HomeMy WebLinkAbout0385 WAKEBY ROAD - Health 385. Wakeby Road
Marstons Mills
A= 028-109
i
I
i
®® SMEADJ
{ No.2-153LY
UPC 12934
emead.cam • Made in USA
'fir WO
FW US®M TM iRO=LK
01A FAMOMS
C
I �
P C-k► &ll IMF ouct.� ;�-- ,,,�. V'Q
l
t r �
{ I
d
C
7/Z
do,W 3/a7/v-7 o, ��"��
/ `�TOWN OF BARNSTABLE
0F1FS J 60 SEWAGE #
VILLAGE Z2)?4:;590r-24 ASSSEDDSSO MAP & L T O 9
'J NAME&PHONE NO��a/b ��s�
SEPTIC TANK CAPACITY Od l
LEACHING FACILITY: (type) f?1'7` (size)
NO.OF BEDROOMS
BUILDER
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility �� Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300-&,vj t of leaching faci ' Feet
Furnished by `_J: 7 lUM YJS' � ��' 7
I `✓�V
I 1��
N Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS es
Zipplitation for Dispoeal 6pstrm Construction i3Prmit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 25 W41<aY Qll� Owner's Name,Address,and Tel.No.
t(4004 6APJZ6-rr
Assessor's Map/Parcel 1 ® r'I 3� lsi/ — �Z
Installer's Name,Address,and Tel.14o.510$-477—g$77 Designer's Name,Address,and Tel.No.
c-AP&cvt a6;
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) OUTL&7' 7-E7C
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Si ed Date 9'a-9"oZc2 (7
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. Date Issued
'1
�.. r..
ODA
No. ! .:,. .n.-_..,.. ,. ...;.a Fee f
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ? „•�"
Ues
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
application for Disposal *pstrm Construction permit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 3 95 j,,t f A R Owner's Name,Address,and Tel.No.
� � 41DI, I H owc AS 0.4 PAa-rr
r`�Assessor's Map/Parcel ® 1,Vl+g--pV A j>
Installer's Name,Address,and Tel.No.5*!D$-4'77-9977 Designer's Name,Address,and Tel.No.
C�°►�E-LtJt Des ��T�"?��.15'ES
t��� COfa�t�ci -to-G:' �T t�f5f�p �fA
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) 1V ST-(,.(.. OU?'C Fi?"
L � •
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Si ed _ Date g-/aq"
Application Approved'by% _ +i. Date /
Application Disapproved by Date
1
for the following reasons
Permit No. �, t t.— Date Issued
------------------- ---------------- -- -- -------------- ------------------------ -- - - - - - - -------- - -------
THE COMMONWEALTH OF MASSACHUSETTS
ii JJ BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( X) Upgraded( )
Abandoned( )by 006 u..)f E A j" 4{s
at 385; W/E1445gy Rb M M has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No / ,//^ dated
Installer CAPEW(D6 EIvT s!5' Designer LA
#bedrooms Approved design flow gpd
The issuance of this permit shall'not be construed as a guarantee that the system will function.as des§ig�ned:
Date ! Inspector
---------------------------------------------------------------------------------------------------------------------------------------
No. ° l "� Fees
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS
Vsposal�*pstrm Construction j3Ermit
Permission is hereby granted to Construct( ) Repair O Upgrade( ) Abandon( )
System located at L1J 1bt{1i / S't�j1 s t ([,�,�
t
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction mush be completed within three years of the date of this permit w__ t
Date OK") Approved by ; _ ..•-
r
Commonwealth of Massachusetts
v Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
385 Wakeby Rd.
Property Address
David Barrett
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 3/09/2011
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: A. General Information
When filling out
forms on the �I C
computer, use 1• Inspector:
only the tab key
to move your Robert Paolini
cursor-do not Name of Inspector
use the return
key. Capewide Enterprises,LLC.
Company Name
f� P.O.Box 763
Company Address
Centerville Ma. 02632
City/Town State Zip Code
(508)477-8877 S14454
Telephone Number License Number
B. Certification
i
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 CM 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
3/09/2011
Inspector's Signatur 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.
Lq /1
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Dysposal System Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
M 385 Wakeby Rd.
Property Address
David Barrett
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 3/09/2011
every page. Cityfrown 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:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
The septic system is in proper working order at the present time.
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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
^M 385 Wakeby Rd.
Property Address
David Barrett
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 3/09/2011
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 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
�M 385 Wakeby Rd.
Property Address
David Barrett
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 3/09/2011
every page. CitylTown 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 1/2 day flow
t5ins•11/10 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
385 Wakeby Rd.
Property Address
David Barrett
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 3/09/2011
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply
well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area— IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
Lt5ins11/10regional office of the Department.
11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
^M 385 Wakeby Rd.
Property Address
David Barrett
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 3/09/2011
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): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
385 Wakeby Rd.
G„M
Property Address
David Barrett
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 3/09/2011
every page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 1
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ® Yes ❑ No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available last 2 ears usa e, d NA
9 ( Y g (9p ))�
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: 3/09/2011
Date
CommercialAndustrial 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
;M 385 Wakeby Rd.
Property Address
David Barrett
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 3/09/2011
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
385 Wakeby Rd.
Property Address
David Barrett
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 3/09/2011
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer (locate on site plan):
Depth below grade: 1
feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: 10'+
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Joints appear tight.No evidence of Ieakage.System vented through the house vents.
Septic Tank(locate on site plan):
6"
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 gallon
Sludge depth:
2°
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
�M 385 Wakeby Rd.
Property Address
David Barrett
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 3/09/2011
every page. City/Town 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
30"
Scum thickness
V.
Distance from top of scum to top of outlet tee or baffle
7"
Distance from bottom of scum to bottom of outlet tee or baffle
13"
How were dimensions determined? Measured
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pump tank every two years.lnlat and outlet tees are in place.No evidence of Ieakage.Tank appears
structurally sound.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 385 WakebY Rd.
�
Property Address
David Barrett
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 3/09/2011
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont,.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
f
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 385 Wakeby Rd.
Property Address
David Barrett
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 3/09/2011
every page. City[Town State Zip Code Date of Inspection.
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert No
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Box is Ievel.Box has one outlet Iateral.No evidence of solids carryover.No evidence of leakage.
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•11/10 Title 5 Official Inspection.Form:Subsurface Sewage Disposal System•Page 12 of 17
L
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
ac
°M 385 WakebY Rd.
Property Address
David Barrett
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 3/09/2011
every page. City/Town State Zip Code Date of Inspection
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.):
Sandy soil.No signs of hydraulic failure.Water level was 3' below invert at time of inspection.Stain line
observed 20" below invert.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
385 Wakeby Rd.
Property Address
David Barrett
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 3/09/2011
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•11/10 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
_���
_,
'_��
I +!
