HomeMy WebLinkAbout0115 FOXGLOVE ROAD - Health .I15 g f oxglove aRoad
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No.....ZeL 2,?? 7i Fis....�/. . ...........
NO— THE THE COMMONWEALTH OF MASSACHUSETTS
! BOAR® OF HEALTH
..._.10��...................o F..... 1
ApplirFatiun for Disposal Works Tonstrurtiun Prrmit
Application is ereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
�
� �� r 'LL5
................_...... .�-...................._.. i ..........!..... v ............................................................
Location-Address � No.
Gam . P,�...._.., � ._..:. Lot .....AA
Owner Address
Installer Address
Type of Building Size Lot...20,.Z5._l_....Sq. feet
V Dwelling—No. of Bedrooms.............3...........................Expansion Attic (Ab) Garbage Grinder ( j
Other—T e of Building No. of persons............................ Showers
a Other—Type g ---------------•--•-•------- P ( ) — Cafeteria ( )
dOther fixtures ......................................................................................................................................................
Desi n Flow............. gallons per person per day. Total daily flow._........ -_�
W g �,�......... f8�---g P P �'°�o t, Y• � , o,f ---•....................... o gallons.
W Septic Tank—Liquid capacity.----....._.gallons Length. Width Diameter........... Depth..!to(
�T
x Disposal Trench—:�o. .................... Width.................... Total Length.................... Total leaching area...................sq. ft.
Seepage Pit No._._...._..................... Diameter....._5.......... Depth below inlet.....(0........... Total leaching area...P C"....sq. ft.
Z Other Distribution box (1-1 Dosing ta;ik ( ) S
Percolation Test Results Performed by �......L_..N.Y 9.........�.._.��oN.S.._.. Date.....::_��.'_�........
Test Pit No. 1........ per inch Depth of Test Pit----!_a,........_.. Depth to ground water.0V I*,?-r
4A Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
...........................A._._.....................
1_N... . � .............
.. ...............
Description of Soil.....�,> � ®1 . ® ........... -----------
..__..........._.......
.. - � .. -.-. v
---.------•-----------------------•----- -.�... ...-----•---•------------------------- •.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 TI:,
p 5 of the State Sanitary Code—T4 undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b sued b bo off heeaelt-h-.
Si ed..... � ` ` -
Application Approved ... -•-•-•----------•--...-------•--•...--•---------••--••--•-•-•-•-••-••------_.. y._l.. z_
Date -----•.'
Application Disa rov or he following reasons:...............................................................................................................
_
------------------------------•-----•--......_......_....---•------•-----•-•---............................................................
Date
PermitNo.......................................................... Issued.......................................................
- — - Date -- - —�
i�
ll
No......
.........._.....7% FES.............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
(0wo...................OF.................. � .................................
Applira#ion for Disposal Works Tongtrnrtion Famit
Application is hereby made for a Permit to Construct ( ) or Repair ( ' ) an Individual Sewage Disposal
System at: 4
.GoT 22 M� �oNS NI,I.I.S b Ott ov --------a�.................••--•------..............
................_ ......... ..............._.. .... ...... - -•-••----•-ocati Address t No.
- - out . ...��v l... �? �2~� Pf . 0.x..........�o.......Cc.nr�r .......E
A/,O.QwAer/ Address
p rN� rurY
.................................................................... --........------. �4!2.!V.`�T�R91?a...�
Installer Address ��
Type of Building Size Lot....
....,..... .......Sq. feet
Dwelling—No. of Bedrooms............. ..........................Expansion Attic (/�} Garbage Grinder (�
'_l Other—Type T e of Building ............... No. of ersons.._..._..............__.._.. Showers — Cafeteria
a YP g ------------- P ( ) ( )
04 Other fixtures ..------•----------------------------------•--•-•-•---••-•••-•-•••-••----••-•-----------------••••••••••--•-.................-••------...............
W Design Flow..............53............,� ..gallons per person per day. Total daily flow__........��.�.......................gallons.
W Septic Tank—Liquid capacity............gallons Length..!?..'....".. Width..-...�_......_ -
........�...
x Disposal Trench—No. .................... Width.................... Total Length............ Total leaching f area........:..... sq. ft.�} 13----
Seepage Pit No......................Diameter.......-............ Depth below inlet.....!........... Total leaching area...-...20...........sq. ft.
Z Other Distribution box Dosing tagk
WL IV E �OAIE =
Percolation Test Results Performed by................................................�J..----.....�!.... Date....... ...............................
aTest Pit No. 1........2...minutes per inch Depth of Test Pit.....�.�-'.......... Depth to ground water..vl?. .Y3,
Gz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
fi Ao Description of Soil Q- LOAM u ttw.....S h
. ..-- .......................U � ��-..t t... 1 N ....... :i4:W ------------•-•-•----•-•-----•. .._.......-•-------•--.....
