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COMMONWEALTH OF IVIASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
' DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION-FORM NOT FOR VOLUNTARY,ASSESSMENTS
SUBSURFACE SEWAGE.DISPOSAL SYSTEM FORM
PART A
CERTIFICATION .
Property Address:" 15 Sturbridge Drive
Osterville, MA 02655
Owner's Name: Arlene Santangelo �\
Owner's Address.
Date of Inspection: Nowniber 2, 2007
Name-of Inspector: (Please Print) James M..Ford �.
Company.Name: James M.Ford t
Mailing Address: P.O.Box 49 -
Osterville,MA 02655-0049 l lJ`
Telephone Number: 008)862-9400 � 1
P e
C)
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal:system at.this address and that theformatioi4 repod.
below is true;accurate:and complete as of the.time of.the inspection. The inspection was per f ed based on my
training and experience in the proper function and maintenance of on site sewage disposal syst I ama-DEe;� '
approved system,inspector pursuant to Section 15.340 of Title 5.(310 CMR 15.000). The sys em:
co
✓ Passes � r=
Co itionall Passes - '
Y - .
Nye s Further Evaluation by the Local Approving Authority
F '1
Inspector's Signature:
Date: November 12, 2007
The system inspector shall sub 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: .
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 notaddress:how.the system will perform.in the future under the same or:different
conditions of use:
Title.5 Inspection.Form 6/15/2000 paged
Page 2 of 11
OFFICIAL INSPECTION FORM.-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: .15 Sturbridge Drive
Osterville. MA
Owner's Name: Arlene Santangelo
Date of Inspection: November 2. 2007
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 breakout 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.inspectioh 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: 15 Sturbridge Drive:
Osterville, MA
Owner's Name: Arlene Santangelo
Date of Inspection: November 2; 2007
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.
t
.1. S.ystem.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 privyis within 5,0 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 protecis 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
Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION-FORM
PART A
CERTIFICATION .(continued)
Property Address: 15 Sturbridge Drive
Osterville, MA
Owner's Name: Arlene Santangelo
Date of Inspection: November 2. 2007
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 iwcesspool is,less than 6"below invert or available volume is less than %day flow
_ ✓ Required pumping more than 4 tunes 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 ofa 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 feetof 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 I1.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 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
y
Page 5 of 11 y
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL'SYSTEM INSPECTION FOR_ M
PART B
M CHECKLIST
Property Address: -15 Sturbridge Drive
Ostervi_lle; MA
Owner's Name: Arlene Sdntangelo
Date of Inspection: November 2. 2007
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 uncoyered,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 Absor tiodS stem SAS`"on the site has been y p Y ( ). 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•I5.302(3)(b)].
1-
5
Page 6 of 1.1
OFFICIAL INSPECTION FORM=NOT.FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C ,
SYSTEM INFORMATION
Property Address:. 15 Sturbridge Drive
Osterville,.MA
Owner's Name: Arlene Santangelo
Date of Inspection: November 2, 2007
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.20.3 (for example: 110 gpd x#of bedrooms): 330
Number of current residents: 2
Does residence have a garbage grinder.(yes orno): n/a
Is laundry on a separate sewage system.(yes or no): Wa [if yes separate inspection required]
Laundry system inspected(yes or no'):L No
Seasonal use(yes or no): No
Water meter readings,if available(last2 years usage(gpd)): Unavailable
Sump Pump(yes or no): No
Last date of occupancy: Currently occupied.
COMMERCIALANDUST_RIAL
Type of establishment: . '
Design flow(based on 310 CMR 15.203): gpd
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 systein(yes or no):
Water meter.readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: Unavailable
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 h
✓ Septic tank,distribution box;soilabsorption 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:
Date of installation:unknown m
Were sewage;odors detected when arriving at the site(yes or no): No
6
f
Page 7 of 11
OFFICIAL INSPECTION-FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 15 Sturbridge Drive
Osterville. MA
Owner's Name: Arlene Santangelo
Date of Inspection: November 2,=2007
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: 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'ga1.
Sludge depth 2"
Distance from top of sludge to bottom of outlet tee or baffle: 3011
Scum thickness: 4"
Distance from top of scum to top of outlet tee,or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle: 10"
How were dimensions determined:. Measurinz 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 did not appear to be'an 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.):
Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORIVMATION.(continued)
Property Address: 15 Sturbridge Drive
Osterville, MA
Owner's Name: . Arlene Santangelo
Date of Inspection: November 2, 2007.
