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Home My WebLink About0155 RIVER RIDGE DRIVE - Health 155 River Ridge Drive. Marstons Mills P -- - A = 059 007011 i I ~ - TOWN OF BARNSTABLE LOCATI'ON ,15 5- `�-J✓c� " J"d5 e- Dr- SEWAGE S P VILI:�EiGE 1� �N1'�r� ASSESSOR'S MAP&PARCEL NAME&PHONE NO.�, O(_L aC, K e i J SEPTIC TANK CAPACITY /D LEACHING FACILITY:(type) (size) 1660 ✓r NO.OF BEDROOMS OWNER W►i� �er;'l� PERMIT DATE: COTVfPttA-NeE DATE:1 S P 0"-, 1 l 1 S I og 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 f, River Ridge Drive Water Service 27 { 34 30 33 Y 39' , _ 57 -- n� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 155 River Ridge Drive Property Address Will Everitt 50 . CDO- C) l Owner Owners Name required for is Marstons Mills required for MA 02648 January 15, 2008 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: A. General Information When filling out forms on the k�-j C� `�'0 � computer,use 1. Inspector: only the tab key to move your Patrick M. O'Connell cursor-do not use the return Name of Inspector key. Septic Inspection Services Co. Company Name � 189 Cammett Road Company Address Marstons Mills MA 02648 law City/Town State Zip Code 508-428-1779 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 1:5 340-of Title 5(310 CMR 15.000). The system: 9 ® Passes 1 ❑ Conditionally Passes ❑ Fails3 ❑ Needs Further Evaluation by the Lo al Approving Authority Fm%% U January 15, 2008 _ - — Ins ctor'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. 08-10 Eveiritt.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w. 155 River Ridge Drive Property Address Will Everitt Owner Owner's Name information is Marstons Mills MA 02648 -January required for 15, 2008 every page. Cityrrown 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: Tank is not in need of pumping at this time, leaching pit was half full at time of inspection with a high stain line indicating pit has 10"of effective leaching B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the❑ for the following statements. If"not determined,"please explain. ❑ The septic tank is metal and over 20 years old'or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. "A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed 08-10 Eveiritt.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commo nwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 155 River Ridge Drive Property Address Will Everitt Owner Owner's Name information is Marstons Mills required for MA 02648 January 15, 2008 every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 08-10 Eveiritt.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 155 River Ridge Drive Property Address Will Everitt Owner Owner's Name information is required for Marstons Mills MA 02648 January 15, 2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than_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. 08-10 Eveiritt.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 155 River Ridge Drive Property Address Will Everitt Owner Owner's Name information is Marstons Mills MA 02648 January 15 2008 required for ry every page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 08-10 Eveiritt.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 155 River Ridge Drive Property Address Will Everitt Owner Owner's Name information is Marstons Mills MA 02648 January 15 2008 required for ry every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ 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)) 08-10 Eveiritl.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15 Commonwealth of Massachusetts : . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 155 River Ridge Drive Property Address Will Everitt Owner Owner's Name information is Marstons Mills required for MA 02648 January 15, 2008 every page. Citylrown State Zip Code Date of Inspection 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 Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): 160,000 gal. _ 219 gpd. Sump pump? ❑ Yes ® No Last date of occupancy: Currently Occupied Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CIVIR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): 08-10 Eveiritt.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 155 River Ridge Drive Property Address Will Everitt Owner Owner's Name information is Marstons Mills required for MA 02648 January 15, 2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Tank pumped 2003 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) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Compliance date: 10/18/87 Were sewage odors detected when arriving at the site? ❑ Yes ® No 08-10 Eveiritt.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 155 River Ridge Drive Property Address Will Everitt Owner Owner's Name information is Marstons Mills required for MA 02648 January 15, 2008 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 2'feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 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: 10.5' long x 5.8'wide- 1500 gal. Sludge depth: 2° Distance from top of sludge to bottom of outlet tee or baffle 30" Scum thickness 2 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 12" How were dimensions determined? Measured 08-10 Eveiritt.