HomeMy WebLinkAbout0459 RACE LANE - Health 459 RACE LANE, MARSTONS MILLS
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Commonwealth of Massachusetts
1 Title 5 Official Inspection Form
%�I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
459 Race Ln
Property Address
Chuck Robbins
Owner Owner's Name
information is required for every Marstons Mills MA 02648 6-10-19
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 S# 180 qR
Shawn Mcelroy
Name of Inspector
Upper Cape Septic Services
Company Name
P.O. Box 73
Company Address
E. Falmouth MA 02536
City/Town State Zip Code
1-508-495-0905 S 13971
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);I 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
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
6-10-19
ilspector'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
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.
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r
Commonwealth of Massachusetts
,w Title 5 Official Inspection Form
M Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
459 Race Ln
Property Address
Chuck Robbins
Owner Owner's Name
information is required for every Marstons Mills MA 02648 6-10-19
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:,
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
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):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
459 Race Ln
Property Address
Chuck Robbins
Owner Owner's Name
information is required for every Marstons Mills MA 02648 6-10-19
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 El ❑ ND (Explain below):
❑ obstruction is removed ❑ Y El ❑ 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 of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
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r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
C�'i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
r,r
459 Race Ln
Property Address
Chuck Robbins
Owner Owner's Name
information is required for every Marstons Mills MA 02648 6-10-19
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:
❑The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
[]The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate "Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/26/2618 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
r� Title 5 Official Inspection Form
i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
459 Race Ln
Property Address
Chuck Robbins
Owner Owner's Name
information is required for every Marstons Mills MA 02648 6-10-19
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 '/z day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303,therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems:To be considered a large system the system must serve a facility with a design
flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA) or a mapped Zone II of a public water supply well
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
ibi Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
9 p Y rY
459 Race Ln
Property Address
Chuck Robbins
Owner Owner's Name
information is required for every Marstons Mills MA 02648 6-10-19
page. City/Town 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?
Wasthe facility owner(and occupants if different from owner) provided with
® El 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.
0 ❑ 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)]
i
t5insp.doc•rev.7/26120;18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts
r� ,w Title 5 Official Inspection Form
I"I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1:. ? 459 Race Ln
Property Address
Chuck Robbins
Owner Owner's Name
information is required for every Marstons Mills MA 02648 6-10-19
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flowbased on 310 CMR 15.203 (for example: 110 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: 6-2019
Date
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18
Commonwealth of Massachusetts
j Title 5 Official Inspection Form
I"f'
Ill, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
459 Race Ln
Property Address
Chuck Robbins
Owner Owner's Name
information is required for every Marstons Mills MA 02648 6-10-19
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 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: Owner----pumped 2 yrs ago
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
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
459 Race Ln
Property Address
Chuck Robbins
Owner Owner's Name
information is required for every Marstons Mills MA 02648 6-10-19
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
❑ 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:
1987
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 30"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
w
I'll Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
.- 459 Race Ln
Property Address
Chuck Robbins
Owner Owner's Name
information is required for every Marstons Mills MA 02648 6-10-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
-
6. Septic Tank(locate on site plan):
24"
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1500 gal
Sludge depth: Err
Distance from top of sludge to bottom of outlet tee or baffle
26"
Scum thickness
1"
611
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
15"
How were dimensions determined? Tape
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
it Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
459 Race Ln
Property Address
Chuck Robbins
Owner Owner's Name
information is required for every Marstons Mills MA 02648 6-10-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank (tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18
Commonwealth of Massachusetts
Title 5 Official Ins ection Form p
01 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
c
F ?. >' 459 Race Ln
Property Address
Chuck Robbins
Owner Owner's Name
information is
required for every Marstons Mills MA 02648 6-10-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank (cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
"Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box (if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert 0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Good condition with water at working level and no sign of back-up from pit.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
459 Race Ln
Property Address
Chuck Robbins
Owner Owner's Name
information is required for every Marstons Mills MA 02648 6-10-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
® leaching pits number: 1-1000 gal
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
awl•
Title 5 Official Inspection Form
! i�► Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
r a <,
� :. .� 459 Race Ln
Property Address
Chuck Robbins
Owner Owner's Name
information is required for every Marstons Mills MA 02648 6-10-19
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.):
Leach pit in good working order with water level and stain line at 30" below top of tank. Inlet enters
into riser.
