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INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY /
LEACHING FACILITY: (ty ) � (size) [ ��
NO. OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
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Commonwealth of Massachusetts
ro Title 5 Official Inspection Form
� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
113 Cammett Road
Property Address
Keefer=
Owner Owners Name
information is required for every MarstOns mills Ma 4/25/19
page. City/Town State Zip Code Date of Inspection
f r1
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. Inspector Information 610- 3 Lf
on the computer,
use only the tab Chad hathaway
key to move your Name of Inspector
cursor-do not H PS
use the return Company Name
key.
tt�"
Company Address
Forestdale Ma 02644
City/Town State Zip Code
774 274 2581 12866
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 CM 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 1 have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
4/25/19
Inspector's Sig re Date
The system inspector shall su it a co of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 ys of co pleting this inspection. If the system has a design flow of
10,000 gpd or greater, the i sector 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 Lr-ev7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 ,
Commonwealth of Massachusetts
11 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
113 Cammett Road
Property Address
Keefe
Owner Owner's Name
information is
required for every Marstons mills Ma 4/25/19
page. Cityrrown 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:
Septic functioning as designed no failure criteria encountered duringinspection.
p Tank wa pumped
durin
g Inspection as It was due for maintenance. Recommend pumping every 2 years under normal
usage
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 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
113 Cammett Road
Property Address
Keefe
Owner Owner's Name
information is required for every Marstons mills Ma 4/25/19
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.7/2612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
c Commonwealth of Massachusetts
r- - ip Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
. 113 Cammett Road
Property Address
Keefe
Owner Owner's Name
information is
required for every Marstons mills Ma 4/25/19
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ 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 asses if the well water analysis, performed at a DEP p y , p 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:
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
t5i.nsp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
113 Cammett Road
Property Address
Keefe
Owner Owner's Name
information is required for every Marstons mills Ma 4/25/19
page. Cityfrown 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 Y2 day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public 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
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
113 Cammett Road
Property Address
Keefe
Owner Owner's Name
information is required for every Marstons mills Ma 4/25/19
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
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
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal.flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as NIA)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ 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)]
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18
f
Commonwealth of Massachusetts
Ul
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
113 Cammett Road
Property Address
Keefe
Owner Owner's Name
information is required for every Marstons mills Ma 4/25/19
.page. City/Town 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
Description:
Number of current residents:
1
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
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: current
Date
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
,F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
113 Cammett Road
Property Address
Keefe
Owner Owner's Name
information is required for every Marstons mills Ma 4/25/19
page. Cityfrown 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: unknown
Was system pumped as part of the inspection? ® Yes ® No
If yes, volume pumped: 1000
gallons
How was quantity pumped determined? tank size
Reason for pumping: maintenance
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
< Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
w 113 Cammett Road
Property Address
Keefe
Owner Owner's flame
information is required for every Marstons mills Ma 4/25/19
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):
Approximate age of all components, date installed (if known)and source of information:
1999
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 1.5'
feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: 10,
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
no signs of leakage or poor venting. house is on a slab and plumbing under concrete floor
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of.Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
113 Cammett Road
Property Address
Keefe
Owner Owner's Name
information is Marstons mills Ma 4/25/19
required for every
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: .75
feet
Material of construction:
®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain)
1000 Gal. H10
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
8'6"x5' 1000 gal
Sludge depth:
8"
Distance from top of sludge to bottom of outlet tee or baffle
26"
Scum thickness
5"
Distance from top of scum to top of outlet tee or baffle
3"
Distance from bottom of scum to bottom of outlet tee or baffle
16"
How were dimensions determined? tape and sludge judge
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
baffles in place. Tank was pumped during inspection. no signs of heavy decay or leakage
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Fort:Subsurface Sewage Disposal System•Page 10 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
F Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
113 Cammett Road
Property Address
Keefe
Owner Owners Name
information is required for every Marstons mills Ma 4/25/19
page. City/Town 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):
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
15i.nsp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts
p Title 5 Official Inspection Form
�- Subsurface,Sewage Disposal System Form -Not for Voluntary Assessments
113 Cammett Road
Property Address
Keefe
Owner Owner's Name
information is required for every Marstons mills Ma 4/25/19
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.):
"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 0
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.):
D63 H10 Dbox is at working level no signs of being overfull
15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
113 Cammett Road
Property Address
Keefe
Owner Owner's Name
information is required for every Marstons mills Ma 4/25/19
page. Cityfrown 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.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
no inspection port present probed area of SAS no signs of hydraulic failure present
Type:
❑ leaching pits number:
® leaching chambers number:
4 I nfultrators
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc-rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18
f
Commonwealth of Massachusetts
re - Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
113 Cammett Road
Property Address
Keefe
Owner Owner's Name
information is required for every Marstons mills Ma 4/25/19
page. Cityrrown 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.):
probed area of SAS no signs of ponding or hydraulic failure
12. 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
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
113 Cammett Road
Property Address
Keefe
Owner Owner's Name
information is required for every Marstons mills Ma 4/25/19
page. Citylrown 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.):
4
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18
f
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
a
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
113 Cammett Road
Property Address
Keefe
Owner Owner's Name
information is required for every Marstons mills Ma 4/25/19
page. Cityrrown State Zip Code Date of Inspection
D. System Information (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:
® hand-sketch in the area below
❑ drawing attached separately
F-1
P3_ as 83_ a�
3
. o/
C�m
t5insp.doc•rev.7/26/2018 TiUe 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
t
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u 113 Cammett Road
Property Address
Keefe
Owner Owner's Name
information is required for every Marstons mills Ma 4/25/19
page. Cityrrown 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: 38
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:
lot el. 70 per barnstable GIS mapping
You imust describe how you established the high ground water elevation:
low in area el. 32 pond level
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
.. 113 Cammett Road
Property Address
Keefe
Owner Owner's Name
information is required for every Marstons mills Ma 4/25/19
page. Cityrrown 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
TOWN OF BARNSTABLE
SEWAGE #C
l 950
i LOCATION
VILLAGE Q7 ASSESSOR'S MAP & LOT �O
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY _,/e i"a -
LEACHING FACILITY: (type) IA44&,4U lat—S (size)
NO.OF BEDROOMS
BUILDER OR OWNER
i
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
i 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
d within 300 feet of leaching facility) Feet
Furnished by
,nn
!s
TOWN OF BARNST ABLE EvCQ
LOCATION I - SEWAGE #
VILLAGE_ %IL —C —ASSESSOR'S MAP & LO'T �D
;INSTALLER'S NAME&PHONE NO. M 4 20 C-4 a e Ce--42:6 C
SEPTIC TANK CAPACITY r 7
o
LEACHING FACILITY: (type) Z i6!5i�� , jy�.� (size) a
NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
r .
