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Home My WebLink About0177 SCUDDER ROAD - Health 177 Scudder Road' °t Osterville P A = 140 189 i JJ 0 o - e TOWN OF BARNSTABLE LCI�ATION I? SGV CCe/- 4! SEWAGE # VILLAGE D ST'erv►1L ASSESSOR'S MAP & LOT I d /9 INSTALLER'S NAME&PHONE NO. LOT SEPTIC TANK CAPACITY / M // LEACHING FACILITY: (type) A-rs toX& (size) 10V0 NO. OF BEDROOMS / BUILDER OR OWNER ' mG/Ab PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leacInfacility) Feet Furnished byen .�• �Oj C 6 � t i A 8 3a 33 Q 3 a 33 3-7 3 34 yo O y y ss y %pr U4 1 b UbAbp p.1 l ,ppia %no Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not fogy Voluntary-Assessments+" 177 Scudder Road Property Address Patrick+ Eleanor Mclaughlin Owner Owner's Name information is required for every OsterviIle MA 02655 3-31-15 page. Gty/Town Slate Zip Code gale of Inspection Inspection results must be submitted on this form.Inspection fofnts may not be altered in any way.Please see completeness checklist at the and of the form. Important:when A. General Information filling out forms ' ��Uuuiiinrrb . On the computer, 0Fw1ASi�0/4 use only the tab key to move your 1. Inspector ¢ o'• . . :qc�G . { cursor-do not - i JAMES :rn use the return James D.Sears , key. Name of Inspector c y CapewideEnterprises,LLC *`` a/f Iffi I I Company Name 153 Commercial Street - '�''�q, s'INSPEGp��`��. CornpanyAddress a Mashpee MA Cityrrown Zip Cod Slate Zip Code . . 508-477-8877 S1623 .. Telephone Number License Number s 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:ptum4ant to Section 15.340 of Title 5(310 CMR 15.000).,,The system: ® Passes 0-Conditionally Passes' ' Fails 0 Needs Further Evaluation by the Local Approving Authority. 4-4-15 . . specter's Signature Date , The system inspector shall submit a copy of this inspection report to the Approving Authority(Hoard 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 systern 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. tSlra•3113 Title 5 Ortidd kgmction Farm:Subsurface Sewepe Disposal System•Pape t or 17 Apr U4"1 b UbAdp p.2 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 177 Scudder Road Property Address Patrick+Eleanor Mclau hlin Owner Owner's Name, information is required rorevery Osterville MA 02655 3-31-15 page. City/Town State Zip Code Date of InspecIfon B. Certification (cont.) Inspection Summary. Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: d The system is a 1000 Gal.Tank and two pits 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. a 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 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. ❑ Y ❑ 'N ❑ ND(Explain below): t5ins-aft 3 TWe 5 Oftel Vapection Form:Suesurace Sewage Disposto System.Page 2 or 17 a H iJI V4 i�vo:4ap r.�. p.3 4 Commonwealth of Massachusetts Title 5 urface Sewage Inspection Form Disposal System Form Not for Voluntary Assessments 177 Scudder Road Property Address Patrick+Eleanor Mclaughlin Owner Owner's Name information is required for every Osterville MA 02655 3-31-15 page. cityrrown State Zip Code Date of Inspection B. Certification (Copt~) , ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cunt.): ❑ 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'byelovr): ❑ 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. 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: ❑ r ' 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 • f51ne•3113 ~ Title 5 OfAdal kwpectlon Form:SuGwRam Sewage olepwal Symem+Page 3 of 17 ,�Nv� ICJ VJ.YJfJ lraJ p.4 Commonwealth of Massachusetts Titie 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 177 Scudder Road Property Address Patrick+Eleanor Mclaughlin Owner Owner's Name irlfortnetion Is required for every Osterville MA 02655 3-31-15 page. Cftyrrown State Zip Code Dale 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 fecal colifonn 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 A/,4 ❑ ❑ Static liquid level in the distribution~ box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Liquid depth in is less than 6°below invert or available volume is less than%day flow "0"Ts t5ins•3113 U19 5 Of cw fnapecton Form:Subsurface Sewage Oisposai System Page 4 0117 :;;�,Ni v-+ 10 vo:4ap p.5 Commonwealth of Massachusetts r} Title 5 Official Ins pecti on .Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 177 Scudder Road Property Address Patrick+Eleanor Mcliughlin Owner Owner's Name Information is required for every Osterville MA 02655 3-31-15 page. cltyrrown State Zip Code Date of Inspection B. Certification (cont) Yes No 0 ® 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 colifarm 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 some a facility with a design flow of 10,000 gpd to 15,000 gpd. For large,systems,you must indicate either"yes"or"rio"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 faded. 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. 