HomeMy WebLinkAbout0033 WATERS EDGE - Health 33'WATERS EDGE 'MARSTON MILLS
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VILLAGE �T _ASSESSOR'S .&PARCEL
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SEPTIC TANK CAPACITY I OOC)
LEACHING FACILITY:(type) 5 1n T(`•?UPS (size)
NO.OF BEDROOMS
OWNER
PERMIT DATE: DATE rT 3 31 I 1
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the 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 etlands exist within
300 feet of leaching facility) Feet
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Commonwealth of Massachusetts
Ville 5 Official Mspec$i®n Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
33 Waters Edge
Property Address
Ford, Julsonnet
owner information Owner's Name r:
is required for Marstons Mills MA 02648 12/11/17
every page. .•;,
City/Town State Zip Code Date of Inspection sw'
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.
A. General Information S( 1 a 986?
1. Inspector:
Frank Nunes III
Name of Inspector
saa
Company Name
Box 841
Company Address
East Falmouth MA 02536
Cityrrown State Zip Code
508.272.6433 13010
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system: -
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
12/11/17
lnspectdWSigna0 Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original should be sent to the system owner and copies sent to the
buyer, if applicable, and the approving authority.
""This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
33 Waters Edge
Property Address
Ford, Julsonnet
Owner information owner's Name
is required for every page. Marstons Mills MA 02648 12/11/17
C41-rown 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:
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):
15ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of V
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
y 33 Waters Edge
Property Address
Ford, Julsonnet
owner information Owners Name
is required for every page. Marstons Mills MA 02648 12/11/17
City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will,pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Tile 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
r 33 Waters Edge
Property Address
Ford, Julsonnet
Owner information Owner's Name
Is required for
every page. Marstons Mills MA 02648 12/11/17
g
Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health(and Public Water Supplier,if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6"below invert or available volume is less
than %day flow
t51ns.doc-rev.6f16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
r
Commonwealth of Massachusetts
-- Title 5 Official inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
33 Waters Edge
Property Address
Ford, Julsonnet
Owner information Owners Name
is required for every page. Marstons Mills MA 02648 12/11/17
Citylrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis,performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303,therefore the system fails.The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area-IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed.The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304.The system owner should contact the appropriate
regional office of the Department.
t5ins.doc•rev.5/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
33 Waters Edge
Property Address
Ford, Julsonnet
Owner information Owner's Name
is required for every page. Marstons Mills MA 02648 12/11/17
Citylrown 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): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440
t5ins.doc-rev.6116 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Mspec$i®n Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
33 Waters Edge
Property Address
Ford, Julsonnet
Owner information Owner's Name
is required for
every page. Marstons Mills MA 02648 12/11/17
City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?(Include laundry system inspection
information in this report.) ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
Sump pump?
❑ Yes ® No
Last date of occupancy: Occupied
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Forma
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
33 Waters Edge
Property Address
Ford, Julsonnet
Owner information Owner's Name
is required for revery page. Marstons Mills MA 02648 12/11/17
Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: Pumped May 2017 per owner
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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
