HomeMy WebLinkAbout0022 WOODCREST ROAD - Health 22 Woodcrest Road
Marsions Mills; P y
\ A 030 075^
ii
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3>
Property Address
Owner G l R d`I -o
Owner's Name
required for
is every
f ,/S D� r L
required for eve lr( a /�--/'�. Z / /
page. City/Town State ZipCode
Date of nspe tion
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. General Information
filling out forms
on the computer,
use only the tab 1 Inspector:
key to move your
cursor-do not
kee the return Name of Inspector
y �Gf�
4:1
Company Name
Company Address
City/To !J 6 zo
�v� State � Zip Code
Telephone Numbe �(• Number
Number p�
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 systerns. I an, a DEP approved system inspector pursuant to Section 95.340 of
Title 5(310 15.000).The system:
Passes ❑ Conditionally Passes ❑ Fails
❑ Nee Further Evaluation by the Local Approving Authority
Inspecto 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 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
p coon does not address how the system will perform in the future under
the same or different conditions of use.
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
�0ali rs
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-lNot for Voluntary Assessments
>• �- Uoo d C I-ef s2c�
Property Address /
Owner G b �
Owner's Name
information is /
required for every ar.� � /O /
page. City/ oa 6 rown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) Syste asses:
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.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage
Disposal System Form -Not for Voluntary Assessments
14 c�
Property Address A
Owner Owner'sC W1 C.(&1.f
Name
information is �
required for every C Pr ✓!1 1 0, 0
page. City/Town State Zip Code Date f In pec on
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
Pumps/alarms are repaired.
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins.doc•rev.6116 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 3 of 17
l
Commonwealth of Massachusetts
a Title 5 Official Inspection Form
R Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address '
Owner !wne:esName bV1 f 11 A km-f
information is
required for every 4vts
page. Cityrrown State'l Zip Codev O Date of I pecti
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
I
ogged 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
❑ goo 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.doc•rev.6/16
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
"s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address wIood c/•{f
Owner G "" (�C►
Owners Name
information is
required for every
page. City/Town State Zip Code v Date of I pecti in
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:
❑ ny 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.
❑ ny portion of a cesspool or privy is within a Zone 1 of a public well.
❑ y 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.]
❑ e 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 1,5.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd:
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
L
Commonwealth of Massachusetts
e Title 5 Official Inspection Form
Subsurface Sewage Disposal System
,Form - Not for Voluntary Assessments
00 d�C 1,,ex 4-
Property Address led
Owner
information is Owners
required for every6 t fy /u
Date of I spe ioff
page. Cityi I own State Zip27
Code
C. Checklist
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes �001 -
1111
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?
❑ as 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): Number of bedrooms (actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): J �O
t5ins.doc-rev.6/16 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
~ J-a �Ioo dc re s � i4?d
Property Address
Owner
information is
Owner's Name
/§ v
required for every GtrS �eJ � / I�j
page. City/Town State ZipCode /
Date Ins ction
D. System Information
Description:
WL
4/�
C;- l0
Number of current residents:
Does residence have a garbage grinder?
El Yes
Is laundryJo
on a separate sewage system?(Include laundry system Inspection
information in this report.) ❑ Yes No
Laundry system inspected? ❑ Yes [4- 1�0
Seasonal use?
❑ Yes iVo
Water meter readings, if available(last 2 years (gP ))usage d :
Detail:
Sump pump?
[� Yes No
Last date of occupancy: (A✓/e•ti
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
W 00 C/'e l
Property Address �� ��
Owner Owner
s Name
information is
required for every
page. City/Town State �L Zip Code Date of In ectio
D. System Information (cont.)
Last date of occupancy/use:
Date
Other(describe below):
General Information
Pumping Records: �1
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 S em:
Septic tank, distribution box, soil absorption system
LJ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form--Not for Voluntary Assessm nts
��Property Address
Owner
Owner's Name
information is ' !�required for every (�/f4mj S OJ 6"� / /J
page. City/Town State Zip Code Date of spe ion
D. System Information (cont.)
Approximate age of all components, date installed(if known)and source of information: ?07/V
l a �• D��9 r rl�L �i� �✓ .��S
Were sewage odors detected when arriving at the site? ❑ Yes o
Building Sewer(locate on site plan): /
Depth below grade:
feet
Material of constructi�40
❑cast iron PVC
❑ other(explain): / l
Distance from private water supply well or suction line: ` G
feet �
Comments(on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade:
feet
Materia construction:
concrete ❑ metal ❑fiberglass ❑ polyethylene y ❑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: S
Sludge depth:
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
( /00 dc I-es
Property Address
Owner
information is /�✓/ V o�b��
required for every �/�
page. City/Town State Zip Code Date of In p
Owner's Name
h f
ect' n
D. System Information (cont.)
Septic Tank(cont.) /
Distance from top of sludge to bottom of outlet tee or baffle `
Scum thickness LA V7
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined? gk7lo--n e(/(C
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,
liquid levels as related to outlet invert, evidence of leakage, etc.): structural integrity,
aw 4, 014
4 LOH it?!or7
Grease Trap(locate on site plan):
Depth below grade:
feet
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑polyethylene
El other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
Date
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
A Subsurface Sewage Disposal System Form-Not for Voluntary Assessmen s
(A-laodc es7-
Property Address �_ / /
Owner Owner's Name v"/l Il l G�1
information is � &pectic
required for every Ci/,s ,/i S � //✓f/� /
page. City/Town State Zip Code Date of I
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 9 ❑polyethylene El 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.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage DisposalSystem Form - of for Voluntary Assessments
Property Address � G�'!
