HomeMy WebLinkAbout0131 STARLIGHT DRIVE - Health 131 Starlight Drive
Marstons Mills P
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Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .
si051g4,
M 131 Starlight Drive 14l
Property Address
John Zappala
Owner Owner's Name
information is t
required for Marstons Mills Ma. 02648 10/03/2008
every page. City/Town State Zip Code Date of Inspection
t
�\ r
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.
Importantg
When filling out A. General Information
forms on the
computer,use 1. Inspector:
only the tab key
to move your Robert Paolini
cursor-do not Name of Inspector
use the return
key. Capewide Enterprises,LLC.
Company Name
r� P.O.Box 763
Company Address
Centerville Ma. 02632
City/Town State Zip Code
(508)428-4028 S14454
Telephone Number License Number
B. Certification
1 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 15340 of
Title 5(310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
c :�;
'r ( 10/03/2008 cry
Inspector's Signature` Date '
The system inspector shall submit a copy of this inspection report to the Appro ing Authority(��oard
of Health or DEP)within 30 days of completing this inspection. If the system is h 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. A2 G
s 0 �
t5ins•09/08 Title 5 Official Inspecti :Subsurface Sewage Disposal System•Page 1 of 2
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
° M 131 Starlight Drive
Property Address
John Zappala
Owner Owner's Name
information is Marstons Mills Ma. 02648 10/03/2008
required for
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary:Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
The septic system is in proper working order at the resent time.
P Y P P 9 P
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by "
the Board of Health,will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 2
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 131 Starlight Drive
Property Address
John Zappala
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 10/03/2008
every page. City/Town 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):
I�
❑ 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 pirpe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 3
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
131 Starlight Drive
Property Address
John Zappala
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 10/03/2008
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within.50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private'water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory,for 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 Y2 day flow
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 4
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary-Assessments
�M 131 Starlight Drive
Property Address
John Zappala
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 10/03/2008
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply..
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ -® Any portion of a cesspool or privy is within 50 feet of a private water supply
well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ Z 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
El ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA)or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large.
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 5
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 131 Starlight Drive
Property Address
John Zappala
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 10/03/2008
every page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate "yes" or"no"as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
El ® 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?
El ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® El available
as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
❑ ® Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 6
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 131 Starlight Drive
Property Address
John Zappala
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 10/03/2008
every page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
The septic system consists of a 1000 gallon septic tank,Distribution box and two 500 gallon leaching
chambers.
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ® Yes ❑ No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)): 200 ,000
2007::85
,000
Detail: t
2006:191 gpd. 2007:232 gpd.
Sump pump? ❑ Yes ® No
Last date of occupancy: Date 08
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 7
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 131 Starlight Drive
Property Address
John Zappala
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 10/03/2008
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: Capewide Enterprises,LLC.
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: 1000
gallons
How was quantity pumped determined? Measured'
Reason for pumping: Maintenance
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no)(if yes, attach previous inspection records, if any)
Innovative/Alternative technology, Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 8
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 131 Starlight Drive
Property Address
John Zappala
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 10/03/2008
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
New Leaching Chambers installed in 1997
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 18feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
feet
Comments (on condition of joints, venting, evidence.of leakage, etc.):
Joints appear tight.No evidence of Ieakage.System vented through the house vents.
Septic Tank (locate on site plan):
. 18"
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 gI.
Sludge depth: 0
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 9
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
131 Starlight Drive
Property Address
John Zappala
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 10/03/2008
every page. City/Town State Zip Code Date of Inspection
D. System Information (cost.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle NA
Scum thickness 0
Distance,from top of scum to top of outlet tee or baffle NA
Distance from bottom of scum to bottom of outlet tee or baffle,.. NA
How were dimensions determined?. Tank pumped at time of
inspection.
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert,evidence of leakage, etc.):
Pump septic tank every two years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank
appears to be structurally sound.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 10
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
131 Starlight Drive
Property Address
John Zappala
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 10/03/2008
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 11
Commonwealth of Massachusetts .
W Title. 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
131 Starlight Drive
Property Address
John Zappala
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 10/03/2008
every page. City/Town 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 No
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.):
Box is Ievel.Box has one outlet Iateral.No evidence of solids carryover.No evidence of leakage into or
out of box.