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration,
Depth —top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc-rev.7/26/2618 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�h Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
459 Race Ln
Property Address
Chuck Robbins
Owner Owner's Name
information is required for every Marstons Mills MA 02648 6-10-19
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.7/2 612 01 8 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Iw�'
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
-W
� i
459 Race Ln
Property Address
Chuck Robbins
Owner Owner's Name
information is required for every Marstons Mills MA 02648 6-10-19
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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P •e.? If
fir'..
•.✓J�y .
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t5insp.doc•rev.7/26/20118 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
r � Commonwealth of Massachusetts
Title 5 Official Inspection Form
%i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
��
459 Race Ln
Property Address
Chuck Robbins
Owner Owner's Name
information is required for every Marstons Mills MA 02648 6-10-19
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: 20
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 greater than 20'.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc-rev.7/2 6120 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
r�► Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1. ;> 459 Race Ln
Property Address
Chuck Robbins
Owner Owner's Name
information is required for every Marstons Mills MA 02648 6-10-19
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.
P P
® 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
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
459 Race Lane
Property Address
Pat Howitt
Owner Owner's Name
information is required for every Marstons Mills MA 02648 08/06/12,
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form.Inspection forms may not be altered in any
way.Please see completeness checklist at the end of the form.
Important:When A. General Information
filling out forms . Al
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Michael Kellett
use the return Name of Inspector
key.
Aardvark Environmental Inspections
Company Name
PO Box 896
Company Address
East Dennis MA 02641
Cityfrown State Zia Code
508-385-7608 S13742
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address endthat--b.
information reported below is true,accurate and complete as of the time of the inspection.The;it�spes on
was performed based on my training and experience in the proper function and main enance obon site
sewage disposal systems. I am a DEP approved system inspector pursuant to.-$ection 15`340 o
Title 5(310 CM
R 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails i f
❑ Needs Further Evaluation by the Local Approving Authority ,
t q
cl ;tea
•� 08/07/12
inspe 1'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'submitthe
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.
LA
t5ins•11/10 Title 5 Official l e ' n Form:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
459 Race Lane
Property Address
Pat Howitt
Owner Owner's Name
information is Marstons Mills NIA 02648 08/06/12
required for every
page. Cityf 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:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired.The system,upon completion of the replacement or repair,as approved by
the Board of Health,will pass.
Check the box for"yes","no"or"not determined"(Y,N, ND)for the following statements.If"not
determined,"please explain.
The septic tank is metal and over 20 years old`or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exf ltration 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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
459 Race Lane
Property Address
Pat Howitt
Owner Owner's Name
information is Marstons Mills MA 02648 08/06/12
required for every
page. City(rown 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 mannerwhich will protect public health,
safety and the environment:
I
❑ 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
t5na•1 VIC TM9 5 0ftiai 1i15p itori Fbilri:srobs&&ace seriage ussposai sratern•page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
459 Race Lane
Property Address
Pat Howitt
Owner
Owner's Name
information is required for every Marstons Mills MA 02648 08106/12.
page. Cityfrown 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 ef8'uent to the surface of the ground or surface waters
due to an overloaded or clogged.SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6"below invert or available volume is less
than'r4 day flow
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form.
si Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
459 Race Lane
Property Address
Pat Howitt
Owner Owner's(dame
information is required for every Marstons Mills MA 02648 08/06/12
page. Citylrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year MOT 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 welt.
❑ ® 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 11 of a public water supply welt
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 fatted.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 Tide 5 Official Inaction Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurtace Sewage Disposal System Form-Not for Voluntary Assessments
459 Race Lane
Property Address
Pat Howitt
Owner Owner's Name
information is
required for every Marstons Mills MA 02648 08/06/12
page. C 1"rown State Zip Code Date of Inspection
D. System Information
Description:.