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: 'eallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping: 7.
Comments(condition of alarin 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 clean; No solids were present.
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 1
OFFICIAL INSPECTION FORM-.NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 15 Sturbridge Drive
Osterville, MA
Owners Name: Arlene Santangelo
Date of Inspection: November 2,.2007
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type -
✓ leaching pits,number: I-6'x 6'(10QQZaI)
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.):The leach 12it had 1'o fi uid on the bottom. There did aQLappear to be an ysi ns o_-failure. The bottom to rade was 8.5'
CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth-top q
of li u.id.to inlet invert
.
Depth of solids layer:
Depth of scum layer:
Dimensions of'cesspool:
Materials.of construction:,
Indication of groundwater inflow(yes or no) r
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.):
Page 10 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Pro er t Address: l S Stitt Y"P Y b td e Drive-
Osterville".MA
Owner's Name; Arlene Santahkelo
Date of Inspection: November 2, 2007.
7.
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage,disposal systern.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.
e ,
13
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10
Page 11 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM-INSPEC,TIONt FORM.
PART C
SYSTEM.INFORMATION(continued)
. F 4
Property Address: 15 Sturbridge Drive
Ostervllle, MA
Owner's Name:. Arlene Santangelo
Date of Inspection: November 2, 2007
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 30+/- feet.
Please indicate(check)all methods used to determine the high groundwater 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:,
m
Using Barnstable topographic.and water contours aps the maps were showing ypproximate.1y 30'+/ to groundwater at this
site.
This report has been prepared.only for the septic system and components described herein. This septic system has been
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 septic system; the inspection, this report and/or any components of the septic system which have not
been located and"inspected.
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' 11
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Stap up to
kitchen
sting House Beyond-
Not in scope of work — ® ' U to loft
CD
13 risers @ 71 18° ♦10°treads ._
Cost closet
APpprox.38°w x 24"d CD
Q�
"type x shestrock o 4r ewe pos
new walls&exlsOng whIng I Laundry Closet ,n
per code. 4 I N Mud Room Approx 681w x 30°d L
�
I 170 square feet }/1r
140 square feet toe floor _ C/J
In
® -- Pantry/ T
Storage
I
Pantry
® Approx 48"w x 24"d
I ® O o
((D N I u to Refrigerator Nook CS
p room , Approx 33"w x 39"d O
mud
I I I x4 w l typ. �
I I I I Qp
I �pqq
I Existing Garage 10 I I " I auaFnnrE uourrtrn V
I I I � � I suaFnce sourrtso r�
I I I A5 A4 I wossscsar Q �
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ounET(\'an°v l°G)
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Existing Access Door
Crawl Space Crawl Space '� l
Note:Conflrm calling height Is less than
36"or add collar Iles Q 36"h
m Built-In Cabinet Custom Built-In Cabin Q
approx 361w x 24°d - approx.361w x 24•d
Q�
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knee A at 36"It
B27
Built In wet Bar space ♦n
24 nder Counter vJ
'dge Space U') .
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Down to Mud Room
3'°
Anderson TW 400 j
Y New knee wail at
3g•Ih gh
2'0°x 3 6O q
Berson 1 00
P
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New Loft Space
approx 362 square feet carpel g
oEscwr � VL
. rwamtr � Aa
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Anderson TW 400 - Anderson TW 400
Loft(Flow Plan
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TOWN OF BARNSTABLE U
LOCATION !� r�r��S{- �� SEWAGE # )Ud 123
`,VILLAGE 62-161211k ASSESSOR'S MAP & LOT/44- /O/
INSTALLER'S NAME&PHONE NO. L'oT
SEPTIC TANK CAPACITY �j
LEACHING FACILITY: (type) P-T �ox6 I aoa (size) 3 S 7'0ni,
NO, OF BEDROOMS
BUILDER OR OWNER mAr1 c 1Jt A
PERMPTDATE: u COMPLIANCE DATE:-3y U
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by�/1 T/KG77y� T FD/
► Deck ,
A a
a I a�
A a,6
3
3 So
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No. aeFo ' ` Fee .
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
Z(ppliration for dig og r *p�tem �Congtruction Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) O Complete System 8�Tttdividual Components
Location Address or Lot No. 15- S—fu e- r, 21 9 L_ Owner's Name,Address and Tel.No.
Assessor's Map/Parcel ()S�Q rV i
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.140.
� R vs
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 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) 1✓ 90y, re-P A i r
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued b this Board of Health.
Signed Date
Application Approved by Date le)
Application Disapproved for the following reasons
Permit No. �-�� — �L 3 Date Issued o D `�
No. G b ! 5
Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
�__ Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS
2pprication for Migpogal *pztem Cottgtruction Permit
Application fora Permit to Construct( )Repair(✓)Upgrade( )Abandon( ) O Complete System individual Components
Location Address or Lot No. 15 �e r',r G� e Owner's Name,Address and Tel.No.
LL
Assessor's Map/Parcel 0 OC_
Installer's Name,Address,and Tel.No. Designer'sY' 's�Name,Address and Tel.No.
(SO Dn �U n,nuS
_.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 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) ,J " O 1C (If-0
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
t in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this Board of Health.
Signed 4 � ,f _ Date
Application Approved by Date
Application Disapproved for the following reasons #
Permit No. Date Issued �i O i c-
THE COMMONWEALTH OF MASSACHUSETTS ��
BARNSTABLE, MASSACHUSETTS r I, cf
Certificate of (Compliance
THIS IS TO CERTIFY, thafthe On-site Sewage Disposal System Constructed( )Repaired O'Upgraded( )
Abandoned( )by
at /S S l Ir cjG Te t' 0 S rV j I Lchas been constructed
with in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. D u o L/-j)(13 dated `3/l a At
Installer ' r61 ni)S Designer /
The issuance o this permit shall not be construed as a guarantee that the sy tem 11 function as designed.
Date 3// 0-/ Inspector
� c
� A
No. D co L/ --o� � Fee So
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
Migpogar *pgtem Construction Permit
Permission is hereby granted to Construct( )Re air(,, �6pgrade( )Abandon( )
System located at S S 7 U i r+�c,L CSTer V
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:Construction must be completed within three years of the date of this rmit�
Date: ZO�C`- Approved by
TOWN OF BARNSTABLE
LOCATION l ryjr� Sti �r SEWAGE # ud 7�0 9 3
ELLAGE 11 VICv►ILk ASSESSOR'S MAP & LOT/G6'
INSTALLER'S NAMEA PHONE NO. L'0 PSI',
SEPTIC TANK CAPACITY 1 A _
LEACHING FACIL17N: (type) Pr CX(v (size)
NO. OF BEDROOMS
BUILDER OR OWNER MAr1 c br
PERMITDATE: ")a COMPLIANCE DATE: U
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 306 feet of leachin facility) Feet
Furnished by
/
�1►dLr Q
► deck �
a a.w 3 1 3
y
30
3�
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTEjTT�ON �®
MAR 2 3 2004
TMN yr BARNSTABLE
HEALTH DEPT.
TITLE_ 5
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 15 Sturbrid¢e Drive Y a
Osterville, MA 02655 MAP {1 b
Owner's Name: Marie Dray ®
Owner's Address: PARCEL. '
LOT '
Date of Inspection: February 28, 2004
Name of Inspector: (Please Print) James M. Ford
Company Name: James M. Ford
Mailing Address: P.O. Box 49
Osterville,MA 02655-0049
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—W of Title 5(310 CMR 15.000). The system:
✓ Passes
Conditionally Passes
Nee Further Evaluation by the Local Approving Authority
Fail
Inspector's Signature: Date: March 4, 2004
The system inspector shall sub 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.
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.
1
Title 5 Inspection Form 6/15/2000 page I -
Page 2 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 15 Sturbridge Drive
Osterville, MA
Owner: Marie Dray
Date of Inspection: February 28, 2004
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: 15 Sturbridge Drive
Osterville, AM
Owner: Marie Dray
Date of Inspection: February 28, 2004
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
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
Page 4 of 11
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 15 SturbridRe Drive
Osterville, MA
Owner: Marie Dray
Date of Inspection: February 28, 2004
D. System Faflure 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 1.00 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 I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B .
t
CHECKLIST
Property Address: 15 Sturbridge Drive
Osterville, M4
Owner: Marie Dray
Date of Inspection: February 28, 2004
Check if the following have been done: You must,indicate des 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 CNIR 15.302(3)(b)].
