
information is required for Osterville Ma. 02655 4/10/2009
every page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
❑ Inspection Summary: A, B, C, D, or E checked
❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
❑ System Information—Estimated depth to high groundwater
❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
4.
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
r
COMMONWEALTH OF MASSACHUSETTS
U9EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PR I TEtfLub&IVED
�7 Oo'3 JAN 0 6 ZG03
TOWN OF BARNSTABLE
HEALTH DEPT.
TITLE 5
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Cotacheset Condominiums
Property Address: 716 Main Street, Building A
Osterville, MA 02655
Owner's Name: First Property Management
Owner's Address:
Date of Inspection: December 17, 2002
Name of Inspector:(Please Print) James M. Ford
Company Name: James M. Ford
Mailing Address: P.O. Box 49 Map: 141
Osterville,MA 02655-0049 Parcel. 037
Telephone Number: (508) 862-9400
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
✓ Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: December 20, 2002
The system inspector shall b racopy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
`\ Page 2 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 716 Main Street, Building A
Osterville, MA °
Owner: First Property Management
Date of Inspection: December 17, 2002
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. 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:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please
explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION. (continued)
Property Address: 716 Main Street, Building A
Osterville, AM
Owner: First Property Management
Date of Inspection: December 17, 2002
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require ftirther evaluation by the Board of Health in order to determine if the system
is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from,a
private water supply well". Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
3
I
Page 4 of 11
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 716 Main Street, Building A
Osterville, AM
Owner: First Property Management
Date of Inspection: December 17, 2002
D. System Failure Criteria applicable to all systems:
You must indicate either`yes"or"no"to each of the following for all inspections:
Yes No
✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/r day flow
✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped_.
✓ Any portion of the SAS,cesspool or privy is below high ground water elevation.
✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
✓ Any portion of a cesspool or privy is within a Zone 1 of a public well.
✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well..
✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large System:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd•
You must indicate either`yes"or"no"to each of the follo_wing:
(The following criteria apply to large systems it addition to the criteria above)
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area- IWPA)or a mapped
Zone II of a public water supply well
If you have answered`yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
4
I
Page 5 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 716 Main Street, Building A
Osterville, MA'
Owner: First Property Management
Date of Inspection: December 17, 2002
Check if the following have been done: You must indicate"yes"or"no"as to each of the following:
Yes No
✓ _ Pumping information was provided by the owner,occupant,or Board of Health
✓ Were any of the system components pumped out in the previous two weeks?
✓ Has the system received normal flows in the previous two week period?
✓ Have large volumes of water been introduced to the system recently or as part of this inspection ?
✓ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
✓ Was the facility or dwelling inspected for signs of sewage back up?
✓ Was the site inspected for signs of break out?
✓ _ Were all system components,excluding the SAS,located on site?
✓ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
✓ _ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes No
✓ _ Existing information. For example,a plan at the Board of Health.
✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)[310 CMR 15.302(3)(b)).
5
I
Page 6 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 716 Main Street, Building A
Osterville, MA
Owner: First Property Management
Date of Inspection: December 17, 2002
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): n/a Number of bedrooms(actual): 18
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): n/a
Number of current residents: n/a
Does residence have a garbage grinder(yes or no): Yes
Is laundry on a separate sewage 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 2 years usage(gpd)): Unavailable
Sump Pump(yes or no): No
Last date of occupancy: Currently occupied
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gad
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no)
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information:_ .Pumped yearly-per management
Was system pumped as part of the inspection(yes or no): No
If yes,volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
✓ Septic tank,distribution box, soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) (if yes,attach previous inspection records, if any)
Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight Tank Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Unknown
Were sewage odors detected when arriving at the site(yes or no): No
6
Page 7 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 716 Main Street, Building A
Osterville, AM
Owner: First Property Management
Date of Inspection: December 17, 2002
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: _cast iron _40 PVC' other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: Approx. 18"
Material of construction: ✓ concrete _metal _fiberglass _polyethylene
_other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 4000 gal. -per information on file
Sludge depth: . 2"
Distance from top of sludge to bottom of outlet tee or baffle: --
Scum thickness: 2"
Distance from top of scum to top of outlet tee or baffle: 9"
Distance from bottom of scum to bottom of outlet tee or baffle: --
How were dimensions determined: Measuring stick
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 were present. The liquid level was even with the outlet invert. There were no signs of leakage.-Recommend pumping every
Year for maintenance. The covers were to grade.
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(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
7
i
Page 8 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 716 Main Street, Building A
Osterville, AM
Owner: First Property Management
Date of Inspection: December 17, 2002
TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: _concrete metal _fiberglass _polyethylene _other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: Even
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.):
The D-box was level. The cover was to grade.
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.):
8
♦ Page 9 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 716 Main Street, Building A
Osterville, 1M
Owner: First Property Management
Date of Inspection: December 17, 2002
SOIL ABSORPTION SYSTEM(SAS): ✓ '(locate on site plan,excavation not required)
If SAS not located explain why:
Type
✓ leaching pits,number: - 3- 1000 gal.
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
Innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.):
One pit 03)had approx. 6"of water on the bottom. Another pit(#4)had approx. 6"of water on the bottom. The other pit 05)
was dry. There were no signs of failure. All covers were to grade. The bottom to grade was approx. 13'.
CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth -top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: 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.):
9
Page t 0 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 716 Main Street, Building A
Osterville, MA
Owner: First Property Management
Date of Inspection: December 17, 2002
Map: 141
Parcel: 037
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
c �
a I
D
S y 3 i cq�P post
Al ^ it • �P�-Zq�
�Pa- TO
A;.- 2a cP3- ya
A3-
g�- 3a c-PS- !A7
10
Page 1 I of 11
y-
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 716 Main Street, Building A
Osterville, MA ' .
Owner: First Property Management
Date of Inspection: December 17, 2002
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 20' +/- feet
Please indicate (check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked, date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
✓ Checked with local Board of Health-explain: Topographic and water contours maps
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Using the Barnstable topographic map andthe Cape Cod Commission water contours map,the maps were showing approximately
20'+/-to ground water at this site.
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.
11
No. �03. Fee 56—
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
01pprication for ;h6pool *p5tem Construction Permit
Application for a Permit to Construct( )Repair(Upgrade( )Abandon( ) ❑Complete System LA'Itidividual Components
Location Address or Lot No. 7 AA/A, S T' Owner's Name,Address and Tel.No'-7—
c�
Assessor's Map/Parcel J 141't- f 7-- �-
Installer's Name,Address,and Tel.No. 3_4 X 17 9,r o2 f pa Designer's Name,Address and Tel.No.
Type of Building: C O ti T7 o S
Dwelling No.of Bedrooms 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
Nature of Repairs or Alterations(Answer when applicable) C -
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 b*issudalbbyhis Board of Health.
Sign Date ��� 'Application Approved by .S Date�/`-/17—Q.3Application Disapprovedng reasons
Permit No. Date Issued l !�?
lo. f p Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:�_
4. 4Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
2pprication for.33i.5p0al *pgtem Construction 3permit t
Application for a Permit to Construct( )Repair(Al'Upgrade( )Abandon- ( ) ❑Complete System 1<lividual Components ;
Location Address or Lot No. 719 A1 A//V 5 T Owner's Name,Address and Tel.N
G/?
o.
C.�S
Assessor's Map/Parcel T
7/G /JI ti T G S`T
Installer's Name,Address,and Tel.No. j d g' 9 7�' a r 00 Designer's Name,Address and Tel.No.
tF e4 (' Ati c o 3 J-
Type of Building: } p w l7 5-
Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
j .
f 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
Nature of Repairs or Alterations(Answer when applicable) ,
Date last inspected: _•
h
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 iss d by this Board of Health.
Signed Date
' Application Approved by s ro Date // /'7—UU
Application Disapproved for the following reasons
Permit No. Date Issued / )
————————————————————— — -—— --
/ / THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
T
Certificate of Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired ( Upgraded( )
Abandoned( )by A 2(& 014 ti C o 13 4; 7- Gu• f-��/e
at U 4- 7` has been constructd in ccordance
with the pr iswo s of Title 5 and the for Dis osal System Construction Permit No.Z60 3-.SS(� dated 1111,7163
Installer Lem ` - - Designer
i
The issuance of this pe t shall not be construed as a guarantee that the system w 1 f �Ii as es e�
Date �j1/71A Inspector
r .M
No. 2 pv3' --------------------------Fee 'no--�,"'
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTSw
=it o.5al stem Construction Permit
Permission is hereby granted to Construct( )Repair( v)`Upgrade( )Abandon( )
System located at_ 7� /1l/�/z. ST c� ST"
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.
Provided:Constructio musf a completed within three years of the date of this perm' . f
Date: /'7 l)3 Approved by /� J
_ COMMON WEAI-,'1'JI OF MASSACIIUSE'J"I'S
_ - EXECUTIVE OFFICE, OF ENVIRONMENTAL AFFALPZS,
DEPARTMENT OF ENVIRONKENTAL PIZOTEC14ON
• ONE WINTER STREET, BOSTON MA 02109 (617) 292.-5500top
\� Ca
} JA/ 6 2
350 MAIN STREET Y01 ftv S sre �ry
WEST YARMOUTH, MA DQ.ACID B 5RUI S
ARGEO PAUL CELLUCCI C ii
508-775-2800 1 Ssioner
Governor r n d`
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
MAP 141 PAR 037
PROPERTY ADDRESS: 716 MAIN STREET, OSTERVILLE BLDG A ADDRESS OF OWNER:
DATE OF INSPECTION: DECEMBER 15, 1999 VILLAGE COTTAGE ASSOC
NAME OF INSPECTOR : JAMES D.SEARS
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 9310 CMR 15.000)
COMPANY NAME: A&B Canco
MAILING ADDRESS: 350 Main Street,West Yarmouth,MA 02673
TELEPHONE NUMBER: (508)775-280.0
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:
X PASSES
CONDITIONALLY PASSES
NEEDS FURTHER EVALUATION BY THE LOCAL APPROVING AUTHORITY
FAILS 1p
INSPECTORS SIGNATURE: DATE: 1,2 �, y'
The system Inspector shall submit a 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 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.
NOTES AND COMMENTS: REPORT 1 OF 2
SITE OVER ALL PASSES,INSPECTION OF SYSTEM IS BASED ON CONDITION OF SYSTEM AT THE TIME
OF THE INSPECTION.THERE IS NO GUARANTEE ON.THE LIFE OF THE SYSTEM.
revised 9/2/98 1
�R .r
n
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 716 MAIN STREET, OSTERVILLE BLDG A
Owner: VILLAGE COTTAGE ASSOC.
