HomeMy WebLinkAbout0051 CROOKED CARTWAY - Health 51 Crooked Cartway Road
Marstons Mills ,
=A 065-010
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I
Commonwealth of Massachusetts
0tp5- 010
. Title 5 Official Inspection Form
a
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments s
51 Crooked Cartway Assessor's Map: 65 Parcel: 10
Property Address
Thomas M, and Janine M. Robertson
Owner Owner's Name
information is
required for every Marstons Mills MA 02648 March 31, 2018
page. City/Town State Zip Code Date of Inspection A=
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
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not David D. Coughanowr
use the return Name of Inspector
key.
Eco-Tech Rapid Response
r� Company Name
155 George Ryder Road South
Company Address
Chatham MA 02633-1621
City/Town State Zip Code
508 364-0894 1328
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
�ZH OF MAS
❑ Needs F au he Local Approving Authority
o DAVID
o D.
Z� U HANOWR
March 31, 2018
Inspector's Sig re p�c G/STE Date
M
The system ins it a copy of this inspection report to the Approving Authority (Board
of Health or DEP) wi I 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 should be sent to the system owner and copies sent to the
buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
C4M , 51 Crooked Cartway Assessor's Map: 65 Parcel: 10
Property Address
Thomas M, and Janine M. Robertson
Owner Owner's Name
information is required for every Marstons Mills MA 02648 March 31, 2018
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
Inspector's Notes==> The septic system described herein is deemed to pass this Real Estate
Transfer Inspection if it does not meet any of the failure criteria enumerated in Section D on pages 4-
5, or specified by local regulations. The scope of this inspection is limited to health and environmental
compliance and the septic system has been evaluated according to the conditions observed on the
day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing
determination.
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
a ,
❑ Y ❑ N ❑ ND (Explain below):
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 51 Crooked Cartway Assessor's Map: 65 Parcel: 10
Property Address
Thomas M, and Janine M. Robertson
Owner Owner's Name
information is required for every Marstons Mills MA 02648 March 31, 2018
page. CityTrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms 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 accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
o�^M 51 Crooked Cartway Assessor's Map: 65 Parcel: 10
Property Address
Thomas M, and Janine M. Robertson
Owner Owner's Name
information is required for every Marstons Mills MA 02648 March 31, 2018
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well"*.
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than %day flow
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
wM 51 Crooked Cartway Assessor's Map: 65 Parcel: 10
Property Address
Thomas M, and Janine M. Robertson
Owner Owner's Name
information is
required for every Marstons Mills MA 02648 March 31, 2018
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�^M 51 Crooked Cartway Assessor's Map: 65 Parcel: 10
Property Address
Thomas M, and Janine M. Robertson
Owner Owner's Name
information is required for every Marstons Mills MA 02648 March 31, 2018
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:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 300 gpd
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
51 Crooked CartwaY s Assessor' Map: 65 Parcel: 10
Property Address
Thomas M, and Janine M. Robertson
Owner Owner's Name
information is required for every Marstons Mills MA 02648 March 31, 2018
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 1
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)): 177 gpd
Detail:
2017: 65,000 gallons 2016: 64,000 gallons
Sump pump? ❑ Yes ® No
Last date of occupancy: Current
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Com
monwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 51 Crooked Cartway Assessor's Map: 65 Parcel: 10
Property Address
Thomas M, and Janine M. Robertson
Owner Owner's Name
information is required for every Marstons Mills MA 02648 March 31, 2018
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: owner's agent
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: 1000
gallons
How was quantity pumped determined? Disposal Works Permit
Reason for pumping: maintenance
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):
Septic Tank and Leach Pit
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
J
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 51 Crooked Cartway Assessor's Map: 65 Parcel: 10
Property Address
Thomas M, and Janine M. Robertson
Owner Owner's Name
information is required for every Marstons Mills MA 02648 March 31, 2018
page. CityTrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
Age: 43+ years. Certificate of Compliance for a new system was issued 1/31/1975 (Permit#75-14 at
Health Department).