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 155 River Ridge Drive Property Address Will Everitt Owner Owner's Name information is Marstons Mills re uired for MA 02648 January 15, 2008 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Liquid level was found at bottom of outlet invert, tees are intact and clear. Tank is not in need of pumping at this time. 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 Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain): 08-10 Eveiritt.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - N 9 p y of for Voluntary Assessments 155 River Ridge Drive Property Address Will Everitt Owner Owner's Name information is required for Marstons Mills MA 02648 January 15, 2008 every page. Cltyrrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): No solids or high stains observed. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 08.10 Eveiritt.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 155 River Ridge Drive Property Address Will Everitt Owner Owner's Name informationis Marstons Mills required uired for MA 02648 January 15, 2008 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: One 6x6 pit. ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Liquid level iin leaching pit is at 50% capacity; high stain line indicates pit has 10"of effective leaching. 08-10 Eveiritt.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealt h of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 155 River Ridge Drive Property Address Will Everitt Owner Owner's Name information is required for Marstons Mills MA 02648 January 15, 2008 every page. Clty/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 08-10 Eveiritt.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 co of Massachuseitts: f 4itl#e 17' f�ca�1 Ini� ol Subsurface Sewa a Dis'p osat System Form of for Voluntary Assessments 155 River Ridge Drive Property Address Will.Everitt Owner ;Owners ame information is required for MarMons Mills MA 0264:8. January 15, 2008 every page. City/Town State Zip Code Date of Inspection D. System Imformatio:n (cont.) Sketch Of.Sewag.e Disposal System: Pro vide.a sketch of the sewage disposal system including ties to at least two permanent reference landm,00ks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the;building. River fed ae Drive Water Service /. \ \ \ \ \ \ \ ♦ \ \ ♦ \ Y/Y/YJY/YlY/YJYJY/Y/\lY JY/Y/YJ♦/\J\/\/♦. J / ! .+ / / / \/\/\!♦/\J♦!\J\r\JY/\/Y!Y/YlYJY/Y/YJ♦JYJ♦/♦/� ♦� ! � 3 -X♦J♦/`/\J\/♦ `♦1\/\/♦!\/\/Y/YlY�Y/Y/\/Y/Y YJY!\/YlYr\/Y/Y/\IYIY J;/YJ,J`J\!\JYJY/Y/Y/♦/YJ`/\/♦/\/Y/Y/Y/t/Y/Y/,/Y/Y/YJYIYJY1Y/\/♦JYJY!,JY ;l\,\r;J\J1/♦/;/\JY/;/♦JY/\/YJ�JYJYJ\JYJ\J`J`r`/Y�`!;/Y/\f\f\/Y/1!\!Y/\/Y/`JY Y/\�;!♦/\�\�\!�/Y�'YJYr\/\/\!\r;/Y/\JYJY JYJY✓♦/\J`J`JY/Y/\/`/Y7`/`/Y!♦/Y J;/�J,_ .YJY/\/,/\/Y!,/Y/YJY/YrY JYJYJYJYJYJYJYJYJ\!\JYJYJYJ\/YJY!\JY/YIYI\IYIY/YlYJYJ\ 27 34 30 33 39 57 ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 155 River Ridge Drive Property Address Will Everitt Owner Owner's Name information is MarstonS Mills required for MA 02648 January 15, 2008 every page. Cltyrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to 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: USGS topo map and town GIS You must describe how you established the high ground water elevation: Town groundwater contour map shows water at el. 25 and topo map shows property above el 50 08-10 Eveiritt.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 Town of Barnstable • �p 1HE Tp� Regulatory Services BARM ,,S,,,B Thomas F. Geiler, Director mass. 9$ 1639. �� Public Health .Division ,or fD MA'S A Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system.in the future nor does this,Division agree with any technical observation s and interpretations contained within this report. 4 In addition,by receiving this report the Town of Barnstable Health'Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would-be listed on the"Disposal Work Construction Permit". If you should have any questions regarding this report,please contact the certified Septic System Inspector who conducted the inspection. zf-- COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS lop? l z DEPARTMENT OF ENVIRONMENTAL PROTECTION JIVED e ti� eW i�^M SJev FFEBTITLE 5 BARNSTABLETH DEPTOFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 155 RIVER RIDGE RD MARSTON MILLS 02648 t),59 00'j Owner's Name: MARK O'BRIEN Owner's Address: 107 CAMERON MEWS ALEXANDRIA VA 22314 Date of Inspection: 2/3/03 MAP Name of Inspector: (please print) JOHN GRAC1, INC. PARCEL ®� — — Company Name: SEPTIC INSPECTIONS LOT ; Mailing Address: P.O. BOX 2119 TEATICKET,MA. 02536 Telephone Number: 508-564-6813 FAX 508-564-7270 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: X Passes _ CoIrl' sses _ Nevaluation by the Local Approving Authority Fa Inspector's Signature: Date: 2/3/03 The system inspector shall suf this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this ine system is a shared system or has a design now of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments THE SYSTEM PASSES TITLE V INSPECTION. RECOMMEND PUMPING NOW AND EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. ****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. Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 155 RIVER RIDGE RD MARSTON MILLS 02648 Owner: MARK O'BRIEN Date of Inspection: 2/3/03 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING NOW AND EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. B. System Conditionally Passes: _ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined"please explain. n/a The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: n/a n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): _ broken pipe(s)are replaced _ obstruction is removed _ distribution box is leveled or replaced ND explain: n/a n/a The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): _broken pipe(s)are replaced _obstruction is removed ND explain: n/a Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 155 RIVER RIDGE RD MARSTON MILLS 02648 Owner: MARK O'BRIEN Date of Inspection: 2/3/03 C. Further Evaluation is Required by the Board of Health: _ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ 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 n/a "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: n/a Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 155 RIVER RIDGE RD MARSTON MILLS 02648 Owner: MARK O'BRIEN Date of Inspection: 2/3/03 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all-inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _ X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than ''/z day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped NOT IN LAST YEAR INFO FROM AGENT. X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X 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. 4 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 155 RIVER RIDGE RD MARSTON MILLS 02648 Owner: MARK O'BRIEN Date of Inspection: 2/3/03 Check if the following have been done.You must indicate "yes" or"no" as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks _ X Has the system received normal flows in the previous two week period? _ X Have large volumes of water been introduced to the system recently or as part of this inspection? X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out? X _ Were all system components,excluding the SAS,located on site? X _ 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? X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no X _ Existing information. For example, a plan at the Board of Health.. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302/43)(b)] S Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 155 RIVER RIDGE RD MARSTON MILLS 02648 Owner: MARK O'BRIEN Date of Inspection: 2/3/03 FLOW CONDITIONS RESIDENTIAL 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 Number of current residents: 0 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): NO Seasonal use: (yes or no): NO Water meter readings, if available(last 2 years usage(gpd)): ( _ � 'Ucp Sump pump(yes or no): NO _ Last date of occupancy: 1/1/02 COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings,if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: NOT IN LAST YEAR INFO FROM AGENT Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: n/agallons--How was quantity pumped determined? n/a Reason for pumping: n/a TYPE OF SYSTEM X 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) _Tight tank Attach a copy of the DEP approval Other(describe): n/a Approximate age of all components,date installed(if known)and source of information: 1987 ;INFO FROM ASBUILT Were sewage odors detected when arriving at the site(yes or no): NO 6 Page 7*of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 155 RIVER RIDGE RD MARSTON MILLS 02648 Owner: MARK O'BRIEN Date of Inspection: 2/3/03 BUILDING SEWER(locate on site plan) Depth below grade: 22" Materials of construction:_cast iron X40 PVC_other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting,evidence of leakage,etc.): TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade: 16" Material of construction: Xconcrete_metal_fiberglass_Polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no):NO(attach a copy of certificate) Dimensions: L 8' 6" H 5' 7" W 4' 10"" Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle: 31" Scum thickness: 3" 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: 15" 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.): SEPTIC TANK AND ALL COMPONENTS ARE STRCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING NOW AND EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. GREASE TRAP:_(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): n/a 7 Page•8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 