HomeMy WebLinkAbout0174 THISTLE DRIVE - Health i
174 THISTLE DRIVE
A = 149 - 130 - 020
i
Commonwealth of Massachusetts /49_ 130- I) 0.
r Tile 5 Official Inspection Form
Subsurface Sewage.Disposal System Form -Not for Voluntary Assessments
X)
y�. 174 Thistle Dr. Centerville, MA '
Property Address
ha�
Linda Smith
Owner Owner's Name t t
information is Centerville MA 02632 2/22/18
required for every � --•-
page. CitylTown State Zip Code Date of Inspection .
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. General Information
filling out forms Sj 4t
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Darrell Stone
use the return Name of Inspector
key.
Cape Cod Septic Inspection
r14 Company Name
P.O. Box 1466
Company Address
Harwich MA 02645
CityfTown State Zip Code
508-240-2500 S14995
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 16.340 of
Title 5 (310 CMR 15.000).The system:
® Pass onditionally Passes ❑ Fails
❑ Ne s er Eva[ tion by t al Apdrovil
2/24/18
spector's S' ure Date
T 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.
t5ins=3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
174 Thistle Dr. Centerville, MA
Property Address
Linda Smith
Owner Owner's Name
information i e required for every Centerville MA 02632 2/22/18
-
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
i
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:
p
I
B) System Conditionally Passes:
r ❑ 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):
xa -
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
QA Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
174 Thistle Dr. Centerville, MA
Property Address
Linda Smith
Owner Owner's Name
information is Centerville MA 02632 2/22/18
required for every
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑`Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is.not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3r13 Title 5 Official Inspection Form:Subsurfabe Sewage Disposal System•Page 3 of 17
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
174 Thistle Dr. Centerville, MA
Property Address
Linda Smith
Owner Owner's Name
information is Centerville MA 02632 2/22/18
required for 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 fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all.inspections
Yes No
E ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
El ® 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
:Sins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Vu
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,. 174 Thistle Dr. Centerville, MA
Property Address
Linda Smith
Owner Owner's Name
information is required for every Centerville MA 02632 2/22/18
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the-system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply,
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
174 Thistle Dr. Centerville, MA
Property Address
Linda Smith
Owner Owners Name
information is Centerville MA 02632 2/22/18
required for every State Zip Code Date of Inspection
page. City/Town
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?
Y❑
Has the system received normal flows in the previous two week period?®
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
Were as built plans of the system obtained and examined? (If they were not
® ❑ available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with ,
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
3
Number of bedrooms (design): 3 Number of bedrooms (actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):
335
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
t5ins•3/13
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
174 Thistle Dr. Centerville, MA
Property Address
Linda Smith
Owner Owner's Name
information is Centerville MA 02632 2/22/18
required for every
page. City(Town State Zip Code Date of Inspection
D. System Information
,i
Description:
3 bedroom residential dwelling -
0
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes 0 No
Water meter readings, if available(last 2 years usage (gpd)):
Detail:
Sump pump? ❑ Yes ® No
Unknown
Last date of occupancy: 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection' Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
e
174 Thistle Dr. Centerville, MA
Property Address
Linda Smith
Owner Owner's Name
information is Centerville MA 02632 2/22/18
re for every
page.
CityrTown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Unknown
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or-no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the.DEP approval.
❑ Other(describe): '
• Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page
t5ins 3/13
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-.Not for Voluntary Assessments
174 Thistle Dr. Centerville, MA
Property Address
Linda Smith
Owner Owner's Name
information is Centerville MA 02632 2/22/18
required for 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:
1984 tank and pit, 1998 Infiltrators, 2005 D-box per BOH
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
23"+l-
Depth below grade: 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.):
Apparent good condition
Septic Tank(locate on site plan):
17"
Depth below grate: 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
1000 gallon
Dimensions:
1811
Sludge depth:
t5ins-3/13 Title 5 Official,Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
174 Thistle Dr. Centerville, MA
Property Address
Linda Smith
Owner Owner's Name
information is Centerville MA 02632 2/22/18
required for every State Zip Code Date of Inspection
page. City/Town
D. System Information (cont.)
Septic Tank(cont.)
