HomeMy WebLinkAbout0091 WIANNO AVENUE - Health 91 WIANNO AVENUE
Osterville
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Commonwealth of Massachusetts
�m Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments i t
91 Wianno Ave
V�
Property Address
John and Joan Connolly, TTEES
Owner Owner's Name� / y
information is
required for every Osterville V NIA 02655 08/10/2020
page. City/Town State Zip Code Date of Inspection ;
es
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:
forms When
fillip out f A. Inspector Information �'/ ILI�(a
f
on the computer,
use only the tab Michael T Bisienere
key to move your Name of Inspector
cursor-do not Cape Septic Inspections
use the return Company Name
key.
52 Rivers End Road
Company Address
Teaticket Ma. 02536
Cityrrown State Zip Code
508-280-3356 S13938
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system 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 form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: 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.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
Commonwealth of Massachusetts
�e Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u�
91 Wianno Ave
Property Address
John and Joan Connolly, TTEES
Owner Owner's Name
information is Osterville MA 02655 08/10/2020
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) 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:
This 3 bedroom ihome has a main cesspool feeding a precast leaching pit with stone. At the time of
the inspection no visible failure criteria was found. The main cesspool was pumped after the
inspection.
2) 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):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
91 Wianno Ave
Property Address
John and Joan Connolly, TTEES
Owner Owner's Name
information is required for every Osterville MA 02655 08/10/2020
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ 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):
3) 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.
a. 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:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form.
5 1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
91 Wianno Ave
Property Address
John and Joan Connolly, TTEES
Owner Owner's Name
information is required for every Osterville MA 02655 08/10/2020
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cost.)
❑ 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
b. 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.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
M 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
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
l
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u
91 Wianno Ave
Property Address
John and Joan Connolly, TTEES
Owner Owner's Name
information is required for every Osterville MA 02655 08/10/2020
page. City[Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® 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
El ® 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 water supply
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 2000 gpd-
10,000 gpd.
❑ ® 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.
5) 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 CA.
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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
is Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
91 Wianno Ave
V
Property Address
John and Joan Connolly, TTEES
Owner Owner's Name
information is required for every Osterville MA 02655 08/10/2020
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (bout.)
If you have answered "yes"to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate "yes" or"no"for each of the following for all inspections:
Yes No :
i
® ❑ 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)]
i
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
91 Wianno Ave
V
Property Address
John and Joan Connolly, TTEES
Owner Owner's Name
information is Osterville MA 02655 08/10/2020
required for every ,
page. Cityrrown State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
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 plus
Description:
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonaluse? Yes ❑ No
Water meter readings, if available last 2 ears usage town water
9 ( Y 9 (gpd))�
Detail:
In 2019-245,000 gallons were used and in 2018-198,000 gallons were used
Sump pump? ❑ Yes ® No
Last date of occupancy: occupiedDate
i
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u � 91 Wianno Ave
Property Address
John and Joan Connolly, TTEES
Owner Owner's Name
In is
requiredaired for every Osterville MA 02655 08/10/2020
for
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
2. 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
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: Inspector
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: 1000
gallons
How was quantity pumped determined? drivers.estimate
Reason for pumping:
To check the structural integrity
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18
AN
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
� 91 Wianno Ave
Property Address
John and Joan Connolly, TTEES
Owner Owner's Name
information is Osterville MA 02655 08/10/2020
required for every ••
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
4. 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):
Main cesspool feeding a leaching pit
Approximate age of all components, date installed (if known) and source of information:
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 24"feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: town water
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Water was flushed and came freely.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18
' I
Commonwealth of Massachusetts
Title 5 official Inspection Form
15 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u—
91 Wianno Ave
Property Address
John and Joan Connolly, TTEES
Owner Owner's Name
information is required for every Osterville MA 02655 08/10/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, liist age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined?
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
I
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u-
91 Wianno Ave
Property Address
John and Joan Connolly, TTEES
Owner Owner's Name
information is required for every Osteryille MA 02655 08/10/2020
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
i
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
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. 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
t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts
�� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
91 Wianno Ave
Property Address
John and Joan Connolly, TTEES
Owner Owner's Name
information is required for every Osterville MA 02655 08/10/2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
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.):
i
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert WA
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.):
I ran a camera down the pipe and did not see a D-Box.
I
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
I? Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
91 Wianno Ave
Property Address
John and Joan Connolly, TTEES
Owner Owner's Name
information is Osterville MA 02655 08/10/2020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No"
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
r
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
® leaching pits number: One
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
I ❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
i
r
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
`1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
f,
91 Wianno Ave
Property Address
John and Joan Connolly, TTEES
Owner Owner's Name
information is required for every Osterville MA 02655 08/10/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
At the time of the inspection no visible failure criteria was found.