Owner W l! I G
Owner's Name /
information is
required for every /J'4 of f f 04`C�� / /� /
page. City/Town State Zip Code Date of I
D. System Information (cont.) pectl
Distribution Box(if present must be opened) (locate on site plan): /
Depth of liquid level above outlet invert
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
te
So lT,,�
//0
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.doc•rev.6/16
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 '
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^
Property Address d �G
TI
Owner c C✓I /1( a d`1 s
information is Owner s Name
G,i
page required for every KS /�S �v l/y'(o Apage. City/Town -Zip Code
Date of inspe ion
P
D. System Information (cont.) State
Type: CO v► �/� c�plf L??b
❑ leaching pits number:
❑ 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.):
�� •�s rGw!r c �e ne .
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
t6ins.doc•rev.6/16 Title 6 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
dic re,f- f
Property Address ,- /
Owner
information is Owner's Name
required for every �jt/��(itf / / s e9c�6
page. City/Town State ZipCode �O
Date of In ecti n
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.doc-rev.6/16
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
r ��
6/oo dc-/?S� ,-
Property Address /
Owner C t/✓
information is Owners Name
required for every / �Kl I �s
A4
page. Cityfrown State Zip Code U Date/of nsp ction
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two pe3gaent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where pub' ater supply enters the building. Check one of the boxes below:
and-sketch in the area below
drawing attached separately
I
1114 ^�✓ r/
33
/4 /`�
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Property Address rx ZA,
Owner Owner's Name
information is /
required for every �YS &IJ �/ zV Ua-6Q,-- / to /
page. Cityfrown State Zip Code Date of spe tion
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
❑ served site (abutting property/observation hole within 150 feet of SAS)
Checked with Ioca� I Beard of Health —plain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must ribe how yo establilished the high ground water elevation:
4 CA
0OG
/1117
C i4o
r 14H
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins.doc-rev.6/16 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
c7 i(i✓oo cJG�s�
Property Address /
Owner G �l 6 l G 110�
Owner s Name
information is / S //d e��! r-
required for every a� �1 '„rti
page. City/Town State Zip Code
P Date of In ectio
E. Repo Completeness Checklist
Inspection Summary:A, B, C, D, or E checked
Inspection Summary D(System Failure Criteria Applicable to All Systems)completed
LJ
o
5 em Information—Estimated depth to high groundwater
Sketch f Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 17 of 17
it
WIN
COIIIIUNtt-E_�L1'H OF NLASS 1CHC SETTS
(:T EXECUTIVE OFFICE OF E\t7R0\`_1,rE\TAI <kFFAIR`
DEPARTMENT OF E-2\1ZRONTMENTAL PROTECTTO
'TITLE 5
OFFICIAL INSPECTION FORA—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAI. SYSTEM FOR11
PART A 1
CERTIFICATION
Property Address: C)_C� W oO�CiesT A01
�r ohs /l4 Oa.6, ?
Owner's Name: G r.j SC,
Owner's Address: cZ. - oo Cres71 L✓
rt o HS /1J�y/S 9 aA d S
Date of Inspection: 6 ( o
Name of Inspector• (please print) Grlf
Company Name: L—`/Y!/i p — T'E'G y
Mailing Address: ro
Telephone Number6�_ s 77[flf t
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information rr ortedw_,
below-is true, accurate and complete as of the time of the inspection. The inspection was perfornedabased on', y
training and experience in the proper function and maintenance of on site sewage disposal systems '�m a D& co
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The sysre`ni:a
6:
Passes
Conditionally Passes tv va
Needs Further Evaluation by the Local Apgro-vir�*- ntherri: cn
Fails `
.Inspector's Signature: � Date: 6 6 O
The system inspector shall submit a copy of this inspection report to the Approving Author.-,",,,-(Board of Health or
DEP)"within 30 days of completing this inspection. If the system is a shared system or has a design +c
pd or greater, the inspector and the system owner:hall subnut the report to the arproprate DEP. The orizinal should be sent to tine s��s'em owner and copies sera to the bu,:er, if a plicaele. and it e
_uthor ty: .
and Comments
""This report onl describes conditions at the time of inspection and under the conditions Of uq at that
ime. This inspection does not address hobs the s%-stem Will
cunrlition� of trse. perform in the future under the same or different
Page 2 of I 1
OFFICI-aL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SELVAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
^� CERTIFICATION (.continued",continued
Property address: �OL 6,looc/JGl-P,s4 Rd
Owner:
Date of Inspection: p'
Inspection Summary: Check A.B,C,D or E ALWAN'S compleie all of Section D
A. �S�stPasses:
I have not found any information which indicates that any of the failure criteria described in-310 0 R
15.303 or in 310 C),IR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
B,.�/Svstem Conditionally Passes:
14 One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired.The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,i\,N,-D)in the 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.
ND explain:
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(:- ith
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or rep'aced
ND exoiain:
The system t.-quired pumping more than 4-imes a year due to broken or
pass inspection if(with approval of.he Board of Health):
—broken pipe(sI are replace-'
obstnsction is ren:cv ed
;��^•<p;air:
Pace= of 12
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SENVAGE DISPOSAL SYSTE1I INSPECTION FORM
PART A
CERTIFICATION t contii-uedl
Property Address: C)-oZ 1/00�Ci?S4 /Q"J -
V7
Owner• S�c
Date of Inspection: (p 6 0
C.�f Further Evaluation is Required by the Board of Health:
V Conditions exist which require further evaluation by the Board of Health in order to determine if e s�stem
is failing to protect public health,safety-or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CAIR 15.303(1)(b) that the
system is not functioning in a manner which will protect public health.safety-and the environment: _
_ Cesspool or privy is within 50 feet of a surface water
_ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any-) determines that the
system is functioning in a manner that protects the public health,safety and,environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary-to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone I 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
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 f et 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 lbboraton-. for coliio:-m
bacteria and volatile organic compounds indicates that the veil is free from pollution from that facility-and
the presence of ammonia nitrogen and nitrate nitrogen is equal.to or less than 5 ppm provided that ro other
failure criteria are triggered.A copy of the analysis must be attached to this form.
3. Other:
Pj�Te 4 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNT—RY ASSESS-NIENTS
SUBSURFACE SE«'AGE DISPOSAL SYSTEM INSPECTION FORA
PART A
CERTIFICATION(continued)
Property Address: �� �/Oo�✓ /Qr� ��
0-wrier: SCo
Date of Inspection: s'o O
D. System Failure Criteria applicable to all systems:
You must indicate"yes" or"no"to each of the following for all inspections:
Yes No
r/ Backup of sewage into facility or system component due to overloaded or cloC?ed SAS or cesspool
V Discharge or ponding of effluent to the surface of the around 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 cloa2ed SAS or
cesspool "
squid depth in cesspool is less than 6",below"invert or available volume is less than 1�day flow
_ _
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).\umber
�f times pumped
Any portion of the SAS, cesspool or privy is below high ground water elevation.
v Any portion of cesspool or privy is within 100 feet of a surface water supply-or tributary to a surface
�ater supply.
ny portion of a cesspool or privy is within a Zone 1 of a public well.
�knsportion 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. t
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm;provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
/V (Yes;10)The system fails.I have determined that one or more of the above failure crteria exist as
described in 310 CNIR 15.303,therefore the system fails. The system owner should contact the Board of
Health to deternune 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 flour of IM00 gpd to 15.000
gpd•
You must ndicate either"yes"or`no"to each of the foLewir.2:
fThe following criteria apply to large systems in addition to the criteria above)
:rs :o
the system is �yinhin 400 feet of a surface drinkire .eater s:;ur_!v
the system is within 200 feet of a tributary to a surface d_ )king«Ater supply
-- — lane s vstem is located in a nitro?en sensitive area llntcrir �V_-ilhtad Pr .e ,;,Jn A:` _
one II of a;ublic.water supp?y'•yell
_nu ..a�.e an sere; %es" to an,.question in Section E .ae s. 4 reu - - -
YJ i;t \. D 4h sieTr,Is cOraiu? < ?rii ;•_�i_, ---. _
colon o�e the large s,.s..n:„ 'ed. The -
i� -v[ 1er�e ti - -r n r a J
e apprcpriare
l
Page ` of i 1
OFFICIAL INSPECTIO\ FORM-'SOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SER AGE DISPOSAL SYSTEM I\SPECTIO- FORM
PART B
/ CHECKLIST
Property _address: r�� (,�/OG�CIPJ4 RCj
Owner: Sao
Date of Inspection: G Off^
Check if the following have been done" You must indicate"yes"or"no"as to each of the tollo,,vii g:
i
�'A�_- o
Pumping information was provided by the owner, occupant, or Board of Health
� ��ere any of the system components pumped out in the previous two weeks
Has the system received normal flows in the previous two week period'?
�ave 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\:,-k)
Was the facility or dwelling inspected for signs of sewage back up?
fWas 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-?roper
maintenance of subsurface sewage disposal systems'?
L
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no��
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
is unacceptable) f310 CNIR 15.30_2(3)(b)i
t
Pa•e6of11
OFFICIAL INSPECTION FOR-1I—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SENVAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFOR-NIATION
Property_address: 02-z (,✓0"C'/C1'-'4 4ec—i
G rs' �^S �•�fl ���
O«ner• SC 07 '
Date of Inspection:.
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): .2 Number of bedrooms(acraal'l:
DESIGN flow based on 310 C�II,Z 15.203 (for example: 110 gpd x--of bedrooms}: 3�a
Number of current residents:�_ --
Does residence have a garbage grinder(yes or no):/YQ
Is laundry on a separate sewage system(yes or no): �cif ties separate inspection required'
Laundry system inspected(yes or no): 1/�
Seasonal use: (yes or no):
`ti"ater meter readings, if available(last 2 years usage(gpd)):
Sump pump(yes or no):
Last date of occupancy: -7L—
COM-NIERCIAL/IN Dti STRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gYpd
Basis of design flow(seatslpersonsrsgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings; if available:
Last date of occupancy:'use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: X-19
Was system pumped as part of the inspection(yes or no):140
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
_O"-�-rt ow cesspool
_ Prit'v
_ Sitar cd systc'I,1 I yes or ro? (if yes. attach pr,vious inspection r,,orus.
iM-vatiye AltcrrlatiVe tecllnolcgy. Attach }p`:Of. t r• .1 -
3 .e urren. ,pc dI:J^ _ -
clfainei from s,,stem owner) "• `..`-..__..�..�_ _ -- .
_Ti ht-ank ----attach a copy of fir:DEP approval
— O-her(describe i.-
.\pproxii-nate a`c Oi a1i cot,1p 0 Lrts. date
�
i '
Pare - of 1 I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SENVAGE DISPOSAL, SYSTEM INSPECTION FORM
PART C
^� SYSTEM INFORNIATIO`(continued)
Property address: C7`d �Iov C,-e.I� R�
X!n�0,vvner• n
Date of Inspection:
BUILDING SERVER(locate on site plan)
Depth below•grade:
Materials of construction:— ast iron 40 PVC_other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting, evidence of leakage,etc.):
SEPTIC TANK:_(locate on site plan)
Depth below grade:
Material of construction: _-oncrete_metal_fiberglass polyethylene
other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a cope of
certificate)
Dimensions: �s'Xe '
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle: �fl
Scum thickness: oZ
Distance from top of scum to top of outlet tee or baffle: 6 ,�
Distance from bottom of scum to bottom�f outlet tee or b ffle:
How were dimensions determined: �`✓✓, iC
Comments(on pumping recommendations,inlet and outle ee or baffle condition, scucrsral nte?rity, liquid levels
as related to outlet inveL . evidence of�eakage, etc.): //
�H ctii in H0 `fEE%G'2 y os� 7"�itf �!�'!Pi %a..L� Cv. d
Ices
GREASE TRAP: locate on site plan)-
Depth below. grade:
Material of construction:_concrete_metal_fibe-class_pCt -ethvile-e
(explain):
Dimensions:
Scum thickness:
Distance .ro ,iop ;fs,7.ml to t%Ip of out'_:ie_ e~
Distance -rorn boom of scum to bottom of outlet tee or baffle:_
Date of last pumpin : .