Separation Distance Between the:
Maximum Adjusted Groundwater fable and 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 FaciLty'.(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
r
-�
� �
.�
I
a _ ,
33 � ��
No' k-. . + Fee 4" 522
THE COMMONWEALTH OF MASSACHUSETTS Entered mputer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
ZIpprication for Miggoal *pgtem Congtructto.n Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) El Complete System individual Components
Location Address or Lot No. `� C_AVKMe 8 S Owner's Name,Address and Tel.No.
Assessor's Map/Parcel ®��r <2 vs`-'
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
C
Design Flow gallons per day. Calculated daily flow~ � gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank - t�` 0CV Cc 0VJ Type of S.A.S. m.
Description of SOB:
Nature of Repairs or Alterations(Answer when applicable)
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 noeto place the system in operation until a Certifi-
cate of Compliance has been issue ar ealth.
Sig A °` Date
Application Approved by Date
Application Disapproved for Re fol owing reasons
Permit No. - Date Issued
No.-� 5-0
�— "° `A Fee
THE COMMONWEALTH OF MASSACHUSETTS. Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
3ppficatton for �Digool *pgtem Construction Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System `individual Components
Location Address or Lot No. Gs4/11M t S Owner's Name,Address and Tel.No.
Assessor's Map/Parcel y_U u C C�v
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building. '`` No. of Persons Showers( ) Cafeteria( )
Other Fixtures
- -2,-, -�\C,
Design Flow 5 .� gallons per day. Calculated daily flow J"t I gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S. o ' C5 ,Ci l ec
Description of Soil a,Y,� ��
Nature of Repairs or Alterations(Answer when applicable) �:r`O-'STA- _J=�j <2- t 1 t
(Ati l 1 �� �Z�lb�P n�ti. S 1�0,,2-Cj�rc.��i
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
v 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 issue -' oarHeall . -
`( ..-
Signed- \ Date
Application Approved by Date I 5/9
Application Disapproved for ge fol owing reasons
Permit No. Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
P
BARNSTABLE, MASSACHUSETTS
(Certificate of (Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( r )Repaired( )Upgraded J
Abandoned( )by �✓-� t C.. - -� ?—,, -,
at 6 ga aa.S ` has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. - dated,..,
Installer 1 Designer 4! .
t n �� (' /,%f ,�
The issuance of this ermit shall not be construed as a guarantee that the(-' function�.as desvgn��e'd.<��
Date l n, 10 Inspector 4, �l 70ii
No. - - Fee l ��
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
g"
Iniopo0ai 6potem (Con6truction Permit
Permission is hereby granted to Construct( )Repair( )Upgrade Abandon( )
System located at C iA0A 1�-C"
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 permit.
Date: / _ I -�� Approved by
t/669
NOTICE: This Form Is To Be Used For the
Septic Systems Only. Repair Of Failed
CERTIFICATION OF SYVTCH -y-D ..APPLICATION FOR A DISPOSAL
�'✓ORKS CONSTRUCTION PERMIT MTHOUT DESIGNED PLAYS)
hereby certify that the application for disposal works
canstruction permit signed by me dated
concerning the
property located at
meets all of the
following criteria:
/, The failed system is conner;ed ;o a residential dwei ln,' o
only. There are no commercial or business
uses asscctated with the dwelling.
• and the percolation rate is less than or equal to 5 minutes per inch.
The soil s classified a, CLASS [
There are no wetlands within 100 feet of the proposed septic system
• ,/There are.no private wells within l °
(,/ .;0 gee,of the proposed septic system
• Where is no increase in flew and/or chiange in use proposed
There are no variances requested or needed.
The bottom of the proposed leacaing facility will not be located less than five feet above the
mwarnum adjusted groundwater table-!cvation. [Adjust the groundwater table using the Frimptor
e,hod waen applicable]
• If the S.A.S. will be located v�ith 250 feet of any vegetated wetlands, the bottom of the proposed
leaching faCility will not be located less Uun foureen (1,) fec, above the maximum adjusted
groundwater table elevation,
Please complete the following:
A) Top of Ground Surface Z!tr/adori(using GIS information)
\ B) G.W. elevation tV _ the NL-,X- High G.,V_ Adjustment
D[I-FEERENCE BETWEEN A and B �- --
SIGNED
DATE:
[Sketch proposed plan of s7zem on bath].
q:health folder:cent
o a _
<®� z . .
• - '�►
F
. COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS John Graci
DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector
ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119
TeaTicket,Ma.
(508)564-6813
TRUDY COXE
Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 113 CAMMETT RD. MARSTONS MILLS APARTMENT
Name of Owner PAUL CHUDY
Address of Owner: SAME
Date of Inspection: 11124/99
Name of Inspector:(Please Print)JOHN GRACI �ED
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)
p 9"c 2 8 19
Company Name: n/a 99
Mailing Address: n/a �4W
Telephone Number: n/a H OFBM�IST,
;
a
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:
X Passes The Inpection Is based on criteria defined In Title V
Conditionally Passes code 310 CMR 15.303.My findings are of how the system is
_ Needs Further E lu ion By the Local Approving Authority performing at the time of the Inspection.My inspection does
Fails not imply any warranty or guarantee of the longgevity of the
septic system and any of its components useful life.
