HomeMy WebLinkAbout0114 JONES ROAD - Health .1.14 640S-
Marst6iis i'lis
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TOWN OF BARNSTABLE
LOCATION, J/y Tc^10-5 'ec� SEWAGE # ,�/
VILLAG$ ,a/, fps /�,� 5 ASSESSOR'S MAP&LOT ` 04-T
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY 6a,
LEACHING FACILITY: (type) 1: Ler c4 o0, ,f- (size) Ian, (a
NO.OFBEDROOMS
i
BUILDER OR OWNER
PERMTTDATE: COMPLIANCE DATE:
Separation Distance Between the:
i
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
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Commonwealth of Massachusetts
W Title 5 Official Inspection Form
1
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
J ^M 114 Jones Road 0 ](Q _ ob 1
Property Address
Christopher Dooling
Owner Owner's Name
information is Marstons Mills Ma. 02648 5/01/2008
required for
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.
Important:When filling out A. General Information
forms on the
computer,use
only the tab key 1. Inspector:
to move your Robert Paolini
cursor-do riots -
Name of Inspector i
use the return
key. Capewide Enterprises,LLC
Company Name C�
raa P.O.Box 763 � t
Company Address
Centerville Ma. 6632
return City/Town State Zip ode
(508)428-4028 S14454 T
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
A6,V"
5/01/2008
Inspect s Signatu re' 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 system will perform in the future under
the same or different conditions of use.
114 Jones Rd.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M
114 Jones Road
Property Address
Christopher Dooling
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 5/01/2008
every page. City/Town State Zip Code, Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
The septic system is in proper working order at the present time.
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 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.
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
114 Jones Rd.•0108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
.' 114 Jones Road
Property Address
Christopher Dooling
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 5/01/2008
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ 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:
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
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.
114 Jones Rd.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 114 Jones Road
Property Address
Christopher Dooling
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 5/01/2008
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
C) Further Evaluation is Required by the Board of Health (cont.):
❑ 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 Yz 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.
114 Jones Rd.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
114 Jones Road
Property Address
Christopher Dooling
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 5/01/2008
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems (cont.):
Yes No
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply
well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory, for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
114 Jones Rd.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15
i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
114 Jones Road
M
Property Address
Christopher Dooling
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 5/01/2008
every page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate "yes" or"no" as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
®
Was the site inspected for signs of break out?❑ P 9
® ❑ 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)]
114 Jones Rd.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
° 114 Jones Road
Property Address
Christopher Dooling
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 5/01/2008
every page. City/Town State Zip Code Date of Inspection
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
Number of current residents: 2
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
Seasonaluse? ❑ Yes N No
Water meter readings, if available last 2 ears usage d 2006:31,000
g ( y g (gpd)): 2007:58,000
Sump pump? ❑ Yes ® No
Last date of occupancy: 5/01/2008
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe):
114 Jones Rd.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
114 Jones Road
Property Address
Christopher Dooling
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 5/01/2008
every page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
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):
Approximate age of all components, date installed (if known)and source of information:
1978
Were sewage odors detected when arriving at the site? ❑ Yes ❑ No
114 Jones Rd.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
114 Jones Road
Property Address
P Y
Christopher Dooling
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 5/01/2008
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan):
1'
Depth below grade: feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: 20'+
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Joints appear tight.No evidence of Ieakage.System vented through the house vents.
Septic Tank (locate on site plan):
1'
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: 1000 gallon
Sludge depth:
6"
Distance from top of sludge to bottom of outlet tee or baffle
26"
0
Scum thickness
Distance from top of scum to top of outlet tee or baffle
8"
Distance from bottom of scum to bottom of outlet tee or baffle
16"
How were dimensions determined? Measured
114 Jones Rd.•03i08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
114 Jones Road
Property Address
Christopher Dooling
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 5/01/2008
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.):
Pump septic tank every 2 years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank
appears to be structurally sound.
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.):
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):
114 Jones Rd.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
114 Jones Road
M
Property Address
Christopher Dooling
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 5/01/2008
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Tight or Holding Tank(cont.)
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
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
No Distribution Box present.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
114 Jones Rd.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 114 Jones Road
Property Address
Christopher Dooling
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 5/01/2008
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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:
Type:
® leaching pits number: 1-1000g1. with 3'
stone
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Sandy dry soil.No signs of hydraulic failure.Leaching Pitwas dry at time of inspection.Stain line is 29"
below invert pipe.
