HomeMy WebLinkAbout0126 PEACH TREE ROAD - Health 126 PEACH .71'
A=057-080
Yrl at '"S
Y Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
126 Peach Tree Road `
Property Address
David &Carole Webber Trust
Owner Owner's Name
information is required for every Marstons Mills MA 02648 11/10/12
page. Cityrrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Ricky Wright
use the return Name of Inspector
key.
B & B Excavation,lnc.
Company Name
14 Teaberry Lane
Alf Company Address
r Forestdale MA 02644
City/Town State Zip Code
508-477-0653 S14595
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
11/12/123
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****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.
tsins•1 v10
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 126 Peach Tree Road
Property Address
David &Carole Webber Trust
Owner Owner's Name
information is required for every Marstons Mills MA 02648 11/10/12
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:
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
f
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form Not for Voluntary Assessments
M 126 Peach Tree Road
Property Address
David &Carole Webber Trust
Owner Owner's Name
information is required for every Marstons Mills MA 02648 11/10/12
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303 1 b
( )( )that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o/ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 126 Peach Tree Road
Property Address
David & Carole Webber Trust
Owner Owner's Name
information is required for every Marstons Mills MA 02648 11/10/12
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health, .
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloade
d or clogged SAS or cesspool
99 p
❑ ® 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 '/z day flow
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
r
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 126 Peach Tree Road
Property Address
David & Carole Webber Trust
Owner Owner's Name
information is required for every Marstons Mills MA 02648 11/10/12
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA) or a mapped Zone II of a public water supply well
If you have answered"yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 126 Peach Tree Road
Property Address
David &Carole Webber Trust
Owner Owner's Name
information is required for every Marstons Mills MA 02648 11/10/12
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
❑ ® Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
❑ ® Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
15ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
126 Peach Tree Road
Property Address
David &Carole Webber Trust
Owner Owner's Name
information is required for every Marstons Mills MA 02648 11/10/12
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
2010 = 63 gpd 2011 =61 gpd
Sump pump? ❑ Yes ® No
Last date of occupancy: July 2012
Date
Commerciallindustrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present?
❑ Yes ❑ No
Industrial waste holding tank present?
❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 126 Peach Tree Road
Property Address
David &Carole Webber Trust
Owner Owner's Name
information is required for every Marstons Mills MA 02648 11/10/12
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ❑ No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
126 Peach Tree Road
Property Address
David & Carole Webber Trust
Owner Owner's Name
information is required for every Marstons Mills MA 02648 11/10/12
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
1998 field upgraded (tank is original)
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 3 1/2'
feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: >20feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
At time of inspection building sewer appeared to be in working order. No sign of leakage or blockage
Septic Tank (locate on site plan):
Depth below grade: 2 1/2'
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ® No
Dimensions: 1000 gal
Sludge depth:
31"
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 126 Peach Tree Road
Property Address
David &Carole Webber Trust
Owner Owner's Name
information is required for every Marstons Mills MA 02648 11/10/12
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle no sludge
Scum thickness no scum
Distance from top of scum to top of outlet tee or baffle no scum
Distance from bottom of scum to bottom of outlet tee or baffle no scum
How were dimensions determined? scour stick
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
At time of inspection septic tank appears to be structurally sound. No sign of back-up.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene El other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
Date
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
f
Commonwealth of Massachusetts
u W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 126 Peach Tree Road
Property Address
David & Carole Webber Trust
Owner Owner's Name
information is required for every Marstons Mills MA 02648 11/10/12
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,
9 Y,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•11/10 Title 5 Official Insp
ection Form:Subsurface Sewage Disposal •System Page 11 of 17
Y 9
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
126 Peach Tree Road
'M
Property Address
David & Carole Webber Trust
Owner Owner's Name
information is required for every Marstons Mills MA 02648 11/10/12
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution
st bution Box if resent must be opened) to n( (locate o site Ian
P P ) ( 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.):
New d-box installed as part of inspection.