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration One- Round
8„
i
Depth—top of liquid to inlet invert
Depth of solids layer
5"
Depth of scum layer
Dimensions of cesspool 6 X 6
Materials of construction Block
Indication of groundwater inflow ❑ Yes ® No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
At the time of the inspection the liquid level was at working level.
t5insp.doc-rev:7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
!� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
91 Wianno Ave
Property Address
John and Joan Connolly, TTEES
Owner Owner's Name
information is Osterville MA 02655 08/10/2020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. 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.):
I
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
f
4
`-. Commonwealth;of.Massachusetts -
4 .
�Titie 5 -Offi'cial"Insobction Form
'- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
91 Wianno Ave
Property Address
John and Joan Connolly, TTEES
Owner Owner's Name
information is required for every Osterville MA 02655 08/10/2020
page. City/Town State Zip Code Date of Inspection
D. System Informaton'(cont:)
14. 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:
',Z-,.hand-sketch in the area below ;
0 drawing attached separately
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t5 nsp.doc•rev.726/2018 ,T' Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
Commonwealth of Massachusetts
Title 5 Official' Inspection Form
l; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
91 Wianno Ave
V�
Property Address
John and Joan Connolly, TTEES
Owner Owner's Name
information is required for every Osterville MA 02655 08/10/2020
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: 12 plus feet
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
I augered a hole at a lower elevation and shot it with a transit.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
}IQ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
>r;
u-
91 Wianno Ave
Property Address
John and Joan Connolly, TTEES
Owner Owner's Name
information is Osteryille MA 02655 08/10/2020
required for every
page. Citylrown State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1;2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist)completed
® D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18
tin 27'1411:35a p.1
Commonwealth of Massachusetts l
--9 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
91 Wianno Ave
Property Address ,
John and Joan Connolly
Owner Owners Name
information is Osterville MA 02665 6-24-14 _
required for every _ ____—
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. General Information
filling out forms n ( �V MkI1ulrFill/z�v
on the computer, / L ���� �HOF U4
use only the tab 1 Ins actor.
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key_ .*:•
CapewideEnterprises,LLC ,�..o��__�,�a.:��a _
Company Name �zF 5 I N SPEG�������
153 Commercial Street '�nr„ tall I
,
Company Address
Mashpee MA 02649
City/Town state - Zip Code .
508-477-8877 S 1623
Telephone Number License Number
i
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. 1 am,a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 115.000).The system:
® Passes f ❑, Conditionally.Passes• ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
6-27-14
pec t&s Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000.gpd or greater,the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP.The original should be sent to the system owner
and copies sent to the buyer, if applicable,and the approving authority.
4
"""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'-3113 Title 5 Official Inspeca Fo S sutfaoe Barrage Dis al System•Page 1 of 17
i,
Aln 271411:35a p.2
,
Commonwealth of Massachusetts
Title 5 Official Inspection Form-
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
91 Wianno Ave
Property Address
John and Joan Connolly
Owner Owner's Name
information is Osterville MA 02665 6-24-14
required for every
page. Ctyrrown State Zip Code Date of inspection
B. Certification (cont.)
Inspection Summary. Check A,B,C,D or E 1 always complete all of Section D
A) System Passes:
® 1 have not found any information which indicates that any ofthe.failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below_
Comments: i
Garbage Disposal
4 ,
B) System Conditionally Passes:
D One or more system components as described in the"ConditionalPass"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.
0 Y ❑ N, ❑ ND (Explain below):
Gins=3J13 - rdk 5 Oland Inspection Form:Subsurface sewage Dismal system-Page 2 of i7.
Jun 271411:35a p.3
Commonwealth of Massachusetxts
Title 5 Official Inspection Forr
Subsurface Sewage Disposal System'Form-Not for Voluntary Assessments
91 Wianno Ave
Property Address
John and Joan Connolly
Owner Owner's Name
information is MA 02665 6-24-14
required for every Osterville
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumpstalarms not operational. System will pass with Board of Health approval if
pumpstalarms are repaired.
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 accordancewith 310 CNIR
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
'ts.ns-.3rta.. Title 5 OfF.dal InspedDri Form:Subsurface Sewage Disposal System•Page 3 0117
Jun 271411:36a p.4
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
- 91 Wianno Ave
Property Address
John and Joan Connolly
Owner Owner's Name
information is required for every Osterville MA 02665 6-24-14
page- Cityrrown 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 systenn has a septic tank and.SAS and the SAS is,within 50 feet of a private water
supply well. "•i .
ti ❑ 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 ata 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
4 ❑ ® Discharge or popding 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
El ® Liquid depth in is less than 6'below invert or available volume is less
than'%day P�T flow -
t5uis,•8113 Title 5 Official Ins ection Form Suhwfaoe_ P Sewage 0isposal5ystem-Page 4 of 17
Jun 271411:36a p.5
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
91 Wianno Ave
Property Address ar.