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.):
J ,
'a
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 12
t
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 131 Starlight Drive
Property Address
John Zappala
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 10/03/2008
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 2-500 gl. LC
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Sandy dry soil.No signs of hydraulic failure.Leaching Chambers were dry at time of inspection.Stain
line is 15: below 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 13
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
131 Starlight Drive
Property Address
John Zappala
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 10/03/2008
every page. City/Town State Zip Code Date of Inspection.
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 14
Map Page 1 of 2
Town of Barnstable Geographic Information System
Parcel Viewer Custom Map Abutters Map Size ® Zoom Out J J'J J J JIn
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0 20 Feet
Set Scale 1" = 20. I Aerial Photos I MAP DISCLAIMER
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http://www.town.bamstable.ma.us/arcims/appgeoapp/map.aspx?propertyID=099052&map... 10/3/2008
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 131 Starlight Drive
Property Address
John Zappala
Owner Owner's Name
information is Marstons Mills Ma. 02648 10/03/2008
required for
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
f ❑ Shallow wells
t ,
Estimated depth to high ground water: Bottom of leaching 25'
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:
As-Built Card
❑ Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
USED:USGS Observation Well Data.USED:Technical Bulletin 92-000-01 plate#2 annual ranges of
groundwater elevations.
Before filing this Inspection Report,please see Report Completeness Checklist on next page.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 16
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
131 Starlight Drive
Property Address
John Zappala
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 10/03/2008
every page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
E Inspection Summary:A, B, C, D, or E checked
E inspection Summary D (System Failure Criteria Applicable to All Systems)completed
E System Information—Estimated depth to high groundwater
E Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file .
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
COP
don
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
ID= W
DEPARTMENT OF ENVIRONMENTAL PROTECTION
RECEIVED
� d I
4 A�
MAY 1 2 2003
TOWN OF BARNSTABLE
TITLE 5 HEALTH DEPT.
OFFICIAL INSPECTION FORM—NOT FOR VOLUIN r ARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 131 STARLIGHT DRIVE MARSTONS MILLS,MA 02648, QCIct
Owner's Name: ROBERT WLTKES
Owner's Address: 8 JONATHAN AVE MILLBURY,MA 01527
Date of Inspection: 4/15/03
Name of Inspector: (please print) JOHN GRACI,INC.
Company Name: SEPTIC INSPECTIONS
Mailing Address: P.O. BOX 2119 TEATICKET,AIA.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:.nd 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 systenis. I am a DEP approved system
inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
X Passes
_ Conditionll
y asses
_ Needs Fu r Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: 4/15/03
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.
Notes and Comments
SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE
SYSTEM'S USEFUL LIFE.
****This report only describes conditions at the time of inspection and under .:le conditions of use at that time.This
inspection does not address how the system will perform in the future under ti,.e 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: 131 STARLIGHT DRIVE MARSTONS MILLS,MA 02648
Owner: ROBERT WITKES
Date of Inspection: 4/15/03
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:
SYSTEM PASSED TITLE V INSPECTION.RECOMMEND PUMPING 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 3of11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 131 STARLIGHT DRIVE MARSTONS MILLS,MA 02648
Owner: ROBERT WITKES
Date of Inspection: 4/15/03
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: 131 STARLIGHT DRIVE MARSTONS MILLS,MA 02648
Owner: ROBERT WITKES
Date of Inspection: 4/15/03
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for alLinspections:
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 nLa.
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 1 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.]
NO (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 11 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.
d
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 131 STARLIGHT DRIVE MARSTONS MILLS,MA 02648
Owner: ROBERT WITKES
Date of Inspection: 4/15/03
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(3)(b)]
I� 5
Pad;,6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 131 STARLIGHT DRIVE MARSTONS MILLS,MA 02648
Owner: ROBERT WITKES
Date of Inspection: 4/15/03
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): YES
Water meter readings, if available last 2 ears usage d
g , ( Y g (gp )) l-
Sump pump(yes or no): NO 1
Last date of occupancy: 4/13/03
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: n/a
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 WITH A REPAIR IN 1997 PERMIT 97-633
Were sewage odors detected when arriving at the site(yes or no): NO
C,
Page 7 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 131 STARLIGHT DRIVE MARSTONS MILLS,MA 02648
Owner: ROBERT WITKES
Date of Inspection: 4/15/03
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: 1000 GALLON$)
Sludge depth: I"
Distance from top g of sludge to bottom of outlet tee or baffle: 33"
Scum thickness: 0"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: 18"
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 STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.
