HomeMy WebLinkAbout0116 FOXGLOVE ROAD - Health 116 Foxglove Road
-- Marstons Mills
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
116 FOXGLOVE RD
Property Address
MOSBY
Owner C1w.,e �,hi-_-
information is "r
required for r l Won��/
�n `t S MA 02632 10/20/09
every page. City/Town State Zip Code
Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out A. General Information
forms on the
computer,use 1_ Inspector:
only the tab key / v
to move your DOUGLAS A BROWN
cursor-do not Name of Inspector
use the return p
key.
DOUGLAS A BROWN INC
ICI Company Name
P.O. BOX 145
Company Address
( CENTERVILLE MA 02632
City/Town State Zip Code
5080420-4534 S14297
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
w O^. Title 5(310 CMR 15.000).The system:
co
&I ® Passes ❑ Conditionally Passes ❑ Fails
uz
❑ Needs Further Evaluation by the Local Approving Authority
CK3 .p
O >
10/20/09
zz Inspe Signature
Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the 4stem will perform in the future under
the same or different conditions of use.
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
U I I
Dq
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
116 FOXGLOVE RD
Properly Address
MOSBY
Owner Owner's Name
information is CENTERVILLE required for MA 02632 10/20/09
every page. Gtyrrown State Zip Code Date of Inspection
B. Certification (cunt.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not
determined,"please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�Y 116 FOXGLOVE RD
Property Address
MOSBY
Owner Owner's Name
information is CENTERVILLE required for MA 02632
every page. Clty/Town 10/20/09
State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N
❑ ND(Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
4
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
116 FOXGLOVE RD
Properly Address
MOSBY
Owner Owner's Name
information is CENTERVILLE required for MA 02632 10/20/09
every page. Clty/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 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 Y day flow
t5ins•09/08
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Amm= Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
116 FOXGLOVE RD
Property Address
MOSBY
Owner Owner's Name
information is CENTERVILLE required for MA 02632 10/20/09
every 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.
i❑ ® 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 CM 15.304.The system owner should contact the appropriate
regional office of the Department.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
116 FOXGLOVE RD
Properly Address
MOSBY
Owner Owner's Name
information is CENTERVILLE required for MA 02632 10/20/09
every page. Cltyfrown 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):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330
t5ins•09i08 I'
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
116 FOXGLOVE RD
Property Address
MOSBY
Owner Owner's Name
information is CENTERVILLE required for MA 02632 10/20/09
every page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
ACCORDING TO AS-BUILT CARD SYSTEM CONSISTS OF A 1000 GALLON TANK D-BOX AND
TWO 500 GALLON DRYWELLS
Number of current residents: 1
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use?
❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)): 07-199 08-200
Detail:
Sump pump?
❑ Yes ® No
Last date of occupancy: Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CM R 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal g p System Form Not for Voluntar
y Assessments
116 FOXGLOVE RD
Property Address
MOSBY
Owner Owner's Name
information is CENTERVILLE required for MA 02632 10/20/09
every page. Crtyrrown -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:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system(yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
116 FOXGLOVE RD
Property Address
MOSBY
Owner Owner's Name
information is CENTERVILLE required for MA 02632
every page. Cdy/Town 09
State Zip Cade Date
ate of Inspection
D. System Information (cont.)
Approximate age of all components, date installed(if known) and source of information:
LEACHING SYSTEM INSTALLED IN 2001 BY ROBINSON SEPTIC
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade:
feet
Material of construction:
❑cast iron ❑40 PVC ❑ other(explain):
Distance from private water supply well or suction line:
feet
Comments(on condition of joints,venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade:
feet
Material of construction:
®concrete ❑ metal ❑fiberglass ❑polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
Sludge depth:
t5ins-09/00
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�f 116 FOXGLOVE RD
Property Address
MOSBY
Owner Owner's Name
information is
required for CENTERVI LLE MA 02632 10/20/09
every 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
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined?