John and Joan Connolly
Owner Owner's Name
information is required for every Osterville MA 02665 6-24-14
page. Cityrrown State Tip Code Date of Inspection
B. Certification (cost.), I
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ IN 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.
❑ JZ 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 wetl 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-
10,0009pd.
❑ 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 10 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 ..
.^r
❑ ❑ 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
1f 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.
15 ns•3f13 i Title 5 Official Inspecdon Form Subsurface Sewage Disposal System•Page 5 of 17
Jun 271411:36a p.6
Commonwealth of Massachusetts
Title 5 OfficialInspection Form
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
91 Wianno Ave
Property Address
q. e.
John and Joan Connolly
Owner Owner's Name
information is required for every Osterville MA 02665 6-24-14
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been,done: You must indicate"yes'or"no"as to each of the following:
J. Yes No .
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were anyrof the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
El
® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ElWere 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?
9 ❑ Were all system components, excluding the SAS, located on site?
im ❑ 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,
I dimensions,depth of liquid,depth of sludge and depth of scum?
Cl ® 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 of 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): NA Number of bedrooms(actual): 3
DESIGN flow based on 310,.CMR 15.203(for example: 110 gpd x#of bedrooms):
330
` Isiric Z 21.13 Till.6 ORdawl In.Fmc n Form:liubaurfxo Sowyo Oi:pood 6yolom-Pago 0 of'7
Jun 271411:36a p.7
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
91 Wianno Ave
Property Address
John and Joan Connolly
Owner Owner's Name
information is Osterville MA." 02666 6-24-14
required for every
page. City/Town State Zip Code Date of Inspection
D. System information
Description:
The system is a c.pool and pit
Number of cu
r;rent resident
s': ...
21
I Does residence have a gart�age grinder? ® .Yes ❑ No
Is laundry on a separate sewage system? (Include laundry system inspection Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes Z No
2012-230,000Gai
Water meter readings, if available(last 2 years usage(gpd)). 2013-206,000Gal's
Detail: f
t
Sump pump? El Yes ® No
Last date of occupancy: Present
s Date
CommerciaUlndustrial Flow Conditions:
t
Type of Establishment:
Design flow(based on 310 CMR 15.203): ;Gallons per day(gpd)
Basis of design flow(seatslpersons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present?. ❑ Yes ❑ No
t
Non-sanitary waste discharged to the Title 5 system?. ❑ Yes ❑ No
Water meter readings, if available:
l5jns 4 3113 Title 5 Olfidal Ucpecticn Form Subsurface Sewage Disposal System•Page 7 of 17;
t
Jun 271411:37a p.8
Commonwealth of Massachusetts
Title 5 Official Inspection Forma
Subsurface Sewage DisposahSystem Form - Not for Voluntary Assessments ,
91 Wianno Ave
Property Address
John and Joan Connolly
Owner Owners Name
information is
required for every Osterville ._ MA 02665 6-24-14
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont:)
Last date of occupancy/use: Date
t
Other(describe below):
c
General,Information
Pumping Records:
Source of information: NA
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 UA system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
Mns-W13 Title 5 Offlcal hspeclion Form:Subsurface Sewage Disposal System-Page a of 17
Jun 271411:37a p.9
Commonwealth of Massachusetts
Title 5 Official., Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
91 Wianno Ave
Property Address
John and Joan Connolly
Owner owner's Name
information is required for every Osterville MA 02666 6-24-14
page. Cityrrown State Zip Code Date of Inspecdon
D. System Information (cont.)
Approximate age of all components,date installed (if known) and source of information:
C.pool na/ pit 1983 permit # 83-850.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
3
Building Sewer(locate on site,plan):
50"
Depth below grade: feet
Material of construction: "
❑cast iron ®40 PVC other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Pipeing is 4" PVC SCH 40 and clay.
Septic Tank(locate on site plan):
Depth below grade: 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) 0 Yes.❑ No
Dimensions:
Sludge depth:
15insP 3113'' _ntle 5 Offidal Inspection.Form:Subsurface Sewage Disposal system•Page 9 of 17
4, - 4 ..
Jun 271411:37a p.10
Commonwealth of.Massachusetts
Title 5 official Inspection Form
S Subsurface Sewage Disposal-System Form-Not for Voluntary Assessments
- 91 Wianno Ave
Property Address
John and Joan Connolly
Owner Owner's Name
information is required for every Osterville MA 02665 6-24-14
page. Cityrrown State Zip Code Date of Inspedion
D. System Information:(cont.),
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
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
How were dimensions determined?