Inspector's Signature: Date:2/17/99
The System Inspector sha isit 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 now 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 to the
system owner and copies sent to the buyer,if applicable,and the approving authority.
NOTES AND COMMENTS
THE SYSTEM FOR THE APARTMENT PASSES TITLE V INSPECTION. RECOMMEND MAINTAINING SYSTEM EVERY TWO YEARS TO PROLONG
THE SYSTEM'S USEFULL LIFE.
revised 9/2/98 Page 1 of 11 \
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 113 CAMMETT RD.MARSTONS MILLS APARTMENT
Owner: PAUL CHUDY
Date of Inspection:11124/99
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
_ I 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:
System passes Title V inspection
B. SYSTEM CONDITIONALLY PASSES:
nta 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 ND).Describe basis of determination in all instances.If"not determined",explain why not.
Wa 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 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.
nta Sewage backup or breakout or high static water level observed 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
n& 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
revised 9/2/98 Page 2 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 113 CAMMETT RD.MARSTONS MILLS APARTMENT
Owner: PAUL CHUDY
Date of Inspection:11124/99
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) 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 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.
1
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 n/a-(approximation not valid).
3) OTHER
nLa
i
revised 9/2198 Page 3 of 11
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 113 CAMMETT RD.MARSTONS MILLS APARTMENT
Owner: PAUL CHUDY
Date of Inspection:11/24/99
D. SYSTEM FAILS:
You must 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 be necessary to correct the failure.
Yes No
X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool.
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow,
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped n/a.
X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
X Any portion of a cesspool or privy is within a Zone I of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well,
X 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 ompounds,
ammonia nitrogen and nitrate nitrogen.
X The liquid level in the SAS is over the invert pipe,is in Hydraulic Failure.
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
X the system is within 400 feet of a surface drinking water supply
X the system is within 200 feet of a tributary to a surface drinking water supply
X 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 15.30412).Please consult the local regional office of the
Department for further information.
revised 9/2/98 Page 4 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 113 CAMMETT RD.MARSTONS MILLS APARTMENT
Owner: PAUL CHUDY
Date of Inspection:11/24/99
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) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 16.303(1)(b)THAT THE SYSTEM IS
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.
I .
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 nLa_(approximation not valid).
3) OTHER
nLa
revised 9/2/98 Page 3 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 113 CAMMETT RD.MARSTONS MILLS APARTMENT
Owner: PAUL CHUDY
Date of Inspection:11/24199
D. SYSTEM FAILS:
You must 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 be necessary to correct the failure.
Yes No
X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool.
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
X Liquid depth in cesspool is less than 6"below Invert or available volume is less than 1/2 day flow,
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped nLa.
X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
X Any portion of a cesspool or privy is within a Zone I of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well,
X 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 ompounds,
ammonia nitrogen and nitrate nitrogen.
X The liquid level in the SAS is over the invert pipe,is in Hydraulic Failure.
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
X the system is within 400 feet of a surface drinking water supply
X the system is within 200 feet of a tributary to a surface drinking water supply
X 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 15.30412).Please consult the local regional office of the
Department for further information.
revised 9/2198 Page 4 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 113 CAMMETT RD.MARSTONS MILLS APARTMENT
Owner: PAUL CHUDY
Date of Inspection:11/24/99
Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following:
Yes No
X Pumping information was provided by the owner,occupant,or 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 that 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 N/A,
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 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:
X Existing information,For example,Plan at B4O,H,
X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)
[1 5.302(3)(b)]
X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of
SubSurface(Disposal Systems.
revised 9/2/98 Page 5 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 113 CAMMETT RD.MARSTONS MILLS APARTMENT
Owner: PAUL CHUDY
Date of Inspection:11/24/99
FLOW CONDITIONS
RESIDENTIAL:
Design flow:llQ g.p.d./bedroom
Number of bedrooms(design): 1 Number of bedrooms(actual):-
Total DESIGN flow: IV
Number of current residents:-
Garbage grinder(yes or no):NQ
Laundry(separate system)(yes or no): NO If yes,separate inspection required
Laundry system inspected(yes or no):JLQ
Seasonal use(yes or no):JLQ
Water meter readings,if available(last two year's usage(gpd): nLa
Sump Pump(yes or no): NO
Last date of occupancy: n&
COM M ERCIAL/INDUSTRIAL
Type of establishment: n&
Design flow: n(a gpd(Based on 15.203)
Basis of design flow: n&
Grease trap present:(yes or no):JLQ
Industrial Waste Holding Tank present:(yes or no): NQ
Non-sanitary waste discharged to the Title 5 system:(yes or no):NQ
Water meter readings.if available:nla
Last date of occupancy: n&
OTHER: (Describe)
nLa
Last date of occupancy: n&
GENERAL INFORMATION
PUMPING RECORDS and source of information:
SEPTEMBER 1999
System pumped as part of inspection:(yes or no):NQ
If yes,volume pumped n&- gallons
Reason for pumping: n&
TYPE OF SYSTEM
X 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)
I/A Technology etc.Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other: n&
APPROXIMATE AGE of all components,date installed(if known)and source of information:
19DA
Sewage odors detected when arriving at the site:(yes or no): NQ
revised 9/2198 Page 6 of 11
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 113 CAMMETT RD.MARSTONS MILLS APARTMENT
Owner: PAUL CHUDY
Date of Inspection:11/24/99
BUILDING SEWER:
(Locate on site plan)
Depth below grade: V 6"
Material of construction:_ cast iron X 40 PVC _ other(explain)
Distance from private water supply well or suction line: TOWN
Diameter: Wa
Comments: (condition of joints,venting,evidence of leakage,etc.)
nLa
SEPTIC TANK: X
(locate on site plan)
Depth below grade: 1
Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain)
WA
If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NQ
nLa
Dimensions: L 8'6"H 6'7"W 4'10"
Sludge depth: 4
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: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: 11.
How dimensions were determined: MEASURED
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.)
SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING SYSTEM EVERY TWO YEARS,
GREASE TRAP:
(locate on site plan)
Depth below grade:
Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain)
DIA
Dimensions: nLa
Scum thickness: n&
Distance from top of scum to top of outlet tee or baffle:inLa
Distance from bottom of scum to bottom of outlet tee or baffle nta
Date of last pumping: Wa
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.)
nla i
revised 9/2198 Page 7 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 113 CAMMETT RD.MARSTONS MILLS APARTMENT
Owner: PAUL CHUDY
Date of Inspection:11/24/99
TIGHT OR HOLDING TANK: MQ (Tank must be pumped prior to,or at time of,inspection)
(locate on site plan)
Depth below grade: n/a
Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain)
Wa
Dimensions: n&
Capacity: nta gallons
Design flow: tVa gallons/day
Alarm present: NQ
Alarm level:jila_ Alarm in working order:Yes_No_ MQ
Date of previous pumping: n&
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
19a
DISTRIBUTION BOX: _
(locate on site plan)
Depth of liquid level above outlet invert:n&
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.)
JlL
PUMP CHAMBER: NQ
(locate on site plan)
Pumps in working order:(Yes or No): NO
Alarms in working order(Yes or No): NO
Comments:
(note condition of pump chamber,condition of pumps and appurtenances.etc.)
Wa
revised 9/2198 Page 8 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 113 CAMMETT RD.MARSTONS MILLS APARTMENT
Owner: PAUL CHUDY
Date of Inspection:11/24/99
SOIL ABSORPTION SYSTEM(SAS): X
(locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods)
If not located,explain:
nLa
Type:
leaching pits,number: 1000 GALLON LEACH PIT
leaching chambers,number: _nLa
leaching galleries,number: j3&
leaching trenches,number,length: n&
leaching fields,number,dimensions: nta
overflow cesspool,number: Wa
Alternative system: n&
Name of Technology: _nLa
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.)
THE LEACH PIT IS STRUCTURALL SOUND AND FUNTIONINC PROPERLY THE PIT HAS NOT HAD MORE THAN 1'OF WATER IN IT
CESSPOOLS: _
(locate on site plan)
Number and configuration: Wa
Depth-top of liquid to inlet invert: nla
Depth of solids layer: nLa
Depth of scum layer. Wit
Dimensions of cesspool: Wa
Materials of construction: nta
Indication of groundwater: Wa inflow(cesspool must be pumped as part of inspection)nLa
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
nLa
PRIVY: _
(locate on site plan)
Materials of construction:WA Dimensions:nLa
Depth of solids: Wa
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
nta
revised 9/2198 Page 9 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 113 CAMMETT RD.MARSTONS MILLS APARTMENT
Owner: PAUL CHUDY
Date of Inspection:11/24/99
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)
n/a
4>4 2i
AC 4a
revised 9/2198 Page 10 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 113 CAMMETT RD.MARSTONS MILLS APARTMENT
Owner: PAUL CHUDY
Date of Inspection:11/24/99
NRCS Report name: n&
Soil Type: n&
Typical depth to groundwater: n&
USGS Date website visited: n&
Observation Wells checked: NQ
Groundwater depth:Shallow _ Moderate _ Deep _
SITE EXAM _ Slope
_ Surface water
_ Check Cellar
Shallow wells
Estimated Depth to Groundwater 12 Feet
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
X Used USGS Data
Describe how you established the High Groundwater Elevation.(Must be completed)
USGS MAPS AND CHARTS-12+FEET
e
revised 9/2/98 Page 11 of 11
o-7 ,
Commonwealth of Massachusetts
EX@Ct1tiV9 Office Of EnvlfOnmentOl AffairsJohn GradD.E.P. Title V Septic Inspector
Department of P.O. Box 2119
Environmental Protection Teaticket,MA02536
(508) 564-6813
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A ✓
CERTIFICATION kilVC0 ✓
JUL
Property Address: 113 Cammett Rd. Martsons Mills House Address of Owner: 199
Date of Inspection:7J23197 (If different) 7pftor T N
Name of Inspector:John Gracl Mrs.Collins;116 Wlndshore Dr.Hyannis Ma.02 40 Hfgt HD pp LE
Company Name,Address and Telephone Number: A 4*
E Z
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:
X Passes This inspection Is based on criteria defined in Title V
Conditionally Passes code 310 CMR 15.303.My findings are of how the system is
Needs Further Evaluation B the Local Approving Authority performing at the time of the Inspection.My Inspection does
— y pp g tY not Imply any warranty or guarantee of the longevity or the
— Fails septic system and any of its components useful life.
Inspector's Signature: Date: 7129197
The System,lnspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspections. 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 to the system owner and copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
Check A, B,C,or D:
A] SYSTEM PASSES:
X I have not found any information which indicates that the system violates any of the failure criteria
defined as in 310 CMR 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 determined(Y, N,or ND). Describe basis of determination in all instances. If "not determined", 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.
(revised 11115195)
One Winter Street • Boston,Massachusetts 02108 9 FAX(617)556-1049 . Telephone(617)292-5500
1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 113 CammettRd.Martsons Mills House
Owner: Mrs.Collins;116 Wlndshore Dr.Hyannis Ma.02601
Date of Inspection:7123197
_ Sewage backup or breakout or high static water level observed in the distribution box is 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 leveled 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
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) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS
NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER, IF APPROPRIATE)DETERMINES
THAT THE SYSTEM IS FUNCTIONING 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 of water supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and is within a Zone 1 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 analysis for coliform bacteria volatile organic compounds indicates that the well is
free from pollution for that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm.
3) OTHER
D] SYSTEM FAILS:
I have determined that the system violates one or more of the following failure criteria as defined 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.
Backup of sewage in 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
cesspool.
SAS is in hydraulic failure.
(revised 11115195)
2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 113 CammettRd.Martsons Mills House
Owner: Mrs.Collins;1161Mndshore Dr.Hyannis Ma.02601
Date of Inspection:7123197
D) SYSTEM FAILS(continued)
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).