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
TANK LOOKS CLEAN AT THIS TIME
Grease Trap(locate on site plan):
Depth below grade:
feet
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene
❑ other(explain):
I
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
Date
t5ins•09M
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
116 FOXGLOVE RD
Property Address
MOSBY
Owner Owner's Name
information is
required for CENTERVILLE MA 02632 10/20/09
every 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 ❑ metal ❑fiberglass ❑ polyethylene
❑other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping:
Date
Comments(condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins-09r08
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
r 0 116 FOXGLOVE RD
Property Address
MOSBY
Owner Owner's Name
information is
required for CENTERVILLE MA 02632 10/20/09
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
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.):
BOX LEVEL NO LEAKAGE OR SOLID CARRY OVER
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.):
Soil Absorption System(SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•09M
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
116 FOXGLOVE RD
Property Address
MOSBY
Owner Owner's Name
information is CENTERVILLE required for MA 02632 10/20/09
every page. Clty/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 2-500 GALLON
❑ 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.):
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-09108
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
116 FOXGLOVE RD
Property Address
MOSBY
Owner Owner's Name
information is CENTERVILLE required for MA 02632 10/20/09
every page. CltylTown 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•09)08
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
116 FOXGLOVE RD
Property Address
MOSBY
Owner Owner's Name
information is
required for CENTERVILLE MA 02632 10/20/09
every page. Cltyfrown 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
t5ins•09/D8
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
6_
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
' 116 FOXGLOVE RD
Property Address
MOSBY
Owner Owner's Name
information is
required for CENTERVILLE MA 02632 10/20/09
every 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: 5 FT+++
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed:
Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
HAND AUGERED TO 10 FT NO G.W ENCOUNTERED
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-09/08
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
yY 116 FOXGLOVE RD
Property Address
MOSBY
Owner Owner's Name
information is CENTERVILLE
required for MA 02632 10/20/09
every 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
Z System Information—Estimated depth to high groundwater
Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins-ogJUs
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
APR.12.2006 11:38AM BARNSTABLE BOARD OF HEALTH NO.301 P.1i1
TOWN OF BARNSWABLE
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BUR DWOR OWNER �aQM t p4 Vj
P13 wr m m: COMPi.[ANCE DATE:=7 �SIa7�4�
1
Separoacm No 11ce Between the:
Maximum Adjusted Groundwamr 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) Felt
Edge of Wetland and Leaching Facility,(If Any wetlands exist
within 300 beet g facility) .,,.... �
Furnishod by
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r
` COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
1
TITLE 5 `
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 1 1 6 Foxglove Rd.
Centerville, Ma
Owner's Name: Jack Grossman
Owner's Address: same
Date of Inspection:
Name of Inspector:(please print) Wi 1 1 i am E. •Rob i_nson Sr.
Company Name: William E. Robinson Septic Service
Mailing Address: P O Box 1089
Centerville, MA
Telephone Number: (5 0 8) 7 7 5—8 7 7 6
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 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 SS tion 15.340 of Title 5(310 CMR 15.000). The system:
6 Passes "
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails,
Inspector's Signature:�.� % %cam— ' Date: 7, ,5— (3
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Heanh"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 6/15/2000 page 1
Page 2 of l l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
• love Rd.116 Fox
Property Address. g
en ervi e
Owner: Grossman
Date of inspection:
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
✓ 1 have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Co ents:
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.
Answer yes,no or not determined(Y,N,ND)in the for the following statements.If `not determined please
explai,i
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unso nd,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the
exi ing tank is replaced with a complying septic tank as approved by the Board of Health.
*' metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
in icating 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
explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
p s inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
Page 3 of l 1
OFFICIAL'INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 116 Foxglove Rd.
Centerville
Owner: Grossman
Date of Inspection: 'S-
R
C. Further Evaluation is Required by the Board of Health:
AConditions exist which require further evaluation by the Board of Health in order to determine if the system
fai,ng 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.
2. ystem will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
sys in 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 frorh 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.
3. Other:
3
Page 4 of 11 '
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 1 1 6 Foxglove .Rd.
Centerville
Owner: Grossman
Date of Inspection: 1 e
System Failure Criteria applicable to all systems:.