PumpChamber
(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
d Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
126 Peach Tree Road
Pr
operty ert Address
P Y
David & Carole Webber Trust
Owner Owner's Name
information is required for every Marstons Mills MA 02648 11/10/12
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: (4) 3050
infiltrators
❑ 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.):
At time of inspection leaching appears to be in working condition. No sign of hydraulic failure
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
126 Peach Tree Road
Property Address
David r a d &Carole e Webber Trust
Owner Owner's Name
information is required for every Marstons Mills MA 02648 11/10/12
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
126 Peach Tree Road
Property Address
David &Carole Webber Trust
Owner Owner's Name
information is required for every Marstons Mills MA 02648 11/10/12
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
A
EE C4
3
n
A 1
i�2 : 32t
PS3 37'
-UI = 5 '
57'
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
f
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 126 Peach Tree Road
Property Address
David & Carole Webber Trust
Owner Owner's Name
information is required for every Marstons Mills MA 02648 11/10/12
page. CityrTown 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: >15'feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 126 Peach Tree Road
Property Address
David &Carole Webber Trust
Owner Owner's Name
information is required for every Marstons Mills MA 02648 11/10/12
page. CityTrown State Zip Code Date of Inspection
E. Report Completeness Checklist
E Inspection Summary: A, B, C, D, or E checked
E Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
E System Information—Estimated depth to high groundwater
E Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
TOWN OF BARNSTABLE
LOCATION 12,(A SEWAGE# 2O (2— 3& I
VILLAGER - /"A 1 11 S ASSESSOR'S MAP&PARCEL
INSTALLER'S NAME&PHONE NO. t II �CCQUC! (p(� 5 0 8-y l7-0653
SEPTIC TANK CAPACITY 10 Do q CLl
LEACHING FACILITY:(type) (size)
NO.OF BEDROOMS
OWNER bQu10 + CQr'DIe VJebber`TrusT
PERMIT DATE: t i/( 6112, COMPLIANCE DATE:
Separation Distance Between the: )- BN replaces
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
A -
DECK
3 � �
Al =
A2- 32 '
A3 - 3'7 '
Bl !- 5 '
B2= Iq '
B3 ' S7 '
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes
4pliLation for Mispo$al 6pstpm Construction Permit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System individual Components
Location Address or Lot No. Qwner's Name,Ad ress,and Tel.No. - `
A4 if IS Dav i D �- Laro le Web bu T"r U5 r-
Assessor's Map/Parcel 15
Installe 's N e,Address,and Tel.No. ag -�7 -Z)(53 Designer's Name,Address,and Tel.No.
-ri33xc-av�-pn � A
Type of Building:
Dwelling No.of Bedrooms 13 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
t+16) 1 &y
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued b this Board�o5e�alth. /
ig ed s Date 1 / 2-11 —
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. Date Issued
1
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered computer.
PUBLIC HEALTH DIVISION =TOWN OF BARNSTABLE, MASSACHUSETTS Yes E
01pplication for Disposal 6pstetn (Construction Vermit
Application for a Permit to Construct( ) Repair O Upgrade( ) Abandon( ) ❑Complete System Individual Components
Location Address or Lot No. C,.h/ p ner's Name,Ad ess,and Tel.No. U `l
I A4111 S 6 v 10 4 LCA r c,i `����I:ae,r T`r u S I—
Assessor's Map/Parcel � 0( S t-o t-)<, M ( 1 I,;
Installer's Name,Address,and Tel.No. ti 17 6)�v5 b Designer's Name,Address,and Tel.No.
I j 1 X G n\)00 I C(—) 1
AAA `�/� A
Type of Building:
Dwelling No.of Bedrooms .3 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
i Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
i
Size of Septic Tank Type of S.A.S.
Description of Soil
i
i
Nature of Repairs or Alterations(Answer when applicable) i
H
Date last inspected:
Agreement: i
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance his been issued b this Board of Health. /
ig ed Date 1 ( Z
Application Approved by / 4 '/ Date i
Application Disapproved by — Date
for the following reasons
i i
I
Permit No. Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
.1 BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(✓) Upgraded(, )
Aband'ned( )bye V(_-Li 16
at 1 CIS h (�{' 1`.onC'i has been construct in ac r ance
with the.provisions of Title 5 and the for Disposal System Construction Permit No b dated
f` Installers U' l ..j l (,� Designer i
#bedrooms Approved design flow gpd
The issuance of this permit shall notbe construed as a guarantee that the system will-fiinction as4e(ssiigned.
Date 1 'cam Inspector
------------------------------------------ ---- ---------------------------- ---------------- ---- -------- - - - - -------
i
.� a�
r—
No. _ Fee�_
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Disposal *pstem Construction Permit �
Permission is hereby granted to Construct( ) .Repair( •_w. Upgrade( ) Abandon( )
�! System located at � '( 1 C � ' ���("6
i
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
i
Provided:Cons ti m t b cord leted within three years of the date of this permit.
