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Home My WebLink About0030 THYME LANE - Health 30 THYME LANE, OSTERVILLE r _ A = 165 008 i i i Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 30 Thyme Property Address Joe Lucier Owner Owners Name information is required for every Osterville Ma 02655 11/21/2012 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form! Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: G key to move your (� cursor-do not Michael DiBuono �J use the return Name of Inspector key. Company Name 31 Penobscot Ave Company Address Pocasset MA 02559 Cityrrown State Zip Code 508-364-9587 S113522 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by t Local Approving Authority— 11/22/2012 In pectors Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•11/10 Title 5 0 al I ection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 30 Thyme Property Address Joe Lucier Owner Owner's Name information is required for every Osterville Ma 02655 11/21/2012 page. Cityrrown State Zip Code Date of Inspection B. Certification 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: 3 stone packed L'C's are in good working order.. Soil is ideal leaching material and is leaching well. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair,.as approved by the Board of Health, will pass. Check the box for"yes", "no"or"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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 30 Thyme Property Address Joe Lucier Owner Owners Name information is required for every Osterville Ma 02655 11/21/2012 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑, Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of,Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,: safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 30 Thyme Property Address Joe Lucier Owner Owner's Name information is required for every Osterville Ma 02655 11/21/2012 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 30 Thyme Property Address Joe Lucier Owner Owner's Name information is required for every Osterville Ma 02655 11/21/2012 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ❑ Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ❑ Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ❑ Any portion of a cesspool or privy is within 50 feet of a private`water supply well. ❑ ❑ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ❑ The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall'upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments b 30 Thyme Property Address Joe Lucier Owner Owner's Name information is required for every Osterville Ma 02655 11/21/2012 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ 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) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins-1 Ill 0 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M ,a 30 Thyme Property Address Joe Lucier Owner Owner's Name information is required for every Osterville Ma 02655 11/21/2012 page. City/Town State Zip Code Date of.Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] F❑ Yes ® No Laundry system inspected? $ ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears us-age d 586 9 ( Y (gp ))� Detail 2010 196,000 2011 235,000= 586 GDP.. Dwelling is equipped with Irrigation. Sump pump? ❑ Yes ® No Last date of occupancy: occupied Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 30 Thyme Property Address Joe Lucier Owner Owner's Name information is required for every Osterville Ma 02655 11/21/2012 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Currently uccupied Date Other(describe below): General Information Pumping Records: Source of information: 2003, 2006, 2012 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records,'if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 iL Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments v1,y 30 Thyme Property Address Joe Lucier Owner Owner's Name information is required for every Osterville Ma 02655 11/21/2012 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: New LC,s and Distribution box installed in 2000 Were sewage odors detected when arriving at the site? ❑ ;Yes ® No Building Sewer(locate on site plan): Depth below grade: 1 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.): Septic Tank(locate on site plan): Depth below grade: 3 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ -No Dimensions: 1500 Gallons 6'x 6'x 10' Sludge depth: 1" t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r 30 Thyme Property Address Joe Lucier Owner Owner's Name information is required for every Osterville Ma 02655 11/21/2012 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 49" Scum thickness N/A Distance from top of scum to top of outlet tee or baffle N/A Distance from bottom of scum to bottom of outlet tee or baffle 33" How were dimensions determined? Observation Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Septic tank was pumped On 11/1/2012 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 15ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 30 Thyme Property Address Joe Lucier Owner Owner's Name information is required for every Osterville Ma 02655 11/21/2012 page. Ciityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction:' ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 30 Thyme Property Address Joe Lucier Owner Owner's Name information is required for every Osterville Ma 02655 11/21/2012 page. Cityrrown State Zip Code Date of Inspection D. System Information (cost.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Level to 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.): Distribution Box appeared in good working condition Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.) Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M 30 Thyme Property Address Joe Lucier Owner Owner's Name information is required for every Osterville Ma 02655 11/21/2012 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4 Type: ❑ leaching pits number: ® leaching chambers number: 3 ❑ 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.): S A S. Includes one 1500 gallon tank, One Dbox, And Three LC'S. Soil condition is ideal for leaching and leaching well. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth-top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal'8ystem•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments s e'r 30 Thyme Property Address Joe Lucier Owner Owner's Name information is required for every Osterville Ma 02655 11/21/2012 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of-construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 15ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y 30 Thyme Property Address Joe Lucier Owner Owner's Name information is required for every Osterville Ma 02655 11/21/2012 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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 ❑ drawing attached separately 26 d- a 34' a 0 0 O V Ff0#1 + (� t5ins-11110 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 16 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments wM 30 Thyme Property Address Joe Lucier Owner Owner's Name information is required for every Osterville Ma 02655 11/21/2012 page. City/Town State Zip Code Date of Inspection Q. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 20 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: 2000 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Obtained High water from reports and permits on file with the town of Barnstable Health Department ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: B.O.H. Reports and permits Before filing this Inspection Report, please see Report Completeness Checklist on next page.. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 30 Thyme Property Address Joe Lucier Owner Owner's Name information is required for every Osterville Ma 02655 11/21/2012 page. Cityfrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file ?5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 Y =, CO'MMONIVEALTH OF MASSACHLSETTS _ EkEcUTATE OFFICE OF E:�'VIR01A1E\TAL AFFAIRS = = F DEPARTMENT OF F;NmoNMENTAL PROTECTION ONE TINTER STP.EE . BOSTON hLA,02106 i61: 292-550v TRi DY COKE Secretary ARGEO PAIL CELLUCCI DAVID B STP.-uc Governor Cotnnussioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Prop"Address:30 Thome Lane , Osterville NameofOwner roe T,acier _ Address of owner: q C t aneti -r i H,..p T CH Wayland. Date of Inspection: —CDC r Name of Inspector:(Please Prirrt)Wm. E. Robinson Sr. I am a DEP approved systerta inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) CornpanyName: Wm. E . Robinson Septic Service Mailing Address: PO BOX 10 9. Centerville , MA Telephone Number: CERTIFICATION STATEMENT I certify that 1 have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: (/Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fails J ; - � r Inspector's Signature: [//� Date: 5 v The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty (30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original shouldbe sent to the system owner and copies sent to the buyer,if applicable, and the approving authority. NOTES AND COMMENTS A ct 0 • �1 1D 0D revised 9/2/9E Page Iof11 n i• ?ed on Rea•c;rd Pane, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) 'rope"Address: 30 Thyme Lane , Osterville owner: Joe Luc ier Date of inspection: V� 3 /�� INSPECTION SUMMARY: Check IA, I6, C, or D: � A. SYSTEM PASSES: 1 have not found any information which indicates that any of the failure conditions described in,310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. . COMMENTS: B. SYSTEM CONDITIONALLY-PASSES: Once'or more system components as described in the"Conditional Pass' section need to be replaced or repaired. The system, upon ompletion of the replacement or repair,as approved by the Board of Health,will pass. Indicate ye�, no,or not determined(Y. N,or ND). Describe basis of determination in all instances. If "not determined'.explain why not. The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attachedl indicating that the tank was installed within twenty(20)years prior to the date of the inspection: or the septic tank,whether or not metal,is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipets) or due.to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). s broken pipets)are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipets). The system will pass inspection if(with approval of the Board of Health): broken pipets)are replaced obstruction is removed i Y 1 , _e'v_sed 9/2/98 Page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 30 Thyme Lane, Osterville Owner: Joe Lucier Date of Impection: �.-,3_6 F-) C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing-to protect the public health,safety and the environment. 1) YSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CM1R 15.303 0)(b)THAT THE SYSTEM NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) THEIR } revise—,-; PaRc3oril SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM , PART A CERTIFICATION(continued) Property Address: 30 Thyme Lane , Osterville owner: Joe Luc ier Date of Inspection: <'_3_ 6 0 D. SYSTEM FAILS: You Mest indicate either "Yes" or"No" to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will bi necessary to correct the failure. Yes o Backup of sewage into facility-or system component due to an overloaded or-clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. _ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E. LA GE SYSTEM FAILS: You m t indicate either "Yes" or "No" to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone If of a public water supply well) The ow r or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 PageAor11 . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART B CHECKLIST 0 Thyme Prop"Address: 3 Lane , Osterv111e owner: Joe Luc ier Date of Inspection: e— 3- 03 0 Check if the following have been done:You must indicate either "Yes" or "No" as to each of the following: Yee No Pumping information was provided by the owner,occupant,or Board of Health. ✓ _ None of the system components have been pumped for at least two weeks and the system has been-receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. _ As built plans have been obtained and examined. Note if they are not available with N/A. ✓ _ The facility or dwelling was inspected for signs of sewage back-up. _ The system does not receive non-sanitary or industrial waste flow. . L� _ The site was inspected for signs of breakout. _ All system components,excluding the Soil Absorption System,have been located on the site. 12 _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction,dimensions,depth of liquid, depth of sludge,depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: t Existing information. for example,Plan at B.O.H. _ Determined in the field (if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) 11.5.302(3)(b)1 The facility owner(and occupants,if different from owner) were provided with information on the Propermaintanaaca-0f Subsurface Disposal Systems. r revised 0/2/98 Page 5of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION 'rop"Address:30 Thyme Lane , Osterville Owner: Joe Luc ier Date of Inspection: �5 w FLOW CONDITIONS RESIDENTIAL: �. Design flow: J { g.p.d./bedroom. Number of bedrooms(design): Number of bedrooms(actual): Total DESIGN flow .6 7 .�✓ _ Number of current residents:_ Garbage grinder)yes or no):;ji,0 Laundry Iseparate system) lyes or no):/Z'U: If yes,separate inspection required Laundry system inspected (yes or no) Seasonal use(yes or no):_A, 0 Water meter readings,if available(last two_year's usage(gpd): 1999 93, 000 gal. Sump Pump)yes or no): .:O 1998 49, 000 gal. Last date of occupancy: COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: qpd ( Based on 15.203) Basis of design flow Grease trap present: (yes of no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary.waste discharged to the Title 5 system: (yes or no)_ Water meter readings,if available: Last date of occupancy: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS ands urce of information: i7 9 System pumped as part of inspection: (yes or no) / c� If yes, volume pumped: gallons Reason for pumping: TYPE OF YSTEM Septic tankldi�tribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes, attach previous inspection records;if any) IIA Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed(if known)and source of information: Sewage odors detected when arriving at the site: (yes or no)L b revised 9/2 ,6E Page 6ofII ress: ane , Us erviiie Owner: Joe Lacier Date of Inspection: BUILDING SEWER: (loc)beti, site plan) Deptw grade:_ Mate construction:_cast iron_40 PVC_other(explain) Distaom private water supply well or suction line DiamCom :(condition of joints,venting, evidence of leakage,-etc.) SEPTIC IC TANK: (locate on site plan) 1 _ ' Depth below grade: Material of construction:_/concrete_metal_Fiberglass _Polyethylene_other(explain) If tank is metal,list age_ (sage confirmed by Certificate of Compliance_ (Yes/No) Dimensions: Sludge depth:_ Distance from top of sludge to bottom of outlet tee or baffle:Ll Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How dimensions were determined: :omments: (recommendation for pumping, condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) fit/ <'6- G 4 l ,,;L < " /tiv , G GR E TRAP: (locate n site plan) Depth b low grade:_ Material of construction:_concrete_metal_Fiberglass _Polyethylene_othe►lexplain) Dimens ons: Scum hickness: Dista ce from top of scum to top of outlet tee or baffle: Dis nce from bottom of scum to bottom of outlet tee or baffle: D e of last pumping: Corn ents: (re.co mendation for pumping, condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity, evid nce of leakage,etc.) =eviS'_d Page 7of11 . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) �ropertyAddress:30 Thyme Lane , Osterville Owner: Joe Luc ier Date of Inspection: 3 HT OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) (lo ate on site plan) Dep h below grade:_ Mat ial of construction: _concrete_metal_Fiberglass_Polyethylene_other(explain) Dime ions: Capac ty: gallons Desig flow: gallons/day Alarm present Alar level: Alarm in working order:Yes_ No_ Date of previous pumping: Co ments: (c ition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:y (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) - ,X, PUMP HAMBER:_ (locate n site plan) Pump in working order: (Yes or No) Alarm in working order(Yes or No) Comm nts: (note c ndition of pump chamber, condition of pumps and appurtenances,etc.) revised 9/2/98 Papc8of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 'roperty Address: 30 Thyme Lane , Osterville Owner: Noe Lusier Date of Inspection: s—3— / SOIL ABSORPTION SYSTEM(SAS): t/ (locate on site plan, if possible;excavation not required,location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits; number:_ leaching chambers,number: leaching galleries, number:_ leaching trenches,number, length: leaching fields, number, dimensions: overflow cesspool,number:_ Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.) t C POOLS:_ (locat on site plan) Numbe and configuration:_ Depth-to of liquid to inlet invert: 7epth of olids layer: .)epth of um layer: Dimension of cesspool:_ Materials o construction: Indication o groundwater: in ow (cesspool must be pumped as part of inspection) Comments: (note cond ion of soil, signs of hydraulic failure. level of ponding, condition of vegetation, etc.) PRIVY: (locate on site