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage,.etc.)
i
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: _
i Date
t5ins 3#13 2 Title 5 Official InspecIlIon Form:Suosurfaoe
v Sewage Disposal System•Page 10 of 77
1
t
Jun 271411:38a p.11
{
Commonwealth of Massachusetts,
Title 5 Officiate Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
91 Wianno Ave
Property Address
John and Joan Connolly "
Owner Owner's Name
information is required for every Osterville MA 02665 6-24-14
page, CitylTown State Zip Code Date of Inspection
D. System Information (cont.)"
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
i
m pumped at time of inspection) locate on site Ian :
Tight or Holding Tank (tank must be pu p p ) ( plan):
Depth below grade: t
Material of construction:
❑ concrete ❑'metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions: l ,
Capacity:
gallons
Design Flow:
gallons per day
Alarm.present: ❑ Yes ❑ .No
Alarm level: Alarm in working'order: ❑ Yes ❑ No
1
s
' Date of last pumping:
l Date-
Comments(condition of alarm and float switches, etc.).
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes 0 No
15ins-;3/13 Tile 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17.
1
Jun 271411:38a p.12
Commonwealth of Massachusetts
Title 5 Official Inspection Form
al Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
91 Wianno Ave
Property Address
John and Joan Connolly
Owner Owner's Name
information is F
�6-24-14
'
6
required for every OStervlli e MA 02665
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
opened) locate onsite Ian
Distribution Box if resent'must be ope ) ( plan):.
( P
Depth of liquid level above outlet invert
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover,any
evidence of leakage into or out of box, etc.):
Pump Chamber(locate on site plan):
Pumps in working order. ❑ Yes ❑ No`
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System(SAS)(locate on site plan, excavation not required):
If SAS not located;explain why:
t°ins 3/13 TRIG 5 0 cial.impoo6m Form:Suba rfaea Sam, do Disposal Symms•Pag412 d IT
Jun 271411:38a p.13
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
� 91 Wianno Ave
Property Address
John and Joan Connolly
Owner owner's Name
information is Osteryille MA 02665 6-24-14
required for every
page. Cityr town State Zip Code Date of Inspection
D. System Information (cost.) v
Type:
® leaching pits number.
❑ leaching chambers' number:r.
❑ 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.):
Leaching is a 1000 Gal. precast pit Pit at 4' below grade w/cover,at 1'. 1'water in pit, No sign of
over loading or solid carry over. No high stain line,wall's clean.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration " 1
a _ 61
Depth —top of liquid to inlet.invert
4°
Depth of solids layer
depth of scum I 21
p layer —_.
Dimensions of cesspool. 6'x8'
Materials of construction Block and Brick
Indication of groundwater inflow ❑ Yes ® No
9 ..
Mrs•3/13 Tille 5 Official impaction Form:Subsurface Sewage Disposal System•Page 13 or 17
4;
Jun 271411:39a p.14
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
91 Wianno Ave
Property Address
John and Joan Connolly
Owner Owner's Name
information is required for every Osterville MA 02665 6-24-14
page. Cilyf 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):s
Materials of construction:
' Dimensions
Depth of solids' ,
Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t6ins 3113 s Togo 6 Official Mspocticn Form:Subsurfoeo Sow go Disposal Systom•Pago 14 of 17
271411:39a p.15
t
Commonwealth of Massachusetts
Title 5 Official Inspection Fortin
6 Subsurface Sewage Disposal System'Foam-Not for Voluntary Assessments
91 Wianno Ave
Property Address
John and Joan Connolly
Owner Owner's Name
information is required for every osterville MA 02665 :. 6-24-14
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 feast 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
73
CZ£.�.�
r
i
h
15Fs�-3113 - Tble 6 Ofr.-W Inspectlon Forme Subsurface Sewage Disposal system•Pago 16 o1 17
f
Jun 271411:39a p.16
..�1
Commonwealth of Massachusetts
-, Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
91 Wianno Ave
Property Address
John and Joan Connolly
Owner Owner's Name
Information is required for every Osteryille y MA 02665 6-24-14
page. City/Town State Zip Code. Date of Inspection
D. System Information (cunt.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar -
❑ Shallow wells
Estimated depth to igh ground water. 30+'
feet
Please indicate all methods used to determine the high ground water elevation:
i ❑ Obtained from system design plans on record
If checked, date of.design plan reviewed: Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
permit#63-850 on file at b.o.h. no ground at 30'+
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:'
s
You must describe how you established the high ground water elevation:
Barn. b.o.h. permit#83-850 < s
"
Before filing this inspection Report, please see Report Completeness Checklist on next page.
15ins•3113 e ' Me 6 Official inspection ram:Wmrlece Sewage Mpc,aW System'.Page l8 d 1T
t..