W ••--••------------------------------------------------••••----------•---............-•••-•----•---------•••-•---------...--•.......----•...-•----------•------••---••--•----•--•--.....--•-•••--•-......
VNature 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 ILTLL 5 of the State Sanitary Code— T nhg undersigned further agrees not to place the system in
operation until a Certificate of Compliance has be sued b boa of health.
)D.
Sig.hed - ----•----- ------ •....... ........•---•------•----•---•--.....-- --•---
ApplicationApproved,BY -•----�---------------•---•------•-----------•----••--•----•-•---•-•---------------- ----•--` ! Dat
Application Disajjpprroove or .the following reasons:................................................................................................................
..................•........��,,, ......--•--------......••••-•-•-•-•--•----•---....•-••-••••--------••--••-••-•----------------•-•-•-•--------......•---•-...............Date--•-.....-----
k_
PermitNo......................................................... Issued-.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
_ BOARD OF HEALTH
......1 ouJN...................OF..........� IVS.ice....NC........--•--...............
Cnrrfif iratr of Toutplianrr
THIS IS= C,&,RTIF�Y�Thatithe ndividual Sewage Disposal System constructed ( V�/Or Repaired ( )
by-------------_---- •--• -•----•---••••.......................-------•----------------•----•-------•---••••---.....•--•----•-••-----•---.........•••-••--------...--•--..............--
Installer
l,!!j 2- e x ovE- �
at -- ----- ------- --•---- --.--....._._... ---- -- -- ----- --- ----
has been installed in accordance with the provi ons of T "-LE of The State Sa.nitaryj de s -cribed in the
application for Disposal Works Construction Permit N o------------------- -/� �
-------------- dated---------r---�...............................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE AS A GUARANTEE THAT THE
SYSTEM W L FUNCTION SATISFACTORY.
DATE...��`... Z.......................................................... Inspector...-- --- ........................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD2O.,,F HEALTH
,. !. uJM ..OF.........VNST �.E.......
No... •?....?. 1 FEE........................
Mspo nrhii Tonotr ion rrmi#
Permission is hereby granted.............l:� :1 _.._....._..__....._
---------•--•------------•---•-•-•------------•--•-•--....••••-•-•--•........................
to Constru or Repair ( an •ividual Sewage Disposal System
. ,
at N .......... -•---••---•-••---••--- ....................
•---------- -.
Street
as shown on the ppli ion for f ispo Works Construction Permit No.................... �a ed`` .... �...�..�...........
-••-••......---•••••......_... ........ • -••-•••••..........••-•••......--•••--
--- -------
Boa of Health
RVN 12 5 ,oess & WARREN. INC., PUBLISHERS
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USE 100o GAL..
p15Po5AL PIT V 1~ 1000 CsAL. /
Igo.
SOTTOM AREA s •. l o F•.
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'ToTA1- DA 1 LY FL-oW ' 330 G•PQ �7 1
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Commonwealth of Massachusetts0-
1 Title -5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
115 Foxglove Rd. ;
Property Address p�
Owner Mustone
information is Owner's Name "-
/ "k,.
required for Marstons Mills V MA 02632 10/19/18
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
A. Inspector Information si-ff j3q'4-i-
Frank Nunes III
Name of Inspector
saa
Company Name
Box 841
Company Address
East Falmouth MA 02536
City/Town State Zip Code
508.272.6433 X 13010
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title
5(310 CMR 16.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
10/19/18
InspectW tignat6w-` Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note:This report only describes conditions at the time of inspection and under the
conditions of use at that time.This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
115 Foxglove Rd.
Property Address
Owner Mustone
information is Owner's Name
required for Marstons Mills MA 02632 10/19/18
every 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:
2) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
I
Commonwealth of Massachusetts
F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
115 Foxglove Rd.
Property Address
Owner Mustone
information is Owner's Name
required for Marstons Mills MA 02632 10/19/18
every 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):
I
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N' ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18
Commonwealth of Massachusetts
F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
115 Foxglove Rd.
Property Address
Owner Mustone
information is Owner's Name
required for Marstons Mills MA 02632 10/19/18
every page. Cityrrown 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 passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
115 Foxglove Rd.
Property Address
Owner Mustone
information is Owner's Name
required for Marstons Mills MA 02632 10/19/18
every page. Cityrrown 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 Y 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 Il of a public water supply well