♦ � � t.,
1
. r
'�
Map Page 1 of 2
Town of Barnstable Geographic Information System
1
Parcel Viewer Custom Ma Map Size Zoom Out
P Abutters In
'm K RP
2 as 4q
3 CIS �3
Iq
G,
r
yt
;y
a
01 20 Fee
._.__- . -___....-_ .._..._ ...
Set Scale 1" = Zp ' I Aerial Photos �4r I MAP DISCLAIMER
r:nn—inht 9nVK_9M0 Tnum of R—nct.hlc AAA All rinhtc rocnne
http://66.203.95.236/arcims/appgeoapp/map.aspx?propertylD=028109&mapparback= 3/9/2011
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
;M 385 Wakeby Rd.
Property Address
David Barrett
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 3/09/2011
every page. City/Town 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: Bottom of LP 45'
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health - explain:
As-Built
❑ Checked with local excavators, installers - (attach documentation)
❑ Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
USED:USGS Observation Well Data.USED:Technical Bulletin 92-0001 plate#2 annual ranges of
groundwater elevations.
I
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•11/10 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
^M 385 Wakeby Rd.
Property Address
I
David Barrett
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 3/09/2011
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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
No. tl Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
es
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
ZIPPYitation for -Misposal 6pstem Construction permit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 3$S W*kc6t • MIb Sf Si�S Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel 6 � J�
Installer's Name,Address,and T 1.No. Ghtr STEaug Designer's Name,Address,and Tel.No.
K Ux 11 nar(� Ws vr►��3, w►ft• Oze4 8
'I�pe of Building: �I
Dwelling No.of Bedrooms 3 2rExPs4%a\ Lot Size �2�30�.� sq.ft. Garbage Grinder( )
Other Type of Building CSi 10,\cL\ No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) :I3 O gpd Design flow provided 330 gpd
Plan Date Number of sheets Revision Date..,
Title
Size of Septic Tank 14M g4j. Type of S.A.S. )000 crrl. Qi 4-
Description of Soil
Nature of Repairs or Alterations(Answer when ap licable) /QAAiw�a i-JGA- 'Ire T cwwX CXe).i&-atJ1-
J
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board
Signed Date 16110111.
Application Approved by �'lr Date o
Application Disapproved by Date
for the following reasons
Permit No. i 3`7 7 Date Issued tl
". 7(� /o
No. U I I 3 1 - Fee //
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:ILZ
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
ftplication for MispoBal 6pstem Construction Permit
Application for a Permit to Construct( ) Repair( .) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
" . Location Address or Lot No. 3�5 w� tby t2� rtNRST r-I"5 Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel
Installer's Name,Address,and T 1.No. Glh(, 51Ev=IV S Designer's Name,Address,and Tel.No.
?1UOx 1 1 h1g12S'%Q% WIL,-5, MK. OZ64
Type of Building:
DwellingNo.of Bedrooms sX1S1N1 Lot Size q) sq.ft. Garbage Grinder( )
Ik
1
\
Other Type of Building a S�`t-\\a\ No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) '2�,S Q gpd Design flow provided --%3 Q gpd
Plan Date Number of sheets Revision Date
i
E Title
I Size of Septic Tank M OG q41. Type of S.A.S. )OOU 9 w�• �i
i
Description of Soil
1 Nature of Repairs or Alterations(Answer when aVQviek".
cable) /�cLc�ir.Q (��e� fir. 7 CAK& C\•ezv�-o
7 Jrf.(r4- �v
I
Date last inspected:
Agreement: E
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
t
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this BoarpLgeaffir
_ Signed Date
Application Approved by Date 4. /
Application Disapproved by Date
for the following reasons
Permit No. d ° — 3 L/7 Date Issued u
------------------------------------------------------------------------------------------------=----------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS .
Certificate of (Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( )
Abandoned( )by C.C90 L '5Vt,.►e y\S ► f
at 39T W a ve 6Si has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. o l�`3/ ! dated u J_(Al
i
Installer &1?tC. ST7vPNS Designer
#bedrooms Approved design flo 33 0 gpd
The issuance of this ermit shall not be construed as a guarantee that the system wi�l/ o as de§A ned.
Dated Inspector �/� /
-----------------------------------------;----------------------
L/7 Fee
No. �S o
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS
Misposal *pstrm Construction Permit
Permission is hereby granted to Construct(y) epair( ) Upgrade( ) Abandon( )
i System located at 3 0-S (uJ to
i .
s
j and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construc ion ust be completed within years of the date of this permit.
Date U Approved by V.
51
14
- s
h � ry 11
IMA
k
1 L1
� s
i
•. ._��.
- a
�� �
. r
9 3
•L'� �
� { � � { { 2 �ni .. � '
S
P � � i
e Fyy t r �
w'/ i Q
f t; a ^��� i s
� �� �� �
'' � i
_�
,_� _
...,.
_ _ �
,�
�:
_.•. _.
o J 9 � � f� � � ��
V
a `'d
i
5
Sp-)t �
1
j {
ti � t
4 ,� ,•4 YEA � � `�y�*i � �J�'`�„FV,1~'t•r� � i
� � 1
' • Y
4'
� y
-
.�
� �' <��i�>Mt�4 'j �r '-�� `�il6 ll :i"_����' � �� Q�4�! `t� i i*.t�`�s�a _�,,t a yi ��.:�r .}' t ,�'r � � _ .� •.
1•h. :G� 1 5� � � �. 1f�iy`. ; ,.,�"��.(�, � 94 Y--•S,q'�p "pair, � !° "-
+, ' �� � ����: ' .7,�,.�.. i_J+� a 11 �. P•+ � 1 :1'GY'F. .� ,. - r / '
4 r`I �' +` Wst r �_ in' _ t�•'�"•�•��� �� ,r+' +et��, , a.7�trr J a.�4��s•'��'
r�~ Div�`4g� '{'�"`7_'� '�"'"�`' r��•�b"'�w���y �zi'�\•y�.4".x��,�, ��`6"'����?�"tgf� '°� w:s� .•Y .�S f.y`�'�` r �,i,rt,
`r * "'�Y€��.,�F �sH:` �"�°''*+wt���M�1♦5�..+..�„ _�': .•Z wt_-w.'tKtfty,•'f(�iv.fT�.��-y° .�;�R� �- d a•' '�• � \
c . _
4�,,� ;
LIA-
TO
AIR
_ z
Y7, � 1- ';d'� js — �K,,.� � —•'/",}.�L .
,✓^-t"- .�y,�'r'�•` Ls�,ia� �.���: ��� ry� 9d��e i����'F�' ,`��.��'-"'�?,u^',a' y '�'°'"•! `sl*`�` r ,.�t+dr'�.aj-g ��- �- ,�'h
�� ,^ _ x s�E,,, 'a��•�u�'w''" ""''� w`i !Y*��,�l+e�� -'�7E!' Y•�. 'S��•�FSTJe�+� -J Yii:��r-�,^�'n•�'��� � *w * °� .'w.. d':
.. �� :�.,.- y, 'ct:A�i•"-•„ ,-. ^� •.a�Sy-N�., ��f 'GaL+``.e� - �'� _-f�w.l.,� F,�., � - �}�cjA"r��s'`in•j....