plan) Materials o construction: Depth of s lids: Dimensions: Comments: (note condi ion of soil, signs of hydraulic failure,level of ponding; condition of vegetation, etc.) revise .9 2;7E Peke 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Noperty Address:30 Thyme Lane , Osterville Jwner: Joe Luc ier .)ate of Inspection:,5' SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) 61 t J i j I revised 9/2/9? PaRv10of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) nVertyAddress: 3� Thvme Lane , Osterville Owner: Joe uc 1er Date of Inspection: I NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope . Surface water Check Cellar Shallow wells Estimated Depth to Groundwater�7 AFeet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site(Abutting property, observation hole, basement sump etc.) Determined from local conditions Checked with local Board of health _Checked FEMA Maps Checked pumping records Checked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) { I revise,: 9/2/98 Pape II of 11 T i , 6 t ' DATE: ,4/12/99 PROPERTY ADDRESS; " 30 T-hyme Lane Osterville ,Mass . 02655 On the above date, I Inspected they "Ptic eystom at the above address. This system conalsts of the following: 1 . 2-6 ' x8 ' b16ck cesspools ' 2. 1-1000• gallon precast leaching pit . Baead bn my Into- ctlon, I cerilfy the following conditions: 3. This is . riot a title' Five SepticcSyst'.•dw! r 4 . This is a sewage 'system•. That •is ' in proper working~ order at the present . - 5. Rec: -That "theT—two cesspools be pumped , t 81GNATUR Name . J P . }{_acomber . r_,_ • i Company'_J• P .Macoigber b ;on—'Inc ,, •; � , R 2 3 1999 10 __C e n �_p r v,� 1 L e �,}L�,s,,y,;_Q 2 b 32 •' '10N1��g,za • 9 THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY SOSEPH P, MANMBER '& SON; -IN C , T+nk+-C�upo0 "',ch(I0'da Pumped L In3lall►4 ' 'town Siwor Connection; P.O. Box 66' Centerville, MA 02632.0066 77.5-3358 7764412 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 292.5500 TRUDY CORE Secretary ARGEO PAUL CELLUCCI DAVID B. STRUHS Governor Con ntissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address:3 0 Thyme Lane Name of Owner John Jefferson Osterville ,Mass . 02655 Addressofowrw: 30 T vme Lane Data of Inspection: 4/12/93 Osterville ,Mass . 02655 Name of Inspector:(Please Print) o s e n h P-M a n o m b e r Jr . I am a DEP oved system inspector pursuant to Section 15.340 of Tittle 5(310 CMR 15.000) Company Name: J.rM a c o m b e r & Son Inc . MaMngAd&&": Rnx 66 ('.pntagir oIMass . 92632 Te+eptane Number: 5 0 8-7 7 5-113 R CERTIFICATION STATEMENT I certify that I have personally Inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The Inspection was performed based on my training and experience in the proper function and maintenance of Viteswage disposal systems. The system: asses Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails Inspector•sSignature:114.41 Date: The System Inspector all submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty (30) days of completing this Inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner 'shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should'be.sent tovm system owner and copies sent to the buyer, if applicable, and the approving authority. NOTES AND COMMENTS revised 9/2/98 Page Iof11 0 A . t, Printed on Recycled Piper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICA71ON (cont4wed) Property Address: 30 Thyme Lane Osterville ,Mass . OwT'w- John Jefferson Date of Inspection: 4/1 2/9 9 INSPECTION SUMMARY: Check A, A C, o/ A A. SYSTEM PASSES: r I have not found any Information which indicates that any of the failure conditions described In 310 CMR 1-6.303 exist. Any failure criteria not evaluated are Indicated below. COIMME)M: B. SYSTEM CONDITIONALLY PASSES: �y One or more system components as described In the 'Conditional Pass' section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes,no,or not determined(Y, N. or NO). Describe basis of determination In all Instances. If 'not determ ned', explain why not. The septic tank Is metal, unless the owner or operator has provided the system Inspector with a copy of a Certificate of Compliance(attached)Indicating that the tank was installed within twenty(20)years prior to the date of the Inspection; or the septic tank, whether or not metal,Is cracked,structurally unsound, shows substantial Infiltration or exfihration, or tank failure Is Imminent. The system will pass Inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Aloltp Sewage backup or breakout or high static water level observed in the distribution box Is due to broken or obstructed pipe(*) or due to a broken, settled or uneven distribution box. The system will pass Inspection if(with approval of the Board of Health). broken pipe(*) are replaced obstruction Is removed distribution box Is levelled or replaced �(✓(� - The system fsquired pumpMg•moTe than•fourZfines a yeardue to broken or obstructed pips(s). The ryrtem W*-pvsr- Inspection if(with approval of the Board of Health): - broken pipes) are replaced obstruction Is removed revised 9/2/98 Page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) NoWWAddress: 30 Thyme Lane Osterville Mass . Owner: John Jefferson D:te of'&P—ion' 4/12/9 9 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 falling to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES W ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTE IS NOT FUNCTIONING W A MANNER WHICkjyALLPRa=CT THE PUBUC 8EALTH.AND SAFETY AND THE MLBONMEKT: D Cesspool or privy is within 60 feet of surface water Cesspool or privy Is within 60 feet of a bordering vegetated watland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBUC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM C FUNCTIONING IN A MANNER THAT PROTECTS THE PUBUC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system(SAS)and the SAS Is within 100 feet of a surface water supply or tributary to a surface water supply. /U The system has a septic tank and soil absorption system and the SAS Is within a Zone I of a public water supply wall. The system has a septic tank and soil absorption system and the SAS Is within 60 fast of a private water supply weU. The system has a septic tank and soll absorption system and the SAS Is less than 100 feet but 60 feet or more from a private water supply well,unless a well water analysis for collform bacteria and volatile organic compounds indicates that t) well Is free from pollution from that facility and the presence of smmonia nitrogen and nitrate nitrogen Is equal to or less than 6 ppm. Method used to determine distance(approximation not valid).