t5insp.doc•rev.7/26/201 S Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
115 Foxglove Rd.
Property Address
Owner Mustone
information is Owner's Name
required for Marstons Mills MA 02632 10/19/18
every page. CitylTown 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 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)]
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
115 Foxglove Rd.
Property Address
Owner Mustone
information is Owner's Name
required for Marstons Mills MA 02632 10/19/18
every page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): n/a Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): n/a
Description:
There are no engineering plans on file, the permit was not filled out to indicate the number of
bedrooms, the certificate of compliance on file states 2 bedrooms, the system is typical of 3+
bedrooms
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: Occupied
Date
15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
cam, Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
115 Foxglove Rd.
Property Address
Owner Mustone
information is Owner's Name
required for Marstons Mills MA 02632 10/19/18
every page. Citylrown 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: Pumped 2 years ago per owner
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How-was quantity pumped determined?
Reason for pumping:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
115 Foxglove Rd.
Property Address
Owner Mustone
information is Owner's Name
required for Marstons Mills MA 02632 10/19/18
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known)and source of information:
1988 per BOH record
Were sewage odors detected when arriving at the site? ❑ Yes ❑ No
5. Building Sewer(locate on site plan):
4'
Depth below grade: 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.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
r
cam, Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
115 Foxglove Rd.
Property Address
Owner Mustone
information is Owner's Name
required for Marstons Mills MA 02632 10/19/18
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
3'6"
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
H-10 tank appears to be structurally sound, inlet cover raised to 4"of grade
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000g
Sludge depth:
2"
Distance from top of sludge to bottom of outlet tee or baffle >12
Scum thickness trace
Distance from top of scum to top of outlet tee or baffle >211
Distance from bottom of scum to bottom of outlet tee or baffle
>2"
How were dimensions determined? measured
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pumping suggested every 3yrs to prolong the life of the system, pumping not necessary at this time
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
115 Foxglove Rd.
Property Address
Owner Mustone
information is Owner's Name
required for Marstons Mills MA 02632 10/19/18
every page. Citylrown 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
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
f
Commonwealth of Massachusetts
F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
115 Foxglove Rd.
Property Address
Owner Mustone
information is Owner's Name
required for Marstons Mills MA 02632 10/19/18
every page. Citylrown 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.):
D-box 43" below grade
t5insp.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
115 Foxglove Rd.
Property Address
Owner Mustone
information is Owner's Name
required for Marstons Mills MA 02632 10/19/18
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
If pumps or alarms are not In working order, system is a conditionalpass.
11. Soil Absorption System (SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
® leaching pits number: 2
❑ leaching chambers number:
❑ 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 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
115 Foxglove Rd.
Property Address
Owner Mustone
information is Owner's Name
required for Marstons Mills MA 02632 10/19/18
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System(SAS) (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
No adverse conditions at this time, Pit"D"was excavated, it is 4' below grade, 2"of effluent at this
time, no indication of past hydraulic failure, cover raised to 4" of grade
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
f
cam, Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
115 Foxglove Rd.
Property Address
Mustone
Owner information is Owner's(Name
required for Marstons Mills MA 02632 10/19/18
every page. Cityrrown 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.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
115 Foxglove Rd.
Property Address
Owner Mustone
information is Owner's Name
required for Marstons Mills MA 02632 10/19/18
every page. CitylTown 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
/,T
r
l_c--
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
115 Foxglove Rd.
Property Address
Mustone
Owner information is Owner's Name
required for Marstons Mills MA 02632 10/19/18
every page. City/Town 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: >15'
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:
Past inspection reports have GW>15', neighboring property eng. plan has NGW 132"
❑ Checked with local excavators, installers-(attach documentation)
® Accessed USGS database-explain:
TOPO mapping
You must describe how you established the high ground water elevation:
See above
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
115 Foxglove Rd.
Property Address
Owner Mustone
information is Owner's Name
required for Marstons Mills MA 02632 10/19/18
every 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 as completed appropriate
P
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
COMMONWEALTH OF MASSACHUSETTS
f EXECUTIVE OFFICE.OF ENVIRONMENTAL AFFAIRS
a DEPARTMENT OF ENVIRONMENTAL.PROTECTION
t
TITLE 5
OFFICIAL INSPECTION:FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL'SYSTEM F9
PART A RECi�E®
CERTIFICATION
MAY 2 12092
Property Address: b�
"d TC'.^.`" OF'r-ASTABLE
Owner's Name � Al cPT.
O
Owner's Address:
30
Date of Inspection: T_ ^ ��
Name of Inspector: please print). 4_ �T enr llp 1�-4' T
Company Name kdt'.�,�Xc-• MAP 1 h 4 ;
Mailing Address: .d t"i PARCEL : 30�O S
C9aCa _
,Telephone Number: Vie' nT
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the i.nformationrfponed
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:
d/ Passes
Conditionally Passes
Needs-Further Evaluation by the Local Approving Authority
Fail
Inspector's Signature: Date:
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection.If the system is a shared.system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the.
DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable, and the approving
authority.
Notes and Comments
****This report only describes"conditions at the time of inspection.and under the conditions of use at that
time. This inspection does not address how the system will.perform in the future under the same or'different
conditions of use.
Title 5 Inspection Form 6/192000 page 1
Page 2`of l I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
A
Owner: O
Date of Insp tion:
Inspection Summary: Check A,B,C,D or E LWAYS complete all of Section D
A. System Passes:
1 have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are:indicated below.
Comments:
B. System Con ditionally,HPasses:
One or more system,components as described in the"Conditional Pass"section need to be replaced or
re area"The system u on com: letion of the replacement or repair, as approved b the Board of Health will ass.
P system, P Y P P P � PP Y p
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please
explain.
,The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank.is replaced with a:complying septic tank as'approved by the Board of.H.ealth.
*A metal septic tank will:pass inspection.if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will:pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The.system required pumping more than 4.times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Health):.
broken pipe(s)are replaced
obstruction-is removed
ND explain:
. 2
Page 3 of Il
OFFICIAL INSPECTION FORM -;NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION-FORIVi
PART A
CERTIFICATION(continued).
Property Address:
Owner: � ��
Date of Inspe ion:
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
Z. 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 aseptic 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 I of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and SAS and the SAS is less than 100,,feet but 50 feet or more from.a
private water supply well"..Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered.A,copy of the analysis must be attached to this form.
I Other:
3
t ,
Page 4 of 1 l
OFFICIAL.INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
�J�
Owner: �(/, ,
Date of Ins a on:
P a
A System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"toeach of the following for all inspections:
Yes
V1 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
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
l water supply.
_ U Any portion of a cesspool or privy is within a Zone l 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. f This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic.compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen.is equal to or less than 5 ppm, provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
J�o (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E.' Large Systems:
To be considered a large.*systemahe system must serve a facility with a'design flow of 10,000 gpd to 15,000
.gpd•
You must indicate either"yes"or"no"to each'of.the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone I.I of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered
"yes"in Section D above the large system has failed.The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
4
i t T
Page 5 of 1.1
OFFICIAL.INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE`RISPOSAL SYSTEM INSPECTION'FORM,
`.PART B
CHECKLIST
Property Address: '
Owner
Date of Inspe on: _
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?
t/ _ 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
vl" _ Were the"septic tank manholes uncovered, opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction, dimensions,depth of liquid,depth of sludge and depth of scum?
Was.the facility owner(and occupants..if different from.owner).provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has been determined based on:
Yes. no
Existing information. For example,a plan.at the Board of Health..
Determined in the field(if any of the failure criteria related to Part C.is at issue.approximation of distance
is unacceptable) [310 CMR 15.302(3)(b)].
5
Page 6 of 1 l
OFFICIAL INSPECTION-FORM=NOT FOR VOLUNTARY ASSESSMENTS
•
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTI.ON.FORM
PART C
SYSTEM INFORMATION
Property Address:
Owner:. YC� '
Date of Inspec ton: Ga
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): : Number of.bedrooms(actual): 3,
DESIGN flow based on`310.CMR 15.203 (for example: 110 gpd x#of bedrooms):
Number of current residents: a
Doesresidence have.a garbage grinder(yes or no):-w` '.IX40V- . U4.0w
Is laundry on a separate sewage system(yes or t-. &-f if yes'separate,inspection required]
Laundry system inspected(yes or no): �
Seasonal use:(yes or,no): '
Water meter-readings if available(last 2 years usage(gpd)):
Sump pump(yes or-no):
Last date of occupancy: yo'o
COMMERCIAL/INDUSTRIAL. _/
Type of establishment:..
Design flow(based on 310 CMR.15.203): gpd "
Basis of design flow(seats/persons/sgft,etc,).
Grease trap present(yes or no):_
Industrial waste holding tank present(yes or no):_
Non-sanitary waste discharged to the Title 5 system(yes or no):-_
Water meter readings, if available:
Last date of occupancy/use:
OTHER.(describe):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system.pumped as part of the inspection(yes or no)�d•- V
If yes,volume.pumped: gallons--How was quantity pumped'determined?
Reason for pumping:
TYPE OF SYSTEM
_ S'eptic tank,distribution box,soil absorption system
Single cesspool
_Overflow cesspool
Privy
Shared system.(yes or no)(if yes, attach previous inspection records, if any)
_Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
_Tight tank _Attach a copy'of the DEP.approval
Other°(describe):
Approximate age of all components,date installed(if known)and source of information:
Were sewage odors-detected when arriving at the site(yes or not `.
