HomeMy WebLinkAbout0021 MARSHVIEW LANE - Health 21 Marshview Lane,..Marstons Mills
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Commonwealth of Massachusetts ,
w Title 5 Official Qnspecti®n. Form.
hI Subsurface Sewage Disposal System Form -Not for.Voluntary Assessments
J, T,; ;` 21 Marshview Ln
Property Address
Richard Edwards i
Owner Owner's Name /
information is Marstons Mills ✓ - MA 02648 10-29-2020
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. Please see completeness checklist at the end of the form.
A. Inspector Information
Shawn Mcelroy
Name of Inspector t
Upper Cape Septic Services
Company Name
P.O. Box 73
Company Address
East Falmouth MA 02536
City/Town State Zip Code
508-495-0905 S13971
Telephone Number License Number
B. Certification
I certify that:l am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000);1 have personally inspected the sewage disposal system at theproperty address listed
above;the information reported below is true, accurate and complete as of the time of my inspection; and
the inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that
the system:
1. ® Passes
2. ❑ Conditionally Passes . 0.
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
10-29-2020
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
Y P 9 P Y 9
10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time. This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc•rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18
Commonwealth'of Massachusetts • ' �``
Title 5 Official. Ins ection Form
it Subsurface Sewage Disposal System Form --Not for Voluntary Assessments
21 Marshview Ln
Property Address
Richard Edwards
Owner Owner's Name
information is Marstons Mills MA 02648 10-29-2020
required for every
page. City/Town ' State Zip Code Date of Inspection
C. Inspection Summary r, ...
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) 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:
System is in good working order with no sign of failure.
-,
2), System Conditionally Passes: .
• , ❑ One or more system components as described in the "ConditionalPass"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):
r
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
) Subsurface Sewage Disposal System Form,-Not for Voluntary Assessments
21 Marshview Ln
Property Address
Richard Edwards
Owner Owner's Name
information is required for every Marstons Mills MA 02648 10-29-2020
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑Y' `❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑Y ❑N ❑ ND (Explain below):
❑ obstruction is removed ❑Y ❑N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board dof.Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts • "
,w. Title 5 Official Inspection Form
Subsurface Sewage Disposal System'Form -Not for Voluntary Assessments
21 Marshview Ln
Property Address
Richard Edwards
Owner Owner's Name
information is 'If I • . u
required for every Marstons Mills MA 02648 10-29-2020
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.) "° =
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects,the public health,
' safety'and environment: 'r
❑The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑The system has a septic tank and SAS and the.SAS is within a Zone 1 of a public water
supply.
❑The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑The system has a septic tank and.SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must
be attached to this form.
c. Other: -
f
4) System Failure Criteria Applicable to All Systems: f
You must indicate "Yes"or"No"to each of the following for all inspections:
• -Yes No
❑ ® Backup of sewage into facility;or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc-rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18
1�
Commonwealth of Massachusetts
�� fw Title 5 Official Inspection, Form.
Hi Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
21 Marshview Ln
Property Address
Richard Edwards
Owner Owner's Name
information is required for every Marstons Mills MA 02648 10-29-2020
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1/2 day flow '
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a.facility with a design flow of 2000 gpd-
10,000 gpd.
® The system fails: I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303,therefore the system fails. The
system owner should_ contact the Board of Health to determine what will be
M necessary to correct the failure.,
5) Large Systems:To be considered a large system the system must serve a facility with a design
flow of 1-0,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no,'to each of the following, in addition to the
questions in Section CA. f
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA) or a mapped Zone II of a public water supply well
t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form,
"I�I Subsurface Sewage Disposal System Form =Not for Vol untary,Assessments
21 Marshview Ln
Property Address
Richard Edwards '
Owner Owner's Name
information is required for every Marstons Mills MA 02648 10-29-2020
page. Cityfrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes"to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade,the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the'Department.
6. You must indicate "yes" or"no"for each of the following for all inspections:
Yes No
® ' ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ , ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (if they were not
available note.as N/A)
®' ❑ Was the facility or•dwelling inspected for signs of sewage back up?