Jun 271411:40a p.17
e
'Commonwealth of Massachusetts
110 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
91 Wianno Ave
Property Address
John and Joan Connolly
Owner Owner's Marne
information is required for every Osteryille MA 02665 6-24-14
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspecbon Summary.A, B, C, D, or E checked
® Inspecbon 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
f
t
l
t5ins-3/13 .T tW.5 OfNaed Insoection Form Subsurfaoe Smage Dlsposal Sysl"•Page'17 of�17 t
TOWN OF BARNSTABLE !�
LOCATION / !N%G-�1110 ✓� SEWAGE # Zd O4
VILLAGE 0, ASSESS R'S & LOT-1 11
1A�INSTALLER'S NAME&PHONE/N0.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO. OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE: 13
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 leaching facilitvL / Feet
I� Furnished by
✓e
A
A 12
3
6 �Cle�:►� ov
3`�Qelo�v
Fee 701
THE COMMONWEALTH OF MASSACHUSETTS.'. Entered in computer:
Yes
PUBLIC HEALTH DIVISION TOWN OF BARNSTABLEi MASSACHUSETTS
01ppYication for Mi5pogaf *pgtem Con!6tructiott ,V"Crmit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) El Complete System ❑Individual Components
Location Address or Lot No. v
Owner's Name,Address and Tel.No.
� e. Vff
Assessor's Map/Parcel ✓04n ��17 a/y
Ins er's Name,Addmss,and Tel.No. Designer's Name,Address and Tel.No..
d °�yzo Z5�
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. 'Z f' .�uZ�- �UZ✓
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) /-Z C . /`w,m" //Gy�/ / �'I"
CP S�L�
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 brda
rssrr "th' oard He
� .
Sig Date
r
Application Approved by DateIle
Application Disapproved forte following reasons
Permit,No. . & Date Issued
-------------
Fee
No. /
Entered in computer!
THE COMMONWEALTH OF MASSACHUSETTS Yes
PUBLIC HEALTH DIVISION -TOWN OF-BARNSTABLE, MASSACHUSETTS
No.
Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:'
PUBLIC HEALTH DIVISION - TOWN OF BARNSTAB.LES MASSACHUSETTS Yesx
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No. r"; Fee
- Z THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
� ZIpplication for -Mi.5po.5al 6potem Construction Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) O Complete System El Individual Components
l
Location Address or Lot No. Owner's Name,Address and Tel.No.
`• Assessor's Map/Parcel
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building: x
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)
Date last inspected:
Agreement: 'q
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 by this Board of Health..
Signedf w� .� •,� • _.: �•.»�p Date f }'
Application Approved by _ Date
Application Disapproved for the•following reasons
f t t
Permit No. '"fir' ')� . - Date Issued t°tt
----_ ,
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance �
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( );Repaired( )Upgraded
Abandoned ( )by
at z t L ,, +.. 1:N V zr''"";". has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. - % 5dated
Installer Designer n n
The issuance of this pefmit shall not be construed as a guarantee that the syste• will4fu ton as d �Z
Date i 'a j/ Inspector `
---------�ti —.--- ---------------------------
No. Fee
THE COMMONWEALTH OF-MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
Mi5po5al *pgtem Con$truction Permit
Permission is hereby granted to Construct( )R p ii( )Upgrade(,q )Abandon
System located at rr1 _�;" v 1 1�s Q
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.f this permit.
Date: ��f & Approved bys,
8/3/2020 ShowAsbuilt(1700x2800)
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LOCATION /��✓iL�t/r0 �I✓C SEWAGE#204'I ,�
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INSTALLER'S NAME At PHONE NO. f/ c �h
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) (size) Z1M�
NO.OF BEDROOMS .3
BUILDER OR OWNER Cow
PERMITDATE: %610ol' COMPLIANCE DATE: 3
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of teaching 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 leaching facit e / Feet
Furnished by �e r/� f��L'�l
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Commonwealth of Massachusetts
Executive of Environmental Affairs
Department of
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Environmental Protection '
19,96
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM-
PART A 44
CERTIFICATION 9
Property Address: ;
Address of Owner: A
(if different)
Date of Inspection:
Name of Inspector: Michael DeDecko
Company Name, Address and Telephone number: Atlantic Environmental
P.o Box 2384 - Mashpee Ma 02649. Tel : (508)4771420
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and
that the information reported below is true, accurate and complete as of the time of
inspection . The inspection was performed based on my training and experience in the
proper function and maintenance of on site sewage disposal systems. The system
Passes
---- Conditionally Passes
---- Needs further evaluation by the local Approving Authority
---- Fails
Inspector 's Sign a. Date:
The system Inspector shall submit a copy of this inspection report to the Approving
Authority within thirty (30) days of completing this inspection. If the system
is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the
system owner shall submit the report to the appropriate regional office or the Department
of Environmental Protection.
The original should be sent to the system owner and copy sent to the buyer, if applicable
and the approving authority.
