Loading...
HomeMy WebLinkAbout0246 TURTLEBACK ROAD - Health 246 Turtleback Road Marstons Mills P Nov 13 2016 15:50 Jim The Inspector Man 5085349919 page 19 6(o 3-- ba h Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments C 246 Turtleback Road Property Address Jill Quin -a Owner Owner's Name MM information is Marstons Mills r;? required for every I/ MA 02648 11-10-16 page. Cityrrown State Zip Code Date of Inspection W 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 ( "r,trllllrtrr/ on the computer, v / �� H 6F use only the tab 1. Inspector: ,�°�`�•' "•sSq�%; key to move your cursor-do not James D.Sears �� JAMES• 'N' key the return y. Name of Inspector In= Capewide Enterprises, LLC *•. �, *_ Company Name Ts°�Q 153 Commercial Street i4/'/i/41 5 INSPEG����`�` Company Address rwlr� Mashpee MA 02649 CdylTown State Zip Code 508-477-8877 S1623 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 16.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails' ❑ Needs Further Evaluation by the Local Approving Authority 'j�t"� �� 11-10-16 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP) within 30 days of completing this inspection. If the system 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. 15tns.doc•rev.rum Title 5 official Inspection Farm:Subsurface Sewage Disposal System-Page 1 of 17 V V � Nov 13 2016 15:51 Jim The Inspector Man 5085349910 page 20 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments , 246 Turtleback Road Property Address Jill Quin Owner Owner's Name information is required for every Marstons Mills MA 02648 11-10-16 page. Cltyrrown 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 system is two block c pool's and a pit. 13) 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 y" lease 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): Mns.doc•rev.6116 a Title 5 Official Inspection Form:Subsurface Sewage Disposal Systam•Page 2 of 17 Nov 13 2016 15:51 Jim The Inspector Man 5085349919 page 21 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 246 Turtleback Road Property Address Jill Quin Owner Owner's Name information is required for every Marstons Mills MA 02648 11-10-16 page. City/Town State Zip Code Date of Inspection B. Certification (cunt.) ❑ Pump Chamber pumpslalarms not operational. System will pass with Board of Health approval if pumpslalarms 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 ❑ NO (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. I. System will pass unless Board of Health determines in accordance with 310 CMR 16.303(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 lSiru.doc•rev 6/1 B Tille 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Nov 13 2016 15:51 Jim The Inspector Man 5085349919 page 22 N Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 246 Turtleback Road Property Address Jill Quin Owner Owner's Name information is required for every Marstons Mills MA 02648 11-10-16 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. , ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of.a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to.overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an 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 P/7- 15ins.doc'rev.6/16 - Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Nov 13 2016 15:51 Jim The Inspector Man 5085349919 page 23 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 246 Turtleback Road Property Address Jill Quin Owner Owner's Name information is I required for every Marstons Mills MA' 02648 11-10-16 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 clue 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. [Phis system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of'the above failure criteria exist as described in 310 CMR 15,303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems. To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone 11 of a public water supply 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.00c-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Nov 13 2016 15:52 Jim The Inspector Man 5085349919 page 24 Commonwealth of Massachusetts • Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 246 Turtleback Road Property Address i Jill Quin Owner Owner's Name information is required for every Marstons Mills MA 02648 11-10-16 page. City/Town State Zip Code Date of inspection C. Checklist Check if the following have been done. You must indicate'yes"or"no"as to.each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two,week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?.(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? i ® ❑ 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): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins.doo•rsv.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Nov 13 2016 15:52 Jim The Inspector Man 5085349919 page 25 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not forVoluntary Assessments 246 Turtleback Road Property Address Jill Quin Owner. Owner's Name information is required for every Marstons Mills MA 02648 11-10-16 page. City/Town State Zip Code Date of Inspection D. System Information Description: The system is two c. pools and one precast pit Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection , information in this report.) ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): 2014-43,000GaIs Detail: , 2015A0,00013al's Sump pump? ® Yes ® No Last date of occupancy: Present . 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.doc•rev 6116 Titles Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Nov 13 2016 15:52 Jim The Inspector Man 5085349919 page 26 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 246 Turtleback Road Property Address Jill Quin Owner Owner's Name information is required for every Marstons Mills MA 02648 11-10-16 page. Cityfrown 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: NA Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 800 gallons How was quantity pumped determined? Gage on Pump Truck Reason for pumping: Part of inspection 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 I ❑ Tight tank. Attach a copy of the DEP approval. ❑ . Other(describe): 15ins.doc•rev.6116 title 5 Official Inspection Form:Subsurface SewAge Disposal System•Page Aof 17 Nov 13 2016 15:52 Jim The Inspector Man 5085349919 page 27 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 246 Turtleback Road Property Address A Jill Quin Owner Owner's Name information is required for every Marstons Mills MA 02648 11-10-16 page. Cltyrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: NA/Pit 1978 permit# 143 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 30" feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Pipeing is 4"PVC SCH 40 Septic Tank(locate on site plan): 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: Sludge depth: t5ins.doc•rev.6/16 Title 5 Official Inspeotion Form:Subsurface Sewage Disposal System•Page 9 of 17 Nov 13 2016 15:53 Jim The Inspector Man 5085349919 page 28 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 246 Turtleback Road Property Address Jill Quin _ Owner Owner's Name information is required for every Marstons Mills MA 02648 11-10-16 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 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 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.).- 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 l5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sawage Disposal Syslerr•Page 10 of 17 Nov 13 2016 15:53 Jim The Inspector Man 5085349919 page 29 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments y 246 Turtleback Road Property Address Jill Quin Owner Owner's Name information is required for every Marstons Mills MA 02648 11-10=16 page. City/Town State Zlp 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: Elconcrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ Nin 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 15ins.doc•iev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposel System•Page 11 of 17 f Nov 13 2016 15:53 Jim The Inspector Man 5085349919 page 30 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 246 Turtleback Road Property Address Jill Quin Owner Owner's Name information is required for every Marstons Mills MA, 02648 11-10-16 page. Cltyrrown 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 Box 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 ❑ 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: I t5ins.doc rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Nov 13 2016 15:53 Jim The Inspector Man 5085349919 page 31 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessment:, 246 Turtleback Road Property Address Jill Quin Owner Owner's Name information is required for every Marstons Mills MA 02648 page. Cityfrown State Zip Code D&t of frlspection D. System Information (cont) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: - ❑ leaching fields number, dimensions: ---- ® overflow cesspool number: — ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is a old block c.pool and a precast pit. Over flow pool full. Over flow pit wet bottom. No sign of over loading or solid carry over. No high stain line. Pit 6'deep w/cover at 14". Over flow pool 6' deep w/cover at 2'. Cesspools (cesspool must be pumped as part ofl inspection) (locate on site plan): Number and configuration 1 Depth —top of liquid to inlet invert 4„ Depth of solids layer 4" Depth of scum layer 3'I Dimensions of cesspool 6' Deep Materials of construction Block' Indication of groundwater inflow ❑ Yes ® No t5ins.doc-rev.6116 Titte 6 Off ciel Inspedion Form.Subsurfaca Sewage Oisposaf System-Page 13 of 17 f Nov 13 2016 15:53 Jim The Inspector Man 5085349919 page 32 Commonwealth of Massachuseft Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 246 Turtleback Road Property Address Jill Quin Owner Owner's Name information is every Marstons Mills required for eve MA 02648 11-10-16 page. r Cltylrown State Zip Code Date of Inspectlon i D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Main pool at