HomeMy WebLinkAbout0460 WHISTLEBERRY DRIVE - Health 1
TOWN OF BARNSTABLE
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ALLAGE (�,�r3 c�S �(1/l�\�i ASSESSOR'S MAP&PARCELOG-3 ®�T-
-4949 'S R OA&PHONE NO. c�a
SEPTIC TANK CAPACITY S®� S'�
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LEACHING FACILITY. (type) (size) G` Y, `f��c��,.
NO.OF BEDROOMS
OWNER t t oz�-`u
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
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Commonwealth of Massachusetts Title 5 Official Inspection Formcop'l
l�
o
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
19 Waters Edge
w
Property Address
Frederick Kozak__
Owner Owner's Name
information is Marstons Mills August MA 02648 16 2016
_—
required for every — — — - —"
page. City/Town State Zip Code Date of Inspection �}
W
N
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. General Information filling out forms
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Patrick T. Sullivanuse the return Name of Inspector
key.
Ready 'Rooter Excavating
rQ Company Name
P.O_. Box 89 _
Company Address
„ Forestdale MA 026 4
Cityrrown State P
de
508-888-6055 S112843
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
August 25 2016
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17
40eVS.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
19 Waters Edge
Property Address
Frederick Kozak__
Owner Owner's Name
information is required for every Marstons Mills MA 02648 August 16, 2016
-- -
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
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. If
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 ❑AND (Explain below):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
L
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form ;Not for Voluntary Assessments
19 Waters Edge
Property Address
Frederick Kozak
Owner Owner's Name
information is MA 02648 Au ust 16, 2016
required for every Marstons Mills
page. 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 bpken, settled or uneven distribution box. System will
pass inspection if(with approval of Board,of Health):
i
❑ broken pipe(s) are replaced j ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is level/dor replaced ❑ Y ❑ N ❑ ND (Explain below):
i
❑ 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 j i❑ Y ❑ N ❑ ND (Explain below):
l
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 pu/blic 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 syste is not functioning in a manner which will protect public health,
safety and the environme t:
❑ 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
6DTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
19 Waters Edge
Property Address
Frederick Kozak
Owner Owner's Name
information is MA 02648 August 16, 2016
required for every Marstons Mills __ _ ___.__. �— _ -
State Zip Code Date of Inspection
page. City/Town
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:
i
** 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 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
❑ N Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1/2 day flow
t5ins•3/13 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
19 Waters
Property Address
Frederick Kozak
Owner Owner's Name
information is Marstons Mills MA 02648 August 16 2016
required for every State Zip Code Date of Inspection
page. CitylTown
B. Certification (cont.)
Yes No
El ® 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-
Ej 10,000gpd.
❑ Z 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. i
Yes No
❑ ❑ the system is within PO feet of a surface drinking water supply
❑ ❑ the system is whin 200 feet of a tributary to a surface drinking water supply
it
❑ El Area
system is to ated in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA) r a mapped Zone II of a public water supply well
If you have answered"yes" to and 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.
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
t5ins•3/13
Commonwealth of Massachusetts
v Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
� w 19 Waters Edge
Property Address
Frederick Kozak
Owner Owner's Name
information is required for every Mafstons Mills MA 02648 Auu ust 16, 2016
—
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?