1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: `�\
Owners : Sy,,V,,,
Date of Inspection:
INSPECTION SUMMARY:
Check A, B, C, or D
A) SYSTEM PASSES:
A I have not found any information which indicates that the system violates any of the
failure criteria as defined in 310 CM 15.303.Any failure criteria not evaluated are
indicated below
B) SYSTEM CONDITIONALLY PASSES:
---- One or more system components need to be replaced or repaired. The system, upon
completion of the replacement or repair,passes inspection.
Indicate yes, no, or not determinate (YR or ND). Describe basis of determination in all
instances. If"not determinated",explain why not.
---- The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or
exfiltration, or tank failure is imminent. The system will pass inspection if the existing
septic tank is replaced with a conforming septic tank as approved by the Board of
Health.
---- Sewage backup or breakout or high static water level observed
9 P 9 e ed in the distribution
box is due to broken or obstructed pipe(s)or due to a broken, settled or uneven
distribution box. The system will pass inspection if(with approval of the Board of
Health).
--- broken pipe(s)are replaced
----- obstruction is removed
---- distribution box is levelled or replaced
---- The system required pumping more than four times a year due to broken or obstructed
pipe(s). The system will pass inspection if(with approval of the Board of Health):
----- broken pipe(s)are replaced
----- obstruction is removed
r
0
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address :
Owner :
Date of Inspection :
C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
--- Conditions exist which require further evaluation by the Board of Health in order to de-
termine if the system is failing to protect the public health ,safety and the environ-
ment
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE
SYSTEM IS NOT FUNCTIONING INAMANNER WHICH WILL PROTECT THE
PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
---- Cesspool or privy is within 150 feet of a surface of water
---• Cesspool or privy is within 50 feet of a bordering vegetated wetland or a small
marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER
SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNC-
TIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY
AND THE ENVIRONMENT.
--•- The system has a septic tank and soil absorption system and is within 100 feet to a
surface water supply or tributary to a surface water supply.
---- The system has a septic tank and soil absorption system and is within a Zone I
of a public water supply well
-•-- The system has a septic tank and soil absorption system and is within 50 feet
of a private water supply well.
--- The system has a septic tank and soil absorption system and is less than 100
feet but 50 feet or more from a private water supply well, unless a well water analy-
sis 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 notrogen is equal to or less than 5 ppm.
D)SYSTEM FAILS:
-• I have determined that the system violates one or more of the following failure criteria
as defined in 310 CM 15.303. The basis for this determination is identified below.
The Board of Health should be contacted to determine what will be necessary to cor-
rect the failure.
-•- Backup of sewage into facility or system component due to an overloaded or
or clogged SAS or cesspool.
3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: q% t►�,�,,_,"
Owner:
Date of Inspection :
D) SYSTEM FAILS (continued)
-- 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 over-
loaded 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 cesspool or privy is within 100 feet of a surface water supply
ortributary 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 ana-
lysis. 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.
h•
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection :
E) LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above :
The design flow of system is 10,000 gpd or greater Large System and the system
is a significant threat to public health and safety and the environment because
one or more of the following conditions exist :
--- the system is within 400 feet of a surface drinking water supply
--- the system is within 200 feet of a tributary to a surface drinking water supply
--- the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area IWPA)or a mapped Zone II of a public water supply well
The owner or operator of any such system shall bring the system and facility into full compli-
ance with the groundwater treatment program requirements of 314 CM 5.00 and 6.00.
Please,consult the local regional office of the Department for further information.
r -
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
Owner: ,
Date of Inspection:
Check if the following have been done :
-x Pumping information was requested of the owner , occupant and Board of
Health.
--x None of the system components have been pumped for at least two weeks
and the system has been receiving normal flow rates during the period. Large
volumes of water have not been introduced into the system recently or as part
of this inspection.
--x As built plans have been obtained and examined. Note if they are not available
with NIA.
--x The facility or dwelling was inspected for signs of sewage back-up.
--x The system does not receive non-sanitary or industrial waste flow.
--x The site was inspected for signs of breakout.
--x All system components,excluding the Soil Absorption System,have been
located on the site.
---x The septic tank manholes were uncovered, opened and the interior of the sep-
tic tank was inspected for conditions of baffles or tees,material of construc-
tion, dimensions, depth of liquid, depth of sludge, depth of scum.
---x The size and location of the Sod Absorption System on the site has been deter-
mined based.on existing information or approximated by non-intrusive methods
---x The facility owners and occupants if different from owner were provided with
information on the maintenance of proper Subsurface Disposal System.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
Owner: ,,,
Date of Inspection:
RESIDENTIAL:
Design flow : 3-60 gallons
Number of bedrooms : o'a,
Number of current residents:
Garbage grinder (yes or no) : Pc_-)
Laundry connected to system (yes or no):
Seasonal use (yes or no) : #,_�
Water meter readings, if available: Qk R
Last date of occupancy : t ,�a
COMMERCIALANDUSTRIAL:
Type of establishment:
Design flow: gallons/day
Grease trap present: (yes or no)
Industrial waste holding tank present (yes or no) :
Non-sanitary waste discharged to the Title 5 system (yes or no) :
Water meter readings, if available:
Last date of occupancy
Other: (Describe) ............................................................................................................