Numbers 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] LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria:
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:
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 compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 11115195)
3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CH ECLIST
Property Address: 113 CammettRd.Martsons Mills House
Owner: Mrs.Collins;116 Wlndshore Dr.Hyannis Ma.02601
Date of Inspection:7123197
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 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.
NaAs built plans have been obtained and examined. Note if they are not available with N/A.
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 septic tank was Inspected
for condition of baffles or tees,material of construction,dimensions,depth of liquid, depth of sludge, depth of scum.
X The size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 11115195)
4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 113 Cammett Rd.Martsons Mills House
Owner: Mrs.Collins;116 Wlndshore Dr.Hyannis Ma.02601
Date of Inspection:7123197
FLOW CONDITIONS
RESIDENTIAL:
Design flow: "0 gallons
Number of bedrooms: 4
Number of current residents: 0
Garbage grinder(yes or no): No 4
Laundry connected to system(yes or no): Yes
Seasonal use(yes or no): No
Water meter readings,if available: nla
Last date of occupancy: Dec.1996
COMMERCIAL/INDUSTRIAL:
Type of establishment: rda
Design flow:0 gallons/day
Grease trap present:(yes or no) No
Industrial Waste Holding Tank present: (yes or no) No
Non-sanitary waste discharged to the Title 5 system: (yes or no) No
Water meter readings,if available: n1a
Last date of occupancy: Na
OTHER: (Describe) nla
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System has not been pumped in the last year.
System pumped as part of inspection: (yes or no)Yes
If yes,volume pumped: 1500 gallons
Reason for pumping: Maintenance.
TYPE OF SYSTEM
X Septic tank/distribution box/soil absorptions system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) ( if yes, attach previous inspection records,if any)
Other(explain)
APPROXIMATE AGE of all components,date installed(if known)and source information:
1987
Sewage odors detected when arriving at the site: (yes or no) No
(revised 11/15/95)
5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 113 CammettRd.Martsons Mills House
Owner: Mrs.Collins;116 Windshore Dr.Hyannis Ma.02601
Date of Inspection:7123197
SEPTIC TANK: X
(locate on site plan)
Depth below grade: 1'
Material of construction:X concreate_metal_FRP_other(explain)
Dimensions: L 8'6'H 5'7"W 4'10-
Sludge depth:1'
Distance from top of sludge to bottom of outlet tee or baffle: 20"
Scum thickness:8'
Distance from top of scum to top of outlet tee or baffle:3'
Distance form bottom of scum to bottom of outlet tee or baffle: 13"
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.)
Septic tank and all components are structurally sound.Recommend pumping septic system every two years for maintenance.
GREASE TRAP:
(locate on site plan)
Depth below grade: n1a
Material of construction: _concrete metal FRP_other(explain)
Dimensions: n1a
Scum thickness:n1a
Distance from top of scum to top of outlet tee or baffle:n1a
Distance from bottom of scum to bottom of outlet tee or baffle:nla
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.)
Na
(revised 11115195)
6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 113 CammettRd.Martsons Mills House
Owner: Mrs.Collins;116 VVlndshore Dr.Hyannis Ma.e26e1
Date of Inspection:7123197
TIGHT OR HOLDING TANK:
(locate on site plan)
Depth below grade: n1a
Material of con siruction:_concrete_metaI_FRP_other(explain)
Dimensions: n1a
Capacity: n1a gallons
Design flow: n1a gallons/day
Alarm level: nla
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
n1a
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert: n1a
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box etc.)
n1a
PUMP CHAMBER:
(locate on site plan)
Pumps in working order:(yes or no)
Comments:
(note condition of pump chamber,condition of pumps and appurtenances, etc.)
nla.
(revised 11/15/95)
7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 113Cammettl1d.Ma►tsons Mills House
P Y
Owner: Mrs.Collins;116 Windshore Dr.Hyannis Ma.02601
Date of Inspection:7123197
SOIL ABSORPTION SYSTEM(SAS):x
(locate on site plan,if possible; excavation not required,but may be approximated by non-intrusive methods)
If not determined to be present, explain:
n1a
Type:
leaching pits,number: 1,000 gallon leach pit
leaching chambers,number:n1a
leaching galleries,number: nfa
leaching trenches,number,length: n1a
leaching fields,number, dimensions:n1a
overflow cesspool,number:n1a
Comments:(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
The overflow is structurally sound and functioning properly.It had 1'of water in it.
CESSPOOLS:_
(locate on site plan)
Number and configuration: n1a
Depth-top of liquid to inlet invert: n1a
Depth of solids layer: n1a
Depth of scum layer: nia
Dimensions of cesspool: n1a
Materials of construction: n1a
Indication of groundwater: nfa
inflow(cesspool must be pumped as part of inspection)
nla
Comments:(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
n1a
PRIVY:
(locate on site plan)
Materials of construction: n1a Dimensions: n1a
Depth of solids: n1a
Comments:(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.)
nla
(revised 11115195)
8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 113 Cammett Rd..Martsons Mills House
Owner: Mrs.Collins;116 Wlndshore Dr.Hyannis Ma.02601
Date of Inspection:7123197
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
of .� LCIJA
AC
qq �7
�A4 M
B
�A
�Bay
C H�
DEPTH TO GROUNDWATER
Depth to groundwater:12 feet
method of determination or approximation:
USGS Maps and Charts-12+feet
(revised 11115195)
9
TOWN OF BARNSTABLE
LOCATION, (itw► K a A O SEWAGE #
VILLAGE ° � ASSESSOR'S AP Pa Lov"720, - L'" Y-
INSTALLER'S NAME & PHONE NO.� Az Ll,�
SEPTIC TANK CAPACITY I6�'�
LEACHING FACILITY:(type) l _ (size) /&VV
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER C nl S'
DATE PERMIT ISSUED: �-
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
eg ^.
a
f
e
No....V._.... F.