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 2
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 evidence of leakage or backup into dwelling.
Septic Tank(locate on site plan):
Depth below grade: 2
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 8.5' x 5' x 6-1000 gallon
Sludge depth: 10 inches
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
51 Crooked Cartway Assessor's Map: 65 Parcel: 10
Property Address
Thomas M, and Janine M. Robertson
Owner Owner's Name
information is required for every Marstons Mills MA 02648 March 31, 2018
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle 24 inches
Scum thickness 4 inches
Distance from top of scum to top of outlet tee or baffle
8 inches
Distance from bottom of scum to bottom of outlet tee or baffle 12 inches
How were dimensions determined? Disposal Works Permit
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank was pumped at time if inspection for maintenance. Maintenance pumping is recommended
every 2-4 years with year round occupation. Tank and tees appear structurally sound and functioning
as intended. No evidence of leakage in or out was observed.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
51 Crooked Cartway Assessor's Map: 65 Parcel: 10
Property Address
Thomas M, and Janine M. Robertson
Owner Owner's Name
information is required for every Marstons Mills MA 02648 March 31, 2018
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete El metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
i
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
51 Crooked Cartway Assessor's Map: 65 Parcel: 10
Property Address
Thomas M, and Janine M. Robertson
Owner Owner's Name
information is Marstons Mills MA 02648 March 31, 2018
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Pump Chamber(locate on site plan):
Pumps in working order: ElYes ❑ 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:
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
51 Crooked Cartway Assessor's Map: 65 Parcel: 10
Property Address
Thomas M, and Janine M. Robertson
Owner Owner's Name
information is required for every Marstons Mills MA 02648 March 31, 2018
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
No evidence of surface ponding, breakout, lush vegetation, or other evidence of hydraulic failure was
observed. A hole was dug into leaching pit stone and no effluent contact staining was observed in the
stone or overlying soils. No standing effluent was observed to a depth of 2 feet below the top of the
leach pit
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth —top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
51 Crooked Cartway Assessor's Map: 65 Parcel: 10
Property Address
Thomas M, and Janine M. Robertson
Owner Owner's Name
information is required for every Marstons Mills MA 02648 March 31, 2018
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 51 Crooked Cartway Assessor's Map: 65 Parcel: 10
Property Address
Thomas M, and Janine M. Robertson
Owner Owner's Name
information is required for every Marstons Mills MA 02648 March 31 2018
page. —City/Town - ---- State-----Zip-Code------Date-of-inspection-- --.—----
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
❑ hand-sketch in the area below
❑ drawing attached separately
SEPTIC�N F SAT NOT
EC® TO
SCALE
rDWELUNG
� L Oo CAA §Oo nMS
—OF SEPTIC COMPONENTS
—DISTANCES IN DECIMAL FEET
A B
B 9 1 21.5 37.5
2 26 44
3 41.5 57.5
A
1
THIS SKETCH IS 1000 GALLON
BEST VIEWED IN SEPTIC TANK
COLOR FORMAT >-
Q 2
LEACH
PIT
;o W
_j
� PESQe
508 364-0894
CROOKED C A R T WA Y
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
0 51 Crooked Cartway Assessor's Map: 65 Parcel: 10
Property Address
Thomas M, and Janine M. Robertson
Owner Owner's Name
information is required for every Marstons Mills MA 02648 March 31, 2018
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 50+
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:
Barnstable GIS Department records
You must describe how you established the high ground water elevation:
Town of Barnstable GIS Department records indicate that the property is over 50 feet above Little
Pond
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 51 Crooked Cartway Assessor's Map: 65 Parcel: 10
Property Address
Thomas M, and Janine M. Robertson
Owner Owner's Name
information is required for every Marstons Mills MA 02648 March 31 2018
page. -City/Town -- State---Zip-Code ----Date-of-Inspection. _
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
GEOHYDROLOGICAL PROFILE
- NOT TO SCALE
+qe
PRECAST
g �
LEACH
PIT
-
B :
O
to BOTTOM
OF
LEACHING
PIT
LEACHING IS
ABOVE HIGH
,GROUNDWATER
V
ITTLE POND ELEVATION
ER GIS MAPS
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
7
v"
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Dept. of Environmental Protection
One winter Street Boston,Ma. 02108 .Jo1ut Grad
' D.E.P. Title V Septic Inspector
P.O. Box 2119
Teaticket, MA 02536
WILLIAM F.WELD (508)564-6813
Governor.