Y u must indicate"yes"or"no"to each of the following for all inspections:
Ye 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''/s 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 I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [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.]
(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:
� y
T be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
g d.
ou must indicate either"yes"or"no"to each of the following:
( e following criteria apply to large systems in addition to the criteria above)
y 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 ou have answered"yes"to any question in Sextian E the system is considered a significant threat,or answered
s"in Section D above the large system has failed.The owner or operator of any large system considered a
sig ificant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15. 04.The system owner should contact the appropriate regional office of the Department.
4
Page 5 of l l
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 1 1 6 .Foxglove Rd.
Centerville
Owner: Grossman
Date of Inspection:—7'- V-6 Z
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?
i
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?
t/'_ 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?
r% 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.
V _ 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
�I
Page 6 of 11
OFFICIAL INSPECTION FORM.—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 1 1 6 Foxglove Rd.
Centerville
'Owner: Grossman
Date of Inspection: -5-6 i
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): .3 Number of bedrooms(actual): t3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):3 '7
Number of current residents:_e,
Does residence have a garbage grinder(yes or no):ti o
Is laundry on a separate sewage system(yes or no)ho [if yes separate inspection required]
Laundry system inspected(yes or no):/1
Seasonal use:(yes or no):A-d
Water meter readings,if available(last 2 years usage(gpd)): 2000 6 7 ,0 0 0 gal.
Sump pump(yes or no): a 1999 63,000 gal.
Last date of occupancy:
CO MER' IAL/INDUSTRIAL
Type f establishment:
Desig flow(based on 310 CMR 15.203): gpd
Basis f design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Indus al waste holding tank present(yes or no):
Non-s itary waste discharged to the Title 5 system(yes or no):
Wate meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information:_ � I.- c' �
Was system pumped as part of the inspection(yes or no):
v
If yes,volume pumped: v z> allons--How was quantity pumped determined? ) O' d
Reason for pumping: /4-,4r w 5 cf S
_2TYP "OF SYSTEM
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:
�z-w �,5'�► ,� -- �-t5 n � �• �E-Were sewage sewage odors detected when arriving at the site(yes or no):
6 "
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 116 Foxglove Rd.
Centerville—
Owner: Ciro ssman
Date of Inspection:
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction:_cast iron _40 PVC_other(explain):
Distance from private water supply well or suction line:
�ni Com ents(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: L(locate on site plan)
1
Depth below grade: J
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: G C
Sludge depth: p
Distance from top of sludge to bottom of outlet tee or baffle:Y�
Scum thickness: —go ,
Distance from top of scum to top of outlet tee or baffle: _
Distance from bottom of scum to bottom of outlet tee or baffle:l`10� '
How were dimensions determined:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of.leakage,etc,):
G ASE TRAP:_(locate on site plan)
Depth below grade:
Material of construction:_concrete_metal_fiberglass polyethylene_other
(expla ):
Dimenrsions:
Scum thickness:
Dista ce from top of scum to top of outlet tee or baffle:
Dista,ce from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Co ents on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as r lated to outlet invert,evidence of leakage,etc.):
7
Page 8 of l l '
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 1 1 6 Foxglove Rd.
en ervi e
Owner• Grossman
Date of Inspection:7t `-a r
TI T or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Dephl below grade:
Mater 1 of construction: concrete metal fiberglass_polyethylene other(explain):
Dimen ions:
Capacit),: gallons
Desig Flow: gallons/day
Alarm present(yes or no):
Al level: Alarm in working order(yes or no):
Date f last pumping:
Co ents(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: t/ (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.):
PUM CHAMBER: (locate on site plan)
Pump in working order(yes or no):
Al s in working order(yes or no):
Co ents(note condition of pump chamber,condition of pumps and appurtenances,etc.):
8
Page 9of11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 116 Foxglove Rd..