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as part of inspections or no):..... ......
if yes,volume pomped: .................... gallons
Reasonfor pumping:...........................:..............................................:.................................
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
t SYSTEM INFORMATION (continued)
Property Address: 9k 1?J� ,��
Owner: , -
Date of inspection:
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)
Other (explain).... ,., .c av
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 .
SEPTIC TANK : ..... ?
(locate on site plan)
Depth below grade: ..........
Material of construction: ....... concrete .......... metal........ FR P........ other (explain)
....................................................................................................................................
Dimensions: ........
Sludge depth:...............
Distance from top of sludge to bottom of outlet tee or baffle:...............................
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:...............e.......
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.)......................
` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 6t► v z, tic #fi__._
Date of inspection: C�;
GREASE TRAP : .....
(locate on site plan)
Depth below grade: ...............
Material of construction: ........concrete.........metal........FRP........other(explain)....
...........................................................................................................................................
D imensions:.........................:.....
Scum thickness:........................
Distance from top of scum to top of outlet tee or baffle:.......................................
Distance from bottom scum to bottom of outlet tee or baffle:...............................
Comments:
(Recommendation for pumping condition of inlet and outlet tees or baffles, depth of liquid
level in relation to outlet invert,structural integrity,evidence of leakage, etc.)........................
................................................................................................................................................
................................................................................................................................................
TIGHT OR HOLDING TANKS:....!JC
(locate on site plan) 1
Depth below grade:...............
Material of construction:........concrete........metal ........FRP..........other (explain)..........
................................................................................................................................................
Dimensions:............................
Capacity: gallons
Design flow:...............gallons/day
Alarm level:.............................
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
9
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: q► v.,►evtT„C;
Owner:
Date of inspection:
DISTRIBUTION BOX:..�.0
(locate on site plan)
Depth of liquid level above outlet invert:...................
Comment:
(note if level and dstribution equal evidence of solids carryover, evidence of leakage into
orout of box, etc.)..................................................................................................................
................................................................................................................................................ .
PUMP CHAMBER:.....
(locate on the site)
Pumps in working order: (yes or no)...............
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)....................
................................................................................................................................................
..................................................................................................................:.............................
SOIL ABSORPTION SYSTEM (SAS):.... ��....
(locate on site plan, if possible; excavation not required,but may be approximated by non-
intrusive methods)
if not determined to be present, explain:
........................................,.......................................................................................................
................................................................................................................................................
Type:
leaching pits, number: ..................
leaching chambers,number:........
leaching galleries, number:...........
leaching trenches,number ,length:.....................
leaching fields, number,dime ions:...................
overflow cesspool, number:...1. irx G'
Comments:
(note condition of soil, signs of-hydraulic failure, level of ponding, on ition of veg ation,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PAR T C
SYSTEM INFORMATION (continued)
Property address: g i W%Rio ",L,
Owner: em,
Date of inspection:
CESSPOOLS:... .
(locate on site plarn�)
Number and configuration: ....
Depth-top of liquid to inlet invert: ......4...................
Depth of solids layer: ...a .............
........................
Depth of scum layer:....6:`.......................................
Dimensions of cesspool: .. .k.b.........
Materials of construction ....'ns. J.�
Indicator of ground water: .. . ........
inflow (cesspool must be pumped as part of inspection)
.............!-?v............................I..............................................
...................................................................I.............................
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
1Jc�
(locate on the site)
Material of construction: ...................................
Dimensions: ......................
Depth of solids: ......... ...
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation,
etc.).
........... ............................ ...............
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address : 1�t
Owner:
Date of inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks locate at
wells within 100'
A
O
P�2- I's` vs`
DEPTH TO GROUNDWATER:
Depth to groundwater: .:.�Q feet
Method of determination or approximative:
.................................... ........ ......... ......
. ..................................................................................................................................................
.....................................:..........................................................................................................
LOCATION. SEWAGE PERMIT NO.
VILLAGE
I N S T A LLER'S NAFAE i ADDRESS
0 U I L D E R OR OWNER
DATE PERMIT ISSUED
DAT E COMPLIANCE ISSUED
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........L.[J .........O F....� . .......................................
Appliration for Uiipoiittl Workii Tongtrurtion Vamit
Application is hereby made for a Permit to Construct ( ) or Repair (v) an Individual Sewage Disposal
System at:
,1�PY� ------ ----------- --------------------------------------------------------------------------------------------------
Locat'. r Lot No.