14"
Distance from top of sludge to bottom of outlet tee or baffle
6'I
Scum thickness
511
Distance from top of scum to top of outlet tee or,baffle
' 11"
Distance from bottom of scum to bottom of outlet tee or baffle
Sludge Judge
How were dimensions determined?
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Grade to inlet cover 1" Outlet 2" Normal liquid level No sign of leakage Sch 40 outlet tee
The septic tank is in need of maintenance pumping
Recommended maintenance pumping every 2-3 years
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
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
15ins•3113
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
174 Thistle Dr. Centerville, MA
Property Address
Linda Smith
Owner Owners Name
information is Centerville MA 02632 2/22/18
required for every State Zip Code Date of Inspection
page. CitylT�own
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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
a< 174 Thistle Dr. Centerville, MA
Property Address
Linda Smith
Owner Owner's Name
information is Centerville MA 02632 2/22/18
required for every,
page. Cityfrown State Zip Code, Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
OilDepth of liquid level above outlet invert
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.):
Grade to box 24" Cover 7" OK condition 2 outlet with speed levelers
Normal liquid level No sign of leakage No scum No sign of failure
Most flow goes to the Infiltrators the pit only recieves water with higher usage flows
r
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working.order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan,*excavation not required):
If SAS not located, explain why:
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
174 Thistle Dr. Centerville, MA
Property Address
Linda Smith
Owner Owner's Name
information is required for every Centerville MA 02632 2/22/18
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1
® leaching chambers number: 5
❑ 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.):
SAS#1
1, (6x6') pit with 2'stone
Grade to pit 37" Was previously overloaded and SAS#2 was installed in 1998
SAS#2
5 Infiltrators with stone (8'x35'x10")
Grade to Infiltrator 49" Inspection port to grade Bottom 64" Dry
No sign of hydraulic failure
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
F ,
Commonwealth of Massachusetts
Title 5 Official Inspection Form '
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
174 Thistle Dr. Centerville, MA
Property Address
Linda Smith
Owner Owner's Name
information is required for every Centerville- MA 02632 2/22/18
page. Cityrrown 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
174 Thistle Dr. Centerville, MA
Property Address
Linda Smith
Owner Owner's Name
information is required for every Centerville MA 02632 2/22/18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
J�7
t
I
A ( B
1 I7-I0 I 3�_z
.2 23 --5
4 U
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspect
ion tion Form
a Subsurface Sewage Disposal System Form Not for Voluntary Assessments
M 174 Thistle Dr. Centerville, MA
Property Address
Linda Smith
Owner Owner's Name
information is Centerville MA 02632 2/22/18
page City/Town Arequired for every State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
® Check cellar
❑ Shallow wells
>5
Estimated depth to high ground water: feet
Please indicate,all methods used to determine the high ground water elevation:
i
® Obtained from system design plans on record
1984
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:
Plan from 1984 and elevation letter from 1998
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Elevations from the 1984 design plan
Bottom of SAS#1 ELV. 90.8
Bottom of Test hole ELV. 86.8 NWE
Separation >4'
Elevations from the 1998 elevation letter
Property ELV. 68.0
GW ELV. 35.0
Bottom of SAS#2, 64"
Separation >5'
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-3113 r Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
Commonwealth of Massachusetts
4 r Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
174 Thistle Dr. Centerville, MA
Property Address
Linda Smith
Owner Owner's Name
information is required for every Centerville MA 02632 2/22/18
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
ri
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
5•
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 174 THISTLE DR �/ 1/ r
CENTERVILLE 5 c o Co
f ca
Owners Name: COTAGIS
Owner's Address: y
Date of Inspection: 11/15/05 rn
Name of Inspector: (please print) Douglas A.Brown C
Company Name: Douglas A.Brown Septic Inspections
Mailing Address:P.0 Box 145
Centerville,MA 02632
Telephone Number: 508-420-4534
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.I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system:
X Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: 11/15/05
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
****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.
Title 5 Inspection Form 6/15/2000 page 1 Revised on 10/31/2000
Page 2 of 11
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 174 THISTLE
CENTERVILLE
Owner's Name: COTAGIS
Owner's Address:
Date of Inspection: 11/15/05
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 winch indicates that any of the failure criteria described in 3 10 CMR
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
at this time system MEETS MIN MUM PASSING REQUIRMENTS
B. System Conditionally Passes:
one or more system components as described in the"Conditional Pase' 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 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
distribution box is leveled or replaced
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
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 174 THISTLE DR
CENTERVE LLE
Owner's Name: COTAGIS
Owner's Address:
Date of Inspection: 11/15/05
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 15.3030)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
_ Cesspool or privy i s 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 I 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 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 trigge-ed. A copy of the analysis must be attached to this form.
3. Other:
Page 4 of 11
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 174 THISTLE DR
CENTERVILLE
Owner's Name: COTAGIS
Owner's Address:
Date of Inspection: 11/15/05
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 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
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 3 10 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
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
_ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped
Zone 11 of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
yeslm 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
r
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 174 THISTLE DR
CENTERVILLE
Owner: COTAGIS
Date of Inspection: 11/15/05
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?
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)]
5
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 174 THISTLE DR
CENTERVILLE
Owner's Name: COTAGIS
Owner's Address:
Date of Inspection. 11/15/05
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN How based on 3 10 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Number of current residents: 2
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):
Seasonal use: (yes or no): NO CO--70,00C:1
Water meter readings,if available(last 2 years usage(gpd)): off - ))000
Sump pump (yes or no):
Last date of occupancy:
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sqft,etc.):
Grease trap present(yes or no):_
Industrial waste holding tank present(yes or no):_
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part of the inspection(yes or no): _
If yes,volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
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):
Approximate age of all components,date installed(if known)and source of information:
INSTALLED 1998 J.P.MORIN
Were sewage odors detected when arriving at the site (yes or no)? NO
Page 7 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 174 THISTLE DR
CENTERVILLE
Owner's Name: COTAGIS
Owner's Address:
Date of Inspection: 11/15/05
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: cast iron _40 PVC_other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK:_ (locate on site plan)
Depth below grade: 12"
Material of construction: _concrete_metal_fiberglass _polyethylene
other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no): _(attach a copy of
certificate)
Dimensions: 1500 gal
Sludge depth: TRACE
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: TRACE
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
How were dimensions determined:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.)-
TANK LOOKS STRUCTUALLY SOUND AT THIS TIME
GREASE TRAP:_(locate on site plan)
Depth below grade:
Material of construction:_concrete metal_fiberglass—polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 174 THISTLE DR
CENTERVILLE
Owner's Name: COTAGIS
Owner's Address:
Date of Inspection: 11/15/05
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/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches, etc.):
DISTRIBUTION BOX: X (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.):
PUMP CHAMBER: (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
Page 9 of 11
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 174 THISTLE DR
CENTERVILLE
Owner's Name: COTAGIS
Owner's Address:
Date of Inspection: 11/15/05
SOIL ABSORPTION SYSTEM(SAS): _(locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:
X leaching chambers,number: 5
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.):
5 INFILTRATORS 8X36
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 or 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.):
Page 10 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 174 THISTLE DR
CENTERVILLE
Owner's Name: COTAGIS
Owner's Address:
Date of Inspection: 11/15/05
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.
Ac _ is
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Page ll of 11
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM ] INSPECTION FORM.
PART C
SYSTEM INFORMATION (continued)
Property Address: 174 THISTLE DR
CENTERVIL,LE
Owner's Name: COTAGIS
Owner's Address:
Date of Inspection: 11/15/05
SITE EXAM
Slope:
Surface water:
Check cellar:
Shallow wells
Estimated depth to ground water feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavat3rs,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
TO CATION � �1� S E.W A G E PERMIT NO.
VILLAGE
I N S T A LLER'S ,NAME i ADDRESS
,�'S U I L D E R OR OWNER
DATE PERMIT ISSUED e_ L
DATE COMPLIANCE ISSUED ��o
:,. 90
S`
No... ..._.`. � Fim.............................
