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Home My WebLink About0104 WINDING COVE ROAD - Health 104 WINDING COVE ct,�, � tCnS H'As A= 057 019 I .� Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 104 Winding Cove Road 5 Property Address Diane Klaiber Owner Owner's Name H information is ':9 rec uired for every Marstons Mills Ma 02648 11-16-15 page. Cityrrown State Zip Code Date of Inspection r�. Inspection results must be submitted on this form. Inspection forms may not be altered in any ram' way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms j/ f 2(07 on the computer, use only the tab 1. Inspector: key to move your cursor-do not Matthew F. Gilfoy use the return Name of Inspector key. Excavation Company � Company Name 14 Teaberry Lane Company Address I Sandwich Ma. 02644 City/Town State Zip Code (508)477-0653 S113640 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 11-16-15 Inspector's Signatur Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner arrd 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. �o Vs t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal yst m•Page 1 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 104 Winding Cove Road Property Address Diane Klaiber Owner Owner's Name information is required for every Marstons Mills Ma 02648 11-16-15 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ one or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 104 Winding Cove Road Property Address Diane Klaiber Owner Owner's Name information is required for every Marstons Mills Ma 02648 11-16-15 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 l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts - Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M �< 104 Winding Cove Road Property Address Diane Klaiber Owner Owner's Name information is required for every Marstons Mills Ma 02648 11-16-15 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 ❑ ® 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 '/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 o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 104 Winding Cove Road Property Address Diane Klaiber Owner Owner's Name information is required for every Marstons Mills Ma 02648 11-16-15 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 Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 104 Winding Cove Road Property Address Diane Klaiber Owner Owner's Name information is required for every Marstons Mills Ma 02648 11-16-15 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 system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts w - Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 104 Winding Cove Road Property Address Diane Klaiber Owner Owner's Name information is required for every Marstons Mills Ma 02648 11-16-15 pace. 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 Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d see below 9 ( Y 9 (gP ))� Detail 2014- 144,000gallons 2013- 106,000gallons Sump pump? ❑ Yes ® No Last date of occupancy: current 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 I - Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 104 Winding Cove Road Property Address Diane Klaiber Owner Owner's Name information is required for every Marstons Mills Ma 02648 11-16-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: pumped every 2 years per owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form .I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 104 Winding Cove Road Property Address Diane Klaiber Owner Owner's Name information is required for every Marstons Mills Ma 02648 11-16-15 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: 1995 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2.5'feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: feet ' Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallon Sludge depth: 8° 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 104 Winding Cove Road Property Address Diane Klaiber Owner Owner's Name information is required for every Marstons Mills Ma 02648 11-16-15 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 28" 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 14" 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 appeared to be in working order with liquid level equal with outlet invert. Tank is due for pumping at this time. 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 thins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts 4 Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 104 Winding Cove Road Property Address Diane Klaiber Owner Owner's Name information is required for every Marstons Mills Ma 02648 11-16-15 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 104 Winding Cove Road Property Address Diane Klaiber Owner Owner's Name information is required for every Marstons Mills Ma 02648 11-16-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of Liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): At time of inspection D-box is in working order with no sign of back but with some carry over present. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 104 Winding Cove Road Property Address Diane Klaiber Owner Owner's Name information is required for every Marstons Mills Ma 02648 11-16-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1-6'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. Water level in pit was 2' below invert with no higher staining present. 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•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 ,M 104 Winding Cove Road Property Address Diane Klaiber Owner Owner's Name information is required for every Marstons Mills Ma 02648 11-16-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5. Official Inspection Fora' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 104 Winding Cove Road Property Address Diane Klaiber Owner Owner's Name information is required for every :Marstons Mills Ma 02648 11-16-15 page. CityrTown 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 �'r•On� D� hOuSc/ I I O O A � - I� ` 0 - 216 A2- 26' BZ - 24 ` g3 - 2 3 ' A y - 54' 13y -3+' - � No+ drawnto ,Scale t5ins-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 ,M 104 Winding Cove Road Property Address Diane Klaiber Owner Owner's Name information is Marstons Mills Ma 02648 11-16-15 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: No Gw 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: 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: Large drop off in rear of dwelling. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 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 104 Winding Cove Road Property Address Diane Klaiber Owner Owner's Name information is Marstons Mills Ma 02648 11-16-15 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments G'M 104 Winding Cove Rd. Property Address Diane Klaiber Owner Owner's Name information is required for Marston Mills Ma. 02648 7/11/14 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out A. General Information D forms on the computer,use 1. Inspector: Ciq only the tab key to move your Ricky L. Wright cursor-do not Name of Inspector use the return key. B&B Excavation Company Name r� 14 Teaberry Lane Company Address Sandwich Ma. 02644 City/Town State Zip Code (508)477-0653 S14595 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and thaTle Z information reported below is true, accurate and complete as of the time of the inspection. Tre:inspe�a.gcl�l ion was performed based on my training and experience in the proper function and Djmihtenance_gf on s4 =i sewage disposal systems. I am a DEP approved system inspector pursuant to Section 1&340 ofl Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails w ❑ Needs Further Evaluation by the Local Approving Authority ` 7/11/14 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 Inspecti LWfF : ubsurface Sewage Disposal System-Page 1 of 17 . Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 104 Winding Cove Rd. Property Address Diane Klaiber Owner Owner's Name information is required for Marston Mills Ma. 02648 7/11/14 every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined;" please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 104 Winding Cove Rd. Property Address Diane Klaiber Owner Owner's Name information is required for Marston Mills Ma. 02648 7/11/14 every page. Cityrrown 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 104 Winding Cove Rd. Property Address Diane Klaiber Owner Owner's Name information is required for Marston Mills Ma. 02648 7/11/14 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 a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/day flow t5ins•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 104 Winding Cove Rd. Property Address Diane Klaiber Owner Owner's Name information is required for Marston Mills Ma. 02648 7/11/14 . every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal,coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachuse tts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 104 Winding Cove Rd. Property Address Diane Klaiber