working level. one line in- Two out w/tee's 6'pool w/cover at 6" Privy (locate on site plan): Materials of ccnstruction: Dimensions Depth of solids Comments (ncte condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 15ins.doc-rev 6/16 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 14 of 17 Nov 13 2016 15:53 Jim The Inspector Man 5085349919 page 33 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 246 Turtleback Road Property Address Jill Quin Owner Owner's Name information Is Marstons Mills MA 02648 11-10-16 required for every _ page. Cityfrown 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: I ® hand-sketch in the area below ❑ drawing attached separately i K 311" IQ EA k V3/•� O ! O o ov4R-FY`' 14 1 t5ine,doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage,Disposal System•Page 15 of 17 Nov 13 2016 15:53 Jim The Inspector Man 5085349919 page 34 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 246 Turtleback Road Property Address Jill Quin Owner - Ownef s Name information is required for every Marstons Mills MA 02648 11-10-16 page. City(rown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar , ❑ Shallow wells N 141+ Estimated depth to igh ground water: feet Please indicate all methods used to determine the high ground water elevation:, ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Area high, Abutting property drop's off 14'+ Bottom of pit at 8'below grade Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc- ev.5116 Title 5 Official Inspection Form:Subsuriaoe Sewage Disposal System•Page 16 of 17 Nov 13 2016 15:53 Jim The Inspector Man 5085349919 page 35 n Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 246 Turtleback Road Property Address Jill Quin Owner Owner's Name information is required for every Marstons Mills MA 02648 11-10-16 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurfa:e Sewage Disposal System•Page 17 of 17 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION Ea � v TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Properi y Address: 246 Turtleback Road ' `t Marstons Mills MA 02648 Owner's Name: Robert Crotty NOV 2 1 2��3 Owner's Address: Same - Date of Inspection: October 24,2003 TOWN OF BARNSTABLEHEALTH DEPT. Name of Inspector: PATRICK M.O'CONNELL MAP Compa(ty Name: SEPTIC INSPECTION SERVICES CO. Mailing Address: 189 CAMMETT ROAD PARCEL MARSTONS MILLS MA 02648 LOT Teleph:)ne Number: 508-428-1779 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below im,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 approvod 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: C -- Date: I0 2-` 10� The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)w,ithin 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or;treater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.Tfte original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authorhy. Notes avid Comments: Cesspool with two overflows. Observed 10"effective leaching in most recent overflow pit,other pit was dry due to a crushed pipe which was replaced and now flowing properly. ****Tli is 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 I Page 2 .,f 11 f OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Properi.y Address: 246 Turtleback Road,Marstons Milts Owner: Robert Crotty Date of Inspection:October 24,2003 Inspect ion Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _XX_ 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. Commwnts: 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. (be septic tank is metal and over 20 years old*or-the septic tank(whether metal or not)is structurally unsoum:.,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 met:d 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 exf.ain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstruc:.-d 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 j distribution box is leveled or replaced ND exriain: i'he system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass in:pection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND exI lain: Page 3 .)f 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Propeuy Address: 246 Turtleback Road,Marstons Mills Owner, Robert Crotty Date of Inspection: October 24,2003 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 failin:,to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(l)(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 "'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 lailure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: Page 4 )f I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Proper:y Address: 246 Turtleback Road,Marstons Mills Owner; Robert Crotty Date ol'Inspection: October 24,2003 D. SyAem Failure Criteria applicable to all systems: You mi,ist indicate"yes"or"no"to each of the following for all inspections: Yes No K_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _K_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _K_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool K_ Liquid depth in cesspool is less than 6"below,invert