155 RIVER RIDGE RD MARSTON MILLS 02648 Owner: MARK O'BRIEN Date of Inspection: 2/3/03 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX: X(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE 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.): D-BOX IS STRUCTURALLY SOUND. PUMP CHAMBER:_(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a R Page 9 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 155 RIVER RIDGE RD MARSTON MILLS 02648 Owner: MARK O'BRIEN Date of Inspection: 2/3/03 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type 6' X 4' LEACH PIT leaching pits, number: 1 n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a innovative/alternative system Type/name of technology: n/a Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): THE LEACH PIT IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.THE PIT SHOWS SIGNS OF THE LIQUID BEING 6" TO PIPE.THE PIT WAS EMPTY AT THE TIME OF THE INSPECTION DUE TO THE HOUSE BEING VACANT FOR OVER 1 YEAR.THE BOTTOM IS AT 8' 6". CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): n/a 9 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 155 RIVER RIDGE RD MARSTON MILLS 02648 Owner: MARK O'BRIEN Date of Inspection: 2/3/03 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. �qcELI k a eclC edt o � D C ° aA b� y AC bS 3 in Page 4 1 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 155 RIVER RIDGE RD MARSTON MILLS 02648 Owner: MARK O'BRIEN Date of Inspection: 2/3/03 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 12+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record- If checked,date of design plan reviewed: n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) NO Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: GROUNDWATER WAS DETERMINED BY HAND AUGER- 12+ FEET a I1 70 7 SS LOCATION SEWAGE PERMIT NO. VILLAGE (\,INSTA LLER'S NAME A ADDRESS B U I L D E R -9 R--'-'O1IW11-EvR DATE PERMIT ISSUED /0 ' , , -� DAT E COMPLIANCE ISSUED ,� � �,� c 3 � 3�=� x � �� _ � 4. �� e� , T O'......r .. (:: .� THE COMMONWEALTH OF MASSACHUSETTS /J BOAR® OF HEALTH ..............OF... ................................... Appliraffun for Biipuual Works Tonutrnrthin ramit Application is hereby made for a Permit to Construct ('�) or Repair ( ) an Individual Sewage Disposal syst ---- --- -------- -. ----- ....... ........ ............................... -•• tLocatio -Addre . or t N ...._.......- ......... •................---........_ ..........- ....... . .�....... ----------- ------- -----------!�=��. ...................................... Installer Address Type of Building Size Lot..d J._13 7----Sq. feet U Dwelling—No. of Bedrooms___________ ______________ __ Expansion Attic (,L9�j Garbage Grinder (00 _•__________-- No. of persons............................ Showers — Cafeteria a Other—Type of Building ....:......... p ( ) ( ) Q' Other fixtures ---------------------------•---. . . W Design Flow...........11�........................gallons per person per day. Total daily flow-_J.'Q__.._.._........._......._..__gallons. R: Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................ Disposal Trench—N?o. .................... Width.................... Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No-_----------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ) /� '—' Percolation Test Results Performed by---------- °� ------ ----------- Date...[ _" � 7 Test Pit No. 1................minutes per inch Depth of Test Pit...._._.________.___ Depth to ground water........................ fi Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water--___-____-_-_-...____. •------------------------------ O — _�c%tt`-_._ ..Description of Soil---------Q----- t S•• ......................... x .. _—.�z--- :..... W -----•••---------------------------•----••--•-••-•-----------------•------...--•-------------------------------------•-----------------•-. --------------------------------------------------------- UNature of Repairs or Alterations—Answer when applicable_________________________________________________________________________________•--_•-----___. ------------------------------------------------------------------------•-------•--...........-•--------•-------------------------------------------------------------------------------------.....----- Agreement: The undersigned agrees to install the afor edescribed Individual Sewage Disposal System in accordance with the provisions of iT 11, 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certihca,e of Compliance has been issued by the board of heal _ --- -- - --- - - Applicat Approved .... 7 ' / ••--- Date Application Disapproved for the following reasons:-----•--------------------------------------------- •--------------------------------------•----•---•-------•-•- --------------------------•••-------------------------•------...••-••---.....•••--------...--••--•----•-•........--..................................................................................... Permit No.....