15fns-3h3 TNe 5 Offidal lnspntion Fa .SLbmi t w Sewage Disposal System-Pege 5 of 17 ` mpr V4 I O U0:5Up p.6 Commonwealth of Massachusetts Title 5 Official Inspection action Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 177 Scudder Road Property Address Patrick+Eleanor Mclau hlin Owner information Is owner's Name required for every Osterville MA 02655 3-31-15 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 etch DAthe 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 NIA) ® ❑ 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? ❑ 0 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: . ® ❑ 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)1310 CMR 15.302(5)) D. System Information Residential Flow Conditions: Number of bedrooms(design): NA Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 151ns•3,M3 Title 5 Oftldaf Inspection Form:Subsurbee Sewspa Disposal,System-Page 6 of 17 �7rApr u4 r O ub:bup p.7 Commonwealth of Massachusetts , Title 5 Official lnspection' Form, Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 177 Scudder Road Property Address Patrick+Eleanor Mclaughiin : Owner Owners Name information is required for every Osterville MA 02655 -3-31-15 page. City/Town State Zip Code Date of Inspection D. System Information Description: The system is a 1000 Gal.Tank and two pits Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage 2013-38,000Gals 9 ( Y 9 (gPd))= 2014=43,0000al's Detail: ' Sump Pump? y ❑ Yes ® No Last date of occupancy, NA Date Commercial/industrial Flow Conditions: Type of Establishment Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design Row(seats/personsfsq.fL,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: ----- t51ns•3113 Title 5 OMrdel inspection Faint Sutsurfece SeWNP Disposer System-Page 7 of 17 mpr v'+ i o vo:oup C7 p.8 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 177 Scudder Road Property Address Patrick+Eleanor Mclaughlin Owner Owners Name Information every Osterville required wired for ar eve MA 02655 3-31-15 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: gate Other(describe below): General Information Pumping Records: Source of information: 10/ 121 14 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gaporu How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, NJ soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no)(if yes,attach.previous inspection records,if any) ❑ Innovative/Altemative 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): 151ns-3113 Title 5 Olficie!Ins pection Foam SubwAeca Sewage Olepmet System•Page 8 at 17 '7MP1 L)-+ 10 vo:o r p p.9 Commonwealth of Massachusetts L_ Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 177 Scudder Road Property Address Patrick+ Eleanor Mclauahlin Owner Owners Name information is required for every OSterville MA 02655 3-31-15 page. City/Town State Zip Code Date of Inspection D. System Information(cons.) Approximate age of all components,date installed(if known)and source of information: ' NA Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of 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.): Pipeing house to tank cast iron,tank to pit#1 orange burge. Pit#1 to pit #2 PVC.. Septic Tank(locate on site plan): 22" Depth below grade: feet Material of constiWion: ®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 1000 Gal.Precast H-10 Sludge depth: t5ins•343 Tide 5 Ulridal Ytspedion Form:SuLsuface Sewage Disposal System•Page 9 of 17 , r.Ni vr I�vo.a i p p.10 � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 177 Scudder Road Property Address Patrick+Eleanor Mclaughlin Owner Owner's Name information required for every Osterville MA 02655 3-31-15 e page. Citylrown State Zip Code Date of Inspedion D. System Information (cont.) Septic Tank(cunt.) Distance from top of sludge to bottom of outlet tee or baffle' 29" Scum thickness" l/ Distance from top of scum to top of outlet tee or baffle 12" Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? Asbuilt-Tape Sludge Judge Comments (on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tank at working level.Tank at 22"below grade w/cover's at 6". In and outlet baffles. No sign of leakage or over loading. 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•3113 Tree 5 Mini hnpedisn Form SubsuAaee Sewage Disposal System-Page 10 d 17 Commonwealth of Massachusetts Title 5 Official' Inspection Form, ' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 177 Scudder Road Property Address Patrick+ Eleanor Mclaughlin Owner information Owner's Name is required for every t?sterville MA 02655 3-31-15 page. Clty/rown 'State. Zip Code Dale 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.): 9 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 yl ❑other(explain): Dimensions: Capacity: gallons Design Flow. - gallons perday„ 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 15rnc•3113 - _ ride 5 OffirJal Ird"Won Form:subsurraze Sewage Dispoeel syelem•pne 11 or 11 Mi.JI v'+ 10 vo:ozp _ p.12 ` Commonwealth of Massachusetts IBM Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments %1Wj 177 Scudder Road Property Address Patrick+Eleanor Mclaughlin x Owner Owner's Name information is Osterville required for every MA 02655 3-31-15 page. Gty/Tovvn 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 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover,any evidence of leakage into or out of box,etc.): Pump Chamber(locate on site plan): Pumps in working order. ❑ Yes ❑ No' Alarms in working order. ❑ Yes ❑ No' Comments (note condition of pump chamber,condition of pumps and appurtenances,etc.): "If pumps or alarms are not in working order,system is a conditional pass. I Soil Absorption System(SAS)(locate on site plan,excavation not required): If SAS not located,explain why: t5ins•3113 T1119 5 OffkW Irepectlan form:SubsuAeoe Selvage DIspoael System•Pape 12 of 17 <h r+pr u4 I b Ub:bLp �p.13 Commonwealth of Massachusetts Title 5 Official .Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments" 177 Scudder Road Property Address - Patrick+Eleanor Mclau hlin y Owner Owners Name information is Osteryille a MA 02655 3-31-15 required for every page. citylrown State Zip Code Date of lnspedion D. System Information (cont) Type: 'leaching its number. 2 9P ❑ leaching chambers number. ❑ leaching,galleries - number: ❑ leaching trenches. number,length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number. ❑ 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.): Leaching is two 1000 Gal Precast Pit's Piped in line. Pit#1 is 21"below grade w/cover at.10" 1' water no in or out tees. Pit#2 is 30"below grade w/cover at 10",Dry with stain line at 40". No sign of overloading or solid carry over. 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 Mine•3113 Tale 5 Offiaal 6upedon form:$�beurfxe Sewage Disposal System•Page 13 of 17 r,Ni v'+ i o L)o:otp p.14 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 177 Scudder Road Property Address Patrick+Eleanor Mclau hlin Owner Owner's Name Information is required for every Oste viiile MA 02655 3-31-15 pagState 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.): 15ins•3113 TJtle 5 Official lnspec9on Form.Subsurface Sewage Disposal System•Pape 14 0117 p.15 Commonwealth of Massachusetts Title 5 Official Inspection Form , Subsurface Sewage Disposal System Form-Not for Voluntary Assess.ments 177 Scudder Road Property Address Patrick+ Eleanor Mc laughlin Owner• Owner's Name requiredlon is Osterville MA 02655 3-31-15 required for every page. City/Town State Zip Code' Date of Inspection D. System Information (cony.) 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 where public water,supply enters the building.Check one of the boxes below: ®_ hand-sketch in the area below -DEC k . . 1 sQ B ow y o Q-a A•3 =31=( ' 8L3-3;C ' 31 -s 5 t5irts-373 ' -nUo 6 OfftW kWearMFora 8UbWAftW SWM0 0bPQ l SYSUM•Pap.5 of 17 ryl v-+ IQ v0.0op - p.1*6 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ` 177 Scudder Road Property Address Patrick+Eleanor Mclaughlin Owner Owners Name information is required for every Osterville MA 02655 3-31-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check S16pe ❑ Surface water - ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water. 15'+ 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: Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators,installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the-high ground water elevation: Ck Abutting property area high. Bottom of pit at 9'below grade. Before filing this Inspection Report,please see Report Completeness Checklist on next page. 65ins•3113 Title 5 OfBdel Inspection Fomc SubsuAaoe Sewage Disposal Syefem•Pegs 16 0!17 i M(Jl 6t+ 1 o uo:o,sp - - - p.17 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Forth-Not for Voluntary Assessments 177 Scudder Road Property Address Patrick+Eleanor Mclaughlin Owner Owner's Name requir required Osterville MA 02655 3-31-15 required for every - page. Cdyrrown 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 depot to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file Mns•3113 Title 5 Oflidal hspwbn Foal SUbbalace Sewago Disposal System•Pape 17 of 17 i COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROT ' EDR e- :.: "zt E JAN06203 E TC0VVN Or B;=,L<i JSTABLE L_HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM F. PART A „ CERTIFICATION S-sl = O0 t Property Address: 177 Scudder Road Osterville,MA 02655 Owner's Name: Pat McLaughlin MAP Owner's Address: - Same PARCEL. ; -- Date of Inspection: December 6. 2002 LOT Name of Inspector:(Please Print) James M. Ford - Company Name: James M. Ford Mailing Address: P.O.Box 49 Map:140 Osterville,MA 02655-0049 Parcel: 189 Telephone Number: (508)862-9400 Lot:8 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 urther Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: December 16, 2002 The system inspector shall subm copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use'at that 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: 177 Scudder Road Osterville, MA Owner: Pat McLaughlin Date of Inspection: December 6, 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): - F ; broken pipe(s)are replaced obstruction is removed ND explain: 2 f t Page 3 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: '177 Scudder Road Osterville, AM Owner: Pat McLaughlin Date of Inspection: December 6, 2002 C. Further Evaluation is Required by the Board of Health: Conditions exist which require furthm 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 l 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. I 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 177 Scudder Road Osterville,MA Owner: Pat McLaughlin Date of Inspection: December 6, 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 %z 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 following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of 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 Page 5 of 11 OFFICIAL INSPECTION FORM = NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 177 Scudder Road Osterville, MA r Owner: Pat McLaughlin Date of Inspection: December 6..