ARGEO FAUL CELLUCCI
U.Governor �
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A \'
CERTIFICATION
4.
o j t'1
Property Address: 51 Crooked Cartway Marstons Mills Address of Owner: - F E B 5 1998 A
Date of Inspection: 1/21/98 (If different)
Name of Inspector: John Graci Pat Davis i ; ,,1OFF'P?,'-,BLF
I am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000)
Company Name,Address and Telephone Number:
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 InTM*V
_ Conditionally Passes code 310 CMR 15203.My findings are orhowthe system Iq
performing at the time of the Inspection.My Inspection does
_ Needs Further Evaluation By the Local Approving Authority not Imply any warrantyor guarantee of the long•vgyo'the
Fails septic system and any of Its components usarul Itfe.
Inspector's Signature: Date: 1121198
The System Inspector 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.
COMMENTS:
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,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 conforming septic tank
as approved by the Board of Health.
(revised M7197)
One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 IS Telephone(617)292-5500
a '
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 51 Crooked Cartway Marstons Mills
Owner: Pat Davis
Date of Inspection:1121M9
_ Sew.acie backuR or.breakout.or. hioh.static water level observed.in.the distribution box is due to a broken,
or obstructed pipe(s)or due to broken,settled or uneven distribution box.The system will pass inspection if
(with approval of the Board of Health). Describe observations:
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 watersupply 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 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 presense of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method usedto determine distance (approximation not valid)
3)Other
D] SYSTEM FAILS:
You must indicate either"Yes"or"No"as to each of the following:
_ 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.
Yes No
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 0412747)
r '
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 51 Crooked Cartway Marstons Mills
Owner: Pat Davis
Date of Inspection:1121199
D]SYSTEM FAILS(continued)
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 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:
You must indicate either"Yes"or"No"as to each of the following:
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:
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)
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 0412V97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECLIST
Property Address: 51 Crooked Cartway Marstons Mllls
Owner: Pat Davis
Date of Inspection:1121199
Check if the following have been done:YGU must indicate either"Yes"or"No"as to each of the following:
_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.
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.
x The size and location of the Soil Absorption System on the site has been determined based on
— — The facility owner(and occupants, If different from owner)were provided with information on the proper maintenance of
Sub-Surface Disposal Systens.
x Existing information. Ex. Plan at B.O.H.
x Determined in the field(if any failure criteria related to Part C is at issue,approximation of distance is
— — unacceptable)[15.302(3)(b)]
(revleed 03127)87)
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 51 Crooked Carlway Marston Mills
Owner: Pat Davis
Date of Inspection:1121198
FLOW CONDITIONS
RESIDENTIAL:Design flow: g•pd/bedroom for S.A.S.
Number of bedrooms: 3
Number of current residents: t
Garbage grinder(yes or no): No
Laundry connected to system(yes or no): Yes
Seasonal use(yes or no): No
Water meter readings,if available:(last two(2)year usage(gpd):
rda
Sump Pump(yes or no): No
Last date of occupancy:nla
COMMERCIAL/INDUSTRIAL:
Type of establishment: ^ls
Design flow:11 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: nra
Last date of occupancy: n1a
OTHER:(Describe) rva
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System was last pumped last summer.
System pumped as part of inspection:(yes or no)No
If yes,volume pumped:G gallons
Reason for pumping: rda
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)
I/A Technology etc.Copy of up to date contract?