Date of Inspection: DECEMBER 15, 1999
INSPECTION SUMMARY: Check A,B, C,orD:
A] SYSTEM PASSES: YES
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR
15.303. Any failure criteria not evaluated are indicated below.
COMMENTS: q
B SYSTEM CONDITIONALLY PASSES: N/A
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 is failure is imminent. The system will pass inspection if the existing septic tank is replaced with a
conforming septic tank as approved by the Board of Health.
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 pa
pass inspection if(with approval of the Board of Health),
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled 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
revised 9/2/98 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 716 MAIN STREET, OSTERVILLE BLDG A
Owner: VILLAGE COTTAGE ASSOC.
Date of Inspection: DECEMBER 15, 1999
CJ FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: N/A s
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)THT 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.
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 THE ENVIRONMENT:
The system has a septic tank and soil absorption system(SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
The system has a septic tank and 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 and is equal to or less than 5 ppm. Method
used to determine distance (approximation not valid).
3) OTHER
revised 9/2/98 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 716 MAIN STREET, OSTERVILLE BLDG A
Owner: VILLAGE COTTAGE ASSOC.
Date of Inspection: DECEMBER 15, 1999
D]SYSTEM FAILS: N/A
You must indicate either"Yes"or"No" to each of the following:
I have determined that one or more of the following failure conditions exist as described in 310 CMR
16.303. 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 over-
loaded 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''Y2 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 surface water supply or tributary to a
surface water supply.
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 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: N/A
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
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
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 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 716 MAIN STREET,OSTERVILLE BLDG A
Owner: VILLAGE COTTAGE ASSOC.
Date of Inspection: DECEMBER 15, 1999
Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following:
Yes No
X Pumping information was provided by the Board of Health.
X 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.
X As built plans have been obtained and examined. Note if they are not available with N/A.
X The facility or dwelling was inspected for signs of sewage back-up.
X The system does not receive non-sanitary or industrial waste flow.
X The site was inspected for signs of breakout.
X All system components,.including the Soil Absorption System,have been located on the site.
X The septic tank manholes were uncovered,opened,and the interior of the septic tank was
inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid
depth of sludge,depth of scum. The size and location of the Soil'Absorption System on the site
Has been determined based on:
X Existing information.Ex.Plan at B.O.H.
X 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)]
X The facility owner(and occupants,if different from owner)were provided with information on
the proper maintenance of Sub-Surface Disposal System.
revised 9/2/98 5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION -
Property Address: 716 MAIN STREET,OSTERVILLE BLDG A
Owner: VILLAGE COTTAGE ASSOC.
Date of Inspection: DECEMBER 15, 1999
FLOW CONDITIONS
RESIDENTIAL:YES
Design flow: g.p.d./bedroom for S.A.S.
Number of bedrooms(design) Number of bedrooms(actual):
Total DESIGN flow
Number of current residents: N/A
Garbage grinder(yes or no): NO
Laundry(separate system) (yes or no): N/A If yes,separate inspection required
Laundry system inspected(yes or no): N/A
Seasonal use(yes or no) SOME
Water meter readings,if available(last two(2)year usage(gpd): UNAVAILABLE
Sump Pump(yes or no): NO
Last date of occupancy: N/A
COMMERCIAL/INDUSTRIAL: N/A
Type of establishment:
Design flow: Gpd(Based on 16.203)
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:
1994,1995,1996,1997 BARNSTABLE PLANT
System pumped as part of inspection:(yes or no)
If yes,volume pumped: gallons
Reason for pumping
TYPE OF SYSTEM
X 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:
1985-86
Sewage odors detected when arriving at the site:(yes or no) NO
revised 9/2/98 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 716 MAIN STREET, OSTERVILLE BLDG A
Owner: VILLAGE COTTAGE ASSOC.
Date of Inspection: DECEMBER 15, 1999
BUILDING SEWER: N/A
(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: YES u
(Locate on site plan)
Depth below grade: 2'
Material of construction X concrete _ metal _ Fiberglass Polyethylene other(explain)
If tank is metal,list age Is age confirmed by Certificate of Compliance (Yes/No)
Dimensions: 4,000 GALLONS
Sludge depth: 4"
Distance from top of sludge to bottom of outlet tee or baffle: N/A
Scum thickness: 4" y
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: N/A
How dimensions were determined TAPE&AS BUILT ,
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.)
TANK AT WORKING LEVEL,TWO INLET TEES,ONE OUTLET TEE .
BOTH COVERS 2'STEEL AT GRADE
GREASE TRAP: N/A
(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 7
. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 716 MAIN STREET,OSTERVILLE BLDG A
Owner: VILLAGE COTTAGE ASSOC.
Date of Inspection: DECEMBER 15, 1999
TIGHT OR HOLDING TANK: N/A (Tank must be pumped prior to,or at time,of inspection)
(Locate on site plan)
Depth below grade:
Material of construction _ concrete _ metal Fiberglass = Polyethylene other(explain)
Dimensions:
Capacity: Gallons
Design flow: gallons/day
Alarm present
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: YES
(locate on site plan)
Depth of liquid level above outlet invert: 0"
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc,)
D BOX IS 30"X 30",3'BELOW GRADE.
ONE LINE IN,ONE LINE OUT
BOX IS CLEAN 2"STEEL COVER AT GRADE
PUMP CHAMBER: NIA
(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.)
V
z
.. a .. ..
revised 9/2/98 8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
. PART C
SYSTEM INFORMATION (continued)
Property Address: 716 MAIN STREET, OSTERVILLE BLDG A
Owner: VILLAGE COTTAGE ASSOC.
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS): YES
(locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods)
If not located, explain:
Type:
Leaching pits,number: 3
Leaching chambers,number:
Leaching galleries,number.
Leaching trenches,number,length:
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.)
THREE PRE CAS PITS,PIT 1 -30"BELOW GRADE,6"WATER
PIT 2-66"BELOW GRADE 10"WATER
PIT 3—66"BELOW GRADE 10"WATER
ALL PITS ARE 7' DEEP WITH 2' STEEL COVERS AT GRADE
CESSPOOLS: N/A
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater.
inflow(cesspool must be pumped as part of inspection)
Comments::
(note condition of soil,signs of hydraulic failure, ,level of ponding,condition of vegetation,etc.)
PRIVY: N/A
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids:
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
revised 9/2/98 9
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 716 MAIN STREET, OSTERVILLE BLDG A
Owner: VILLAGE COTTAGE ASSOC.
Date of Inspection: DECEMBER 15, 1999
SKETCH OF SEWAGE-DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'(locate where public water supply comes into house)
10
h .
o T_
O'. ° °
revised 9/2/98 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 716 MAIN STREET, OSTERVILLE BLDG A
Owner: VILLAGE COTTAGE ASSOC.
Date of Inspection: DECEMBER 15, 1999
NRCS Report name
Soil Type
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Ground water depth: Shallow Moderate Deep
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells
Estimated Depth to no groundwater 20 Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observation of Site(Abutting property,observation hole,basement sump etc.)
Determine it from local conditions
x Check with local Board of health
Check FEMA Maps
Check pumping records
Check local excavators,installers
Use USGS Data
Describe in your own words how you established the High Groundwater Elevation. Must be completed)
NOTE: GROUND WATER DEPTH TAKEN OFF INSPECTION REPORT ON FILE BARNSTABLE HEALTH DEPT.1996
revised 9/2/98 11
1 /
u
. v/
CERTIFIED SEPTIC SYSTEM REPORT
LOCATION
THE VILLAGE AT COTACHESET
BUILDING A.
716 MAIN ST .
OSTERVILLE, MA 02655
MAP 141 PARCEL 037
PREPARED FOR
5 a
c�
MR. ANDREW WITTER
FIRST PROPERTY MANAGEMENT
832 MAIN ST . 199�
OSTERVILLE, MA 02655 Ea.
, J
�u
BUYER
NONE AT THIS TIME
PREPARED BY
HILLIARD HILLER
P .O. BOX 250
CENTERVILLE, MA 02632
508-778-1472
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Department of
Environmental Protection
WNW F.Weld Trudy Core
Ga mot S"'~mly
N9eo Paul Caliucci David B. Struts
LL GOMM Cort+mman.r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
TIFICATION
, A-1 G /� r, Address of Owner. y> F/k'Sj Q,E'G�iOt%1%Y
Property Address: 7 iG, /�f i S i m IJSi.rat//L.L,C•"
ffereat)(If di /y/7�//f�st-i'r.i'.�T
Date of Inspection: j fi3 f/y 7
Name of Inspector.
Company Name.Address and Telephone Number. le�a 43r-'n a Sv US jC2��icGE �/� ozCSS
CERTIFICATION STATEMEIr'T SD8-77�=/y71.
I certify that I li ve penally 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
ma1Tt1}rOnro of on-site sewage disposal systems. The system: .
_�a88eS
_ Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Sigsatm-e: 213�� Date: //-//
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,
sport to the appropriate regional office of the Department of Environmental Protection.
The original sh—ld be sent to the system owner and copies sent to the buyer, if applicable and the approving authority.
INSPZ=ON SUKKARY:
Chace?"C,or D:
Al SYSTEM PASSES:
I hs�re not£Quad any information which indicates that the system violates any of the failure criteria as defined in 310 CUR 15303.
Any fn7trte criteria not svalusted are indicated below.
B) SYS'I'EK CONDITIONALLY PASSES:
Ors of more system components need to be replaced or repaired. The system,upon mmpie=n of the replacement or repair,passes
Iadirata yes,ea or mot determined(Y, N, or ND). Describe basis of determination in all instances. If"not determined-, explain why pot)
_ This septic tank is metal. cracked. strucuraily-,resound. snow substantial infiltration or emfiltratron. or tank failure in
+•*�•*�+went. The system will pass --spec-.on -.f the ?X:stmg septic tans is replaced with a Conforming septic tank as approved
by the Board of Health.
(revised 11/03/95) 1
Ons Yfintar Street • Boston,Massachusetts 02108 • FAX(617) 556-1049 • Talsphone(617)292-5sw
w
�v„r.r•a a.a.cxNd aao,.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Addrers !J /LO//v G �9. 7/G iLi/7i/✓ S T ��S T i2G /L.,G
Owner.