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonaluse? ❑ Yes ® No
Water meter readings,if available(last 2 years usage(gpd)):
Detail:
Sump pump? ❑ Yes ® No
nt
Last date of occupancy: Datee
Commemiatlindustrial 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
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
459 Race Lane
Property Address
Pat Howitt
Owner Owner's Name
information is required for every Marstons Mills MA 02648 08/06/12
page. City/rown State Zip Code Date of Inspection
D. System Information.
Description:
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No
Laundry Y P system inspected? ElYes ® No
Seasonaluse? ❑ Yes ® No
Water meter readings,if available(last 2 years usage(gpd)):
Detail:
Sump pump? ❑: Yes ® No
Last date of occupancy: current
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15203): 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•11110 Title 5Official Inspection Form:Subsurface Sewage Disposal System•rage 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
459 Race Lane
Property Address
Pat Howitt
Owner Owner's Name
information is required for every Marstons Mills MA 02648 08/06/1'2.
page. City/'r wn State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(descnbe 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/Altemative 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 VA 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 Sewaga Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
459 Race Lane
Property Address.
Pat Howitt
Owner Owner's Name
information is required for every Marstons Mills MA 02648 08/06/12
page. City/Town State Zip Code Date of Inspection
D. System Information (cant.)
Approximate age of all components,date installed(if known)and source of information:
1987 per BOH
Were sewage odors detected when arriving at the site? ❑ Yes N No
Building Sewer(locate on site plan):
Depth below grade: 3.1
feet
' I
Material of construction:
❑cast iron 0 40 PVC ❑other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints,venting,evidence of leakage,etc.):
Septic Tank(locate on site plan):
Depth below grade: 2.5
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: 1;000 gal
Sludge depth: 311
t5ins•11110 Tdle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
459 Race Lane
Property Address
Pat Howitt
Owner Owner's Name
information is required for every Marstons Mills MA 02648 08l06/t2
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cons.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle 28"
Scum thickness 4'
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 14"
How were dimensions determined? measured
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,
liquid levels as related to outlet invert,evidence of leakage,etc.):
The tank was sound and tight with tees in place and liquid at outlet invert.
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑concrete ❑metal ❑fiberglass ❑polyethylene Q 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
Commonwealth of Massachusetts
Tithe 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
.'~ 459 Race Lane
Property Address.
Pat Howitt
Owner Owner's Name
information is required for every Marstofis Mills MA 02648 08/06/12
page. Cityfrown state Zip Code Date.of Inspection
D. System Information (cunt.)
Comments(on pumping recommendations,Net and outlet tee or baffle condition,structural integrity,
liquid levels as related to outlet invert,evidence of leakage,etc.):
Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑concrete ❑metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons:per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes, ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches,etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins-11/10 Titie5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
w 459 Race Lane
Property Address
Pat Howitt
Owner Owner's(dame
information is required for every Marstons Mills MA 02648 08/06/12
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert even
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.):
The box was level and tight with no sign of carryover.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order. ❑ Yes ❑ No
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
Soil Absorption System(SAS)(locate on site plan,excavation not required):
If SAS not located,explain why:
t5ins-11/10 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
MW Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
459 Race Lane
Property Address
Pat Howitt
Owner Owner's Name
information is required for every Marstons Mills MA 02648 08/06/12
page. Cityfrown state Zip Code Date of inspection
D. System Information (cont.)
Type:
® leaching pits number:
1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number,length::
❑ leaching fields number, dimensions:.
❑ overflow cesspool number:
❑ innovative/altemative system
Type/name9Y
of technology:
Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of
vegetation,etc.): .
This system has a 6'x6'precast pit surrounded by 2'of stone.There was 26"between the liquid and
the inlet invert.
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•11110 Trde.5 Official Inspection Form:Subsurface Sewage Disposai System•Page 13 of 17
Commonwealth of Massachusetts
W
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
459 Race Lane
Property Address
Pat Howitt
Owner Owner's Name
information is required for every Marstons Mills MA 02648 08/06/12
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.):
t5lns•11/10 Title 5 Official Inspection Form:Subsurface Sewage D*iisat System-Page 14 of 17
4 Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
459 Race Lane
Property Address
Pat Howid
Owner Owner's Name
information is required for every Marstons Mills MA 02648 08/06/12.
page. City/Town State Zip Code Date of Inspection
D. System Information (cunt.)
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
r
/y
7
ba
1a
t5ins•11/10 Me 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
't 459 Race Lane
Property Address
Pat Howitt
Owner Owner's Name
information is required for every Marstons Mills MA 02648 08/06/12
page. City/Town State Zip Code Date of Inspection.