RECOMMEND PUMPING 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
I' 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: 131 STARLIGHT DRIVE MARSTONS MILLS,MA 02648
Owner: ROBERT WITKES
Date of Inspection: 4/15/03
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 WAS VIDEO INSPECTED AND APPEARS TO BE STRUCTURALLY SOUND.
PUMP CHAMBER: _(locate on site plan)
Pumps
u ps 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 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 131 STARLIGHT DRIVE MARSTONS MILLS,MA 02648
Owner: ROBERT WITKES
Date of Inspection: 4/15/03
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
n/a
Type
n/a leaching pits, number: n/a
500 GALLON CHAMBERS leaching chambers, number: a 6
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.):
CHAMBERS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.SYSTEM SHOWS NO SIGNS
OF FAILURE. CHAMBERS WERE EMPTY AT TIME OF INSPECTION. STAIN LINES INDICATE-- ��
NEVER HAD ANY LIQUID IN IT,BOTTOM IS AT 6 FT. �-
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
A
1
Page 10 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 131 STARLIGHT DRIVE MARSTONS MILLS,MA 02648
Owner: ROBERT WITKES
Date of Inspection: 4/15/03
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two pern.anent reference landmarks or benchmarks.
Locate all wells within 100 feet.Locate where public water supply enters the building.
vy
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Page l I of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 131 STARLIGHT DRIVE MARSTONS MILLS,MA 02648
Owner: ROBERT WITKES
Date of Inspection: 4/15/03
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:
HAND AUGER- 12+FT.
ti
s ..
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS John Grad
DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector
ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119
TeaTicket,Ma
(508)564-6813
TRUDY COXE
Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Govemor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
t.
r�,
Property Address: 131 STARLIGHT DR. MARSTONS MILLS MAP A99 PAR 52 L 46 � �
Name of Owner MATTHEW PERNICK 1
Address of Owner: 636 MYSTIC DR.MARSTONS MILLS MA.02648 P
Date of Inspection: 11/9/99 4/b �`+(/ ��
Name of Inspector:(Please Print)JOHN GRACI
I am a DEP approved system inspector pursuant to Section 15.340 of Tide 5(310 CMR 15.000) roy� 0
Company Name: n/a yo� y �'9,9
Mailing Address: n/a o1 T;Ike `9 �+o
Telephone Number: n/a
.y .
t ,91
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 Passes The Inpectlon Is based on criteria defined In Title V
Conditionally Passes code 310 CMR 15.303.My findings are of how the system Is
_ Needs Further E al atfon By the Local Approving Authority performing at the time of the Inspection.My Inspection does
_ Falls not Imply any warranty or guarantee of the longgevity of the
septic system and any of Its components useful life.
Inspector's Signature: Date:11/10/99
The System Inspector sha submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of
completing this inspection.If the system Is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner
shall submit the report to the appropriate regional office of the Department of Environmental Protection.The original should be sent to the
system owner and copies sent to the buyer,if applicable,and the approving authority.
NOTES AND COMMENTS
THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING THE SYSTEM EVERY TWO YEARS TO PROLONG THE SYSTEM'S
USEFULL LIFE.
revised 9/2/98 Page 1 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 131 STARLIGHT DR.MARSTONS MILLS MAP A99 PAR 62 L 46
Owner: MATTHEW PERNICK
Date of Inspection:11/9199
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
_ I have not found any information which Indicates that any of the failure conditions described In 310 CMR 15.303 exist.Any failure criteria not evaluated
are indicated below.
COMMENTS:
System passes Title V inspection
B. SYSTEM CONDITIONALLY PASSES:
n/a One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the
replacement or repair,as approved by the Board of Health,will pass.
Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not.
n/a The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance(attached)indicating that the tank was Installed within twenty(20)years prior to the date of the inspection;or
the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank
failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
WA Sewage backup or breakout or high static water level observed In the distribution box is due to broken or obstructed pipe(s)
or due to a broken,settled or uneven distribution box.The system will pass Inspection if(with approval of the Board of Health).