®' '~ ❑ Was the site inspected for signs of break out?
® ❑ ' Were all system components,"excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid,•depth of sludge and depth of scum?
® 0 Wasthe 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:
F ® ❑ Existing information. For example, a,plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts
a t; Tide 5 Official Inspection Form
Subsurface Sewage Disposal System,Form -Not for.V_oluntary,Assessments
21 Marshview Ln ,
Property Address
Richard Edwards
Owner Owner's Name
information is required for every Marstons Mills MA 02648 10-29-2020
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 3 Numberof bedrooms(actual): 4
DESIGN flowbased on 310 CMR 15.203 (for example: 1,10 gpd x#of bedrooms): 330
Description:
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Sump pump? ❑ Yes ❑ No
Last date of occupancy: 10-2020
Date
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
c Commonwealth of Massachusetts r /'
4. 3 Title 5 official Inspection Form,
I, Subsurface Sewage Disposal System Form --Not for Voluntary Assessments
21 Marshview Ln
Property Address
Richard Edwards
Owner Owner's Name
information is required for every Marstons Mills MA 02648 10-29-2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions: '
-Type of Establishment: '
Design flow(based on 316 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below): .
3. Pumping Records:
Source of information: Owner---pumped 9-2020
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping: Maintenance
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18
Commonwealth of Massachusetts
fw Title 5 Official Inspection. Form
p Subsurface Sewage Disposal System Form--' Not for Voluntary Assessments
21 Marshview Ln
Property Address
Richard Edwards
Owner Owner's Name
information is required for every Marstons Mills MA 02648 10-29-2020
page. City/Town - State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System: ,
® Septic tank, distribution box, soil absorption system
❑ Single cesspool j
❑ 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:
1994
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 12"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.):
Good condition.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
,'. Title 5 Official Inspection Form
! I Subsurface Sewage Disposal System Form -*Not for Voluntary Assessments f<
21 Marshview Ln
h
Property Address
Richard Edwards
Owner Owner's Name
information is Marstons Mills MA 02648 10-29-2020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 4 '� �' F' - r
6"
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass' ❑polyethylene ❑ other(explain)
t .
If tank is metal, list age. '
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: _. 1000 gal
Sludge depth:
3"
Distance from top of sludge to'bottom of outlet tee or baffle
2g° .
Scum thickness 0
Distance from top of scum to top'of outlet tee or baffle 6'` "
Distance from bottom of scum to bottom of outlet tee or baffle
16"
Tape
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 is in good condition with baffles.installed and no sign of leakage.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18
Commonwealth of Massachusetts
r Title 5 Official Inspection Form
�f Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
21 Marshview Ln
Property Address
Richard Edwards
Owner Owner's Name
information is required for every Marstons Mills MA 02648 10-29-2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan): s
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.):"
r
8. Tight or Holding Tank (tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts '
,'. Title 5 Official Inspection Form
it Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
21 Marshview Ln
Property Address
Richard Edwards
Owner Owner's Name
information is required for every Marstons Mills MA 02648 10-29-2020
page. City/Town State Zip Code Date of Inspection
D. System Information (coat.) "
8. Tight or Holding Tank (cont.) '
Alarm present: ❑ Yes ' ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box (if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert 0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Good condition with water at working level and no sign of back-up from field.
i
• f
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
Commonwealth of Massachusetts f
fw Tile 5 Official Inspection Form
� I Subsurface Sewage Disposal System Form Not for Voluntary Assessments
21 Marshview Ln
Property Address
Richard Edwards
Owner Owner's Name
information is Marstons Mills :
required for every MA 02648 10-29-2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) 1.
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass. r
11. Soil Absorption System (SAS) (locate on site plan,-excavation not required):
If SAS not located, explain why:
Type: ,
❑ leaching pits ' number:-
® leaching chambers number: 4-Flodiffusers
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts -
�. 4 Title 5 ®foci l I n a sp ecti®n Form
-i i Subsurface Sewage Disposal System Form Not for Voluntary Assessments '
21 Marshview Ln
Property Address
Richard Edwards '
Owner Owner's Name
information is required for every Marstons Mills °" MA 02648 10=29-2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Flodiffuser field in good working order and empty at inspection with stain line at 2"off bottom of
chamber.