Other:
APPROXIMATE AGE of all components,date installed(if known)and source Information:
22 years
Sewage odors detected when arriving at the site:(yes or no) No
(rsvlsedo4r27)8T1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 51 crooked Cartway Marstons Mills
Owner: Pat Davis
Date of Inspection:1121199
SEPTIC TANK: x
(locate on site plan)
Depth below grade: 2'
Material of construction:x concreate_metal_FRP_Polyethylene—other(explain)
If tank is metal, list age nia . Is age confirmed by Certificate of Compliance No (Yes/No)
Dimensions: Le5••1467•'w410'•
Sludge depth:2"
Distance from top of sludge to bottom of outlet tee or baffle:25"
Scum thickness:4"
Distance from top of scum to top of outlet tee or baffle:6"
Distance form bottom of scum 10 bottom of outlet tee or baffle: 14"
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.)
Sep6e tank and all components ere structurally Bound.Recommend pumping every two years.
GREASE TRAP:
(locate on site plan)
Depth below grade: roa
Material of construction: _concrete_metal_FRP_Polyethylene_other(explain)
Dimensions: nla
Scum thickness:rda
Distance from top of scum to top of outlet tee or baffle:rda
Distance from bottom of scum to bottom of outlet tee or baffle:nle
Date of last pumping;d,
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.)
nfa
BUILDING SEWER:
(Locate on site plan)
Depth below grade: 2V
Material of construction:_cast iron x 40 PVC_other(explain)
Distance from private water supply well or suction line?
Diameter: 4•
Qgmments:(conditions of joints,venting,evidence of leakage,etc.)
(revised 0412787)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 51 crooked Cartway Marstons Mills
Owner: Pat Davis
Date of Inspectlon:11211ltit
TIGHT OR HOLDING TANK:
(locate on site plan)
Depth below grade: rda
Material of construction:_concrete_metal_FRP_Polyethylene_other(explain)
Dimensions: rde
Capacity: We gallons
Design flow: rda allons/day
Alarm level:_n1a Alarm in working order?_Yes_No
Date of previous pumping:
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
rds
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert: We
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box etc.)
rda
PUMP CHAMBER:
(locate on site plan)
Pumps in working order:(yes or no)No
Alarms in working order(yes or no)Yes
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
rda
(revised 04127197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 51 Crooked Cartway Marstons Mills
Owner: Pat Davis
Date of Inspection:1121199
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:
nla
Type:
leaching pits,number: 1AW gallon roach pR
leaching chambers,number:nla
leaching galleries,number: nla
leaching trenches,number,length: nla
leaching fields,number,dimensions:rJa
overflow cesspool,number:nla
Alternate system: rva Name of Technology._we
Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.)
System and all components are strucb"lly sound.tt has never been more than 112 full.
CESSPOOLS:
(locate on site plan)
Number and configuration: rda
Depth-top of liquid to inlet Invert: nla
Depth of solids layer: nh
Depth of scum layer: nla
Dimensions of cesspool: Na
Materials of construction: Na
Indication of groundwater: n1a
inflow(cesspool must be pumped as part of inspection)
n!a
Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
rda
PRIVY:
(locate on site plan)
Materials of construction: Na Dimensions: rda
Depth of solids: Na
Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
roa
{revlaed 04r27)87)
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
• PART C
SYSTEM INFORMATION(continued)
51 Crooked Cartway Marstons Mills
Pat Davis
1121I98
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references, landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes into house)
(L" � R
� 3l6
�A
Page ! o! 10
(revleed04f27197)
I�
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
31 Crooked Cartway Marstons Mills
Pat Davis
1121199
Depth of groundwater 12.
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from design plans on record.
Observation of Site(Abutting property,observation hole, basement sump etc.)
Determine it from local conditions
Check with local Board of Health
Check FEMA Maps
Check pumping records
Check local excavators, installers
X Use USGS Data
Describe in your own words how you established the High Groundwater Elevation.(MUST be completed)
USGS Maps and Charts
I
(revlsed04r171S7) page 10 of 10
Z74
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LOCATIO ' `S� 5EWW. :�E PERMIT UO.