_ broken pipe(s)are replaced
_ obstruction is removed
distribution box is levelled or replaced
i I
nLa The system required pumping more than four times a year due to broken or obstructed pipe(s).The system will pass
Inspection if(with approval of the Board of Health):
_ broken pipe(s)are replaced ;
obstruction Is removed
j
revised 9/2198 Page 2 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
i
Property Address: 131 STARLIGHT DR.MARSTONS MILLS MAP A99 PAR 62 L 46
Owner: MATTHEW PERNICK
Date of Inspection:1119/99
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 IN ACCORDANCE WITH 316 CMR 16.303(1)(b)THAT THE SYSTEM IS
NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
i
_ Cesspool or privy Is within 50 feet of 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well.
_ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well,
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the
well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen Is equal to or less
than 5 ppm,Method used to determine distance nla_(approximation not valid).
3) OTHER
tl/fl
t
Y
t
revised 9/2198 Page 3 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 131 STARLIGHT DR.MARSTONS MILLS MAP A99 PAR 62 L 46
Owner: MATTHEW PERNICK
Date of Inspection:11/9/99
D. SYSTEM FAILS:
You must indicate either"Yes"or"No"to each of the following:
I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is
identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
X Backup of sewage into facility or system component due to an 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 1/2 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 n(a.
X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
X Any portion of a 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.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic ompounds,
ammonia nitrogen and nitrate nitrogen.
X The liquid level in the SAS is over the invert pipe,is in Hydraulic Failure.
E. LARGE SYSTEM FAILS:
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:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and
safety and the environment because one or more of the following conditions exist:
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)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the
Department for further information.
revised 9098 Page 4 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 131 STARLIGHT DR.MARSTONS MILLS MAP A99 PAR 62 L 46
Owner: MATTHEW PERNICK
Date of Inspection:11/9/99
Check if the following have been done:You must indicate either"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 None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates
during that period.Large volumes of water have not been introduced Into the system recently or as part of this inspection.
X As built plans have been obtained and examined.Note if they are not available with N/A,
X The facility or dwelling was inspected for signs of sewage back-up.
X The system does not receive non-sanitary or industrial waste flow.
X The site was inspected for signs of breakout,
X All system components,excluding the Soil Absorption System,have been located on the site.
X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles
or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption
System on the site has been determined based on:
X Existing information,For example,Plan at B4O,H,
X Determined in the field(if any of the failure criteria related to Part C is at Issue,approximation of distance is unacceptable)
[1 5.302(3)(b)1
X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of
SubSurface Disposal Systems.
i
}
revised 9/2/98 Page 5 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 131 STARLIGHT DR.MARSTONS MILLS MAP A99 PAR 62 L 46
Owner: MATTHEW PERNICK
Date of Inspection:1119/99
FLOW CONDITIONS
RFSIDFNTIAL :
Design flow:JJQ g.p.d./bedroom
Number of bedrooms(design): 3 Number of bedrooms(actual):$
Total DESIGN flow: 1111
Number of current residents:2
Garbage grinder(yes or no):NQ
Laundry(separate system)(yes or no): NO If yes,separate inspection required
Laundry system inspected(yes or no):JLQ
Seasonal use(yes or no):JM
Water meter readings,if available(last two year's usage(gpd): n/a
Sump Pump(yes or no): NO
Last date of occupancy: nLa
CO M M ERCIAL/INDUSTRIAL
Type of establishment: n&
Design flow: n&gpd(Based on 15.203)
Basis of design flow: n&
Grease trap present:(yes or no):�LQ
Industrial Waste Holding Tank present:(yes or no): MQ
Non-sanitary waste discharged to the Title 5 system:(yes or no):No
Water meter readings.if available:n/a
Last date of occupancy: nLa
OTHER: (Describe)
Wa
Last date of occupancy: n&
GENERAL INFORMATION
PUMPING RECORDS and source of information:
THE SYSTEM WAS PUMPED IN 1997
System pumped as part of inspection:(yes or no):MQ
If yes,volume pumped nLa_ gallons
Reason for pumping: n&
TYPE OF SYSTEM
XSeptic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no)(if yes.attach previous inspection records,if any)
I/A Technology etc.Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other: nLa
APPROXIMATE AGE of all components,date installed(if known)and source of information:
ORIGINAL SYSTEM IN 1987 WITH A REPAIR IN 1997 PERMIT97-633
Sewage odors detected when arriving at the site:(yes or no) DLO
revised 9/2198 Page 6 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 131 STARLIGHT DR.MARSTONS MILLS MAP A99 PAR 62 L 46
Owner: MATTHEW PERNICK
Date of Inspection:l l/9/99
BUILDING SEWER:
(Locate on site plan)
Depth below grade: 22_
Material of construction:_ cast iron X 40 PVC _ other(explain)
Distance from private water supply well or suction line: TOWN
Diameter: n/a
Comments: (condition of joints,venting,evidence of leakage,etc.)