THE COMMONWEALTH OF MASSACHUSETTS
f� BOAR® OF HEALTH
1U.CA- ...A..)....--.....OF.
Appliration for Diipnsal Works Tons rurtiun lirrmit
Application is hereby made for a Permit to Construct X) or Repair an Ind1 ual Sewage Disposal
Syst t 771f5 f ZE Ae.
........ ... ......................... ..... ---------------..._........... ---...---------------------------- -- .or
Locati -Add
---- A d��'!. P. �'J 1.tU�'' ------------------•--------•-.........•. ... ..--•-•-......------------.........------.
� _/.a
Owner ....•---------------------------Address�t_..:bh --------------------------•----------------------... .....------- ..........................---•-•-----••----
Installer PQ Address //
Type of Buildin� AM Size Lot. '?�_..Sq. feet
13
Dwelling—No. of Bedrooms............................................Expansion Attic ( Garbage Grinder
Other—Type of Building ............... No. of ersons.......................... Showers
a g ----•-------- -------•P--• -- ( ) — Cafeteria ( )
dOther fixtures ---�..-----••-••---•--•-•-----•-•••-• •-----------•••----------------------------•-••-••-------•-•-----•---•--..........•--------
W Design Flow.....................�5. ..gallons per person,p�d;q. Total dagy�fipw............ ---------3..Q..._..... io s.a
IX)o
W Septic Tank—Liquid capacity............gallons Length-�------------- Width..`i�.------... Diameter-----........... Depth...................
x Disposal Trench—No..................... Width.................... Total Length......... ._. Total leaching area--- sq. ft.
Seepage Pit No..
......1--------- Diameter..........9..... Depth below inlet........ Total leaching area. .._sq. ft.
Z Other Distribution box Dosing t k ( ) A , -3
~' Percolatio Test Results Performed by........ cy_�.. ._ Date........................................ 1
o. 1......�-.minutes per inch Depth of Test Pit.._.. _�____. Depth to ground water--- ..✓...
f-IL, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.---................--..
D�esc;ipti of Soil -- — -- - �.�
J�JI)CJ ----
f
V .........................
W
VNature 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 TI'L 1E 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been ' d y the board of health.
Signed--------- ---- -- . I( ..
Application Approved By....................... ......K......................................
Date
Application Disapproved for the following reasons---------------------------•---------••------•-------------...------•-----------... ...........................
--•--•-----•••.......••--•....--•----•-•--•-••----....•-•-•-......--•---•-•-•------------------•••-•-----------•---•---•--•-------•---•--------.......----------•••--•-•-•----•-----•-•--•----...••----.
Date
PermitNo......................................................... Issued........................................................
Date
�-- - — - --------------------- =_=___ --- --�.� -------- --
r // y
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
f..r'. ....J..............oF.... .. .. JI1�, �- -
: ... . .
Appliratiun for Dispas al Works Tonstrn.rtion ramit
i<��Application is hereby made for a Permit to Construct X) or Repair ( ) an Indiv' ual Sewage Disposal
,-
system t
041.
Loeat',n-Add s or Lot No.
r.1.... ... �-------1-�......•. -•----------------------------•-----------•-•-------••-•-----•----•-------------...........------.
Owner Address
W
Installer Address
Type of Buildin - Size Lot.071 ?.4?)6- ....Sq. fee
Dwelling—No. of Bedrooms------✓•--..................................Expansion Attic Garbage Grinder
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
d Other fixtures -----------•------------•-----------------------------.-------•------------------------------------------._.:�-- .......------------•-----------.
---
Design �.. ............gallons per perso�er clay. Total daill fi�ow.._...........✓__`�_.Q........._.�alpns.�
w Flow____________________ �/" C'
WSeptic Tank—Liquid*capacity4 -e...gallons Length .."C?...._ Width.:=/U_.. Diameter_______________ Depth_- -"n._..
x Disposal Trench—No..................... Width.................... Total Length........ _. Total leaching area.... sq. ft.
Seepage Pit No--------/---------. Diameter...........f....... Depth below inlet.......?..... Total leaching area. .__sq. ft.
Z Other Distribution box (4-T— Dosing t nk ( ) _ AA ,,
'~ Percolatio Test Results Performed by.._.... �x-- _._ :..I`�?__._. _ -_..... Date........................................ �
._minutes per inch De th of Test Pit_-- ; �
o. 1.._._. = p p Depth to ground water__�.�_�E?.._..__.�v
(s, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
__P4 = •-- . ... . . /
Dptio of Soil------. �-
-------------------------------------•-.._....._..-•-•---- ---••-.........._._..----•-••-•--------•----•------...... .---
-
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 issued by the board of health.
Signed .......................................................
Application Approved By............................
........................................................... --•-•••••• ----•--- ••-•---•--
Date
Application Disapproved for the following reasons-----------------------------------------------------•---------------•---------------------•--•-------••.......
-•---•-•-••••-•-----••....................•--------••------------•--•---•-•-----................-•-------••----•--•-----•----------•-••-----•---•••----•---••--••••-•-----------••--•-•--------•••.•••--
Date
PermitNo...................-...-----------------------------------
Issued-.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF..............................................'....'*'**........ ......
Trrtifiratr of Tontplinu
THIS IS TO Y, That the Individual Sewage Disposal System constructed ( ) or Repaired ( `)
y ------------ --- X
at
........ ...........................................................................•-•--.............__......._........_........__......_.__.._.__.....
has been installed in accordance with the provisions of TITLE r anitary Code as described in the
47 application for Disposal Works Construction Permit No...............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM _W1A FU CTION SATISFACTORY.
DATE....,. .. 3f 1("`, ................................................. Inspector. .. ............................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�,/
No.......... .......••- FEE........................
Disposal trnrtion amit
Permission is ereb - granted •-----------------•---:_...................
to Construct ors air an ua'1 =a a ] osal S ste
Street
as shown on the application for Disposal Works Construction Permit Nye........ ........ Dated..........................................
_ -•' Board of Health
DATE.-------- ..................•-•-•......._
FORM 1255 A. M. SULKIN. INC.. BOSTON �`y
<at►.�G>_C FAMIL-`!
).JD GARBAGE 69-1wDEGL . r
D n,►t+ F LO W .: ►lox 3 = �3 C2 P. R /S/.7$ '"('"l
SEPTIC- TArJK = 330x15o% = A95G-P. R ly9 'fj /�'� ►I �� •��
U 5 ti=- ►o 0 o GA�-. �.6 5 N j
• I000 GAL. / Zo, �3�d �� � � '?
Dt5Po5AL PIT U5E c/
'S t paWALL AQ-Sh, III 30_ N
1.5o 5.F 2.5 = 37 5 G.Pr?
BOTTOM AR;-:Az *5.F•_
-ToTAL pE51GN o .g25 (,.PD.
-TOTAL 'DA.►L•Y Ft-ov! - 33o �•P� �I t
✓`.% `
qo
PE2Co�.ATIoN RATE ; 1"iNJ 2MW oP--LE55
37.yo1
o _
�Lr4���H CiF
�y 99UA
WILLIAM ��•;?, (. �;, S('o• Z 3 � 7 •9 v .
TIiJIIN
Igo. 29976 H
Nu. 19334 r�; \ .�, p�
FCIST£�� 4 y r4 Or( `v
SURv�yD •►`yy SI_ i '�.►i�:�:
44 .> T o P F N U-=Io/
'► Na�� 7//. �g3 C� _ yip -,j0i9
� D►ST• ca.�. 97G
SU3S�/L q INJ' �'S6PrcC.
BvX 97� Y`TANK :
1000
� � Ioao INl. r
LP
X8
it LEAGLI
PIT INV.. INV.
M/1TLl
y7o y�Z
I• /�L� 1�3�4•I�i
WP,S%4SD
c
�� S4�/a 6-rvµ6 •
GEQTIFIGD Pt-oT PLAN
I L L o G A'T 10 r-•I /kl/4 lz
N o SCALE S CA L E
II Pt-PN REFE�ENGE
�I I CERTIFY -CHAT T NE�2oi�o�EDF�bSNowN /
I` y{ER EDhI GOMPI-`(5 Y�4TN Z HE S l oEt_1N f.-.Ur
' AuD 56TQ4GK R.�QU►R.EMENT� oF 'C14�
�� 'ToW►� OF 34 �T4f3'LL% ANC IS 40�
l_OC TN N 1 2,4Ti:—
DATES g ►�� �_. BAXTE2e. IJ`(E INC.
RLS61SZI✓26UII,.AwD S��vEYoes
'Tu15 PL&KJ 15 f\IUT (3n5c D o►c1 AN 057E-2.VILD
j 1N5TR.UMF-- NT e,UZVC-Y � -T1AE p1:FSETS Suout,D CaiciJiN4�n��T�/ 7i? „tip
NoT [>E U51_ 0-To 0E-Te F-/^ING LOT t'INES i�PPLICP.►-IT y
TOWN OF `AfMt2 bA05M&6
LOCATION•
C 7 <
VILLAGE:
LOT # : PERMIT # :
INSTALLER''S NAME: /' thae-I'l-0
INSTALLER' S PHONE # :
LEACHING FACILITY: (type) -4 ,ffL� fize)
NO. OF BEDROOMS:
BUILDER OR OWNER:
PERMIT DATE: / _'
COMPLIANCE DATE:
DRAW DIAGRAM ON BACK
C�-/t� c .
CCA'2�
�v
.3C -
2 Zk
33 ® .� T
No. /�9— 7 Fee If 0,
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
RppItration for Di_4pogal 6potem Construction J)errnit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address
MAjap/Parcelddyress or Lot No. �f � ;—�� v owtya��ress an Tel.No.
Assess/es 7/1 P `/ /30, Q�� �[J
Installer's e,Address,and Tel.No. 7 Designer's Name,Address and Tel.No.
Type of Building: G
Dwelling No.of Bedrooms Lot Size ! sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 3"30 gallons per day. Calculated daily flow 3 35� gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank /606 Type of S.A.S.
Description of Soil
Nature of Repairs or Alt
do (An wer en ap licable)
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 provisio le 5 of the Environmental Code and not to place the system in operation until a Certifi-'
cate of Compliance has been iss d by f 's B oard o e
Signed ' Date'
Application Approved by Date
Application Disapproved for the following reasons
Permit No. W" 7 gr Date Issued
No. 7 Fee 90,
,
THE COMMONWEALTH OF.MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWNARNSTABLES MASSACHUSETTS Y�
0(ppYication for Migaal *p5tem Construction Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) El Complete System ❑Individual Components
Location Address or Lot No. // Ow ss an
A Tel..NNo�y�'�
—.c 7 1111i JJ /
Assessor's Map/Parcel /'l/Q � yG. /30,
o 2,0
Installer'?vne�A us an 7 3
d Tel.No. Designer's Name,Address and Tel.No.
,vtddG s 7� r -v
Type of Building: G
Dwelling No.of Bedrooms Lot Size -I T ( sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 3 gallons per day. Calculated daily flow 3 3-5-- gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank /DOO Type of S.A.S.
Description of Soil
Nature of Re airs or Alte atio (An wer w en a licable)
�, � Lv' L
5
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore descrkbed�on-site sewage disposal system
in accordance with the provisio le 5 of the Environmental Code and not to place the-systG_M_t UQP2esattoRiM!L a Certifi-
cate of Compliance has been issl d by)t 's and LL
Signed Date
- —• 4• Application-Approved by Date
Application Disapproved for the following reasons -_
Permit No. 8 Q4ie;:Issued
——————— IIIi'°
—————————————————
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
(tertificate of (tompliance
THIS IS TO CER7kY.tat t n-site Sewage Disposal System Constructed( )Repaired)Upgraded( )
Abandoned by
at 17 T has been constructed in accorda
with the provisions of Title 5 and the for Disposal System Construction Permit No. 9�" 7 7f dated /Z �S 9r
Installer Designer
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
Date Inspector
i
—————— ——— ————————————
q G —�� -- --- -�i
No. /1--7A- — -— y Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE} MASSACHUSETTS
lwigozaf *pgtem construction 'Permit
Permission is hereby granted to C�}S ct( ) pair(�grade ) andon
System located at /
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 must be completed within three years of the date of this peunit.