® El information
the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual):
3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):
330 GPD
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
I
Commonwealth of Massachusetts
q2 (z Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
19 Waters Edge
Property Address
Frederick Kozak
Owner Owner's Name
information is Marstons Mills _MA 02648 August 16, 2016
required for every
State Zip Code Date of Inspection
page. City/Town
D. System Information
Description:
2
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes ® No
2014 + 2015= 88
Water meter readings, if available (last 2 years usage (gpd)): GPD
Detail:
Sump pump? ❑ Yes ® No
Current
Last date of occupancy: Date
Commercial/industrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow (seats/persons/sq.ft., etc,.):
Grease trap present? / ❑ Yes ❑ No
Industrial waste holding tank present?/ ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
t5ins-3/13
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,H 19 Waters Edge
Property Address
Frederick Kozak
Owner Owner's Name
information is MA 02648 August 16 2016
required for every MarStonS Mills
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:
Ready Rooter records: Pumped Sept. 2012
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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
19 Waters Edge
Property Address
Frederick Kozak
Owner Owner's Name
information is MA 02648 August 16 2016
required for every Marstons Mills _ —
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:
System installed 06/11/1985. Certificate of Compliance on file at Health Dept.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
18"
Depth below grade: feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
n/a
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):
101,
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
10.5' x 5.5' x 5' 1500 gallons
Dimensions:
4"
Sludge depth:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
i
Commonwealth of Massachusetts
�w u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 19 Waters Edge
Property Address
Frederick Kozak
Owner Owner's Name
information is Marstons Mills MA 02648 August 16, 2016
required for every
State Zip Code Date of Inspection
page. City/Town
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
28"
8" at inlet, 4" at outlet
Scum thickness
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
10"
Tape measure and dip tube.
How were dimensions determined?
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Inlet and outlet PVC tees in place. Liquid level at outlet invert. Tank due for maintenance pumping.
Owner to schedule with Ready Rooter, Inc.
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�toop of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
I—
Commonwealth of Massachusetts
qv Title 5 Official Inspection Form
im Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
19 Waters Ede —
Property Address
Frederick Kozak
Owner Owner's Name
information is Marstons Mills MA 02648 Au�c Ust 16, 2016
required for every State Zip Code Date of Inspection
page. City/Town
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 ❑ fibergla s ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow: / gallons per day
Alarm present: / ❑ Yes ❑ No
Alarm level: j
— — Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
i
i
/
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
l5ins•3/13
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form Not for Voluntary Assessments
19 Waters Edge
Property Address
Frederick Kozak
Owner Owner's Name
information is Marstons Mills MA 02648 August 16 2016
required for every — State Zip Code Date of Inspection
page. City/Town
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
0"
Depth of liquid level above outlet invert
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
One inlet, one outlet. D-box is poly plastic. No sign of high water staining over outlet invert. Light
solids carryover not affecting system operation. Riser brings concrete cover within 4" of grade. 2' x 2'
cover with center pull out.
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.):
1
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:
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
t5ins•3/13
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
M 19 Waters Edge
Property Address
Frederick Kozak
Owner Owner's Name
information is Marstons Mills MA 02648 August 16, 2016
required for every
State Zip Code Date of Inspection
page. Cityrrown
D. System Information (cont.)
Type:
1-6' x6' w/
® leaching pits number: stone.
❑ 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.):
Leach pit located and inspected with camera. Liquid level 4'+-below invert at time of inspection. High
water staining 2'+-below invert. No sign of past hydraulic faulure. Clean stone visible through side
wall.
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 f
i
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater'inflow ❑ Yes ❑ No
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
42 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
w 19 Waters Edge
Property Address
Frederick Kozak
Owner Owner's Name
information is Marstons Mills MA 02648 August 16 2016
required for every — State Zip Code Date of Inspection
page. City/Town
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
1
i
i
/ I
i/
Privy (locate on site plan):
Materials of construction: i
Dimensions
i
i
Depth of solids /
Comments (note condition of soil, si ns of hydraulic failure, level of ponding, condition of vegetation,
etc.):