D. System Information (cunt_)
Site Exam:
® Check Slope
❑ Surface:water
® Check cellar
❑ Shallow wells
Estimated depth to high ground water: 20.0
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 maps show an elevation of over 20.0 feet
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
Tithe 5 Official Inspection Form
s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
459 Race Lane
Property Address
Pat Howitt
Owner Owner's Name
information is required for every Marstons Mills MA 02648 08/06/12
page. City/Town state Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary:A, B,C,D,or E checked
® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins-11110 Idle 5 Official lnspedon Form:Subsurface Sere Disposal System Page 17 of 17
TORN-!/.BAIL sTaL
SEWAGE#.
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DATE:_' /8/95
PROPERTY ADDRESS:_`459 Race Lane
Marst'ons Mills
Mass 02648
On the above date, 1 Inspected the septic system at the above Address.
This system consists. of the following:
1 . 1 -1000 gallon tank.
2. 1 -dsitribution box.
3 . 1.'-1000 gallon leaching pit.
Based on my IhR:wction, I certify the following conditions:
1 . This is- a title five septic system.. '( 78 Code ' )
2. Tan-k,.has leakage problem.Must pump and cement weep hole in tank,
• 3 . Cover --have to be raised on the septic tank,Distribution box
and the leaching pit. � )
! . Once repairs are made . the s%stem will be ijr"proper working ord
en. - -
SIGNATURE:
Name: J. P.,Macomber Jr..
Company:_J. P_Macomber & Son-_Inc . l� dd
� 12
Address:_ _g�______,�___,__
_-Centerville LMa_s__02.632 S
N
Phone:
--_5Q8 -5A3338---- - • � q�'t�'
3 �
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
WW
JOSEPH P. MACOMBER & SON, INC.
Tanks-Ces4pools-Leachflelds
, Pumped & lnsttlled
Town Sewer Connections
P.O. Box 66' Centerville, MA 02632-0066
775-3338 77"412
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
®apartment of
Environmental Protection
William F.Weld
Govemor
Trudy Coxe
Secretary,EOEA
David B. Struhs
Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 459 Race Lane Marstons Mills Address of Owner:
Date of Inspection: 9/8/9 5 (If different)
Name of Inspector: Joseph P. Macomber Jr .
Company Name, Address and Telephone Number:
Box 66 Centerville ,Mass . 02632
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 proper function and
maintenance of on-site sewage disposal systems. The system:
X.Jx Passes
_ Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
_ Fails
Inspector's Signature: Qu / / ��1 1'' "'"c�( Date: 9/1 9/95
The System Inspector shall 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 revional office of the Department of Environmental Protection.
The original should be sent to the systeim owner and copse= sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
Check A, B, C, or D:
A] SYSTEM PASSES:
XXXX 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.
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, Yeas, no, or not determined (Y, N, or ND), Describe basis of determination in all instances. If"not determined", explain why not)
AL 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.
(revised 8/15/95)
One Winter Street • Boston, Massachusetts 02108 • FAX(617) 556 1049 ® Telephone (617)292-5500
L N p';n .l..,.12—lwl P.—
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property AddrMT: 451 rRalcesL�nejarstons Mills
Owner: 9�8�95
en urg
Date of Inspection:
BJ SYSTEM CONDITIONALLY PASSES (continued)
f Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
F pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the
Board of Health):
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced f
Ij The system required pumping more than fourtimes a-year duertor 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:
2 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.PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT: '.`''
The system nas a seuuL (enk and suil au�,orpoun systen) and is within 100 feet to a surface v:atcr supply Gr;ribu;a y tc 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 well.
N The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
The systen-, 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 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.
D) SYSTEM FAILS:
f1! 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.
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
IBC Discharge or ponding of effluent to the surface,of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
(revised 8/15/95) 2
L
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 459 Race Lane Marstons Mills
Owner: Mrs . Francis Braudenburg
Date of Inspection:9/8/9 5
D] SYSTEM FAILS (continued): •
N Static liquid level in the distribution box above outlet invert due'to an overloaded or clogged SAS or cesspool.
AL Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow.
Required pumping more than f4 _mps in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped / /+�✓ )4),V7'
AL 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.
AL Any portion of a cesspool or privy is within a Zone I of.a public well.
Al Any portion of a cesspool or privy is within 50 feet of a private water supply well.
AC Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
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
Tr and the environment because one or more of the following conditions exist:
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`
The owner or operator of any such system shall bring the system and facility into full compliance 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.