6
Page 7 of 1 I
OFFICIAL.INSPECTION FORM-.NOT.FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM.INFORIVIATIO.N(continued)
Property Address:
Owner:/" � ? .
Date of Inspection: a
BUILDING SEWER(locate on site plan)114 l
Depth below grade:
Materials of construction:_cast,iron _40 PVC, other(explain):-
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC.TANK:4,41ocate on site plan)
Depth below grade:
Material of construction: ['concrete_metal_fiberglass___polyethylene
—other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a.copy of
certificate) {�
Dimensions: S X 69 'kr 5-
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle: 32-
Scum thickness:(o
Distance from top of scum to top of outlet tee or,baffle: u
Distance from bottom of scum to bo om of outlet tee or baffle: -�
How were dimensions determined:
Comments(on pumping recommendation!(, inlet and outlet tee or baffle condition,structural integrity, liquid levels
related to outlet invert, evidence of leakage, etc.):
1-7
&24C, Z1,21, A)W J2AAA &V4
GREASE TRA�(locate on.site plan)
Depth below grade:_
Material of construction:_concrete_metal_fiberglass_polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations, inlet and outlet.tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage, etc.):
7
Page 8 of 11
OFFICIAL-INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
:PART C
SYSTEM INFORMATION(continued)
Property Address:
Date of IsiP
s eLeion:
TIGHT or HOLDING TANI (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass_polyethylene other(explain):
Dimensions:_
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and-float switches, etc.):
DISTRIBUTION BOX: present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:��Gni ✓� 2
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of
kage into or out of box—etc.):
s c „ ,
PUMP CHAMBEI✓J�(locate on site plan)
Pumps in working order(yes or no): .
Alarms in working order(yes or'no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
8
Page 9 of 11
OFFICIAL INSPECTION FORM.—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: (al
Owner.
Date of Insp ion: U
SOIL ABSORPTION SYSTEM (SAS):. (locate on site plan,excavation not required)
If SAS not located explain why:
Type _
eaching.pits,number: P
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,
et .):
1? /006"qt_ &0X1 Zo 67 -Vill
G t°l e�Y/�I
CESSPOOL (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth—top of liquid to inlet.invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,.signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
PRIVX:,&d,�—(locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
9
Page 10 of 1]
OFFICIAL INSPECTION FORM.'NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property.Address:
�
.�l
Owrier:�,�
Date of Inspef, ion: 4lmoz 14.20OR
SKETCH'OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet.Locate where public water supply enters the building.
P PP Y g
yy 90
�g q9
. 6
10
f
Page I 1 of 1 I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C .
SYSTEM INFORMATION(continued)
Property Address:
Owner:`(/ e
Date of Insp ion:
SITE EXAM.
Slope
Surface water
Check cellar.
Shallow.wells
Estimated depth to ground water N feet
Please indicate(check).all methods used to determine the high ground water elevation:
Obtained from.system design plans on record-If checked,date of design.plan reviewed:.
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
----'Checked with local excavators, installers-(attach documentation)
Accessed USGS database=explain:
You must describe how you established the high ground water elevation:
/ _
P '
11
0 M-,v,
[q l
941
Permit Number: Date:
Completed by:.
HIGH GROUND-WATER LEVEL COMPUTATION
Site Location: �® �'(�C• Lot No.
Owner: l (�'f Address.-._��� D �,
Contractor:— ���OIy`3 C�,�9 -Address: S�eZ� oy�J�,
Notes:
STEP. 1 . Measure depth to water table.
tonearest.1110`ft...............................................;.......................:............ .Date _—�—
month/day%year
STEP- 2 Using.Water-Level.Range Zone '
and Index W61[:M:a.p.locate
site an.ddetermine:
L
O Appro.priate.index well-...................... -
Water-level range z.one.:-............_....._....
STEP::3:. Using monthly.repo.rt,:"Current
Water Resources Conditions"
determine currentdepth to ����� �T
water.level for index well ...........................
51
month/year
STEP. 4. Using:Table.of•Water-level Adjustments
for index well (STEP 2A),..current depth
to waxer 1evel for index well (STEP 3):,
and water-level zone (STEP 2B)
determine water-level adjustment ..................
STEP, 5 stimate depth to high water
by subtracting the water
level adjustment..(STEP 4)
from.measured.depth to water
level-at site.(STEP 1) ............