33 Waters Edge
Property Address
Ford, Julsonnet
Owner information Owner's Name
is required for
every page. Marstons Mills MA 02648 12/11/17
Cityrrown State Zip Code Date of inspection
D. System Information (cont.)
Approximate age of all components, date installed(if known)and source of information:
Original septic tank per age of the home, new d-box and infiltrators 1999 per BOH record
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade:
3'
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.):
Septic Tank(locate on site plan):
Depth below grade: 2'6"feet
Material of construction:
®concrete ❑ metal ❑fiberglass ❑ polyethylene
❑other(explain)
H-10 tank, outlet cover raised,
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000g
Sludge depth: trace
151ns.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 9 of 17
Commonwealth of Massachuseft
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
°f 33 Waters Edge
Property Address _
Ford,Julsonnet
Owner information Owner's Name
is required for
every page. Marstons Mills MA 02648 12/11/17
Citylrown State Zip Code Date of Inspection
D. System Information Y tlon (cont.) ,
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle >12
Scum thickness trace
Distance from top of scum to top of outlet tee or baffle '2 11
Distance from bottom of scum to bottom of outlet tee or baffle '2
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.):
Effluent exits the side of the tank, there is a speed leveler at the center outlet in place to restrict flow
to the old system that is documented as a"Fail', tank is equipped with a filter at the outlet T,tank
appears to be structurally sound
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.doc•rev.6116 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
33 Waters Edge
Property Address
Ford, Julsonnet
Owner information Owner's Name
is required for
every page. Marstons Mills MA 02648 12/11/17
Citylrown 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
[I 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.):
I
I
e
I
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins.doc-rev.6/16
Title 5 official Inspection Form:Subsurface Sewage Disposal System•page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
33 Waters Edge
Property Address
Ford, Julsonnet
Owner information Owner's Name
is required for
every page. Marstons Mills MA 02648 12/11/17
Clty/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
0"
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D-box is 4'below grade, cover raised to 6" H-10 construction
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
*If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System(SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
I
l5ins.doc•rev.6/16
Title 5 Official Inspection Forth: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
33 Waters Edge
Property Address
Ford, Julsonnet
owner information Owner's Name
is required for
every page. Marstons Mills MA 02648 12/11/17
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number:
5 Infiitrators
❑ leaching galleries number:
❑ leachingtrenche
s 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.):
Infiltrators were video inspected, piping to the chambers was clean above expected stain line,
chambers are end loaded damp at this time, no indication of past backup
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
15lns.doc-rev.6/16 Tide 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
ug
33 Waters Edge
9
Property Address
Ford, Julsonnet
Owner information Owner's Name
is required for Marstons Mills every page. MA 02648 12/11/17
Cityffown 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.):
Soils are compact and dry
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.):
l5ins.cloc•rev.6/16 Title 5 Official Inspection Form:Subsurface a Dis
posal sposal System•Page 14 of 17 p
I •
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
33 Waters Edge
Property Address
Ford, Julsonnet
Owner information Owner's(dame
is required for every page. Marstons Mills MA 02648 12/11/17
Cityrrown 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
V%A- 0-Q
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o l O 5yS1z�
15ins.doe•rev.6/16 Title 5 Official insp
ection Forth:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
- - Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
33 Waters Edge
Property Address
Ford, Julsonnet
Owner information Owner's Name
is required for every page. Marstons Mills MA 02648 12/11/17
Citylrown 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: >20
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:
Previous inspections
❑ Checked with local excavators, installers-(attach documentation)
® Accessed USGS database-explain:
TOPO mapping
You must describe how you established the high ground water elevation:
Site is approximately 40'above the nearest surface water
Before filing this Inspection Report,please see Report Completeness Checklist on next page.
5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
I
Commonwealth of Massachuset
ts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
'< 33 Waters Edge
Property Address
Ford, Julsonnet
Owner information Owner's Name
is required for every page. Marstons Mills MA 02648 12/11/17
Citylrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary:A, B, C, D, or E checked
® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins.doc-rev.W 6 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
33 Waters Edge Drive
Property Address
Donald Filiault
Owner Owner's Name
information is y Marstons Mills MA 02648 May 31 2011
required for ,
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 the
computer,
r,use 1. Inspector: �
only the tab key
to move your Patrick M. O'Connell
cursor-do not Name of Inspector
use the return
key. Septic Inspection Services Co.
Company Name
r� 189 Cammett Road
Company Address
Marstons Mills MA 02648 _
City/Town State Zip Code
508-428-1779 SI 12855 _
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ eds Furt valuation by the L al Approving Authority
i
May 31, 2011 Job# 11-90 _
140ktori-gignatt 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.
l5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
I!
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
33 Waters Edge Drive
Property Address
Donald Filiault
Owner Owner's Name
information is Marstons Mills MA 02648 May 31, 2011
required for Y
every page. Citylrown 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:
Tank was scheduled for pumping following inspection. Leaching system showed no signs of
surcharge or saturation.
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
33 Waters Edge Drive
Property Address
Donald Filiault
Owner Owner's Name
information is Marstons Mills MA 02648 May 31, 2011
required for Y
every page. Cityrrown 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
al 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
r
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
w ' 33 Waters Edge Drive
Property Address
Donald Filiault
Owner Owner's Name
information is Marstons Mills MA 02648 May 31, 2011
required for y
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than_day flow
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
33 Waters Edge Drive
Property Address
Donald Filiault
Owner Owner's Name
information is Marstons Mills MA 02648 May 31, 2011
required for y
every page. CitylTown 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 felst
from a private water supply well with no acceptable water quality analysis. [Tihis
system passes if the well water analysis, performed at a DEP certified
laboratory, for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
15ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 33 Waters Edge Drive
Property Address
Donald Filiault
Owner Owner's Name
information is Marstons Mills MA 02648 May 31, 2011
required for y
every page. Cityrrown 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): 4 Number of bedrooms (actual): 4 —
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
15ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
33 Waters Edge Drive
Property Address
Donald Filiault
Owner Owner's Name
information is
required for Marstons Mills MA 02648 May 31, 2011
every page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 3
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:
Sump pump? ❑ Yes ® No
Last date of occupancy: Currently
Occupied. _
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:
15ins-11110 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 33 Waters Edge Drive
Property Address
Donald Filiault
Owner Owner's Name
information is Marstons Mills
required for MA 02648 May 31, 2011
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: Tank pumped over two years ago.