<:- 7 .8._...... Issued 2a� --7------ ate No..................'... - FE:sL'..... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH -- ----------OF. / Alip ira#inn for Diopnoai Works Tnnotrn.rtion unlit Application is hereby made for a Permit to Construct (�) or Repair ( ) an Individual Sewage Disposal System at: l�.. - := �..1:..��_..- `! ! •----------------------- -- - - Locat: Addf or' t N . -� .. .... .................................. .......... 1 �% 1.............................................................------ . . Ow dd s Insta"er Address d Type of Building Size Lot.J,/,.1_✓_7-----Sq. feet aDwelling—No. of Bedrooms............................................Expansion Attic 00) Garbage Grinder ((?Q) Q, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) aOther fixtures ............................................................. W Design Flow........../l.�.........................gallons per person per day. Total daily flow_J,,'1 Q_......._........._.•..........gallons. 9 Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................ Disposal Trench—No. __.................. Width.................... Total Length.................... Total leaching area..............._....sq. ft. Seepage Pit No--------------------- Diameter--------------..... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing to ) _ 7 ~' Percolation Test Results Performed by.......... ,� .°�.._. ._._..._.._. Date..C(................................. Test Pit No. i................minutes per inch Depth of Test Pit----- Depth to ground water--_-_-_-___-_-____..___. Grq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ------------• .. Description of Soil--••--a -------••-•---------------------------------------------------------- O z -2-1-..L1-•------ r� :... ...._... v ---------------------------------------------------------------------------------------•-------------------------------------------------1` -----------------------------------------------------•---- U Nature of Repairs or Alterations—Answer when applicable.........................._--------------------------------------------------------------------- -------------------------------------Agreement: The undersigned agrees to install the afo:edescribed Individual Sewage Disposal System in accordance with the provisions of I-,TLE 4 of the State Sanitary Code—The undersigned further agrees not to place the system in operatio/on it a Certificate of Compliance has been issued by the board of heal•h. d/^(�/% - �Signed = r ............ p .... ApplicaApproved By................------••--•------....� ' Date Application Disapproved for the following reasons-------------•----•--------------•-----------------------------•-------------•------------------------••-•-.----- -----------------------------•----•------•--•-----••-----------------------------•---------•--•- -------__-............-•-------•------------------------------------------------------------------•--- Date Permit No... .......................................... Issued-.......... ---------------------- THE \ au COMMONWEALTH OF MASSACHUSETTS BOARD OF HE�A-LTH/f ..........O F... t i ✓ -`...c- ........................... (Infifiratr of TI-Implittnrr THIS I TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired ( } by.......l er4L_,...... .... ---•-•...................• -••--•• •-•-----•-••------•-•.....-•--• ---•---_._.._ ....--•-••---------•- � nstal has been installed in accordance with the provisions of TiTIE j of The State Sanitary C-�l_e a desc ibed�n the application for Disposal Works Construction Permit No... � - j ��' / � � -_ «r..... d�L�e.�i-------------- ------- ------------------------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT 7NE SYSTEM WILL FUNCTION SATISFACTORY. DATE...................( CJ• - ....................... Inspector.. ............................................... ^� ✓ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH . .li�' t t , w ................... � FEE.........1.!.,. . Disposalr / orkii Tons mlion amit Permission is hereby granted............. .................................................................. to Construct (✓ or Repaj� ( ) an Indw' )idual Sewn j ispos / ystem at No.....,�u �1_._...��:.. ............/b. .�l ..... -—------1--`--*---�G-- /1' . Street a Z.,J as shown on the application for Disposal Works onstruction Per i -�io. .___� _ Dated....... _Q . ......... .,, . Board of Health DATE----------- ---�•�----�..-�----�-� l FORM 1255 HOBBS & WARREN, INC., PUBLISHERS ` I , ( -Mo i , I , II : : I I. : , i \ G- L 1 y i i-- y : C /C� tb ,I NCs .S PAM I L.Y o G N _am.tom�� GiZ.._ . -- 11`1D'�l� n" SI:pTIG TAtQr1 X t50'10 5 G�,P, 0- �?5 E coa (SO&L 't"AKJ K : , 1 1 DISPoS&jL PIT -,.. U'SM' 7//G s I zo e Vua LLAU S1- s," 13.OTTOM SEA z ISd 5.K - IiSB ur- x L, o lSd-4.Rv.. - `T'bTA L.. To-;&L- t:-.�I w F-Lovi _ ssaCA. P.D. - �t.�-rtot� Vic.; �" iN 2ht,iN ou LE55 • Tks't -aid i - _L 1r Ca SIB f71ST. - 1000 _ 1 I►JJ co( .. 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