Date: z Approved b
PP Y ��!tx-�
I
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 /1 , ��� , concerning the
property located at J L( meets all of the
following criteria:
• There are no wetlands located within 100 feet of the proposed leaching facility
• There are no private wells within 150 feet of the proposed septic system
• There is no increase in flow and/or change in use proposed
• There 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) 3�
SIGNED : - DATE: f fG
LICENSED SE IC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
[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
to—s
103. E gad
o, -7y
-3
TOWN OF � � dC
LOCATION: `
VILLAGE:
LOT # : n PERMIT
INSTALLER' S NAME:
INSTALLER' S PHONE # :
LEACHING FACILITY: (type) f 3�,,/L��f�,g� ize)
NO. OF BEDROOMS:
BUILDER OR OWNER:
PERMIT DATE: (,T `J
COMPLIANCE DATE: / '�- ' r"7 ` S
i
DRAW DIAGRAM ON BACK
--s 5�.
�': s�
No. r-- Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
Zipplicatton for �Dtzpoal �bpgtem Congtructton Permit
Application for a Permit to Construct O Repair Y) Upgrade O Abandon O ❑Complete System ❑Individual Components
Location Address or Lot No. 17 17 -r s Q Owner's Name,Address,and Tel.No.
Gd+ea 15 l SACA�C
Assessor's Map/Parcel 'i H Ct U
I`nsttaaller's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building:
Dwellin No.of Bedrooms /v r 'J°x t Size sq.ft. Garbage Grinder ( )
t er Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this PeTr4 of Health.
Sianedz Date 2
Application Approved by Date b110j_—
Application Disapproved by: Date
for the following reasons
Permit No. Go�� ��� Date Issued t ��
J `
No. o�VVf^� i� Fee /U0.
t THE COMMONWEALTH OF MASSACHUSETTS Entered in compute
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
ZIpprication for Migoar *p.tem Con.5truction Permit
Application for a Permit to Construct O Repair()4 Upgrade O Abandon('j ❑ Complete System ❑Individual'"Components
Location Address or Lot No. ( 7 4/ 10 A 'e Rd Owner's Name,Address,and Tel.No.
Assessor s.Map/Parcel J Li 9! 3pp'A0 v
lnstalle-'s Name,Address,and Tel.No. Designer's Name,Address and Tel.Not.
Type of Building:
'J �P/h tQ W21r/�
' �DwellinNo.of Bedrooms " �Yj�� U t Size sq.ft. Garbage Grinder ( . )
{ Other Type of Building No.of Persons Showers( ) Cafeteria( )
Ot er Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan .Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
i
Nature of Repairs or Alterations(Answer when applicable) ,GCE t
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and,maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this -oard>of Health.
0
Signed ' — -_ Date
Application Approved by 11AI 2 S_ Date
Application Disapproved by: Date
for the following reasons
Permit No. .?Gu Date Issued±I 1�/#S
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
ID- TIOx
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired (x) Upgraded ( )
Abandoned( )by ire S A
at 1 7y KC� has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. ?00s--_5- ,6 dated % 61 .
Installer�)0A G-s A N Designer
#bedrooms 1r,w L b, Approved design flow K) A gpd
The issuance of this permit shall not be construedas a guarantee that the system will ff u tion^gdestgned.
Date Inspector �• __! � � --� .--�
----------------------------------------------
No. 1900_ r Fee /UU—
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS
lwigont i§p5tem Con5truction Permit
Permission is hereby granted to Construct ( ) Fepair (x ) Upgrade ( ) Abandon ( )
System located at t-1 t i
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty
to comply with Title S and the following local provisions or special conditions.
Provided: Construction must be completed within three years of the date of t M
itDate d Approved byG V"• /� t2 S,
TT j