Date of Laspeation: it/3 D/Y/5 7
Cbsck if the following have been done:
r/Pumping information was requested of the owner. occupant, and 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. ],�Z
_.The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow
_L,:� i'he site was inspected for signs of breakout.
✓All system components,4cluding the Soil Absorption. System. have been located on the site.
t-1 h septic tank manholes were uncovered. opened. and the interior of the septic tank was inspected for condition of baffles or
teas, material of construction, dimensions, depth of liquid, depth of sludge,depth of scum.
�/Tba size and location of the Soil Absorption System on the site bas been determined based on existing information or
approximated by non-intrusive methods.
IZThe fac lity 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
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
f1
11'roperty Addr°'a 7/� i�/l`iti S% �JSi l/IGGG=
Owner. 7o
Date of Inspection: ///3 t/f//9,7
FLOW CONDITIONS
RESIDENTIAL'
Design flow�lloaa
Number of bedrooms:
Number of natant residents:y
Garbage grinder(yes or no):_
I.w=&y c=nscted to system(yes or no):_
Seasonal us.(yes or no):'54`c uv/Ts
Water meter readings, if available:
Last data of oecnpaary: i G y
COMMERCIAL/INDUSTRIAL-
Type of establishment:
Deciga now: • aaallons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
N(n.am tuy waste discbargea to the Title 5 system: (yes or-
.no)-Water meter.readings, if available:
Last date of oaapaacy:
OTB313L Meeen'be)
Last date of occupancy:
GENERAL INFORMMATION
PUMP RECORI d source Q�,67�
/ y y
87aum pumped as part of insperaon: (yes or ao)-j v
If yes,volume pumped: Gallons
Beason for pumping:
TYPE OF SYSTEM
uwk dixtz .+on box/soil absorption system
sin&csespool
Overflow casspool
8bsrsd.systam(yes or no) (if yes,attach previous inspection records, if any
Other(crpiain)
APPROID ATE AGE of all components, date installed(if known) and source of information:
p_ 15y -S`QP VK .
sewage odon dnteetwd when arriving at the site: ryes or nog
(revised 11/03/95) 5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Add'—
Owner.
Date of Inspection: Y /L�idvi9G L�-,f'vT
SEPTIC TANK_v
(lorats on site plan)
Depth below V%da: Q
MstwW of coition: �/osnrsete_metal_FRP—other(explain)
Dimensions:_ l 7't 4U7x 6- 7 S" ,a�6i°
Bhwp depth: /a"
Distance from top of sludge to bottom of outlet tee or baffle: 7S
9cnm thiclMag -X i I,
Distance hom top of scum to top of outlet tee or baMe: IA-
Distance from bottom of scum to bottom of outlet tee or baMe: Sol r
Comments:
(r mmmsndation for pumping, condition of inlet and outlet tees or baffles, depth of squid level in reiation to outlet invert, strurural integrity,
evidence of leakage, etc.) 7A /, GGs l--Y49 Jl. 5iezi of GR�f'f fl f %mod S 4i�%l.� jam
/J G.£i✓�TF/S / t] T�TL !��
GREASE TRAP-
(locate on alto plan)
Depth below grade:
Material of eonstnuetion: _Concete_metal_FRP _othenezplainj
Dimensions:
8=thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance hom bottom of scum to bottom of outlet tee or baffle:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of'quid ievei in relation to outlet invert, structural integrity.
evidence of leakage, etc.)
(revised 11/03/95) 6
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
/J i riG /f
Pmperty Address:
Omer.
Date of Inspection: /l
TIGHT OR HOLDING/TANK
(locals on site plan)
Depth below grade:
Material of suction: _conceis_metal_FRP_ather(�plaia)
Dimensions:
Capacity Gallons
Design flow Rallons/day
Alarm level
Comments:
(condition of islet tee,condition of alarm and float switches. etc.)
DISTRIBUTION BOX
(locate on site plan)
Depth of liquid level above outlet invert:
(note if level and distribution is equal,evidence of solids carryover, evidence of leakage into or out of box. etc.) /W—
PUMP CSAI®ER:_
(losu on sits plan)
pups is warhng,ordan(yes or no) -
Comments:
(Mote ooaditian_of pump chamber, condition of pumpa and appurtenenc-• etc.)
(revised 11/03/95) T
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION.(continued)
Property Address: (�U/G pi vG A
Owner.
Date of laspecUont
SOIL ABSORPTION SYSTEM (SAS):�.
(locate on site plea, if possib ;excavation not required, but may be appr mated by non intrusive methods)
If not detawiasd to be present,arplain:
Type:
her-hrng pits, number
leaching chambers,number-_,
lssehing galleries, number.
Caching tranches, number,length:
hsehing 5alds, number,dimensions:
overflow aasspool, number-
Comments:(note condition of soil. signs of hydraulic failure. level of ponding, condition of vegetation-etc.)
CBBSPOOLS:_
(locate on site plan)
Number end mm8ggmmtion:
Depth-cp ad liquid to inlet invert:
Depth of solids layer:
Depth ofmun layw-
Dimeasioas of osaspoch
Materials of construction.
Indication of szo=dwatm.
iadow(oaespool must be pumped as part of inspections
Commentc(note aandidon of soil signs of hydraulic failure, level of n po ding, condition of vegetation, etc.)
PRIVY:_
(locate on site plan)
Materials�ofirmDimensions:
Depth of lids:
commeats (mots m nA*ion of soil. signs of hydraulic failure, level of ponding, condition of vegetation- etc.)
(revised 11/03M) e
f
e
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
I.3L�/G.Oifjv fl
Propatty Addzvew
Owner
Data of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
iarh�de ties to at Last two permanent references landmarks or benchmarks
beats all wens within 100'
I
3y'��`
a
I
I �
;
I
G i �
i
DEPTH TO GROUNDWATER
Depth to Ram iwssar: 3 I-r feet
methodof.duannina:i= or apprex.=A oa /�A.�trS/79�G1 �� S/7�U�i5 7l7�� SiTf /9�xavL' EGl�iis'T/off/
3,6
-Ive7 -3.6 = 3.�3
(revised 11/0395) 9
311
Commonwealth of Massac
husetts
Executive Office of Environmental Affairs
Department of LEE
Environmental Protection 96William F.Weld T.Governor ABLE
Trudy Co,a
Secretary,EOEA
David B. Struhs
Comminioner
` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
�(t I
a CON 00_ l PART A
cc
C5 T'�4as�I ) iy J CERTIFICATION
Property Address: V N 1 r \ �1._ O SYevx 4\ _ Address of Owner: U.)OXTC t--Zepl►ssot4 `
Date of Inspection: ACt P (If different) �b )
Name of Inspecton—jz,;a
Company Name, Address ankTelephone N mber:
l�Zra�.w� i
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 sewagedisposal systems. The system:
V Passes
_ Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signat Date: y 8'-2jp
The System Inspector shall.submit a copy o his 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 sen; ;c the system owner and copies sent to the.buyer, ii appiicable and the approving au hori;�.
INSPECTION SUMMARY:
Check A, B,C, or D:
A) ,SYSTEM PASSES:
v 1 have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
B) SYSTEM CONDITIONALLY PASSES: l
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,1N, or ND). Describe basis of determination in all instances. if"not determined", explain why not)
_ The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as
n approved by the Board of Health.
(revised 8/15y95)
V
One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500
�' `0 Printed on Recycled Paper
1.
r
. SUBSURFACE SEWAGE DISPPOSRALASYSTEM INSPECTION FORM
CERTIFICATION (continued)
Property Address: LA-(!i Zi 5 57Lrr
Owner: ��.eti+T AJ
Date of Inspection:
BI A SES (continued)
NDITIONALLY S ,(
SYSTEM CO . P.
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
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 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.
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 wstem has a septic tanK ano soil absorption system anu is withiii 10G icci io a auia—ce 'Water 5uppi) or tributary" to a
surface water supply.
The vstem ha, a septic tank and soil absorption system and is within a Zone I of a public water supply well.
es P
system and is within 50 feet of a rivate water supply well.
_ system has a septic tank and soil absorption � P
The s�ste p
_ The systen-, 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•
D] SYSTEM FAILS:
1 have determined that the system violates one or more of the following failure criteria as defined 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.
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.
(revised 8/15/95) 2
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
( CERTIFICATION (continued)
Property Address: V1
Owner.— 1�•,e�3o�
Date of Inspection:
DJ SYSTEM FAILS(continued):
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.
IV Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
N_ Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
/U Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Li Any portion of a cesspool or privy is within 50 feet of a private water supply well.
ILI 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.
El LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above:
The design flow of system is 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:
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 suppiy well`
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 8/15/95) 3
SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: U NV er ur
Owner .-..-e'-`X- ►L
Date of Inspection:
Check if the following have been done:.
:dumping information was requested of the owner, occupant, and Board of Health.
one 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.
�he facility or dwelling was inspected for signs of sewage back-up.
__fhe system does not receive non-sanitary or industrial waste flow
,_lhe site was inspected for signs of breakout.
_ II system components, excluding the Soil Absorption System, have been located on the site.
,,,,Ire septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or
tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has beewdetermined based on existing information or
approximated by non-intrusive methods.
F 1e facili;� c..:, ;a'. ' occapar.ts, if di'ere from; o\,rne-' Were provided with information on the proper maintenance of Sub-.
Surface Disposal System.
(zevised`s/15/95).. 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: L FtiT�31a- 051 t ru 1�\e r.
Owner: r"
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow 6L� gallons
Number of bedrooms: 3
Number of current residents: V
Garbage grinder (yes or no):
Laundry connected to system (yes or noA
Seasonal use (yes or no):
Water meter readings, if av ilable: A! A
Last date of occupancy: J
COMMERCIAIJINDUSTRIAL:
Type of establishment:
Design flow:_gallons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non-sanitary waste discharged to the Title 5 system: (yes or no)_
Water meter readings, if available:
Last date of occupancy:
OTHER: (Desciibe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as part of inspection: (yes or no)_
If yes, volume pLimred gallons
Reason for pumping:
TYPE O EM
Septi c tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records,-if any)
Other(explain)
APPROXIMATE AGE of all components, date installed (if known) and source of information:
VrySewage odors detected when arriving at the site: (yes or no)
(revised„ /15/95) 5
t
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: V ILt T'
Owner:
Date of Inspection:
SEPTIC TANK:]
(locate on site plan)
Depth below grade: O�
Material of construction: V'_concrete metal _FRP other(explain)
_
Dimensions:
Sludge depth: Or 7`�
Distance from top of sludge to bottom of outlet tee or baffle:
`i
Scum thickness: J �V
Distance from top of scum to top of outlet tee or baffle:_
Distance from bottom of scum to bottom of outlet tee or baffle:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.) yev-1 do Q�.j C— " V.