)�s l........... . .d ress . d?... .... ....----------.....-------....................
Owne dress
a ------3l._ a �..-- •---..--- �� .............................................
Installer Address
Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
U
aOther—Type of Building ............................ No. of persons............................ Showers ( ) —.Cafeteria ( )
Q' Other fixtures ------------------------- •-•-•- •
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
1:4 Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
W Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
x
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. 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........................
. -------------••--•.... t'
Description of Soil..... d q.k� /......................•------------•.-----------------------..._.....---••-----•---
x
W ---•-------•------ ----------------••--•-•--•-••-•-•-----•----.....•-•••••--•----•----••--••••-••--•----•••••-••--•----------•••----••••---..•-•-••......)•-•••----•••-
UNature of Repairs or Alterations—Answer when applicable.............1.-1� �.t9_a4.�Lr..............._.._.............................
--------------------------•--•--......-••-•••-•-•••-•-•-••••-•-••-•••-•--••••-••-•--•--••-••....................•••---••-•••••---•-•-•----•---•---•••--•••••...........................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has be issue by.the board of health. nn
Sid . . . -- •..... .---....•-•_.. =1-= _------ - ---- -
ation Approved Y :� _� 'Date
isapproved for t e 110 reasons---------------------------------------------•---.....•.....-----••-•-•---------........................--......
...--•................•----..............------------.......•...-•-•-•---•--•----•---•---•-----••-•-•--••---••--•--•-•••-•••••-••••-•.....---•••......-•---•-••--------
Date
................................................ Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........ ... .;. ?........OF......./ -�D..., 1 Q.
A;ip ira ion for Bhip ial Marks Tonotriir#'ion rumit
Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal
System at:
/ O / 1 /� ) y� j
..._
1 Location dress r Lot No
....... . .t � i:'+r 6 r,l ... .. +�11.f?.............:..... (��'�ll � ......... ...............
Owned d ss
............L.._f•'• <__ ...........................................
a t Installer `' Address
d Type of Building ., Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Q' 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 ( )
Percolation Test Results Performed by..................................•-----•------•-•----•--•---••----_.----• Date----...--------.......--------..........
aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Gz, Test Pit No. 2...............minutes per inch Depth of Test Pit.................... Depth to ground water........................
- ---------------•-
De � �.scription of Soil------------------ 'r.l_ -•----------•---------------------- -- --------.------•----- --•---.------
V
W -------------------------------- ...........................------------------. r ...........................
--- ---------------
UNature of Repairs or Alterations—Answer when applicable..............)---!j � _..__ � --,-•,---._._.........__.....
--------•----------------------------------------------------------•---------•----------•-•-•.......----......--------------•--------------•....-----•----•--••-•------•................................
Agreement:
The undersigned agrees. to install the aforedescribed Individual Sewage Disposal System in!a1ccordance with
the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has be issued,by the b d of health r
,ll
_ �___.... ........ ------ ------
�,; ate
Application Approved y. "y
-------- - - -
` Date
Application Disapproved for -f011 • g reasons:_.. --•--------------••-----•--•-------•--------------...._...--------=--•----•-•----•---..........................................
----------------•-----------•---....--•-...-------•----------------------...... ___
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASS.ACH.USETTS
BOARD OF HEALTH
.............. , L<e !%' .....oF........a`�`a�1" '.j` . -? ........
(9rdif iratr of &trA;AiFtnrr
TH14-JS TO C TIFY, That the oa +ndividu Sewage Dis osal System constructed ( . ) or Repaired
y--
.... oi
•----
has been installed in accordance with the provisions of TIT ` of The State Sanitary Co s scribed in the
r r <-; 2
application for Disposal Works Construction Permit �o__ . .. ............... -dated ____ .. ..
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT B>CONSTR : ® `S A GUARANTEE THAT THE
SYSTEMWI /Ff�NCT10N SATISFACTORY.
DATE.-••�-Z . ...................................... Inspecto -• .................... ................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD QF HEALTH,
j p .............�.t/. i......OF....... ..........r� k.......................... i
N _......�.. FEE......................
din o 1 r o Tonstr ion rnttt
,�
Permission is hereby .granted---- = --------------------- -�.. .... •. ............................
to Constru ( ) or Re air (t-)--anr ew dividual agEe Disposaj System
at No...............Z.-`-- /C.l2.j'"�' ..... 1 -1!' �111� °---=-----•---•--------•---•------•------•-- . _ ..........
Street /
as shown on the pplica ' for Disposal Works Construction Permit No........... ........ ... -'......................
fi -- •-------••---•-•................... .. ...............................................................
Board of Health
DAT O
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FORM 1255 A. M. SULKIN, INC., BOSTON