Comments (on pumptn'd recommendations. inlet and outlei ree or battle cc`;"Jlvon. si—u--' -
aS relate` To 01.:I1 t i^\ ^. el.','der: e of'eaka''e. etc.).-
1-�r':., � ,.-,...•r;.,.. -..,,,, G C ter.."��
I
Pazc S of 1 1
OFFICLaL INSPECTION FORM-NOT FOR VOLUNTARY ASSESS-MENTS
SUBSURFACE SENVAGE DISPOSAL SYSTEM INSPECTION FOR11
PART C
SYSTEM INFOR-IATION(continued')
Property address: 0�oz G✓DodC"eS� Qd
O-*N ner:
Date of Inspection: p
TIGHT or HOLDING TANK: IV(tank:must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal tiberelass_polyethylene othmexplsin):
Dimensions:
Capacitv: gallons
Design Flow-: gallons day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: C/�ofp"sent must be opened)(lecate on site plan)
Depth of liquid level above outlet invert: NO✓dti a Z -
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover. any evidence of
leakase intq or out of bo etc.):
P, V4?1/, /Ud So/f C il/o e a s
PUMP CHAMBER: 4 (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
J
Pa_:e9of11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION icontinued)
Property address: cka 4,lovdClvPr
�Y �s 2 ,71
O«•ner: sco
Date of Inspection:
SOIL :ABSORPTION SYSTEM (SAS): (locate on site plan. excavation not required)
If SAS not located explain why:
Type
leaching pits, number:_ I ..�./ (J�+��a���,�
leaching chambers.number: `�
leaching galleries,number: 9�f n�.,
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, damn soil, condition of-,-e_etat-on.
etc.): � /' // `
OhQ G✓L ✓� o/ / (i/f -vi Crr.�cf �i
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 laver:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil;signs of hydraulic failure. level of ponding. condition cf vegetation. et
PRIVY: (locate on site plan)
Materials of cons.:,action:
Dimensions: _ ---
Depth of solids: -- — _
l.(�rrnwnts (note ct}ncllr'on of soil. si m; of ii%drawIl i 3l t:re
c , a .
Pa,z 10 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SlSTE1'I INFORMATION(continued)
Property Address: czc�_ 6LI00
G✓1 nl .� /L!/�- r
O%vner• �Co
Date of Inspection: b U
SKETCH OF SE«'aGE DISPOSAL SYSTEM
Provide a sketch of the see\age disposal system including ties to at least nvo permanent re`erence landmarks or
benchmarks. Locate a;l Nxells within lot) feet. Locate where public eater supply enters the building/4 J 196 -212
l
?' i1 of I
i
OFFICLAL INSPECTION FORA-NOT FOR VOLLNTARX" ASSESS-\IE\TS
SUBSURFACE SEWAGE DISPOSAL SYSTE-M INSPECTION FORM
PART C
SYSTEM INFORM aTION(contiruedl
Property address: C
0,* ner: J C o
Date of Inspection: 0
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells � 109,
Estimated depth to ground water feet
Please indicate(check) all methods used to determine the high ground water ele-,-ation:
Obtained from system design plans on record-If checked, date of design plan re-,iew-ed: _
r•ed site(abutting property;'observation hole within 150 feet of SAS)
Checked with local Board of Health-explain: �O _<'
Checked with local excavators, installers-(attach documentation)
Accessed L SGS database-explain:
You must describe how you established the high ground wa�t. r elevation:
I r «C7 G a,�ro H it 5�
eve
r,,
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTE ,'d*F `I"S;ABLE
sy erU R 28 Phi 2. 48
If,ION
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION AP
Property Address: W oa-- (2-�''7 e j�
Owner's Name: n A �5.1 '
Owner's Address: ,,�C ��
. 9 3 JUyc�
Date of Inspection: i U
Name of Inspector.G(PlfaseZ1 Pn ) b
Company Name: ty ,J ,t d I
Mailing Address:
x
�GLi') rf
Telephone Number. 47ski L EE
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
Passes
Conditionally Passes
F Needs Further Evaluation by the Local Approving Authority
'
Inspector's Signature: Jam ) ( �,, --
Date: t t�j
The system inspector shall submit a copy of this' on 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, d the app
authority.
Notes and Comments /�'�}
****This repo y 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,
t
Page 2 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
RTIFICATION (continued)
Property Address: o� �d ej r
Owner. ��C�'3 � ! w <56
Date of Inspection: v —
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
k/ I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 3I0 CUR 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.
Answer yes,no or not determined(Y,N,ND)in the 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)i
unsound,exhibits substantial infiltration or exfiltration or tank failure is innmmen.System will s strnciurally
pass inspection ffthe
existing tank is replaced with a complying septic tank as approved by the Board of Health
A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water Ieve]in the distribution box due to broken or
Obstructed pipe(s)or due to a broken,settled or uneven distribution box System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required Pumping more than 4 times a year due to broken or obstructed pass inspection if(with approval of the Board of Health): pipe(s).The system will
broken pipe(s)are replaced
obstruction is removed
ND explain:
f
Page 3 of I I
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
1 CERTIFICATION(continued)
Property Address: �(( t.%
e--j--"� ire*7--d�� j ! c�a2 6 I
Owner. n—& l ^ ,
Date of Inspection: 3 v-)`
Vrther 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.
I. 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
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 anal
bacteria and volatile or ems'performed at a DF_P certified laboratory,for coliform
gamic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered.A copy of the analysis must be attached to this form-
3. Other. Aiz
C
L .
Page 4 of l l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 02 �vv JL, e
. F ,
S
Owner.
Date of Inspection: -7 -13
D. System Failure Criteria applicable to all systems:
You most indicate`dyes"or"no"to each of the following for all inspections:
Yes No
_ _v 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
"I:iquid depth in cesspool is less than 6"below invert or available volume is less than y2 day flow
— - �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 tnbutary to a surface
water supply.
-_ ✓Any portion of a cesspool or privy is within a Zone 1 of a public well.
y 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 coliform bacteria and volatile organic compounds
indicates that the well is flee from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis most be attached to this form.]
L_(Yes/No)TMe 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.
K Large Systems:
To be considered a large system the system must serve a facility with a design flow of l0,000 gpd to 15,Oo0
gPd-
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
— L�the system is within 400 feet of a surface drinking water supply r
— the system is within 200 feet of a tnbutary to a surface drinking water supply
_ t/the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWpA or a
Zone H of a public water supply well ) mapped
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
significant threat under Section E or failed under Section D shall operator of arty Large system considered a
I5.304.The system owner should contact the a upgrade the system in accordance with 310 CMR
appropriate regional office of the Department.
Page 5 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
Owner-. �N<<rs dJ � - -�I.'��S ��j�S S 0-2 6
i
Date of spection:
Check if the following have been done_You must indicate`fires"or"no"as to each of the following:
Yes N
. 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?
_ .wave large volumes of water been introduced to the system recently or as part of this inspection?
t� 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?
-L�— Was the site inspected for signs of break out?
-LZ_�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
o the taffies or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
,4 Was the facility owner(and occupants if different from owner)provided with information on the r
maintenance of suhsiuface sewage disposal systems? p
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
-Le"' 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 i
is unacc s at issue approximation of distance eptable)P 10 CUR 15.302 3
Page 6 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
nnSYSTEM INFORMATION
Property Address: �C}Uc7 d�C•-�ec,_/��
'l�l 1e-I.1jS !�Lz(0
Owner:
Date of Inspection:
FLOWCONDITIONS
RESIDENTIAL
Number of bedrooms(design): .3 Number of bedrooms(actual):
DESIGN flow based on 310 CUR 15.203(for example: 110 gpd x#of bedrooms): 3 c�
Number of current residents:L—
Does residence have a garbage grinder(yes or no): A)J
no
)
Laundry system fif yes separate inspection required)
Is laundry on a separate sewage system(yes or
inspected(yes or no):
Seasonal use:(yes or no): $,J J
Water meter readings,if able(last 2 years usage(gpd)): ,vZ)
Sump pump(Yes or no): O j
Last date of occupancy: ,
COMMERMLANDUSTRIAL'
Type of establishment: �VA
Design flow(based on 310 CUR 15.203):
Basis of design flow(seats/persons/sgft,etc_):
Grease trap present(yes or no):_
Industrial waste holding tank present(yes or no):_
Non-sanitary waste discharged to the Title 5 system(yes or no):—
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
Pumping Records
GENERAL INFORMATION
� ^?Source of information:
Was system pumped as part of the on(yes or no):2
Ifyes,volume pumped:70 —How was gran pumped determined?
Reason for pumping: _
v
V 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)
Tight tank _Attach a copy of the DEP approval
_Other(describe):
Approximate age ofAll coy",sentq. da installed(if]mown)and so
onmation
c PL ( L
Were sewage odors detected when arriving at the site(yes or no):ZOO
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
P `tY • �� t
Pro a Address. I 1� JQ
Owner. -12^. '1�
Date of Inspection: }
BUILDING SEWER(I on site plan)
Depth below grade: /�V/
Materials of construction: cast iron 40 PVC other(explain)_
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK:—(locate on site plan)
Depth below grade:
Material of construction: L--65—ncrete metal fiberglass_polyethylene
other(expIain)
If tank i metal list age:_ Is age confirmed by a Certificate of Com
certificatt e) Pliance(yes or no):—(attach a copy of
Dimensions:
Sludge depth:
Distance from top of sludge tp bottom of outl tee or baffle:
Scum thickness:
Distance from tOf of s to top of outlet tee or baffle:
Distance from bottom of scam to bottom of outlet tee or e:
How were dimensions determined:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition'structural inte liquid levels
as related t outlet * ert,evidence of leakage,etc.): gnu'
GREASE TRAP:%ocate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass_polyethylene other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on Pumping recommendations,inlet and outlet tee or baffle condition'structural irate
as related to outlet invert,evidence of leakage,etc.): integrity,liquid levels
I
Page 8 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: �
L
rl S v�6
Owner. it ac.
Date of Inspection• "—
TIGHT or HOLDING TANK: (tank mast be pumped at time of i nspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass y
_.polyeth lene other(explain):
Dimensions:
Capacity:— Pa-ions
Design Flow: gaRons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: `�{if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
PUMP CHAMBER k�ocate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of and
pumps appurtenances,etc.):
Page 9 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
5
Owner: q ti c, ,o ,
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS notlaqated exp n why:
Type
leaching pits,number._
leaching chambers,number
teaching 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.):
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 or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: el
(Iocate 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.):
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner: „ r
Date of Inspection-
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building.
U
0 X
C
i
g 3� � die-ul'
AC 313 0-- -W
9 ��
Page 11 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: da t9,0 co, 11-e S
Owner:
Date of Inspection: met ` ' 4316
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water -30 feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
,.-*'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)
_,—.,Kcrossed USGS database-explain:
Y ust descn'be how you established the high ground water elevation:
C-i 5
Date: 1
TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM
NAMEOFBUSINESS: ) t
BUSINESS LOCATION: 2- C 8, 2.S M1Whn6- fiWas l '�f, d�6 �
MAILINGADDRESS: Mail To:
TELEPHONE NUMBER: 928- 06 Iq Board of Health
RSf �� Town of Barnstable
CONTACTPERSON: �lV L U . P.O. Box 534
EMERGENCY CONTACT TELEPHONE NUMBER: Hyannis, MA 02601
TYPE OF BUSINESS: Hnusc :2 4
Does your firm store any of the toxic or hazardous materials listed below, either for sale or for you own
use? YES _, NO
This form must be returned to the Board of Health regardless of a yes or no answer. Use the enclosed
envelope for your convenience.
If you answered YES above, please indicate if the materials are stored at a site other than your mailing
address:
ADDRESS: 22 l ookQfJ5+ RJ , OAAIU+0/U S fn(j •
TELEPHONE: 6 U% - q a s -
LIST OF TOXIC AND HAZARDOUS MATERIALS
The Board of Health has determined that the following products exhibit toxic or hazardous character-
istics and must be registered regardless of volume. Please estimate the quantity beside the product that
Y
ou store. NOTE: LIST IN TOTAL LIQUID VOLUME OR POUNDS.
Quantity Quantity
Antifreeze(for gasoline or coolant systems) Drain cleaners
NEW USED Cesspool cleaners
Automatic transmission fluid Disinfectants
--Engine-and-radiator flushes- ---- Road Salt (Halite) -
Hydraulic fluid (including brake fluid) Refrigerants
r Motor oils Pesticides
✓ NEW USED (insecticides, herbicides, rodenticides)
Gasoline, Jet Fuel Photochemicals (Fixers)
Diesel fuel, kerosene, #2 heating oil NEW USED
Other petroleum products: grease, Photochemicals (Developer)
lubricants, gear oil NEW USED
Degreasers for engines and metal Printing ink
Degreasers for driveways & garages Wood preservatives (creosote)
Battery acid (electrolyte) Swimming pool chlorine
Rustproofers Lye or caustic soda
Car wash detergents Jewelry cleaners
Car waxes and polishes Leather dyes
Asphalt & roofing tar Fertilizers
if Paints, varnishes, stains, dyes PCB's
_V _� Lacquer thinners Other chlorinated hydrocarbons,
_-- NEW USED (inc. carbon tetrachloride)
Paint & varnish removers, deglossers Any other products with "poison" labels
Paint brush cleaners (including chloroform, formaldehyde,
Floor & furniture strippers hydrochloric acid, other acids)
Metal polishes
Laundry soil & stain removers Other products not listed which you feel
(including bleach) may be toxic or hazardous (please list):
Spot removers & cleaning fluids 7
(dry cleaners)
Other cleaning solvents
Bug and tar removers
WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS
TOWN OF BA_LRNSTABLE
LOCATION A �Wn- yPRP4A ?c/• ClAd SEWAGE # Z-ft -S-)
VILLAGE ('(401 1 ASSESSOR'S MAP &LOT Loll 16
INSTALLER'S NAME&PHONE NO. 0AA 't ToC uta TIC . (,90$)36;t-.4991
SEPTIC TANK CAPACITY 1000-q A]
LEACHING FACILITY: (type) .3 rni,-,+Ae-+o f 33OS (size) Z-
NO. OF BEDROOMS 3
BUILDER O O R
PERMITDATE: 9 -11 -0 d "e 1 COMPLIANCE DATE:
Separation Distance Between the::,
Maximum Adjusted GroundwateTable 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
Furnished by
S�
P
O
• 4
y TOWN OF B.AFtq
STILE
< /LC?CA`FION �m �,PPS [� ��f�1 — SEWAGE # Laub=
�.rz�U1 � 4 ,
/ ...,
Vr LAGE �r�1rU 1 f ASSESSOR'S MAP &LOT 1, 16 360�S
INSTALLER'S NAME&.PHONE NO. l A4l `T TrUd tea T C. (S'0,'),36;--9AA 1
SEPTIC TANK CAPACITY _1ddC�QR]
LEACHING FACILITY. (type) , Cei-k A`+ar 8305 (size) 7, S X r 0. 3'x �-
NO. OF BEDROOMS
BUILDER O R
OC
'ERIvIITD'ATE C&OLTANCE DATE
Separation Distance Between the:
Niazimum Adjusted:Groundwater Table and Bottom of Leaching'Facility feet
°Private Water Supply Well and Leaching Facility (If any wells exist
on site or�nthin 200 feet of Ieaclupg facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands'eust
within 30.0,feet of leaching facility)
Feet
Nimshed by
A-c= �3Ack o �Ja�sc
q
A F �
4
T3-E= 3 - .
.i
TOWN OF BARNSTABLE `s
LOCATION SEWAGE #
VILLAGE 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:
t?Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
-Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
TOWN OF BARNSTABLE
LOCATION SEWAGE #
VILLAGE /ryV v a ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO. 1 2
SEPTIC TANK CAPACITY 16 QD
LEACHING FACILITY:(type) /GO d ize)
NO. OF BEDROOMS PRIVATE WELL OR UBLIC WATE
/`
BUILDER OR WNE k/ E
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
t. .'
r
t;/� � �
� �� a
�1' � � ooa ���
o . l ��,���
,
� 3 ,
3' �
y No. v Fee_�o
THE COMMONWEALTH OF MASSACHUSETTS Entered in coinputer: �L
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS Yes
2 pprication for Mio pooar *p5tem Construction Permit
Application for a Permit to Construct( /Repair Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No.Aa w�cq esl xd, Owner's Name,Address and Tel.No.
/0A0es /li 14i/lg •JirAW P_Ljd"LC
Assessor's Map/Parcel wao4 rc r'esi Pot
c Vv
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
6sh'5 Truck o ct� I+ue.
PO•a
MA. 03161f 02
Type of Building:
Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( )
Other Type of Building Stele Csm.ll No.of Persons Showers( ) Cafeteria( )
Other Fixtures J
Design Flow -314 12 ef gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title'
Size of Septic Tank 1660F AY16AY AxysiAu j Type of S.A.S. * I'ul�- y ReCh-4gger �36'S
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
,s o
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issu d y thj oard of Health.
Signed -2 Date />Lo®
Application Approved by Date
Application Disapproved for the following reasons
Permit No. Date Issued
>- ' Fee
No: ✓
Entered in computer:
HE COMMONWEALTH OF MASSACHUSETTS p
r,x���:. .. _._ _ .. .....Yes
PUBLIC HEALTH DIVISION-�TO /N OF BARNSTABLE;MASSACHUS TTSNVI
-
»� Z[pprtcatfon for -Migpogaf *pgtem Congtruction Permit
Application for a Permit to Construct( XRepair Upgrade( )Abandon( ) El Complete System ❑Individual Components
-Location Address of Lot No. r Owner's Name,Address and TO.No. `
Assessorts Map/Parcel 4A W O6d c r-c'Sf Pot,
od ! 0� S
Installer's Name,Address,and Tel.No.. j Designer's Name,Address and Tel.No.
CAshs fiv�k,� Tex. t
'Po.t3ak
W,,,afY"LWrf MA. 02611 CSOS)162-3,121
Type of Building:
Dwelling No.of Bedrooms_3 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building I No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 13 y !9 pd gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank /d60FA/�0AJ 6013 uwa Type of S.A.S. 4 C�,I�r� ReehecT r 3CSf'S ► JX' $�o;
c
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
tAil
Date last inspected: ¢
Agreement: '
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issu thi oard of Health.
Signed 44ZDate //A0 o
Application Approved by :' /C�;Date
Application Disapproved for a following reasons
Permit No. Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed(-V,1 Repaired( )Upgraded( )
Abandoned( )by— (�!aTl 5—TA"tk i 1�o R6,e 0fki 62& r
at has be—en,,pbnstructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. ated
Installer * Designer
The issuance of this permit sh Jof be onstrued as a guarantee that the syste funct' n assig'ned.
Date S �� Inspector
--� __
No. O� � -------------------------Fee
� a� . THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE,, MASSACHUSETTS
Migogal Opgtem Construction Permit
Permission is hereby granted to Construct( XRepair( )Upgrade( )Abandon( )
System located at .2,2J r Jc .-np!g+ Rai 14 ang6A A K I I k
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:ConstructioA must 6e completed within three years of the date of this p
Date: Approved by
1/6/99
NOTICE:' This Form Is To-Be Used For the Repair Of Failed
Septic Systems Only.
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PL�_LSi
1, r g A hereby certify that the application for disposal works
construction permit signed by me dated Q117lOd , concerning the
property located at 9A (,Lbag/r2e A,es //s meets all of the
following criteria:
• This failed system is connected to a residential dwelling only. There are no commercial or business
uses associated with the dwelling.
• The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch.
• There are no wetlands within 160 feet of the proposed septic system
• There are no private wells within 150 feet of the proposed septic system
• There is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
• The bottom of the proposed leaching facility will not be located less than five feet above the maximum
adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when
applicable]
• If the S.A.S.will be located with 250 feet of any vegetated wetlands,the bottom of the proposed
leaching facility will not be located less than fourteen(14)feet above the maximum adjusted
groundwater table elevation,
Please complete the following:
A) Top of Ground Surface Elevation(using GIS information) '1/®
B) G.W. Elevation'.*XS'3 a +the MAX. High G.W. Adjustment.A,q _ 17. g
DIFFERENCE BETWEEN A and B 13 ,8
SIGNED : DATE: ?/00
[Please Sketch proposed plan of system on back].
NOTICE
Based upon the above information, a repair permit will be issued for bedrooms maximum. No
additional bedrooms are authorized in the future without engineered septic system plans.
q:health folder:cert
c
e
1
C�
� 1
Is _
r ••. p T EHOD AYMB o�Lo wo Aocouwre
�. 'CASH_ GIN
0
STUCKIN ` �'
C
OUTH^POR un
-YARM OR
53 574/113
PAY N m l �.
e
TOTAL tom: -^TO THE -.:r :: ' _ . r DAT
COVNT . ORDER
oy
AMOUNT OF CHECK
..w
s
- AND TRUST COMP �K' `- }`• "- DOLLARS-El
_
■� 4
oii
30 5.7 �._
ti 9 9�0 _
u
g
4hp
�
-
D000
w --
:.J
��
A" Q.;F �co coi'c
{ -
.�
C D. 4 d O L O4
! Q. 0 2 ' ? mr i cL Ic fit.
W "J I C 6 C C C
tL E _ J w� �£S 92—b0 T =i.o � �;Tm�, 1 ;' ' rQC7r✓60000t� SO SZTO TI I .V0 _���
_ z
L(1 h N L7 A ° Yf:. M. �, �o l I as m o c
CD
Em
�. {'� a'� O �`Q 1 y .~O N U d C C
d L7 ' OU ` x yb aroa cm w
M Z �F' 1s 3E 9 LA
w m M d rnf� 'R¢I f (4 s� u • i '� �v>yam=i�S-`
G tr CO l" 4-
O 7LLI f !i na1 ♦ <+axe
LL
F I N
O m O O. Y `, LL I _ . Vl�t Y r, ,t .,�'r�„ k n- •i .y� tm�
w Z :WO.
>- a
= d U O wI h4s� s � Tw `k fit:' ak+� �o mco ,a e
,. Lu UJ air
~ F W I k"Q k fF IC n>ti::.."§, A } .3r >@ I �' �" .i r�• C. u-
E 0..
a I ttac °E
` O i ` L 2 Y F U w u)
Ill �. ., -- � i, ,
�..
x,�.. v""i� a% �.� m� a, v.,�� � � a..r t ` r�3f* Fry ""'�•. ��tc . . a �� 5� .. ....9. :.z }.", ,
- � TOWN OE BARNS,TA:BLE
1 LOCATION ��2YP�'t°ST �c�• �,fc.�� � _ SEWAGE # Zoab-:-S3`� t
a3oo�s E
VILLAGE �t �Ul ASSESSOR'S MAP & LOTLoFJJ6
INSTALLER'S NAME&.PHONE NO.ask S Trod t' a x,
SEPTIC TANK CAPACITY 1000�q R�
LEACHING FACILITY: (type) TAe+ur (size) 2 7.5 X to. 3'X 7-
NO. OF BEDROOMS 3
BUILDER O O R a... Ycsz�
PERIvIITDATE. =Z 2 p
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
Ed e'"of Wetland and Leaching Facili If an wetlands exist
g g ty( y
within 300 feet of leaching facility)._ Feet..