GREASE TRAP:_
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _FRP other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom rv,crtim to hr)ttnrr of Oiltlpt tee Or batlle-
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.*)
6
(revised 8/15/95)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM,
PART C
SYSTEM INFORMATION (continued)
Property Address: VNvT (�)— 65T- rY-0 —�
Owner:
Date of Inspection:
TIGHT OR HOLDING TANK:
(locate on site plan)
Depth below grade:
Material of construction: _concrete metal _FRP —other(explain)
Dimensions:
Capacity: eallons
Design floe-: gallons/day
Alarm level:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:
(locate on site plan;
Depth of liquid level above outlet invert:
Comments
tnote ii ievei and distribuoul, i> eyua , e\.dunce of solid_ ca,r�o%er, evidence of leakage into or out of box, etc.
G o✓� ;S'�t�/La /��n
PUMP CHAMBER:
(locate on site plan)
Pumps in working order:(yes or no)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(zevised`e/15/95) 7
1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: Uf-f t T- 3i D- 05r-e'r
Owner: __�?,evT'A_J
Date of Inspection: '9--*
SOIL ABSORPTION SYSTEM (SAS):
(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:
leaching chambers, number:_
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
Comments: (note condition of soil, signs of hydraulic f i�lure, level of ponding, condition of vegetation,etc.)
J
CESSPOOLS:
(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 grounds%ate..
inflow (cesspool must be pumped as part of inspection)
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.)
(revised 8/15/95) 8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: UN f T'
Owner: tct,t
Date of Inspection:
�4-e-V
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
0
DEPTH TO GROUNDWATER
Depth to groundwater: feet
method of determination or approximation:
�y
-Arevised 8/15/95) 9
i
BAXTER & NYE, INC.
Registered Land Surveyors and Civil Engineers
7 Parker Road/Osterville, Massachusetts 02655/Tel. (617)428-9131
WILLIAM C.NYE,R.L.S.-President
RICHARD A.BAXTER,R.L.S.-Vice President PETER SULLIVAN,P.E.-Vice President-Engineering
March 5 , 1987
Town of Barnstable
Board of Health
Box
Hyannis, MA 02601
RE : Silvia &Silvia - 85-269
Main Street Condominium
Osterville
Dear Board:
Per your request, I have inspected the inlet tees .
on the septic tank for Units 7 through 12 . The tees are
in accordance with state and local requirements .
Very truly yours ,
Peter Sullivan, P . E.
Baxter & Nye, Inc .
PS/fmj
CC : Siliva and Silvia
OF ; <.
v°�nL �s�cMsq
PER'
U SULLIv)u4
No. 29733
DiP dSTE� �yv'�
j
MEMBERS OF
CAPE COD SOCIETY OF PROFESSIONAL ENGINEERS AND LAND SURVEYORS I AMERICAN CONGRESS ON SURVEYING AND MAPPING
MASSACHUSETTS ASSOCIATION OF LAND SURVEYORS AND CIVIL ENGINEERS
BAXTER & NYE, INC.
Registered Land Surveyors and Civil Engineers
7 Parker Road/Osterville, Massachusetts 02655/Tel. (617)428-9131
WILLIAM C.NYE,R.L.S.-President
RICHARD A.BAXTER,R.L.S.-Vice President PETER SULLIVAN,F.E.-Vice President-Engineering
March 4 , 1987
Town of Barnstable
Board of Health
P .O. Box 534
Hyannis, MA 02601
RE: Silvia & Silvia
12 Unit Condominium
Pain Street - Osterville
Bear Board;
Please be advised that I personally supervised
the installation of the septic systems for the 12
condominium units . The systems have been installed
in accordance with the approved plan.
Very truly yours ,
Peter Sullivan, P . E .
Baxter & Nye, Inc.
PS/fmj
„ .:.OF
.�� P.TER v�
SULLIVAN.
No. 29733
r ;
MEMBERS OF
. -CAPE COD SOCIETY OF PROFESSIONAL ENGINEERS AND LAND SURVEYORS/AMERICAN CONGRESS ON SURVEYING AND MAPPING
MASSACHUSE9TS ASSOCIATION OF LAND SURVEYORS AND CIVIL ENGINEERS
FNo......
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
..........:...�V'�r).....:...OF................. .........................
Appliration for Uiipuiial Workii Cnnnitrnrtinn Vanfit
Application is hereby made for a Permit to Construct (A) or Repair ( ) an Individual Sewage Disposal
System at:
1C�...... 4............. ..... ......N.1............P--�:�:--�-o...• ..................
Lo�\h t;on-A d ess y� '��j��i j�� �
J.!.d � r .`�.�Lo..... _...... l..J_��!_.l !...•...�r4 - Lot No:.•' .............
ner "��"+A dress a
Installer Address d a� e Type of Building Size Lot___ -1��. 11S....Sq. feet
U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
a Design Flow.Other fixt��_-_-v ::gallons per person per day. Total daily flow................ .6................d I
w
WSeptic Tank—Liquid ca acit .k��-allons Length Total Length leaching area_-_Depth-...---sq. ft.
x Disposal Trench No. ..P.......Width.... . g
Seepage Pit No...........Q..... Diameter-------g o...... Depth below inlet...&' .. Total leaching area....sq. ft.
z Other Distribution box (p-� Dosing nk ( ) ,/�
Percolation Test Results Performed by... - �"._` .!_1 �L. . J. 1 Date.......1.o-�..: /_.__._.....
4 Test Pit No. 1___... ._.minutes per inch Depth of Test Pit...... . ......... Depth to ground water-----�`�............
ri, Test Pit No. 2................minutes per inch Depth of Test Pit..... .. . ...... Depth to ground water........................
P4 ....-------•---•-•-•-•--•-•...-•-••----•-•---••--------------------------•--.........-------•-"'--.......-•-----•----.....-•----------•--------'•----•------
D Description of Soil-------------------- -----•-- . --
WL
W ---------•••..........................•---------•------------------------------.V••-------- •-------•--•------------------------•-------=--...----•-•-------•-••----•------•------.....------.....
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 iITLL 5 of the State Sanit y ode— and igned further a rees not to place the system in
operation until a Certificate of Compliance ha ee issued y he b a d of 1 alth.
Signed s �.' ---- •----- `_lb 7
Date
Application Approved ��..-�.... --.. Q ua,..............
Date
Application Disapproved for the following reasons-----------------------------------------------------------------------------------------------------------------
.................•-...---..........--------•---....•-------------•--•---------•----....----•------------------------•---------•----------•------------•--•--••-----•-•---------•--------------••----•---
Date
PermitNo......................................................... Issued_.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
! /'G�.��..I........OF............ }'!"�... . . .
............ . . ......................
f
amp if iratr of Touttpliattrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constracze� -g ) or Repaired_( _)
by------------------••-------------------•-------------'_._•-•---------------•-----•--------------------------------.......----------------•------------------•-•-•----------------------.----------.
at - --------fir. ------. 1...---- ��
` _�( a er
has been installed in accordaneVAvith the provisions of TITLE j of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No... '.2_-.-.r�-Y.............. dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
` BOARD AF HEALTH
skb/.(, .l...I..........OF.......... /1. �
- -•- FEE.......................
Biopog t1 World T-Faanitrndion "anti#
Permissionis hereby granted---------------------------- ----------•------------------•----------••-------•-•••-•----------•-••-•------........----.......----•-....---
to Construct (-A) or Repair 1 ) an In 'vidual,.Sewag sposal Syst
atNo.......................................
Street
as shown on the application for Disposal Works Construction Permit No..................... Dated..........................................
...� ... -M---- -------------------------------------•-_
and of Health
DATE....................................................................-----------
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
No..-----81 s y Fiz$...... ...............
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® HEALTH
.............. . .81.........OF.............. :: :Y:J�i .[t�!�.�' F- ..........------------------
Appliration for Disposal Works Tonotrnr#iun Prrmit
Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal
System at:
_P P LZ-9........................
or Lot No.
ner A ress
a ........................1C�.�::..��..7k........................................ :.Ir..... . . ...
I si.s.•. --
Installer Address n f
l�� _U Type of Building Size Lot.._._ __ ----Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
`4 Other—Typ8,,of Building No. of persons............................ Showers — Cafeteria
Otherfixtures ...--•------------------------------------------------•------•------------------------- ---------•--•-•-••--
W Design Flow.....................55.............gallons per person per day. Total daily flow.................
WSeptic Tank—Liquid*capacity.1allons Length................ Width................ Diameter_______________. Depth................
x Disposal Trench—No..................... Width.................... Total Length......:.........._.. Total leaching area...... •------___sq. ft.
Seepage Pit No...........Q..... Diameter........9.1----- Depth below inlet.::.'......... Total leaching area....��._sq. ft.
Z Other Distribution box ( Dosing nk ( ) n /J _
'—' Percolation Test Results Performed by.... �' .. a._i J _rr- ?S Date........10.:-�_ . .........
a Test Pit No. I.......a...minutes per inch Depth of Test Pit.......j. _.__._ Depth to ground water------N------------
(i, Test Pit No. 2................minutes per inch Depth of Test Pit...... Depth to ground water------_`.............
W' ----------------
.........................................................
O Description of Soil '. r -•----••------•-••---
--- -- -------- - - - --
�C
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 TIT12 5 of the State Saniaec unde 'gned further a rees not to place the system in
operation until a Certificate of Compliance hahe b o a of1 lth.
Signed �.' . •--- .
Date
Application Approved By..... . ..
' Date
Application Disapproved for the following reasons----------------------------------•---------------------•------------------------------------------._.........•--
...............•-•--•----.....---•--•-------•--------------•......-----------------..........--------•---•-•--•-•---•-•••••--••---••----•-•••---...•-••-•••••••-•••---••••--•-••-----•--•••-••-•--------
Date
PermitNo......................................................... Issued........................................................