Date Approved by
TOWN OF BkRNSTABLE 1✓
t LOCATION I Z f� ��Q�Gi7`d Q r SEWAGE # cIF- 773
VILLAGE A a,0`6,} 41"I 1 S ASSESSOR'S MAP & LOT Q5 7
INSTALLER'S NAME NAME&PHONE NO.. �
SEPTIC TANK CAPACITY l 5 C,7 I x r.l"
LEACHING FACILITY: (type)"1 (size)
NO.OF BEDROOMS vN d9—
BUILDER O OWNER L ev
PERMTTDATE: Z' 3 99 1? COMPLIANCE DATE: /Z ` T- % F
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
QA C
C r
ti 13
ti
A 3 Q3 -LL
TOWN OFn BARNSTABLE
LOCATION SEWAGE # ,� 7— 7 7_3
VILLAGE/� -S �+� /�/I i'/�S ASSESSOR'S MAP & LOT Q5-—OP
INSTALLER'S NAME&PHONE NO.
l SEPTIC TANK CAPACITY / c/x
LEACHING FACU-rTY: (type)-Iu ���� PYc' S (size)
NO.OF BEDROOMS -3
BUILDER 0 OWNER ' L e ',GC
PERMTTDATE: Z- 3 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
yl
ems,
\� c,
1
3.3-1-- 0 L
1
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES Yes MASSACHUSETTS v/
01ppYication for Migpogal *pgtem Congtruction Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System Xbdividual Components
Location Address or Lot No. Owner's Name,Address and Tel.No.
Assessor's Map/Parcel Q 5—?—060
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow 3�GJ gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank eK�'s LO dDJ Type of S.A.S.
Description of Soil k� SWdD
Nature of Repairs or Alterations(Answer when applicable) (A-STk4l1 G 0"6&te v12 14 r
t, t1 vim. �L-Tvc.-to I2 w t 5,yu-, om-- A v
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and no to place the system in operation until a Certifi-
cate of Compliance has bee s
Signed I Date f
Application Approved by Date
Application Disapproved for the following reasons
Permit No. Date Issued s
.�- No. ^17 ` Fee
s
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION'- TOWN OF BARNSTABLE., MASSACHUSETTS\, r. �e�
Application for Mi-4pogat *pttem ttCon!6truction Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System [Individual Components
Location Address or Lot No. \ �� Ve
Owner's Name,Address and Tel.No.
Assessor's Map/Parcel L_ (fo
0 5�—080
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
�t�o-C,wr� s� M C
Type of Building:
Dwelling No.of Bedrooms Lot Size i" sq.ft. - Garbage Grinder( )
Other Type of Building t E XNo.�of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow —7--3, gallons per day; Calculated daily flow �� 1 gallons.
Plan Date Number of sheets'; Revision Date
Title '
Size of Septic Tank 5--- K to60 51A L Type,ofS'A'S. LA Cu tD cc.r� �^��C�(--I
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) fi
_l.- ,LT VC, G l v
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and no to place the system in operation until a Certifi-
cate of Compliance has beg sstie �j
Signed Date ` 7c J
Application Approved by Date
Application Disapproved for the following reasons
/ ♦ / it
Permit No. Date Issued /g,"1
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired ( )ITpgiaded((/�
Abandoned( )by c- S ti
at has been constructed in accordance
with the provisions of TitIp 5vand the for Di osal System Construction Permit No.y dated -1'iW
Installer r .,0t Designer
The issuance of this permit shall not be construed as a guarantee that the system ll functio desigped. Q
Date r1 --9� Inspector
---------------------------------------
No. Fee ��
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
lwi6po5ar bpotem Con5truction Permit
Permission is hereby granted to Construct( )Repair( )Upgrade Aba don( )
System located at I I�G I f 12 � _ i c�
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
i
Provided:Construction must be completed within three years of the date of this rmit.
Date: l ! Approved
i ,
IL
i
w ..
1"197
,
I
,
NOTICE: This Form Is To Be Used Fo�rtthe Repair Of Failed
Septic Systems Only: f_•..' "'
CERTIFICATION OF SKETCH AND APPLICATION FOR A
DISPOSAL WORKS CONSTRUCTION PERMIT WITHOUT
ENGINEERED PLANS) !� l
F
hereby certify that the application for disposal works
construction permit signed by me dated concerning the
property located at�/c� �����T�`� 'r" t0�`S meets all of the
following criteria:
/. There are no wetlands located within 100 feet of the proposed leaching facility
3
There are rid private wells within 150 feet of the proposed septic system
There is no increase in flow and/or change in use proposed
ere are no variances requested or needed.
i
., • If the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the
proposed leaching facility will=be located less than fourteen(14) feet above the maximum adjusted
groundwater table elevation.