THE COMMONWEAL9 ......... 4,,/...
S `��O MASSACHUSETTS
BOARD OF HEALTH
J
, ppliration for Oiupuottt Works Tonstrurtion rumd
Application is hereby made for a Permit to ConstructS
( ) or Repair ( ) an Individual Sewage Disposal
System at`- (. .. `` .. C 1.........}}_........�'�...1...... ....... `T.D ...............................•
i _ -- ---... -- .... ....
-•--Location- ddres
-......... .� 1. ;f; �............ C.2.-[.\. ............................. . ...........
.Y_��........"_�
ner Address
a .�� _�.. 3:=- - u'' c=:.: �:5:. s.3.�........4tz�z f'':.....�.s..._..
....._
M Installer
Address
UType of Building Size Lot................ Sq. feet
1-.4 Dwelling—No. of Bedrooms----------. ...............................Expansion Attic ( ) Garbage Grinder ( )
14 Other—T e of Building _........... No. of persons............................ Showers
a YP g ...............• P ( ) — Cafeteria ( )
Other fixtures
--------
-------------------------•----------••---------------------------
•--....------------------•-•-------------...........
W Design Flow............................................gallons per person per day. Total daily flow.............................................gallons.
Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Dept h................
W 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 ( )
1.4 Percolation Test Results Performed by...........................•-----•-----.......••....-----••--•--......_... Date........................................
Test Pit No. l................minutes per inch Depth of Test Pit.................... Depth to ground water........................
G4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
9 ............. ---....---•-...•••-- -•••----•---•--••-•-----•.....••-••.....•--.......•-•-•----._...----•-••••-----•-•......--•--•-•--•---•.....
D Description of Soil.. ...............-Z�:.....-•---•-•••----•••-•--••--•--•••---------------•-••-•-----.......-•--...----------......._•---............---•--••----.
U Nature of Repairs or lterati s—Answer when applica. l ..... ��.` _ . '__....._ ------ _......`�...............
x \.... � S ors.Q`;'� ....... ._.... ............ :... /.u_n--.....- .. :.. ....................................
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 beim issued by y the board of h
Signed..... . jw��� O
Application Approved By... -...... -:. -•-•---..................... •......--•••-••••• -
-- E aRrt -----------
Application Disapproved for the following reasons:.........................................................................................................._._
...................................................... • •. . -�----......----...----•.-------•--------------------•-----....-----• -----........---.....................----....._
��,., Date
Permit No.. --......
----------------_ Issued...... ............................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......... .��.....................OF...... .. ..1'.'.......................�.4.0. .......
...........
fIrrtif irate of Tompthtnrr
T IS TO CERTIFY, T at the Individual 6e}yage Disposal System constructed or Repaired
by F - _�.. _�-�......... .....................`--=���...`.a. - . .. ............ ......( .--- --• -.. (....>
-•---
2 Installer O
has been installed in accordance with the provisions of TIT F T Sanitary Cod s s t'in the
application for Disposal Works Construction Permit No.._......__ .C$. dated___._._... _ ...........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A ARAN EE TT THE
SYSTEM WILL FUNCTIO1 SATISFACTORY.
A
DATE.....-- .........?......................I........... Inspector••- `-.... ..` ..... ........................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEATH
.............. ................oF.---........�... ..r. ................................................... .�.-�.
No. . Fn..... .. ..........
Dioposttt(Fil
ork �ontr toter it .
Permission is hereby granted..............= 6`` ....r ram.. �' `... ` C"'L ............•........................___
to Construct (---l—or; Repair ( an Individual Sewage TT I i�spQsal System j f
at No........ �� - ....`....--�•.............•--......•-J ------... ...................................................
�
Street (�
as shown on the application for Disposal Works Constructio rmit No. .......... .-- Dated ..(7.....
DATE... ......�� fJ o
Board of Health
FORM 1255 A. M. SULKIN, INC., BOSTON
II
s
MAP _ Q7
No.... / � 4.�( Fizs........�
THE COMMONWEAL40 MASS CHUSETTS
q BOARD OF HEALTH
....1...............OF............. �. °..�... 01..o.......... f.
Appliration for Uhipati al Works Tonstrnrtiun Prrutit
Application is hereby made fo/r�a Permit to Construct ( ) or Repair an an Individual Sewage Disposal
System at: ! • �-J��S• '±�-V
-••.--• .r.�n�.b.I l................................. ........................... .---- •-•---.--.._._....---.........
j� Location- ddress r Lo
ner (. Address
Installer Address
Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms......... ........... _._..Expansion Attic ( ) Garbage Grinder ( )
Other—Type e of Building No. of persons............................ Showers
YP g -•-------------------------• P ( ) — Cafeteria ( )
a' 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........................................
a
,.� Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit....................•Depth to ground water........................
04 --••------ •
0 Description of Soil..............�..�`.�� ................................ ....................-----------. ..................................- -.....................
W4
U ---------------------
•-•-----------------------------
--------------
•-•-------------------------
._.......-------------------------------------------------------
-----------------------
---------------•-
W •••--•-••-••-----•••-----------•----------------------••....--•-•--•-----•--•--•--••----------------- --- -
/�
U Nature of Repairs or lterati9ps— nswer when applicab _... . .� .._.._._f e _ '
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of LITLL 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of he lth.
Signed-_.. O
Application Approved By_- .. . -----• ........ '.._.._..
Date
Application Disapproved for the following reasons-------------•--------------•----.....---------------•---------•---•-------------------------------•------....._
......................................................... ----....-•--- -�-----•---------------------------------- •---------------- -•--------------•-•---•---
ao,
Permit No. •---•---...... Issued_ ag A
--------------------•--. -----•--...._...----•-•----•---Hate......
Date
.. ��........- ----------------------------
l Q,CA T ION 3 S E W A. G E PERMIT NO.