Figure 11--Reproducible computation form;
i
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS John Grad
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: 116 FOXGLOVE RD. CE RVILLE MAP 149 PAR 130 L 22
Name of Owner KAVANAUGH
Address of Owner: SAME \n `� 8 . ..J 9�
Date of Inspection: 8/16199 V
Name of Inspector:(Please Print)JOHN GRACI
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) �, S,
�p 1 Fp
Company Name: n/a �{` 0
Mailing Address: n/a 4 Tofy4o �9
Telephone Number: n/a b �'Bqy �,�
r 'I�0 'YF
�•.
r
0
CERTIFICATION STATEMENT
f „
I certify that I have personally inspected the sewage disposal system at this address and that the information reported bel'ow�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 Ev a n 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:8/17/99
The System Inspector sh II submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of
completing this inspectio .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.
NOTES AND COMMENTS
THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING THE 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: 115 FOXGLOVE RD.CENTERVILLE MAP 149 PAR 130 L 22
Owner: KAVANAUGH
Date of Inspection:8/16/99
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:
nLa 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 se Ptic 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.
Wa 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
nta 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: 116 FOXGLOVE RD.CENTERVILLE MAP 149 PAR 130 L 22
Owner: KAVANAUGH
Date of Inspection:8116/99
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.
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 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: 115 FOXGLOVE RD.CENTERVILLE MAP 149 PAR 130 L 22
Owner: KAVANAUGH
Date of Inspection:8/16/99
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 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: 115 FOXGLOVE RD.CENTERVILLE MAP 149 PAR 130 L 22
Owner: KAVANAUGH
Date of Inspection:8/16199
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)
11 5.302(3)(b)j
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: 115 FOXGLOVE RD.CENTERVILLE MAP 149 PAR 130 L 22
Owner: KAVANAUGH
Date of Inspection:8/16199
FLOW CONDITIONS
RESIDENTIAL:
Design flow:-=g.p.d./bedroom
Number of bedrooms(design): 3 Number of bedrooms(actual):.a
Total DESIGN flow: =
Number of current residents:-1
Garbage grinder(yes or no):M
Laundry(separate system)(yes or no): NO If yes,separate inspection required
Laundry system inspected(yes or no):M
Seasonal use(yes or no):DLO
Water meter readings,if available(last two year's usage(gpd): n1a
Sump Pump(yes or no): NQ
Last date of occupancy: nla
COM M ERCIALrINDUSTRIAL
Type of establishment: n1a
Design flow: n1a gpd(Based on 15.203)
Basis of design flow: Wa
Grease trap present:(yes or no):DLO
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:n1a
Last date of occupancy: n&
OTHER: (Describe)
n1a
Last date of occupancy: n&
GENERAL INFORMATION
PUMPING RECORDS and source of information:
SPRING 99
System pumped as part of inspection:(yes or no):MQ
If yes,volume pumped n1a_ gallons
Reason for pumping: n&
TYPE OF SYSTEM
X Septic lank/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: Wa
APPROXIMATE AGE of all components,date installed(if known)and source of information:
THE Y T M IS 16 YEARS ni D
Sewage odors detected when arriving at the site:(yes or no): N_Q
revised 9/2198 Page 6 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 115 FOXGLOVE RD.CENTERVILLE MAP 149 PAR 130 L 22
Owner: KAVANAUGH
Date of Inspection:8/16199
BUILDING SEWER:
(Locate on site plan)
Depth below grade: V 6"
Material of construction:_ cast iron _40 PVC X other(explain)
Distance from private water supply well or suction line: TOWN
Diameter: nta
Comments: (condition of joints,venting,evidence of leakage,etc.)
nta
SEPTIC TANK: X
(locate on site plan)
Depth below grade: V
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): No
n(a
Dimensions: L8'6"H 5'7"W 4'10"
Sludge depth: 1'
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness:-Q
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle: n&
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 TR TURA Y OUND R COMM ND P h^PIN VERY TWO YEARS FOR MAINTENANCE
GREASE TRAP:
(locate on site plan)
Depth below grade:
Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain)
nla
Dimensions: n/a
Scum thickness: nta
Distance from top of scum to top of outlet tee or baffle:Jl(a
Distance from bottom of scum to bottom of outlet tee or baffle nta
Date of last pumping: nta
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.)
Wa
revised 9/2/98 Page 7 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 116 FOXGLOVE RD.CENTERVILLE MAP 149 PAR 130 L 22
Owner: KAVANAUGH
Date of Inspection:8/16/99
TIGHT OR HOLDING TANK: NO (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)
n/a
Dimensions: n&
Capacity: nla gallons
Design flow: Wa gallons/day
Alarm present: NQ
Alarm level:j)AL Alarm in working order:Yes_No—: NQ
Date of previous pumping: Wa
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
Wa
DISTRIBUTION BOX: X
(locate on site plan)
Depth of liquid level above outlet invert:LIQUID I FVFL WITH BOTTOM OF PIP
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.)
