HomeMy WebLinkAbout0360 TURTLEBACK ROAD - Health F360 Turtleback R �U
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
360 TURTLEBACK RD
Property Address
ZAPPALA
Owner Owner's Name
information is MARSTONS MILLS required for MA 02648 1/15/10
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:
When filling out A. General Information
forms on the 7(�
computer,use 1. Inspector:
only the tab key
to move your DOUGLAS A BROWN
cursor-do not
use the return Name of Inspector
key. DOUGLAS A BROWN INC
Company Name h „
Q P.O.BOX 145 _ , �a
Company Address 'M
ZE
CENTERVILLE s
City/Town MA Q2632 t'
State Zio-xc We
508-420-4534 SI4297 c�
Telephone Number License Number
B. Certification
rn
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:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
' � �✓" 1/15/10
Inspector Signature Date
The(system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
"*"This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•09)D8
Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 1 of 17
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
360 TURTLEBACK RD
Property Address
ZAPPALA
Owner Owner's Name
information is MARSTONS MILLS re uiredfor MA 02648 1/15/10
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
NEWEST LEACH PIT IS DRY WITH STAIN LINE @ 1 FT
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not
determined,"please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
• c
Z
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
'< 360 TURTLEBACK RD
Property Address
ZAPPALA
Owner Owner's Name
information is required for MARSTONS MILLS MA 02648 1/15/10
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required equired 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•09)08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
0
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
rY 360 TURTLEBACK RD
Property Address
ZAPPALA
Owner Owner's Name
information is required for MARSTONS MILLS MA 02648 1/15/10
every page. City(rown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health(and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
*"This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6"below invert or available volume is less
than Y day flow
t5ins•09/08
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
360 TURTLEBACK RD
Property Address
ZAPPALA
Owner Owner's Name
information is MARSTONS MILLS required for MA 02648 1/15/10
every page. Crwf own 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 CM 15.304.The system owner should contact the appropriate
regional office of the Department.
t5ins•09/08
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Q
1
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
360 TURTLEBACK RD
Property Address
ZAPPALA
Owner Owner's Name
information is MARSTONS MILLS required for MA 02648 1/15/10
every page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner,occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
❑ ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
❑ ® Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field(if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
y� 360 TURTLEBACK RD
Property Address
ZAPPALA
Owner Owner's Name
information is MARSTONS MILLS required for MA 02648
every page. Clty/Town bate/10
State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)):
Detail
HOUSE IS VACANT
Sump pump?
❑ Yes ® No
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:
l5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
l
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
360 TURTLEBACK
RD
Property Address
ZAPPALA
Owner Owner's Name
information is required for MARSTONS MILLS MA 02648 1/15/10
every page. Cityrrown 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:
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):
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
n
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
yr. 360 TURTLEBACK RD
Property Address
ZAPPALA
Owner Owner's Name
information is required for MARSTONS MILLS MA 02648 1/15/10
every page. CVTown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed(if known) and source of information:
NEWEST PIT APPEARS TO HAVE BEEN INSTALLED IN 1991 ACCORDING TO ASBUILT
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 2.5
feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints,venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade: 3
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: 5X8
Sludge depth:
6"2
t5ins•09108
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
f
0
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
y�
360 TURTLEBA
CK RD
Property Address
ZAPPALA
Owner Owner's Name
information is MARSTONS MILLS required for MA 02648 1/15/10
every page. Clty/Tovm 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
26"
Scum thickness 0
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? WOODEN POLE
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 VERY CLEAN AT THIS TIME
Grease Trap(locate on site plan):
Depth below grade:
feet
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene
El other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
Date
t5ins•09M Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
orm
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
360 TURTLEBACK RD
Property Address
ZAPPALA
Owner Owner's Name
information is
required for MARSTONS MILLS MA 02648 1/15/10
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene
El 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-0908
Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 11 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
'( 360 TURTLEBACK RD
Property Address
ZAPPALA
Owner Owner's Name
information is
required for MARSTONS MILLS MA 02648
every page. Crty/Town 1/15/10
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 D-BOX PRESENT
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.):
Soil Absorption System(SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•09=
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
rY 360 TURTLEBACK RD
Property Address
ZAPPALA
Owner Owner's Name
information is MARSTONS MILLS required for MA 02648
every page. CltylTown 1/15/10
State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 2
❑ 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.):
OLD PIT IS STILL IN PLACE NEWEST PIT IS DRY WITH SLIGHT STAIN LINE AT @ 1 FT
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•0908
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
f
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for VoluntaryAssessments sessments
yt b
360 TURTLE
BACK RD
Property Address
ZAPPALA
Owner Owner's Name
information is MARSTONS MILLS required for MA 02648
every page. Cl rr wwn 1/15/10
State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•09/08
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
360 TURTLEBACK RD
Property Address
ZAPPALA
Owner Owner's Name
information is MARSTONS MILLS required for MA 02648 1/15/10
every 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
t5ins-09r138 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
l
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
r 360 TURTLEBACK RD
Property Address
ZAPPALA
Owner Owner's Name
information is required for MARSTONS MILLS MA 02648 1/15/10
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: 50.5 FT
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:
OFF PREVIOUS INSPECTION DATED 4/6/06 BY ENVIRO TECH
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•09108
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
360 TURTLEBACK RD
Property Address
ZAPPALA
Owner Owner's Name
information is required for MARSTONS MILLS MA 02648 1/15/10
every 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•09/08
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
TOWN OF BARNSTABLE
LOCATIOy �4rcTL� R p�
SEWAGE #
VILLAGE'&Slo_ >.0
ASSESSOR'S MAP & LOW� '
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY Oo�
LEACHING FACILITY:(type)
-.J
NO. OF BEDROOMS -� PRIVATE WELL OR PUBLIC WATER
Ace
BUILDER O OWNER &L
i C'a,
DATE PERMIT ISSUED: ,t
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
I
i
t
i
,= e7\ . 3
No...91f... FEs �..........
THE COMMONWEALTH OF MASSACHU SETTS
arnst .•atior Cyr-..iF.sionBOARD OF HEALTH
�3 OWN OF BARNSTABLE
Sig, ned for Uhipliiial Work,5 Tvaa.itrur#uan Vamit
Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal
System at f`.2�............�����
00, 'q yoca' Address /
Owner Address`
Installer Ad ress / V
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder- ( )
Other—T e of Building ............................ No. of persons........................... .Showers — Cafeteria
Otherfixtures ------------------------------------•................................................... .
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 ( )
y.:ercolation Test Results Performed.b ............... Date........................................
p ;
aTest Pit No. I.................minutes per inch Depth of Test Pit...___________'___--: Depth to ground water--_-_-_._---:--_--_--_..
Gz, Test Pit No. 2................minutes per inch Depth of.Test Pit.................... Depth to ground water-----_----_-___-__---__.
x .................................. .........................................................
0 Description of Soil......................... '
U. ---------------------------•-------._...------------------......---•-----=------------------------------•---•---------------....._..------------------------------.••----• ---------
---------
W ----------------------------------------------------------------------------------------------------- ,
UNature of Repair or Alterations-Answ hen.applicable.._� 1 ` _ ._. .:----_--
�o?- ---------- '� C'
Agreement: �1.ay.c� to�"-�j. G p 0 o Y" w,;i S't, ��TI {y
The undersigned agrees to install the aforedescribed Indivilua Sewage Disposal ystem in acc r�' e wtt r� jLS
the provisions of TITLE .5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance ha en issued by the board of health.
ed....----- --....
��e.. .... Dare
Application Approved B ...:..........:.-..-`-------------........................ .. . �
Y -----------
Dace
Application Disapproved for the following reasons: ........................................ - ................................................... .........................
................ .......................................... ................... ...._......................... ....... .........................
�7 Date
Permit No :...f. .....'''.. - Issued ..................`..^:�J f .....
- Date
THE . .
COMMONWEALTH OFMASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
CZerttfictt#e of Croraylianrt, i
.THIS IS TO CERTIFY, That the Individual Sewage Dt posal System constructed ( ) or Repaired
by ... .: . ..
Iler �q l J/
� .. ... .. r at
. ..! f �...., .- /.f / .. .. e" +,.............................