_-. Please complete the following:
A)Top of Ground Elevation(according to the Engineering Division G.I.S.map) 6r
f
B)Observed Groundwater Table Elevation(according to Health Division well map) 0
f / ] 41co
SIGNED : DATE: G'
l
LICENSED SE C SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER i
i [Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan,
this plan should be submitted]. ^
i
,
a:health folder.tort
� �����, C
® � -� �� ' 3
v
{ . `_ _' �.
:. � ,(
.• �#
�.
':- i
�r � '� .
R
� ,
, _ , r
Commonwealth of Massachusetts
Executive of E nvuonmental Affairs CIVAR
��cc�� IV
J. C 60
Department ofEnvironmental Protection
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A .
CERTIFICATION
Property Address: ►ate ��-�.\2�L_ FU. �q��TouS ���� . H, ,
Address of Owner:
.(if different)
Date of Inspechon:._�1�_��c�
Name of Inspector:
Company Name, Address and Telephone number:
_:. �T ?t•c,_.. ���wY��.,.�v�; C.00 2c6y
Sad, kZc )
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and
that the information reported below is true, accurate and complete as of the time of
inspection. The inspection was performed based on my training and experience in the j
proper function and maintenance of on site sewage disposal systems. The system
Passes
---- Conditionally Passes
---- N eeds further evaluation by the local Approving Authority
---- Fails
Inspector's Signature.
The system Inspector shag submit a copy` of this inspection'report to theApprovmg�
Authority within thirty (30) days of completing this inspection. If the system
is a shared system or has a design flow of10,000 gpd or greater,the inspector and the
system owner shag submit the repot to the appropriate regional office or the Department `
of Environmental Protection. : -
The original should be sent to the system owner and copy sent to the buyer,if applicable k=�
and the approving authority.
t
it
• rv. - z
..-�,..-•� .._.�,.,�,,:� ._.s °mac"..-��.�rrt>.� ,a=W�...:x , .,:..e.r ;:'"F�`*s:r.�r� i.x..,.,.�+: �w,k'�i.['Yam;K'�.':"5"!',t^.�%';`�"1.'"«�.'^ �4i'-w"., .`��""&`�..�..' .
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A -
CERTIFICATION (continued)
Property Address: -
0 wners :
D ate of Inspection: 3\,V ,e
INSPECTION SUMMARY:
Check A,B,C,or D
A)SYSTEM PASSES:
• 1 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 .__.__
B)SYSTEM CONDITIONALLY PASSES:
--•• One or more system components need to be replaced or repaired; The system,upon .
--- - completion of the replacement or repair,passes inspection. _
Indicate yes,no,or not determinate(Y,N,or ND). Describe basis of determination in all
instances. If"not determinated",explain why not.
•-•- The septic tank is metal,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. _
•-•- 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 I(with approval of the Board of_-----__ -_
Health).
-�-- broken pipe(s)are.replaced
t
-- obstruction is removed _
... .distiibuaon box is levelled or re -red
x.
••-- 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
3,—. � Rai. 'a k�r ��' ac. 't t e ,,y y,�, p ,$`y,M.•;:
w
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
--PART A
CERTIFICATION (continued)
Property Address: \1�
-
Date of Inspection: 3\ \gam
C) FURTHER EVALUATION 1S REQUIRED BY THE BOARD OF HEALTH:
---- Conditions exist which require further evaluation by the Board of Health in order to de-
termine if the system is failing to protect the public health,safety and the environ-
ment.
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 SAFETYAND THE ENVIRONMENT:
.•.._ Cesspool.or privy is within-50 feet of a surface of wate_t�_.,
-•--.Cesspool.or privy is within 50 feet of a bordering vegetated wetland or a small__
marsh. .
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER
SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNC-
TIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY
AND THE ENVIRONMENT.
•--• The system has a septic tank and soil absorption system and is within 100 feet to a
surface water supply or tributary to a surface water supply.
•... The system has a septic tank and soil absorption system and is within a Zone I
of a public water supply wet
-•-• The system has a septic tarn and soil absorption system and is within 50 feet
of a private water supply well.
••-• The system has a septic tank and soil_absorption»system and is less than 100
feet but 50 feet or more from a private water supply well,unless a well water analy- _
sis 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 notrogen is equal to or less than 5 ppm.
D)SYSTEM FAILS: T ,
--• 1 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:f `
The Board of Health should be contacted to determine what will be necessary to cor-
rect the failure.
-•-- Backup of sewage into facility or system component due to an overloaded or .-
or clogged SAS or cesspool
a,
{ !
44
"Poe;
f --
�,,
• tt y
`.: f'"' y
��._1�irsKi•,fi�-r.�. . � arras�.,n.Yti�4.f^.)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A -
CERTIFICATION (continued)
Property Address: _--
0 caner:k_c �
Date of Inspection:
D)SYSTEM FAILS (continued)
--• 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 over-
loaded or clogged SAS or cesspool.
--- Liquid depth in cesspool is less then 6"-below invert or available`-volume isr-�=-==
less than 1/2 day flow.
--- Required pumping more than 4 times in the last year N 0 T due to clogged
or obstructed pipe(sj
number of times pumped
--- Any portion of the Soil Absorption System,cesspool or privy is below the high
groundwater elevation.
--- Any portion of cesspool or privy is within 100 feet of a surface water supply
ortributary 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 ana-
lysis. If the well has been analyzed"to be acceptable, attach copy of well
water analysis for coliform bacteria,volatide organic compounds,ammonia
nitrogen and nitrate nitrogen. -
z
Or
...:._.__.-__ _.__�....,.,,_..�...,.a,�a..,,,.. ,......,r.....,;y>.;,,.,.,cr:-.+w«...rn».n ._ _.. ._...�-�a.�r..s» ti^ir:�+•xr:- �-.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued) _
— - Property Address: --
Owner:
Date of Inspection:
E) LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above:
The design flow of system is 10,000 gpd or greater Large System and the system
is a significant threat to public health and safety and the environment because
one or more of the following conditions exist:
the s stem`is within'400 feet of a surface:drinking:.water.s �`
y upply .
--- the system is within 200 feet of a tributary to a surface drinking water supply -
--- the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area IWPA)or a mapped Zone I I of a public water supply well.'- _
The owner or operator of any such system shall bring the system and facility into full compli-
ance with the groundwater treatment program requirements.of 314 CMR 5.00 and 6.00.
Please,consult the local regional office of the Department for further information.
._'t_
.Y s
� '1 PA••-x� 4ro
a
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: \2t,
Owner.�s��Q-- -
Date of Inspection: ,`�6
Check if the following have been done:
Pumping information was requested of the owner,occupant and 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 the period- --�-
volumes of water have not been introduced into the system recently or as part
of this inspection.
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.
K All system components,excluding the Soil Absorption System,have been
located on the site. r ... .
The septic tank manholes were uncovered,opened and the interior of the.sep-
tic tank was inspected for conditions of baffles or tees,material of construc-
-___ liquid;-depth.of sludge,-depth--of-scum.--=-- --
The size and location of the Soil Absorpti014 System on the site has been deter-
mined based on existing infamation or approximated by non-intrusive methods
t. :
The facility owners and occupants if different from owner were provided wRh
information on the proper maintenance of Subsurface Disposal System.
t.
d�jXA`d'-t
.yzw`.- s'+.aS.3s!+x,<.a X,. w". �5i�}tG i3,i i 5 S..:.r;xn` , ;a•. .r -t$ ay....<Y. ..4 . , -..tfi.,w.'�••�;: R+ .
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM_
- PART C -
SYSTEM INFORMATION
Property Address: -%I,.
Owner:
Date of Inspection:
RESIDENTIAL:
Design flow: 330 gallons -
Number of bedrooms : 03
Number of current residents: o�--
Garbage grinder(yes or no): Po _
Laundry connected to system(yes or no):
Seasonal use(yes or no):
Water meter readings,if avaiIable�`6\P.:
Last date of occupancy:7�>Q<
COMMERCIAUINDUSTRIAL
Type of establishment:
Design flow: gallons/day -
Grease trap present: (yes or no)Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 system (yes or no)
Water meter readings,if available:
Last date of occupancy:
Other. (Describe)
Last date of occupancy:
GENERALfNFOAMATION-
PUMPING RECORDS and source of information: =, e
. ... . ...............
System pumped as part of inspection(yes or no):...:1._?10...........if yes,volume pomped: ... gallons
Reason for pumping .. r
i .
'fir} , rAd3 wA.4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C -
- SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of inspection: 3�
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)
... Other (explain). ....................................... .............. .--
. ...... ..............................
APPROXIMATE AGE of all components,-date installed(if known)and source of information—=_ `
_- -
---- . . _
S swage odors dete-cted when arriving at the site: (yes or no)....
SEPTIC TANK: . � .....
(locate on site plan)
Depth below grade. 1st:.....
Material of construction: ...X,. concrete ......... metal........ FRP........ other(explain)
................................................................................................................................................
Dimensions: .s x
Sludge depth:...Q::......
Distance from top of sludge to bottom of outlet tee or baffle:.......3y................
Scum thickness:...Q..:`.............
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle... .................
Comments: — ---- ,-----------------------_.—_.__-----
w
(recommendation for pumping, condition of inlet and outlet tees or baffles,depth of riquid
level in relation to outlet invert,structural integrity,evidence of leakage,etc. . ....................
�c�...►.�cr�..�� ��?.�c :p.:!u�.�T�.�i"T. .�.��.. ::.5,��\� :.!tlf:`�.��Twr.� .. •;•� :�.�.o�l
. vey....`ti'..:Q-e .Gv� .Za..o
'
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of inspection: -3
GREASE TRAP: ..... ,�....
(locate on site plan)
Depth below grade: ...............
Material of construction: ........concrete.........metal........FR P........other(explain)....
..........................•...................................................................................................................
Dimensions:...............................
Scum thickness:.............. : ....
Distance from top of scum to top of outlet tee or ..... ......
Distance from bottom scum to bottom of outlet tee or baffle:.::::...::.:.-: --
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.)............:..........
.
................................................................................................................................................
TIGHT OR HOLDING TANKS:..Uo.....
(locate on site plan)
Depth below grade:...............
Material of construction:........concrete........metal.........FRP..........other(explain)..........
Dimensions:.............................
Capacity:....................gallons
Design flow:...-...........gallonslday
---------- - Alarm level............:.................
Comments: j'
(condition of inlet tee,condition of alarm and float switches, etc.)
..
.............................................................. �.........................................................
................................................................... ...........�.. ..............................................•...........
-�:(��� ,. a'�` .... .. • :d� *.u""� •'� v3"�;, '�.r�' .�yi.� �k..,�ail zwia,���s��y� ��;�:,
^s¢, ..,:,.A`�.�. ... _r. a`•A. 1:�, '�r., l �ct _.
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C -
SYSTEM INFORMATION (continued)
Property Address:
- Owner. •c-o��c-�� __. _._
Date of inspection: S\,�q 6
DISTRIBUTION BOX:..9�e S _
(locate on site plan)
Depth of liquid level above outlet
Comment:
(note if level and distribution equal evidence of solids carr over,evidence of leaks e into
or out of box,etc.' 4 ..�4,.ti:->,.<,.1... .....��..:6 ��rau�r .... .,.
- . - PUMP CHAMBER:.--.
_
(locate on the site) _ P.Q.
Pumps in working order: (yes or no)...............
Comments:
(note condition of pump chamber,condition of pumps and appurtenances,etc.)....................
................................................................................................................................................
SOILABSORPTION SYSTEM (SAS):... :Q.=5...
(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,numbeLm6er:
A e�:b..P•�
leaching chambers, ........ ;>
leaching galleries,number:........... rF
leaching trenches,number,length......................
leaching fields,hi,U* er,-dimensions•....................
overflow cesspool,number:..........
Comments: _
(note condition of soil,signs of dr uric f ilure,level of pondin ,condition of vege ti_17-71 ,
.0t TT
AK
,y4'2
3... ,..,,. .,. -mow .. !. --. •� t-n
x
.t ,`?',';"!m`±5k3�.te'"' "'�'"t!Z_•�_,'\.. .•_..- �:1. _r`E;":""•".. ..�+."-'-`:�`c�.�-�j." ,�.�'�sE",:' i""`,� � 'aka" "`�l�%:''�`�''w?1'�i s.-.._:: i >....:n..� 94!. _ .. ... s� �.a .. -merit
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property address:
Owner:
Date of inspection:
CESSPOOLS:...t7-',o....
(locate on site plan)
Number and configuration: ....................................
Depth-top of liquid to inlet invert: - -...........................
Depth of solids layer: ...............................................
D epth of scum .layer: ...............................................
_ _ .. . ..- _
......................
Materials of
Indicator of ground water: ....................
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.) -
......................................................................................................................................I.........
................................................................................................................................................
PRIVY: . .
(locate on the site)
Material of construction:
Depth of solids: ................ T.,
Comments:
r (note condition of sod,Rsigns of failure,leveler of p6iding,'conditiion of vegetation, -
etc.).
................................................................................................................................................
.try
t
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 9-,:K
Owner�sT�� _
Date of inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks locate at
wells within 100'.
� a
(>L Sl.Is
A 3 5Cj
gL\ 3S
DEPTH TO GROUNDWATER: R
t Depth to groundwater fi'�o-3o.feet
Method of determination or approximativw. a.