Date
THE—COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
7�> .......0F.............&.1-11.. 1..b
- (9rdif iratr of TomptiFanrr
THIS IS TO CERTIFY, That the.Individual Sewage Disposal System constructed (-�I- ) or Repaired ( _ )
by----------------------------•-----------------------------------------------------------------------------------------------------------------------------------------------------------------------
at•--••-•-•-_.....)�--r�--•-•----_ .......... 1............ `...--------•--•-----------•----•--------•------------------------------------------••......•...
has been installed in accordance with the provisions of TITLE: 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No...Afl_-.,r1.Y............. dated-...............................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector...............-------------------------- -•--------- -------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD Qf HEALTH
rbl .......................... 40W
•-•-
No..................... FEE- •...................
Disposal Works Tonstrrnrtion rranit
Permission is hereby granted..............................................................................................................................................
to Construct (�[_) or Repa}'� ( ) an In 'vidual.Sewag�' posal Syst 1
atNo......................--••••-••••.:._t. ...........� .�.k ...... = 7
Street
as shown on the application for Disposal Works Construction Permit No..................... Dated...........................................
� -------------•-•••......--..............
a�Health
DATE................................................................................ ,.
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS -
No...B -.� Fms... .. ..................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............JA=n- ...........OF......1 Q,�.n�� -�_1Q
ApplirFatiViu for Uiopooal Vorkg Tomitrurtion ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
...... .� _._m .t: _.. t .. .... � ... .. ....._ ECL.... �..............•.
Locati Addr s • , No.
............
-...111 .Q..... b.... , .. . �n ............9e .. ._ .................
O er Address
a -•-•------------------AL_..... ����------------------....-------------- ------.. r-� �.__��.-/_:1_. ...
Insta ler Address p O q,
� 11 !</3/A► ...S feet
d Type of Building �j Size Lot_.. _�_.
U Dwelling—No. of Bedrooms............ ------._-_---__--•--___-_---Expansion Attic ( ) Garbage Grinder ( )
pal Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Other fixtures --------------- --------------- - - � y y� �.`
W Design Flow................................gallons per person per day. Total daily flow.............."y..-ll✓...._..____._....gallons.
W Septic Tank—Liquid'capacity) allons Length................ Width................ Diameter..--------------
Depth................
x Disposal Trench—No. ..............:..... Width.................... Total Length........ .__....... Total leaching area_._... .__-__......sq. ft.
Seepage Pit No.___...._.a.__.. Diameter.._...�.o_...._ Depth below inlet.....�g.1........ Total leaching area.. .....sq. ft.
Z Other Distribution box (J,�' Dosi tan ( ) _
'-' Percolation Test Result Performed by. ... 1 ,.1 __ �__. Date......
,tea Test Pit No. 1.... ------minutes per inch Depth of Test Pit......1._ _ p ground._..._. Depth to ound ______________
(i, Test Pit No. 2................minutes per inch Depth of Test Pit..... .. ....... Depth to ground water..........._-.........
P4 ----------•--------•----•-•....•--------•-•-•-••----•-•--•-•--------•.......................................................................................
D Description of Soil--------------------- ..,-------•--•-
x
- -------------------------
.....----•-----•••---...•---
UNature of Repairs or Alterations—Answer when applicable.-------------------------------------------------------------------------•------------•---:---.
---------------------------------------------------------•-•------------------------..............----------------------------------------------.......................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITL% 5 of the State Sanita de— T e under ' ned further agrees not to place the system in
operation until a Certificate of Compliance has a ssued y e bo r of h alth.
Signed �'� ............. . , ........
Date
Application Approved By--•--• •- -... ./i�1 •. l`?, `-•-....••.
Date
Application Disapproved for the following reasons-----------------------------------------------------------------------------•--•---------------•---------_...._
-----•--•-•---•-••-•-••------•--•--.---•••----•---•••----•-...•---•----•-••---------------•-•-•-••...--•--••-----------.........-•----•--•-•-•---•-•--••--•--••---•-•----------•----•-.................
Date
PermitNo.-•........................•---...---- ............... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEALTH
............... 1.......OF......... n. )-e_..........................
Trrtif irate of Toutpltaata
TIIIS IS TO-CERTIFY, That the Individual+Sewage; Disposal System constructed (4) or Repaired ( )
by......................••---••------•...----q-•----•-----------....----•••-•-•--•-•---•--•---••---------------•--•----.....-•--••--•---•---••-----•-----•-•-------------•••-•------......----....._
/) / / -'--Installer
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No._t __._ f. ............... dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.....�i .,)n.......OF........&r. ............................. r
No.............•--........_ FEE........................
Disposal Vork.5 TDoatotrurttioat profit
Permission is hereby granted...................................................................--.------••---....-•---•------•----•---••----------...............---......
to Construct (X) or Repair�(� ) an Individual Se��age is osal System
atNo...--•---•--= -•-•--i Url------ .................. Street
as shown on the application for.Disposal Works Construction Permit No..................... Dated.._..........___.._.__....................
..........................................-
oard of Health
DATE................................................................................
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............ ...........oF....... n�..... .. .. .7�i.........dal:e.....................----...-----
Appliration for Disposal Works Tonstrurtion Vrrutit
Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal
System at:
... 618. ............I
Locati Add re s o Lo No.
-----.. �'+�1 x.c-...... ... ..... z a-�. �'x ..: �_�.,- .... -- �"��- .................
O er Address
a 1'�_�,.._..__ (a. ii.�.------------------------------------ -------- tom.> G�1 ...1 'J.i 11 .........................
Insta ler Address O U Type of Building Size Lot._0.1....(// ..Sq. feet
Dwelling—No. of Bedrooms___..._.__"4............................ Attic ( ) Garbage Grinder ( )
PL4 Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
Pa Other fixtures ------------------------------ - -------------•---
Design Flow.................... ..............gallons per person per day. Total daily flow.............. ...............gallons. ��<<
WSeptic Tank—Liquid capacity__f 5 allons Length................ Width................ Diameter---------------- Depth................
x Disposal Trench—No_____________________ Width_ ....... Total Length.....___jj__._.._... Total leaching area_____.,- --------sq. ft.
Seepage Pit No-----------Q...... Diameter........ ..._._. Depth below inlet...... �...___. Total leaching area___�QQ...sq. ft.
Z Other Distribution box Dosi tank ( )
Percolation Test Results Performed by. XT�....t-_I1 . �_.. lip_ ._yt.A.__ Date....... .� .r__......
Test Pit No. 1-----a-____-_minutes per inch Depth of Test It_.._._.J_- ........ Depth to ground water_____________1 ____.
f=, Test Pit No. 2................minutes per inch Depth of Test Pit........ _ ______ Depth to ground water............_-_____--.
•---•-••-------=---------------•-••----........._...--..--•----------._.............----...---:._......._........._...:.......-----•-----.._..--•--•-..._...
Description of Soil = :-••----•-- - '-?
x
--------------------•-•-
U ----•-•••-----•------•---- ------------- r� lr ---_.1'�.t1 ------ `0... ) .( r i ad--------•----------------
UW --•-----••-•-----------------•-•-•-•--••----•--•-•----•--------. - � -----------------------------------------------------------------•---------------------...•-•-----------...------
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 TITIZ 5 of the State Sanita de— T e under ned further agrees not to place the system in
OP until a Certificate of Compliance has b e issued y e bo r of h alth.
Signed_ __._ ... ........... -------- t ��✓r '"'
Date
Application Approved By-__-_ .............................. ...... W`-...........
Date
Application Disapproved for the following reasons_______________•____________________-________________________________________________._______-_._._.......__._.._
•-------------------------------•-•----------------•--------------------------------------••---•-----------••••-----•--------•--------••--------••-----------------------•----•---------•---------_.....
Date
PermitNo......................................................... Issued_.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD Of HEALTH
............... .. .OF......... : .Y.02b.b.). ..........................
_ f�er�ifirtt#r of f�utAt�rli�attrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
r Installer
has been installed in accordance with the provisions of TITIZ 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No:_ _"', t" '_______________ dated-...............................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE............................................•---._...-------•----------•-_-•--_. Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
661k .10-
.11e�J17.......OF.......... ................................................
No.. 63 FEE... r............
Disposal Works Tonstrudion rrutit
Permissionis hereby granted..............................................................................................................................................
to Construct (. ) or Re air ( ) an Individual Sewage isposeeSystem
at No............ )4�0 ---•-•-•- sal
as shown on the application for Disposal Works Construction Permit No..................... Dated..........................................
. - ... � .........................................
oard of Health
DATE................................................................................
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
1
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
� .�n....- ....
oF..:..., ,�
� � w. .. .......................
, ppUratiou for Diopooal Works Tomitrurfiort thernfit
Application is hereby made for a Permit to Construct (Jo or Repair ( ) an Individual Sewage Disposal
System at:
........`�..LC�.._rY .�.._ :... ` ..
Locat' -Add e s o Lot No.
Wcaner1 ,e Addre
�, . ....-- _. _ Y. ,r 7a .._._ l
-------------------------
Installer Address. yy
Type of Building Size Lot_.�_d�__6.a.sS...Sq. feet
U Dwelling—No. of Bedrooms.............• ---_--..-._-_---•-__--__--Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
fs, Other fixtures -------------------------------- -
W Design Flow...................�.!S............gallons per person per day. Total daily flow.._....__..._..................gallons. Qa
WSeptic Tank—Liquid capacity_l allons Length______________ Width._.............. Diameter---------------- Depth................
x Disposal Trench—No..................... Width.................... Total Length..... __-._._..._ Total leaching area....................sq. ft.
Seepage Pit No........ Diameter......9-°-__-_-_- Depth below inlet..._6 Total leaching area....!100...sq. ft.
Z Other Distribution box (>rr Dosi tank ) /� n 81
�
`-' Percolation Test Results Performed by.l l'_1t"____ �_._/_fit ... S.7' Date_._.-____.1� _:4�J____....
a
,4 Test Pit No. L......a...minutes per inch Depth of Test it......1_ Depth to ground water...j. .................
fs, Test Pit No. 2................minutes per inch Depth of Test Pit-----/.' .-_____-- Depth to ground water-----'�...............
x ----------------------------------------------------------------------------------------------------.........................................................
0 Description of Soil........................ -----------------------
W -------------------- -------------------------------- ------.....---=........................................................................................................
UNature of Repairs or Alterations—Answer when applicable................................................................................................
-•------------------------------------------------------••-•------------------------......._........-•••----------------.......--•---•--•-••-----------....--•----------••---••--•--••••.._.......--•-•-
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT11 5 of the State Sanit C de—T e under ' ned further agrees not to place the system in
operation until a Certificate of Compliance has b e ssued y e bo r of 119 lth.