114 Jones Rd.•03i08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
114 Jones Road
Property Address
Christopher Dooling
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 5/01/2008
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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.).
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.):
114 Jones Rd.•03A08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15
Map Page 1 of 2
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http://www.town.bamstable.ma.us/arcims/app&eoapp/map.aspx?propertyID=046064&mapp... 5/1/2008
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
114 Jones Road
Property Address
Christopher Dooling
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 5/01/2008
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: Bottom of LP 50'
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
i
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
As-Built Card
❑ Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
USED:USGS Observation Well Data.USED:Technical Bulletin 92-000-01 Palte#2 annual ranges of
groundwater elevations.
114 Jones Rc.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15
COMMON TEALTH OF?YIASSACHUSETTS
EmcumE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTAIENT OF ENVIRONMENTAL PROTECTION
TILE 5
OFFICLkL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEwAOE DISPOSAL SYSTEM FORM
PART A
/ CERTIFICATION
Property Address: T�[3 rt S Q 6,l 6 A V
Owner's Name: 1 yn n e A)ee->'a-
Owner's Address:lCY' A�me Rel
Bate of Inspection: -7-�D-�� --
-Name of Inspector:(pleaseprlar) �dlGt�y�l ����f_/T_
Company name:
Maiting Address: ? :; 6 3
Telephone Number: Zi !T- Z{9-51 C 2/05"
c_ 1 -C,
CERTIFICATION STATEMENT
I certify that I have pemonaliy inspected the sewage disposal system at this address and that the infoTm Cion reported i
below is true,accurate and complete as of the time of the inspecdorL The inspection was peribrmed b on my,-- r--
tramm.-and experience in the proper function and mainteutaace of on site sewage disposal system.I x n a DEP-1 �
approved sys€ern iuspet-£or pursuant to ion I5340 of Title 5(310€MR 15.000). The system:
Passes
Conditionally Passes
Needs Further Evaluation by.the Local Approving Authority
Fails
Inspector's Signature. � Date: -7-Jq-t1,
Thy system inspector shall submit a copy of this inspection report to the Approving Authority{Board of Health or
DEP)witWn 30 days of completing this inspection.If the symm is a shaved system or has a design flour of l 0,0W
ar greater,the inspector and the system owner shall submit the report to the alspropriafe 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
avt_iority.
No'zs and Comments
""This report only describes conditions at the time of inspection Sad under the conditions of use at that
£im-e.Tliis inspection.does not Address huw the system will'perform.in the future under the same ar different
conditions of use.
T;ria S tY.cvvrtinri�.nrm F.tt S!?rnn ,,.,.-a a
Page 2 of I
OFFICIALLNSpECMN FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSU-RFACF SEW AGE DjSpOSAL SySTEm INSPECT ON FORM
PART A
CERT AC ATION(continued)
Froperty Address: 11y .Tcyt e5 1?4,1
A44 5&as It -
Owner.
Date of inspection:
iinspettivn Summary: Cbe& AAC�D or E i 4W YS complete sit of Section D,
A. System Fasses:
not found any information which indicates that any of the faihire criiesia described iD 3 i 0 Ci�iR.-
15.303 or in 310 CIOR l 5.304 exist Any£�iht�criteria nci evaluated am?ttcli�ed below.
Comments:
.w•
B. System,Conditionally Passes:
sJp yr citonc dysreax:ecrrnponea s ea ci�scr[-boa is the`°t anditioMi 3pass"section need to be replacer Or
repaired.The system,upon completion of the replace-meui or repair,as approved by the Board of Health,will pass.
Answer yes,no or not detertnined(Y l ND)in the for the following statements.if"mist determined"please
explain..
ne septic tank is metal and over 20 yea€s old*or the septic tank(whether metal or not)is structurally ,
nnsaund;exhibits substantial infi1tration or exfiltration or wA failure is innninent.System will pass bmection of the
existing tank is replaced wick a complying septic unk as approved by d=Board of H=th.
*A metal septic tank will pass inspection if it is struc'rnally sound,not leaking and if a C2rtif care of Compliauce
izidicating that the tank is less than 20 yews old is available.
explain:
Observation of sewage backup or break out er High static waxer level in the distribution box due to broken or
obstructed pipe(a)or due to a svroken,settled or iaiieven distribution b f System will pass iWection if(with
approval of Board of Heahh):
broken pipes)are replaced
obstruction is removed
dis-triibution box is.leveW orreplaced
ND explain:
ne system required pumping more than 4 doves a year due bo broken or obstructed pipes).'The system will
pass inspection if(With approval of the Board of l•-'xeal%):
broken pilse(s)are replaced
obstruction is removed
ND explain:
Page 4 of I
OFFICUL INSPECT h FORM--NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM LNSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address.