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number-and configuration
Depth—top of liquid to inlet invert' a
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.):
F M1
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
fY Tide 5 Official Inspection dorm
Hi Subsurface Sewage Disposal System Form -Not for.Voluntary;Assessments
r�t:
21 Marshview Ln
Property Address r
Richard Edwards
Owner Owner's Name
information is required for every Marstons Mills MA 02648 10-29-2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 .
s Commonwealth of Massachusetts
Title 5 Official- Inspection Form
w_�
_inr Subsurface Sewage Disposal System Form -Not for Voluntary-Assessments
r'' 21 Marshview Ln
Property Address
Richard Edwards
Owner Owner's Name
information is required for every Marstons Mills s MA 02648 10-29-2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
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t5insp.doc•rev.7/2 612 01 8 °' r Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18
i
ti Commonwealth of Massachusetts
Title 5 Official Inspection Form
i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
21 Marshview Ln
Property Address
Richard Edwards
Owner Owner's Name
information is
required for every Marstons Mills MA 02648 10-29-2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) -
15. Site Exam: .,
❑ Check Slope
❑ Surface water ,
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 8'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:
USGS and town maps show groundwater at 10'. Bottom of leach field at 24"
Before filing this Inspection Report, please see Report Completeness Checklist on next 9 a e.
p
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18
Commonwealth of Massachusetts -
Title 5 Official . Inspection Fora
"'i Subsurface'Sewage Disposal System Form -Not for Voluntary Assessments
:- T, �>`' 21 Marshview Ln
1.-J
Property Address
Richard Edwards
Owner Owner's Name
information is required for every Mar'stons Mills MA 02648 10-29-2020
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of: _
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria)and 6 (Checklist) completed-
® D.'System Information:
For 8: Tight/Holding Tank'—Pumping contract attached '
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t i
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18
•
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTALIRSJ
DEPARTMENT OF ENVIRONMENTAL OTECTION
ONE WINTER STREET. BOSTON. NIA 02108 61 i-I �-5';00 3I8dSN°B�oN�I d0
8661 o/
W1LL1A.\1 F.WELD '�!P s
�?RUDY CORE
`lq'��'9 Secretary
�F�' Cf
ARGEO PAUL CELLUCCI 'VID B.STRUHS
Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM + �� Commissioner
PART A t
`{ CERTIFICATION
Property Address: 2 /f�irrJhv�-«v Aan.L / WI&,i .N,//s Address of Owner:
Date of Inspection: ;l —///� 9$ (If different)
Name of Inspector:. 7Uh.2_ f/,,G 1161
1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CM
R 15.000)
Company Name: g4,1r.4,c Seyy�GP
Mailing Address: _/S"V L!/,,,Id2 , s� /Y/G/ vr,s �,�/S ��, pZG y9
Telephone Number: <o 9 r.!25-
CERTIFICATION STATEMENT
I certi�, that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete'as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
1l-11Passes
_ Conditionall�' Passes
_ Needs Further Evaluation By the Local Approving Authority
_ F ills pp
Inspector's Signature: Date: !8
The System Inspectors all submit a copy of this inspection report to the Approving Authority within thirty (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 Department of Environmental Protection. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
INSPECTION SUMMARY: Check A, B, C, or D:
AJ SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
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.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not.
_ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or
the septic tank,-whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
(revised 04/25/97) Page 1 of 10
DEP on the World Wide Web: http:/Avww.magnet,state.ma.us/dep
0 Printed on Recycled Paper
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION ((continued)
Property Address: 2� /��GYf�vic�Gei �uHP/ IVA-t/6'hS '41)'XlSi
Owner: VV/H
Date of Inspection:
BI SYSTEM CONDITIONALLY PASSES (continued)
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the
Board of Health). Describe observations:
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh,
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM.IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or
tributary to a surface water supply.
The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that
the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method used to determine distance (approximation.not valid).