DISTRIBUTION BOX IS STRUCTURALLY SOUND
PUMP CHAMBER: NQ
(locate on site plan)
Pumps in working order:(Yes or No): NQ
Alarms in working order(Yes or No): NQ
Comments:
(note condition of pump chamber,condition of pumps and appurtenances.etc.)
n/a
revised 9/2/98 Page 8 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 116 FOXGLOVE RD.CENTERVILLE MAP 149 PAR 130 L 22
Owner: KAVANAUGH
Date of Inspection:8/16/99
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:
nta
Type:
leaching pits,number: 2-1000 GALLON I EACH PIT
leaching chambers,number: _nLa
leaching galleries,number: _n!a
leaching trenches,number,length: n&
leaching fields,number,dimensions: nta
overflow cesspool,number: n(a
Alternative system: n&
Name of Technology: ja&
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.)
THE LEACH PITS ARE TR 1CTURALL SOUND AND FUNTIONINC PROPFaY.THE NEW PIT HAS NOT OF WATFR IN IT
CESSPOOLS:
(locate on site plan)
Number and configuration: Wa
Depth-top of liquid to inlet invert: n&
Depth of solids layer: n&
Depth of scum layer. nla
Dimensions of cesspool: nfa
Materials of construction: n(a
Indication of groundwater: n(a 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.)
nla
PRIVY: _
(locate on site plan)
Materials of construction:Wa Dimensions:n(a
Depth of solids: n(A
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
nLa
revised 9/2/98 Page 9 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 115 FOXGLOVE RD.CENTERVILLE MAP 149 PAR 130 L 22
Owner: KAVANAUGH
Date of Inspection:8116/99
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
0—
A
4
a AC Li
�n
5(t
(3c 76
go 4a
revised 9/2/98 Page 10 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 116 FOXGLOVE RD.CENTERVILLE MAP 149 PAR 130 L 22
Owner: KAVANAUGH
Date of Inspection:8116/99
NRCS Report name: nLa
Soil Type: nLa
Typical depth to groundwater: iVA
USGS Date website visited: nLa
Observation Wells checked: NO
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
revised 9/2/98 Page 11 of 11
TOWN OF BARNSTABLE g
ATION w Flo�,��. -� —SEWAGE #
_ VILLAGE ASSESSOR'S MAP LOT
INSTALLER'S NAME PHONE NO. A & B CANCO 775-6264
SEPTIC TANK CAPACITY
t
LEACHING FACILITY:(type) Z- size)
NO. OF BEDROOMS PRIVATE WELL PUBLI : WATER
BUILDER OR OWNER_ kA V417A104
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED: -1%- Yr
VARIANCE GRANTED: Yes No ✓��
a
® 90 �q
a
F-o3Z9t®U� �.
Board of Health
-My 'Town of Barnstable
P.O. Box 534
.... . Fes$....a0.
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
PP ±n.....................0F....1. e!Y1.S.ai.e...............--------•------------•.......................
Applira#iun for Uhip ual Warkii Tomo rnr#iun rrmit
Application is hereby made for a Permit to Construct ( ) or Repair (. ) an Individual Sewage Disposal
System at
wail ............. ..................................................................................................
Location-Address O � or It
o.
.r.. .. ------------------------------------------------ �I - 1C �.. ... g4.Owner � •" ?C ull��
.. ...................................-----•..............•-- Ad res
�35a /nlsin aeslt --------•---------------•---
Installer Addfffess
Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms................................ .....Expansion Attic ( ) Garbage Grinder ( )U
Other—Type T e of Building No. of persons............................ Showers
P� 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 ( )
14 Percolation Test Results Performed by.......................................................................... Date........................................
a
0-1 Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water•-____--_-_------_.-___.
GT4 Test Pit No. 2................minutes per inch Depth of Test Pit,.................... Depth to ground water------------------------
P4 -----------------------------------
•-.......
••------------------
•-----------------------------
•------------------
•---------------------------------
.....
0 Description of Soil........................................................................................................................................................................
x
U --•-------------•--•---•---------------------••-•-------------•-•--•-•--•----------••---......---•-------•--••---------------•---•---•------•--•••-•------•--------••---------•----------------------_..
W
x -----•-------------•--•----------- -•------•-•--••••---•--••--•---•----------------••-----•------•---•-----•---.• •-•-•- --------------------------
•-------------------------------------------
U Natµµre of Repairs or Alterations—Answer when applicable.__ �4!�7.9-1_Y! Q._._1�ULtD..rltc¢p, � ►...P.4.wj..............