- 3) OTHER e revised 9/2/98 Page 3of11 a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:30 Thyme Lane Osterville ,Mass . Owner: John Jefferson Data of Inspection: 4/12/9 9 D. SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: A/0 I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No _ Backup Of-sewage into fscili"r•system component-due tto an overloaded orclegged-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. N17j"E_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times In the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is-within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for »coliform bacteria, volatile organic-compounds, ammonia nitrogen-and nitrate nitrogen. - E. LARGE SYSTEM FAILS: 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: The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No &A the system is within 400 feet of a surface drinking water supply NA the system-is-within 200 feet of-e-tAWtsry-to a eurfaoel6okiwg•water-6upply r the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area:IWPA) or a mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further infor nation. revised 9/2/98 Page 4orn P SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST 30 Thyme Lane Osterville Mass . Property Address. Y r Owner: John Jefferson Date of Inspection 4/12/9 9 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No A Pumping information was provided by the owner,occupant,or Board of Health. -None of the systemxorrmwasnt.s hamsJ3san puaiped4oFatJeast two xveWw and•the-rystem has lawwwacaiwag wAw".flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. tom�/l All system components,i�Cluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered,opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions,depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System orrthe site has been determined based on: _ Existing information. For example, Plan at B.O.H. _ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) — [15.302(3)Ibq The facility owner.(and.occupants,If diffaraW from-owned.werapraxided.with iaf,="oann t_ impLu maintenaac&of SubSurface Disposal Systems. revised 9/2/98 page sorli 1 ( I I l SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 30 Thyme Lane Osterville ,Mass . Owrw: John Jefferson Data of kupec&)n: 4/12/9 9 FLOW CONDITIONS RESIDENTIAL: Design flow: UZ g.p.d./bedro m. si n : Number of bedrooms(actual): Number of bedrooms Ida )� _ Total DESIGN flow ' Number of current resi�.�+ Garbage grinder(yes or no):-ITP Laundry(separate system) ( es or no)*h If yes, separ-I Jnspectlon.required Laundry system Inspected yes or no) Seasonal use (yes or no): g�rt Water meter readings,If available (last two year's usage(gpd): 1;q0- ZIA Sump Pump(yes or no): j' %�• � Last date of occupancy: '+ COMMERCtALANDUSTRIAL• 11 Type of establishment: r /ITL Design flow: V avd ( Based on 15.203) Basis of design flow Grease trap present: (yes or no) Industrial Waste Holding Tank present: (yes or no)Zf ,9 Non-sanitary waste discharged to the Title 5 system: (yes or no)Z Water motor readings,if available: Last date of occupancy: AM OTHER:(Describe) IVA Last date of occupancy: A GENERAL INFORMATION PUMPING RECXM,.u�810"7 so �r ad ,/1/i�,w�'`lrZL System pumped as part of inspection: (yes or no)� JJIi'I��L/ ,/l� � ./ If yes, volume pumped: gallons Reason for pumping: �l TYPE OF SYSTEM Septic tank/distribution box/soil absorption system Single cesspool I _ Q-00 A&W cesspool Ot9ki►►{1,Db0 A)1 Privy Shared system(yes or no) (if yes, attach previous Inspection records,if any) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank NA Copy of DEP Approval Other A�, XI TE;QGE of all components, date Installed{if known)-and source o{enf mation: -� �'� 'f�/ / - -!JITL��,q4 " 'rS SowbW odors detected when arriving at the site:(yes or no)� revised 9/2/98 Page 6of11 P SU8SURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) ProponyAcickss:30 'thyme Lane Osterville ,Mass . Owrw: John Jefferson Date of Inspe n: 4/12/9 9 BUILDING SEWER: (Locate on site plan) Depth below grade: Material of construction �ast IV in 40 PVC_other(explain) 1 r• I Distance from�ri ate wat r supply well or suction line�_ Diameter Comments: (condition of joints,venting,evidence of leakage,-etc.) — Joints gp pa_ r right, Uo nlridehse e€ leakage SE C TANK: (locate on site plan) Depth below grade: Material of construction:NQconcrete4�l etaLoV4FiberglassN&Polyethylene//,dother(explain) 1 If tank Is (natal,list ages• Js.age.confumed by Certificate of Compliance (Yes/No) Dimensions: Sludge depth: VA Distance from top of sludge affl ge to bottom of outlet tee orbe: r>f� Scum thickness: /r Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle:, A14 How dimensions were determined: AW Comments: (recommendation for pumping,condition of Inlet and outlet tees or-baffles, depth of liquid level In relation to outlet invert, structura"ntegrity, evidence of leakage, etc.) Pump main CPRRp nn1 g nnrl tenth ragcp•nn1 Aver ?