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
33 Waters Edge Drive
Property Address
Donald Filiault
Owner Owner's Name
information is
required for Marstons Mills MA 02648 May 31, 2011
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
Leaching system installed 8/4/99
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grader 3'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: 8.5' long x 5.2'wide- 1000 gal.
Sludge depth:
4°
15ins•11/10 Title 5 Official Inspection Form.Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 33 Waters Edge Drive
Property Address
Donald Filiault
Owner Owner's Name
information is
required for Marstons Mills MA 02648 May 31, 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 26"
Scum thickness 2"
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
12"
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.):
Liquid level was found at bottom of outlet invert, tees were intact. Tank was scheduled for pumping
following inspection.
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-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
4 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
33 Waters Edge Drive
Property Address
Donald Filiault
Owner Owner's Name
information is Marstons Mills
required for MA 02648 May 31, 2011
every page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments on pumping recommendations inlet an( P t d outlet tee P 9 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
15ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
33 Waters Edge Drive
Property Address
Donald Filiault
Owner Owner's Name
information is required for Marstons Mills MA 02648 May 31, 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
0"
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Observed a trace of solids carryover in box no high stains present.
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:
15ins•11110 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
33 Waters Edge Drive
Property Address
Donald Filiault
Owner Owner's Name
information is MarstOnS Mills
required for MA 02648 May 31, 2011
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number:
Five Infiltrators.
❑ 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.):
Interior of Infiltrators were video inspected found no standing water or evidence of surcharge
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
15ins•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
33 Waters Edge Drive
Property Address
Donald Filiault
Owner Owner's Name
information is Marstons Mills
required for MA 02648 May 31, 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
Dept,i of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
15ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 0 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
33 Waters Edge Drive
--Property Address ...—...-...........__.._.._..-- - --- -- ---------- ...- ... ----------- -
Donald Filiault
Owner Owner's Name
information for
is
MarStons Mills MA 02648 May 31, 2011
required fo
every page. cityrrown 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
"N'N'N 1", 11-1
\ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \
25
55
35 66
8,1,
r
Commonwealth of Massachusetts
Rom
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
33 Waters Edge Drive
Property Address
Donald Filiault
Owner Owner's Name
information is Marstons Mills MA 02648 May 31, 2011
required for y
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: 20+
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:
Low areas of abutting properties with no surface water are considerably lower than SAS.
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
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 33 Waters Edge Drive
Property Address
Donald Filiault
Owner Owner's Name
information is y ,Marstons Mills MA 02648 May 31 2011 required for '
every page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
l5ins•11/10 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 17 of 17
TOWN OF BARNSTABLE
✓ LCCATION [ l SEWAGE # "'
V??,LAGEA# S Al (l3 ASSESSOR'S MAP& LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY A&) _ -- - -_- - -------_-
LEACHING FACILITY: (type) /2/33 5 f 6"Size)
NO. OF BEDROOMS
BUILDER OR OWNER Af
PERMIT DATE: COMPLIANCE DATE: "'
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
. . �
,k
• $
a
e
e.
�'
-. �
d �
ti. ,�,�.�,G• �)
�� � 'D
�-�
�Z� �y
_ �
� � �^z-�
ss l � _
I -�
No. Fee CJ
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
01pphratton for ni.5pogar 6p5tem Construction Vertu
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) El Complete System P54ndividual Components
Location Address or Lot No.'37Z Owners Name,Address and Tel.No.
Assessor's Map/Parcel 1k' Xt f Y^`O (L,,N
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
-1 0-tot
c,5 St ,
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures cc
Design Flow UVAC) gallons per day. Calculated daily flow `� � gallons.
Plan Date Number of sheets Revision Date
Title Size of Septic Tank i00Q Type of S.A.S. ,%L C�nCI i m—tu-'er VI_X4-1ki
Description of Soil
,1�-�lJ1n
Nature of Repairs or Alterations(Answer when applicab ) (h.�S��4��
0�p C-C-a� ����Lc IL-,- JCS %A—r >d'%_-1 --I- C((« U4Q.L,`1��t
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Co and not to place the system in operation until a Certifi-
cate of Compliance h issue y t t
Signed Date
Application Approved by Date -36,
Application Disapproved for the ollow g reasons
Permit No. Date Issued
No.