(revised 8/15/95) 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 459 Race Lane Marstons .Mills ,Mass ,
Owner: Mrs. Francis Braudenbu*rg
Date of Inspection:9/8/9 5
Check if the following have been done:
Pumping information was requested of the owner, occupant, and Board of Health.
YNone 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.
Y_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
Y The site was inspected for signs of breakout.
YAll system components, t% luding the Soil Absorption System, have been located on the site.
YThe 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 existing information or
approximated by non-intrusive methods.
The facility ov.ner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-
Surface Disposal System.
Recommendations
1 . Covers should be raised on the septic tank. 3211 below grade
2. Cover on leaching pit should be raised. 2511 below grade.
3. Septic tank should be pumped. '
(revised 8/15/95) 4
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
Owner:
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow:.gall ns
Number of bedrooms: �`
Number of current residents:___-
Garbage grinder(yes or no):Alo is
Laundry connected to system (yes or no):-
Seasonal use (yes or no):Yeli
Water meter readings, if available: J y a3 SZ oa1
Al �6 �'P h �4'9 g�;0� ��h1s=a7 ��9 G'•��,
Last date of occupancy:
COMMERCIAL}INDUSTRIAL:
Type of establishment:
Design flow:_AQ� gallons/day
Grease trap present: (yes or no)-a#
Industrial Waste Holding Tank present: (yes or no)&�
Non-sanitary waste discharged to the Title 5 s stem: (yes or no)�
Water meter readings, if available: 4
Last date of occupancy:AIIX
OTHER: (Describe) 4/4
Last date of occupancy:
GENERAL INFORMATION
PUMPING ECORD�andource source i fo�rmation:. � )� M �
4
System pumped as part of inspection: (yes or no)
If yes, volume pumped. allons
Reason for pumping:
i
TYPE Of,SYSTEM
Septic tank/distribution box/soil absorption system
24 Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
Other (explain)
APPRO I TE AGE of all com one s, date installed f nown),Kid sour
ce of information:
Sewage odors detected when arriving at the site: (yes or no)
(revised 8/15/95) S
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C•
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
SEPTIC TANK:: ISO�gX���� ,
(locate on site plan)
u
Depth below grader
Material of construction: Zoncrete _metal _FRP—other(explain)
Dimensions: b d' ! rq
Sludge depth: utt 1
I
Distance from top of sludge to bottom of outlet tee or baffle:.2
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: I{
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, stru ural
integrity, evidence,of leakage, etc.) ' T �' ,fir Tee' &_ 6 MA >; ��
T r l r -T 040114,
GREASE TRAP:
(locate on site pl n)
Depth below grade;
Material of construction Vj4concrete/Vgnetal/ RP*ther(explain)
Dimensions: Alle
Scum thickness:
Distance from top of scum to top of outlet tee or baffle-4/t
Distance from bottom n( srum in bottom or outlet tee or baffle:
Comments:
(recommendation for pumping, condition of i let and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.) ��
r;
(revised 8/15/95) 6
SUBSURFACE SEWAGE DISPOSAkSYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
TIGHT OR HOLDING.TANK:
(locate on site plan) '
Depth below grade:
Material of constructio : concrete_metal _FRP—other(explain)
v
Dimensions:
Capacity: allons
Design flow: allons/day
Alarm level:
Comments:
(condition of i 1pt t , condition of alarm and float switches, etc.)
DISTRIBUTION BOX: .
(locate on site plan)
Depth of liquid level above outlet invert:_W
Comments:
(note ii level and distribu6w, is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)_0 i 9v 1 b r
► , zvr a r 6.
p
PUMP CHAMBER:
(locate on site plan)
Pumps in working order:(yes or no)
Comments:
(note condition f pump chamber, condition of pumps and appurtenances, etc.)
(revised 8/15/95) 7
SUBSURFACE SEWAGE DISPOSAL;SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS):
(locate on site plan, if possible; excavation not required, but m.1y be approximated by non-intrusive methods)
If not determined to be present, explain:
Type:
leaching pits, number:,
leaching chambers, number:
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
r
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, con ition of vegetation,etc.)