Signed. s ..•• . �� c�°it 4 yp Pate
Application Approved By..... L ....... l ----------------•-•------- -•- ------•------
Date
Application Disapproved for the following reasons-------------------------------------------------------•------------------------------------..........-----..._.
......................................-----------•-----------------------------------.........-------•--••-------------------------------............................................................
I Date
PermitNo......................................................... Issued_.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
_ BOARD OF HEALTH
.........J.��...........OF........&-V-IAqL�Aabl�p ,.........-•---.......
�rrtifiratr of Toutpliattrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( or Repaired ( )
by..........................................................................................---•-••-•---•--------------•...------•--•----...................----...------------------•---------------
J/ --- . ��' . � Installer
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.__ _.>lg. ............. dated_------------------...........................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector.....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
(� r..r�' .61
NO._.��`✓6� FEE........................
�io�o�ol ork� �000�rtion rani#
Permissionis hereby granted...............................................:..............................................................................................
to Construct ( or Repair ( ) Bann Inndividual Sewage Dis sal System
atNo............................r)-d-k ......---� e .ik .... ...... "
Street
as shown on the application for Disposal Works Construction Permit No..................... Dated..........................................
------.....................................-
Bo of Health
DATE........................................... ......-•---••.................
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
No..$1'.5 Z— Fes$....._ ......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............. .........OF.........
�.: .: .�-� _: .. � �r.......................
Appliratilan for Diipuial Vorkg Tontitrnrtirrn Permit
Application is hereby made.for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at:
._._ .1.. .............................................
Lmati Addr s _ y'`�� e Lot No. 1
GJ G:SC ...... �.1F._. .. ..:t7G_.. !..!..J _,1.7L�r 1..............1,1�-•----................--
wner Address
W.a ------------------------------!(�1<---- l A.�_� .x............................... ............ _I�. :�.?1 ).....�.(.11_ ----.....-----•.
Installer Address _
d Type of Building Size Lot.....� &DS..Sq. feet
j__
U Dwelling—No. of Bedrooms............. ---------------------------Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building ....... No. of persons............................ Showers — Cafeteria
P4 Other fixtures tll .................................................
W Design Flow......................5_4,5_._...._...gallons per person per day. Total daily flow................... 4.6...........gallons.. �QC
W 'Septic Tank—Liquid capacity..�_5Ctallons Length................ Width................ Diameter-_.-----•-_-__- Depth................
x Disposal Trench—No. ....*............... Width.................... Total Length......._.!!_._....... Total leaching area....................sq. ft.
Seepage Pit No........ ---_--- Diameter.......2........ Depth below inlet.._..(b.......... Total leaching area.....X/QQ..sq. ft.
Z Other Distribution box (fir Dosing.ank )
Percolation Test Results ^ Performed b f. .. �. _ ., )it
Ant_
Test Pit No. I........aS___minutes per inch Depth of Test ._..._.ly....... Depth to ground water....!_
(s, Test Pit No. 2................minutes per inch Depth of Test Pit......I_ ....... Depth to ground water....................
------------------------------------
•------•-----------------......------------.......------•.------
----------------
•----------------------
•-----------------
D Description of Soil--------•-------•-•-----� •..:............... .n . t �t %-moo
-•-••-
- ------U -----------------------
UW •••------•-----------------••-•--•-------•.....••-•-----•--••-•-----••--- - ------•-------------------
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 TITLE 5 of the State Sanita Co e—Th undersi ed further agrees not to place the system in
operation until a Certificate of Compliance has n sued t e board of lie th.
w 2
Signed.. ,. �. ._ . _ ...... 4 ........ljlo..........
o ate
Application Approved BY-----`- - 1 ...... r ............................
Date
Application Disapproved for the following reasons-----------------------------•---------------------------------•-------------------------- ....................
.............................................................:...........................................................................................................................................
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
T
BOARD OF HEALTH
-�^ i
...........1.... . `..............OF.........:... Y:. 1 ..............................
wrtifiratr of Tomptiana
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( or Repaired ( )
bY----------------------- ----------------------------------------------------------------
* t1 Installer
at.................-•- �•a•--r n - ...... .. ------------------------•-----------•----•-•-----•-•------------------------------------••--------------
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No::__ .... _.41- dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................. Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD Or HEALTH
No....ex FEE..:3:f....
Dispaii al Workii T11iiotra tion "permit
Permission is hereby granted.............................................................
to Construct ( 1 or Repair ( ) an Individual Sewage Disp at ystem
at No...._..._.. . 1- �--,=• -----.--- - -------------•-••-----------------------•-------•--------------••---••-----......
r
Street
as shown on the application for Disposal Works Construction Permit No..................... Dated..........................................
1, Boa of.Health
DATE................................................................................
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
Flss:............_...............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
-
j n........oF...1i�x 1 , , ..................
Appliration for Dhipati al Workii Tomitrurtion ramit
Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal
System at:
..� ..... i..s,,r.�.. fir..:._.... - ......... ......... ......141...........Pe.L....�l). ....................
01 on, d ess <Lot No.
....
Ow e Addre c
a . .��e r... 1
n��...i ?'1 z 1 -------------------------
Installer Address ryry
Type of Building Size Lot..1_,,._..6. ..Sq. feet
U Dwelling—No. of Bedrooms--------4--------------------------------Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons............................ Showers — Cafeteria
QI Other fixtures ------------------------• --
W Design Flow..............:�--------------------gallons per person per day. Total daily flow..........._....���..............gallons.
WSeptic Tank—Liquid ca.pacity.Vgallons Length................ Width................ Diameter--------------:_ Depth.................
x Disposal Trench—No. .................... Width......... ....... Total Length.................... Total leaching area.... .._..._.....sq. ft.
Seepage Pit No.---------a------- Diameter.__..._.. 1.... Depth below inlet.._........... Total leaching area.4L�Q_.._sq. ft.
z Other Distribution box (✓' Dosin tanks( ) n
Percolation Test Results Performed by.: l C' .!-.I y_ a %...1.--_E Date-...V.'��... 1...........
minutes per inch Depth of Test Pit......,.tt_�� Depth to round water.._. :.
,-� Test Pit No. 1------- ---- P P T--------- P g )I.q...............
Test Pit No. 2................minutes per inch Depth of Test Pit......ta....... Depth to ground water.._.`-.................
R+ ----------------------------------••----••------•-••---•-•-------•------......- ....--•-•----------..:..---•--....---....----------.......------------------
ODescription of Soil............... { x ----- ...........1 --------------------------
>�1 .. L�ale •. �----- 11 1�21_. 1 a.._..
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 TIT12 5 of the State Sanitar C de— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has. ssued y he rd �"ealth.Signed ' ` .. . ---
Date
Application Approved BY-----. -/ .......
---✓ -------------------------- ---•- rQ / .............
Date
Application Disapproved for the following reasons:................................................................................................................
...........................................................-.............................................................................................................................................
Date
PermitNo......................................................... 'Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
••1• S.......-OF...... :Y'. 1 .1pa........................
_ (9rdifirtttp of Toutpliattre
THIS IS�TO CERTIFY, That the Individual Sewage Disposal System constructed (X) or Repaired ( )
b
Installer
at-------�1(a_-•J k'n----- ------_-------•-0�� --•-------_------_-_------------•---------------------------------------------•---------------
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit .............. dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector...................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
L. 1n............OF......... ..........................
No. ................... FEE._✓ .............
�liu�ou�tl urk� C�uttuirion rruti� . _
Permissionis hereby granted..............................................................................................................................................
to Construct (.'/,) or R nn-I�ndeividual .wage Disposal S stem .
...............7
as shown on the application for Disposal Works Construction Permit No....................• Dated..........................................
•�% -------------------------•--------------------
Board of Health
DATE................................................................................
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
No.... �2 Fps....., ..:....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF.... 1-1T1. > blk. .................................
ApplirFatiou for Uhipmtal Workii Toatstrurtaoo rrmit
Application is hereby made for a Permit to Construct (yC ) or Repair ( ) an Individual Sewage Disposal
System at:
-4..:.._..-- ....... ......... -p---.-!y 1--- ------p�_L....... r)....................
Lo ion• d ess Lot No.
...
a O
t Addre
l ..r : _ato. I YI i..l.� ---------.........------
Installer Address
Q Type of Building Size Lot_ �....&.0 ..Sq. feet
aDwelling—No. of Bedrooms...... --------------------------------Expansion Attic ( ) Garbage Grinder ( )
p.l Other—Type of Building ____________________________ No. of persons........................... Showers ( ) — Cafeteria ( )
fz, Other fixtures -------••--------•------••-•-••• - --------------------------- ------------- ------------------------
W Flow................._,?``..?..........._......_..gallons per person per day. Total daily flow____.._............ ........_...............gallons.
PQC
W
WSeptic Tank—Liquid capacity.l500gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No..................... Width.................... Total Length...._............... Total leaching area....._. ........sq. ft.
Seepage Pit No.......... ....... Diameter.........2_.1.... Depth below inlet....4Q_!......._. Total leaching area.. ----sq. ft.
Z Other Distribution box (vj Dosin tank ( ) n -_._
Percolation Test Results Performed b ._ .er_ .�1. .:.__: _-- l �s.._!._.. Date.....)0.`-._ . ...........
Test Pit No. 1....... __--minutes per inch Depth of Test Pit_______1Y________ Depth to ground water..... ___•__--____--
Li, Test Pit No. 2................minutes per inch Depth of Test Pit......J.!;k....... Depth to ground water.._...............____
P4 ..............................-•----••-•-----•-•...............•-----••--••--•-----------------••-----•-----••---......---...•-•-•---••--------.._...._......
D Description of Soil.........=---•--- . • ,n _
-t _.__..l k. ._!/Q..- .CAkl - _.: ----_-__-_--------_-----
w
UNature of Repairs or Alterations—Answer when applicable.____...........................................................................................
--•-•-------••-•--•••--•--•••--•----•---•--------•-----•-----•-•--•--•-•-•----•.•-•-•..............•••.........-•••-••------•••---••------••---.......................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITLE 5 of the State Sanit Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance hasa . a issue y the o rd of ealth.
Signed. _ _ _........... __ ---- -•---• -or....
Date
Application Approved By...... _ .x--• ..... .............................. -.••-'!"°1'/�', #`..............