n/a
SEPTIC TANK: X
(locate on site plan)
Depth below grade: -VC
-
Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain)
nLa
If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NQ
nla
Dimensions: L 9'6"H 6'7"W 4'10"
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: Z"_
Scum thickness: V
Distance from top of scum to top of outlet tee or baffle:G_
Distance from bottom of scum to bottom of outlet tee or baffle: M
How dimensions were determined: MEASURED
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level In relation to outlet invert,structural integrity,evidence of leakage,
etc.)
SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND RECOMMEND PUMPING.SYSTEM EVERY TWO YEARS
GREASE TRAP:
(locate on site plan)
Depth below grade:
Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain)
Wa
Dimensions: n&
Scum thickness: n&
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 nla
Date of last pumping: Wa
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,
etc.)
nla
revised 9098 Page 7 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 131 STARLIGHT DR.MARSTONS MILLS MAP A99 PAR 62 L 46
Owner: MATTHEW PERNICK
Date of Inspection:111/9/99
TIGHT OR HOLDING TANK: NO (Tank must be pumped prior to,or at time of,Inspection)
(locate on site plan)
Depth below grade: n/a
Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain)
n&
Dimensions: n/a
Capacity: n/a gallons
Design flow: n/a gallons/day
Alarm present: NO
Alarm level:ji/a. Alarm In working order:Yes—No—: NO
Date of previous pumping: n/a
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
Wa
DISTRIBUTION BOX: X
(locate on site plan)
Depth of liquid level above outlet Invert:LEVEL WITH BOTTOM OF PIPE
Comments:
(note if level and distribution Is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.)
DISTRIBUTION BOX IS STRUCTURALLY SOUND
PUMP CHAMBER: NQ
(locate on site plan)
Pumps in working order:(Yes or No): NQ
Alarms in working order(Yes or No): NQ
Comments:
(note condition of pump chamber,condition of pumps and appurtenances.etc.)
n/a
revised 9/2/98 Page 8 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 131 STARLIGHT DR.MARSTONS MILLS MAP A99 PAR 52 L 46
Owner: MATTHEW PERNICK
Date of Inspection:11/9/99
SOIL ABSORPTION SYSTEM(SAS): X
(locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods)
If not located,explain:
n1a
Type:
leaching pits,number: n&
leaching chambers,number: 2-CHAMBERS
leaching galleries,number: -n&
leaching trenches,number,length: n(a
leaching fields,number,dimensions: nfa
overflow cesspool,number: n/a
Alternative system: n/a
Name of Technology: -n&
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.)
THE LEACH FIELD IS FUNCTIONING PROPERLY.
CESSPOOLS:
(locate on site plan) `
Number and configuration: nLa
Depth-top of liquid to inlet invert: n(a
Depth of solids layer: nfa
Depth of scum layer. nLa
Dimensions of cesspool: n/a
Materials of construction: n&
Indication of groundwater: ji& inflow(cesspool must be pumped as part of inspection)n[a
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
n1a
PRIVY: _
(locate on site plan)
Materials of construction:n1a 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
revised 9/2198 Page 9 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 131 STARLIGHT DR.MARSTONS MILLS MAP A99 PAR 52 L 46
Owner: MATTHEW PERNICK
Date of Inspection:11/9/99
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes Into house)
n/a
I Der-
I�
o �-
. pb
0
pA aye
AC 31
FA 43y
revised 9/2198 Page 10 of 11 "
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 131 STARLIGHT DR.MARSTONS MILLS MAP A99 PAR tit L 46
Owner: MATTHEW PERNICK
Date of Inspection:1119/99
NRCS Report name: n/fl
Soil Type: n&
Typical depth to groundwater: n&
USGS Date website visited: n&
Observation Wells checked: MQ
Groundwater depth:Shallow _ Moderate _ Deep _
SITE EXAM _ Slope
_ Surface water
_ Check Cellar
Shallow wells
Estimated Depth to Groundwater 12 Feet
Please indicate all the methods used to determine High Groundwater Elevation:
_ Obtained from Design Plans on record
_ Observed Site(Abutting property,observation hole,basement sump etc.)