Owner Owner's Name information is required for Marston Mills Ma. 02648 7/11/14 every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan.at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 L Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 104 Winding Cove Rd. Property Address Din i Diane Klaiber ber Owner Owner's Name information is required for Marston Mills Ma. 02648 7/11/14 every page. Cityrrown 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 E No information in this report.) P ) Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d n/a 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current 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 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 104 Winding Cove Rd. Property Address Diane Klaiber Owner Owner's Name information is required for Marston Mills Ma. 02648 7/11/14 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 104 Winding Cove Rd. Property Address Diane Klaiber Owner Owner's Name information is requirec for Marston Mills Ma. 02648 7/11/14 every 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: 1995 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2.5 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: >20feet Comments (on condition of joints, venting, evidence of leakage, etc.): At time of inspection building sewer appeared to be in good working order no sign of leakage. Septic Tank (locate on site plan): Depth below grade: 1.5 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gal. Sludge depth: 6" 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 °M 104 Winding Cove Rd. Property Address Diane Klaiber Owner Owner's Name information is required for Marston Mills Ma. 02648 7/11/14 every page. Cityrrown 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 31" Scum thickness no scum Distance from top of scum to top of outlet tee or baffle no scum Distance from bottom of scum to bottom of outlet tee or baffle no scum How were dimensions determined? scour stick 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 appeared to be in working order,Tees present no sign of back- up.Liquid level equal with outlet invert. 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 104 Winding Cove Rd. Property Address Diane Klaiber Owner Owner's Name information is required for Marston Mills Ma. 02648 7/11/14 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Il 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1Winding M 04 Cove Rd. Property Address Diane Klaiber Owner Owner's Name information is required.or Marston Mills Ma. 02648 7/11/14 every page. Cityrrown State Zip Code Date of Inspection D. System Information 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 no sign of leakage or carryover. Pump Chamber be (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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 l Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 104 Winding Cove Rd. Property Address Diane Klaiber Owner Owner's Name information is required;or Marston Mills Ma. 02648 7/11/14 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 6x6 ❑ 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 in working order no sign of hydraulic failure.Water level was 2' below invert at time of inspection. 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 104 Winding Cove Rd. Property Address Diane Klaiber Owner Owner's Name information is required for Marston Mills Ma. 02648 7/11/14 every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•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 �< 104 Winding Cove Rd. Property Address Diane Klaiber Owner. Owner's Nart1e information is required for Marston Mills_ Ma. 02648 7/11/14 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch 0f 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 -El drawing attached separately /31 Q O O � � - 2(3 A2- 231 8 � - 2W A3.-- 3q ' 93 -. 2 3 ' A� - 54 ' B`4 -34 ' No+ drawnto Scale t5ins•3/13 Title 5 Official,Inspection Form:.Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 104 Winding Cove Rd. Property Address Diane Klaiber Owner Owner's Name information is required for Marston Mills Ma. 02648 7/11/14 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 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: rear of dwelling drops off. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 104 Winding Cove Rd. Property Address Diane Klaiber Owner Owner's Name information is required forMarston Mills Ma. 02648 7/11/14 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file i t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 _ I T` TOWN OF BARNSTABLE LOCATION , O SEWAGE # VII i:AGE Irl/Jl9g�/l) Yylp L Lam_ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet I Furnished by I; 1,v ,Cove ��. PROPERTY ADDRESS: 1_0_4_Winding_Cove Road � Marstons Mills _ l Mass . 02648 F On the above date, I inspected the septic system at the above address.)Cpto This system consists of the .following:1 . 1-1000 gallon septic tank. R2. 1-Distribution box NOV23. 1-1000 gallon leaching pit. mvNoFaBased on my inspection, i certify the following conditions: 1 . This is a title five septic system. ( 78 Code ) CU 2. The Septic system is in proper working order at the present time. SIGNATURE- _s L— Name:_Joseeh P.- Macomber Jr_.- Company-J_P_Macomber_& Son Inc.. Box 66 Address: -------------------- __ Centerville_jMass _ 02632 Phone: 508=275-U3 L______ THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY � I JOSEPH P. MACOMBER & SON, INC. Tanks-Cesspools-LeachfIelds Pumped & Installed Town Sewer Connections P.O. Box 66 Centerville, MA 02632-0066 .775.3338 775-6412 • . ,. p y . .mom . . , :4. �S.'-.pe - ., ?�� P. •�. ,a, S'_... .•±&r.Nt. .if,..._ r ' .. r - - u Coilmonweatfh of Massachusetts j Executive Office of Environmental Affairs Department of aD U. P. Environmental Protection Wiliam F.Weld. e _ Trudy CoxCe' •�ti�,+rlt�ltEOtJ1,•eT`", :4f,'. -;. :'.4 .. .. , . DAvld B.Struhi< SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 10 Winding C , Road, Address of Owner Date of Inspection: 11%14/9 5 - .4 "`�`(If�different) llesley,Mass . Name..o.fJnspector;,-J-oseph Pi .,Macpmbe-r� Jr. 02181 Company Name,,Address and Telephone Number. J.P..-Macomber & 'Son Inn Box 66 Centerville ,Mass . .02632 508=775-3338 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 as performed based on my training and experience in the proper function and and complete as of the time of inspection. The inspection w maintenance of on-site sewage disposal systems.,The system: Passes + Conditionally-Passes ; r Y Needs Further Evaluation By the Local Approving Authority Fails I Sis — Y Date: p g Inspector's nature: The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspection; If the stem,is,,a shared sy stem or,has,a design flow,of 10,.000 gpd or•greate(, the inspector,and.the system owner.shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B,C, or D: A) SYSTEM PASSES �,.•.'k t ,1(-4-J (..:^ 3^z "�'a"-,SF iht.:r _ t...-X a,... t.^- ' . -... :.. .:y ... .. .. I have not found any information which;ndicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B) SYSTEM CONDITIONALLY PASSES: A16_ One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not) tank°is4netal,'cracked structurally unsound, shows substantial infiltration orexfiltradw, or tank failure is GIST -' The=septic imminent. The system will'pass inspection if the existing septic tank is replaced with a conforming septic tank as ' -appfove&by the Board 6f'Health. (revised 8115195) 1 Ond Winter Street 9 Boston,Massachusetts 02108 • FAX(617)556-1049 9- Telephone(617)292-5500 5 U SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 104 Winding Cove Road Marstons Mills ,Mass . Owner: Thomas Classen Date of Inspection: 11 /14/95 B) SYSTEM CONDITIONALLY PASSES (continued) 0 Qjo Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced d/p The system required pumping more than four 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 C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: (� Cesspool or privy is within 50 feet of a surface water jg 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 APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The sv5tem nds a hePtll tdlik dnU bull ibbUrpliUll Sy$ILII) and li within 100 feet to a surface % ater supply Cr tributary, tc a surface water supply. �Q The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis 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• D) SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an 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. (revised 8/15/95) 2 V � SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A i CERTIFICATION (continued) Property.Address: 104 Winding Cove Road Marstons• Mills ,Mass . Owner: Thomas Classen Date of Inspection: 11 /14/9 5 • D)SYSTEM FAILS(continued): • AM Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. 6th Liquid depth in cesspool Is less than 6"below invert or available volume is less than 1/2 day flow. A0 Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped AV Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. bo Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone.I of.a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Q 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The design flow of•system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: the system is within 400 feet of a surface drinking water supply dIQ -the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the.groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 6/15/95) 3 U SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 104 Winding Cove .Circle' Marstons Mills ,Mass . Owner: Thomas Classen .. Date of Inspection: 11 /14/9 5 Check if the following have been done: Pumping information was requested of the owner, occupant, and Board of Health. ,None of the system components have been pumped for at least two weeks and the system has been regeiving normal flow rates i during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. 2As built plans have been obtained and examined. Note if they are not available with N/A. , The facility or dwelling was inspected for signs of sewage back-up. the system does not receive non-sanitary or industrial waste flow -.f< 'he site was inspected for signs of breakout. i YAII system components,iluding the Soil Absorption System, have been located on the site. ! ZThe septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. 2-The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. Zhe facility owner land occupants, if different from owner) were provided with information on the proper maintenance of Sub. Surface Disposal System. i (revised 8/15/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 104 winding Cove Road Marstons Mills ,MASS. Owner: Thomas Classen Date of Inspection: 11 /14/9 5 FMOW CONDITIONS RESIDENTIAL: �J y Design flow:, allo s� V'�y Number of bedrooms: Number of current residents: Garbage grinder(yes or no):A& Laundry connected to syst m (yes or no):- Seasonal use(yes or no):2 Water meter readings, if available: s ACC l 1 Last date of occupancy: COMMERCIAUINDUSTRIAL• Type of establishment:. AM Design flow: mA allons/day Grease trap present: (yes or no)_o Industrial Waste Holding Tank present: (yes or no- n-sanitary waste discharged to the Title 5 system: (yes or no) \,ater meter readings, if available: Last date of occupancy:-ALB— OTHER: (Describe) Last date of occupancy:�f _ GENERAL INFORMATION PUMPING RECORDS ano source of in ormation: nq System pumped as part of inspection: (yes or no) If yes, volume pumped. M11 a Ion Reason for pumping: TYPE OF STEM 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) Other(explain) APPRO (MATE AGE of all components, date installed (if known) and source of information: rage odors detected when arriving at the site: (yes or no) (revised 6/15/95) 5 { pA1LY FLovJ Ito .x 3 336 G:P. D. ; . 5EPT1�- TANK - TA►3 _.... :kSSc_ loo p . . DisPosAL PIT ^- vsr= ►o00 &AL" sC� Sr4•�cT TaTAL Pssi6N- 4Z5 Q'•P• D• -roTAL. DA%Ly ' F OUR = '330 G:P.c:)• :..: .. . P uJ, oQ LESS . . . . .. ... . . . : � .. . � . . _.:_..... N OF �S " : .... . . . . ......... PETER �yGN ' RiCHARn ; o "SULLIVAN A. No.29133. .. BAMR ( _ . Na 24048� _ RST All t Aw --�-�� . , '► Gal. /HY B c� �.�'Pr{c. �'. . • . :. ark I �95.. :�,�� wa7-E2 cE.eri.Cy TH,4r T�'�'F*-r-�/ "/ _ _. ..; y�,�Eov GQMPLY.S W/7717,ME:s/1�E,t;/ "i ' '.:.:. :.�.: .,.;..:: .B,�Xt�•e ,t/!'�;/,vG: �,4AIP ' D1t/�i/!tF F sTAf�LC AMP .eY/Ll.C' �• .��.�..:. _ .. 7 . GOG.4T�,O `1//l''V11V j4 .G1 .4if�r '' TF� //D DE.4U n .T.f/lsmo ils'hO20T..OA46P40Nv.aOV/X�— SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C. SYSTEM INFORMATION (continued) Property Address: 104 Winding Cove Road Marstons Mills ,Mass . Owner: Thomas Classen Date of Inspection j 1 /1 4/9 5 • SEPTIC TANK%V/ (locate on site plan) K Depth below grade:, Material of construction: 2concrete_metal _FRP_other(explain) 41 Dimensions: • ' Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle:_ Scum thickness: 0 Distance from top of scum to top of outlet tee or baffle:_ Distance from bottom of scum to bottom of outlet tee or baffle:_ Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) p wo t o hr e e a r let & outlet tees are in place;Tanlc empty pumpeu Cluriligi Ms tic tank is structurally soun ; o signs ol Ieaxage. QP prasen ime. GREASE TRANS (locate on site plan) Depth below grader Material of construction: concrete_metal _FRP—other(explain) Dimensions: AM Scum thickness:kW Distance from top of scum to top of outlet tee or baffle: AJA Distance from bottom nt <<um tn bottom of outlet tee or baffle:-&& Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth-of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 6/3.5/95) 6 SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 104 Winding Cove Road Marstons Mills ,Mass . Owner: Thomas Classen Date of Inspection:11 /1 4/9 5 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: Material of construction:Wconcrete_metal _FRP—other(explain) Dimensions: "A Capacity: hM gallons Design flow: raA gallons/day , Alarm level:— I_ Comments: (condition of inlet tee, condition of alarm and float switches, etc.) N' DISTRIBUTION BOX:, (locate on site plan) Depth of liquid level above outlet invert: AD Comments: (noted level and distribut.ui. ey�a;, 'dent of`�olids tarn ver, evident of le ag into or out of box, etc.) Distribution box is eve�;lVO, evidence o so, s carry over;no evidence ea age in or out or the box. -no repairs are ne—e-T-ect at THis time . PUMP CHAMBER: (locate on site plan) Pumps in working order:(yes or no)AIJ_ Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc. A49 (revised 8/15/95) 7 SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 104 Winding Cove Road Marstons Mills ,Mass , . Owner: Thomas Classen Date of Inspection: 11/14/9 5 SOIL ABSORPTION SYSTEM (SAS):,,, (locate on site plan, if possible; excavation not required, but my be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number: leaching chambers, number:,Q leaching galleries, number:_Q leaching trenches, number,length: in leaching fields, number, dimensions: 0 overflow cesspool, number:_Q Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) See page 6A CESSPOOLS:Xrr (locate on site plan) Number and configuration: /UA _ Depth-top of liquid to inlet invert: A)IA Depth of solids layer: 104 Depth of scum layer: MR Dimensions of cesspool: T)A •. Materials of construction: ilk Indication of groundwater: Id A _ inflow (cesspool must be pumped as part of inspection) AM Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY:WA (locate on site plan) Materials of construction: Nil Dimensions: Depth of solids:,,_ Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) Nerve-. (revised 8/15/95) 8 � " SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ' SYSTEM INFORMATION (continued) Property Address: 104 Winding Cove Road`Marstons Mills ,Mass . Owner: Thomas Classen Date of Inspection: 11 /14/9 5 SKETCH OF SEWAGE DISPOSAL SYSTEM: • • . include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' Town Water 0 i 7 4,t o i I. DEPTH TO GROUNDWATER Depth to groundwater: feet • method of determination n: See Page 6A. No Water encoun ered at -IJI (revised 8/15/95) 9 11 Y•"If1TT1 YR1T�fTT1SirTt.X'TTfT-'-.T.T.T..T.::'STT:TSTi:TS:S�..'.'l Tri�LZ Ti�T'CT.tip .� ..... .. —. TTT.ttf:�TTTT::S F 'I'UNN OF Barnstable WARD OF HEALTH 1 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART U •- CERTIFICATION -..�. �•••4f•,-T•'.-::f—T.,,R•'.T.TT,1S^n•R:1Stu�ir':.^•fT�r'IT,•T�.'•T.::T�L ITT.1TT�'�TlSfT..riTTTL7rJTr.Crl.sTTifRlJrrRTQTCiCri3TT,R•rRTrT•Trr4•S -TYPE OR PRINT CLEARLY- PROPERTY INSPECTED STREET ADDRESS 104 Winding Cove Road Marstons Mills ,Mass . ASSESSORS MAP, BLOCK AND PARCEL # • OWNER' s NAME Thomas Cla.ssen PA117' D - CERTIFICATION r NAME OF INSPECTOR Joseph P. Macomber Jr. COMPANY NAME J•P•Macomber & Son Inc. COMPANY ADDRESS Box 66 Centerville ,Mass . 02632 Street Town or City State LIP COMPANY TELEPHONE ( 508 775 3338 FAX (508 790 - 1578 rsaesrtra ss„earrer mo�i.�a�rn�� - - m CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposa'l system at this address and that the information reported is true, accurate, and complete as of the time ,of :inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one: XXXXX Systeui PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15 . 3,03 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. System FAILED* The inspection which. I have conducted has found that the system fails to protect the public health and the environment in accordance with Title ,5 , 310 CMR 15 . 303, and as specifically noted on PART C FAILURE CRITERIA of this inspection form . Inspector Signature Date 11 /1'4/95 ' One copy of this certification must be provided to the OWNER, the BUYER ( where applicable) and the BOARD OF ) EALZ'it. * If the inspection FAILEb, the owner or.".operator shall u d within one year of the date of the. inspection, unless allowed ortrequi.redhe m otherwise as provided in 310 ChJR 16 . 305 . nnr.4•.i ,a.._ �y b THE COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION BE IT KNOWN THAT Joseph P. Macomber, Jr. Has satisfied the Department's qualifications as required and. -is hereby authorized to use the title CERTIFIED TITLE 5 SYSTEM INSPECTOR as provided in 310 CMR 15 .340 and Section 13 of Chapter 21A of the General Laws. Issued by The Department of Environmental Protection. June 8, 1995 Acting Director of the ion of Water Pollution Control L 0' 10 r�- ��SMEA G E PERMIT NO. VU LAG E Mg,�r�=ls I N S T A LLER S NAME i ADDRESS ATE foN�T. s U 1 L D E R OR OWNER DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED f /c,D cr, �- /000 a`5]�NG ASSESSORS MAP N0: �`s7 I ` No.. . _.�. `1 PARCEL NO.: i ��- F�$.. _. a" THE COMMONWEALTH OF AAS!MV'HUSETTS BOARD OF HEALTH .........................................OF.............................---...... -..................-.............................. Appliratiun for UinVuutt1 Workii Tonotrnr#iun ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: P .. : =- - • : .- .. . ..... . _ ... .............................-•-•.............. ... Location-Address or Lot No.� ti .._.. /\ Vn ....................... . ............._.._. � -- -•-- ^•---- -ddress....................... .....................................• •. ----•--•----•--.._...._..... I Address dType of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms.._. ..............................Expansion Attic ( � Garbage Grinder ( ) `4 Other—T e of BuildingNo. of persons ............ Showers Cafeteria a' Other fixtures -------------------------------•.-----....--------- •. w Design Flow.............. .........gallons per person p`er day. Total daily flow........-.AS ....................gallons. G: Septic Tank—Liquid capacity-/ gallons Length................ Width._6......... Diameter....6......... Depth................ t 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 ( ) Dosin tank ) Percolation Test Results Performed by. .................................. Date _..____.....:....________........._. aTest Pit No. 1................minutes 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........................ .. ..� ! - Description of Soil � .. .:........a -a. - . --- ....................................................... w UNature of Repairs or Alterations—Answer when applicable............................................................................................... ----------------------------•---•-------------------•-•------•-•-------•......•-------••--•----••-•--------•--•-------------------------------••-------------•---------------------------------...------ Agreement: , The undersigned agrees to install the aforedescribed Iridividual Sewage Disposal System in accordance with the provisions of TITA IE 5 of the State Sanit Code—. e undersi ned further agrees not to place the system in operation until a Certi to of Compliance has ee u bar of health. (� Signed. • ---- — Date jk�t�ionp'*pr ed BY ........................ ............... Date Application Disapproved for the f o wing reasons-------------•--------------•-----...--------•-------------------•-------•-•-----------------------............. N ........................................................................................................................................................................................................ PecmitNo......................................................... Issued_..........................................Date •....... Date ------------------- f No.-- �.._.a �,e FEB............._....._..... r , THE COMMONWEALTH OF MASS.,ACHUSETTS BOARD OF HEALTH .............. .::......................OF......................................... Appliration for Elispasal Works Tonstrnrtinn ramit Application is hereby made for a Permit to Const uct ( ) or Repair ( ) an Individual Sewage Disposal tem ......Scst_..1. t• ..................................¢M� L(J�/`C.- ..............................�................................................... Location-Address or Lot No. r�___ /� � wne`r - �J/Address f Installer C. Address d Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms ______________________________Expansion Attic ( �) Garbage Grinder ( ) Other—T e of Building No. of persons_____-._2._____________ Showers — Cafeteria Q' Other fixtures --------------•------------------------------- w Design Flow............. `_....�_I __...____gallons per person per day. Total daily flow................................................ gallons. WSeptic Tank—Liquid capacity_:` - gallons Length._._.�______.. Width_.-".�_......... Diameter....!�7%........ Depth................ x Disposal Trench—No_____________________ Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank.(- Percolation Test Results Performed by..''a%ss% ! l f._ a -_____----•--------••---••-•--------- Date Test Pit No. 1________________minutes per inch Depth of Test Pit.................... Depth to ground water........................ f� Test Pit No. 2................minutes per. inch Depth of Test Pit.................... Depth to ground water........................ i � Description of Soil....3-........-=-=<"............................-................................................. ............................................................. x --------••------------------------------...................................... •-------------------------------------------------•------------------•-------------•--•-------------------------------- w VNature of Repairs or Alterations—Answer when applicable............................................................................................... ------------------------------------------------------------------------=---------------------------------------------------------------------------------------------------------------------•-•-•----- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of A.ITI.r� 5 of the State Sanitary Code—.`The undersigned further agrees not to place the system in operation until a Certifi to of Compliance has i ee `ee ssued;hy-the ardof health. f, � n Signed_ / :�,- 'Y={=- !``• ? .. l F=` An y r3' v�� \_tS tt. ' ............... ........................................1 Application Approved BY ._..._... ... Date Application Disapproved for the f ollo ing reasons--------------••--••-------------------------------------------•------------------------•--..._..•----•••_---_._ .......................................................................................••- Date PermitNo......................................................... Issued-....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD O.F�f HEALTH ... ^,1..........OF.....I&:1-�`-: (Irrtif iratr of f�lant littnr�e THIS IS TQ CERTIFY, That the Individual S�gSe Disposal System constructed ( ) or Repaired ( ) Installer at-------------•-`-.-'-`�---..---------`{-.......------ �-.!_."�....�`� C� w�`...._ I� y 1 } r"� � - has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code d scribed in the application for Disposal Works Construction Permit No._-_________ ___�:�t� dated............. Pv................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFAOR y. .�- .1 DATE... ........ ......... - _._.. Inspector----------.......----------...._.....-----•--------....._._._...._._..--------•---• , THE COMMONWEALTH OF MASSACHUSETTS _ ~BOARD OF HEALTH"J �f ~.. r NO.........................�� ...........................................OF......w�-�'.._.........___..____....._........ ._......_........___............. FEE........................ Di nsttf arks Tunstrnrt' n f amit Permission is ereby granted---------------------o _V,-\�J---------. _7T�..__F'..... 4 :. ................. to Construct pr Re it ( ) an Individual Se`v�=age Disposal Sy�4em r ; f� Street as shown on the application for Disposal Works Construction Permit No.... ..7_ Dated___�_: ....................... -- > -----....---•-._...-•--------- V�-------->---------- I { -�- ,1 Board of Health DATE---=------ - -�`-.-.-J-'---........................................... FORM 1255 A:M. SULKIN, INC., BOSTON '- .t O r 494ss P'TER it Y„ 2 _ ... RICHARD. Sf-I- o SULLIVAN A. No. 29733 o BAXTER o �No.2ao48 A�O,� ST& � i �@° F �. i �'s'S/ YAL�`eG` �ISTE�y Zg , 51 s: •. } , one '.' tsKe 97, i 06 5�9 .3 I 23 ~ 'I 1 rLG7 ` 'GAMILY - 3 6Cp2ooM __ _..__.. . . .._ .. . .. No GA lZ8AGG Cr?-i l uC2.. PAILY FLOW a 110 .x 3 s 33o G..P D. • 5EP1-t c. TANK- 330 x 156 fo *49S G,P.o usG00 i �°►L...TAIJK. . . 0 D%S POCAL PIT V SE 1000 6-AL. 151 OSWAU` AMZGA ' 375". C3: P. O, So 5. F. x I.o ?oTAL PC516N = 4ZS- o- P• D. . ToTAI DA%LY ' F-i_oW.= 33o G;P.O. PE, _, RATE 1 ui►•I Z M!�, oR* L65S . ... PUP yam'j g. . .." RICHARO �. SULLIVAN A. .y BAXTER No.29733 No.24048 74P-HoA.E JIM n'��r.,ta,../ - E�.i�_ mil. :1•,' Ta�F/ Nod L.. :KL.� s ! /.Yt/. zz �U3�iL ( t�" Disc ! �C'GO .,,• ZA to I •, , ; ; : ;; GAL • . ox �.� . - ... ._ taAc.N39.. rH 1 _ r � 5�/D •• 7o WiSHC-D Ei , . v, /:«.eTi,�Y Tf/,QT Tye' /fir/�✓'SHow.v_,:: :_, , //E,L�EON GOMPLY.f G 17W 7 VW,S/dEAl v , t - BgXT�,2'f'iVYE/�vG AN�.SETI�/�G,� ,2�QV/,C�Ek1ENT.S O� Tiy� _ ',2EcsisT .P�D �tivo.St�.eYEy?�, 5 - � 3-z�- T.f�lt P iv'/s 'iS/oT.I�AfEO an/.QiV/rY.ST,tz- rd�IEiYT.�v,2�/GY�tit/O '•.ShbGY�f�E.e�ON,•S.4�Gt/�.�NET ErE U.SEp