Date
Application Disapproved for the following reasons:----•----------•----•-----------------------------------------------------------------------------------------_
---------------------------•-•---••-•----••----.._..-------------•--------....----------.......--•--•-----••-••••---•-••--•----•--•••--•••-•••••-•-•------•-•-•-•-••--••-••......---••--•-••-----•------
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........... ...........OF.........C;�Q-.r.rr.,) 1 .........:...........:..
(9rdifiratr of Toutpliaata
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed O4 or Repaired ( )
bY-------------i..............-••.....•-••-........-•_.._...:---...--•------•--••-- ...._•.......--------••--••------.......-•--•--•..............-----------•....------•---••--•--•-------•-....._
nstaller
at......... •i t_p------- aw. ---•-------------•--•-------------------•----•----•-------•---•-•-•-----•-----------
has been installed in accordance with the provisions of TITLE j of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.. Q..!!Xe/............... A-ated.................................................
THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE...............••---•---•--.._.........................: ...................... Inspector....................................................................................
THE COMMONWEALTH`OF MASSACHUSETTS
BOARD OF HEALTH
i
Now -s'd� ........`..C ..............OF.......... .: A...C.�SAO.: !! FEE..w'' ....
RsVooFal Vorkii Toatotrudioat rrutit
Permissionis hereby granted..............................................................................................................................................
to Construct (,4) or Repair ( ) n Individuate .wage Disposal S stem
atNo................ qa�• o ...��_y-I.-f L1---- ....-----....... �----------------------------------------------------------------------------
reet
as shown on the application for Disposal Works Construction Permit No..................... Dated..........................................
�. - -- - --------------------------------•--------------•-
{ �f Health ,
DATE................................................................................
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
fNo...SInI DU? FEB....
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® -OF HEALTH
..........1a.W.n..............OF........�r�-11�D,"!' ��-Q.i.-------------------•----..------
Appliration for Mipmal Workii C omilrurtion ramit
Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal
System at:
r
(?�1 =_ ----.•. ---�.---'41.---•-------------�-I.-_.9.........................
.......1.!1 +.� a:io - ddressy ( 1_3!5U�n__ 1.....or.
Lot-No
--= ------•---•-------•
�w r Ad esso
........................... ��111�1_et -------- ....._....__�G$.�9r� .. �..I� ... ...........
Installer Address
d Type of Building Size Lot�1,_6as-5....Sq. feet
U Dwelling—No. of Bedrooms___...•.___............................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
a' Other fixtures ......................................................
W Design Flow............. ...................gallons per person per day. Total daily flow---- gallons. Q�
WSeptic Tank—Liquid capacity. -Sallons Length................ Width.........:...... Diameter---------------- Depth................
x Disposal Trench—No_____________________ Width.................... Total Length__________.____.___ Total leaching area....................sq. ft.
Seepage Pit No.______Q--------- Diameter........ ...... Depth below inl ............ Total leaching area___4M...sq. ft.
Z Other Distribution box (vT' Dosing tank
Percolation Test Results Performed by. J� - y __ Date..,.... ...........
a Test Pit No. 1.....cQ......mmutes per inch Depth of Test Pit____ __ .q._..___ Depth to ground water...... _____________
Test Pit No. 2................minutes per inch Depth of Test Pit... ..... Depth to ground water_-- __________-
•---------------------------------------------•-----------------------------.........----....................................................................
0 Description of Soil___________ •_ ----• - ---- I.. a
x ---•----------------------------•-----•--•- Y1 �`> I/te..[—.---- .__�e�1urn- �+---•------•-••----•-----------------
U
W -----------•--------------------------------------------•----•------•-•--------•--•------------------------__.---------....----•---------••----------------------•----------------••-._._...._---_-••--
UNature of Repairs or Alterations—Answer when applicable...............................................................................................
--------•--------------------------------------------------•-•-----•••--•--••-•--_._........-----------•..--•------------••----------------•--------•-------•------------•-•-•-••--•-•--........._------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITI.E 5 of the State Saint ry Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance ha ee issued y the bo of 1 alth.
Signed r P - ----••-•-- fir-- .......1__' ". ...
Date
Application Approved By..... '----���. .................................. -- -----
Date
Application Disapproved for the following reasons----------------•------------------------------------------------------------------------------------.......-----
......_....•--•-•---•-----•---•--....-•--••••-----•---••------•-•--•--•---------------•---•-•-•••--------I----•-•-••----•------•••---•------•----•••••---••••-•----••-•••----•----•------------•...._.__.
Date
PermitNo......................................................... Issued_.......................................................
Date
-------------- ----
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
......_OF............ Y z']� :�.t�...........................
Tntifirtttr of TOutplianrr
THIS IS'TO-CERTIFY, That the Individual Sewage Disposal System constructed (X-) or Repaired `-
bY--------------------------------------- ----
•----•_-----`---------------------e--------------------------------__-_---_-_-__-__._---------------------_--_--__-__-----•---------•••--------------
�1] y�/���� Installer
at. \.�.'C� 1-----�--- ... ..........
has been installed in accordance with the provisions of TITLE 5 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 CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE...........................................................:.................... Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
��. 1:...........OF.......... r._.aSAa.0 1_R ...........................
No..-�-- ..�S d A FEE..
Dispiw al World Tnnotrnr$ivan rrntit
Permission is hereby granted..............................................•...........................................---------------•--.._...--•---.._.._._............
to Construct JL) or Repair ( ) an Individual S�ewa e Disposal System
at No..-----•-- R =
Street
as shown on the application for Disposal Works Construction Permit No..................... Dated3__-______-________-_____-__________-_-__-
. - + s---------- -------•--------•----------------------
Board Health
DATE................................................................................
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS ' ,
AS;•' r
No.._ 2.' .P.. FEs.... ;f.................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD 'OF HEALTH
....... ....oF........ .....n. .A....�.�._....6t.e..................................
Apptiration for Disposal Works Tontrurtiun Vernfit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
atio -Idd,e,F or Lot No.
Own r Adess,
a .............•---..........'�.L.-•-.. fit.�.� ................................ -••-----....1�Y1C�. :` �t 1��►...t..rl+..1-.:5.. .......................
Installer Address r-�
Type of Building Size Lot-
...Sq. feet
Dwelling—No. of Bedrooms..............1----------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Other fixtures -----------•----•----------------•-------•----•••-
W Design �.5 ...y-.......__;_gallons per person per day. Total daily flow------- ..........................gallons. Q�e
WSeptic Tank—Liquid ca acit 1allons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No. .................... Width.................... Total Length. --- Total leaching area....................sq. ft.
Seepage Pit No.._..__.Q--------- Diameter........81...... Depth below inlet....�„t........... Total leaching area.._q XD_._sq. ft.
z Other Distribution box ( voT Dosing,tank ( )
'—' Percolation Test Results Performed by__iwyt .1'�k..'.. _ 1�!:_: rQ f,_:'Date....... .:_�` ..........
Test Pit No. 1----- ______minutes per inch Depth of Test Pit..........I. ...... Depth to ground water......N.............
Test Pit No. 2................minutes per inch Depth of Test Pit........I.a..... Depth to ground water..__•'__----_--_.
---------------------------•-•-- -•-----••------•-••........................................................................................................
0 Description of Soil---- ...... .............. . . ------••--- •----- -----------•----•-•----------------
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 TITIE 5 of the State Sanit y Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance ha ee ssued y he bo of alth. ,,��}}��..
Signed s •----•-•• - Sal[...• ....... _` .....
�...
Date
Application Approved BY r • ?, 'Sf✓.� �--------
Date
Application Disapproved for the following reasons---------------------------------------------------------------•--------........................................
..-•---•...•----••--•-•---•------...••••....-•--••-•---•--•-••-•••--••--•---•-•--••••.....................••••-•-••--••-•••--•-•-•••••-••-•••••-•--•--•------------................•...................
Date
PermitNo......................................................... Issued_.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........1.Q.W..............OF........... �:. � .. .1.1��. :.:......:.................
Trdifiratr of Toutphattrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (x) or .Repaired
by------------------------------------------------
--------------------------------------------------------------------------------------------------------------------------------•-•--------------•--
y�/� ^ Installer
at. ---•--•----=------------------- n--- -=--------
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No---- ............ d-ated:...............................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A.GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEALTH
Y�'x-spa ........... . .........r..:.S.........bi
....................:..........•-
No......................... FEE. .f.............
Uiopoial Workii T11nstration rrnti
Permission is hereby granted..............................................................................................................................................
to Construct--( I —or Repair,( ) an Individual Sewage Disposal System
at No.......... ..1VU.... .1.1�._...���...............
Street
as shown on the application for Disposal Works Construction Permit No..................... Dated,-_-•--.----_------.--.-..-_---.._.._:__--
- _ --�---------------------------------
Board Health
DATE................................................................................
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS
No....A.9:::...i. Fss. f.............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
tow-o.................OF.....�III.FJ.I.I �jL .......................................
Appliration for Disposal Works Tonstrurtiun ramit
Application is hereby made for a Permit to Construct (*)f ) or Repair ( ) an Individual Sewage Disposal
System at:
....._ .t. ...: � ..:.. ► M .' .!...._. l �1
. ---
Locati n-Ad ss or Lot No.
------.. --- .:.--. I]d1.�Jl � ��hl. S.T.----------•-----0..Sr. ----------------------
Owner Address
a ...................................ik�---------Fowai-iz, --------------------- .....................................MA��... ---........
Installer Address
UType of Buildin Size Lot__._..(.�.- ..Sq. feet
Dwelling No. of Bedrooms...A...... ..............Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
dOther fixtures ------------------------------------------------------------------------------------••....--------••------••-•--------....
W Design Flow................_.__..___. ._._..gallons per person per day. Total daily flow_.._..............._..�'�®......gallons. EA�Cg
WSeptic Tank—Liquid capacity] .gallons Length................ Width---------------- Diameter................ Depth................
x Disposal Trench—No..................... Width.....*----..__..... Total Length.............F.._--- Total leaching area....................sq. ft.
Seepage Pit No........`2 ......... Diameter--------45------- Depth below inlet...... ._._..... Total leaching area..... )..sq. ft.
Z Other Distribution box (V) Dositig tank ( )
'-' Percolation Test Results Performed by- �. ._.+A -_-_...- !JvQi�-.1't�Date_._...��.p�.��__..._.....
Test Pit No. 1.... .....minutes per inch Depth of Test Pit...../�...... Depth to ground water.... -_.
Test Pit No. 2................minutes per inch Depth of Test Pit------/:Z..... Depth to ground water_-__"'...............
--------------------------------------------------------------------------------------------•-------.........................................................