_ Determined from local conditions
_ Checked with local Board of health
_ Checked FEMA Maps
_ Checked pumping records
_ Checked local excavators,installers
XUsed USGS Data
Describe how you established the High Groundwater Elevation.(Must be completed)
USGS MAPS AND CHARTS
revised 9/2/98 Page 11 of 11
TOWN OF BARNSTABLEfjt(,'
LVCAP.ON SEWAGE # 9 7- �3
VILLAGE M w [h ► L ASSESSOR'S MAP & LOT 19
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY. Joao //
LEACHING FACIL=: (type)2-,F00 a�LF�aG� �`ia��� ie) 2S X l3'z
NO.OF BEDROOMS 3
BUILDER OR OWNER
PERMTTDATE: // - 3 -!7 COMPLIANCE DATE: I I - 4 9
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 V Lf-v
�.:a' 7.
a
L3wcl
yc
�/�G'r � — ---�
3 '
�,
�_
�s
CO3 e _ d
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
ZIpp iratton for 10t.5pozat *pgtem Comarurtton Vermtt
Application for a Permit to Construct(4-j Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. Sf%i r/!-re Di'I Y/; Owner's Name,Address and Tgl.No. 45,(9
yy/4,^sr ails m�/1s �'hart�l �s/ P. 4/rek-
Assessor's Map/Parcel ,
Instaaller's Name,Address,and Tel.No. e/'71—a 14/f Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil S.awz
Nature of Repairs or Alterations(Answer when applicable) Yra& 1-S"00 l= 16-4L/
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this Board of Health.
Signed M4,pal Date — -%
Application Approved by Date e
Application Disapproved for the fo ng reasons
Permit No. 33 Date Issued
+..a.
00
No. r7 Fee
~ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
,,. . PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
ZippYicat on for Digoml *pztem Con5tructio ft Permit
Application for a Permit to Construct(!'Repair( )Upgrade( )Abandon(",,eo Complete System ❑Individual Components
Location Address or Lot No. 131 ,Si-m r/i r D,- t//s Owner's Name,Address and Tej.No. 11.4 g'`f 991f
��erstOhS ��//s /�pptt6'l�cv l�•cr/tlic�
Assessor's Map/Parcel ® S3S TDi7 ,
l
Installer's Name,Address,and Tel.No. 419 9—d 3 V f Designer's Name,Address and Tel.No.
WAS
Type of Building:
Dwelling No.of Bedrooms 3, Lot Size sq.ft. Garbage Grinder
Other Type of Building No.of'Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow } gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
"Size of Septic Tank Type of S.A.S.
Description of Soil 5Aa wl
t Nature of Repairs or Alterations(Answer when applicable)/ K SrA 2- .S 0a G ,04 f. 16,wG l 0g
CLi.e r�r/9EH.5 4&,,TLi 9" ,Tome- Pi=Aa' `51-00 !
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this Board of Health.
Signed Date — 3 " r1
Application Approved by Date
Application Disapproved for the fol ing reasons
Permit No. 3?, Date Issued /M
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired (G.-�Upgraded( )
Abandoned( )by 1ps e'pA d,c /3neecp.s
at l 3/ Sri4eh,"F Dr�10; A1. W,VA has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. dated
Installer Jo.se194 O-e- 13ok-Ara$ Designer 'kj�eR,4 0 13AW.-Og.t
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
Date , 1 } _ Inspectors_
01
Fee •5
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
'Wi0pozar *p6tem Construction J:ermit
Permission is hereby granted to Construct( )Repair(6..-�Upgrade( )Abandon(' )
System located at f 3/ STta rh P e Vei y/s
wits
and as described in the above Application for Disposal System Construction-Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction m t b completed within three years of the date of this p rai�
Date: ? T7 Approved by
10/9/97 „
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
CERTIFICATION OF SKETCH AND APPLICATION FOR A
DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT
ENGINEERED PLANS)
hereby certify that the application for disposal works
construction permit signed by me dated l/— 3 -9 , concerning the
property located at� 1--o r� ��/err Q�r�ii= meets all of the
following criteria:
"ere are no wetlands located within 100 feet of the proposed leaching facility
• ere are no private wells within 150 feet of the proposed septic system
There is no increase in flow and/or change in use proposed
• ere are no variances requested or needed.
• If the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the
proposed leaching facility will=be located less than fourteen(14)feet above the maximum adjusted
groundwater table elevation.
Please complete the following:
A)Top of Ground Elevation(according to the Engineering Division G.I.S.map)
B)Observed Groundwater Table Elevation(according to Health Division well map) _
SIGNED DATE:
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER y
[Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan,
this plan should be submitted].
q:health folder:cert
S'Tr�v f r-e 01-i yr .
Eck
e
Ax�gr�hq 97
o
NOTICE: This Form is to be used for the Repair of Failed � �~
j Septic Systems Only
CE111'IFICA'1'ION OF SKETCH AND'APPLICATION FOIL A DISPOSAL
W01W CONSTIIUCTION !,I;Im!1'1'(IVIT!10U'1' DESWNEV PLANS)
1, Jose hereby certify that the application for disposal works
construction permit signed by me dated i/' 3 ,?7 ; concerning the
property located at / '3 Z9j-i V15 meets all of the
following criteria:
here arc no wetlands within 300 feet of the proposed septic system
• icrc arc no private wells within 150 feet of the propose!septic system
aC The observed groundwater table is 14 feet or greater below the bottom of the leaching facilily
'here is no increase in flow and/or change in use proposed
sc"4fhere are no variances requested or needed.
SIGNED DATE: // --1-57-1
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBI✓R
101ch a sketch plan or the proposed system. Also if the licensed installer posesses A certified plot plan,
this plan should be submitted).
qCp 2
LOCATION SEWAGE PERMIT NO.
86-50
VILLAGE.
INSTALLER'S NAME b ADDRESS
d U I L D E R OR OWNER
s
ATE PERMIT ISSUED
DATE COMPLIANCE ISSUED
LET 44
aK
. f
s q3
a9
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
OW..11 ....OF..7-%�.A...R.iU....STA.STARL-C.
App irFation for Diopos ai Works Tonitrnrtion Frrmit
Application is hereby made for a Permit to Construct (--r"o*,r Repair ( ) an Individual Sewage Disposal
System at:
Location-Address or Lot No.
�_tt-w fi t ._y. .�. �.. �sz,r:.A
Owner Address
----•--------
W Sf�ilrs:. VUW"P 1�1.r..).................. ... `_- ,�L tCaE; 1 f _.�/de_.1 j.1 �"5
a
Installer Address
d Type of Building Size Lot. $�.. --------Sq. feet
U Dwelling—No. of Bedrooms...... __________________________________Expansion Attic ( ) G?rbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Other fixture
W Design Flow..............Y.'?S.....................gallons per person per day. Total daily flow______ 34-3.........................gallons.
WSeptic Tank—Liquid capacity....../_...gallons Length...... __.____ Width...... Diameter________________ Depth��._.__...
x Disposal Trench—No_____________________ Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by_------------------------•-- --•------••----•-•--------------•------ Date........................................
Test Pit No. 1-------�___minutes per inch Depth of Test Pit____________________ Depth to ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
...........................................
-......
••-----..._-_--___-----•---•--•-•---•- ---•-•----------------------
•--------------------•-------_-----
0 Description of Soil-------.•-- .__ , y 1 '� --
x
............................................. •-•••---------------•-•--••--•----••••------••----•••-----•---•--•----------•----------•------•--•--•---•-•-------•------------•-•--•-•-•---....-••--••---
UNature of Repairs or Alterations—Answer when applicable...............................................................................................
--------•-•--•-••--------••_._... ------------------
--------------------
•-----------
•----------------
---------------------------•----------•---------------------------------------•--
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT j 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been i ued by the board of health.1
ned___.
Si
�- g ••---•-- - 0- 3--e—D••-•------- ----------•------- _49w iS1:__�
Application Approved By........... !'t---•------ ----•-• �!.iG�r
( Date
Application Disapproved for the following reasons:-------------•---•-•-•--------•--•------•--•--•--...------•-----•-•-•-•-------•-----•---•---•-----•-------•--•--
-----------------------------------•--._...---•----...-•----••------•-----...-•--------------•-------•---...------------••-----------•-•---------------•--••-•----•---••----•----••-._.....-------_--•---
Permit No................. _. Issued..........................................Date---.-••---
Date
r
•J•
........................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD_ OF HEALTH
........... ......_OF.-................
..�`e�.�....�.��T`�I�il�_C �v
Appliratioat for Bi-4poii al '.Forks Towitratrtaon Prrmit
Application is hereby made for a Permit to Construct (6-1 or Repair ( ) an Individual Sewage Disposal
System at:
............................ ................•-----•--•......_..------..........-•-
Location-Address or Lot No.
�.... /fnY ...............................:c !�' f J y� :/�
._._._.. ........................................ .................. .__•.._
Owner _ A dress
af!1,1+_..1.?-.t.3 t tk. ,X^ �'-`_ C ?. .......---a� cat ........._..
Installer Address
d Type of Building Size Lot.!? '.. ........Sq. feet
Dwelling—No. of Bedrooms._....3..................................Expansion Attic ( ) Garbage Grinder ( )
04 e� Other—T yp of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
� Other fixtures..•-•-•---------•------....-•--•---•-----•-•----._._...-•---•............................------------=--•--------------•---••---•--------.....--------
W Design Flow..............�t'-�fC-. ....................gallons per person per day. Total dailyjow_______3__y�--r.........................gallons.
9 Septic Tank—Liquid capacity......I___gallons Length------ Width_______ ______ Diameter......_.._______ Depth.`-��____.__..
W Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area............_-------Sq. ft.
x
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1--------7-__.minutes per inch Depth of Test Pit.................... Depth to ground water.........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
R+ --- ---------------------------------------••--------- --•--------•--------------------------------------------
O Description of Soil----------- " . ., .::, a.: -- --- r r`-4`: !
W
UNature of Repairs or Alterations—Answer when applicable...............................................................................................
-----------------------------------•------------------------------------•-------------...--•--------------------------------------------------------------------------------------------....---•----•---
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been isjued by the board of health.
Signed.............. ----•-------------- `-
1
- (1 Dad t 1crs
Application Approved.BY - vl+ -.: "--- k"''--------.............
-' Date
Application Disapproved for the following reasons-----------------------------•-----•----------------------------------------------- ......Da
..............
'I ...................-......................................................................................................................................................................---=-----------
Date
Permit No................... � ..t-31------= - Issued-.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Z,
^'r....................OF............
...................�.....................................
TI= ifiratp of TootpliFattrr
THIS IS TO CERTIFY, at the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by ....-- ---•--•--••------•----------------------------------------------------------------•---•---•------------_---•------_.----•---•------------
Installer
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as Oescribed in the
application for Disposal Works Construction Permit No.___..... r2_`__ _ dated_...........! __ _G_______..
THE ISSUANCE OF THIS CERT➢FICATE SHALL NOT BE CONSTRUED AS A GBJAR NTEE THAT THE
SYSTEM WIL F PICT ON SATISFACTORY.
DATE._... _ . _ Chi
2 Inspector
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
C I - OF................ Ill1�L _
i.. FEE...:�...........
Disposal Iforks (ffonl- t uan irktit
Permission is hereby granted..........-----== �--==}.'ll�------A-,1--� ---•-------•---•-----------------------•--•--------.._............_....
to Construct ( L,)-6r Repair ( ) an-zIndividual ewage L) sposal System
at No.................. .......... d' T Yv_
" Street
- Dated--------- �
as shown on the application for Disposal Works Construction Permit No---U______:'��
..........................✓.._`...•--F-_•✓_<J•� �__ _----•-•_•---••.-_•_-----_-•-----•--•-
Board of Health
DATE.................. 1 �' --•••---
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
S/�/GLE F�tiy/L Y ~ 3 BE0.2o4N1 y/ z ►?, -
it/O G4�2BAGE G•e//C/OE.e � � ..._.._,.-�-2--�
OA/L Y AL.o kl _ //D X 3 '= 330 G.PO. ►,'' L� ~�
SEPT/c T,4.c/� = 33aX/Soo =5`9�G.P,o
O/.S�I2S,4L /�/T•-USE /,400 /f 4
s/OEW,c1LG .�1.2�.4 /So S.� 5 ; • 7 /7
7'oTA,C vE,s/GEC/ _ 1742.3-G P o.
OES/GN P•E.eCOL4T/p.S/,P�IT�' ��Q�` ` �
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AAI,:P.S l/�G.� .eE4u/�E/vlE//TS d.� Th'� .2EGisr�ecl�4.vo,Sli,2riEyaP�
[��� ' , l A.�G/c,4,vr- C_,�1;1•�,�/CT'r '��'�.�.r�'_-:f:7_s %.�. .
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S�lT/it/.�E,e�4N.S�G�!/C•!>�pT l E USEp