Fee U
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes /
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS v
Application for �Digogar *pztem Cow5tructiou Fern tt
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System Individual Components
Location Address or Lot No.j3 �/.! �2• OC Owner's Name,Address and Tel.No.
Assessor's Map/Parcel Dr a _ b 4 ` A' Ai N\O o,t u '
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
(�S'\O-ctA e e_'S (��\,
(5 (_0v\S SZ ,
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures 1 ,
Design Flow �~\�'\� gallons per day. Calculated daily flow ql� gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank �000 Type of S.A.S.
Vim.Description of Soil V
�� S K, 2
Nature of Repairs or Alterations(Answer when applicab e) �_ ULS\60C- UL,
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance h _ issue y t
Signed Date
Application Approved by Date ' - 30—
VJL
Application Disapproved for the llow g reasons
Permit No. ��/— ���/ Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of (Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed ( )Repaired ( )Upgraded(lr
Abandoned( )by — t= S
C.-
at 7, w v ,v 1= has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. 9/*- dated
Installer Designer
The issuance of this permit shall not be construed as a guarantee that the s 11 function as de igned
Date Inspect
le ell
r
No. / / J` Fee _
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
Xigpo5a1 *p!6tem Construction Permit
Permission is hereby granted to Construct( )Repair( )Upgrade(Abandon( )
System located at
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided: Construction must be completed within three years of the date of this permit.
Date: g r� 7 7 Approved by��> >
.M
1/6i99
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERNIIT (WITHOUT DESIGNED PLANS)
F� hereby certifythat the applicatio
n for disposal works
construction permit signed by me dated concerning the
property located at -3,3 I A meets all of the
following criteria:
(/• The failed system is connected to a residential dwelling orily. There are no commercial or business
�es associated with the dwelling,
. Tlhe soil is
classified as CLASS I and the percolation rate is less than or equal to -
� minutes per inch.
There are no wetlands within 100 feet of the proposed septic system
There are no private wells within 150 feet of the proposed septic system
here is no increase in flow and/or change in use proposed
There are no variances requested or needed.
The bottom of the proposed leaching facility will not be located less than five feet above the
ma..-dmum adjusted groundwater table elevation. (Adjust the groundwater table using the Frimptor
method when applicable]
V ,
• If the S.A.S. will be located with 2M feet of any vegetated wetlands, the bottom of the proposed
leaching facility will not be located less than fourteen(1.1) feet above the madmum.adjusted
groundwater table elevation,
Please complete the following:
A) Top of Ground Surface Elevation(using GIS information)
B) G.W. Elevation ] ��:the MAX. High G.W. Adjustment
DIFFERENCE BETWEEN A and B
` SIGNED, : DATE:
I
(Sketch proposed plan of system on back].
q:health folder.cent
,� � �
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TOWN OF BARNSTABLE
LOCATION ✓64ea5 ��/. SEWAGE #
VILLAGE ' /'/ Ss ��ls •
- ASSESSORS MAP& LOT�� Bl
j INSTALLER'S.NAME&PHONE NO.
SEPTIC TANK CAPACITY /fifty) _
. LEACHING FACILITY: (type) 4213
`ze)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMIT DATE; /f 4 "' 9 COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the 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
I Edge of Wetland and Leaching Facility(If any wetlands exist'
within 300 feet of leaching facility. Feet
Furnished by
j
61
i
,2
I r
-> COMMONWEALTH OF I LkSSACHt'SETTS
EXECUTIVE OFFICE OF ENVIRONAIENT.k1 A F.�IF
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE RZ\TER STREE"'. BUSTO\ \L4 02106 (61 i i 292 :;:����
TRUDY COS:
Secret ar.