5
Page 6 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 15 Sturbridge Drive
Osterville, MA
Owner: Marie Dray
Date of Inspection: February 28, 2004
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: 1
Does residence have a garbage grinder(yes or no): No
Is laundry on a separate sewage system(yes or no): Yes [if yes separate inspection required]
Laundry.system inspected(yes or no): Yes
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 CUR 15.203): apd
Basis of design flow(seats/persons/sgtetc.):
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 every 3 years-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:
Installed approximately 21 years ago-per owner(no as built card on file)
Were sewage odors detected when arriving at the site(yes or no): No
6
Page 7 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 15 Sturbridge Drive
Osterville, AM
Owner: Marie Dray
Date of Inspection: February 28, 2004
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: 20"
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 gal.
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 30"
Scum thickness: 2"
Distance from top of scum to top of outlet tee or baffle: 8"
Distance from bottom of scum to bottom of outlet tee or baffle: 10"
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 did not appear to be any 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.):
1
7
f
Page 8 of 11
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property YAddress: 15 Sturbridge Drive
Osterville, MA
Owner: Marie Dray
Date of Inspection: February 28, 2004
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 broken down structurally. A new D-box was installed(see Permit#2004-093)
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
I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 15 Sturbridge Drive
Osterville, Am
Owner: Marie Dray
Date of Inspection: February 28, 2004
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
✓ leaching pits,number: 1 -6'x 6'(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.):
The pit had 2'of water on the bottom. The scum lane was at the same level. There did not appear to be any signs offailure. The
bottom to grade was 91
.
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
D
Page 10 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 15 Sturbridge Drive
Osterville, MA
Owner: Marie Dray
Date of Inspection: February 28, 2004
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.
71
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i a a�
a ace 31 3
. y
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10
M
Page I 1 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 15 Sturbridge Drive
Osterville, MA
Owner: Marie Dray
Date of Inspection: February 28, 2004
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 25 +/- 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
25'+/-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 andlor this report.
11
o
4L0CAT10-N SEWAGE PERMIT NO.
(etc- - �� C'✓y-� �' �.�Q.��L�°�✓�;�
"VILLAGE
i,
I N S T A LLER'S NAME A ADDRESS
iU1LDEIII OR -4WWO
zf-
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED � � , ��
f.
r r
d...............
THE COMMONWEALTH OF•MASSACHUSETTS
BOAR® OF HEALTH
//,? .
OF....................................... ... .
AVOIr�a#ion for Uhipaii al Workii Tnnitrnrtion Prruat
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
1L 2�aG V 2 - -6 l
........ .......... .... -•--....... -...
ocation-Address o�ro�t No.
.......Vl*? -1 ..... :.... �.. ........................................ .... Sx !::X:/k�•'t•-•--•--.. 'd
Owne w(� Address
E:::... '. -----•----______--•--• -----------------••--•- ----•-----••••••-•--•-•---------------------
Addddreresss
Type of Building Size Lot............................Sq. fee
U Dwelling—No. of Bedrooms.______.._: -__._Expansion Attic � Garbage Grinder
p, Other—Type of Building _._.4VQ _ .__. No. of persons........................... Showers ( ) Cafeteria ( )
Q' Other_fixtures ------------------------------
W Design Flow...... ________________________________gallons per person per day. Total daily flow_._.._._.__..1�•3v...................gallons.
WSeptic Tank—Liquid capacityJ-0°a.gallons Length................ Width................ Diameter................ Depth...............
x Disposal Trench—No...... =........ Width___._.._:'—:..... Total Length.........`-....... Total leaching area________ .......sq.`ft.
Seepage Pit No.....I. Cj... Diameter........1_2—.=. Depth below inlet......0......... Total leaching ...sq. ft.
z Other Distribution box ( ) Dosin tank )
'—' Percolation Test Results Performed b "¢SS-.-�Z.�:___,___._ .__....____ Date._.___' 7
y
Test Pit No. 1________________minutes per inch Depth of Test Pit.................... Depth to ground water........................
(i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P.' ----------------------------------------------------------------------•-._._........-•-•------..._....-•-•-•---•--=---------•-----•••-•--•-......._-•-•_--
0 Description of Soil........................................................................................................................................................................
U •••••-•••••••••-••••••••-•••-•••••-•-••-----•••----•-•••••-----•••••••••-•---•••••--•••........••••••-••••••••-••••••-•--••••-•••••••-••-•-••-----••••-•-•-•••••••••-•••---••-••----•-••••••-••-•-••-•--
W -•-••••••-••--------------------------------•----...................................................................... --------•••••••••••••-•-----••••••••-•••••••-•--•-•••••••-••••••••--•---•-----•-
UNature of Repairs or Alterations—Answer when applicable........................._.....................................................................
Agreement: r
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITI TLE .5 of the State Sanitary de— The undqf sigr`t�ed fur r agrees not to place the system in
operation until a Certificate of Compliance has issued the and of h t e
' Dat
Application Approved By....... •••• -••._....- ---�_/ __.. .. ------•------------------ ..... .............
Application Disapproved for the following reasons--------------------------------------------------------•------------------------•---------...•••-••••-•-=-•--••-
....•••.......••••••.........••••-•---•••••••-•••---••••••••--•--••••••••••••--------•----•-••••-•••...•-••••-•-••-•-••-••••-----••------•••----•••=•••••••••••••••••••••------•----••-••••-•-•••--•---
Date
PermitNo--------------------------------------------------------- Issued-.......................................................
Date
J
r No.. '.�'` '-- . _ Fxs.., ..............
1
THE COMMONWEALTH OF MASSACHUSETTS
BOARD. OF HEALTH
........OF..................................................`....._................................
AvOiration for Uhiogii ai Workfi Tongtrurtion ramit
Application is hereby made for a Permit to, Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
..... ! 6 ............. °=-='..� --- - ----- ....................... -
-r—Zocation Address Y or'Pt No r A
1._ ...
Owne ----•-___________ ....................£ Address -
W
t .............................� •-•------•----------------
•---------------
...
Installer Address
dType of Building ,I Size Lot............................Sq. feelt
V Dwelling—No, of.Bedrooms Expansion Attic Garbage Grinder (-
p`�, Other—Type of Building ._,gip __ _--- No. of persons............................ Showers ( ) — Cafeteria ( )
Other fixtures . ----------------•--•-•--------------•- :
------------------------- ----------------•..._....---•
W Design Flow.......................................gallons per person per day. Total daily flow........... ........gallons.
9 Septic Tank—Liquid capacity,. .gallons Length................ Width................ Diameter................ Depth................
W Disposal Trench—No.......!'.......... Width........"""_':...._. Total Length.........I ........ Total leaching area....... -----------sq. ft.
Seepage Pit No.... _.. Diameter _ -e. Depth below inlet............... Total leaching area___ I ...sq. ft.
Z Other Distribution box ( ) Dosing,tank .,(.. )
Percolation Test Results Performed by...............€.�` ................................................ Date....... _'. _
aTest 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........................
a --•----------- ---------• __------••----•---------------•---••••........
•--•--------------
•-_. _.........
oDescription 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 TITILE 5 of the State Sanitary Code—The undersigned furjtd er agrees not to place the system in
operation until a Certificate of Compliance has `eeJ iskued /the ard of h slth.
S �'P
j d r
Application`Approved B �»-`_. r.__ _._ �___...._
PP PP y--------- .. . ----- - ---0�e-----•••-••-•-•-- 'f Date
Application Disapproved for the following reasons:---------••-•..•---•--•------•--•----•-••--•--•••-•-•-••----•------•-------•----•----------------------------
--•••---•••................•---------•-....-•---------••----------•..................•-••--•----------••-•-•--•-----........------------.................---.............-................ ............
Datz
PermitNo.......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............/.e :..........OF..... r? ! '' '....................................
%-E rtifiratr of Tnntpliattrr
THIS IS TO CERTIFFY.�+ Th t the Individual Sewage Disposal System constructed (�) or" Repaired ( )
by-••-......�••-• ......._--.. - - -----•-- -----------•-•-------------
y ...... Installer
at ny r' l 5 � ' < ' S: .. ............•--------..._
.. z. ...:.
has been installed in accordance with the provisions of TITLE r of The State Sanitary Code as described in the
� G ••------••---- da.ted---•-------•------••--._.._..._
application for Disposal Works Construction Permit No______________________7 ...__..._________
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE........................................... ............... Inspector../-4
THE COMMONWEALTH OF MASSACHUSETTS r Q
BOARD OF, HEALTH
o .............. OF........:. e- 6 .
N ........................ FEE •-•--.................
0hiji ial Vorkv TOnstrudian rrntft
Permission is hereby granted............Of A...----- = . ---- •-•••-••-•---•-----••-•-•----••----•-••-•-----•--•--•----•.........................
to Construct ) r Repair ( )) .fin Individual Sewage Disposal S stem
Street
as shown on the application for Disposal Works Construction Permit No ....... ,Dated .......................................
, A-----•.............. ••-------__-----------••-•---••-------•----
�rd of Health
DATE.................. _._ .5"" ......................
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS �.
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