-Tears Septic tank is net prasant GREASE TRAP: (locate on site plan) Depth below grader Material of construction,.AJJ%oncrate4fimetalWiberglassN Polyethylene4other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle:VJ Distance from bottom of sc m to bottom of outlet tee or baffler Date of last pumping: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert. structural integrity, evidence of leakage,etc.) Greasp trap i g not i scant revised 9/2/98 Page 7of11 I , 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Prop"Addre-1:30 Thyme Lane Osterville ,Mass . Owner: John Jefferson Data of Inspection: 4/1 2/9 9 TIGHT OR HOLDING TANK: !� (Tank must be pumped prior to, or at time of, inspection) (locate on site plan) Depth below grade: VA Material of construction:NA concrete 41Ametal&FiberglassAAPolyethyleney4other(explain) Dimensions: AN ~ Capacity: '/d gallons Design flow: A,'V gallons/day Alarm present NA Alarm level: 4 Alarm in working order:YesWh NoV#9 Date of previous pumping: Vtj Comments: (condition of inlet tee, condition of alarm and float switches,etc.) Tight or holding tanks aRF NOT PRF4FNT _ DISTRIBUTION BOX:4,)4111Q, (locate on site plan) Depth of liquid level above outlet invert: Comments: (note-if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) Distribution box is not :scant PUMP CHAMBER:—AbVe, (locate on site plan) Pumps in working order:(Yes or No)1N A Alarms in working order(Yes or No) 1 Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) Pump rhamher is not Pgosent - revised 9/2/98 Page 8of11 I -j SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 30 Thyme Lane Osterville ,Mass . Owner: John Jefferson Date of Inspection: 4/12/9 9 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan, if possible; exca ation not required,location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits,number: leaching chambers, number: leaching galleries,number: leaching trenches,number,length: leaching fields, .number, dime sions: overflow cesspool,number:, Alternative system: A2A A Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.) Loamy sand to bo.ney tine san o signs o y rau ie failure or ponding soil is dry - Vegetation is normal _ CESSPOOLS: (locate on site plan) 1 ✓� Number and configuration: Depth-top of liquid to inlgt jnvert: 16" !.tl awl" Depth of solids layer: ((!! Depth of scum layer: 74 if Dimensions of cesspool: Materials of construction: iZ Indication of groundwater: inflow (cesspool must be pumped as part of inspection) 0 One cesspool was ry . No signs water intrusion . , Comments: (note condition of soil, signs of hydraulic failure,.level of ponding,condition of.vegetation, etc.) Same as above PRIVYA'iVe' (locate on site plan) Materjals of construction:_ Dimensions: �Lo! Depth of solids:�� Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation;etc.) Privy is not present , revised 9/2/98 Page 9of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(con*x-d) PropeMAddra": 30 Thyme Lane Osterville ,Mass . Ownw: John Jefferson. DZU of 4uwcd«* 4/12/9 9 SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where publlc water supply comes Into house) 20 TgyMe N sfea,lle � I i Z. a � 3 tb �/ frQrJ* 3� Z O � QAcK 4y o revised 9/2/98 Page 10of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) PropertyAd&—: 30 Thyme Lane Osterville ,Mass . Owf1 : John Jefferson Data of Inspection: NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep _ SITE EXAM Slope Surface water Check Cellar Shallow wells i Estimated Depth to Groundwater Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record -j'Abserved.Site(Abutting propertybservation hole, basement sump etc.) L,�etermined from local conditions Checked with local Board of health _Checked FEMA Maps / t/ Checked pumping records Checked local excavators,installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) Installed leachin pit 1980 Used Gahrety & Model 12/16/94 revised 9/2/98 Page 11of11 RRT.—R t'Rr-T-1RITJIR'AiSRJ'STTl i'SfT.lTltiSlPSTTTlTRRRR.TILTR�J I1T�TtCr IT1 TOWN OF Barnstable BOARD OF HEALTH 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSi'FCTION FORM - PART D •- CERTIFICATION `� �"•Tt•t-T••,•t: —T..IT.�...:rTtm TSn•.f.'tSi T�TIC.aT.Irr•.r.rf :--.t•r+1Vs+11artnvr"TT+n'RvnY fi�TRSTrTsrs rsm nImrler.iptrr.-rrl+-•.+.rrr•r-•�. .-..� -TYPE OR PRINT CI.EARLY- PROPERTY INSPECTED STREET ADDRESS 30 Thyme Lane Osterville ,Mass . ASSESSORS MAP , BLOCK AND PARCEL # OWNER' s NAME John Jefferson PART D - CERTIFICATION r NAME OF INSPECTOR Joseph P.Macomber Jr . COMPANY NAME J. P.Macomber & Son In'c COMPANY ADDRESS Box 66 Centerville ,Mass . 02632 Street Town or C1ty State LIp COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX (508 ) 790 - 1578 - i CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate ) and complete as of the time of ,inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one : �Syst_e66 PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public Health or the environment as defined in 310 CMR 16 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. System FAILED* The inspection which I have con ilcted has found that the system fails to Protect the ilublic health and the environment in accordance with Title 6 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection orm Inspector Signature Date One copy of this certification must be provided to the OWNER, the BUYER ( where applicable ) and the 130ARD OF HBAL1'II. * If the inspection FAILED, the owner or"" 'Perator shall upgrade ' the system within one year of the date of the inspection, unless allowed or required otherwise as provided in 3.10 CMR 16 . 305 . partd .doc TOWN OF B ARNSTABLE �/i Co, e ' Q LOCA i JN f��v f9�1 SEWAGE # ��O `3 VILLAGE 0--i 2 ASSESSOR'S MAP & LOT f , ov INSTALLER'S NAME&.PHONE NO. ci�s SEPTIC TANK CAPACITY LEACHING FACILITY: (type (size)�o� �`7T NO. OF BEDROOMS BUILDER OR OWNER Z y C i LIZ, PERMITDATE: � '!3 � COMPLIANCE DATE: —Cs-� Separation Distance Between the: Maximum Adjusted Groundwater Table and Botto f Leaching Facility Feet Private Water,Supply Well and Leaching Eaci ' (If any wells exist on site or within 200 feet of leaching fac ry) - ` Feet Edge of Weiland and Leaching Facilitys any>.wetlands exist - �= within 300 feet of leaching facility) ,.