)turf 13 1Ll•t s
Q3yrner:
Date of Inspection:
D. Sysfena Failure Criteria applicable to all systems:
You must indicate`yee or"ne to each of the following for i inspections:
Yes No
Backup of semmge inao facility or system component due to overloaded or clogged SAS or cesspool
Discharge or podding os ef'7r uent to the surface of the ground or stu2'ace waters date to an overioaded or
choked SAS or cesspool
Static liquid level in the distribution box above outlet invert clue to an overloaded or clogged SAS or
/ cesspool
J Liquid depth in cesspool is less than 6"below invert or available volume is less than i day flow
— _�Required pumping more than 4 times in the last year I OT due to clogged or obstructed pipe(s).Number
of times pumped
Any portion of the SAS,evsspool or privy is Mow high ground water elevations.
Any portion of cesspool or privy is witbi f 100 feet ofa surface-water su.•pply or trubutary to a surface
water supply-
Any portion of cesspool or privy is within a Zone I of apublic well.
— ✓/may portion of a cMpuvi sit privy is withi i 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.IThis system passes if the well water analysis,
performed at a DEP certified laboratory,for colilorm bacterm and volatile organic compounds
indicates fufal,the well is free ft-om polludoa€ffit'w Mai laaefliiy aald Cite presenet of ammeaia
aaiietrgen and nitrate nitragen is equal to or less than S ppzn,pmvided that no anther lure criteria
are triggar-ed,A€cagy of the analyses must be attached to this form.]
l"J 0 r'asrvo)The systew fails-1 have derearruiirried that orae or mo;ti aY the ebovo£dune crimria exist as
described in 310 CivM 15.303,therefor the syst=fah;;.The sWern u%men Sknld contact the Board of
Health to determine what will be necessary to correct the faihm.
E. wage Systems:
To be comtsidered a large system the system mim serve a bdUty WM a design flow of 30,11 too�s�
gpd.
You must indicate either yes"or-no"to each ofthe foLowing:
(The following criteria apply to Iacge systems it'addition to the criteria above)
yes no
_ — the system is within 400 feet-of a surface drinking water supply
— _ the system is within 200 fcct ofa tributary to a surface ddnkking water supply
— — the system is located in a ui ogen sensitive area(Interim Wellhead Protection Area-Its°PA)or a;sapped
Zone B 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 awy large system Considered a
significant threat under Sex tion E or failed udder Scctivn D shall upgrade tho system in accordance with 310 CMR
h
15.304.Tb'e Syacem owner sh-ould contact-le appropriate regional office of the Department.
t
' r
Pace 3 of I
OFFI+CIhE INSPECT-40N FORM-NOT FOR VOLUNTARY ASSESSII NTS
SIJ-BSURI"ACE SEWAGE D SpOSAE SySTEm V SPECTION MUNI
PART A
CE TMICATION(conzimued)
Property Address: �I Jvv�eS
lV61--s7`ni 5 rAg 11S
Owner:
Date of Inspectivat:
C. Further Evvivation is Rrquired by the Board a3 Health:
Conditions exist which cquirc€utthcr cvaluati=by the Board of health in order to determine if the system
is failing to protect public health,safety or the environment.
'I. System will pass unlen Berard of Health determines in accordance with 310 CMR 15.303(I)(W)that the
system is not fuuc.ionin-g in a wanne-whaLh wd6 Protect Public health,sa4e"y and the environment,
— Cesspool or privy is within 50 feet of a surface water
_ Cesspool or privy is within 53 feet of a border-ing vegetated w,.lard or a sa3t marsh
Z. System will fail uniess the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects:lae public health,safety and eatvi:ronment:
_ The system has a uprc mil{and soil a -,rpton system(SAS)and the SAS is w-ithm I GO feet of a
surface water supply or trilutaiy w a surfwe v, 'supply.
_ The system has a septic tmk and SAS and the SAS is within a Zone I of a public wager supply.
_ system lies a septic teak and SAS=2 the AS is w3tl p 50 zcct of a Private water supply yell.
— The system has aseptic tastk and SAS and the SAS is less than 100 feet but SG F Ee orintjre Frcvn a
-private water supply well".Method used to detertaine di�nee ..
