HomeMy WebLinkAbout0146 OLDHAM ROAD - Health 146 Oldham Road
Osterville
A= 120-123
C'
No. / Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION — TOWN OF BARNSTABLE, MASSACHUSETTS Yes
Zippfitation for -Misposal 6pstem Construction permit
Application for a Permit to Construct( ) Repair(V Upgrade( ) Abandon( ) ❑Complete System :individual Components-
Location Address or Lot No. ( �e 7
i-/t;g Owner's Name,Address,and Tel.No. «2� s
�v Zyu vey a- �.vmcs
735
Assessor's Map/Parcel a0 a3 W, -DL 3,:;L-
Installer's Name,Address,and Tel.No. 60V Designer's Name,Address,and Tel.No.
C�1e
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
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� ed
c60 i" onM� .24V. m'K �o �L�PS�i'/I9 �! (� / dKl kwAA
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance.4the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Co nd to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health. q
Signed Date /
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. zl� Date Issued d
IY
.Y+.
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS _.._• Entered in computer: Ye
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE 'MASSACHUSETTS
2ipritation.for Misposar *pstem Construction Permit
Application for a Permit to Construct( ) Repair(,� Upgrade( ) Abandon( ) ❑Complete System [Individual Components
Location Address or Lot No. N Owner's Name,Address,and Tel.No.
_ Assessor's Map/Parcel J a0 a S'�cd"t!�. i Otr i51��y�QeSF-
Installer's Name,Address,and el.No. 60F /j1 j r3�9 Designer's Name,A dress,and
LTel.
lNo.
/V/A D `,y�'i t..lJ1vf t'ovq
A i 'DD i - _ X
o �
Type of Building:
Dwelling No.of Bedrooms ., Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided, gpd
w
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S. ,a
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) (^t,,J; � 1 • ,, / V�., ,r�-~£h �` ,4.
Can �l�,�n .P, IprYiC�:. 'r•-'ya f /.ri(`-i`f� fA1��� ���c
j> � j
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--dnd to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Signed Date
Application Approved by Date
Application Disapproved by ' Date
for the following reasons �...
l
Permit No. / Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
o Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( x) Upgraded( )
Abandoned b ,& �»G
at has been constructed in accordance ??
with the provisions of Title 5 and the for Disposal System Construction Permit Nql,�'bb/69— dated
Installer ]r,r t'- - ✓t i .-.1 Designer,.j 1.4�h� y 0E){,,
#bedrooms . Approved design flow gpd
The issuance of tl}is permit shall not be construed as a guarantee that the system wig do designed.
Date ' Inspector (4
------------------------------------------------ --------------------------------------------------------------------------------------
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS
Mis oral stem Construction Permit
� p
Permission is hereby granted to Construct( ) Repair(X) Upgrade( ) Abandon( )
System located at J y(n J� nr! „� T t - �� � ��4
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must be co pleted within three years of the date of this permit. / ----^-�-
Date L Approved
4, .
-- TOWN OF BARNSTABLE
LOCATION ,.�y�,��i'� — SEWAGE# c�DtJ— 4f f
'VILLAGE ����t ,o„�/� ASSESSOR'S MAP&PARCEL , 1� id-3
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY / oou * L
LEACHING FACILITY: (type (size) /_a— C c
NO.OF BEDROOMS
OWNER _
PERMIT DATE: COMPLIANCE DATE: �Jt
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility J—,4 Feet
Private Water Supply Well and Leaching Facility(If any wells exist on
site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching facility) Feet
FURNISHED BY ,Q
,.
• y6l� ` _ a�b�
yv'
i Kb 01d�h�
�-fox ,�e.�l��m���- � •
` LOC SEWAGE PERMIT NO.
V) LLAGE
O 11114
INSTA �L�LER'S NAME i ADDRESS
S� Vie g4ves
B U I'L D E R OR OWNER
DATE PERMIT ISSUED _ _ L�
DATE COMPLIANCE ISSUED oe _ 2y_
f06o 7-Af Ylr/4)0 1)
�3✓�col op
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'Commonwealth of Massachusetts
Titles Official Inspection Form
subsurface Sewage Disposal System Form - Not for Voluntary Assessments
/'16 0%✓tia V'7 �d
Property Address
Owner Owner's Name
information is OS �v / �/f
required for every Q /' Dd 6 SS /o /,7
page. CrtylTown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
on the computer,
use only the tab � Inspector.
key to move your
cursor- not 101a� ,-
use the return
urn �T /
key. Name of Inspector
%EG/} f,
Company Name
/Io Qo is
Company Address /
City/Town
L,5 o-i? State �C Zip Code
Telephone NumbbrLicense 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 inspecoo
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 C R 16.000). The system:
Passes ❑ Conditionally Passes ❑ Fails
zpka �
❑ Need Further valuation by the Local Approving Authority
C)J
/
Inspector Signature Date
The system inspector shall submit a copy of this inspection report to the Appro ing Authority (13 d
of Health or DEP) within 30 days of completing this inspection. If the system Is a shared systemo�
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
f. 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.
'Sala•t trio Tate 5 Offidal Inspection Forth:Subsurface savage Dual Sv9 •Page i d 77
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
/Ll; 0/c a�_7 /�C/
Property Address
Owner Owners Name
information
aUon is
1 v /required for every �.� rQ� / l e
page. City/Town State Zip Code Date of 4nspeefion
B. Certification (cunt.)
Inspection Summary: Check A,B,C,D or E /always complete all of Section D
A) System asses:
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:
t
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.
Check the box for"yes", "no" or'hot 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 orexfiltration or tank failure is imminent. System will pass
a inspection if the existing tank is replaced with a complying septic tank as a
Health. pproved by the Board of III
"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):
• fsins•lvto
11 Title 5 Official Inspection Forth:subsurface Sewage Disposal System•Page 2 of 17
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
UV
Subsurface Sewage Disposal/System Form - Nottffor Voluntary Assessments
Property Address
Owner Owner's Name
information is —k/VI Ile-
required
for every �s ��
page. City/Town State Zip Code Date c4 Insp6cdon
B. Certification (cunt.)
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):
I
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below):
I
obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
,f
r
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection 0(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):
i'
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.
I. 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•11/10 T&5 official Inspection Forth:subsurface swage Disposal system•Page 3 of 17
t`
I
Commonwealth of Massachusetts
Title 5 official Inspection Form
' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
/ 6 )C/ 9d
Property Address
Owner
Owner's Name information is
e �- Ile, //,//� L
required for every OS �r V� 0o
page. City/Town State Zip Code Date of 46spection
B. Certification (cunt.)
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, fecal
aborato for f I
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� `a distribution box above outlet invert due to an overloaded
or dogged SAS or cesspool
❑ Liquid depth in cesspool is less than 6" below invert or available volume is less
k than Y2 day flow
15im•1 v10
Tithe 5 Official hrspechon Form:subsurface sewage Disposal System-page 4 of 17
14
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage 6/Disposal System For n - Not for Voluntary Assessments
0/1 af/`1 1� pl
' Property Address
Owner Owners Name
information is '
required for every OS rv/ �A oa 6sS WafPage. Cityrrowm State Zip Code e 'on
B. Certification (cunt.)
Yes No
❑ Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ L`7 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.
ElIJ Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ LJ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
F ❑ lYJ 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.]
❑ t,/ 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.
i 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
f, ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
rt ❑ the system,is located in a nitrogen sensitive area (Interim Wellhead Protection
;i
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 c 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.
tsins•i vto
Title 5 Offidal Inspection Forth:Subsurface
it Sewage I System•Page 5 of 17
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Commonwealth of Massachusetts
UTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
141/6 0/cA41-7
Property Address
Owner
Owners Name VS ✓�/ Ile
is
for every C(tyRown
State Zip Code Date of lr6pWon
C. Checklist
Check if the following have been done. You must indicate"yes" or"no"as to each of the following:
Yes/ No
L�J ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ I� Were any of the system components pumped out in the previous two weeks?
❑ L✓J 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)
L� ❑ Was the facility or dwelling inspected for signs of sewage back up?
L7 ❑ 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:
dExisting information. For example, a plan at the Board of Health.
❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) (310 CMR 15.302(5)J
D. System Information
Residential Flow Conditions:
.* aNumber of bedrooms (design)` Number of bedrooms (actual):
�30
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):
lama•1 v10
it Title 5 Offidaf Inspection Form:Subsurface Sewage D*xsal System-Page 6 of 17
!p
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
N 6 o/d�a
Property Address
A !/1
C �
Owner Owners Name /��J,
information is
required for every 0S4e✓V//4 / / 0a 6,1s- /o// /I
page. cityfrown State Zip Code Date o Ins ion
D. System Information
Description: / �G 61--, lloo
d�
c.'s ..e-
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 0 1 No
Laundry system inspected? El Yes
Seasonal use? ❑ Yes Er No
Water meter readings, if available(last 2 years usage (gpd)):
Detail
Sump pump? ❑ Yes No
Last date of occupancy: Date
C
` Commerciallindustrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CM 15.203): Gallons per day(gpd)
ip Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
1 Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
't Water meter readings, if available:
t5irts-11/10 Title 5 Olridai I'� nspedion Forth:Subsurface SeNege Disposal System•page 7 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not
for Voluntary Assessments
Property Address
Owner Owner's Name 1 N AW
information is
required for every J I / � / /o( 0, (p�S
page. City/Town State Zip Code Date of fnspeaion
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
G►- — B LVL
Source of information: P f
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 stem:
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):
ts;rm•1 v10
I i T&5 orfidat In"dion Form:Subsurface Sewase DeSPo J System•Page 8 of 17
't
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
VVJSubsurface Sewage Disposal System Form - Not for Voluntary Assessments
/4 6 oldke v,7 1�d
Property Address
Owner Owner's Name
information is 0s�rV1 Ile—
page.
required for every
Citylrown State Zip Code Date o nspe 'on
D. System Information (cont.)
Approximate age of all r date tall (if known) and source of information:
Were sewage odors detected when arriving at the site? ❑ Yes No
Building Sewer(locate on site plan): l�
Depth below grade: feet
Material construction:
cast iron 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade:
feet
Material construction:
concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
F
r If tank is metal, list age:
�. years
#i
j Is age confirmed by'a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
i Dimensions: S X
Sludge depth:
tsi•1 v10 rme s i i osPedion Form:Subsurface Selvage Disposal Sygtern•Page 9 of 17
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
l�16 cxc/ � ► Ad
Property Address
Owner Owner's Name
information is
required for every
page. Cityrrown State Zip Code Date of frqxcfion
D. System Information (cont.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle 7"
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 —
How were dimensions determined? /e �a 0(-e—
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
0 -1 00/ 4,eeclec/ �:,,4
//0 /—.CA
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
I'
Date of last pumping: Date
tsars•71/10
t T"&5 Offaml Inspecfion Fom,:subsurface sevsge Disposal hem.pap 10 of 17
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
/I/C o/d 112d
Property Address
Owner Owner's Name l
information s Os �✓vf / �/, �pl /�� /� �3
required for every �'� / /�7 b
page. City/Town State Zip Code Date of 4nspedon
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
i
Alarm level; Alarm in working order. ❑ Yes ❑ NO
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
t.
tF
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
r tsins•1 v10 Title 5 Offival Inspection Form:Subsurface Savage Disposal System•Pape 11 of 17
is
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
D/i� a
Property Address
Owner Owner's Name WT
informations O� ✓I/! / Ay 0'�6 J /� /,?required for every X/
page. City/Town State Zip Code Date of pe on
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on ! ite plan):
Depth of liquid level above outlet invert
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.): .
&bx ze.,7
O
/V 1-2 4�.r
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):
1 If SAS not located, explain why:
4
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j t5ins•11/10 Title 5 Official Inspedion Forth:Subsurface Sewage Disposal System•rage 12 d 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
`Tto 00 (l Ci V"l l�
Property Address
Owner Owners Name G
information is
required for every t fl V!
page. City/Town State Zip Code Date of Inspe on
D. System Information (cunt.)
Ty Co
pe: W / �
leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number.
❑ leaching trenches number, length.-
El leaching fields number, dimensions:
❑ overflow cesspool number:
f
❑ innovative/altemative system
Type/name of technology: —
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
4-cii"I
0
'ply
y, Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
h Number and configuration
Depth—top of liquid to inlet invert
t, Depth of solids layer
Depth of scum layer
is Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
lsins•11/10
Title 5 Offi ial Inspection Form Subsurface Sewage System.Page 13 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
• Subsurface Sewage Disposal System Forth- Not for Voluntary Assessments
Property Address
Owner Owners Name
information is DS ✓v/ / / D� 5� �O /� ��
required for every
page. City/Town State Zip Code Date of kpec6on
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.): r
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of pond ing, condition of vegetation,
etc.):
i
tsms•r vto True s Offidal i nspecban Form:Subsurface SwABe Disposal yygem•Page 14 of 17
Commonwealth of imassachusetts
Title 5 Official Inspection Form
VVjSubsurface Sewage Disposal System Form -Not for Voluntary Assessments
N6 . 0/C14GVU1
Property Address
Owner Owners Name
information is ye V 0L C-y �O /
required for every
page. Cityrrown State Zip Code Date Ins ion
D. System Information (cunt.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
:7and-s'kethin
e puwater supply enters the building.. Check one of the boxes below:
c the area below
❑ drawing attached separately
3
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rl
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;
e1 t5ins•11110 Title 5 Mial Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
1t
t
Commonwealth of Massachusetts
u P Title 5 Official Inspection Forme
Subsurface Sewage Disposal System Form - Not
for
r
Voluntary
As
sessments
,p Property Address [
Owner �I /71
Owner's Name
s
information (1„✓v� /
required for every J Iz l /% �o� b SJ� �o a
page. Crty[Town State Zip Code Date of Irspectio
D. System Information (cont.)
Site Exam:
Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells /
Estimated depth to high ground water:
feet
Please i icate all imethods used to determine the high ground water elevation:
Obtained from system design plans on record
If checked, date of design plan reviewed:
Date
❑ Observed site (abutting propertylobservation hole within 150 feet of SAS)
L� Checked with local Board of Health -explain.-
Checked with local excavators,.installers - (attach documentation)
❑ Accessed USGS database -.explain:
tt
You must describe how you established the high ground water elevation:
2w1 ( V1S a
O ti✓)
s
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
tsms•t vto -
Title 5 Off=W Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
t
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
bAn
n
Property Address
Owner
Owner's Name
informations DS �Vi /le-- Do�6Jr�
required for every
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Inspection Summary: A, B, C, D, or E checked
Cff/Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
f
Sy tem Information-Estimated depth to high groundwater
Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
6
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t5ins•11/10 -
1, This 5 Official Inspection Form:Subsurface SeAege Disposal System.Page 17 of 17
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-T :i_.: f3FLZ jar E LzII
THE FOLLOWING
IS/ARE THE BEST
IMAGES FROM POOR
QUALITY ORIGINAL (S)
I A- I
DATA
No.... ..... !..... .. - 4 Fimic ............
THE COMMONWEALTH OF MASSACHUSETTS
BOAR HEALTH
..................OF......... r'N. ..L. b.� ................................
App iration for Disposal Works Tonstrurtinn ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
Sys ._ Ja Q �ikc*....... ..................� ..........V...................................................
ocati n- s or o
E: a:!s Qr.' ... it. �u..�'�'ULE �o, s................... ...
Ow r aAAA,l NN��AddrrIess
aW ......•... -�,... .. ...!....._..... .................................. ...............•-'-----• �"`Q `� . ....................................
Installer� Address
U Type of Building rj Size Lot...I51_�M......Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
`4 Other.—Type of Building _. No. of persons............................ Showers — Cafeteria
Q' Other fixtures ............................
W Design Flow............ .....................gallons per person ej i�. Total ijy fl9 _-------30...................... r
}Y1
WSeptic Tank—Liquid capacitylOOMallons Length.. VVidth___f 7h.. Diameter................ Depth.. ..
x Disposal Trench—. o..................... Width '_......._._._..__ Total Length.........`._ Total leaching area....... .__......sq. ft.
Seepage Pit No....... Diameter-----k_.._ Depth below inlet----- ............ Total leaching area...�QQ_sq. ft.
Z Other Distribution box ( ) Dosing to 64flt
dPercolation Test Results Performed by.---_-___ AA.q. F_'._ J PR(s ate.......:7Ver
•�-�..
a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground wa ......._...............
GZ4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Description of Soil------------ ---- �41-0M.."11-3-�-'4- --------------------------------------------
O
----------------------------------------•---•-••-•-•----
x
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 iITL L 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of'health.
Signed...................................................................................... ................................
rr Date
Application Approved By......... .......=................... GT..... 7
Date
Application Disapproved for the following reasons__________________________________________________ .................................•--•---.. --_...........
.................•-•••----....•--...---••••--•--•-•--•----•-••-•-----•-•••-•----••---------•-••--•---•------•-•---•-----•-••-----------------------•--•----•---•-••-•----•------•---------•----.........
Date
Perz� Issued------------------na ._....-------------------------
c..
7�? l
THE COMMONWEALTH OF MASSACHUSETTS
,- - BOARD F HEALTH
.------.... . '�..-.... F........ O 1._ .4_. .I ._....
Appliration for Uiipnmd Vorko Cfnnutrnrtinn Prruat
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
tam
SysZ 0
: . _ ____... _. ... o ...... ........ .----..-.-"-".---............._ _... : •------ -....
b ocah n ess or o
sOwpne�r� r� Address
41
FM—I Installer Address
V Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms_______________13_____________________________Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons..... ...................... Showers ( ) — Cafeteria ( )
Other fixtures -------------------•---------------------•---"----
W Design Flow............Z.+ ______ _________gallons per person per day Total daily flow_______-3 ......................1W10
WSeptic Tank—Liquid capacity 16Ballons Length_______________ Width................ Diameter___-__---------------- Depth_. .... .
x Disposal Trench—. o_____________________ Width_ ..______.____._._ Total Length___.__.___..______. Total leaching area...... _____..._sq. ft.
Seepage Pit No------- Diameter._._.. t ..__._._ Depth below inlet...... t__.____ Total leaching area._._ _sq. ft.
Z Other Distribution box ( ) Dosing tar ( "�""
'-' Percolation Test Results Performed by................... _ � .........................."I ? ate......... Z 19 . 7-.
aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water..................... .
Gz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water________________________
R+
O
Description of Soil............AT .. �* .' ��
U ---•--••-"-"-•---"----••-••-"-----"""-"---"-"-•--"-"---"•-"-••---•-••"""•-•--•--"""••••-...•••------"---""---"••-"-•"•-"-•-"-•-"""-•"-•-•-••-------------"--""•"""---"-"----"-"----"•--"...._•"--••"----
W
---------------------------••---••----•---••------------------ - - - ----------------------------------------------------------------------------.......................
U --•-•••-••-•-- .._..-------------Nature of Repairs or Alterations—Answer when applicable__::_:___" ___________________________.....................................................
----•-------------------------------------•-•---•---------•----•--•---"---•-•-------•-_"----"-----"----"-------•-....--.•-•----------------=----------"---------------•------------...................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLZ 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed.............................................................................. -"---
.. Date
Application Approved BY ! '. . r:?.. `-----------------•
Date
Application Disapproved for the following reasons---------------••---=---•-------•---------------------•------•-----------•------•"------------•-""----"•"---••---
----------------------- ----•-- -=- =-"-------......--=------------ - --- - - ---- ---------------•-•-------•------------------___-------__ -- •- • . - - - --• ---------------------- -- - ----------------_---
- ----Date
PermitNo......................................................... Issued..........................................---------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD Of- HEALTH
!-1 OF...........
... :..�` �''. ....
�rr#ifir��r oaf ��ant�li�nrr
THIS IS TO CERTIFY, That the Individual Sewage.Disposal System constructed (�') or Repaired ( )
/ >�/ri 3 Il r "
by •-"-"" C. ........................'_....._•--"--..... - ....... c---i------.-'. -----------........---•-------...._...--
r Installer f .-� of f t'
-...----- -- -- ---- ---- -----------•--------------------------••-------------
has been installed in accordance with the provisions of T _I Ft 5.of The State Sanitary C�e as described in the
application for Disposal Works Construction Permit No __._w'"____._'� `
.�-� -; -�--�--------. dated-- ---°�-'--------�--�--'-�J---=-------------
THE ISSUANCE OF THIS CERTIFICATE SHALE. NOT BE CO TRIBE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.,
DATE.................. ......................... Inspector............. ...................................
THE COMMONWEALTH OF MASSACHUSETTS
4
BOARD O,FI HEALTH -
t /
No ...... �_ .. FEE._.:m:,,�......•-----
�i��rn��t1 n�k���n���rnnr�inn rrnti�
Permission is hereby granted_____________'V_ ___l�:l.__>..:_ _ <
to Construct (' .)or Repair ( ) an•Individual Sewage Disposal,System
at No.- ::_.: f •: _ ....F- `--'-`--.-- -"-"---".`'.._..••-••-•••-•----------"-"••••--""-••-••_...
' Street /as shown on the application for Disposal Works Construction,P ____ rermit No _�_ ated_.__, _.": "�_ _:____
- -
Board of Health
DATE....................................................._........ -•------ 4
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
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