540
r0- -----------------------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of'THE 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 health.
Signed......... .7:j ......................
Date
Application Approved BY.............a �
Date
Application Disapproved for the following reasons:..............................................................................................................
...........................•-•----...-------•------------•--•------------------......----------...........---...---------••-•--------------------------------------------...------•-•-------•-----.------
y Date
Permit No.........O •::----`s F-------------------- Issued.......................................................
Date
NO..1/_.Q... FEE..............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
1 r
E
O F.............................................
Appliration for DiupouFal Wurkg Towitrurtion "truth
Application is hereby made for a Permit to Construct ( ) or Repair (4 ) an Individual Sewage Disposal
System at:
I
l 1— F *.I.� V- I? L\1 r( C, .i l►
..... ........................:.....................................................•---------- ------•---•----------------.........__...._........------••........_.........--------•------------
Location-Address............................... _ Lot No.
` .._. f:...c ....................(!r sr ...... ..................................
Owner _ Address
r! / /
,i_
Installer Address
UType of Building Size Lot----------------------------Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
�a Other—Type T e of Building No. of persons........................... Showers
yP g ---------------------------- P - ( ) — Cafeteria ( )
Otherfixtures .... ------------------------------------------------------------
•--------.......
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---------------------------------•----
W
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water_------.-__----__-___.-.
Gz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water--__-__..__-____---._-_.
P1 •--------•-------------------------------------------------------------------------•--------•-....--.........................................................
0 Description of Soil........................................................................................................................................................................
W
--------------- ------------------------------------------------------------------------•-------------------------------------------------------------------------------------......................
U Nature of Repairs or Alterations—Answer when applicable- ----------- __..L"__ :.._I_._%.( _E�) F_, 1
- - - ----------------------
1i ,
--------------------------------------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITL
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 issued by the board of health.
Signed---------=•--- ---`--------------------=----------------•-•-------•--------------. . ••-••--- ............
�^� I Date
Application Approved By-----•--•• .... `.l_3_^ ------
J Date
Application Disapproved for the following reasons:------•--------•------------•-----------------------------------------------------------------------------------
---•••-•--.....----•-------...-•-------------•--------••----....---•-----------•--------------•----------•------------------------•-------•-------------------•--•-------•----•---------•••-------------
�./ Date
PermitNo........ _5 Y...1---------------------- Issued-.............------------------------------------------
Dste
Y, THE COMMONWEALTH OF MASSACHUSETTS
L�'1" BOARD OF HEALTH
........... ......:..I.................OF.......... `.......... :'e.................................................
(grrfifiratr of Toutph aurr
THIS IS W
C RTIFThant the Individual Sewage Disposal System constructed ( ) or Repairedby---------•--•----•--•• ... ...................... ......------------------•-----------------------------------..........------------........--..........--------------------------
Installer
at �.L . -------�-.-�amcewilh --C--------I� ----��'� ----------------------------------------------------•----------------
has been installed in accorthe provisions of TITLE of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.... _:. y............... dated...........-.-._--__--..__._-_--_-----_----__.-
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SpAcITISFACTORY.
DATE_.. . •�•............................... Inspector..................... .......:)...............................................
THE COMMONWEALTH OF MASSACHUSETTS
1'`ll 1yf BOARD OF HEALTH
I
:........................................................
QQ Sl/y ...............................OF......i:.............L..: �.
NO..S1.9..........1.... FEE.._........................
giupo.o al Turku �oatu#rttr ion �eruti
Permission is hereby granted------. - ------------•--------------•••-----------•...•-••-........-------•----...._.........._....
to Construct ( ) or Repai1 ( ) an Individual Sewage Disposal System
Street
as shown on the application for Disposal Works Construction Permit No... :.,). _l__ Dated..........................................
............................. y
Board of Health
DATE.............--- ----.�.�j . ()-�----------•----
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
TOWN
pOF STABLE f 0.
LO AT16N SEW E # A
VILLAGE MSS OR'S DrLAP
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY U d
LEACHING FACII.TTY: (ty (size) 1000
NO.OF BEDROOMS
BUILDER OR OWNERl�
PERMTTDATE: 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
an
C.
An
X'. .
y�
.... G A
Q� � r
r�5
LG CAT
SEWAGE
PERMIT NO
.
o+ a2
VILLAGE
b / ''l < mf Its '
INSTA LLER'S NAME & ADDRESS .
mORIN •
it 9, wr
S U I L D;E R OR OWNER
e rH 4 e-R tli .
"DATE PERMIT ISSUED . J�
� DAT E COM ►LIAN.CE ISSUED ���
--CA e �
9
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