'` o
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 o ite 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 8/15/95) 8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
I
i
r
t
0
DEPTH TO GROUNDWATER
Depth to groundwatercg2+ feet - ._.._...__._...___.____.... .._
method of determination or approximation: / r#-Ilurj, Ne T d
t > > O/ r .n ,
(revised 8/15/95) 9
'TOWN OF Barnstable BOARD OF HEALTH
SUBSURFACE SEWAGF DISPOSAL SYSTEM INSPECTION FORM - PART D .- CERTIFICATION yM
�...—...__.._...—_..__.__...ram._._.__...—•-._�—___...�:...:._......... .............._.—.r—.—•_.._. ..._.__........_.._.._._. .._:..rrr�rc�':-�r.�:..:rrr r- 11
-TYPE OR PRINT CI.EARLY-
PROPERTY INSPECTED
STREET ADDRESS 459 Race Lane Marstons Mills ,Mass .
ASSESSORS MAP , BLOCK AND PARCEL #
OWNER' s NAME Mrs _ Mrs Francis Braudenburg
PART D - CERTIFICATION I
NAME OF INSPECTOR Joseph P.Macomber Jr. .
COMPANY NAME J.P.Macomber & Son Inc.
COMPANY ADDRESS Box 66 Centerville ,Mass . 02632
Street Town or City State LIP
COMPANY TELEPHONE ( 508) 775 - 3338 FAX ( 508 ) 790 - 1 578
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at
this address and that the information reported is true , accurate, and
complete as of the time of :inspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems .
Check one :
XXXX System PASSED
The inspection which .I have conducted has not found any information
which indicates that the system fails to adequately protect public
health or the environment as defined in 310 CMR 15 . 303 . Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form.
System FAILED*
The inspection which I have conducted has fo.und that the system fails to
protect the public health and the environment in accordance with Title
5 , 3.10 CMR 15 , 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form .
"r
Inspector Signature 1"A 11
Date 9/19/95
One copy of this certification must be provided to the OWNER, the BUYER
( where applicable ) and the BOARD OF HEALTH.
* If the inspection FAILED, the owner or"'operator shall upgrade ' the system
within one year of the date of the inspection , unless allowed or required
otherwise as provided in 310 CMR 15 . 305 .
partd.doe
WULAm F. wow
coyw..o. ..
Trudy Cozs
S•away.ECEA
Thomas & Power* •
06/12/95
ATTN: Joseph P. Macomber, I1r.
Joseph Macomber and Scan
PO Box 66
Centerville, MA 02632-
Dear Joseph P. Macomber, Jr . , _
I am pleased to inform you that you have attended training, met
the experience qualifications, and have passed the Title 5 System
Inspector exam, pursuant to 310 CMR. 15 . 340 . The passing grade for
the exam was 39/52 or 75% .
This is an official notification that you are a Certified Department
of Environmental Protection System Inspector pursuant to 310 CMR 15 . 340 .
You will receive a System Inspector certificate at a later date .
If you have any father questions, please write to me at the following
address :
Kimball Simpson
D. E. P. Training Center
50 Route 20
Millbury, MA 01527
Thank you very wtuch fo: -oar time and consideration in this matter.
Sincerely,
K� ball �'. Smpson,
DE raining C, :. .er Director
.240 5� FAX 508-755-9253 i n• 50&756-7:01
Roues :'0 • Millbury, MA
r
Water
Conservation
SAVE Tips . .
ME! ,
CHECK FOR LEAKS
Water Loss in Gallons Due to Leaks
Leak
this Loss Per Day . Loss Per Month
Size
120 3,600
• 360 10,800
693 20,790
• 1,200 36,000
1',920 57,600
O 3,096 92,880
® 4,296 128,980
® 6,640 199,200
6,984 200,520
8,424 252,720
9,888 296,640
AUL
11,324 339,720
12,720 381,600
14,952 448,560
TOWN OF BARNSTABLE
LJOCATION It C e SEWAGE #
I.
VILLAGE AA IVtfo ASSESSOR'S MAP &LOT
INSTALLER'S NAME&PHONE NO. . 6
SEPTIC TANK CAPACITY ` �'t /,O�
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and 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 f r yl A C p mil X eA,- r Sa/
4
p
� r
0
TOWN OF BARNSTABLE
nn
LOCATION l&t /3 Kfc,,e j 6"{_ SEWAGE
VILLAGE i �� - or s ASSESSOR'S MAP & LOT P" 710
INSTALLER'S NAME & PHONE NO. 6,#t2y 1-
tyltear'S Sri biti4f
SEPTIC TANK CAPACITY /<'O O
LEACHING FACILITY:(type) tZG« (size)
NO. OF BEDROOMS 3 jPRIVATE WELL'OR PUBLIC WATER_
BUILDER OR OWNER �� / ce 11x�
DATE PERMIT ISSUED: /d - /4 -
DATE . COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
1 .
a�.:
..��,
w,
-,�
0
_�
� f
ti
� '��^
' j rv� � 0 -
L _.
�. sSESSORS ►m'AR NO:
"ARCEI. NO.-
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
I-Va ..4.�'1-----------------0F...7._Bajvyw•
. ppliration for Bh4p sal Works Toustrurtion Frrmit
Application is hereby made for a Permit to Construct (L4 or Repair ( ) an Individual Sewage Disposal
System at:
` --lt -=------------------------------••- ................................ ............
Lo tion-Address or Lot No. 4
Owner Ad res /Q
.......... 1L_1.... ...........
Installer Address /,
Type of Building Size Lot_'3.5.(a.LC_...Sq. feet
DwellingNo. of Bedrooms.............. _.__.Expansion Attic Garbage Grinder (E
`4 Other—Type of Building No. of persons.....................(_.._)Showers
a g --------•-----------------• P ( )'— Cafeteria ( )
dOther fixtures .....-•-------•-•----•-•-•-••--•------•--•-•--............--•---•---•--•--•---•-••------ -------------------•------•----•----
W Design Flow.........6.5..........................gallons per person per day. Total daily flow__� � ' � _. S�.gallons.
WSeptic Tank—Liquid capacity`_'Cb&.gallons Length.�O.:./i__ Width.5c....R.... Diameter......-------- Depth_, .......7
x Disposal Trench—No. .................... Width............:._.__._ Total Length.................... Total leaching area_____-.--•--___•----sq. ft.
Seepage Pit No---------- Diameter.... _¢ /pag ,�............. Depth below inlet_....______.._.. Total leaching area-l0.S.....sq. ft.
Z Other Distribution box_( ) Dosing tank 0
aPercolation Test Results Performed by._9,�r°< _ kA .e e/ . ate.............................•._._..__.
Test Pit No. 1................minutes per inch Depth of Test Pit___//�$_____. Depth to ground water.X)4__tYL_C>_A<'j.
f3. Test Pit No. 2................minutes per inch Depth of Test Pit.../lab"..... Depth to ground water.A_)&A ....f=,r,'/
Uap� -------•--••------------------•-•---•--•---•-�-•-.................
.l e t o : D .. ,.
-
,l� y .�P-cam.. —�
U Nature of Repairs or Alterations— nswer when applicable W _ } /�Lr.`_�_._/. _.... l cC�x __.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with �s
the provisions of T'12
p `J of the State Sanitary Code—The undersig er agrees not to place the sy em in
operation until a Certificate of Compliance has been s feloard o th.
Sl r .............
�-
ate
Application Approved By........... ••••. --. ................. ...,... _
Date
Application Disapproved for the following reasons:--- .............................•------•---•-----••----••-••--•-•----•-•-•-----••.........................
........................................•-------....--------...------•-•------.........----•---•-------------•-••----•--------•---••--------------•-----•-------•--•-----•............................
/�, Date
PermitNo...............................................�K� .. Issued.......................................................
Date
/,s T
NO._� ��....r V FEE.....--...�—�..D.....
w' THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
t
1
, ppfiration for Dispaii al Works Tiamitrnrtinn rrnti#
Application is hereby made for a Permit to Construct ( for Repair ( ) an Individual Sewage Disposal
System at
Y' t � + 72
... ........-•--•------•......................•- .............................. ----
y Location ,fAd ress t or Lot No
s
................k`..�� I S --- s_- .'�{��.. �p `� °C_ri 9:�.. ft.C�lt..`� t�E;.:.. +ice; �a17� °ram y(;��/
Owner Address /
� � - 1
W --- t--.---. `......... ......... ...... ...•..............--------.....-•------... ......... f' ,s�..'"b�.=Y> F:.. Y_k . i..�I S'` .........................i y
Installer Address
d Pq
Type of Building Size Lot4 3_-54.0....._Sq. feet
Dwelling—No. of Bedrooms............ ............................Expansion Attic ( ) Garbage Grinder
aOther—Type of Building ___________________-____-- No. of persons............................ Showers ( ) — Cafeteria ( )
Otherxtures -----'-----•-•-"•'•-'-•"----•-•-------"----'......."•••••----•-•--•'-•---------'•----"----...__...'•-••••----•-'•............•-•----------•--•-•
W Design Flow...... � ..........................gallons per person per day. Total daily flown :,~'� , .E. ;_. :j'....galIons.