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BUILDER 5 Q4VAF- ,,t, ADDRESS
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DATE PERNAIT ISSUED
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD 9,F, HE T
.._.......OF........... -... ................. .. ...-------------------
Appliratinn -fear 11ap at parks Tono#rurtton Vrrntit
Application is hereby made for a Permit to Construct ( ) or Repair ( } an Individual Sewage Disposal
System at: /
• - ----------------------------•----- -•-•-------------••--•----- ...............................................................
L LocaOen.Address . or Lot No.
.........................••.. -• . -----•.. -•-----•--•---............................... ..................................................................................................
r ...............................•-Address
Installer Address
Q Type of Building Size Lot-_------------------------Sq. feet
U Dwellingk- of Bedrooms-_-� ..............Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( )
P' Oth r fixtures ---------------- ------------ - ------
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Design Flow----- _,.d__ _._ .............gallons per person per day. Total daily flow---------------------- � gallons.
WSeptic Tank 4"Liqui capacity/0-04allons Length................ Width---------------- Diameter....__.--------- Depth----------------
x Disposal Trench—No- -------------------- Width...... Total Length........... . Total leaching area_.__._.. ..._.._.__sq. ft.
-�_---- Depth below inlet/JD.......... Total leaching area �---sq. ft.
� Seepage Pit No------/............. Diameter------- p leaching area
z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by-----..................................................................... Date................--------------------._.
Test Pit No. 1................minutes per inch Depth of Test Pit--------------------- Depth to ground water.................-.-___-
riq Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
O ... ..........��� ----- -- ----------------•----•----------------•---••-•--•-•-••--••--•-••--..._..-•-•--------.
Description of Soil-y---,0--- j3-------_---------'� r
U ---------------------------~2- -�------------- � -- --- --- ----
W ��---- ----- ...`.. � �1 �'--� - - ------ ..
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U Nature of Repairs or lte ations—Answer when applicable.-.--_-------.-_-_..................................................................----------.
------------------------------------------------------------------------------------------------------------------ ------- -------------------------------------------------------- ----------------
Agreement: ,
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been is ed by he board of he t
Sig - -- ----------•--• ----•----..••-.-..-•----•-------
ate
Application Approved BYL -- --• --- ...--- -- ��---.:-• 'Z� . �`-5-....
Date .
Application Disapproved for the following reasons:........................................._-.--.-•--..........._.._....----------------.........--••-•-----_-....
-------------•--------...-------•-.------.•-•---..--••--------••---........--•-----------------•---•--••-..------•-•.--..._..--•---.................---•-----------.---_._........--•---•---......•-----
_ Date
PermitNo......................................................... Issued... 3' ------7.)...................
Date
No......7 ..... Fas: rr ...................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD g
H E T
--.OF........... _..................
ApVfira ian -fax 43 ,ipaaoal Workii Tonstrnrtian Prrati#
Application is hereby made for=a"P,&M' it to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
--u. . Aett- X�" ?7�-- -------------------•--..._.... --_-. ---------------- _'
Locatisn-Address or Lot No.
c
Address"
W r /
..- --- -•- --•-- •-- '- ---- ................................... : .. ...................................................
Installer Address
d Type of Building Size Lot............................Sq. feet
U Dwelling A!_No. of Bedrooms.._3-___________________________ Expansion Attic ( ) Garbage Grinder ( )
a Other—Type of Building ---..-_-________________ No. of persons............................ Showers ( ) — Cafeteria ( )
d Oth r fixtures
----- ------
Desi n Flow....... __d. Mons per person per day. Total dail flow______________________ �� gallons.
W I g �,, - -- P P P Y• Y �-------- --------g�
WSeptic Tank Liqui capacity/ allons Length................ Width................ Diameter__.----..-_- __ Depth-...._._-------
x Disposal Trench—No. .................... Width......I------------ Total Length...........------- Total leaching area--- -----sq. ft.