DAVID B STRUHS
ARGEO PALL CELLLCCI comet sS:O'.P:
Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
c l CERTIFICATION
Property Address: 33. �,rj L� 't Name of Owner S ( �
I ,,li Address of Owner: �.l�m�l
LI 1�Al1�S�Uy"
Date of Inspection:'1 I {4� PL/ /
Name of Inspector:1 ease P�rrt) '
I am a DEP approved system inspector pursuant to Section 15.1340 of Title 5 (310 CMR 15.0001
Company Name: Ir? Fk 'ram r— •=- r•fu F c,
MaXng Address:-?.a 9^ 4 7 �4 Ia_2¢SN(�Ft /1�9 UL�jCf-
Telephone Number: �sQ: ! 9;_ / �G
CERTIFICATION STATEMENT t
I certify that 1 have personally inspected the sewage disposal system at this address and that the information reported below is true. accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
Passes
_ Conditionally Passes
_ Needs Further Evalua Local Approving Authority
Fails
Date:
artspector's Sigrutture: �I'g
The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty (30) days of
completing this Inspection. If the system is a shared system or has a design flow of 10.000 gpd or greater,the inspector and the system owner
shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the
system owner and copies sent to the buyer,if applicable, and the approving authority.
NOTES AND COMMENTS
S�Sr�w^ n-ktS cc f— Slams
+►�.eCAk c j� ,� s
� P �
� 9
� II
tn� c1 � FO
Ig99
i/ J"
revised 9/2/98 pace Iorlt
`• Premed om R"k-d Paper
r
t
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
%roperty Address:
Jwner:
Date of Inspection:
INSPECTION SUMMARY: Check A, B, C, Or D:
A.,, npSYSTEM PASSES:
AD I have not found any information which indicates that any of the failure conditions describ d in 310 CMR 15.303 exist. Any failure
criteria not evaluated are indicated below.
COMMENTS:
B. SYSTEM CONDITIONALLY PASSES:
One or more system components as described in the 'Conditional Pass` sectio need to be replaced or repaired. The system, upon
completion of the replacement or repair, as approved by the Board of Health, ill pass.
Indicate yes, no, or not determined (Y. N. or ND). Describe basis of determination in all instances. If 'not determined", explain why not.
_ The septic tank is metal. unless the owner or operator has provi ed the system inspector with a copy of a Certificate of
- Compliance (attached)indicating that the tank was installed w' hin twenty (20) years prior to the date of the inspection: or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the isting septic tank is replaced with a complying septic tank as
approved by the Board of Health.
_ Sewage backup or breakout or high static water levf observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health). r �
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
_ The system required pumping more than tour 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
-
t
revised 9/2/98 P2se2ur11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
PropertyAddress: /
nr: /
Owner:
Date of Inspection:
i
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment. /
1) SYSTEM
FUNICTIONING UNLESSPROTECTDETERMINES ( SYSTEM
N A MANNER WHICH WILL U THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT
S
_ Cesspool or privy is within 50 feet of surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt arsh.
r
• t
SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER/SUPPLIER.IF ANY)DETERMINES THAT THE SYSTEM L .
2) E ENVIRONMENT:
FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND TH
_ The system has a septic tank and soil absorption system(SAS),:and the SAS is within 100 feet of a surface water supply or
tributary to a surface water supply.
_ The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
_ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private watereupply well.
_ system and the SAS Is less than 100 feet but 50 feet or more from a
The system has a septic tank and soil absorption
private water supply well. unless a well water analysis for/eoliform bacteria and volatile organic compounds indicates that the
well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm. Method used to determine distance (approximation not valid).
3) OTHER
i
revised 9/2/98 Page 3of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
owner:
Date of Inspection:
D. SYSTEM FAILS:
You must indicate either "Yes" or -No" to each of the following:
have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this
determination is identified below. The Board of Health should be contacted to determine what will be necessary to corre=t the failure
Yes No
Backup of sewage into facility or system component due to en overloaded or clogged SAS or cesspool.
s.5�,s F 3v vP
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
` St CIS
v 'moo
�( Static liqu)d level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspcol
Liquid depth in cesspool is less than 6" below invert or available volume is less than 112 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipelsi. f
Number of times pumped_.
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a 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 I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well. r
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
kacceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
•coliform bacteria. volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAILS:
You must indicate either 'Yes" or -No" to each of the following:
The following criteria apply to large systems in addition to the criteria above:
Vko The system serves a facility with a design flow of 10.000 gpd or greater(Large System) and the system is a significant threat to public
health and safety and the environment because one or more of the following conditions exist:
Yes No
_ 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)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Department for further information.
revised 9/2/98 Page 4orIt
r n '
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
? }� IA 1 (,�, V[S �
Property Add s: �j J �Lq A / l(.cam W`�
Owner: H012-i'/V Y_�
Date of Inspection:-t5;r/1
/ / 57
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No
NoPumping information was provided by the owner, occupant. or Board of Health.