or available volume is less than %day flow _K_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped .K_ Any portion of the SAS,cesspool or privy is below high ground water elevation. _K_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _:K_ Any portion of a cesspool or privy is within a Zone 1 of a public well. K_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _.K_ 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 mint 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 II of a public water supply well If you 4ve 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.'rhe system owner should contact the appropriate regional office of the Department, A I Page 5 )f 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 246 Turtleback Road,Marstons Mills Owner Robert Crotty Date of Inspection: October 24,2003 Check i Ethe following have been done.You must indicate"yes"or"no"as to each of the following: Yes r.o _X_ __ 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? _X __ 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') _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 conditic n 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 Cis at issue approximation of distance is unacceptable)j310 CMR 15.302(3)(b)] Page6AI1 . OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 246 Turtleback Road,Marstons Mills Owner: Robert Crotty Date of Inspection: October 24,2603 FLOW CONDITIONS RESIDENTIAL Numbe•of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIG 4 flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 Numbe-of current residents:3 Does re sidence have a garbage grinder(yes or no):No Is launc ry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundr r system inspected(yes or no): Season..1 use:(yes or no):No Water r Teter readings,if available(last 2 years usage(gpd)): 2001—45,000/2002—52,000= 133 gpd. Sump p amp(yes or no): No Last da a of occupancy: Currently Occupied COMN IERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis oI'design flow(seats/persons/sgft,etc.): Grease .rap present(yes or no):_ lndustri 31 waste holding tank present(yes or no):_ Non-sai titary waste discharged to the Title 5 system(yes or no): Water r teter readings, if available: Last da a of occupancy/use: OTHE It(describe): GENERAL INFORMATION Pumping Records: Last pumped April 2003 Source of information: Owner Was sy i tern pumped as part of the inspection(yes or no): Yes If yes,volume pumped:_1000_gallons--How was quantity.pumped determined? Size of cesspool Reason for pumping: . Cesspool inspection TYPE OF SYSTEM _Septic tank,distribution box,soil absorption system _Single cesspool —X 01'.-rflow cesspool _—Pri%y _Sh,ired 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 obtain: from system owner) _Tip 1 it tank _Attach a copy of the DEP approval _Othar(describe): Approximate age of all components,date installed(if known)and source of information: Primary cesspool and first overflow pit 1970+/-second overflow pit 1978. Were sewage odors detected when arriving at the site(yes or no): No Page 7 A I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 246 Turtleback Road,Marstons Mills Owner: Robert Crotty Date of Inspection: October 224,2003 BUILII ING SEWER: X (locate on site plan) Depth t elow grade: 2" Materials of construction:_X_cast iron _40 PVC_other(explain): Distanc-from private water supply well or suction line: 26' Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTA TANK: No (locate on site plan) Depth t elow grade:Material of construction: concrete_metal_fiberglass_polyethylene _otht r(explain) If tank s metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certifici.te) Dimens ions:- Sludge lepth: - Distanc.-from top of sludge to bottom of outlet tee or baffle: - Scum tl ickness: - Distanc.from top of scum to top of outlet tee or baffle: - Distanca from bottom of scum to bottom of outlet tee or baffle: - How v ere dimensions determined: STICK WITH HINGE FLAP. Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as relate:d to outlet invert,evidence of leakage,etc.): GREA:�',E TRAP: No (locate on site plan) Depth balow grade: Materia.of construction:_concrete_metal_fiberglass,polyethylene_other (expaaii i): Dimens i ons: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distanc;from bottom of scum to bottom of outlet tee or baffle: Date of East pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as relatod to outlet invert,evidence of leakage,etc.): I Page 8 )f 11 13FFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 246 Turtleback Road,Marstons Mills i Owner:Robert Crotty Date o1'Inspection: October 24,2003 TIGHT or HOLDING TANK: No (tank must be pumped at time of inspection) (locate on site plan) Depth t,elow grade: Materiel of construction: concrete metal fiberglass_polyethylene other(explain): Dimem ions: Capacit y: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm I evel: Alarm in working order(yes or no) Date of last pumping: r- Comm(nts(condition of alarm and float switches,etc.): DISTRIBUTION BOX: No (if present must be opened) (locate on site plan) Depth(f liquid level above outlet invert: - Comm(nts(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: No (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comm(ats(note condition of pump chamber,condition of pumps and appurtenances,etc.): i Page 9 A I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 246 Turtleback Road,Marstons Mills Owner; Robert Crotty Date of Inspection: October 24,2003 SOIL E�BSORPTION SYSTEM(SAS):X (locate on site plan,excavation not required) If SAS not located explain why: Type le tching pits,number: le tching chambers,number: le aching galleries,number: ]etching trenches,number,length: le tching fields,number,dimensions: _X overflow cesspool,number: Two(one 6x6 block and one 6x6 Precast) in novative/alternative system Type/name of technology: Comm(nts(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): Precast pit has 10"effective leaching,block pit was dry due to a crushed pipe and was repaired. CESSPOOLS: X (cesspool must be pumped as part of inspection) (locate on site plan) Numbe-and configuration: One Primary and two overflows Depth- top of liquid to inlet invert: 3" Depth cf solids layer: 6" Depth of scum layer: 6" Dimew ions of cesspool: 6'di:a.x 6' deep Materials of construction: Block Indicati,)n of groundwater inflow(yes or no): No Comm(nts(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc;): Cesspool structurally sound. PRIM: No (locate on site plan) Materie s of construction: Dimens ons: Depth of solids: Comm( its(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n Page 10 of 11 13FFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:246 Turtleback Road,Marstons Mills Owner; Robert Crotty Date of I nspection: October 24,2003 SKETCII OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchrr arks.Locate all wells within 100 feet.Locate where public water supply enters the building. z�s Page 1] of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 246 Turtleback Road,Marstons Mills Owner: Robert Crotty Date of Inspection: October 24,2003 SITE EXAM Slope None Surface water None Check collar Dry Shallow wells None Estimated depth to ground water: More than 50 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) C lacked with local Board of Health-explain: C i,:cked with local excavators,installers-(attach documentation) _X_Accessed USGS database-explain: USGS topo map and town GIS You must describe how you established the high ground water elevation: Town groundwater contour map shows water below el.50 and USGS map shows land elevation above el. 100 BOUSFIELD SANITARY SERVICE 17 Burbank Street Sandwich,Massachusetts 02563 Name k' Seger Permit No./4/3 Location: �y Builder's-Name and Address Bate Permit Issued:f�--7B Date Compliance Issued: '�� Q79 bt No................ .. Fps...Vr�................. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH •----.... I�l' L........OF........ f Allp iration for DiipnsFal Narks Tonstrur#inn frrutit Application is hereby made for a Permit to Construct ( ) or Repair, an Individual Sewage Disposal System at: � �;�,-------------------------- ion....�_ eel 4 G1- .......... ...._._..1...---?�.......... o�;+ -Address o Lot No. Rd....._ --------------------•••••----._.._......... .---...•-•-••......---•-•-•�'�n.....L.......----......-••----•----......_._......_--•--- ----- ---- ------ --- ---- O ner Address W .... -vs�t- L►� ----------------�}:�'�- ....01 ....----................---------....... a - •• •.. . ................. _..._.._ Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms.______.-3_______________________________Expansion Attic ( ) Garbage Grinder ( ) '44 4 Other—T e of Building No. of persons...._..._60............. Showers — Cafeteria a' Other fixtures __________________________________ .............................. _--------------------- ------------------•••--------- W Design Flow............................................gallons per person per day. Total daily flow.......................-....................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 ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ••••----••------••--•-••-•--•--•....•••...-•----••-•••-••••••-•-•--•••-•••••.............•••......................................................... 0 Description of Soil....................................................................------•-------------------------------------------------------...----------------------------•-•--- x U •••••-••••••-••-•--•---••.....••••••--•••--•--•••••-••••••••---•••••••-••••-•••••-•-•........-••-•••••-•••-••--••-•----•-•-••--•-••-•-•-•--•---•-•-••-•••-•--••......••--•-•--•-•-•-•----•-••-•--•••--- -------------------------------------- : 9�1 U Nature of Repairs or Alterations—Answer when applicable.--,,at1%1�._ ,J1C. .L�19j -•-_ ......... ----------------------------------•-----•------------------------ ------------------------......------------. --.._............. Agreeent.:�I��� The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT�.su. 