. YYY .. .. '........� 3 d"�.t/.).....
has beenZir sta�ed in accordance with the provisions of TITLE 5 of The State Environmental Code aside c�ribed in.
the application for Disposal Works Construction Permit No. ... ` . -.�C7.(�...:... dated ..:.:.���,... .~
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT 6E CONSTRU 11,AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
GG / ti
DATE.........�f�`'.' l 1.�f......:..,...:. Inspector.._"_._� L=� ?- :..... ".............` J!
p =-.. .--
THE COMMONWEALTH OF MASSACHUSETTS ,
BOARD OF HEALTH
TOWN OF BARNSTABLE
NO I- / FEE. ........ .....
Permission is hereby granted. = r .,73 `•`.. ...
to Construct ( )_or Repair ( )/an Individual Sewage Disposal
Dil System
,✓f..� �.�.Pr��: f.-...�T!Y+..'fir /'mil��� Str et
as shown on the application for Disposal Works Construction Permit No.,� � %� � �--:_:-� i'%
�s �. ated- ------ ....•--
�.., r ........... ---•-------..
Board of Health
`OBBS&WARREN.INC..PUBLISHERS -
�GJ¢ TOWN OF BARNSTABLE
LOCATIO) 36a -rumal f cp- P.R • SEWAGE # /K�l
VILLAGE M4Ks our A41tj.5 ASSESSOR'S MAP & LOTdz/,,5 4 C lQ
INSTALLER'S NAME & PHONE NO. 36a-K-;L3'7
K
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) P 6 T- (size) do
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER PUc_
BUILDER O OWNER C�Z CQ D
�z
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No v
_.. - �.
--�. o� �'
,�
`'� ��, 1
�,�'
,�,
; .
l
�1
No.--91"..:_.. Fx$ .._....t........
'. P R 0 V E D THE COMMONWEALTH OF MASSACHUSETTS
arnstr.b' rvation Cor.) -;ssionBOARD OF HEALTH
t OWN OF BARNSTABLE
Signed Appliratf for Diup.as al Works Tomitrurtinn fautit
Application is hereby made for a Permit to Construct ( ) or Repair (VI"'an Individual Sewage Disposal
System at
oca' Addr ss ��
.......... ? f,�G.---•-----•--•. --.. tea ---......
Owner Address c.
Installer Address Na
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms.............. .. ...............--......Expansion Attic ( ) Garbage Grinder ( )
a Other—T e of Building No. of persons............................ Showers
Wf� YP g -•-------------•------------ P ( )--- Cafeteria ( )
Otherfixtures ------------------------------------•--•--------------.•••-----••--•-••---•----•••-----------------•----•-•---•-•-_ ------
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..--....................
(14 Test Pit No. 2................minutes per inch Depth of.Test Pit---:................ Depth to ground water........................
9 ---------------------------------------------------
----
---------
•----------------
.•-----------------
---------------------------------------------------------
0 Description of Soil........................................................................................................................................................................
W
V ...........••-•-•••------•-•--•------•-•-...••-•---•-•-----•-•-•---•••-•-••.........•••---....--•-•-••....----•-••••••--••--•----•-•-•----••••......-•-•--••-•.............
W ---••-•-•-••----------------•--•---------••••-•--------•-----------------------••-•-•.....•--•••--•-----•-- ...- - `
U Nature of Repair or Alterations—Answ hen applicable... -
------------ --
-- -- --- -- -
Agreement: O�.str. -
The undersigned agrees to install the aforedescribed Indivilua Sewage Disposal ystem in acc rdartce with t, Ls.'
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the '
system in operation until a Certificate of Compliance ha en issued by the board of health.
ed ........... - ----------------------- `
Date ��
Application Approved By .... . ...... ?
Date
Application Disapproved for the following reasons- ...............................................---- ------...........................-- ------------ ------------------------
.................... .....................
................Dater----'...........
p
Permit No. ................ Issued -----------------
Daze
y qzl
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
\�- rafthokfnx Biwiial Workii Tnntitrnrtion ramit
Application is hereby made for a Permit to Construct ( ) or Repair (Van Individual Sewage Disposal
System at:
- i4
.... � ati i Address�, /� / � ,er� _-0//7• or
tNo.
......� Y :j •oc ....