"nis system passes if the well water analYsiS,pmformed at a DEP certified laboratory,for colifom
bacteria and volatile€ „anic c€xt<spersns3s k4c;ates t the well is f ice from pvilution from that facility and
the presence Ofamzatortaa wtragear snta nitrate•-ft- oa w-q-'-1 w o,k.titan 5 ppm,prowdcd rbzt no voter
failure critesix aTe triggere&A copy of the anOysis, =w1ed w&is fo�
3. Other:
a� i
Page 5 of]i
OFFICIAL INSpE4CM. t FOR —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTF'M INSPECTIGN FORM
PART II
/ CHECKLIST
Property Address' /f 1 -yes KKq
Date of Icrispedton-
--heck if the following have been done.You moist indicate"yes'-or—nf as to each of the fellowh$g:
Y
CS : L�
/Pumping infortrhation was provided by the owner,occupam or Eoarc�of Health�ti ere any of the sysem components pumped out in the previous rwG weeks
V/ Has the system received normal'lows in the previous two week period'
Diva large volumes of}aster been inn—oduced to the sinter 3 recenTly or as paw of i is inspection
e/`;Vcre as built plans of the system obtained � ®r<<and e� ef they welrnoe avatt oa able rae as VIA)
V Was the facility or dwelling inspected for sighs of sewage back up
Was the vita€0zUC;cod furb-cgns or"brmk out?
?✓ _ Were all system components,excluding the SA&Imemd can site?
Were the septic tank manholes uncovered,opened,and the interior of the ta-k hispect—ed for the condition
of die af{les or tees,material of construction,dimensions,depth of liquid,depth of siuoge and depth of sc•�?
ri'vas the facility owner(and vcmpants if different fmm owned provitici with information on fht.proper
maintenance of subsurface sewage disposal system?
Tile size and location of the Sof Vosorpti System(SAS)on the&ix has been;eminnned based on:
Yes no/
Existing tuformtion.For example,a pan.at the Board of Health.
_ Determined in the field(if any c-ftbe fa llure tamer a reia<ed to Pan C is at'Wile approximation of&-fance
is ustacGiptaitle)[310 CNR]53G2(3)(s})
Page 6 of 11
OFFICIAL SPECTfON F4 -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFA.0 S i rA DISposA L SYSTEM INSPECTION FORM
PART C
Property address: /c,I
Owner.
Data Of irnspeeiion: 7
FLOW CONDITIONS
SIREN s7AZ.
dumber of be cltovu ,(si i t): N mzber of bedrooms(ai--tual). �3 �
DESIGN flow rased or,3 iG^,MiR 15.243(.of x.4 of bedroams):
Number of current residents: 3 -
Does residence have a garbage grinder(yes or no):J_Jo
Is laundry on a sepwrate sewage system Ives or no): Iv [if yes separate inspection required]
Laundry system inspected e<or no):
Seasoaal use:(yes or no): Q
Water meter readings,if wrailable east 2 years usage(cpd)};
Sump pump(yes or no)-,
Last date of oeeupancy:
COMMERCMI-I MUSTRIAiu
Type of establishment:
Dczig„flour(braid on 310 C,.-M I5.203): end
Basis of design flow(SM slpersonsfsgtetc.):
Grease trap present(yes or:to):
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 cccupancy/use:
0 r�(desLribe):
GENERAL INFOMMATION
Pumping Records
Sourced information:
Was system pumped as part off-the' con(yes or Qo) _
If yes,Yolume pumped allonnss—Haw was quantity pumped determined`
Reason for pumping:
VP,OF SYSTEM
Septic tank,di � l'�^a-sail absorption system
Single cesspool
overflow cesspool
—
�'PriYy
Share.system(yes or no)(if yes,attach previous inspection records,if arty)
—Innovative/Alternative InnovativelAlternative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
'Fight tank —Attach a copy of the DEF approval
_Other(describe):
Appraaiinate agc of all components,&te imWicu(ifImoWu)zmd svurx:c of irlrb atioa:
12 21
Were sewage odors detected when arriving at The site(yes or no):j4b
Page 7 of 11
OFFICUL LNSPECW- ON FO-RIC4—NOT FOR VOLUIN_I
S URSURFACESEWAGEM M. S�--T
PART C
SYSTEMS LN-POMATION(conf mled�
Property Address. TW-4 A/
Date of Inspection:
BUILDING SEWER"ocaU-1 az
"
Dcptb bciow grade; 11)
M.t.tie,s —cast him _tether(explain):
ftorn D-,--aae.v'm:ter-'11j!tn1y'VV U-11 Q-1 Su C1.1on Hn e:
L.E.TIC T_414-K.- 'locate on site plan-)
Dopth'--w1ow grade,
ction,Material of ccm M, ne
H t aim: iR=CveS0TR0)'_(Vmchacop of
certificate)
w fir
Dimens!Gns.'
Sludge depth,
D-e-ar fmnm c�.-- =0 �' F W�kjudvi wcB orb
Scum thickness:
T.2t f cc f-nrr.m %rp n
_f^iintlet to ar baffle:
Dismce ft. m bottom of S-Cm-1 tO"_!Q.,'- , 'CL�'
How were dimensiom
to
� el
fImk �c condj s��-ummzl negrity,liquid ives
d accoage,C .)_,locate on site plan)
NA awrial.of con-smactmjn:
"explain,-1:
Dimensions--
Scan thicImess;
Dis=cc from top iZx ma
Distance from bortam of i srm --,cc
D=of last pzmap`-
M. and
M2 r!=1�nte UT-,i d I ev e is
Page 8 of 11
OFFICIAL INSpECT40N FORM �� FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMIATION(continued)
Property Address;
1u's
Owner:
Bute of Inspection: i- 2
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: aallonslday
Alarm present(yes or no):
Alarm leve]: Alarm in working order(yes or no):
Date of last pumping.
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX:0(if present must be openedxlocate on site plan;
Dcpth of liquid levcI above outict Mauch
Comments(note if box is level and di=ibution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
FUNIP CCRA-MAF.II;: (locate an site plan)
Pumps in working order Eyes or no):
Alarms in working order(yes or no):
Comments(note condition ofptutip chamber,condition ofpumps and appurtenances,etc.):
page 9 of 1
OEEICLAL INNSPE€.'"MN FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DLSEQSAL SYSTEMI INSPECTION FORMI
PART C
SYSTEM INFORMAT OINT(continued)
Property U&998: Ic S Kd
f 4tif-[iti►� t,BLS
Owner:
Date 9f Inspection:
SOIL ABSORPTION SYSTEM(SAS): (tacate on site plan,excavation not wired)
if SAS not located explain why
Tvpw
leaching pits,number.
leaching chambers,number.
1eeclxire&geItaries,a�rabet=
_leaching trenches,-number,length:
_leaching fields,number,dimensions:
_overflow cesspool,number:_
_innovative/alternativee system Type/name of technology
Comments(note conditions of soil,signs of hydraulic failu€e,level ofPondin&damp soil,ccndidoa of vegetation,
e1c.): r F i
ESSPOOL& (cesspool must be pumped as pare of inspection)(locate on site plan)
Number and eonfigutatiou:
Depth-top of liquid to Her in-vert:
Depth of solids layer.
Depth of scum layer:
Dimensions of cesspool:
Materials of eonsuuct€on:
Indication ofgmundwater irfflow(yes or no):
Comments(note cohditirm of soil,signs ofhydraulic faijuure,level ofponding,condition of vegetations,
PRIVY:!(locate on site plan)
Ma.erials of construction:
Dimensions:
Depth of solids:
Co enss(reoRe condition of soil,signs of hydraulic PAure,level ofposiding,condition of vegetation,etc).
Page 10 of 11
OFFfCIAL INSPEC IhN FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM P SPECTION FORM
PART C
SYSTEM INFORMATION(continued)
PrGpeerty Address:O f l
Owner:
Date of Inspection-
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.
A
f
��t
Page 11 of=1 s . ASSESSMENTS
�� e�� g� �s
O$`4 CII-F" L INSPECTION N&'OS.\M—NOT FOR VOLUNTARY i113 21SRY 1'A�7�7C.SSMEiNTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM EXFORMATION(continued)
Property Address:
Adzils.
Owner:
Date of Inspection:
SITE EXAM
Slope
auriace crater
Check cellar
Shallow wells
Estimated depth to groundwater 39 fect
Plcase indicate(check)all methods used w determine the high ground water elevation:
Obtained fmm system design plans on record-If checked,date of design plan reviewed:
_L/Observed site(abtttfmg property/observation hole witttun 150 feet of SAS)
-"Checked with local Board.of Piealth-expWn:
Checked with local excavators,installers-(attach documentation)
4ccessed USGS database-explain:
You must descTb�e_how you est9blished the bigh gro ad water elevation:
Title 5 Inspection Form 6/15/2000 l l
„ C-O-MM WATER DEPT
CUSTOMER STATEMENT
ACCT NO 10,875 7/27/2005
NEWTON, LYNNE
LOCATION:
114 JONES RD
MM
LOT: L328
MAP&PARCEL : 46064
Consumption History
DATE READ CONS
06/30/05 751 47
12/31/04 704 31
06/30/04 673 18
12/31/03 655 23
06/30/03 632 66
12/31/02 566 50
06/30/02 516 48
12/31/01 468 36
TRANSACTION HISTORY
DATE DESCRIPTION 0 to 30 31 to 60 61 to 90 Over 90
8/1/2000 STARTING BALANCE 0.00. 0.00 . 0.00 178.94
8ii/2000 DEMAND 0.00 0.00 0.00 i0.00
8/29/200 PAYMENT 0.00 0.00 0.00 -50.00
9/18/200 PAYMENT 0.00 0.00 0.00 -138.94
10/2/200 MINIMUM BILL 0.00 0.00 0.00 15.00
1/1/2001 MIN EX 0.00 0.00 0.00 96.20
3/3/2001 INT 0.00 0.00 0.00 1.30
4/2/2001 MIN INT 0.00 0.00 0.00 16.30
4/25/200 PAYMENT 0.00 0.00 0.00 -128.80
7/2/2001 MIN EX 0.00 0.00 0.00 44.00
9/1/2001 INT 0.00 0.00 0.00 0.51
10/1/200 MIN INT 0.00 0.00 0.00 15.51
Balance Due: 113.30
C-O-MM WATER DEPT
CUSTOMER STATEMENT
12/1/200 INT 0.00 0.00 0.00 0.70
1/1/2002 MIN INTIX 0.00 0.00 0.00 62.10
3/1/2002 INT 0.00 0.00 0.00 0.71
4/1/2002 MIN INT 0.00 0.00 0.00 16.43
5/13/200 PAYMENT 0.00 0.00 0.00 -139.96
7/1/2002 MIN EX 0.00 0.00 0.00 116.20
9/1/2002 INT 0.00 0.00 0.00 1.36
10/1/200 INT 0.00 0.00 0.00 1.36
10/17/20 PAYMENT 0.00 0.00 0.00 -118.92
1/1/2003 MIN EX 0.00 0.00 0.00 122.00
2/3/2003 PAYMENT 0.00 0.00 0.00 -122.00
7/1/2003 MIN EX 0.00 0.00 0.00 168.40
7/21/200 PAYMENT 0.00 0.00 0.00 -168.40
1/1/2004 MIN EX 0.00 0.00 0.00 43.70
4/1/2004 INT 0.00 0.00 0.00 0.51
5/1/2004 INT 0.00 0.00 0.00 0.51
6/1/2004 INS' 0.00 0.00 0.00 0.52
7/1/2004 MrN INT 0.00 0.00 0.00 35.52
8/1/2004 DEMAND 0.00 0.00 0.00 10.00
9/1/2004 INT 0.00 0.00 0.00 0.94
9/23/200 OFF/ON NON-PAYT 0.00 0.00 0.00 60.00
9/23/200 PAYMENT J 0.00 0.00 0.00 -151.70
1/1/2005 MIN EX 0.00 0.00 0.00 66.90
4/1/2005 INT 0.00 0.00 0.00 0.78 r
5/1/2005 INT 0.00 0.00 0.78 0.00
5/10/200 PAYMENT 0.00 0.00 -68.46 0.00
7/1/2005 MIN EX 113.30 0.00 0.00 0.00
Balance Due: 113.30
TOWN OF BARNSTABLE to
LOCATION J I q ,r1W PS �d SEWAGE # �/
VILLAGE hfa/s fc".5 A A(S ASSESSOR'S MAP&LOT�7 O4-T
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY 166 0 6c,f
LEACHING FACILITY: (type) Lea c4 )0•_'k (size) l-oao (a.f
NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted.Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by C�f�k-L46,10 /Vt Fl/C,�/
B c,t k j
i
LO CATION SEWYG E PERMIT NO.
R
VI L AG E
t
I N S T A LLER'S NAME i ADDRESS
B U I'l D E R OR OWNER
DATE PERMIT ISSUED � _ 0 _ 7?-
DATE COMPLIANCE ISSUED
,.AA
3 y iq
�)d V
G �
'IMF
No.----.-_�1__��___ . 1 F-s.... .. ...........
� I
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
Town Barnstable 1 P
OF......
, pphra#ion for Ui4pntia1 Workii Ti ntrnrtion runfit
Application is hereby made`,for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal
System at
�� Jones Road �(!�,�'►� /�, Lot 328
.............. ....
----...... . . ........:...•-- l�Xl...._.. ...............................................
••- Location-Address or Lot No.
cyl�f' 1 . 1 �!�►ns .........:...............................
Owner Address
a ....................... .............................................. .................f�'
Installer Address ),� p37
Q Type of Building CA•P12 - SAIcr 6o� Size Lot......_._._? .....Sq. feet
Dwelling—No. of Bedrooms..................3..._....._...__.__..__.Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ____________________________ No, of persons-----------6.............. Showers ( ) — Cafeteria ( )
Q' Other fixtures ............:...............
-- ----------------------------------------------------------------------------------•-•------------•------.._...-------
Design Flow........................55..............gallons per person rper day. Total daily flow-----------------33.0..................gallons.
n
R; Septic 'Tank—Liquid capacity.l000gallons Length__---__-6___._ Width ....-10_ Diameter________________ Depth..5.!_.- ..
Disposal Trench—No. .................... Width........-........... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No......... Diameter.........1�t... Depth below inlet........6t....._. Total leaching area...... 7....sq. ft.
Z Other Distribution box (X) Dosin tank ( )
`-' Percolation Test Results Performed by._�ape___COd _Survey._ConsulaTltDate......Jura.-. .,___18
r_.
,tea Test Pit No. I... 2_-_-minutes per inch Depth of Test Pit......121...... Depth to ground water.....U01.P.........
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water----- --UF. 9
a ........._ . ..... Ts CG
O Description of Soil....____.__0-0.5-_.wood,loam- 0.5-2.5 subsoil--___2.5--12t0.•m ._ y
x coarse sand
--------------------------------•-••--..........--- --•-- ... ........ .._----- . . ------ -----................
--------------- -----------------------------------------------------------------------------------•---------------._...----------------•-...-----------------------•--•--•--• �.------1?AYJ.QR y ..
Nature of Repairs or Alterations—Answer when applicable.................................................................... Na 23741
U .. pp•----------•-----------•----•---•---•--•----------•--•------... y...-•-•- Yoh = w 4�
Agreement: _
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordan
the provisions of iITL L 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.
S i2���
_ Date
Application Approved By L!�1 .. . . --` 7 ..
Date
Application Disapproved for the following reasons:.......................................:..................•----------------............._.......................
.................•--•----............-----•-•------------•--•----------------------....•---------..........
------------------
Date
PermitNo......................................................... Issued-------------------------- -----......................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OWn F...
• ......... ........ . .......... ........OF..........--........--•--•--•........ e................................................
Applirutiun for Dispoii al. Murks Tomitrurtiun Prrntit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
................-................................................................................ -•------••--------..•--- ----------------•......._....
Location-Address or Lot No.
'r ek.....•........................................ ...........:...:1! JY:i i.l..............................................................
_ Owner Address
a .. a .............................................. .................iA.... ........
Installer Address
37
U Type of Building c' !jn S 4-G !sax Size Lot____� a$ ......Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
'4 Other—T e of Building No. of persons_.........�:.............. Showers — Cafeteria
Q' Other fixtures ...................................
W Design Flow................. 55...............gallons per perso,Fliper day. Total daily flow.................330 --__-_---__gallons.
WSeptic Tank—Liquid capacity�99%allons Lengt ._... ..�__.... Width Diameter-____'---------------- Depth.., � ----:_.
x Disposal Trench—No..................... Width ............ Total Length_._....._ .. .... Total leaching area-__. -,....._.sq. ft.
� -Seepage PitNo_____________________ Diameter..._._...XP._..__.___. Depth below inlet........6........ �6 Total leaching area..... ft. _
Z Other Distribution box (Z) Dosing tank )
'-' Percolation Test Results Performed by.. � _ r �"_..f+"�?1> 1late.. _€ 1 .S�__ . ` .
aTest Pit No. I........ .....minutes per inch Depth of Test Pit...... ....... Depth to ground water----n01,10.___,
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
t� ....................................
O Description of Soil---•-•. 0�'.Q'*5._ rI0.0E loam.. 0.a-21.�._ sub_�o l- �.e_ w12 0 med: ��N OF M9s
-------------------•--------------------------------•--•---...-•-•--•--..._..__.....-•--------....--------.....---------•---------•---------•-•----•---•-......--•----•--- f
UNature of Repairs or Alterations—Answer when applicable.................................................................. -o. ......DAY-LOR-.. v
No 23741
..----------•-------•-•---•----•----------------•----------...--------•-----•--•----................---•----......-•-------------------•-------•--••----.........--- ��........----
Agreement: I o iS
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System In ac �,l$
the provisions of TITTIE 5 of the State Sanitary Code—The undersigned further agrees not to place the n
operation until a Certificate of Compliance has been issued by the board of health.
/ 1 F
Sram/.:Z^ --------------------------------------------•----•- -.Z..Y——9....---
Date
_ApPlication Approved By !7 --- Date
Date
Application Disapproved for the following reasons---------------------------•--------•--------------------...--•--------------------------------•-•-••-----------
-----•---------------------------•-------•--------...----.......----•---•--•----------.....---•-------•-----------------------------------------•---•-----------•--•-•---•-•-•----•-------•-••----------
Date
PermitNo. ---------------- Issued........................................................
Date
THE COMMONWEALTH OF MASSACH,YSETTS
BOARD OF HEALTH
Carr lfiratr a ToutpliFatta
THIS IS TO CERTIFY, That:-the Individual Sewage Disposal System constructed or; paired ( )
by................••--••----•-----....------------......-•--- :%�_._ r�! =f..---------------------...............---•--•------•----•-------•-•-----•-----•-........_....--•--...._........
"s " Installer
at... ............ 1 ` r4?-!�/ _ti z_!._ ''�_.:_ I Ec`= 1 ----------------------------•-.---.-- -------- --•--------•-••----•-•-----• ---•-•-•-••------••-•--
has been installed in accordance with the provisions O �' " of The State Sanitary C e -described m the
application for Disposal Works Construction Permit kolG ±�..._ � ................. dated-.ZA
THE ISSUANCE OF THIS CERTIFICATE SMALL NOT BE CONSTRUE® AS A NTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE......� .`._ _ ..................................... Inspector........-
THE COMMONWEALTH OF MASSACHUSETTS
BOARD 9F HEALTH
N................. P '1.................OF....... s� .. ....---.........._..................................... '' �►'f
.... FEE..2.rC
/
19WposFal Works Tonsitfu' r nti
Permission is hereby granted......... �-•--5 r JI-Y--------••--------•--------------------•---------------------------•--........----..........-•---..........
to Construct (� or Repair ( ) an Individual Sewage Disposal System
atNo. •1 t�.. -------- ± t l _...----: = t 1 1 ........-----••-•--------•-------------------------------•------------........
Street
as shown on the application for Disposal Works Construction Per ' No__ ______ _ ___ _ Dated.._. 7 01...7�...........
oar of Health
7
DATE......... _'.. -:1...`.---y ....................................
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS ' '
L O CATION
.. SEWAGE �� ..
G E E RM;IT . N0.
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INSTA LLER'S A--NAME i ADDRESS
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BUILDER -OR OWNER
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.! DA;T E PERMIT ISSY EDP
DATE- COMPLIANCE ISSUED
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SEPTIC ( _.- 6 0 °I ° • •I BLOCK i n
f 1 I TANK e ° SEEPAGE PIT i o • —0A0"56 '
1) 1 �• ' oo i � r e I '
,�.. 20' MINIMUM "�°,'�• ,°i_,__
FOUNDATION -
WASHED STONE r
ELEVATION SKETCH _
TEST BY : C.F.PnrK /�rs/ ,Ntrr —
�lsxs SCALE 1": 4' �'zfA..? TOWN INSPECTOR �4uG _e1'Ci�Ca.9Y`
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TEST MADE ON
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ELEVATION SCHEDULE = T PROPOSED SITE PLAN FDAYI DP
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c I INV • AT FOUNDATION SEWAGE SYSTEM DESIGN
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- 2. INV INTO SEPTIC TANK +*
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p 3. 1 NV. 0 U T OF SEPTIC TANK -- ry1.?r�'S r,,�;g ra�.°a G.Z_S te`
3. 17 SCALE I"=�"!�' ..Jdn/C$ 197=;
4 INV 'PTO DISTRIBUTION BOX ---
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• 5 INV OUT OF DISTRIBUTION BOX
tr- '1� CAPE COD SURVEY CONSULTANTS
` 6 INV INTO SEEPAGE PIT ROUTE 132
lta <3ez HYANNIS, MASS
Z BOTTOM OF PIT A OCVIS10N SUSTON SUNVCY CONSULTANTS, INC.
8. BOTTOM OF STONE LAYER
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