Centerville
Owner: Grossman
Date of Inspection: irs'--o
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Type
�eaching pits,number:
/ _
� 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 vegetati ,
etc.): 190/9
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 or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PR (locate on site plan)
Mate ials of construction:
Di ensions:
De of solids:
Co ents(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 1 1 6 Foxglove Rd.
en erville
Owner: Grossman
Date of Inspection: —�--d
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.
J
3
1 3� �n
� a
i
10
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 116 Foxglove Rd.
en erville
Owner: Gro n
Date of Inspection:_ �o
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water y 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 w't#hin 150 feet of SAS)
L7 Checked with local Board of Health-explain: Igo,6V .
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
v
3
11
r
, r
s r
TOWN OF BARNSTABLE
LOCATION . .� 2 Oi��e1� e�lA SEWAGE # o�0d
VILLAGE :�1 (, ASSESSOR'S MAP &ZOT 1;7e 4;F
INSTALLER'S NAME&PHONE'NO. )NJ Qf I C 7 S 7
SEPTIC TANK CAPACITY _ . Don
LEACHING FACILITY: (type) (size)_Ax13-A25
d .
NO. OF BEDROOMS
BUILDER OR OWNER CCfZo 55m t4rJ
PERMTTDATE: COMPLIANCE DATE: / fin® ,
Sep
aration Distance Between the:
Maximum Adjusted Grou ndwater TablAto the Bottom of Leaching Facility Feet
Private Water.Supply Well and LeachingFacility ty (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��eac ng facility) Feet
Furnished by -/�f3 � C' Cr '
0
0� Q
B A
�Sno� o 0021 -
TOWN OF BA.RNSTABLE �
LOCATION �,X C€s.^ olA t SEWAGE # C200 �i d
VIC LAGE_ � C%M �"` I �SSESSOR'S MAP &�0 9 3� 'Cl
INSTALLER'S NAME&r:PHONE NO.
.SEPTIC TANK CAPACITY '>
. LEACHING FACILITY: (type). 2 ` `it) (size)
Nb. OF BEDROOMS
BUILDER OR OWNER C(ZO,5SM tArJ
PERMITDATE:- . 60 COMPLIANCE DATE: S �
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.ezist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility''(If any wetlands exist
within 300 feet o >eac ng facility)' Feet
Furnished by 7 ��Ar 91�r�
d
a
rz ..
.r
z
T
N.. Z Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
es
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
ZippYication for Migponl *pgtem Construction Permit
Application for a Permit to Construct( )Repair(X )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. Owner's Name,Address and Tel.No.
116 Foxglove Rd. , Centerville Jack Grossman
Assessor's Map/P cel
��i:�,
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Win. E. Robinson Septic Service
P 0 Box 1089, Centerville
Type of Building: 3
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil Sand
Nature of Repairs or Alterations(Answer when applicable)
Title-5 leach system con—
sisting of a D-box and 2 precast leach chambers with stone all
around. �,� OWe It / jo
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Envir nmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this Bo f ealp.
Signed e ✓ — Date
Application Approved by _ Date 44--' -Z !2�e-t
Application Disapproved for the following reasons
Permit No. G9` Date Issued —` G
�G ��Z Fee
No.
THE COMMONWEALTH OF MASSACHUSETTS Entered in compute
des
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
Tipprication for 30i5po5af *pztem Construction Permit
Application for a Permit to Construct( )Repair(X )Upgrade'( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. Owner's Name,Address and Tel.No.
116 Foxglove Rd. , Centerville Jack Grossman
Assessor's Map/Parcel,
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Wm. E. Robinson Septic Service
P O BOX 1089, Centerville
Type of Building: 3
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date - Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil Sand
Nature of Repairs or Alterations(Answer when applicable) Title-5 leach system con-
sisting of a D-box and 2 precast leach chambets with stone all
around. s.✓ �/ A' .�, ,/ cj,r�
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Envir mental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this Bo f ealth.