K
` e'
VILLAGE
e
INST LER'S NA i ADDRESS
Se�P
BUILDER OR OWNER
0AT, E PERMIT ISSUED
OAT E COMPLIANCE ISSUED _a � _ 2
EEi"+
r
,.. ,
� r �
�S� �i
�,
�� �
4 �., r
Q
i ��
��
o `
�`� � c� �� ' cr
G f f� '�
No....................... Fmc � ..:
At.
s THE COMMONWEALTH OF MASSACHUSETTS
� - BOAR® OF HEALTH ��
x Q�f� . ... .....OF......-..��,.-.1 /�
Appliration. for lliipoiia1 VurkB C omtrurtion Vamit
f ,Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
ystem at
......... ;�' G..-=1-•-• .......... ......................................... ........ - -••-
o tion- d ss or Lot No.
ner ddrWY
a •••--•-•------•=--•----•-•••- ... - .................................................... ..................... ........................................
Installer Address
UType of Building Size Lot............................Sq. fept
a
Dwelling—No. of Bedrooms........._ __________________Expansion Attic ( ) Garbage 'Grinder aj
Y
p-, Other—Type of Building ____________ ___________ N o ,e sons__.___.___ ____________ Showers ( ) — Cafeteria ( )
Q' Other fixtures ✓��� - ----------•---
Design Flow___:_.____._��. ._____. ? gallons per person per ay. Total daily flow............................................gallons.
W ,.t�lL
WSeptic Tank-•Liquid capacity _ __ allons Length---------------- Width................ Diameter________________ Depth................
Disposal Trench—N _____________________ Width_.___...__._..._-___ Total Length....._______y Total leaching area sq.
ft.
Seepage Pit No________ _________ Diameter._._.._��-_.___. Depth below/inlet___...__L?__.___. Total leaching area__�_ i sq. ft.
z Other Distribution box ( ) Dosing tank ) ,(�- �, 7 '
Percolation Test Results L Performed b -__._ __. __ ___________________________________ Date...... __= _:d�U._,_______-.
Test Pit No. 1_.�-_.___.minutes per inch Depth of Test Pit____________________ Depth to ground water_-___________________
(14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water--______-_____________-_
a ----------
O Description of Soil--------�-`--- _ . -p••-• -------- 4.1... 5.1
x
W
UNature of Repairs or Alterations—Answer when applicable------------------------------------------------------------------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of'TT
p S of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been iss d the board of health.
Signe ._ •-- - - ---_••--•----- ---------••_... --•----•-•-••-
D e
Application Approved By........ --••-•-•-• -••---•••---•. 7 3l =-
Ly�/ ��Date
Application Disapproved for the following reasons------------------------------------------------- ---------------- -�--- -------------•----
••-------••---------•-•-----------------------------------------•--------------------.....-•---------------••-•-•---••-------••--••-----•-••----••••--•--•---------------•-----•....--••--••--•-•-------
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS Finc
8 2• tJ3� BOARD OF HEALTH
• X..
Ci
, pplirn#ion for Bhipo,13Fal Works Tnntrnrtiun Virmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at {
L/ anon- dress
e or Lot No.
a ....................._p..r......_�
-•-•---.... -•-•---•- -••-•-•--•---- .......................................
wne.r - -........
----...-•------ •---........ % -� --------•............ ----------------
---•-_...
Installer Address
d Type of Building' Size Lot............................Sq. fept
Dwelling—No. of Bedrooms....... r1--------____-----------------Expansion Attic ( ) Garbage Grinder ((
W a. Other—Type of Building - , No of �sons__..._.................. Showers
( ) — Cafeteria ( )
Otherfixtures -------•-- ........------------------------------------•-••••............----
W Design Flow....-------- -• � ---g allons per person er 459 Total daily flow--------------------------------------------gallons.
W 'Septic Tank Liquid capacity allons Length................ Width Diameter---------------- Depth................
g P P P Y• Y g� i
x Disposal Il rlat Total n Total leaching
fi --------
Seepage Pit No. _�Daete4)_____- De tw _ Toal leachig_ _ :______. beloinlet_...___ ! ___ t _.__... q. ft.
Z Other Distribution hoxg;(005 Dosing tank ) , kr
W Percolation Test Results Performed by..__. .{_.. ram-!
Date - -
,� Test Pit No. 1..,,�,�""-minutes per inch Depth of Test Pit.................... Depth to ground water.........................
(? Test Pit No. 2.....>; niinutes per inch Depth of Test Pit.................... Depth to ground water........................
r
�/ - -_. .. ..
O Descriptiori o s Soil------... �--------1-•.. . ..... ........ ...... ...
._._.
V ----------------•-•-•---•••-----•••••••....-•-•--•--••----•--•-••----••--•-----•-•••------------••--••••••-••---•--•-------•-----•--•--•-----•-•----------••--•----•---•---
W
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
.............................................. 1.;, �4«...,.,_........__.................----...._._.._.._...------...................._.......r---._...............------.....-...----._........_.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT
p 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issu d the board of health.
Signe .__... .......................
-- -----• •.••--- --------•--•-••-----•--••------•
Application Approved By.. - ...--............ Qll.114..._7l,�1-�-�:----•-•...
. tf Date
Application Disapproved for the following reasons:_:_.:'.-----------------------------`---`------ --------------------_------ -_------ ------------_-__--
---------------------------------••-•-----••-----•----•-- --•--------•--•--------.....--------••-----------••-•-•-----••----------•--•••••----•-._...--•••-•-----------•------•---•-•••----••-•---••-•--
Date
PermitNo....................................................=---- Issued......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O HEALTH
.........................OF......... .... . .... .......%_........................................
QUrrtifiratr of TontpliFanrr
THIS IS TO CERTIFY what Individual Sewage Disposal-System constructed (4-11—OT Repaired ( )
-
�'/ r Insta11
at e tom" /G./Y, 2 ;y l !- /he.,
. "_..�--..-- --------------------
has been installed in accordance with the provisions of TI r j oftate Sanitary Code as descri e in the
a lication for Dis osal Works Construction Permit No -__. _:_ `PP P r -_ -- - _1 Iodated-- ---- .�X f..'. .............