W /f0 er �y Address
._..._.y.�,,___��/._,.-fir.....__�'d�re.ela�.:.�.t::a'AS.�.Z..... ....... ��, ���i/-•/1�- :f/�,�� A..IYA-• ���/l
Installer Addr ss
Type of Building Stze Lot............................Sq. feet
U Dwelling—No. of Bedrooms............. .......................Expansion Attic ( ) Garbage Grinder ( )
`4 Other—T e of Building No. of persons............................ Showers
W YP g ---------------------------• P ( )--- Cafeteria ( )
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. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
9 ------
"----------------------------------------------------------
.--------
--•-•-•------- .--_----•-------
•-•.....
_----
•-------------------------------------
0 Description of Soil-"--"""""-"-""""""""-""""""""-"-""-"-"-""""""""""--"-"---"--"-""-""-""-""""""""------------"""--"""""-""----""""""""--"""-"--""""""""""""...............•-•--•-•-_--•---
x
c.� "--------"----------------------------
"-""--------------------------------------
--------------------------------------"-----------------------------------------------
---------------•--•-•----
U Nature of Repairs or Alterations—Answer when applicable...__ _
........... ..•.--_... ;�"_------_--- i _
A re ' en : g ot �'""sj q 1!�6' , w osal S S r�� 2�9 bnr
The undersigned agrees to install the aforedescribed Individual' ewage Disposal "ystem in acco dan e with
the provisions of TITLE 5 of the State Environmental 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 . .... ----�� .�-- -------- ------------- ----- /.......%.
Dare
Application Approved BY if ...
V Dare
Application Disapproved for the following reasons- ................................................
--------------- ---------- --------------.....-----------------........................................
----- ...........------.------------
Dare
Permit No- ..................................
--- ----------------------- --..... ............... Issued ------------------ ^....-
Dare
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certificate of GrapItttnre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by.............. . - - -
installer
�' rQ- /�. / t'�y --- r-G'�`-- ------------------ ------
has beensr sta ed in actor ante with the provisions of TITLE 5 of The State Environmental Code as .vibe in
the application for Disposal Works Construction Permit No. --.� ^'--- .. .1�.....-. dated --....���.... .............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.-......�`l . ---- ��f Inspector --------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
!/ TOWN OF BARNSTABLE
No.- n.. �/ FEE...-�;o
�i���a��� �ark� �un,�tr�rtilan .ermit
Permission is hereby granted......... ! ..-_....7-2;.-, s S._.... ____G....................
to Construct ( ) or Repair ( )/an Individual Sewage Disposal System ..................,
as shown on the application for Disposal Works Construction Permit NoM�] .Dated------���i
.."""-"--""""--"-" --••--.--�% ...el
�- . _
--•-••• Board of Health
DATE ----------------•-••.........._
FORM 36508 HOBBS Q WARREN.INC..PUBLISHERS
COMMONWEALTH OF
MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
' a DEPARTMENT OF ENVIRONMENTAL PROTECTION
f
t
/ar ce, / 0 <f9
T
OFFICIAL INSPECTION FORM TITLE 5
FOR VOLUNTARY
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A M
/ CERTIFICATION
Property Address: 360
TNrf�e
r s a
Owner' . �� Oak L s Name: A
Owner's Address: 60 %irN
Date of Inspection: !'
Name of Inspector: lease print) R . ,
Company / B ls�
Narae: lease ' ��!
Mailing
Address: 0 o / b
q _:
Telephone Number: p °a �� ` _ .
CERTIFICATION STATEMENT "
I certify that I have personally inspected the sewage disposal system at this address and that the ' formation 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 erforsyste .I am a DEP-I
approved system inspector pursuant to Se 5340 of Title 5(310 CMR 15.000' The s stem:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature:
Date: 6 �
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 approvin
authority.
g
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
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY SSESSMEA
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
NTS
PART A
CERTIFICATION (continued)
Property Address: 3 b o
Owner: 'J '' S� /j7.� ed-IC 4>'
Date of Inspectio . 06
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. Syste�sses:
C/ 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:
B• Sys em Conditionally Passes:
One or more system components as described in the nal Pass"section need to be"Conditio replaced repaired.The system,upon completion of the replacement or repair, th
approved by the Board of Heal d or
,will pass.