3) OTHER
(revised 04/25/97) Page 2 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: / 1)114,-S//v/« /,,r°-,-P� /i'�y/'S/vhS /0i/j
Owner: 7V�H /— �k Nh
Date of Inspection:
2-/�- gy
D) SYSTEM FAILS:
You must indicate either "Yes" or "No" as to each of the following:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
Yes No
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or ciged 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 112 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliiorm bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E) LARGE SYSTEM FAILS:
You must indicate either "Yes" or "No" as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significam threat to
public health and safety and the environment because one or more of the following conditions exist:
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area-IWPA) or a mapped Zone ll of a
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treats ent program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information..
(r*vixad 04/25/97) page 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: IV14r
Owner:
Date of Inspection:
Check if the following have been done: You must indicate either "Yes" or"No"as to each of the following:
Yes No
1Z _ Pumping information was provided by the owner, occupant, or Board of Health.
None of the system Components have been pumped for at least two weeks and the system has been receiving normal
flow rates during that period. Large volumes of water have not been introduced into the system recently or
as part of this inspection.
v _ As built plans have been obtained and examined. Note if they are not available with N/A.
✓ _ The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary, or industrial waste flow.
✓ _ The site was inspected for signs of breakout.
_ All system components; e*ehiding the Soil Absorption System, have been located on the site.
The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of
baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on:
_ The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of
Sub-Surface Disposal System.
_ Existing information. Ex. Plan at B.O.H.
✓ _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) (15.302(3)(b))
(revised 04/25/97) page 4 of 10
i
}
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION,t/
Property Address: / 41/a A's A v r !cd L.AA74 //Y/GrStvi.,J ///'�`S,
Owner: UpJ�h /9 N h h
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow: #JW g.p.dA)edroom for S.A.S.
Number of bedrooms:
Number of current residents: 3
Garbage grinder (yes or no):,-(v
Laundry connected to system (yes or no): 1�15
Seasonal use tyes or no):--A/0 T p` /� ��� (9: O�
Water meter readings, if available (last two (2) year usage (gpd): , Jb 7
Sump Pump (yes or no): Ale,
Last date of occupancy: JGC"1-2 i{d Nuw
COMMERCI.AUINDUSTRIAL:
Type of establishment:
Design flow:_gallons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: tves or no)—
Non-sanitary waste discharged to the Title 5 system: (yes or no)_
beater meter readings, if available
Lastdate of occupancy:
OTHER: (Describe)
Last date of occupancy.
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as part of inspection: (yes or no)_
If yes, volume pumped: gallons
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)
I/A Technology etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information: 5, s*����
Sewage odors detected when arriving at the site: (yes or no)-Ak
i b
(revised 04/25/97) Page 5 of 10
L
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner: Tv�,�.. P Nh"7
Date of Inspection:
2-//- 9$
BUILDING SEWER:
(Locate on site plan)
Depth below grade: .2
Material of construction: _ cast iron 40 PVC other (explain)
Distance from private water supply well or suction lire
Diameter
Comments: (condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK:_
(locate on site plan)
Depth below grader`
Material of construction: concrete metal _Fiberglass _Polyethylene _other(explain)
If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No)
Dimensions: ex, S x g y
Sludge depth: P1
Distance from top of sludge to bottom of outlet tee or baffle: .21"
Scum thickness: 2/' ,,
Distance from top of scum to top of outlet tee or baffler_
Distance from bottom of scum to bottom of outlet tee or baffle:
How dimensions were determined: 111149 SNrej
Comments:
frecommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.) vc. L f- T-e-e a� <vvr cy�7`P ou! Ll >-
S y
Ta t v.e / !a AA/V ge
GREASE TRAP: "
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of.last.pumpjQg:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.)
(revised 04/25/97) Page 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: Q/ A14 s4 yr'ert/ hG,".e lme4/'s /o"-f
Owner:
Jd`+vr ? 12N vl✓!
Date of Inspection:
95
TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection)
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain)
Dimensions:
Capacir,: gallons
Design flow: gallons/da�
Alarm level: Alarm in working order_ Yes; _ No
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:_
(locate on site plan)
Depth of liquid level above outlet invert: 0
Comments:
(note if level and distribution its equal, evi ence of solids carryover, evidence of leakap,into.orouut of box, etc.)
�ey-e I . Wae,�., r,gi ;, It /'l"// 4 � il -eI-e of
.,urktng order ,Yes of Nv:!.e
_ -dition cf nurnp chamber,
l
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
-�((continued))
Property Address: /45
Owner: 7f7Nv! P ��hH
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS):_
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type:
leaching pits, number:_
leaching chambers, number:__
leaching galleries, number:
`. ,�:' .� Fe8€fiin 'rrertches,.number.len
leaching fields,'number, dimensions:
overflow cesspool, number:
Alternative system: y
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) ,
2 ) fiid•,
CESSPOOLS: _
(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 (cesspool must be pumped as part of inspection)
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.)
(revised 04/25/97) Page a of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 2/
Owner: 7 / , �tihhv�e� �tihe �cirf fi�s 4/0/5 �.v.
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
1/37
ANY
4\
c V
(revised 04/25/97) Page 9 of 10
SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM
PART C
/ SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
Depth to Groundwater/2,1 Feet
Please indicate all the methods used to determine High Groundwater Elevation:
4," Obtained from Design Plans on record
v" Observation of Site (Abutting property, observation hole, basement sump etc.)
Determine it from local conditions
Check with local Board of health
Check FEMA Maps
Check pumping records
/Check local excavators, installers
Use USGS Data
Describe in your own words how you established the High Groundwater Elevation. Must be completed)
0,.Ow
1312 / /(�A" de
/ Gh �`Q,yf.
h o/7,'
(revised 04/25/97) ?age 10 of 10
TOWN OF BARNSTABLE
LOCATION ! Afetr:sl View /y-7 e SEWAGE # 9y 7a3
VILLAGE
ASSESSORS MAP & LOT
INSTALLER'S NAME & PHONE NO.y�aLr�-,
SEPTIC TANK CAPACITY �X,s y /OJOry
LEACHING FACILITY:(type) V-I-lat✓ W,`-q-5or-(size) 23X /G
NO. OF BEDROOMS 3 PRIVATE WELL O PUBLIC WATE
BUILDER O OWNE h Pl
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED: �' `�✓ ��
VARIANCE GRANTED: Yes No
PQ=�
'�
�' ', �`
- — IA�r �' �/y�-_
„-,
� ; y L '
`� ig�'' 1
.��- - \�`
�.
e'►�
ASSESSORS MAPNO: ®7
PARCEL N0.- 0l,
No.. ---- --- •---•- Fxs.
.............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliratilan for Dhi-pw3al Warbi Tomitrnrtiun Vamit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
� v. � � M............................................. � ---� .... .• .---•------------•--•----.......------...-----•-----------•----...----------•-------•-•----•----
ddress or t No.J � z . � L
_.....---.•-
..... -•-•-------••----••-•-•----•-....._• ..... ... ---------
O er . Add!rels-F_1 1........9!---1PJt..---•-•---•---------- ...S . �' !p!. C-•!r!i/�S_....__.
Installer Address
Type of Building Size Lot............................Sq. feet
..� Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type
of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
d Other fixtures .-.-.---•---------------------------------------------
----------------
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length---------------- Width.--------------- Diameter---------------- Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No.-.-_--_. --_--.-.- Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date--- ....................................1
Test Pit No. I-__.----_-.-_-.minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
GT4 Test Pit No. 2................minutes per inch Depth of Test Pit._.----------------- Depth to ground water........................
� ------•--••-----------------••-•---••-----•••••-•••---•---•-----•-••••-•--------•--•-•-•----._...---........................................................
0 Description of Soil...................................................................................................................................... .................................
x
U
w
x •---•••••-----------------------------------------------------------•-------------•---------•--•• ------------------------......------•-----------------.
Natur f Repairs or Alterations—Anns rteg applicable._ � 41 r I-d 4 e-�..�'
U P �, PP -- ----...--- ------------ --------•••-•.
71L
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance a eekf issued by the board of health.
Signed .. . ......... . ----- -------------- - ..........
Dace
Application A roved B a
PP PP y . ..:: —��--------- ----- ----'� -------------------------- .. - -_ .
` Dare
Application Disapproved for the following reasons: ....._------------------------------------------- t...............................................................
------------------- ------------------------ . ..............--------------------------------------------------------------------------------------- ........................................
..
YPermit No. Issued .. -- /..�`'. �.. e ................... Date
� f -
f 67 76
m .........��
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliration for Ulvjip 1 ial Wark,i C omitrurtivit ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: / �J/J /�
i !l'/LVf"' l� r e4 'C �Y/ 1
.............................................. r C -........---•--..... --•---------------------•--------•-------•-- ---- -------•--•---.......-•-------••-•-•----•--
t L cation•Address N/ or Lot
. No. , A.411
...............••••...�?h�?....�.... ......................................... .............{ ..l .............................................
AddressO�ner
.. ---- •-•--•- Installer Address
Type of Building 3 Size Lot............................Sq. feet
I a
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............................................gallons.
WSeptic Tank—Liquid capacitv............gallons Length................ Width_-.--.-...__-__- Diameter................ Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
3 Seepage Pit No_____________________ Diameter-------------------- Depth below inlet...._............... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
0-4 a
Percolation Test Results Performed by.......................................................................... Date...........................-•-••---•---
a Test Pit No. I................minutes per inch Depth of Test Pit_-_____----____-_- Depth to ground water.....................
(i Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
LY ....-•••••••.............................................•-•••-•••--•--••---••-•---•......-----••...........................................................
ODescription of Soil.................................................................................. -----....-----•----------------------------------•-•-------------••------•-•-•---....
x
U ...........................----•--••-•--•••-•--•-•--------••-•--••---••••-•-••••••---------•••-----••----•----•-••••-••----••••.•••-------•...---•••--------------•---••-----••-••-•••••------•-----•-
--------------------------------------------------------------------------------------------------------------------------------------------------------------------•. ••-
U
Nature of Repairs or Alter •tio s—Ans yer when applicable---._Re__ti,r---•_L-04 c 4_-, �i....... .. -_-- -_
...............
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance �beesuedby the board of health.
Signed . . !/f . �1.`. .g�1..
----------------- . .
Dare
Application Approved By _ '-----.'---/--?.- - ....'�...... �.
............
Dare �
Application Disapproved for the following reasons: ...................................... ---------------------------------------------------......................
..................................................... . ... ...........
Permit No. � e J Issued ........ --- -- --- ----- -------- --- ��.....'
Dace
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Ter#ifira e of C11omylian e
THIS IS TO CERTIFY, That the Individual Sew e Disposal System constructed ( ) or Repaired ( �)
by 7vL►.1 I l�u ��
?..._........_......_...._....._........---- --------------- ---------------------- - -------------------- -- - ..... __.......................
Installer
at /....y�u,�s- -.v, c,�• �.c..h ...../I _--------------------------------------------------------------------------------------------------------------
has been installed in accordance with the provisions of TITLE15 of The State Environmental Co,.3e a described i
the application for Disposal Works Construction Permit No. ,"r ..... �� .� ._. dated _ ". `�-.��
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT B CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE----------f. ..--, - �. Y�/.....f r, � Inspecto .... � ...-.
------------ --------------------------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
No� _ TOWN OF BARNSTABLE
/.........•� - FEE. r�
Etspnsttl Workii Tomitrudivit "amit
Permission is hereby granted. J-`- I---- � /� `-_A-------------- ----------------------•---...--------------•---...------............
to Construct ( ) or Repair an Individual Sewage Di posal System
P ✓�
as shown on the application for Disposal Works Construction Per - __/.�--.3_ Dated..____/A"�I ...............-9 y
/,S�/t_ 9y Board of Health
DATE --••••---••----•••-•-•-------------------•-•....
FORM 36508 HOBBS 6 WARREN,INC.,PUBLISHERS