i
i
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
t5ins•3/13
-
Commonwealth of Massachusetts
UTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
19 Waters Edge
Property Address
Frederick Kozak
Owner Owner's Name
information is Marstons Mills MA _02648 August 16, 2016
required for every State Zip Code Date of Inspection
page. Cir own
D. System Information (cunt.)
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
attached separately
drawingp El attac
II
I �
DOL
Titre 5 official inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
t5ins•3113
II
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 19 Waters Edge
Property Address
Frederick Kozak
Owner Owner's Name
information is MA 02648 August 16 2016
required for every Marstons Mills
State Zip Code Date of Inspection
page. Cityrrown
D. System Information (cont.)
Site Exam:
® Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
>5
Estimated depth to high ground water. feet
Please indicate all methods used to determine the high ground water elevation:
❑ 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:
maps.massgis.state.ma.us/oliver.php
You must describe how you established the high ground water elevation:
Base of leach pit 9' below grade. Slope to front of property drops below base of leach pit. Accessed
local ground water contours and topo mapping No high ground water in area of system.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
l5ins•3113
t I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M _ 19 Waters Edge
Property Address
Frederick Kozak _
Owner Owner's Name
information is MA 02648 August 16, 2016
required for every Marstons Mills
State Zip Code Date of Inspection
page. City/Town
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•3l13 Title 5 Official Inspection form.Subsurface Sewage Disposal System•Page 17 of
LGCAT10N SEWAGE PERMIT NO.
*VILLAGE
ALL ER'S NAME i ADDRESS
SUILDER OR OWNER
�DATE� PERMIT ISSUED � c,
JS
DATE COMPLIANCE ISSUED S
.� � -
�: ;� �
a3 O 4 ��
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Y
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
A F DEPARTMENT OF ENVIRONMENTAL PROTECTION
d
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ti
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TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 19 WATERSEDGE MARSTONS MILLS,MA 02648 d� C)
Owner's Name: MRS. FREEMAN
Owner's Address: P.O. BOX .1142, MARSTONS MILLS, MA.02648
Date of Inspection: 8/6/01
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 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 the inspection.The inspection was performed based on my training and
experience in the proper function and.maintenance of on site sewage disposal systems. I am a DEP approved system
inspector pursuant to Section 15.340:of Title 5(310 CMR 15.000). The system:
X Passes
_ Conditionally.Passes
_ Needs Furtherf valuation by the Local Approving Authority
Fails
Inspector's Signature: Date: 8/6/01
The system inspector shall submit 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.
4 .
Notes and Comments :
SYSTEM PASSES TITLE V RECOMMEND PUMPING EVERY TWO YEARS TO MAINTAIN SYSTEM.
/s
****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,,, system will perform in the future under the same or different conditions of use.
I;
Tills S Incnortinn Frirm 6!1 S/1000 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: 19 WATERSEDGE MARSTONS MILLS,MA 02648
Owner: MRS.FREEMAN
Date of Inspection: 8/6/01
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.
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
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
f
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 19 WATERSEDGE MARSTONS MILLS, MA 02648
Owner: MRS. FREEMAN
Date of Inspection: 8/6/01
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
, r ,
r
Page 4 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 19 WATERSEDGE MARSTONS MILLS,MA 02648
Owner: MRS. FREEMAN
Date of Inspection: 8/6/01
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all-inspections:
Yes No
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged
SAS or cesspool
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool
X Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z 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.l
(Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310
CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd.
You 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 260 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.
J
Page 5 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 19 WATERSEDGE MARSTONS MILLS,MA 02648
Owner: MRS.FREEMAN
Date of Inspection: 8/6/01
Check if the following have been done. You must indicate "yes"or"no"as to each of the following:
s ..A
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 ?
Were as built plans of the system obtained and examined?(If they were not available note as N/A)
X _ Was the facility or dwelling inspected for signs of sewage back u
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 I?
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)]
Page 6 of 1l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 19 WATERSEDCE MARSTONS MILLS,MA 02648
Owner: MRS. FREEMAN
Date of Inspection: 8/6/01
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Number of current residents: 2
Does residence have a garbage grinder(yes or no): NO
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or no): 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 , a I
Design flow(based on 310 CMR;15.20, ): 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): YES
If yes,volume pumped: I000gallons--How was quantity pumped determined? n/a
Reason for pumping: MAINTENANCE
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:
16 YEARS
Were sewage odors detected when arriving at the site(yes or no): NO
I r
• Page 7 of 1 I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued) .