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be i ued by th oard of health. Signed_ .. . •-- --•�-� �--'nl..� /�/� Date Application Approved By.... U" L. IIL -------- ,�'':. !� 7 ' Date Application Disapproved for the following reasons-----------------------------------------------------------------------------•-----------------------------.._... --------------------------------------------•-----------------------------------------.......--------------••••--•-•---•••--•••--•-•--•••-•--••-•-•---•-----------------••---••••----•••-------...._.._. Date Permit No......................................................... Issued_.Z.'..R1 _ z-4F.................... Date ! n No.�� .�.`� ... FE$........... ......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...---... -- �Z n:`k..........OF........ . �:L �l:�+.�_..-.._-----------------•-•------- Appliratiou for Dh4pos al Works Towitrurtiou Prrutit Application is hereby made for a Permit to Construct ( ) or Repair (/-/) an Individual Sewage Disposal Sys .. C ......... ::.. ---...---- .�f ..............................................................._ ... J,ggption-Address r r o Lot No. II' 26er I s V�r I l0 LiteY ......... ................ -.._... ...... Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms__..... :.................................Expansion Attic ( ) Garbage Grinder ( ) p,, Other—Type of Building ............................ No. of persons.........(.n.............. Showers ( ) — Cafeteria ( ) QI Other fixtures ------------•---------------------------------- W Design Flow............................................gallons per person per day. Total daily flow............................................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. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ (i Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water______-__-_-_-_.--..___.- --•-------------------------•-•-•-------------------------•---------_---__-----_-_---•---•--•--------..----•-------_...... _... ..... •----- ------------------- 0 Description of Soil....................................................................................................................................................................... x U -••••----•••---------------------------•-••--•-•.._.......---••------•------------••-----------•-•••.....------••-•----•-•--•-•-•--••-------•--•----••-•--•--...-----•-----•-----------••--...-------- ...................•--------..._.........._.........._....----•---..._......................._......----••_•---•---L_--....-----...............---._...................... .. ...I.......... U Nature of Repairs or Alterations—Answer when applicable_.. -4;rZe-4i,.�---/7 .. ....!h!-J....( -•---. -. CP t1�C�......•----------------•-------------------------------------•-------------------------------------------------•--....---.------------•---•-------•-------. Agrent: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITiS y g g p - y 5 of the State Sanitary Code—The undersigned further agrees not to lace the system in operation until a Certificate of Compliance has bee i sued by the-board of health. Signed-----.- ••- -- 14 � Date Application Approved BY----` :..e%-r•+'•- -- ----�'s�-�_2- -•........... ...............•-•- ---��=-•�--�-=---�-�-=------- Date Application Disapproved for the following reasons----------------------------••----------------------•------------•----------------------•----•••---._....---•---- ...................•••---•------------•--....•--••........_....--•--•-•.......••---------•.._...•-------•--------•----•----•---•----•-----------••-----•---•-••----••-----•-••---••----•--------•--_.._. Permit No......................................................... Issued-....3_" Y_'.7_� Date Date THE COMMONWEALTH OF MASSACHUSETTS �`- BOARD ?O HEALTH ..........................................O F........w.� �1!1........................................................ Trrtifiratr of ToutpliFaurr THIS ISYTO CERTIFY/, TTa�the Individual Sewage Disposal System constructed ( ) or Repaired bY......r-:----:.r.......... .% / �---;- ----------------------------------------------------------------------------------------- { Installers has been installed in accordance with the provisions of T 1'_PLE j of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.._`.......���................... ...................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD JF HEALTH /� / : L '.............OF..---...Llt!l.. .No..... .../. FEE....................... Disposal or MI oat�triti~t' u rr it Permission is hereby granted•-`---• - _ to Conq ( ) oar (�an z Ci 'dual Sewag Dispos system/ C.. v _ '- A f at No... //�f �I..:...1% t........,1..� a-.F/.1 � .treet�`� 7 = ................. -5-...---...--•---... Street as shown on the application or Disposal Works Construction Permit-, No./'.._y.._._..._.� Dated. .`----..'.7:............... Board of Health C' (/ DATE--------- ---- ---�----------'•�----•------------------------ FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS '