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Commonwealth:&Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary.Assessments 3.
M 54 Winding Cove Road LL
Property Address s7
�s
.Andrew Newman p_•:
Owner
Owner's Name
information is N�rstons Mills MA 02648 3/118/18 ,mow required for every i
page. City/Town State ..: :: Zip Code Date of Inspection
�a
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, T
use only the tab 1. Inspector:
key to move your
cursor-do not Brett Hickey
use the return Name of Inspector
key.
B&B Excavation
% Company Name
14 Teaberry Lane:
Company Address
Imo! Sandwich Ma. 02644
Cityrrown State Zip Code
(508)477-0653 S113747
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
3/18/19
Insp Si ature... 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 DER 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
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I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
54 Winding Cove Road
Property Address
Andrew Newman
Owner Owner's Name
information is required for every Narstons Mills MA 02648 3/18/18
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:.
Z 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:
i
B) System Conditionally Passes:
El 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.
E Y [I N El ND (Explain below.):
i
t5ins-3/13. 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
54 Winding.Cove Road
Property Address
Andrew Newman
Owner
..Owner's Name I
information is required for every Narstons Mills MA 02648 31,18/18
page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not.operational. System will pass wiftBoard 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.lin 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):
[I, 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 ❑ mN ❑ ND (Explain:below):
Ej 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 pipes) 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 environmen.;t.:
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 Js 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
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
54 Winding Cove Road
Property Address
Andrew Newman
Owner Owner's Name
information is Narstons Mills MA 02648 3/18/18
required for every —
page. City/Town _ 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 aseptic tank and SAS and the SAS:is less than 1:00i 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:. t
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 '/z day:flow
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form:-Not for Voluntary Assessments
54 Winding:Cove Road
Property Address
Andrew Newman
Owner Owner's Name
information is required for every Narstons Mills MA 02648 3/18/18
page. City/Town State Zip Code Date.of Inspection
B. Certification (cont.)
Yes: No
Required pumping more.than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ 0 Any portion of the SAS, cesspool or privy is below high groundwater 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.
El ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ Z 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.]
❑ z The system is a cesspool serving.a facility with a design flow of 2000gpd-
101000gpd.
❑ :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.
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 l l 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-3113 Title 5 Official Inspection Form:Subsurface Sewage.Disposal System•Page 5 of 17
L
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form:- Not for Voluntary Assessments
,M 54 Winding Cove Road
Property Address
Andrew Newman
Owner Owner's Name
information is required for every Narstons Mills MA 02648 3/18/18
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?
Z. ❑ 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 31.0.:CMR 15.203 (for-example: 110 gpd x#of bedrooms): 440
t5ins.-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
I
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments.
M 54 Winding Cove Road
Property Address
Andrew Newman
Owner Owner's Name
information is required for every Narstons Mills MA 02648 3/18/18
page. 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 ❑ Yes ® No
information in this report.)
Laundry system inspected?
❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings,.if available (last 2 years usage.(gpd)):
see below
Detail:
2016 = 68,000 gals 2017 = 67,000:gals _
Sump pump? ❑ Yes E No
- _Last date of occupancy: current
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 MR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft.,.etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste.hblding tank present? ❑ Yes ❑. No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings,:if available:
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
f
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
M 54 Winding:Cove Road
Property Address
Andrew Newman
Owner Owner's Name
_. _. _...
information is Narstons Mills MA 02648 3/18/18
required for every
page. CltyrFown State Zip Code. Date:of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other-(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? EJ Yes ® No
If yes, volume pumped:
gallons
How was:quantit
y y pumped determined.
Reason for pumping:
Type of System:
z Septic:tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool:
Pr
ivy
El Shared system (yes or no) (if yes, attach previous inspection records, if any)
D 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.
El Other(describe):
l5ins•3/13. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts.
u W Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form Not for Voluntary Assessments
54 Winding Cove Road
Property Address
Andrew Newman
Owner Owner's Name
information is required for every Narstons Mills MA 02648 3/18/18
page. Cityrrown State Zip Code. : Date.of Inspection
D. System Information (cont.)
Approximate age,of all components, date installed (if known) and source of information:
1986
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
30
Depth below grade:
„
feet.
Material of construction:
El cast iron Z 40 PVC: ❑ other.(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
At time of inspection building sewer appeared to be in good working order with no sign of leakage.
Septic Tank (locate on site plan):
18
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene. ❑other(explain)
If tank is,metal,.list.age:
years.
Is age.confirmed.by a Certificate of Compliance? (attach a.copy of certificate) _ ❑ Yes ❑ No
Dimensions: 1500 gallon
101,
Sludge depth:
t5ins-3/13. 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
54 Winding Cove Road
Property Address
Andrew Newman
Owner Owner's Name
information is required for every Narstons Mills MA 02648 3/18/18
page. City/Town State Zip Code Date of Inspection
D. System:Information (cont.)
Septic Tank(cone.)
Distance from top of sludge to bottom:of outlet tee or baffle
261,
3"
Scum thickness —
6„
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
13"
How were dimensions determined? measured
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc):
At time of.inspection.septic tank.appears.to be in working order. Tank is.not in need of pumping at
this time but should be pumped every 2 years for maintenance.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions: —
Scum thickness
Distance from top of scum to top of:outlet tee or.baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage.Disposal System•Page 10 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection: Form
s Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
54 Winding Cove Road
Property Address
Andrew Newman
Owner Owner's Name
information is required for every Narstons Mills MA 02648 3/18/18
page. CltylTown State Zip Code Date:of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence:of leakage,:etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below.grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions: —
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑; Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy,of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3/13 Title 5 Official.lnspection Form:.Subsurface Sewage Disposal System•Page 11 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form:- Not for Voluntary:Assessments
54 Winding Cove Road
Property Address
Andrew Newman
Owner Owner's Name
information is
required for every Narstons Mills MA 02648 3/18/18
page. Cityrrown 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.):
At time of inspection d-box appears to be in working order with no sign of carryover.
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):
s.
If SAS not located;.explain,why:
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 12 of 17
f
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for.Voluntary Assessments
54 Winding Cove Road
Property Address
Andrew Newman
Owner -Owner's Name
information is required for every Narstons Mills MA 02648 3/18/18
page. City/Town state Zip Code Date.of Inspection
D. System:Information (cont.)
Type:
® leaching pits number: (2) 6'x6'
❑ 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.):
At time of.inspection.leaching appears to.be:in working order with no sign.of hydraulic failure. Pit#1
was full at time of inspection and Pit#2 was dry.
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
Dimensicns of.cesspool ..
Materials of construction
Indication, of:groundwater inflow ❑ Yes ❑ No
t5ins•3/13 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
54 Winding Cove Road
Property Address
Andrew Newman
Owner Owner's Name
information is required for every Narstons Mills MA 02648 3/18/18
page. City/Town State Zip Code Data of Inspection.
D. System Information (cont.)
Comments (note condition of soil, signs.of hydraulic failure, level of ponding, condition of.vegetation,
etc.)-.
Privy (locate on site plan):-
Materials of construction:
Dimensions
Depth:of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
64 Winding Cove Road
Property Address
Andrew Newman
Owner
Owner's Name
information is Narstons Mills
required for every MA 02648 3/18/18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage:disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 1 00 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® Ihand-sketch in the area below w
:❑ drawing attached separately
{
1'� P rl
> L
!Sins•3/13
Title 5 Official.Inspection Form: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
54 Winding.Cove Road
Property Address
Andrew Newman
Owner
Owner's Name
information is required for every Narstons Mills MA 02648 3/18/18
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:: > 12,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: 12/8/86
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:
Plan on file at BOH.
Before filing this Inspection Report, please see Report Completeness Checklist:on next page.
l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-.Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
A Subsurface Sewage Disposal System Form-.Not for Voluntary Assessments_
t
54 Winding Cove Road
Property Address
Andrew Newman
Owner Owner's Name
information is Narstons Mills MA 02648 3/18/18
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
'I
i
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 17 of 17
Commonwealth of Massachusetts 45
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
GM ' 54 Winding Cove Rd - "_{;;
Property Address
Andrew Newman '
Owner Owner's Name
information is
required for every Marstons Mills MA 02648 5-14-15
Cit /Town State -Zip Code Date of Ins`action
page. Y P P:__
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
(/W
1. Inspector:
Shawn Mcelroy
Name of Inspector
Upper Cape Septic Services
Company Name
P.O. Box 73
Company Address
E. Falmouth MA 02536
City/Town State Zip Code
1-508-495-0905 S13971
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 16.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation the Local Approving Authority
5-14-15
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
l
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 54 Winding Cove Rd
Property Address
Andrew Newman
Owner Owner's Name
information is required for every Marstons Mills MA 02648 5-14-15
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:
System is in good working order with no sign of failure.
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 exriltration 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
m Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
54 Winding Cove Rd
Property Address
Andrew Newman
Owner Owner's Name
information is required for every Marstons Mills MA 02648 5-14-15
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 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•3M 3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
r
Commonwealth of Massachusetts '
W Official Inspection Form Title 5 O
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 54 Winding Cove Rd
Property Address
Andrew Newman
Owner Owner's Name
information is required for every Marstons Mills MA 02648 5-14-15
page. City/Town 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
❑ 0 Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
El ® Liquid depth in cesspool is less than 6° below invert or available volume is less
than Y2 day flow
t5ins•3113 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
M , 54 Winding Cove Rd
Property Address
Andrew Newman ,
Owner Owner's Name
information is required for every Marstons Mills MA 02648 5-14-15
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑' ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or,privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form,]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303,therefore the system fails. The
system owner,should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.,
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3/13 Title 5 Official Inspecdon 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
�. 54 Winding Cove Rd
Property Address
Andrew Newman
Owner Owner's Name
information is required for every Marstons Mills MA 02648 5-14-15
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 4systern 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 NIA) •
® ❑ 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?
1 ,
® ❑ 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-W 3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
54 Winding Cove Rd
Property Address
Andrew Newman
Owner Owner's Name
information is required for every Marstons Mills MA 02648 5-14-15
page. 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 report.) El Yes ® No
information in this reP )
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: 5-2015
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•3/13 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
a Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
54 Winding Cove Rd
Property Address
Andrew Newman
Owner Owner's Name
information is required for every Marstons Mills MA 02648 5-14-15
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: Owner--pumped 2013
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: -
gallons
How was quantity pumped determined?
Reason for pumping: Maintenance
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
e obtained from system owner and a co of latest
maintenance contract(to b d y ) copy
inspection of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):-
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
f
Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
54 Winding Cove Rd
Property Address
Andrew Newman
Owner Owner's Name
information is required for every Marstons Mills MA 02648 5-14-15
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:
1988
Were sewage odors detected when arriving at the site? - ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 24"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.):
Good condition.
Septic Tank(locate on site plan):
Depth below grade: 18"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: 1500 gal
Sludge depth: 12"
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
54 Winding Cove Rd
Property Address
Andrew Newman
Owner Owner's Name
information is required for every Marstons Mills MA 02648 5-14-15
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 20"
2-1Scum 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
14"
How were dimensions determined? Tape
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank is near the edge of the drivway in the front and in good condition with baffles installed and no
sign of leakage.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
I .
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -'Not for Voluntary Assessments
M 54 Winding Cove Rd
Property Address
Andrew Newman
Owner Owner's Name
information is required for every Marstons Mills MA 02648 5-14-15
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
"Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
t5ins•3/13 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
54 Winding Cove Rd
Property Address
Andrew Newman
Owner Owner's Name
information is required for every Marstons Mills MA 02648 5-14-15
page. Cityrrown 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.):
Good condition with water at working level and no sign of back-up from pits.
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:
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspectionform
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
54 Winding Cove Rd
Property Address
Andrew Newman
Owner Owner's Name
information is required for every Marstons Mills MA 02648 5-14-15
page. CityTrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 2-1000 gal
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number,dimensions:
❑ overflow cesspool number:
❑ innovative/altemative 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"G"was empty at inspection with stain line within 6"of inlet invert. Leach pit"F"had water
level and stain line at 24" below inlet invert.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins-3113 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
54 Winding Cove Rd
Property Address
Andrew Newman
Owner Owner's Name
information is required for every Marstons Mills MA 02648 5-14-15
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) F
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions .
Depth of solids
Comments(note condition of soil, signs of hydraulic failure; level of ponding, condition of vegetation,
etc.):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form.-Not for Voluntary Assessments
M 54 Winding Cove Rd
Property Address
Andrew Newman
Owner Owner's Name
information is required for every Marstons Mills MA 02648 5-14-15
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
lop
t � �
-,
33
1
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspect'ion. Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M � 54 Winding Cove Rd
Property Address
Andrew Newman
Owner Owner's Name
information is required for every Marstons Mills MA 02648 5-14-15
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
r
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:
USGS and town maps show groundwater at greater than 20'.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-M 3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 54 Winding Cove Rd
Property Address
Andrew Newman
Owner Owner's Name
information is required for every Marstons Mills MA 02648 5-14-15
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
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
TOWN OF BARNSTABLE
�l/i'n�i�,S Gvc� �� SEWAGE # O (o /j060
vILLAGE „ . �/r ASSESSOR'S MAP & LOT
�� '
INSTALLER'S NAME & PHONE NO. fC ..7 )��'!�S
SEPTIC TANK CAPACITY /,r" (� C
LEACHING FACILITY:(tppe) a S (size.)�pl�
NO. OF BEDROOMS G/ PRIVATE WELL OR BLIC WATER
BUILDER OR OWNER /� / (XL
DATE PERMIT ISSUED: /az// I�
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes
//Luse
�
M
rJ
,i
N.....�_4 SDA FxB...........................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�.O.Wl'_A.............OF.... 176------------------ .......----------Apptiration for Bispaaal Wor Xontitrurtion ramit
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
SYs __
t r)
'Va �2p. A4 ,h, (.!..........................Le-r-a-5......................................
6. . ......... ......
Address or Lot No.
—--------------------------------- ----------—--------------------------------------------------------------------------------------
..............................
wner Address
.... . ......... ....... ........................ ..................................................................................................
Installer Address
Type of Building Size Lot_ q. feet
U
Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder
`4
PL4 Other—Type of Building ............................ No. of persons............................ Showers Cafeteria
Other fixtures
Design Flow................... gallons per person per day. Total daily flow_._._._.....___._... gallons.
W
Septic Tank—Liquid capacityl_$W..gallons Length................ Width................ Diameter---------------- Depth...._........__.
Disposal Trench—No..................... Width....._......._...... Total Length.................... Total leaching area.._.....--._..._LLSQ. ft.
Seepage Pit No...__.._ ameter........1-0...... Depth below inlet........46P...... Total leaching area...63.4-sq. ft.
Z Other Distribution box Dosing tank
Percolation Test Results Performed ......Ne,-,. '........... Date...'
Test Pit No. I.....2--nminutes per inch Depth of Test Pit....._. Depth to ground water.._. -------
Test Pit No. 2................minutes per inch Depth of Test Pit................_._. Depth to ground water-___-_-----.............
...........14-------------------------------------------------------------------------------------------------------------------------------------------------
• . .................................................
0 Description of Soil........ ......Y
-------------------- G
............ .......[17..........YO------ ....................... I.A
-------------- -T
�Pm%Kl AND Ce"
........................................ . ..... .......C ....... en IN S'T�klc
---------------- -------
U Nature of Repairs or Alterations—Answer when applicable................................. .!.:r51A NNAS
.......................................................
......................................................................................................................
......................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of'1I'L U 5 of the State Sanitary Code— The under d rther agrees not to place the system in
operation until a Certificate of Compliance has been iss e the o
Signd......... ... .. ... ... ................................................ ..........................
Date—
ApplicationApproved B ---------_---_---------4------------------------- ................ .......
Date
Application Disapproved for the following reasons:..............................................................................................................
.......................................................................................................................................................................................................
Date
7� 3c) e
PermitNo.----._......................................5?�------- Issued.......................................................
Date
2
a
SDA
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
ApplirFa#ion for Disposal Ivor k�onstrnrtiott rrmit
Application is hereby made for a Permit to Construct ( or Repair ( . .) an Individual Sewage Disposal
System at,
sei ndYtdiT^Address or Lot No.
Address .................
1
j..----•-•••......---•-- •-••--•-•-•......................••---•-•--.. .................--•........-------•-••--•-......--
Installer Address
Type of Building Size Lot...33,655_Sq, feet
U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder
a'4 Other—T e of Building No. of persons......................: Showers
YP g ---------------------------- P ----- ( ) — Cafeteria ( )
44 Other fixtures
Design Flow.................... gallons per person per day. Total daily flow__._._.._._...._..__...1<-� ��.._.gallons.:
----- ------ ------ - - -- ------
Wg �.•---
WSeptic Tank—Liquid capacity.1�..gallons Length................ Width................ Diameter................ Depth............
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area............ '.sq. ft.
Seepage Pit No.......... iameter.........�_>.... Depth below inlet.......... Total leaching area....�?]5sq. ft.
Z Other Distribution box ( V� Dosing tank
'-' Percolation Test Results Performed by „�1Q. ...ri.. t} _..J.Ne .......... Date_._._M7"Z`7— ..
Test Pit No. I.......7o---.-rninutes per inch Depth of Test Pit........ ,.Depth to ground water_-__-
fX4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
9 --•--•--�=•_...:•--•------•-•......--•----•-----•••....------••-------•......--- •-•••••. --......--••---•--••.............•......-----------------•--
D Description of SoiL.._..._. .. ...... -L21�__�Ql. .�..�!�r�_y.__.__ -
x
UZ ----•------------------•.. ............ - �1 1U1 ' 1. �n -A....Z -----•--------------•---•------------------------•-- ---
Nature of Repairs or Alterations—Answer when applicable...............................................................................................
--------•-•--------------------------------------------•--•-----•---------....----........-•----•----•----•---------------------- ----------------•-------------------------.--•-••-••---=-••-•-----•
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code— The unders' d ther agrees not to place the system in
operation until a Certificate of Compliance has been iss d he 1 is3lth.
f.
�d--------- ........ r-"tc fir--
-----••-- ................................
/Date
Application Approved BY �:. - ...................=------------------------- ••--•-......-Z`-l.:.........�/------
Date
Application Disapproved for the following reasons--------------------------------------------------------•------•----------------•---------------•--•-•....----._
........--•----------•--••----------•----••-----------------•--------•-••-•-----...........-------••-•-----------------------••-------------•-----•--------•----------•-••-------•----------•-----------
Permit No...........�� .. a...... Issued-.-----•......----•---------
.................................• --•--......._..............
Date------
Date
THE COMMONWEALTH OF MASSACHUSETTS t
BOARD OF HEALTH
.......oF...........
rZ�J. l-7a: �......................
Tnrtifirtttr of TompliFanrle
re IS T CEWI Y That Qth�e/Individual Sewage Disposal System constructed ( ) or Repaired ( )
byit's . . 1/.!! ` 1-3-7�----------Install--•-----•-----------•-----•-----------------------7.........._._..... -------
at. �--
has been installed in,accordance with the provisions of- TLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit°No.__ = �___.!. .!?._`�... dated_..-----.f._71/.:1 iR ................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL Fi'BNCTION SATISFACTORY.
DATE........ ... ,� ' �-� —� Inspector
..........................q......
V11
F TEI�COINM IWEALTH OF MASSACHUSETTS
VBOARD Q F HEALTH
f_�� ............... -U ��t,:..OF........... �.E! �Z:C`la.l �a. ..----•-..............---•- ->o
No.......................•- FEE..... ,
Disposal Works Tonotr ion permit \
Permissionis hereby granted..............................................................................................................................................
to Construct ( ) or Repair ( ) an Individual Sewage Disposal System y i
�� r-
at No.. .. .. = ._.:. a s!� ---- ------
as shown on the ap lication for Disposal Works Construction Permit tNo._t.....f. ';' Dated '.......
-----------
DATE. // Board of Health
FORM 1255 HOSES & WARREN. INC.. PUBLISHERS
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