0 Description of Soil.......... ....• ----------------------------------------------------
-- - • • - -•------- ---
U
W ---•-----------------•--------------------------------------------------- ------- -----••--------••----------------------- -- ••---------------------------------•---------•-------........_.
UNature of Repairs or Alterations—Answer when applicable-----------------------------------------------------------------------
--------•---------------------------•----------------------•---.:..--------......---................--•---......---•----•....----------•--------•----•----•-------------•-•-------------••---.......----
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has ee issued the b rd of iealth.
Signed a ------
Date
ApplicationApproved By------ ----- ...-•------------------------------- ---- ..............
Date
Application Disapproved for the following reasons------------------------•------------------------------------------------------------------------------..........
.....................•-------•----•----------------------------...-------•-------....----•-•---------------...••---------------------------•------------•---•------------------=-••---••--•-------------
Date
PermitNo......................................................... Issued-.............. .......................................
Date
-----------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
•
o(P.1�..............0F........ . 2h1 ' �. TLC
CTrrtifiratr of Toutpliatta
THIS IS=TO CERTIFY, That-the`Individual Sewage .Disposal System constructed (-t ) or Repaired ( )
by----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Installer
at.............. U.0.....M 1-1`1---------- , ------------ -'----- -------------------------------------------------------------------------------------------------------
has been instaEed in accordance with the provisions of TITLE 5 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 CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...........OF......... fi lm .......................... FEE.. .�. ....
Dis pos tl Works %Tontrt ion Fermi#
Permissionis hereby granted...............................................................................................................................................
to Construct ) or Repair ( ) an Individual Sewage Di s osal System
atNo...........-I:1_.(,*........MA.I13.-•--••....ST- .......................... ------------------•-------•---------------•--------•--------------.........-----••.
Street
as shown on the application for Disposal Works Construction Permit No..................... Dated..........................................
`--- -'.-V....... ..........................................
Bagr'd of frealth
DATE..................................... ..........................................
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
No....$l",5 59 Fps
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.. ..O.val. .................OF....... A.1C h) ?.1.. :'`3.L. .......................................
Applir.a#ion i4ur DWI sat Works Cn nstrurtiun Prrutit
Application is hereby made fort a Permit tb Construct (',( ) or Repair ( ) an Individual Sewage Disposal
System at: 1
z
s
......-ua_...t .c�.. .... '-------------------------------- ----------- ..............-�-1.�,-�----•-I �-----...---.-�L------3I..................
I Location-Ad s or Lot No. .....
+� ;
.......... S Bt 2-.. .:._... : rZi^,r1 ?+ _._:...�. 4r __� .._'a- -----------------� 1......---••---•------..
Owner
==--- ? Address
------------------------•------ !--..._..-•-�!'? _�::!-.Sr!�,..o. -...-.j.-•--•-----•--- .....................................M,�.l2 c7T 121 ....W_t_t�.,s-.`r........----
Installer Address
Type of Building Size Lot...... _�.t_ Sq. feet
IJ
Dwelling 6 No. of Bedrooms.... _...... A�y..............Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ........................... No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures -•-•---------------------------------------•-•-•......•--••-----------•------•-•-•-.....••••••.._....-----...-------•---....--••-------------....----
W
Design Flow...............55.....................gallons per person per day. Total daily flow...........__..........'--4 V_-.-..gallons. eAe-Al
WSeptic Tank—Liquid capacitv.1'900.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..... 1CO..sq. ft.
z Other Distribution box ( ✓) Dosing tank ( )
aPercolation Test Results Performed by. ......... '... _�i..kFbate......_t. _... .._. ..........
Test Pit No. I.....Z.....minutes per inch Depth of Test Pit-----447"(....__ Depth to ground water.....h...............
Test Pit No. 2................minutes per inch Depth of Test Pit.......C;?..... Depth to ground water----- ..............
a ..................---------••-•••-•--....------•-••-----•-•-•-....------------••-•-••••...........•.........................................................
Descriptionof Soil .. -- ----- -- •--------------------------------------------------------------------
'ti
�� ��� �As1 .. � s _1.c1 .... n�J! -----------------------------------------------
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 T IT 1Z 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has �issuedthe b d of iealth.Signed._ 1._� ..
Date
Application Approved BY eQ. •.!!�.... '� .�'� i"----------- .
Date
Application Disapproved for the following reasons------------------------------------------------------------------------ ----------------------------------------
.............................................................................................................................__._....------...---.._._...._...._...........__....._._..__................
Date
PermitNo......................................................... Issued.......................................................
Date
THE'COMMONWEALTH OF MASSACHUSETTS
BOARD �OF HEALTH „
..............OF.........I:�J. .P'J.Z fh 5, :: . ...........
wrdifirab of ToutpliFattrr
-- THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired ( )
bY....................................................................................................................................................................................................
Installer
at............. l-.........MA 11l..._..... ............' -----------------------------------•-------•------------------•------•-------------------•----
has been installed in accordance with the provisions of TITLE, 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No....49_'.?."! ............... dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEALTH
No. Z •fff_. .........TOW.1�.........OF........... .�.`�.1��.�.����.�'�-:�........................... FEE.2� �....
Disposal Works Cwunutrudinn Vprrmit
Permission is hereby granted...................................................................................
•••-•----------•-•••••---•-.............._._................
to Construct (X ) or Repair ( ) an Individual Sewage Disposal System
at No............�l.l.-U-----...AA.d114..........S- - ----- ---- - `
Street
as shown on the application for Disposal Works Construction Permit No..................... Dated.............................
Borid of ealth
DATE..........................................................................
,....
FORM- 1255 HOBBS & WARREN. INC., PUBLISHERS
4 ..
A
ALIGN WITH WALLS BELOW
7-6, 7'-41?
— WLSB•$URb1A•IONBS•ARC�1E(.15
EXISTING DORMERTOBE
A REMOVED-SHOWN DASHED + -
A�C
RELOCATETO NEWSIDEWALL
• REMOVE EXISTING ROOFMFMBRANE ` �7
——— AND RTIONOF OVERHANG AT EXISTING OFFHOUSES OWN DASHED
STORY U,� fOPY D.
O J�ti y
r -- — -- 6d6— --- V l�
- I
o I o.7 o� k
�. F
I PROPOSED BEDRC OM
PEI
- o
0
II
- � REMOV E EXISTING SKYLIGHT '
PATCH BACK PLASTER ANDFRAMNG
AS REQUIRED
I t r
EX.BATHROOM I I ° EXISTING BEDROOM
I W.r.r To E I.BATH I O '
q LAUNDRY b
l IExsn
Dryer _
r k - • . 'Packet Door °
GRAND /Y.
EXISTING BEDROOM EXISTING I \ INf L PE INcwnH -
HALLWAY \ fIN x T MATcx Nc EX.BATHROOM -/"/}
\`T
G
� 7� hevecl
6'-P CASED OPENN
RE LOCATE BA�HROOM EXHAUST a
DUC15 AND FAAAA115 TO NEW LOCATgN v
DETERMINE ElOACT LOCATK7N IN FDLD
PROPOSED STUDY
RELOCATE FLUE
ASSGAS i 1
ENLARGE
FLUE ASSHOWN
ENLARGE BOX AS REQUIRED
TOD ANY REQUIRED
I
AND ANY REQUIRED ELBOWS
OPEN TO BELOW EXISTING BEDROOM
I ` VSQ70 _ JI DH26C6 W DH2646 -NEWDORMERANDWNDOWS
• •. I ————— --BV P3WD (/
NEW STEEL BEAM BELOW DORMER
6, SIZE TO BE DETERMINFD
�. EXISTING SITTING AREA
7 1D 6 11 3 p 4 17' 2 10" .
AND
Schematic Second Floor Plan - REMOVE EC OANOFEWALL-PRAKETATCHNNE
Scale:T/4"-1,4r SHINGLES TO MATCH EXISTING WALLS -
OVER-FRAME GAMBREL ROOF FRAMING
FWITH NEW SHEDROOF.
^ REMOVE EXISTING SKYLIGHT
NEW SHED ROOF DORMERCNER • NEW SHED ROOF DORMEROVER
FOYER/STUDY ADDITION BEDROOM ADDITION
SINGLE PLY ROOF MEMBRANE SINGLE PLY ROOFMEMBRANE
_ RM
716 Main SIT-
rT rrrlllrrr��� REMOVE EXISTING fLAT M D Os[aville,MA
ILI OVERHANGING EAVFS -----add
.
LJL J IL `. 2Ed E'IoaiTian
--—add EzrerioF Elev+r;m�
SCAI-H:1/4"=V-T
I DATE:Febue,y 27,31MS
DRAWN:GI
DRAWING NUhUM
sk-01
Schematic Front ElevationISSUEDMRYERDIII'
0 VMA.]pNPS.Agt�FG154r
'►� r/w - r r ,
1:l t
WISEa A•r0rES-ARCM10
24
AR
JbY D.
140. cn
A q� MPS
EXISTING STUDY
EXISTING PLAYROOM .!
sw EXISTING KITCHEN 1
I 5'CASED OPENING
EXISTING DINING ROOM �—
I a
�4 e 4�
1 v s
NEW STEEL BEAM IN CEILING r
POST DOWN AS INDICATED WITH
. INSTALL NEW BEAM IN CEILING - 3"0 SCHEDULE 40 STEEL PIPE
AS SHOWN TO PICK UP NEW BEAM --->I - COLUMNS.PATCH BACK WALLS AS -
y BELOW DORMER-POST DOWN AS ( REQUIRED-CONFIRM THAT FOOTINGS
INDICATEDAEAM SIZE TO BE EXISTING AT POST LOCATIONS-NOTIFY
DETERMINED.PATCH BACK CEILING - ENGINEER OF CONDITIONS UNCOVERED AND WALL FINISHES AS REQUIRED - FOR ADDITIONAL INSTRUCTION
Schematic First Floor Plan ' EXISTING FOYER 4 i —•-•••
" Scale:ll4"sl'{Y - + �•µ
EXISTING LIVING ROOM
RHVLSIDNS`
J
9)&Rcddmce
a, 716 Main fie¢
Os[erviEe,MA
1717.E
ls[FI—Plan
SCALE:114-1 r
j .. L' DATE:Fe Ury y27,21D6
DRAWN:GI
DRAWING NUMBER
sk-02
ISSUED FORPERAIr
- OWEESIIBMA•J@>FS-ABCFIII'EC15
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