Answer yes,no or not determined(Y,N,ND)in the
explain. P
for the following statements. If"not determined" lease
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not is
unsound,exhibits substantial infiltration or exfiltration or tank failure is ' ) structurally
existing tank is replaced with a complying septic tank as approved by the Imminent.
of Health. will pass inspection if the
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Co lianc e
indicating that the tank is less than 20 years old is available.
mp
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 i
approval of Board of Health): P f(with
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructedpipe(s).
pass inspection if(with approval of the Board of HeaIth): y
The system will
broken pipe(s)are replaced
obstruction is removed
ND explain:
Titic C lncnurtinn �nrn,Aii Vlnnn
2
r Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 07 r ll
Gl.r LA j o
Owner: (Af � 0x 6 q
Date of Inspectio b
z
rther Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if
is failing to protect public health,safety or the environment. the system
1• System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b that the
system is not functioning in a manner which will protect public health,safety and the environment:
_ Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
The system has aseptic tank and soil absorption system(SAS)and SAS e is thin 100 feet of a
surface water supply or tributary to a surface water supply. th wi
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 colifonm
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered.A copy of the analysis must be attached to this form.
3. Other:
Tiflo S Incncntinn Anrm �n�nnnn 3 -
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: t0® �(^✓r�2 ��
Owner: �Lt t.�
Date of Inspecti n: (�
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
logged SAS or cesspool
_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
uid depth in cesspool is less than 6"below invert or available volume is less than %day flow
-Required pumping more than 4 times in the last year NOT due to clogged or obstructed i e s .Number
times pumped gg P P ( )
_ ,.y 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.
C/Ayy portion of a cesspool or privy is within a Zone 1 of a public well.
A p
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 50feet from a private water
supply well with no acceptable water quality analysis. system This s
� y m asses if the wwater
performed at a DEP certified laboratory,for coiiform bacteria and volatile organic compoundss,
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form]
(Yes/No)The system fails.I have determined that one or more of the above failure
.criteria exist as
described in 310 CUR 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
e 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.
Tihlo (ncnunhinn Gn•rn pit�i�nnn 4
Page 5 of l l
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
/ CHECKLIST
Property Address: b T(,t /�Z
Owner:
U i
Date of Inspe ' n:
Check if the following have been done. You must indicate"yes"or"no"as to each of the following.
Yes No /
P ing 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?
�-A 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?
1,7 Was the site inspected for signs of break out?
Were all system components, excludingthe SAS,S,located on site?
41�
_ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the bafWa s or tees,material of construction,dimensions, depth of liquid,depth of sludge and depth of scum?
_ s 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
�xisting 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(3)(b)]
Talo S fnennr}inn pnr 411;ilnnn 5
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property P h'Address:
Owner: G�,i H
Date of Inspect' o
RESIDENTIAL FL W CONDITIONS
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 3 10 C
Number of current residents: MS 15.203(for example: 110 gpd x#of bedrooms): ��v
/
Does residence have a garbage grinder(yes or no): &9
Is laundry on a separate sewage system(yes or no):—H[if yes separate inspection required]
Laundry system inspected( es or no): t%/
Seasonal use:(yes or no):&10
Water meter readings, if available(last 2 years usage(gpd)):
Sump pump(yes or no): �
Last date of occupancy: it,
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): d
Basis of design flow(seats/persons/sgft,etc.): r
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 INFOR.L ATION
Pumping Records
Source of information:
Was system pumped as part of the inspection
If yes, volume pumped: gallons--How was quantity pumped determined?Reason for pumping:
TYP SYSTEM
_Septic tank,distribution box,soil absorption system
_Single cesspool
_Overflow cesspool
_Privy
_Shared system(yes or no)(if yes,attach previous inspection records, if any)
_Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
—Tight tank _Attach a copy of the DEP approval
—Other(describe): `�Q✓✓`� I
Approximate age of all components,date installed(if known)and source of information:
a "' l✓ r til✓7at— Irl-PGv 1,/li .5
Were sewage odors detected when arrivingat the site
(yes or no):,�Q
Titlo C Incnnrtinn cn,,,,�il q�'7nnn 6
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: J 6,o
Owner: G ti t h /7 p (�
/ d-
Date of Inspecti n:
BUILDING SEWER(locate on site plan)
(�
Depth below grade: C2 9
Materials of construction:_cast iron _4` PPVC_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:
Material of construction:_c�e metal fiberglass_polyethylene
—other(explain) —" —
If tank is metal list age:— Is age co ed by a Certificate of Compliance certificate) mP (yes or no):—(attach a copy of
Dimensions: X
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle: CZ9 /
Scum thickness:L.P—�
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 If�kage,etc.):
C;i 0 G7.