WSeptic Tank—Liquid capacity;.ia.._.gallons LengtVa._..?.-_.. Width__._. ._.:.._ Diameter____.:........... Depths-_.--.?...
x Disposal Trench—No..................... Width_.---------------- Total Length.........._......... Total leaching area....................sq. ft.
Seepage Pit No.................... Diameter_f_ ............ Depth below inlet. ..`.._....._.. Total leaching are�0__,;, .......sq. ft.
Z Other Distribution box ( ) Dosing tank ( ) <3�P19
Percolation Test Results Performed bp)?'f d Date........................................
04 Test Pit No. 1................mmutes per inch Depth of Test Pit ' . _.....__._ Depth to ground waten;__c__; Y
(% Test Pit No. 2................minutes per inch Depth of Test Pit t^'''_"....... Depth to ground watej.,j,�__/` ----;4-1
--- --
O Description of Soil —� 7 �/ ?-t✓ mat L' �f ^�' a �r '� c. �i
(W� t sP✓ir�'G-3f1. 1' c-*"S,.r'+ �s,,. .. � ! /� " � "' t �.?✓- t ...d."..(.`_,6.. /:ijl/'.. Ca.ba r r F/ �_ �
--�-- -- ---� - ` - - �
VNature of Repairs or Alterations—`Answer when applicable .rtr�/ s,�:_:; __ ! ..11 �__.r �'.. ?u ,�......
lL _ ,
Agreement: /
The undersigned agrees to install the afor edescribed Individual Sewage Disposal System in accordance with
the provisions of'TTIE j of the State Sanitary Code—The undersigns Lf•tzrtE6r agrees not to place the sy tern in
operation until a Certificate of Compliance has bee issup` board oaf ealth.
S>gned" �... ...... ......... f.-�--.....-- -- l --1- L-:.•.�''
� ...
ate
/��Application Approved B - r { .r_. /e".l �..`�. _q..4................. --•---......
Date
Application Disapproved for the following reasons:__....---"--------------------•-----------'------------------•--------------•'---------"--••'-'--'............
..............................................'------'------...----••-•------•--•--...---••-------------•••--•-••--•-•--•••"'-••-•--'-•'•"---•••••'•••'•-'---•----'--''-----'-------'--••---....••---
.� Date
Permit No.................. C ....--.��=?ram__..... Issued------------------------•-•-----...----•---------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
. f.'_ :. ✓1.................oF..j% .......................................
TyWrfifiratr of Toutplianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed 4"T or Repaired ( }
by............ _=----------------------------------------•------------------------.-.-----------...-----••-•----•--•-•-----.--•---------.-----------------------------------
.+ Installer
J / r s ------------------------------------------------------------
!/
has been installed in accordance with the provisions of Ti T IE 5 of The State Sanitary Code as jescribed in the
application for Disposal Works Construction Permit No ............_... dated_. _./: ;.(' .................
THE ISSUANCE OF THIS CERTIFICATE SMALL NOT BE CONSTRUED AS A ARANTEE THAT YHE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE. `7. _,�. g 7 - Inspector .. -•-----------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
( .1 �
qr
N .,�. '?.-...�._]. FEE .....................
Disposal Work.5 Tu.lnitrndion amit
Permission is hereby granted....................L':.....�:1\__ .A\_`f J-"S..........................................................................
to ConstructL('`.� or Repair ( ) an Individual Sewage Disposal S stem
r [[ �i
at IT ' ..Ct f?�= fr = d�.. .y......_ '.:L _t. ..=TY 7` ':9 p�= ::c !✓'�=....-..-•----'•----------------------------------•-----•-----------
as shown on the application for Disposal Works Construction Permit No __. fC�Dated �..�.Z./_ .............
I' ........
(1 ( Board of Health
DATE-----------------•..
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS
fNL FT KNOCKOUT
IA 247
OUTLET
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