None of the system components have been pumped for at least two weeks and-the system has been-receiving normal flow
rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
inspection.
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.
The system does not receive non-sanitary or industrial waste flow.
The site was inspected for signs of breakout.
All system components, excluding the Soil Absorption System, have been located on the site.
The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles
or tees, material of construction, dimensions,depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on:
lA Existing information. For example, Plan at B.O.H.
Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable)
115.302(3)(b)]
The facility owner land occupants,if different from owner) were provided with information on the propermaintenar^s-0f
SubSurface Disposal Systems.
revised 9/2/98 Py¢c�oftf
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM.
PART C
2 SYSTEM INFORMATION
Iroperty Addles .33 �''�`"-s ���� ��� �v � as
Owner:
Date of Inspection: •
l FLOW CONDITIONS
RESIDENTIAL:
Design flow:-]�— g•p.d.lbedroom.
Number of bedrooms (design):Q3 Number of bedrooms (actual): O�
Total DESIGN flow
Number of current residents:—Q. :1
Garbage grinder(yes or no):_&�
Laundry(separate system) (yes or no): If yes, separate inspection required
Laundry system inspected ye or no)
Seasonal use (yes or no):N
Water meter readings, if available (last two year's usage (gpd):
Sump Pump (yes or no):-4---)—
Last date of occupancy:
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow: 9pd 1 Based on 15.203)
Basis of design flow
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:
OTHER:(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of informatioq
System pumped as part of inspecteo : (yes or not
If yes, volume pumped: gallons
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)
UA Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other q p
APPROXIMATE AGE of all components, date installed(if known) and source of information: F UZ , ���L p
Sewage odors detected when arriving at the site: (yes or no)
I
revised 9/2/98 igc6ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
'roperty Ad_dr s: :?-
Owner: V .
Date of Inspection: `! y /
BUILDING SEWER: l/ L/
(Locate on site plan)
Depth below grade:_
Material of construction: _cast iron_40 PVC_ other (explain)
Distance from private water supply well or suction line
Diameter
Comments: (condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK:4e-j
(locate on site plan)
tt
Depth below grade:
Pol eth lene other(explain)
Y Y _.
Material of construction. concrete _metal—Fiberglass _
If tank is metal,list age_ Is age confirmed by Certificate of Compliance (Yes/No)
Dimensions: WoC'!�E
Sludge depth: '4 L4t(
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: a' J r
Distance from top of scum to top of outlet tee or baffle:_ 1t
Distance from bottom of scum to bottom of outlet tee or baffle:_
How dimensions were determined: io
'omments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, devh of liquid level in relat to outlet' vent`,, structural integrity,
evidence of leakage,etc.) S 0 N S.t
1 ' C� 1.
l
GREASE TRAP:_a&4=,
(locate on site plan)
Depth below grade:_
Material of construction:_concrete_metal_Fiberglass _Polyethylene_other explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments:
(recommendation for pumping, condition of Inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage,etc.)
revised 9/2/98 Page 7of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
.fig f/iS
'roperty Addre
Owner: �� 2/
Date of Inspection:
TIGHT OR HOLDING TANK: r`CJ (Tank must be pumped prior to, or at time of, inspection)
(locate on site plan)
Depth below grade:_
Material of construction: _concrete _metal_Fiberglass _Polyethylene_other(explain)
Dimensions:
Capacity: _gallons
Design flow: gallons/day
Alarm present
Alarm level: Alarm in working order:Yes _ No_
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert:-
Comments:
note if level and distribution is egyal, evidence of solids carryover, evidenc of leakage into or out of box, etc.) _
PUMP CHAMBER: A
(locate on site plan)
Pumps in working order:(Yes or No)
Alarms in working order(Yes or No)
Comments: _
mps end appurtenances, etc.)
(note condition of pump chamber.-condition of pu
revised 9/2/98 pagcsorn
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (/c�ontirwed)
'roperty Address:
Owner:
Date of Inspection:
SOIL ABSORPTION SYSTEM (SIAS):kyt�s
(locate on site plan, if possible: excavation not required, location may be approximated by non-intrusive methods)
If not located, explain:
Type:
leaching pits, number: UA(.
leaching chambers, number:_
leaching galleries, number:_
leaching trenches, number, length:
leaching fields, number, dimensions:
overflow cesspool, number:_
Alternative system:
Name of Technology
Comments:
�tendition of soil, signs of hydraulic failure, level of ponding, damp soil, conditio �veg �ioelc.l
CESSPOOLS:_Ls>
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
)epth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
Inflow (cesspool must be pumped as part of inspection)
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 hydrauric failure, level of ponding, condition of vegetation, etc.)
revised 9/2/98 Page 9of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
IropertY Add re s:
)wnet: r t C p A Jl/4-)
Date of Irsspection: dl^
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
i
Z
3 D oy
Lk';`
—a.Cbt EZ- so
Yam-3zI Y63 _ 5 I'
revised 9/2/98 Page 10ofII
SUBSURFACE SEWAGE DISPOSAL. SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
roperty Address:
Owner:
Date of Inspection:
NRCS Report name ---
Soil Type_ — — -
Typical depth to groundwater__—_._ _ _-_
USGS Date website visited N1
Observation Wells checked
Groundwater depth: Shallow Moderate Deep
SITE EXAM Slope 06
Surface water
Check Cellar NuO
Shallow wells(J(r(�-
Estimated Depth to Groundwater Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observed Site (Abutting property, observation hole, basement sump etc.)
Determined from local conditions
Checked with local Board of health
Checked FEMA Maps
Checked pumping records
Checked local excavators, installers
x Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
c r� c1
V
revised 9/2/98 Page ttorlt
L0CAT10N 33 SEWAGE PERMIT NO.
VILLAGE
I N S T A kLER'S NAME i ADDRESS
R UILOE R OR OWNER
OWNER
a.1 /
012
ors &go/?
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED
{
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f
V
�6
�fl Pz C3'�' �r-(O CAS•2
THE COMMONWEALTH OF MASSACHUSETTS
BOAR OF CHEALTH
........ ....................OF.. .1 `'"'•••.
.......................................
Appl ration for Disposal Works Tonstrar#iun fermi#
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
system t:
W ....._.:.................•..%..CS./..�. :.....
-[�� /.' ...............................................� ' �� .....
Lo .o /
.............
Lt�........................................................... .....................................................................
..................... Ad...---61 P .
Owner Address .!;�. .....---...................
..
Installer Address
T of Building Size Lot...���.0 ,}.Sq. feet
V Dwelling—No. of Bedrooms.... ...........................Expansion Attic ( ) Garbage Grinder
�,
'4 Other—T e of Building No. of persons............................ Showers — Cafeteria
04 Other fixturys
W Design Flow............. .....................gallons per person day. Total
Wx 0 flow...............��0............ lens.
. ( .Se tic Tank—Liquid ca acit .16W allons Length W .. Diameter._ _. ....... Depth
Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
3 Seepage Pit No........... Diameter........S7.... Depth below inlet....... .... Total leaching area.2.00...sq. ft.
Z Other Distribution box ( ) Dosing to ( )
� Percolation Test Results Performed by.........�.. .. .. ..._ Date'. /. . .. ..
Test Pit No. l&.2—minutes per inch Depth of Test Pit... ......... D th to ground watera.A.
P P eP
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
G4 ........--••........ ......... --- •+� r
O Description of SO4* , --.
.- -::.� :.r : :...:: ::: � .._..
U ............................ ................ ........................._..._............_.................................................._.`..................
W
UNature of Repairs or Alterations—Answer when applicable...............................................................................................
--------•--•.............................•--...--••-----•--•---•---.......................•••.•-•--•-----------•••••••--••-----•...•--•-.....•-•••••.................................................._.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITI.i; 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
o perigion ntl A Certi�e of Compliance has been issued by the board of health.
\rM\ Si .........................................................•-•----•--..........-........ ---•---••----•-
r
APPIi tion Approv _ ./. �.� ............
ate
Application Disapprov f the f ollouring reasons:.......................................•------•----..........-•----••----...........-••.._........--••--------_
..................••---.......---..........--•--..................---••-•------------------•---....------•-••-••......_.....•-•-•••-•••......_.........•-•--••----•---•-•..........•----.....----•-•-•-
Date
PermitNo......................................................... Issued....................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
/G� ,t_,,0......---...OF... , P .. ........................................
AVVIlration for Disposal Works Tonsuvdion rermd
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System t ,�' /� ,�
......... `1 -- - Gc. c±!F.�-'.J....... ..�".1..� A........... .. :: - ..: :gy02.�.
Lot No.
,/ ,C ...... oj� [ t^ .....................�... s.� ......f! .�1 ....
Owner Address
a •........•.... .. •Ei4........................................................... ........................................................................ .......... ...........