Seepage Pit No------/............. Diameter....... --------- Depth below inlet./��............ Total leaching area47.-_..sq. ft.
z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by...... ------------------------------------------------------------------- Date----•----------------------------------
Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water...-_-._-_-..-.._-__----
fi, Test Pit No. 2................minutes;p inch Depth of Test Pit ............... Depth to ground water------------------------
t--------
D Description of Soil-1...0 t -------- -.--
--- -- -- -- --
U 0------------k
V Nature of Pepairs or Rlte tionr'k s-Answer when applicable......._____________ _____________________ �'�
-Ir 4
- ---------------------------------------------------
Agreement:
The 'undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been iss ed by e board of he h
Sig ............. ................................
ate
Application`Approved BY - --•-
Date
Application Disapproved for the following reasons:.............................. Date
.............
Date
PermitNo......................................................... Issued...-•....................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD 9,F HEALT
'l !1.....:...........OF. .. .. .�......................
04rtiftrate of Toutplianrr
THIS I CEI�"TI. T e Individual Sewage Disposal System constructed ( �r Repaired ( )
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by......._. -
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nst e
at --------OeState - ----------------
has een installed in accordance with the provisions of :Article XI of Sanitary ode as describedin the
application for Disposal Works Construction Permit No.....7' ----_/�'............... dated'./ _ "7 S:."~"':....
THE ISSONCE OF THIS. CERTIFICATE SHALL NOT BE CONSTRUED AS A)GUARANTEE THAT THE
SYSTEM WIL1L FUNCTION 'SATISFACTORY. / �.
Jit -
DATE...................... .......= f E_: ?............................ Inspector. `'' t ...............L.........................................
1
THE COMMONWEALTH OF MASSACHUSETTS
' BOARD F HEALT
OF
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No. J FEE_
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�ia�a�ttt ,� nu r t $t �rratif
Perms ion�reby granted--•--r`. •--•-•-- ;
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t� ) .or parr ( , ) an 1 tdu l Se is o l''�Sys ,
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at No. �5; f' ! JL(l - + t -------- '�
treet / .
ass shown on t application for Disposal Works Construction Pere ------
Board of Health
DATE " ... • ............. ...........
FORM 1 5 HOBBS & WARREN. INC.. PUBLISHERS
t
TOWN OF BARNSTABLE
UNDERGROUND FUEL AND CHEMICAL STORAGE SYSTEMS
NAME 1 U Fy�M I (-V
ADDRESS VILLAGE dd 61UR LY -ALLr-S
LOCATION OF TANKS: CAPACITY: TYPE OF FUEL AGE: TYPE:
OR CHEMICAL CAq'ZUA1
LION GRou0 D R I&AT Fkml '#-00 Furl O/C S yes 0s a1 LT-
(Give same information for any additional tanks on reverse side of card)
DATE OF PURCHASE OF EACH: 1. 2. 3. 4.
DATE OF FIRE DEPARTMENT PERMIT: /0 _ cJc 9 S ���rFPPRot/iIC 7�3
TESTING CERTIFICATION SUBMITTED:
PASSED DID NOT PASS
�ENTERVJLLE ADpER DWARTMENT
.:
PE
BMIT FOR ..�"TORA 1�'EL =0'LL .
In accordance with provisjons of G4ia ,.G.-- and Regulations
made-under ukhbfii _ of.
Name Paul Davis e.............
o .. .
..... ....... ..... . ... ........ _....
dowser or occupant) , (Installer) ti g
10 Farmers ri11e, kco14xxpp�„ `y:.', Co:
AddressLot,
e on e��o n
Storage
,Burner a
Make ...CaS1121 .. dnk .oval se.�
NFant fact reT . CaY'1171„ COrp p, 1000 dais.(or)Size.
Mo,,jel No. flr Size.. .. ,.F. ?.r.:.graund,,x .frc
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r►�e.z .. ._.... ...Mass A } roval No�
.:Permii issl�ed 1 '
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i T-1 ad of Fire-Depar"rent .
UPON
(THIS.PERMIT MUST�E LDNSPI�U � ,
7HE PREMISES)
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