I I
Il
'i�ti`ur"is.�t`^' aC' s-,a '=+rw +r"�T- _�` �,,,Yfs �, ? ,+^ .. '.� "�'"� a j ♦+a '+aia - = .t,�iA
7. ,A��a����� �}"� �+-�'���y��'-'�'t�.� 'r�YRL+'�'��' s+4..�,< �• _ `K��'� �+♦� - �. ♦:•;'�, .. �'"� .� �,��c.M. j *:_- +"° r."-�.
N. ^g`. r�. :y,.-.X6, iR '.�'j,^.•`� "�`\'+'�i• �t'� s'�'r't:Yti-�?�,��*+i ^�vaY�� y ° � tl+'lr. i � . •A'i„'#1�
l�l��'�`����i�r��7��F�* w.'� of ♦'�=i�+�'Vie. r.5.s*`�,-� �� !�-'�Aa�."+ 4�5• `K+ a«: _ '7 - �..a �
,-R.. y �•w�,,,. �^�+ -;t �.�� r. ,t. a-�*.r���} � en,x.,,�. ?♦ ��® y.,. -...� +r �'• .- ...�:-, y.; ♦_ :-t �.�
r yew- «.ar ,y�+'.d='��Mt ,.xR`'-" ,A�•,....„3;� ,.'SA. .v 'i?: T7�;":, r3`",* .s A�` o-ye^^-' ^'"� ♦,,,_� z•. rb> si .? ti '4�` :. i'�r+'. �'� t,'„^,,,'„�t� �^ •
.. p �j:.:a.•t' , �, � ....°..�.`„^�ar , �'" "�....+ ,�,.,�-`�r��°, a y g� :��:�'�.•:y:-*. Mil,
„'�e` `f,��.,..'`.wk' �•+r"�w• t T7�eN.,�, -
-
s " • .e'�F,r• ��.1" a.- ,, • ' - _ "r., ... . ,may ., ; ^'- r?,w = '' �, - '•r' +:�,-
�y� F�f�
.�.'. .�-;'�+ '.�'"`. ,_ w la.. iw`�`^.s'���^'� }'�.1�`sr. w. gam. �^�"��'�nc � `�' �� s.'�'♦v + 'a`i�
� ►fit •c., -�
.....,+"iC�.�3'����� ^�b��.� _ ^ y^ -!t- "S.n `Fig x. � '�'"+' � '' *J+y!�, `<►_� =' « -.*�' ..Sr:
- 'J4`++.'�n...� .. � „°.'�T"+..7L-�•�t eji1- ,'L��► ^� �� �'� - .IT,�..ni .,'`��t '��o. -p�����^� ��4��`�'� f ' y l�= ��'�'�R. #'�'``� !iv-°�•-
y4 Y+ ti- � � � • .P, "V"'�•caa 4'i .q. ��' '-R! �•�� � w .,,� m' ...,a0 i � - '""�I
,- _ .,♦_ ,a+'9i'� '•�, „ � �`.,:�'' *.may' ��
g ey„
r.
-
rc, t
.e r
p2 �
"' ." �...we 'S�'. �bC.�4�1�w � ♦ Wit, i♦ dtiM .y j�>
.. _ ` -...+ ��v''�; - Fit• ..' ='/' ♦ �!'!�
� Y
• "YY
�� � �� �—
���� U � � h
��,� �.�, � ��� � � � e
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS '
DEPARTMENT OF ENVIRONMENTAL PROTECTION
� r
I:
A
C
04•
M ve
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 385 WAKEBY RD MARSTONS MILLS,MA 02648
Owner's Name: LAUREN KLEINAS
Owner's Address: 385 WAKEBY RD MARSTONS MILLS,MA 02648
Date of Inspection: 9/10/01 a_ v
•.I
Name of Inspector: (please print) JOHN GRACI
Company Name: SEPTIC INSPECTIONS
Mailing Address: P.O. BOX 2119 TEATICKET,MA.02536
Telephone Number: 508-564-6813 FAX 508-564-7270
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is
true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and
experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system
inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
t._
X Passes
_ Condition ly Passes
_ Needs Fu h Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: 9/10/01
The system inspector shall subm a copy of this inspection report to the Approving Authority(Board of Health or DEP)within
30 days of completing this inspe tion. If the system is a shared system or has a design flow of 10,000 gpd or greater,the
inspector and the system owner shall;submit the report to the appropriate regional office of the DEP. The original should be
sent to the system owner and copies sent to the buyer, if applicable,and the approving authority.
Notes and Comments
SYSTEM PASSES TITLE V RECOMMEND PUMPING NOW AND EVERY TWO YEARS TO MAINTAIN SYSTEM.
RECOMMEND NOT DRIVING OVER PIT BECAUSE IT IS H 10
****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 lm�nrrfinn I nrm 611';nnnn I
Page 2 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 385 WAKEBY RD MARSTONS MILLS,MA 02648
Owner: LAUREN KLEINAS
Date of Inspection: 9/10/01
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310
CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
SYSTEM PASSES TITLE V RECOMMEND PUMPING NOW AND EVERY TWO YEARS TO MAINTAIN
SYSTEM. RECOMMEND NOT DRIVING OVER PIT BECAUSE IT IS H 10
B. System Conditionally Passes:
_ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,
upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain.
n/a The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits
substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced
with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it,is structurally sound,not leaking and if a Certificate of Compliance indicating
that the tank is less than 20 years old is available.
ND explain: n/a
n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed i
pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of
Health):
_ broken pipe(s)are replaced
_ obstruction is removed
_ distribution box is leveled or replaced
ND explain: n/a
n/a The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
_broken pipe(s)are replaced
_obstruction is removed
ND explain: n/a
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 385 WAKEBY RD MARSTONS MILLS,MA 02648
Owner: LAUREN KLEINAS
Date of Inspection: 9/10/01
C. Further Evaluation is Required by the Board of Health:
_ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to
protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is
not functioning in a manner which will protect public health,safety and the environment:
_ Cesspool or privy is within 50 feet of a surface water
_ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water
supply or tributary to a surface water supply.
_ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
_ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and SAS and the.SAS is less than 100 feet but 50 feet or more from a private water
supply well". Method used to determine distance n/a
"This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and
volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy
of the analysis must be attached to this form.
3. Other:
n/a
i3 `
Page 4 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 385 WAKEBY RD MARSTONS MILLS,MA 02648
Owner: LAUREN KLEINAS
Date of Inspection: 9/10/01
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for alLinspections:
Yes No
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
_ X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged
SAS or cesspool
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool
X Liquid depth in cesspool is less than 6"below invert or available volume is less than 'h day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times
pumped nLa.
_ X Any portion of the SAS,cesspool or privy is below high ground water elevation.
X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
X Any portion of a cesspool or privy is within a Zone 1 of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with
no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP
certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free
from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be
attached to this form.]
(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 16,000 gpd to 15,000 gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
X the system is within 400 feet of a surface drinking water supply
X the system is within 200 feet of a tributary to a surface drinking water supply
X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat
under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner
should contact the appropriate regional office of the Department.
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 385 WAKEBY RD MARSTONS MILLS,MA 02648
Owner: LAUREN KLEINAS
Date of Inspection: 9/10/01
Check if the following have been done. You must indicate "yes"or"no"as to each of the following:
Yes No
X _ Pumping information was provided by the owner,occupant,or Board of Health
X Were any of the system components pumped out in the previous two weeks?
X _ Has the system received normal flows in the previous two week period?
X Have large volumes of water been introduced to the system recently or as part of this inspection '?
X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
i.
X _ Was the facility or dwelling inspected for signs of sewage back up?
X _ Was the site inspected for signs of break out'? .
X _ Were all system components,excluding the SAS, located on site'?
X _ Were the septic tank mAnholes uncovered,opened,and the interior of the tank inspected for the condition of the
baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance
of subsurface sewage disposal systems ?'
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
X _ Existing information. For example,a plan at the Board of Health.
X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is
unacceptable)[310 CMR 15.302(3)(b)]
t
,i
i
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 385 WAKEBY RD MARSTONS MILLS,MA 02648
Owner: LAUREN KLEINAS
Date of Inspection: 9/10/01
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 2 . Number of bedrooms(actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220
Number of current residents:3
Does residence have a garbage grinder(yes or no): NO
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or no):NO
Seasonal use: (yes or no): NO
Water meter readings,if available(last 2 years usage(gpd)): n/a
Sump pump(yes or no): NO
Last date of occupancy: n/a
COMMERCIAL/INDUSTRIAL
Type of establishment: n/a
Design flow(based on 310 CMR 15.203): n/agpd
Basis of design flow(seats/persons/sgft,etc.): n/a
Grease trap present(yes or no): NO
Industrial waste holding tank present(yes or no): NO
Non-sanitary waste discharged to the Title 5 system(yes or no): NO
Water meter readings, if available: n/a
Last date of occupancy/use: n/a
OTHER(describe): n/a
GENERAL INFORMATION
Pumping Records
Source of information: n/a
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: n/agallons--How was quantity pumped determined?n/a
Reason for pumping: n/a
TYPE OF SYSTEM
X Septic tank,distribution box,soil absorption system
_Single cesspool
_Overflow cesspool
_Privy
_Shared system(yes or no)(if yes,attach previous inspection records, if any)
_Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from
system owner)
_Tight tank Attach a copy of the DEP approval
Other(describe): n/a
Approximate age of all components,date installed(if known)and source of information:
1979 WITH NEW PIT IN 95
Were sewage odors detected when arriving at the site(yes or no): NO
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 385 WAKEBY RD MARSTONS MILLS,MA 02648
Owner: LAUREN KLEINAS
Date of Inspection: 9/10/01
BUILDING SEWER(locate on site plan)
Depth below grade: 12"
Materials of construction:_cast iron X40 PVC_other(explain): n/a
Distance from private water supply well or suction line: n/a
Comments(on condition of joints,venting,evidence of leakage,etc.):
TOWN WATER
SEPTIC TANK: X(locate on site plan)
Depth below grade: 2"
Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a
If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate)
Dimensions: 1000G L 8' 6" H 5' 7" W 4' 10""
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle:32"
Scum thickness: 1"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
How were dimensions determined: MEASURED
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.):
THE SEPTIC TANK AND ALL COMPONENTS APPEAR TO BE STRUCTURALLY SOUND AND
FUNCTIONING PROPERLY. RECOMMEND PUMPING NOW AND EVERY TWO YEARS TO PROLONG THE
SYSTEM'S USEFUL LIFE
GREASE TRAP: _(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle:n/a
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
Date of last pumping: n/a
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.):
n/a
7
Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 385 WAKEBY RD MARSTONS MILLS,MA 02648
Owner: LAUREN KLEINAS
Date of Inspection: 9/10/01
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Capacity: n/a gallons
Design Flow: n/a gallons/day
Alarm present(yes or no): N/A
Alarm level: N/A Alarm in working order(yes or no): NO
Date of last pumping: n/a
Comments(condition of alarm and float switches,etc.):
n/a
DISTRIBUTION BOX: X(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into
or out of box,etc.):
BOX IS STRUCTURALLY SOUND.
PUMP CHAMBER:_(locate on site plan)
Pumps in working order(yes or no): NO
Alarms in working order(yes or no):NO
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
n/a
u
Page 9 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 385 WAKEBY RD MARSTONS MILLS,MA 02648
Owner: LAUREN KLEINAS
Date of Inspection: 9/10/01
SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
n/a
Type
1000 GAL 6' X 6' leaching pits, number: 1
n/a leaching chambers, number: n/a
n/a leaching galleries, number: n/a
n/a leaching trenches, number, length: n/a
n/a leaching fields, number: n/a
n/a overflow cesspool, number: n/a
n/a innovative/alternative system
Type/name of technology: n/a
Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.):
THE LEACH PIT APPEAR TO BE FUNCTIONING PROPERLY.BOTTOM OF LEACH PIT IS AT 9' -
ESTIMATE OF TWO FEET OF STONE-PIT HAS NOT HAD MORE THAN Y OF WATER IN IT.
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: n/a
Depth—top of liquid to inlet invert: n/a
Depth of solids layer: n/a
Depth of scum layer: n/a
Dimensions of cesspool: n/a
Materials of construction: n/a
Indication of groundwater inflow(yes or no):NO
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a
PRIVY: (locate on site plan)
Materials of construction: n/a
Dimensions: n/a
Depth of solids: n/a
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY
ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM IN
PART C
SYSTEM INFORMATION(continued)
Property Address: 385 WAKEBY'RD MARSTONS MILLS,MA 02648
Owner: LAUREN KLEINAS
Date of Inspection: 9/10/01
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.
Locate all wells within 100 feet.Locate where public water supply enters the building.
c
Q
v AA ��L
c Ac
PA
�9 l3
in
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 385 WAKEBY RD MARSTONS MILLS,MA 02648
Owner: LAUREN KLEINAS
Date of Inspection: 9/10/01
SITE EXAM
_Slope
_Surface water
_Check cellar
Shallow wells
Estimated depth to ground water 15+feet
Please indicate(check)all methods used to determine the high ground water elevation:
NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a
YES Observed site(abutting property/observation hole within 150 feet of SAS)
NO Checked with local Board of Health-explain: n/a
NO Checked with local excavators, installers-(attach documentation)
NO Accessed USGS database-explain: n/a
You must describe how you established the high ground water elevation:
GROUNDWATER DETERMINED FROM VISUAL AND USGS MAPS- 15+FEET-BOTTOM OF PIT AT 9'-
ADJUSTMENT TO GROUNDWATER IS 6' FROM AIW 230 ZONE D-AUGUST
s
BORTOLOTTI CONSTRUCTION, INC.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Address Prop Gteeb
a s dons 002
Date of Inspec} Macel Own
7-�7-95 Map, lD �e.v4.
PART A — CHECKLIST
CHECK IF THE FOLLOWING HAVE BEEN DONE:
PUMPING INFORMATION WAS REQUESTED OF THE OWNER,OCCUPANT,AND BOARD OF HEALTH.
V NONE OF THE SYSTEM COMPONENTS HAVE BEEN PUMPED FOR AT LEAST TWO WEEKS AND THE SYSTEM HAS BEEN
RECEIVING NORMAL FLOW RATES DURING THAT PERIOD. LARGE COLUMES OF WATER HAVE NOT BEEN INTRODUCED INTO
THE SYSTEM RECENTLY OR AS PART OF THIS INSPECTION.
AS—BUILT PLANS HAVE BEEN OBTAINED AND EXAMINED. NOTE IF THEY ARE NOT AVAILABLE WITH N/A.
--THE FACILITY OR DWELLING WAS INSPECTED FOR SIGNS OF SEWAGE BACK—UP.
v THE SITE WAS INSPECTED FOR SIGNS OF BREAKOUT.
ALL SYSTEM COMPONENTS,EXCLUDING THE SAS,HAVE BEEN LOCATED ON THE SITE.
L THE SEPTIC TANK MANHOLES WERE UNCOVERED,OPENED,AND THE INTERIOR OF THE SEPTIC TANK WAS INSPECTED
FOR CONDITION OF BAFFLES OR TEES,MATERIAL OF CONSTRUCTION,DIMENSIONS,DEPTH OF LIQUID,DEPTH OF SLUDGE,
DEPTH OF SCUM.
THE SIZE AND LOCATION OF THE SAS ON THE SITE HAS BEEN DETERMINED BASED ON EXISTING INFORMATION OR
APPROXIMATED BY NON—INTRUSIVE METHODS.
//
THE FACILITY OWNER(AND OCCUPANTS,IF DIFFERENT FROM OWNER)WERE PROVIDED WITH INFORMATION ON THE PROPER
MAINTENANCE OF SSDS.
PART B — SYSTEM INFORMATION
FLOW CONDITIONS
RESIDENTIAL
No of Bedrooms No of Current Residents Garbage Grinder
LDS Laundry Connected to System Seasonal Use
NON RESIDENTIAL:
Calculated flow
WATER METER READINGS,IF AVAILABLE:
GALLONS
Pumping Records and Source of Information:
SYSTEM PUMPED AS PART OF INSPECTION? 6 IF YES,VOLUME PUMPED= GALS
Reason for Pumping:
TYPE OF SYSTf M:
V Septic tank/distribution box/soil absorption system
Single Cesspool Overflow Cesspool �• \`tea
Shared system (if yes, attach previous inspection records, if any)
Other(explain)
App�prr ximate age of all components. Date installed,if known. Source of information.
I�mQ. leo
SEWAGE ODORS DETECTED WHEN ARRIVING AT THE SITE? /Yd
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B — SYSTEM INFORMATION (Continued)
SEPTICANK:
Depth below grader Dimensions: FT- S i
Material of construction: Concrete Metal FRP Other}
Sludge Depth CP Distance from top of sludge to bottom of outlet tee or baffle
Scum Thickness Alone_ Distance from Top of Scum to top of outlet tee or baffle
Distance from bottom of Scum to bottom of outlet tee or baffle
CSC ents:
/000 q!�
DISTRIBUTION BOX: j DEPTH OF LIQUID LEVEL ABOVE OUTLET INVERT
Comments:
PUMP CHAMBER: I Pumps in working order?
Comments:
SOIL ABSORPTION SYSTEM SAS
IF NOT PRESENT,EXPLAIN:
TYPE: I^ �000
Comments:
CESSPOOLS: 0 Number and configuration
Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer
Dimension of cesspool Materials of construction
Indication of groundwater inflow(cesspool must be pumped)
Comments:
PRIVY:
Materials of construction
Dimensions Depth of solids
Comments:
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B — SYSTEM INFORMATION (Continued)
SKETCH OF SEWAGE DISPOSAL SYSTEM:
INCLUDE TIES TO AT LEAST TWO PERMANENT REFERENCES,LANDMARKS OR BENCHMARKS.
LOCATE ALL WELLS WITHIN 100'
��oav7"
/7'
a5'
DEPTH TO GROUNDWATER: DEPTH TO GROUNDWATER
METHOD OF DETERMINATION OR APPROXIMATION:
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C — FAILURE CRITERIA
(Indicate Y—yes N—no ND—not determined.Describe basis of determination.If"not determined",explain why not.)
Backup of Sewage into Facility?
/ Discharge or ponding of effluent to the surface of the ground or surface waters?
! Static liquid level in-the districution box above outlet invert?
Liquid depth in cesspool, 6"below invert or available volume, 1/2 day flow?
Required pumping 4 times or more in the last year? Number of times pumped
Septic tank is metal?cracked?structurally unsound?substantial infiltration?substantial exfiftration?
tank failure imminent?
Is any portion of the SAS,cesspool or privy, below the high groundwater elevation?
Within 50 feet of a surface water?
Within 100 feet of a surface water supply or tributary to a surface water supply?
INN Within a Zone I of a public well?
Within 50 feet of a private water supply well?
Within 50 feet of a bordering vegetated wetland or salt marsh (cesspools&privies only, not the SAS)?
Less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water
quality analysis? If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria,volatile organic compounds,amonia nitrogen and nitrate nitrogen.
PART D — CERTIFICATION
I�INSPECTOR: ROBERT J. BORTOLOTTI ADDRESS: 765 WAKEBY RO
AD, MARSTONS MILLS
I�COMPANY: BORTOLOTTI CONSTRUCTION INC. MA 02648 (508) 771-9399
II CERTIFICATION STATEMENT
I CERTIFY THAT I HAVE PERSONALLY INSPECTED THE SEWAGE DISPOSAL SYSTEM AT THIS ADDRESS AND THAT THE INFORMATION
REPORTED IS TRUE,ACCURATE AND COMPLETE AS OF THE TIME OF INSPECTION. THE INSPECTION WAS PERFORMED AND ANY
RECOMMENDATION REGARDING UPGRADE,MAINTENANCE AND REPAIR ARE CONSISTENT WITH MY TRAINING AND EXPERIENCE
IN THE PROPER FUNCTION AND MAINTENANCE OF ON-SITE SEWAGE DISPOSAL SYSTEMS.
CHECK ONE:
Y I HAVE NOT FOUND ANY INFORMATION WHICH INDICATES THAT THE SYSTEM FAILS TO ADEQUATELY PROTECT
EC PUBLIC BL C
HEALTH OR THE ENVIRONMENT AS DEFINED IN 310 CMF 15.303. ANY FAILURE CRITERIA NOT EVALUATED ARE.AS
STATED IN THE"FAILURE CRITERIA"SECTION OF THIS FORM.
I HAVE DETERMINED THAT THE SYSTEM FAILS TO PROTECT PUBLIC HEALTH AND THE ENVIRONMENT AS DEFINED IN
310 CMR 15.303. THE BASIS FOR THIS DETERMINATION IS PROVIDED IN THE"FAILURE CRITERIA"SECTION OF THIS
FORM.
INSPECTOR'S SIGNATURE:
DATE: /
ORIGINAL TO SYSTEM OWNER,COPIES:BUYER(If applicable),APPROVING AUTHORITY
QC V- ION SEWAGE PERMIT NO.
VILLAGE
Alas
I N S T A LLER'S NAME i ADDRESS
BUILDER OR OWNER
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED
�� .. - . r
�. ,. �,
r' z
.0
c.,
' r3 ��
.,����
y
+: .,
� 1 �„' _
� 'k�}
. r",; ` � ,
� %�... 4�
��
,i„ C
i
�.
J V
No........ ............. _« Fim..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
- ..1:.0.W A)...............OF........T'�`.ARN.$..1 A13.4. ..............................
Appliration for Dhipoiia1 10o k Tontarlar#ion ranfit
Application is hereby made for a Permit to Construct ( ) or Repair ( } an Individual Sewage Disposal
System at:
fes.?/�"t .El�' ... ?:....."..1�'�e4.�_StTC2le.1 ...... ..�5.---••-•---•----... : ?7.._.a�--........................................................
Location- drrees j or t o. _J ,
�_jL < _►` ...._.... Cl) ...3:......................• ... ��. ._. ����....--.. c:7t)�5 '-!. �.c .....��
^^
W a . Address
. ..................
-h•. . .. . ............................
Installer Address
QType of Building Size Lot..4/Q-l•...a....Sq. feet
aDwelling—No. of Bedrooms..............3..........................Expansion Attic (NC) Garbage Grinder (lQ)
44 Other—Type of Building ..t\'-/A.............. No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Other fixtures ..................................
-•• ------------------------------------ -i---------•-•-•---------•---------
Design D Flow•.......l.,l... ........................gallons per per delay. Total daily flow........--.J.30_..................gallons.
W
—L _W Septic Tank iquid capacity.�C � gallons Length.$_ � :Width_` _r6F. s__ Diameter________________ Depth._ ` ri
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area___--_------••----sq. ft.
Seepage Pit No......../--------- Diameter-----<3..!_...__ Depth below inlet----dry.............. Total leaching areaJ52- ._0'0.sq. ft.
Z Other Distribution box (&-I Dosing tank ( )
"" Percolation Test Results Performed by. ®1v1�9 .._.4.n...0-0 5 55 44 9JQ_... Date...
1.4 Test Pit No. 1__ .minutes per inch Depth of Test Pit.... '...... Depth to ground water---LlV,0YV 40.-
(a, Test Pit No. 2.4_'_am..minutes per ' , De th of Test Pit-_._l.t:_`...... Depth to ground water........................
t om_ .f -.z-d.. ---•
p
Description of Soil------. --------C 4..ev..... -------5-41 'S.4 ca/ l S_.
v '�'✓ .t$ .�_......t.�Gf�' �a-l� V4!F ................................- ----- -- -- - - •-- -------------------------------
...........s 1 e r�.� ----_GetV.0 .�«.�® _S--------- -4r------� ------
UNature of Repairs or Alterations—Answer when applicable...............................................................................................
•-------•------------------•---.....-------------------•--•-------------•---•-----........:.......----•--------------------------•----..............................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITI i, 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Sieel----------•-------•--------------------------------------------•-•--...--------j--..........--..................
Date
Application Approved By......." ._ � 2--'�~ - -- .-
Date
Application Disapproved for the following reasons--------------------.--------•--•-----------------------•----•---------------------------------------------------
..--------•---•--•--...•-••-----------------•-----------------••-•----------------------•-••----._..........------.....•---•--•------------------•-----------------•--•-•-•--•------- --•--•••--•••.
Date
yr
PermitNo..................................=...................... Issued.......................................................
Date
No.......�1...._....... r Fmc............................_
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
................OF.......7_3A.R)V.5TA8".44................................ }
Applirtttiou for Uhipoiitti Works C outitrttrtiou Frrutit
Application is hereby made for a Permit to Construct (� or Repair ( ) an Individual Sewage Disposal
System at:
f�. .PS- L,D ,c'. -
.-•--.......--.`•----•------•..........................
••-• oc tA
ation- re or t o.
.._..
ne Address
Installer Address
Type of Building Size Lot_510l_.? -----Sq. feet
Dwelling—No. of Bedrooms..............'.__..........................Expansion Attic (tip') Garbage Grinder (Nd)
Other—Type of Building _'-.A A_______________ No. of persons............................ Showers ( ) — Cafeteria ( )
a Other fixtures ..---•-••--••-•-•--•---••---------
W Design Flow.......el/_��.......................•._gallons per+@ em per day. Total daily flow--------.. .....................gallons.
WSeptic Tank—Liquid capacitytQA9.gallons Length -'O.".- Width S!W p._ Diameter_............. Depth.S_.'.'
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 ( r)
aPercolation Test Results Performed by 0,^j4.e.2>..._A.'._l tre,A J kt.S.0-- Date..Aae y.
,a Test Pit No. 1_o_K ..minutes per inch Depth of Test Pit---/A_........ Depth to ground
Test Pit No. 2_.4-...minutes per.inch Depth;of Test Pit..../.?............ Depth to ground water........................
ai -•--------•-•------------ --------••-••-•----------------------•--..................-•••--...,....---..........._._..................-•------.........-----
Description of Soil__.._...-.... _ _ _6
x
U ---•--��C d+� -...... l,r r��+'�- �C�9t✓��----------------•--................r......---- ..G --•---•--•-•--•---....----------------
W ».._._.. ' ' .e?:4 •-t!1A A Ta-J r C?!1J.'�.........1RA.....d a-[f_ f2_......"Vle-. --- C9l�_es------•--••---
VNature of Repairs or Alterations—Answer when applicable.-----------------------------------------------------------------------------------------------
-----------------------------------•-----------------------•------------------------•-----------------------------------------------------------------------------------------------..............•--•--
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITTLE, 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed.,
-------•--•--•-••--------------------------------------•-----•-•--• ............................
Date
i Application Approved BY.._...- -- ...................
YY� Date
Application Disapproved for the following reasons:.............................................................................................................
....................••-----....----•--------•----••-------------•----------------•------•--------..........--------------•------••------------------------------------- .............................
Date
PermitNo.........................................•-------•--•--. Issued.
Date
_ THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
O F
�rrti�irtttp of �uut�rlittttr�e
T��HIS IS CERr FY, at the Individual Sewage Disposal System constructed ( or~Repaired ( }
by..... . . ...... Ile... ---------------------------•--•---------------•-............ .......... ..........................
Installer
has een installed in accordance ith the provisions of TI 5 of The State Sanitary ode as described in the
application for Disposal Works Construction Permit No... q
THE`ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS ; GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. �W
DATE...:....••..--......•S-•- -s--•----•.................................. inspector--•----:_..........:
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OA HEALTH
�9
N .................. FEE....
................
Disposal No Q ul uuiuri rrutit
Permissionis hereby granted:.. ' �' ---------•••-•-••--------•--•--------•.......................................•...•••......---
to Construct or Re ai' ) an In v' ual vra a posal S s em
' ' . f.,
at No. '
--{- - - -- --=...................................
Street
as shown on the application for Disposal Works (construction 7m', ......... Dated__.... ...A.rylr..
}t �`"""rt?' a x
7 BOX of Health
'. DATE. ............................................... r
a
i
FORM 1255,HOBBS &,WARREN. INC.. PUBLISHERS
. .. ""t' •F s. rc.{:. :#- _ «„& z•;'�* `ice- 3 � -,fc' - *ear• __ Ay�',v -:.
� -±? •.t.c:+:,-a r:._3a-'^t3*s.- .4 9+?,.,., --,_._:�• �'} s- .z=-.,..« .._.. t' � ..*�' s: .'.Lj"�'� ,�." _ axal.� `s. -...-,•. 't.. •-..,,. �`.:'a ,�"a..�.� 'fi?i .y R ``S`.�:fii„•w' .,'v ... z !"`a.. :; if u-'„s. •S' ,.fir.".1.� I. + '�_,�w� -i .j^': )q �
- a k� F, �-'Fy a �r� xt4 '.rC a Y r '=. tL ,�,. �._r�F L, l+w.. [ - x,.� ,z4- t s.:r y.� Y-' S<•e :r Fy fi+ 'q:'(Tt-�
' , �R. ......� ;s�^- *a..�-.', e __.`x .�: i._ t 2 s � ''x F.z .L' a:sa d. ;�j, a 4p-•k� .e .=:z,,-e a�f � "'as �;� a y,s t' rfi �".Fry� �,�'f'r`�.*,.
t _ �'�.,. � .P i`3rr - 4'R �_'s� ,tea` >.+ a ��; � k`�,sy... s� ��$'2+. "•"sy'^-, `. tc"z, '�' r C i' ,".
..I. w . a N`� i "� (.g".;{,.e _ -z ,:��- "`6 'tom - c,«a'�C•�'..-.k y' t `u i
� ..} t # 0. f.`,-.-i.. ;� Y. ,,,E.. J�-.r` - 4Sa .�"� 7 �4_ �':."' Jt'L'C-'" -•S`6
It t
'_�. �,.'� ;t� f' �, �'T P f 3` A a+t �# - r _ •;M: �;
4 U4,
j� 11
n • i {iiiT i — 1
i.
` f �4
J 6� � ,kr'S-"' i'� ��+•x J� � 'F�y i"
{ k RESEIL
RVE
tea+.�e'!n•�` .x � t q» g.p �Y�b � +.it _ k.a 's
t.1
^•-� ,-_ .•<•-r ,_ il•yi, ?.�^�if�lyKk4�tyR'` V.4eF�•'i t7 '8;< 's { r: "(I .}.w y
33
# :. ., {.• '� r. ':J: ,`fir - -
/ r
.. � tY{�r. •< �. t � � _
PE
ti
1 Cr HT R., V
r3 U/c�£�iivG s ErL3,nC .e_ cJ/ �/�IEavT.s S C 4 E I `/ 40
F2O/V T Si �� / ��� ,
SE P T J C " 5 y5 7 CC)AX5 T2 UG T/OA/
S.f-/A [-G CONF02M TO M q S5 • DE.5/O AJ FL 7 Gt/ GAL
' ENV/eoN/yc-/v7, Coop i7 -L 17 L E A C.�,� 2,4 TE G 2 M/N. _/I;VC,41
LEACI-1 41,eE,4 l3;u
pT O P /-/EA L T.N TZ f UL A T/O A/S
7"OP. of.. :- r,. _._ < _ _cd n.—
, 4
F�r2�,00�S�
C/2V'/DU5' COV _
O ' Q MA/U 0LE CO V6E 2 70 Ek.TEnl� TO. TO ,a2�VeAJ7 r A.4
W/ 7/-//A/ /' F Fin// N,�O jnAZ7�
;vi✓�.i
t 'i •�-^.5T/1ZoN
M/N/ 6•.M f�J _y 3••MiN_ �/'I D�-_._._ W�T JO.L
P/TGf/ FLOW L.fin/,E x M/A/ .C"iTCt/ -r— --� C
A4 1Xoo7 2., M/n/ �/rtf/ L—f �_ ¢ _/;2 D/A.
ff _Y_ Mint /4 FOOT L t .LlQ� -`WA5 Al4SL
I
;Nv / t I ,5 Tr7 A./E
Gr"L L r_J /iV f/E2T
/IVVE2T / r Ca T-�A C / TY t� 4I�' u^J0
7-A Ail Xl�
�t L �1114 T� T/G //VVL2T I i PST#
NO GAf25ACE t1�JNDL � r
- — - - -�..- 20' M/n//,nit UM
S / Tf, ILL A N PRO ��� �� � �� .
Z_ A 7 ti 13A&&5TABIE...(1�_'1!�_t w Lo-i
2�FE/._'�A J,.:
f
��.,•/�( '�j .r.'�9 (� 1C' .`ry )/ K_ -f-� >/'� #s. ," , c 7 �/eC, ,�/5-T2/BUT/ON
3000 Ps/ Mi/v.
Y"P- iG I
4 AA
or
T CERTIFY T1;; 1301L0iIV SNC�t�JnJ ON T,4'1S ��•
TNT �',�"ft:t�jtd . F ARN . r/ '� '2-1
_A�� /" 7 I�t1 T Z_7.
S s .}.'e�
, -.:
. .
. >w, �r �.__ _ ,..,,._
. .
�.
;
.
. .
.
.
.,
. , : ; 2
. r
-.. ,
1
. is
i
.
.. - -.. I
a
,
: i - ......-. - ,,1
. - ., ,._- -- .
a
. - .._ .� _:.. s-- — a. S_ _ .
3 1 ale,,.'.., I. a i c .- T -,..
_y_ ..,. 1. _ _
.
f
1 y
a.
w. .,_.,.. .. � '
.�., ..,: I . ;:.,,, .,t..::f ....I 6::,.. v.
+n a
6.: j, d
r��
. . . I .�-p._....._,,_._,...;I, A- 1 -i tw ii ® _ _ z�„Pd . ... . . .
. r y .._. ' -- _ ... ..
1_ >'g . a
...: - _ .
l a_. .,,.. .. �_.._.<. 1 9 i
.—.t..
. ,
g
t �S Cl .. ,_ ..
T I.
- -�... I ., > ,.
—A
. .
,. / . .
:1 '
I1A .::fir. to :., , -. .! -� ; t - _.-.
:....- ) F
�. :,5
I
6 '
u "��
-TIw$
:
11
, r� .E a
F -�. �__ _._.._�_ _ ___ __ .
._" �— .
. _
. .,.! ,
. .
. 4 .,. t
1.
. l :
1 t F I ji. I 'I t 's,9 i I* 3 � .._I ...�I ...� i ,�� a`a i - � p: j.. t __ _—
i ;
-" - - - -- - --}-'
I—A
! .. !-- 41-11.
1 .
.. I
1.
-... -
. :
. : �� ! � —
: .
_y. M I f / — — - —'-- ---- ...---
:11 . ....�� � . ... :.
gor . . c :r
. .
7
- -
. . .
: .
-F .1--p...
: Z :
. f ....- ", _. ._, _„—._4 ._. . „__ _,
. . t .
' F
T- -
1--, i
: . 1 : I ; i .
i!,. .
- , i7l ,
� .
.1 '.-
i yC�
.,
.- -
%
. 1 ,$
G
I . . .
tlfol' � ; ; . -
. . . :
.. f-.r,.,,-..�...,.,._.,y.. . 1. � . I I � .. : I I
r
. I -I i : I I . . . : : I I
. : . I I : . . .I
I 11 . � I . .
A7r , .1
+f1. - :
A:
n. .
i^ _ -
I ! : 1 I i i _
r. .i .i
A
Ii. .. .. . .. : . :. : - .. .. _ ..
, .. i , i. ......_ : .:. _ .
. .
' � ' j, r
.. ... . . , _n 99
, .
.
.: _ y�T[(fir} xy)
f.
jF p
! 7f
:.I FIT �' -
.. ,
..
. a
.
I I i , - °.,fl - 1 . . e
; ; . a i P, .
. ;
I �
; .
w. ,+.
.
. .
. .
...
_ .
L{
>
Z`B i
.
. .
f s �;
,
: .
. . .
' .. 1:` 1 1
. .
I ,.,'
�a � , � a
.
... .. .. ... - , i , .
. -
�M
�� ;
a �Lt a ��
. i f '
d
. .. .... ,
y3 _ .. : I ,_
. :.
d
_ I
: :
. ; .. , ..
: 1
�� .- *�'L
. ! I i
. . ..
1 !i .. j r:. H N
. .r -.-,
. 3'- .,'
. - .
a a a a
7 ;
tz
. : .. .., d ;
�} `I'_
:
.
. .. a� Fa
..
. - -.. .
z'
: 1 .I_ r I. ..i. _ ... ��� JT i Ili.
.. a ,
. 1 : .. , .
' .r
( 4.,G
. :. _ _
,'-' `
: I a
...�
:( .. ., _
. . .. .... ..,_.
:
I
1 a
. .. : ...
., 4: h _ �!
. . .. ! t . : !
w
1.
1.
__
; ' t
h r ,��, {.
0. ,
. i r �: �- "�
:
,
.
�,
, -
i .
,
, it,
R
,.:- ._- ,
�, , \
I , I , _. ... -. ' ,��o, \:4 `� i'''^� aye '4 L'� �y
y,, .
} { I ! i i '1 'ice ;`� �� ti,' .\..1. ,LTc- '^' ,I`' ,ti,. `�.I`'\,. y.
.... .. ..
.i• 4 : '*''n -\4 ..'+ t' 'fit S �' '�.}FI ''`L j
Si
. ,
:
. - :... : �,, _
IY 1
.i ' y \
l� ' �
. , `4
R 1
: _
t ,�
'� t \ \ 411' `y,
1 ,1 t. 1
4 3M
I � q t h k { s� ti t
. .. .. .. r .. -
Ir,
: i j?'
z�\.
I : -I
1 \
l
�..
�+T, �',,
. ,... ... ... .. .. a r '.,,-�.
i
I \,N,�'�;. Ly'\ ' S i '., N n, 'i C.
,,
I I ! i i : , 7. ,.t h, 1; a ' ,''�Z`' �'` i.'}a Sa_.. - �;1b V-: -J l�f'1 �.. . �'W LI•+
... : ._... ... .. .. . .. r
t
�l
4���
�' r - a
-'. '�T
Z.
1 \ •�Y�,,� - ` �.�'` .yam..- � i�1 , 4"y,1 '� - i ,� '�+•4 'i..%\ E . _. uLJ -. �,. (� �(`� -1 {��/�' sJ/'-I-1 i p Rom,
N Q F P .. r .j _ .. ` K\ L.'� _,1. t ,���. ,. ,`;'!:1,. I �: i �uFrh\. ,� ,>•,� L
:" , I.
p
SS �.. \h'Ia FM y. i t,y .'"i,''. :.x ` i I�''�0:. t' S lii. 'i':t. �.. t � _.'..15. .. .�-I'V.� ,. �!.' F��"�{
. i
v ='S��-„ A•g. . .. f 1 `p \'y,,�,�ye '•L.�i'rL v..i.�. F„ A, ",ti \i,y ?\ .��1 {4` ,�. Z 4 y ,' 1
h,
,- F C.`? ado-. I I : ,> ' !k '%\�"'\ L `\ S �'�L"' r "�,,, .•ti,..: 'i* �''r , ° z- , _ ..
. .
_..
. No.347-, : I 1 I , ;,� k: , -
-i ' - . _. . i I I r,�,-, �I I', . .
i, P i f. ,
. 1.
I:^.c. %i;i� I -_ \ - \a `, t'%t`��4 IG'I,,'�J I�.r (',r�: .. ., , 1,
y,e I � �I ti \. a ,C
, ,
r
. ti
� „. _,s - .
/ .
� -- / : : . � . . I . �,�-�,,�-,,".,--�,-,.�"z,.�---!-,�--iI -- -- . . I
. : � . p . I I : �------ ----A -.-. � I — .—.----.,-.,.I�— ---T—r—�.—
; 6CIU46 i . w : : I S* ; � �� � ; I .
.
1.. -- ._. -
1.
; .
. . .
z4
--...-- j - . � . 9
�.. _ ., 4 i