Property Address: 19 WATERSEDGE MARSTONS MILLS,MA 02648
Owner: MRS. FREEMAN
Date of Inspection: 8/6/01
BUILDING SEWER(locate on site plan)
Depth below grade: 14"
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: 8"
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:3"
Distance from top of sludge to bottom of outlet tee or baffle: 3.1
Scum thickness:3"
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 EVERY TWO YEARS TO PROLONG THE
SYSTEM'S USEFUL LIFE
GREASE TRAP:_(locate on site plan)
Depth below grade: n/a 1
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
I
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: 19 WATERSEDGE MARSTONS MILLS,MA 02648
Owner: MRS. FREEMAN
Date of Inspection: 8/6/01
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.): !
DISTRIBUTION BOX IS STRUCTURALLY SOUND AND APPEARS TO BE FUNCTIONING PROPERLY.
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
f
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 19 WATERSEDGE MARSTONS MILLS, MA 02648
Owner: MRS. FREEMAN
Date of Inspection: 8/6/01
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: nla
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.):
LEACH PIT APPEARS TO BE FUNCTIONG NORMALLY AND STRUCTURALLY SOUND.THERE IS NO SIGN
OF HYDRAULIC FAILURE. PIT HAS NEVER BEEN MORE THAN HALF FULL. BOTTOM IS AT 9 FEET.
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 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 19 WATERSEDGE MARSTONS MILLS,MA 02648
Owner: MRS. FREEMAN
Date of Inspection: 8/6/01
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.
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Page I 1 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 19 WATERSEDGE MARSTONS MILLS,MA 02648
Owner: MRS. FREEMAN
Date of Inspection: 8/6/01
SITE EXAM
_Slope
_Surface water
_Check cellar
Shallow.wells
Estimated depth to ground water 12 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
NO 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)
YES Accessed USGS database-explain: n/a
You must describe how you established the high ground water elevation:
USGS MAPS AND CHARTS- 12 FEET
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II
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No.. ..S. Flm$......
0 —
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
..........................................O F..........................---............._..---....I.........------..._....._...........
Appliration for Disposal Works Tonstrurtinn ramit
Application is hereby made for a Permit to Construct (--j"or Repair ( ) an Individual Sewage Disposal
System at:
• Location-Address or Lot No.
....-•••-•....C2_R£_G.C?.......
.-• .B1.M.A/.ZD....------•................. -•- .. •.. --•-------••-.•• •--••--•--------•---................................
Owner Address
aL?5.-1 a.._..0 1Ns .4------------------------------------ ----------- --------------------------------------......---
Installer Address
Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms............ -__-Expansion Attic ( ) Garbage Grinder (VQ7
Other—Type of Building No. of persons............................ Showers — Cafeteria
a' Other fix ures .............
W Design Flow...........k�. ....................�gallons per person per day. Total daily flow_.._.............S-1... ............gallons.
C4' Septic Tank—Liquid'capacity�.S®....gallons Length................ Width................ Diameter................ Depth................
W Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
x .
Seepage Pit No---------------_---- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by........................................................-•0.............. Date........................................
,aa Test Pit No. 1...4.��.._minutes per inch Depth of Test Pit.....1.34.5- Depth to ground water------------------------
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
•---------------------------------------------------------------••-•----------............•.....•...-••••--•---------------------------•-•••-----------------
0 Description of Soil........To.p .......sv-&.......9-° �---_--.--- Lt -----E-Q- F........1;L1..........
x11
U •--••••-•••••-•------•------•••-----••-•----------------•-•- •.........•-••-......•-----...................-•••--••-------------------•---•---•.....---•••••------•.............._...--------•-•---•---.
x ----•-•---------------------••----••-••---•--•-•-•--• --------------................................................................... ........--- ..............................................
U Nature of Repairs or Alterations—Answer when applicable....._. 1� ._. .�.t to► ..............................................
.........................................I-------6-)C.-G------- •ems---..t�.l.....--••-`_ ..!.--- ..Srow. ----------------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIME 5 of the State Sanitary Code— The undersignedlfurther agrees not to place the system in
operation until a Certifi e o rrt e'1�s beeaue the board of he lth.
igned
Date
Application Approved By--•- -----------• '
Date
Application Disapproved for the flowing reasons---------------------------------------------------------------------------------•--------------••--------..._._.
...................................................................................................................:.............................................. .......... .......
i •'--Date
PermitNo....................................................... Issued................ -. _ . ......
'-- Dat
i
! ✓ -,-..
OL
No................_....... FHB..��.`�_-_:..:
x'r THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
------------- ------------- ---- -----OF..........................................................................................
,XP Iirtt Ilan fur Diapos al Works Tonstrnrtinn antit
Application is hereby made for a Permit to Construct ('�) or Repair ( ) an Individual Sewage Disposal
yaT�%t:
V i��V� �IV V"�It� Lot or No.
Rc t cops-, I Address
Installer Address
Type of Building *S Size Lot............................Sq. feet
Dwelling—No. of Bedroom `' _______________ ......................... p ( ) Garbage Grinder ).
Ex Expansion Attic �
aOther—Type of Building ......................... No.. of persons............................ Showers ( ) — Cafeteria ( )
Oth�r]�t�aures -•••-• ---- ••-------------- �-- �---N--•----------•-•-----...••-.
W Design Flow____________________________ gallons per person per day. Total daily flow__-__.__.___.____.____.____.................gallons.
WSeptic Tank—Liquid capaci ��...gallons Length................ Width................ Diameter...-............ Depth................
x Disposal Trench—No--------------------- Width:................... Total Length.................... Total,leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( ,)
Percolation Test Re l>;� Performed bY........................................ 4. --------- Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit_-____t............ Depth to ground water.........................
w Test Pit No. 2................minutes per inch Depth of Test, Pit......._............ Depth to ground water........................
..._...... --•-•-
Q . T` Z✓ ' •_... • •-••----••-••••-----•--•...--•.....•••••-----
Description of Soil... t.. . 4r AY £ - QC1�L--•-•--•-(.�...--=-----•-
c, ---••-
txj ure of Repairs or �ltera ons—Answer_ when applicable_ N '� lC-+`� I.p
T W .
k (� •- rl3 - •••.........................................
, ":;-1k Agreement
The undersign agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
{ the provisions of 5 of the State.'Sanitary.Code—The undersigned further agrees not to place the system in
operation u *a' , ertificate of Compliance has be issued b ie board of Aealth.
-
Signed
t✓ ))
APPlication;;Approved By.. -------==---------------------- ---- `.. ...1� -----
�' Dtite
Application Disapproved fort following' -------•-- = :_:.,._... --•-----=--•-•••----==<a-5
__.____..-------------------------------------------------- --------•--------------------------------
ate
PermitNo....................................................... Issued............�. -t�-__---•--•.....................-•-..........----------
ate
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF.....................................................................................
(Inrtifiratr of Trrntplinnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal-System construct ( ) or Repaired ( )
by--- 4�- ------
St
-
has been installed in accordance with the provisions of TIT I E 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No................................. -_--_ dated .............................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONS UED AS A GUAR EE T T THE
SYSTEM WILL FU CT t4:'SATISFACTORY. .,.
DATE................6... -••---....--•-••-----:.._...••__•_.. Inspector.... _..--• •••.....---
THE COMMONWEALTH OFWASSACH ETTS
BOARD OF HEALTH
..........................................OF.-......................-........-.....--......_....-.-...--.---.....----..-.-..-....
No......................... FEE.........................
Disposal Works Tnnstrnrtion antit
Permi • is hereby granted------------•-------------------••------------------•-----•-•---•--•---......-.-..----------••-•-----.-....----...-....................._....
to CQnstrVt or�RepAir ( ), ap I�ividualbjl�
sposal System
at N G�-.. .�YS
Street
as shown on the application for Disposal Works Construction Permit No..................... Dated........_.................................
.--.•.-....-----•-----•-•------•---••--------•--•-------------•-----....-----...---•--•--•-•--•••......_
Board of Health
DATE------------------------•-•-•--•-•---••-•--•••--.::
--------------••--...-•••-
FORM 1255 A. M. SULKIN, INC., BOSTON
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