Installer Address
Ty of Building Size Lot.....44 7i..( Sq. ffe�e�t�
U Dwelling—No. of Bedrooms---..a..2.................................Expansion Attic ( ) Garbage Grinder U
..,
Other—T e of Building No. of persons............................ Showers — Cafeteria
04 Other fixtures
W DesignFlow............. 4. ...............gallons per person -r/da Total io flow...............-
� ..... 8'a P P Y. .5,,,..:�,�...Q........---. lens.
WSeptic Tank—Liquid capacity../.r Cgallons Length._. Width.. ...=&)Diameter................ Depth... .
x Disposal Trench—No. ......... Width.................... Total Length.................... Total leaching area....................Sq. ft.
Seepage Pit No........... ...... Diameter.........87.... Depth below inlet........�� .... Total leaching area ;,2_r_.,C..sq. ft.
Z Other Distribution box ( ) Dosing to ( )
Percolation Test Results Performed by..............� C"rt...(•. :-e.. )ve2r .---Z�ng_Date... ..`..� -%
a .. _. -_... :-
,.a Test Pit No. 1 .. ,...minutes per inch Depth o Test Pit....v ... Depth to ground water.6L:- kf..1
G4 Test Pit No. 2................minutes per inch Depth of Test Pit........................ Depth to ground water........................
! r r ..f............. L..... ...... {..�---------------
+ " --------.--- ...........
._O Description of Soil......... -�--..
W ...........................••--•---....... ._...---...................-----•--------.....---...----.......-----.._.......-----......_.............--•••••-•-•-.............
Alterations—Answer when applicable..........................................................:....................................
U Nature of Repairs or
-•---•-•-•-•---•--••--•--•.............................................................•--•---------.....---..........._.....---....---••---•---....---•-----•--............-•-.._......................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITL1 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
o ion ntilpCCertificate of Compliance has been issued by the board of health.
Si __.....-•-•------------------•-------•--•-------------...-••••----•-•-••••----.•_._._ ... ........••-
7,/ .
� ate
Appliion Approv - `.. ......................................................................... ,�. r7-` ._-----•---.-----
Application Disapprhe following reasons:.........................................................
ate .......__
...............................................................--.......•-----..........---....-----•--..--------...-•--•-......---•--....-----...........::-......--............._..................—
Date
PermitNo........................................................ Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..OF..............................
(Irrtifuttte of Toutplianrie
THIS S TO CERTIFY, That the,Individual Sewage Disposal System constructed �.fSr Repaired
( ( )
.....
Installer
at...... ........... . . ----.---•• . ....... ..................••-•---....._._.........................
has been installed in accordance with. the provisions of.TIT. F 5 of�he State Sanitary Co as ed in the
,. , --
application for Disposal Works Construction Permit No.... .......... ...�!................ dated._. �`�'..,P... .....................
THE ISSUA E OF THIS CERTIFICATE SHALL NOT BE CONSTR AS A GUARANTEE THAT THE
SYSTEhA��L UNCTION SATISFACTORY.
DATE... - 1....... .................... .... Inspector. ...------.............-•------.....---•-----•-•---•--.....................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...........................................O F.,...............................
No......................... Flamm........................
Disposal..Yorks Tonstrudion rrrmft
Permission is hereby granted...:.. / -Z .............•----•.--•---....---.....-----....._ :::----.........................-•---............---...»__...
to Con Rn �_ Rer ,( ) an Individual Sewage Disposal System
O' .
- ---...
Street
as shown on the applicatPigtf for Disposal Works Construction Permit No. ... ... ..Dated' ...•............
................................ .�:q`.. _.... -- --....................................«
DATE.---•--...�`- .'. .......................... board of Health
FORM C-1255 CITY& TOWN FORMS, INC.369-9708 ///'
,5►►.J G LC-. F A M►L_Y
i ►.�:�� 6A.26AGE (�Wt.IDF2
Dia►LY� F1_ow .: 110 x
SEPTIC, TA► K
j U5�- l000 GAL.
Dt5Po5AL- PIT u5E ►voo GAL_.
5►DCY�/ALL. A26A. = ►Jo 5.►=
150 5.t^ x �.•5 = 375 G.PD
i 50T TC>M AQCA= ..
5
o S.F x I. o = 5p G.PD
'ToTA1- DES►GN = .425 G.RD.
'TOTAL DA I L-`' Ft.-C)W 330 G•PP SSE �1�4�� G��✓
li PE2CoLATIoN GZATE1 I'IIN 2MIN ot~.LE55
`1N OF
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BAXTER as v JOKES
. 25100
K0.24,046
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