Signed ✓ . Date
Application Approved by Date c�� %tom.0 l
Application Disapproved for the following reasons
Permit No. �40%0 Date Issued -
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS k
Grossman Certificate of Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired ( X )Upgraded( )
Abandoned( )by Wm. E. Robinson Septic Service
at 116 Foxglove Rd. , Centerviller has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Pe dated
Installer Wm. E. Robinson Sr. Designer
The issuance of this. e_ t shall not be construed as a guarantee that the sy 9 ill function as4designed:
Date `6�`. �, .> Inspecto mot" .tea ''�i�: e�.?.�1
No. 2001^ 4-1-P—Q--------------------------
-Fee $50 ..
/ ,
THE COMMONWEALTH OF MASSACHUSETTS '
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
Grossman
'mfzpoal *pztem Construction i3ermit
Permission is hereby granted to Construct( )Repair(X )Upgrade( )Abandon( )
System located at 116 Foxglove Rd. , Centerville
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply.with Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this
Date: Approved by C'z
rNOTWE:Tbik Form Is To Be Used For the Repair Of Failed
Septic Systems Only_ -
C1gR i'II11C�►TiON OF Ai�Ib AYPLIC.ITIOI�ROR A D—MVQfi&L
WORKS CONSTRUMON PFRII►t!T_ DESMNED PLANSI
L Will iain E. Robinson,: y C"*tlm the appiicadon f x tiiVOW wotics
cans icuoa 9mmik Aped by are dated .''f�`�� � concenwg tie
Fly[ocated at 1 1 6 Foxglove Rd. , Centerville meets all of the
following Mcna:
• The failed sysmm is ooummd w a raidettdd dweUing adP. Throe are:no aonunercial or business
uses associand with the dwdha&
• The soil is cta d as CLAM 1 and ibc perootatian tare is Un*on or e9um to 5 minau m per inch
There sre no ws2humds within 100 foes of dtt p wposed 9gwc kvmcm —
M There art no private wcM within l5o fm al the pmpose+d septic Sys",
There is m increase in flOw aadat c!MW in ttse:pmpOsed
• There are an vatiaa=requeswd or ttw&d.
• The bosom of the tq wia MOP-k=md bm than five 0=abwe the
wam 4 1 Vwwdwater tabk otetrvum IMPS dw gtowtdwater table using the Frimptor
teethed whtas motet
r
If the S_�.S.will be lard wuh 250 het of any veptawd wcftmh.ft boa m of the p aposed
leaching bmM UY wM gait be lowed k=than foonem 1141 Poet above:the:nr&rittu»u adjuswd
_qO=dww"tab)e dcwa*mk
Mace see tie MwiW. r
A) Top of Gm nd Suthm Ekvmim(using G1S Wb=a6jmj
Bi G.W.Elevation +Mt MAX lfi0 G.w_-A t
DIFFERENCE BETWEEN a and B 3 —
✓ ✓� l
SIGNED:_ / DATE: �"�'� ✓
[Sketch p>apmod pine of sysem on back]_
�tYaNb Folder_aan
I
r
g
Z5
M,
...........9
OEM
_MM VON-
'90,
A
TOWN OF BARN
STABLE
LOCATION
00
SEWAGE # 0 00 O<y
ASSESSOR'S M Ap&L0 /33c1
INSTALLER'S NAME&PHONE NO. VO 0
C.T; KCAPAtrrY""1'
AN
O
LEACHING FACILITY:
.(type) (size)
NO::OF BEDROOMS:
BUILDER OR OWNER
LL
COMPLIANCE ;Ic Q I
Separation Betwe, n the:
e.
axlln.IIM,t.Adjusted Groundwater und
AbI6 to the Bottom of'L
water.
Feet
Water SuPply Well and Leach.ing Fac Leaching
Pri Facility
ility If any wells e
on 0 t witj�* )C) Xist
ri 2( feet 6f lea'chin cihty)
fa
9
Edge of Wetland and Leaching Facility(If any wetlands exist. Feet
Within 300 feet o_f3eac#ng facility)
Furnished by Z Feet
----------
a
-----------
7
a
0 ' 0
ESN 9 0021
----------------
DATE
0' CATION SEWAGE PERMIT NO.
Y.I.LLAGE
INSTA LLER'S NAME i ADDRESS
-7 l f �?� i� � �47
R U I L D E R OR OWNER
DATE PERMIT ISSUED
0ATE COMPLIANCE ISSUED G12-7
�" ,�,
��. ��
' �� �� �
3�
i»
No.... �r. .. FEs.._.S.....��
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
l(/N ..................OF.....� ...............................................
Appliratiun for Uhipauttl Workii Tonutrnrtiun ramit
Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal
System at
C �w
..... ..l n�4..... .................. .... .......••-....C.=.V_�_�:1_E.... ...........----:_..... .. -•- ..........................................................
;7, •Lo- lion-address r Lot No.
Owner Address
a ----- ��1/Zti1 ---.... --__ _______-•--- ------------....
� Ins.taller Address �� ���
d Type of Building Size Lot..... _i... .. __.....Sq. feet
U Dwelling—No. of Bedrooms__.._._._IS____________________________Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No. of persons____________________________ Showers — Cafeteria
Otherfixtures _......----•-----•------------------------------------.-------•------------------------------------------------....-----------`---=:_:.......----
W Design Flow._...�_ ��.........................gallons per person per day. Total daily flow.......3-�..__._______..............gallons.
W Septic Tank l�I_iquid capacity
16W._gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No..........0.......... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No------f------------ Diameter....... .......... Depth below inlet.................... Total leaching area.. _.....sq. ft.
Z Other Distribution box Dosing
Percolation Test Results Performed by-___�. lVf�lS ................ Date.....7.�� _.___._
,a Test Pit No. 1___-,'�_ _.____minutes per inch Depth of Test Pit...... ........ Depth.to ground water________________________
Test Pit No. 2................minutes per inch Depth of Test Pit...... ...... ..._Depth to,ground water........................
..r; ::r„_ �
•------ --------- •--- .......
-
D G!/� /� �wC'Duw :: '. Win:_
v •------------------ ..................... ---_.... ...._.....-•....................................
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 TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
opera 'o it Cer ificate of Compliance has been ssqued b the board of health.
0-
Signed. i
.__..:._ .�1!!M_...... ............................... ?1.. .'. .
��pte
plicati Approved By--------------- ._._ ......... t •._.. .. -•-••--__..._... �_- ?.� _ �
Date
Application Disapproved for the f o l wing reasons:------•-------••..............•-----•--•--------------------......-•-------••-------------...--_____._..__.....
........................................................•-•-c.........................................•................................................................................................
Date
C .� C
.�7...... - ...... Issued_-----...�.----V--_�--•�...............Permit No...:.
Date
No....... FEs.......5• ram- 0
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........ ..............OF......... 9/9_1U3 &-
�iru tlaYt f nr i u tt1 orku Tonutrurtion Vautit
Application is hereby made for a Permit to Construct ( v�`or Repair ( ) an Individual Sewage Disposal
System at:
--•........ tom �....
�7�2 ---
��'r/es
�_ / , or Lot No.
Owr}er Address
w Aw?
InstallerAddress
d Type of Building Size Lot.. 6 3Y.........Sq. feet
Dwelling—No. of Bedrooms.....w- ................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building .............:............... No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures ------------------------------------•-----------....------••-•-••-•••••...••••••••---•--••--•••._.:....•--------•-----.....--•••-------....._--------
W Design Flow......S ..............................gallons per person per day. Total daily flow........ ...........................gallons.
WSeptic Tank—Liquid capacity W0....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 ( c/) Dosing tank ( )
~' Percolation Test Results Performed by...... A.. .. x !f��......................................... Date...... ..............................
a
,.a Test Pit No. I.....2�.......minutes per inch Depth of Test Pit.....�:�.......... Depth to ground water.... ........
�Tq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P4 -•-•---•---•-•••-•••-•••-------------•-•------•---- •--------------•----•------•----•-•------------...-•---•-•---._.....------•-•••-•-----•-•---....__....--
O Description of Soil..........Q-3Z... ----------------- `/3' /6E.� S��
------------------•---------------.....--•-------•---•----------•-•------••---•---------
x �p WA -?. EN&4.v 2.�
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 prow 1>s f TITL L 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operat on u �te of Compliance has been ' by the and of health.
Gzy,.
Signed - -----..... -. 6
.---
J;jA
A Application A roved B _......_ Q.� ..�. ti
PP PP Y / S.
Date
Application Disapproved for the f o l wing reasons:....................... '......................................................................................
............................................................. .-•---•---...--•--------•-•-••-----•...--•-------•---....--------••---------••--- ....................................................
Date
Permit No.--------f ....r� ry -... Issued-...------ 67t �•-L�
THE COMMONWEALTH OF MASSACHUSETTS
BOARD_ OF HEALTH
..........................................OF..................... ...........................................................
(Irrtifirtttr of Tour phaurr
THIS IS TO CERTIFY hat the ,kndividual Sewage Disposal System constructed ( ) or Repaired ( )
by _ ..-.�............it.........._...t !:i!:..---•.
Installer
.............3------------F .......W........................................................................
has been installed in accordance with the provision of TITLE • 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.`....� -=y............ dated.................................I...............
THE-ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CO STRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE...........(2-/Z) --�S-------------------------------------------- Inspector.....--- 4-JAI.-
- .... .. .... .........
THE COMMONWEALTH OF MASSA HUSETTS
BOARD OF HEALTH
................ ................0F..........I� 'S �Cfj�. .............................
No........ ..........� FEE..........�...o..
it err it J
Permission is hereby granted......... ••...................... -- ........ .;.._.__..._ .. M...............
to Construct t.&Aor R at ( ):;an �xli�l sposal
atNo.. '.........................
....................................... ....................... :2 h �. ........
Street
as shown on the application for Disposal Works Construction Permit No ................... Dated....,.... .__....._. ..................
of -- ....�
DATE--------•--•-- ........ - th
-. _ j_.. ...
oar
FORM 1255 A. M. SULKIN, INC., BOSTO -�
S/NGL_:E FAlIVIIL Y -- 3 BE0�2ooNt
it/O GA2BaGE
OA/LY FLOW = //D X 3
,SE,oTc TANK - 33 X S / `�`9i' •
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N
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Ficz
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
.............70--1 II.-----....OF.... --------------------------------------------------
Appliration for Disposal Works Tonstrnrtion nmit
Application is hereby made for a Permit to Construct ( P-) or Repair ( ) an Individual Sewage Disposal
•System at
--- -•--- ai) ---- or t No.
.��u110 !°--�.Tr.!0.1.._.j !.:� .............. 1.a P ................................................
....... . .
wner Address
Installer Address
Type of Building Size Lot..-......e.19®n......Sq. feet
�. Dwelling—No. of Bedrooms.......... ............................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons............................ Showers — Cafeteria
Otherfixtures ----------••••. ••••--••••••-•••-•--•-•--••-••.....••-••-••.............•--••--•--------
W Design Flow....-4:6.........................gallons per person per day. Total daily .......................gallons.
WSeptic Tank—Liquid capacity!90..gallons Length................ Width................ Diameter.........--..--. Depth................
x 'Disposal Trench—No..................... Width.................... Total Length.....................Total leaching area....................sq. ft.
Seepage Pit No..../............... Diameter.....8........... Depth below inlet.................... Total leaching area...��......sq. ft.
Z Other Distribution box ( ) Dosing tank (
a Percolation Test Results Performed by........ ?! ��...... .........�....................... Date..... ��.-�. _.,,..//..�...•.....
Test Pit No. 1... ........minutes per inch Depth of Test Pit----1-3.......... Depth to ground water......No`!•�......
f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------..................
tL' .........0-06
- -••-------------------------•--------,----------- -----•--------••----------------•--------.----•---.... ........
O Description of Soil----.Q.:`3-.... -+�`-a�49 > .........
x .-JW/a7�.... Sri u<''1 ........................................................ -•......--•--------•----------
U -
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 TIT L- 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Ce 'fi to of Compliance has
bee s ed byb�oa,r of health..-..
....................................
Appl'� tion A, roved By................. :---- : v..--'_"`
Date
Application Disapproved for the following reasons:--•---------•-----•-----------------•-----------------••--...................................................
........-•---•-••••-•--------•--•-•----•----••-•......•••.............•--••--........---••••--•-•---••--•--•----•----•-•--•--•••-••-•••-•••-•••-•-•-•••••--•---••--------•••••••••--•••••••----••••-----
Date
PermitNo......................................................... Issued_.......................................................
Date
Iv '~ 6r,3� N, k FE$ ............i�
x*; THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............./49u�:✓.....--------OF...................
C�190N !Cr
Appliration for Disposal Works Ton.strnrtion Vamit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual, Sewage Disposal
System at:
........... --i .................... ......................•-•-••••-,......•-�•-•-•-.............-•-••-•-•-•.............._-•••--
Lo tion Address or Lo o.
Og ner Address
44W4 ...........................•••--•-•-••••-
................ ......................................................-
Installer Address
Type of Building Size Lot___,1SI�'0__________ q. feet
Dwelling—No. of Bedrooms____._ ________________________________Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
dOther fixtures -------------------------------------------•--------------------•-••-•-•--------••------------•----------------------.._...•---------.._..••••--•••-•
W Design. Flow..........._ .......................gallons per person per day. Total daily flow............33Q.......................gallons.
WSeptic Tank j—/Liquid capacitypW.O__gallons Length................ Width................ Diameter________________ Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No.._/................ Diameter..._..6_.......... Depth below inlet.................... Total leaching area...20.d.....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----/_3_'........ Depth to ground water.....lu _......
P� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
O ................................ ---•---- •----••--•---------...................................--••------••••-----•----•-----•----••-•--------•---•..._.
Description of Soil...--------�•--3 �^' „�i/�fo!�_.......... �...�3 ����•¢•v3
x •----•-•-•-----••---------•-••--•-----•-------_-•---
W ••--------•••-••-------------------•-•••-•--•----••---•----
.---•-----•-----•-----------------------------•-•-•----•-------------••-•-_-...--------------_----•---------------•--._...------._..__.._..---•----•---••-•------------------..._•••----------••-------
U Nature 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 TIT!2- 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
oper 'on u .1 ar-roficate of Compliance has be ued by t boar of health.
T
------------------ _
A plication�Approved By........... �•--" ._ ,= _.. ��
�.a '........................�` ........4•---------- _
-••----------
Date
Application Disapproved for the following reasons-------------------------------------•-----------•---•---------•-------------------•-••••--•----••-------••-----
.............................................................-......................................................................................... .................................................
Date
PermitNo......................................................... Issued_.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........................................OF...................................................._............................_...
Trrtifiratr of TuntpliFatta -
THIM'b,CERTIFY, That the Individual Sewage Disposal System constructed (� ) or Repaired ( )
by (...... ,:.. ------------------------------------------
W 'nstaller
_1...-/ r
has been installed in accordance with the provisions of TITo T State Sanitary C��e described in the
application for,Disposal Works Construction Permit No________ __________'.�_____.____ dated--- ..............................
._'_THE ISSUANCE OF'THIS CERTIFICATE SHALT. NOT BE CONST UED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE..' -- ....... Inspector.... i -
-------------••--
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
No......................... FEE........................
Dispopt rkii Tnntrnrtion amit
Or k/')
Permissionis hereby granted..............................................................................................................................................
to Constr ) r . e � IncMal Sewage Disposal System
at No... ------ •-•------•-_--•-:' -a
=--------------••••-••--•----•--------- -•--•---...___------.
Street' �,,.�r"'. .�' � J
as shown on the application for Disposal Works Constru t o er it ..... Dated.... __ l._ --' ................
•------•----•-----------••---•---••••----•-------------...............................................
Board of Health
DATE.... -• • z ----••---•--•---
F
FORM 1255 HO BS & WA REN• INC., PUBLISHERS
3
;t/O 64,2BA45E
OA/LY FLOW = //D X 3 = 330
e,y�G.Po
,fTI oTTo�7.Qectl = 7y �'
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