THE ISSUANCE OF THIS CERTIFICATE SHAL�"NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE__..........•--•................ .......... Inspector.....u��}'� f< < /
F✓.
THE COMMONWEALTH OF MASSACHUSETTS
8�~y� BOARD OF HEALTH
s
I FEE.- -----.....--••--~
Rapos al orkii �nnntnrtion unfit ,p. k
Permission s reby grant d........... --------------•----•----....---•-
to Constru ( rpai ) an Indi ual S ,v�rage fsposal System
at No.__-rF� - > :: :---------�- --•••-•••--
,/
V � Street
iA
as shown on the application for Disposal Works Construction Per No._�.._._.._._�a d....... ..........�::..__......_.._._..
f r
Bo r(V o Hea th f
DATE - -------•--••-• 'A� /
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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} LEGEND
'EXISTING SPOT ELEVATION Ox0 >.: CERTIFIED ' . PLpT PLAJ r � +Y�
EXISTING.. dONTOUR
FINISHED SPOT ELEVAT'l0N . . !0_0 LvT �,.,Ct4t►�dM �� @Y
FINISHED CONTOUR - ® MA''l�:S �N`�'
.� E D ® a O F �a i Id
APPROVED -, BOARD 1 -HEi4LTH
,06
DATrE AGENT* SCALE .DATET
fir—_P EOGEk ENG1NEER1 NG CO. INd% Y
CLIENT _. G �/Ns Q
- = ; I CERTIFY THAT. THE ''pR'0PI ,f d
ECISTERE REGISTERED) J0® NO-'77 0R'2 BUILDING SHOWN- ON ',THIS r'PL , aK'
,CIVIL`' '' LAND i
CONFORMS; TO ZONINGrI�a Sf '
ENGINEERS, l- SURVEYORS;) DR. BY' ' �._, �} -_./u%
__ 0 F B'A•R N S T BLE ;, MASS. 5
j m 33 ti( , MAIN S 712 MAIN .aT CH 8Y '
SO YA`RMO.t�1Fi MASS.— HYANNIS MAS ,:
�. SHEET__A. OF s—''_ DATE '. REG.- LAND `'.SURV s'z
+�...A`�)fµ�,�.._'.Y..•\-.-a. �'1..Y;..u.: _ , _ .•r:�. (.-s.'. 4.,.-.. _.. ...- ,r ,. r .. d. :+ ! umv..R +-. C k ' � > ,FY. �i k ' d�.,.w;��a�'.et St,
1- ` 4 .. r' ,3 T+� �! 1.�. •'C '� .I. _ M1 4, �K `y 13 w.,,wY � f� ? t..:l
•
N 0 7'E !/C E/T_ NER 7-1-1 S P TI C TA
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t ,. Piz- AN,= MORE �77RA,V 9ELOW
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'CONCRETE :• �, t 4PVC P/P.� �• � -
A
—,--c--1 /Et/. 0 0,0 I�/M. P/TCsd h(ER v.y. CA ST/?O/Y C o ER C3E USED
' NCO l/E!?S
.o_i f `!-- �2� i�9//d. CO/VC.QE•TE _ '
/� CL GR.4oE CU ✓ER E.4N SANG
�.�•' .� _ °: L/QU/O LEVEL � .'�
4^CAS
( IRON P/PE 2 LAYEIP
i T MI_N. v/TCN ✓ OU t. GAL. p � � f • •I • • • . . • ►, �o o %8�-3/B'"
_StPT/C TANK ' A WA5HEV 5701V—
/9 PERfT' G D/ST, o yfsoia • • • • o f oon '
BOX ° n • f � $ • •. eo • � o o aQ
ri v ° —
J ��i o o � f f •E1=FECT'/✓E' •�q � v _ 3/4., / /2•,
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o i f o. o • o o ® • 1 6 0
. _� a a o o� I f •� • O . s • I o �p n P
o v.e c ��,' � • o� o, o • • • . f� p o v�--- PiPEC,,q.�T SE.EPAGE
/N(/e/�T ELE'/AT/B/V,S r f ■i • o a o • • e e ° o P!7 OR EQU/V
IM!/ERT AT BU/LD/MG 9 %-AFT
INLET SEPr/C TA/VK 97 FT ���. . IFIT,, Z?1AM �;\ C SEE TldULA7
PUTLET SEPT/C TANK _FT.
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INLET Zi1ST/4/BUTIDN BOX 9�� FT. GROUNo HI,gTER T,4BLE
Dune D/STR/BUT/ON BOX _
INLET LEACH//Va /��T FT 6eWACE A0ISP0SAL SYSTE/a1 +
LEACH//VG. P/T 7A46IJLATIONI -
SC.ALE / ( UIMENS/ON A 2-a--FT.
DES/GN CR/TER/A1 /4 = / o
D/MENS/aN $--S2_ FT.
_- - NUMBER OF BEDROOMS � 3 - Q/MENS/ON C 4 F'j; M.../N•
° � GARBAGEp/SPOSAL (/iy/r_-: � . ' � _. SOIL • LOG
TOTAL EST/rraTeo"f-LOPV O G.4L.�DAY` SOIL. ,TEST / SOIL TEST#2 SD%L TEST
NUMBER OF .:EacHlNG f�/T�_, I ELEY. ELEY,_`�5,�
S/OE LEACr!!NG PEfZ PLT• 'S� FT.* ' / r / d 0A E OF So I L TES•T.._ 3 13 ,:?U
RESULTS WITNESSED dY _�� 60Ao'P/C-)S
60TTOM LeiACN/NG PER NIT 7.. $Q. FT, L.v�t-44 1-D� �J L �ot`IVCOLA W01V DATE / LEr{g.5 ----
TOTAL LEAC'N/ivG AREA � � M/N�/NCH
sq FT f Stir3S�/t. pERCOLATio/v RATE 2 T
RESERVE LEACHING AREA_2"� SQ.' FT v'JJ OIL_, / MI/v /lNCN
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