Q► ' ;od,ot`Lk�.T44�Miries.�r�ra..`sa: ....L! 5,...�-�.tra�aw,►.a ... 4.V.' t�
:tvu��;; �.T....�.�"rn:tt�T�s►...g.�/���,...�r).�i:�val�...c�.t-..T�,,....w...v .:�"v:rb�,
(iO
:LO.CATION SEWAGE PERMIT N0.
t;, V LLAGE —
A(
INSTA LLER'S
NAME i ADDRESS
1Q A_ AAl Tn B,ACKHOE SERVICE
150 Walnut Street
Ward-Pam 02668
_,
on OWNEE
C/,,
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED -� ` �r�'`��
.� � '
� }
��
r ,
��.� - �i �
�"� �i r
� i7�- s' '"' / r
r � � � `'� r
�, .- ,
I � ��
�, ,
�� ���
,, ���. ;-
,�
,�
,,
�-�,,.
�� .���
N49).........
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
�O {U..-.........OF....... !�RS ��-TII--- .........................
Appliration for Uiipniia1 Workii Tnnitrurtion Frratit
Application is hereby made for a Permit to Construct (✓) or Repair ( ) an Individual Sewage Disposal
System at:
VD
.... -• ................. ......... ... -
L cation•Address or Lot No.
n
Owner Address
a �Q 1r�C?..... G--/ �k 1./....-. _ f °...........•.....
---•-••-••......... .....:....
Installer Address
QType of Building Size Lot............................Sq. feet
`u Dwelling—No. of Bedrooms..............—3_--..__--.__.________Expansion Attic ( ) Garbage Grinder (Nd)
`4 Other—Type of Building No. of persons............................ Showers — Cafeteria
a' Other fixtures ..................................
Design Flow'%-f _.aQ.@ F+�..............•._gallons per person per day. Total daily flow-------- .....................ga
W lions.
WSeptic Tank—Liquid capacitylQW.gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No.•-_-----_.-_--_-- Width.................. Total Length-----------i....... Total leaching area--------------------sq. ft.
Seepage Pit NoAaQ0...... Diameter-----S._.__._... Depth below inlet................ Total leaching areaeZ.O.a...sq. ft.
Z Other Distribution box (✓) Dosing tank ( )
Percolation Test Results Performed b .fP4- � __.........1-���k .............
a Y---._.. .. �' _... bate.....�--�'- ----------------------
Test Pit No. 1....xn------minutes per inch Depth of Test Pit------- ....... Depth to ground water........................
f� Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
---------------------------------•----------------------------------------•-------------.-... "...
-...
••-----------------------------------------
O Description of Soil.........................................................................-- -- -- ----- ----------------------------------------
_..
V .........................................
...........-........................................................-..............................................--------------•--•-•-•--•---•----------••-----••............---•-••. ...............
U Nature of Repairs or Alterations—Answer when applicable................................................................................................
-------•----•--------------------------•--•----------------•-•-------------------------•--.........-------------•----. ---------------------•--•-----------------•--••-----------------------------•----
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of i i i
p 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the boa- of health.
Sined_-...! ........... ........... . ..> ........
� / D e
Approved By........ /!'l --------•--•-•------••-- .......ill'. .. ell-
Application --.---•--
D ate
Application Disapproved for the following reasons-----------------------------•--•-----------------•----------•-----------•------•-----••--....--•----••-••.......
---•---------------------------------••--••-•------•----------•-••--------•-----------...............-----•••-•--------•-•-•••--••••....•-••-------V--i......----------------------................
�/I Date
Permit No......................................................... Issued_........
..............................................
Date
1 _ J
A'
off,,/ 2 •-- FEs.��..........................
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
-------------oF.�. -
Applira#ion for Biopog al ; orki,tom1rurtion' motif
Application is hereby made for a Permit to Construct �. )/or Repair ( "an Individual Sewage Disposal
System at:
..�._...
_ l
.. �yy ---t-'A••� �'•' tit Nkv-�z a -��.T9:ZS� ---- ------ ['' Lot No.' ..............
Locations~ddressor0 r= t�t�6 ^= fix• t)�va —�6 P.,f._..._. v_ �..� 's�`�C?Jll� Adfrels
W
a C\ � tataller ,`t � f�.. ess .., �
QType of Building Size Lot___________________________Sq. feet
Ua f Bedrooms______________- ..--•-••-••----••-----
Expansion Attic—No. o Garbage Grinder 0)
p• Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
a' Other fixtures ____________________________ _
------------------------------------------------------------------------------------••---•--•----•-
, ......................................
W Design Flow..,•. gallons per person per day. Total daily flow......... � _ _ gallons.
WSeptic Tank—Z,iquid capacity gallons Length................ Width................ Diameter-_-_--✓•____.•- Depth................
x Disposal Trench—No..................�D idth_...____...____..... Total Length.................... Total leaching area.................---sq. ft.
Seepage Pif No._.��}}_ .___.._.. Diameter... Depth Depth below inlet..... -•1........ Total leaching area_ sq..ft.
Z Other Distributiol`box� ) ll8sing tank (_-.)
Percolation Test Results Performed by.._._�_ Date_...__ ._ __ / __
a Test Pit No. 1. iP�c �d� ► ; p g ¢
�..___.mmutes per inch e th o est�'It-----_./�,r.... Depth to round wter---__-_--lam_,..,.......
Gz, Test Pit No. 2................minutes per inch Depth of Test Pit....._.............. Depth to ground water........................
-----------------------------------------------------------•---........_..-••••-•--•----•---_____---.........................................................
0 Description of Soil........................................................................................................................................................................
x 1 U •••••--•-------•••-•---•--•-----------•••
W ---••------------------------------------(_---__-_-___-_--------___-_-•-__-_____--__-___•_-•••-•.----_---__ . '•"_'__-__/------____-.-••_--_-_.-_____.........._....._..........................._.........
UNature of Repairs or Alterations—Answer when applicable...._...........................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of'TT LE, y g g p y
of the State Sanitary Code— The undersigned further agrees not to lace the system in
operation until a Certificate of Compliance has been issued by the board of health.
Si ned ... f ........ --•--
Application Approved By......... ter• •• --- . --- • ----- ---------•------------- ------- ---------------------
Date
Application Disapproved for the following reasons-------------....................................................................................................
•-•--------------------------•----••--------•------•---------.....--••----•--•---------=•-----•-........--•---•••--•••-••-••--•-•••-----••-•---••••---•------------------•-----••---•------•--•...._.._.
Date
PermitNo......................................................... Issued-.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........a'Tvw.. ............OF.........J�W/".. 4;.� .-............................
rrtifiratr of omIfflana
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by---------------------7.0#..*.........�I_�t t?`Q... ••--.. .---•-- -- --------------------------------•---------------------••••...----•-•-••....._
_,I, ta ler
has been installed in accordance with the provisions of TI 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No 9 -.Z.-____________ ___ dated................................................
THE ISSUANCE OF THIS CERTIFICATE SMALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WIL FUNCTION SATISFACTORY.
`�- Inspector_.. �.c
DATE............. . _-� ...... •• -•-• '
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF No. cx_�_ FEE........................
Diopooaal Works T000#raion pamit
Permission is hereby granted-------------I�W/.1/----•-•-----AA4—P...-----------------------------....-•-•---•----------....-•---............•-•-
to Construct ( X.# I Repair ( ) an Individual Sewage Disposal System ` Lv
at No. �/ d '`V ~'' �ftCfY. ,2 "es"----------�/1) N. KILAjr
Street
as shown on the application for Disposal Works Construction mit No.................... Lated..........................................
,,V
oard of Health
DATE................................................................................
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
bat Lam! FLOW =. l ip .4 r,.p.v.
�>:±�("{G 'r�Jk = ��jO�! #C7G 'Jo • �{Gj Ei.r-'•t7. �
?ISPCk AL PiT - uSE. #oG�o CAA-.
TOTAL 1->EG161J i I
c �2r_oLLTIo1-i 2IN-VC-- : 1"tu smIQ orz 37 ,
t. t25 oa
�.� , .
�--
Z-0.4 r1
41 PF r�tsr 6AL
TANK
itiv. tom• ';.
C.E-czT
Mt
'�� �Z _ i•.1ra Vic:+�� �- �C.l'�lrr �1j.G►0 �y.'1.T� M/
Uoa z �'
� c�#z-c#�U 'rtiE�,Y- '�'t-try• �v��'fitb� Ssaow►J Qtl�l�! RL{=��.��.Ir.:=
�-11:.1?t�itil.l G;c:�lr�L�(S v�.'#'t'Hi 'i't-li::: -�1 D C.L.1►-�� t
1�.1.li7 5C't"13nCV t'r.ovi�:�.t�lr:�1'.tT c�� T►-ii;::
V `t C 1 7.,._ ♦ -� 3..lL_ Q�)�TCV?-
Tt-{! Of-A" IS 4-.10T 4W C>;'TLV-VtLL.G o �trCAS4;,
� #{J,r'�:,,�c_w; ;..it•.�/ia�{ ;�, i'{�{:: ��=r_.•,�r�, �iacww AF�{ ..r c_t.��#T �j• �p �,�r-� �
t_1 Ia:a �l.{� &V,5 f f i