� �G1 p a lr j COr � �
. T/0 ti
Iv
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 baffl
Date of last pumping:
Continents(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert, evidence of leakage,etc.):
f Titlo C Incnnrtinn �'nrm �n v�nnn 7
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
/nn't! -I /
Property Address: b �(A
Owner: a rS �, Od 6s�
Date of I sp nect on: 6
TIGHT or HOLDING TANK:ZLV(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: sallons
Design Flow: allons/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: /'- (if present must be opened)(locate on site plan)
)
Depth 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.): /
✓L tom_ LpCg �e
PUMP CHAIMBER:&(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.):
T:tl. �ncnar*inn Rnrm �n;i�nnn s
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
nn SYSTEM INFORMATION(continued)
Property Address: VT-4 r
Owner: L1 A. I r
Date of Inspecti :
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Typ� x � Olr � IvlC, � n
leaching pits,number:�
leaching chambers,number: (O 1 P w r
leaching galleries,number:
leaching trenches,number,length: 3 J TAD K e
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.): IL
a 6-7
r p
G ✓�
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:
Conunents(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
T:tlo S f-.Ptinn 17-- 9
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
o L� c /
Property Address: �v'�� � ��� �
Owner:_(—0 ;n ,
Date of Inspect► a:
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 en rs the building.
�14 IV
S��PS
x
y '`l —�e V✓�✓1
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' Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATIOnN(continued)
Property Address: 6 o e g."
Owner: tit 6 �
s f
Date of Inspectio : _
SITE EXAM (Q�
Slope
Surface water )(�
Check cellar 1 O
Shallow wells r
r-Estimated depth to ground water JOs feet C�✓1
Please indicate(check)all methods used to determine the high ground water elevation:
Ob om system design plans on record-If checked,date of design plan reviewed:
erved site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain: S
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how y u established the high round water @levation:
(r-/-o Ll Iv / rr TC4P,_�'0.7 / 5 S-D
•S �s Ova laWL4 kl
Tales � ►nrnnrhinn Gnrm�ii���nnn 11
No.----- -----•-----•• Fsx.. ......
Cp THE COMMONWEALTH OF MASSACHUSETTS
BOARD °OF .HE LTH
�
I
'7. ----. ...0 F
....... .
Application for Disposal Works Tonstrns#iun PrnYnit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
Syst at: . ...............
ocation-Ad or Lot
• �.. • -
.. ..
w er AddrqgV
W NN
Installer Address
Q Type of Building Size Lot___________________________•Sq. feet
U Dwelling l—�No. of Bedrooms___._....__.-7......�_---------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building .......:.................... No. of persons..__-_____________-_________ Showers ( ) — Cafeteria ( )
PH
�� -------------------------------- --------
Other fixtures _. .______________________ _
d Desl n Flow ... • Ul �. -- -- -• __
W g .. �. ............gallons per person per day. Total daily flow...........�__.� ________-_gallons.
WSeptic Tank zoLiquid capacity//__. _gallons Length.............. Width................ Diameter..._..-____.__.. Depth---•---.--.-----
x Disposal Trench—N .................:....VVid h-__---_.f__.---__ tal"'e ,e _...........` Total leaching area_____ ____-____-sq. ft.
Seepage Pit No.......7.._----.. Diameter_/;�__ _......_..ice'--- Total leaching area_ q. 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_________._____-____._..
�14 Test Pit No. 2................minutes per inch Depth of Test Pit- __-__-_'______:__- Depth to ground water________________________
----• - ----- -------- ------••-•----------------------•----------------------------------•-•---•---------------------------------
ODescription of Soil----------------- +,. `---------------------------------------------------------------------------------------------------------
x
U ................-•--------•.._....---•-••••--•••••••••-••••--••••••••••••-•-••...••------------•-•••--••••••••••••••••••-----------•------••-••••-••••--•-•••--•------•---------------------------------
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
V Nature 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 Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued the boo rrd of health
igned = _ =" ` `�
Dat
Application Approved BY ZZ
�� !