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? n/a 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: t 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)]. r 5 Page 6 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 177 Scudder Road Osterville, AM Owner: Pat McLaughlin Date of Inspection: December 6, 2002 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 Number of current residents: 2 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): avd Basis of design flow(seats/persons/sqft,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 2 months ago-per owner 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 1 I OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 177 Scudder Road Osterville, AM Owner: Pat McLaughlin Date of Inspection: December 6, 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. 16'..' 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: 1000 ttal. Sludge depth: ],IDistance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 3" 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: 12" 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.): The tees were present. The liquid level was even with the outlet invert. There were no signs of leakage. GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 177 Scudder Road Osterville, MA Owner: Pat McLaughlin Date of Inspection: December 6, 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: None (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): 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 11 OFFICIAL INSPECTIOMFORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 177 Scudder Road Osterville,MA Owner: Pat McLaughlin Date of Inspection: December 6, 2002 SOIL ABSORPTION SYSTEM(SAS) ✓ (locate on site plan,excavation not required) k If SAS not located explain why: Type ✓ leaching pits,number: 2-6'z 6'-1000 gal. leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: 3 Innovativelalternative 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 0I)was full. The liquid level was up to the outlet pipe. The other pit 02)had approximately 3'ofwater on the bottom. The scum line was approximately 4'up fro the bottom. The cover was approximately 30"below grade.. 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.): I 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.): i 9 • a Page 10 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 177 Scudder Road Osterville,AM Owner: Pat MCLauzhlin Date of Inspection: December 6, 2002 Map: 140 Parcel: 189 Lot:8 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. y � i 1 I 1 O a A B 136 33 O 3 a 33 3-7 33(oyo O y 10 e ' Page 11 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 177 Scudder Road Osterville,AM Owner: Pat McLaughlin Date of Inspection: December 6, 2002 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 25' +1- 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: The bottom of the leach pit to grade was approximately 9'6': Using the Barnstable topographic map and the Cape Cod Commission water contours map the maps were showing approximately 25'+/-to groundwater 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. i 11 . \ No.---.� .. .. ............ �. THE COMMONWEALTH OF MASSACHUSETTS OARD OF EALTH _ _.... ....OF............. . Apphration -fur Ui,gpu ial Worko Cnonotrurtion Vrrmft Application is hereby made for a Permit to Construct ( ) o air ( an Individual Sewage Disposal System at:: --- ----•--- ------- �� •• I------ -•.......................................11G ----_ �� L;cati A s or Lot No. ....��_----• •• •. ---•-• •------- ..... ---- ••-••-------------•----•--•------•--------......-----•..................••••-------- Owner j:�' !C 1 Address ......... Installer Address Q Type of B i g Size Lot----------------------------Sq. feet U Dwellin No. of Bedrooms---------------------------------------.----Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons-----------------:--------._ Showers ( ) — Cafeteria ( ) P f Other fixtures -------------------------------- - W Design Flow............................................gallons per person per day. Total daily flow------------------------------------------..gallons. WSeptic Tank—Liquid capacity-_-------.--gallons Length---------------- Width---------....-.. Diameter---------------- Depth._____--_.----- x Disposal Trench—No- -------------------- Width_....--___--_---_--_ Total Length.................... Total leaching area----..--_-_-_-__-__sq. ft. Seepage Pit No--------------------- Diameter-------------------- Depth below inlet-------------------- Total leaching area..._____-.-_._-_sq. it. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by...... ------=------------------------- .................................. Date--------------------------------------- a 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-------------------- Depth to ground water---------------.-___-__. 9 0 Description of Soil---------------------------------------------------- - x , WF� ______ _______ _______ G _ W .. .. ............... _ __ -- U Nature of Repairs or Alterations— swer when pp licrble.....��_s- a=---- --- ------------------"-----_-_ J .... Agreement: The undersigned agrees to .,install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article \I of the State Sanitary Code—The undersigned further agrees not t0 place the system,in operation until a Certificate of Compliance has been issued by the board of health. { igned.._--- ------------------------------------------------- ----------------. Date Application Approved By----------- -- "l Dale , , _ e Application Disapproved for the following reasons:-----•------------------------------------------- -- r=- ... bate..,- PermitNo......................................................... Issued...................... ................................. Date No. Ftm$.... .....�.�../... THE COMMONWEALTH OF MASSACHUSETTS OARD OF IEALTH . .......OF............. -- -------- ---------..-.--- -- t r Appliratiun -for Di�ipoiiat Works. Tono#.rnrttnn Vrruift Application is hereby made for a Permit to Construct ( ) o air ( an Individual Sewage Disposal System at: 7. .--- ----- --- .•----- � .--- ------- Meat A r s or Lot No. Owner Address Installer Address Q Type'of Buildi Size Lot-----_-------_---._-----Sq. feet U Dwelling No. of Bedrooms---------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) pa, Other—Type of Building ---------- - p ( ) ( ) _..._._._. No. of persons............................ Showers — Cafeteria Pa Other fixtures ----=-- ---= - =='-. .:.::_--=`-'�='==-=--"--- ="---- --------.:..---...--------------------------------------- d ------------ ----------- -===-=='=-=----=- • : W :.................gallons per person per day. Total daily flow.......................Design Flow:......................... WSeptic Tank.,-Liquid capacity------------gallons Length................ Width_-------------- Diameter---------------- Depth.-....-.---.-_- x Disposal Trench—No.--------------------- Width-------------------- Total Length.............._,-.:_ Total leaching area--------------------sq. ft. Seepage Pit No------------- --- Diameter.--..------ Depth below inlet-------------------- Total leaching area------------------sq. ft. z Other Distribution box ( ) ' . Dosing tank ( ) aPercolation Test Results . Performed by-------- -------------------•-•--......-----....................--...--_-. Date--------------- -_--------------------- ,� Test Pit No. 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water--....--.-.------------- �14 Test Pit No. 2................minutes per inch Depth of Test Pit.._.._.__-_-----.-. Depth to ground water--..-.------------------ Ix -------------------------- ------------- Or ------------------------ ........ Description of Soil ---- x ----------- -------- -- -- ---- ----------------------------------------------------------- -- ------ ...: ---------------- -- U Nature of Repairs or Alterations— saver when ppl ble. �� ----- - -- ------------------------------------------- Agreement The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance,with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board.of health. igned....... ---•---- --•••- - ----------------------------- -------- -- --- --- ate Application Approved By------.--- --- - wT� Application Disapproved for the`following reasons:----------- -- -------------•-_-----••--••---......--•--••---_--•---• ---------------- = Date PermitNo---------------------------------- .................... Issued....................... ................................... Date THE COMMONWEALTH OF MASSACHUSETTS $OARD O HE'ALTH X�3 THI S�TjO C TIFY, a the Indio 1 ewage posal System constructed ( ) or Repaired by �. .. ...- . In a ler ate-.-�rt`r+.... ... ""'. -... -- .R ------ -- .............................. has been installed in accordance with the provisions of Art X� o The State Sanitary Code a b m he application for Disposal Works Construction Permit No... ....,.�VbNSTRUED ....` ......... dated .....:��.�.. ...., 1�... THE ISSUANCE OF THIS ,:CERT1FICATE SHALL NOT AS G R TEE THAT THE SYSTEM WILL FU CTIO19 SATISFACTORY. DATE-*-f: ------ ....�..... ....,7y Inspector---- f . THE COMMONWEALTH OF MASSACHUSETTS BOARD O EALTH " .. , ' ..... .OF..... FEE. � � Y: %qn4-- nr na SC#innrrnti Permission is hereby grante _ ------- ---- to Cori . uct Repair ( Sew Dlspos yste at No ,�,4------ Li . '""`. ------- •--- Street as shown on the application for Disposal Works Cons�uc,>sion Pe > o....... :. !' Da -... .-. -. ...... DATE. 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