< � Y�,Feet ` Furnished by v h, adk - OI rA 1 30 TgYme PN Sferf/rIle 3 I z_ Fr0N7' cb / q Li o a� aAClc 0 No. 4L zr Fee $50 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZippYication for Mtg;pogar *pgtem Con.5trurttou Permit Application for a Permit to Construct( )Repair(X )Upgrade( )Abandon( ) �Kcomplete System O Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. 30 Thyme Lane , osterville Joseph Lucier Assessor's Map/Parcel /!5—o.Op e g S t onebr id.ge Rd. , Wayland., MA Installer's Name,.Address,and fToel.No. Designer's Name,Address and Tel.No. Wm. E.(Robinson Septic Service P 0 Box/1089, Centerville Type of Building: Dwelling No.of Bedrooms 4 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 Sand Nature of Repairs or Alterations(Answer when applicable) New Title-5 s e pt ii) system. Tank, D-box and. 3 leach chambers with stone all around.. 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 not to place the system in operation until a Certifi- cate of Compliance has been issued by this B d o ealth. -a Signed Date Application Approved by <F e Date Application Disapproved for the following reasons Permit No. Date Issued No. 9— ` ��..�.:i ::-� Fee / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ✓ Yes ` 'PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS 01ppYication for �Nopoal *pgtem Con.5truction Permit Application for a Permit to Construct( )Repair(X )Upgrade( )Abandon( ) Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. 30 Thyme Lane, Osterville Joseph Lucier Assessor's Map/Parcel 9 S t onebr idge Rd. , Wayland, NIA Installer's Name Address,and Tel.No. Designer's Name,Address and Tel.No. Wm. E. ,opinson Septic Service P 0 Box' 1089, Centerville Type of Building: Dwelling No.of Bedrooms 4 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 T Description of Soil Sand Nature of Repairs or Alterations(Answer when applicable) New Title-5 Sept* system. Tank, D-box and 3 leach chambers with stone all ar"ound. 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 d not to place the system in operation until a Certifi- cate of Compliance has been issued by this B d earth. Signed Date/ Application Approved by e Date Z l j— I Application Disapproved for the following reasons r ! Permit No. Date Issued --- AS- _. C G 9 THE COMMONWEALTH OF MASSACHUSETTS , BARNSTABLE, MASSACHUSETTS Lucier certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( X )Upgraded( ) Abandoned( )by Wm. E . Robinson Septic Service at 30 Thyme Lane , Os eryi le has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 99- dated ' l 1- 93/ Installer Wm.kA. Robinson Sr. Designer The issuance olf"this permit shall not be construed as a guarantee that the system will function as designed. Date - 1_ ta, Inspector .F--------- -- — — =--- —— No. .... ! (�,.,ay,�y�e„°� /�, ———l——__F4 5 0 —c,— / G 5 -OO y THE COMMONWEALTH OF MASSACHUSETTS Lucier PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS �,iopo�al *pgtem �Con!aruction Permit Permission is hereby _ranted to Construct( )Re�air( X� pgrade( )Abandon( ) System located at 3- Thyme Lane , Os ervi e 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 mut.16 - Date: Z 3` /, Approved by�iM. , 116/99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) r William—E . Robinson,S,rhereby certify that the application for disposal works construction permit signed by me dated f n- 9 concerting the property located at meets all ofthe following criteria: • The failed systemJjis connected to a residential dwelling only. There are no commercial or busi s uses associated with the dwelling.• ' The soil is classP P ed as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. t • There are no wetlands within 100 feet of the proposed septic system t • There are n private wells within 150 feet of the proposed septic system • There is increase in flow and/or change in use proposed, • Ther are no variances requested or needed_ • The bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] • If the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed leaching facility will not be locaied less than fourteen(14) feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) 3 Bj G.W. Elevation +the MAX. High G.W. Adjustment DIFFERENCE BETWEEN A and B .3 SIGNED : z. :✓ DATE: [Sketch proposed plan of system on back]. q:health folder:cen --------- , 1 +,J i . I I I ; , I t I I I i 4 I I I Io ' I i } : t I I ; I r I � I i Q I I ; .iy i I yy �l I 1 I I —_ •ems 1 ' 13O ( � � �� I i LOCATION SEWAGE PERMIT NO• VILLAGE INSTA_LLE 'S NAME i ADDRESS e UILDER OR OWN ER lice DA T E PERMIT ISSY E D DAT E COMPLIANCE ISSUED L H1 �� OLD Cass pool g - No....... ....... Fica...�.....®...... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH _..._70. 1P.....oF... 2�'.Y� 1 ............................. Applira Linn for Binpnsal Works Tat. trur#inn Orrmit Application is hereby made for a Permit to Construct ( ) or Repair (x) an Individual Sewage Disposal System at: 310-.�1h.941.7c... .............. ................ .... ..............._ tion- ddress r Lot No. ... r 1.. .j)lcr.................................. .......--- - .............. Owner ress ------------------------------------------- a S. � ... - Installer Address Type of Building Size Lot............................Sq. feet �., Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) pi Other—Type of Building ............................ No, of persons............................ Showers ( ) — Cafeteria ( ) 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. ft. Z Other Distribution box ( ) Dosing tank.