Date
Application Disapproved for the following reasons------------------------•••••-
Date
PermitNo......................................................... Issued..................................... ...........
Date
No......- ..... FizE .....................
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® QF H L.TH
_�--------------OF....... . .. w �... _-_---_---.---_--_
Apfiration for Disposal Worko C omitrurtiou Vamit
Application is hereby,made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
6
Lo s ocation-Ad ! / or .
:... ...�-- ............•.• . � ---------------------•----
er Addr
aW =0"f . .... ... ..............••.. .....:---_-••---••-----•-•--•--•••.._..-----•--•-•-_•--.....•------••-----•--•--•-------_-•--•••--
Installer Address
UType of Building. Size Lot_____________________._--___Sq. feet
Dwelling Y—V No. of Bedrooms____________ ____•....a......___...__..._Expansion Attic ( ) Garbage Grinder ( )
a Other—Type of Building _•_._-___-__. No. of persons............................ Showers — Cafeteria
QI Other fixtures ........................ ... ......
W
Design Flow............. ....� ...._..._._ allons per person per day. Total daily flow....................
WSeptic T. Liquid capacity/ ____-_-gallons Length................ Width---------------- Diameter---------------- Depth.--.______-__--
x Disposal Trench—No..................... W)Z"N
th....... - to n 1 _......_. _._ Total leaching area--- sq. ft.
Seepage Pit No...... ........... Diameter . ptl elow inlet.._.___..._C .... Total leaching area q. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.................................. Date........................................
Test Pit No. 1_-__•_-_-___.-._minutes per inch Depth of Test Pit._........_.•._..__. Depth to ground water________________________
44 Test Pit No. 2................minutes per i ch Depth of Test Pit.................... Depth to ground water------------------------
--•-••--• --------------•---------------------------------------------------------------------------------------
ODescription of Soil-----------------",�. ... - -- `.....----------------------------------------------------------------------------------------------•-•---
U ••••---•----•----•----•_-•-•----••--------•---------•------•••-_--•-_•_-•-••-•---.............-•-••-••--••-•--•-•-•-•-------------••------•--•----------•----••••-•----------------•-•-••------------.
W
------------------------------------I-------------------------------------------------------------------------------------------------------------------------------------------------------------------
U Nature 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 Article XI 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 b .ard of health,.
i ned- ...---- l ........ ri........
g __.._.._7.. "_ __________________ _________ •.6----------____-___
D
Application Approved BY-------- -, .'_' ...... ....... _........
Date
Application Disapproved for the following reasons:...............................................................................................................
-•--------------------------•----------------------.....----------•--•-----•----•-----_-------•----------------••-•-•------•----••--------------•-..._...-•-----------•-•••-----------•••..............
Date
PermitNo.......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
a
. ..............oF......... '.... . ...............
(Irrtifiraate of Toutpliancr
T S S TO CERTIF 1 the dividual Se ge Disposal System constructed ( } or Repaired ( )
b ....... ••---
Ins ]ler
at. __ --`�-----�------- ----
_•. '
has been installed in accordance with the provisions of Article XI of The State Sanitary C d as scribed in the
application for Disposal Works Construction Permit No...................................... dated ..................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEMI((Lrr L FUNCTION SATISFACTORY.
DATE DATE-----
Inspector---=------••1�
--------------------------------
THE
COMMONWEAL.''�H OF MASSACHUSETTS
];BOARD O�f , HEALT
........
*U- 121v
. ........-.OF.......
•= '
4
No..... • ..................... FEE-•-_••..................
13ispasal:. .Orkii (� a 9tr "last prrit
Permission is hereby granted..'..- _ 1 .. . . . ..... :... �c`___.." �— __ _._...._.___
to Con strr Repair ( ) %dualewa Disp �s System
at No.-
..4
Street
-
as shown on the application for Disposal Works Construction mit " --- � _ _ ___ Dated___ _--
............... `✓ a ----_--_ ..__...._.__.....
t Board of Heal,-",
DATE > - -° -------------------- �- ((��
'� FORM 1255 HOBBS & WARREN. INC.. PUBLISHERt
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