( ) $4 Percolation Test Results Performed by.......................................................................... Date........................................ � 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........................ ........................... O Description of Soil L.aCY l(C�1 L1�!_ •---•-------------------------------------- -------------------------•-----•------------ x w x •••••••---••..........................••-••----•...••-••-•-•-••-•-•-•••-•-••••-------•••--•••••••••--------•----••-•..._....----••-••-------••••--•• ._..•.........••..... ...-••••---•----•-••-•- U Nature of Repairs or Alterations—Answer when applicable.......�__-��Z,0..��Q,C�...._P-/'- _ ........................ ------....-•--------------------------•-------------------•--------------------.........------..............-------------------------------------------------------------------------•............•••••• Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of L I':Li; 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has issued b the b and f 1 lth. p / !r Date Application Approved By -•- . .................................. lz��--------- Date Application Disapproved for the following reasons:..........................................................................................•-•-••............_ ..............•---........-•------•------...........----------....-----•---------...----•--•-•---•------•-••-••-•----•----•-•---•-••••--•-•-•••-••------•-•••••---•••••••------•--••-••--••---------••. Date Permit No.......................................................... Issued-- P-- ..�... - Date THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINALS) A �C(�J-MC DATA 4. No.._....1�1.:........ FEB............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ' ......_... Appliratinn for Disposal Works Corm rnrfiun runtit Application is hereby made for a Permit to Construct ( ) or Repair (V) an Individual Sewage Disposal System at: -T- _--• _. .............•----•--•---•-••-••••----......_--••-- i Location-Address \ or Lot No. c Owner Address . • . 3 f i ffi'/, ` > .� ?"_V i /t - ,f r�r" i7s dc ,a -----•••-•-•--•-•-•,-...........................------ -- - .. � Installer Address 31 Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) `4 Other—Type T e of Building p� yp g ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther 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. ft. z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results .;Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ �Z, Test Pit No. 2................iminutes per inch Depth of Test Pit.................... Depth to ground water........................ D Description of Soil . "..._-,.,...... ..�..-•••-•----`---•----•--•------------------------------------------------.... •--.... ------.... ------•---- x r' U .______________________________________lt__.__._.---------------------.---------------____----------------------------------------------------------------------......------ ...___......____._____._____. W ________________________________________________________________________________________________________________________________________................................................................ U Nature of Repairs'or Alterations Answer when applicable________________________________......f____..................:._-t____.___________._.._____. n - -•-- -....................-........................................................................................-................................................................. Agreement: ' The`undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITL 5 of the State Sanitary Code— The"undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued: issued? the b ard�of Jealth. Si ed ' ... .......................... .... Date „ A lica.tion A roved B .. �- PP PP Application Disapproved for,the following reasons---------------------------•--------•-------•---------------••-------------••-•----------•DaYe._....._••-_.. .......................................t----------'"`=` -...--•---••------._... ..---....------•---------------------------=•-----.---------------------------------------=--------------•-------- . 3, Date PermitNo........-................................................ Issued...................................................... Date THE COMMONWEALTH�OF�MASSACHUSETTS �ft BOARD OF-HEALTH ...............................r.........OF................. .................................... T rtiftratr of Tomplianrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( f ) by...... f_....-------•--'•••. ---•-- --------------• i y - _.•- ;' Installer at......-.............. - , , 1 /- I• has been installed in accordance with. the provisions of TIT . ' 5 of The State Sanitary Code as descriej in the '__l� application for Disposal Works Construction Permit No.. _ __ �____________________ da.ted_._.3�.... �.�_ ............ THE ISSUANCE OF,HIS CERTIFICATE SHALL ®T E�COfN RUED AS A GUARANTEE THAT THE SYSTEM WILL.FUNCTION-SATISFACTORY. / DATE....... ..... .._ -----••--._....--_. Inspector r _.. ' Z n •" ..� .. .� }.. - 5.§Mai j THE COMMONWEALTH OF MASSACHUSETTS ` BOARD OF HEALTH .... ._. OF. y . .....!i Z. . .. . ................................. FEE._..:%.. Dispoal- orkv Tonotrnrtuan rrrmit - Permission,-is hereby granted....-------f---_ ...........................:........................................................ to Construct ( ) or Repair (,v) an Individual Sewage Disposal System at No........_/ /a/!i( r:....__J//e/'._.__......_t I.._ !/ {�! r fr^ /✓�/ �j' -`" •--- ............ Street as shown on the application for Disposal Works Construction Per it N .__ e It ___ Dated.___ ? ------------------- I - Board of He2ftV DATE..-. ':/ '.. a.......................................... FORM 1255 HOBBS-& WARREN, INC.. PUBLISHERS _ - - ,