Fuinished by
q-D=3/ A - Ack o- 14ous�
q->== a
3-C=
- -E- 3 C
3 0
J3F_ •
- - z
A
No......�_.?.......... Fimic .. .......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�� ......--- -- OF...... -------------------------------------
�J
Apptiration for 15iupuaf Vorko Cnuuotrurtiuu Vrrmit
Application is hereby made for a Permit to Construct (�) or Repair ( ) an Individual Sewage Disposal
Syst at' 2�/� E'l�Q�k?�V.'�� �! = #a rr ..............C'�O'��v!:4
7�
Locati n Address Lot No.
� .---- .�................•. ------- --...----••-----.....•.----•-•--••••--...._...................
Owner f /� Address
------ --- _7d J. feet
� Installer Address
Q Type of Building/ �.�� Size Lot_ _l Sq
U Dwelling—No. of Bedrooms___________________________.................Expansion Attic ( ) Garbage Grinder ( )
`PL4L4 Other—Type of Building No. of persons____________________________ Showers — Cafeteria
a Other fixtures -------------------------------- -
W Design Flow....................115�-_------_--_gallons per person per day. Total daily flow............ _!-' -------...______gallons.
WSeptic Tank—Liquid capacity------------gallons Length................ Width---------------- Diameter----------...... Depth_.--._______-._-
x Disposal Trench—No--------------------- Width-__•__________ � Le h--- .. ....... _ Total leaching area--------------------sq. ft.
Seepage Pit No._�_________________ Diameter_ ept—h�ber inlet-•_--___-__-wl.... Total leaching area---UD -!sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date----------------------------------------
,a Test Pit No. 1................minutes per inch Depth of Test Pit..................... Depth to ground water-_--._-_________-_---.-.
�14 Test Pit No. 2................minutes per inch Depth of Test Pit________-----_____ Depth to ground water------------------------
a ---•-•••--• ----- ------ -- ----------- - ------- ---- --- ----------- ---
Description of Soil-------------`- ----- Y. � � �----- _ ••-•-- '
V --------------------------------- -----------•---------------------------------------------------------------------------------------------------------------------------------------------------------
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 Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been iss ed by thp board of health.
�z3 7�
Application Approved By------'._... .... /
Date
Application Disapproved for the following reasons-................................................................................................................
.............................................................
Date
PermitNo......................................................... Issued...................... .................................
Date
g
No. �.�.. Fim...4:...... -......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
t4 4
,
. . .s --------OF...... �r•,t,l� ;�'� fi ------............................
Appliration for Bhipoiittl Workii (foutitrurtinn Prrutit
Application is hereby made for a Permit to Construct O or Repair ( ) an Individual Sewage Disposal
S st at f z 1
4. .. _ ¢¢ _•
0 Location?Address op Lot No.
.....y'Y_.. ------------------------------------- --------•-------•------••-----------•---•-----•-•-----------. ----• ---••-•-•--•---•-----•-_
Owner Address
................. r ,r.-r`j..".f ,_ ........................ ----•.-------
i,
Installer Address
Type of Buildin Size Lot_ '_ .!1. 3_........Sq. feet
Dwelling- No. of Bedrooms........._..................................Expansion Attic ( ) Garbage Grinder ( )
W Other-T e of Building No. of persons............................ Showers — Cafeteria
G4 Other fixtures ....................................................... --
W
Design Flow..................... a............gallons per person per day. Total daily flow..............7 _0.~J_:____.-_--_-_.gallons.
P4 Septic Tank-Liquid capacity-- ,_-----gallons -Length................ Width---------------- Diameter---------------- Depth----_.-__-.--__
r
Disposal_Trench—No...................... Width__. T 1 Le"g��t'h �! /I ..... Total leaching area.-__---___-__----_sq. ft.
Seepage Pit No..j........_-------- Diameter. . _ e i"belinlet.__:__: _= sc. ft.
' .... Total leaching area -_ -. 1
z
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date----------------------------------------
� Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water--.--_----_-__-___-_-._.
r, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------
` -- ---•••••-..............................
O j,> ...
Description of Soil---------------
x f
W ----------------------------------------.......................................................................................................................................... .....................
UNature of Repairs or Alterations—Answer when applicable---------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Agreement:
------•--•------------------•----------------•-----•--------------.------------------------------•------•----•-----------------------------------------------------------------------------------.------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code= The undersigned further agrees not-to place the system in
operation until a Certificate of Compliance has been issued by the board of health
------7` ------------------ Dat-/- ;
APP PP Y lication Approved B ~° ¢ - f fi f ----------•-•-- ----------------------- ---------------
=
Date
Application Disapproved for the following reasons::___....__.f............................................................................. ---------__._.
......................--_----------------------- --------- 9- --- !........•-•---- ----
'.r� _ j�y�--- --- -- -----a---T - -
........... Date
iPermit No........................................................ I Isiiied........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
... ...:. ...............OF........ Fi!G �' ..,: . r...... . .....
............................
0ertif iratr of Toutphattrr
THIS IS TO CERTIFY, That the.Individu ewage isposal S s e co tructed ( 1') or Repaired ( )
by 2� f -
!y .....e ,� A.
staller +
at `` ' ` rl � .- ` -��---,-t-- r* :+
F r
has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No................... :.
---•-- dated =, ..........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE...... � `? ................................... Inspector--�----(--4...+. ...._-•----
� S
THE COMMONWEALTH OF MASSACHUSETTS
BOARD, OF HEALTH
: ,. ' ................ .. . .OF.._ f s.�r �d ...------------........-----.... en
No. ' FEE.. Y................
Rap fat Workii C��a�strixrt" � prstit
Fermissiorr�hereby granted --- . 4 ------ ................
to Constru ( ) r Re air'( an s Individual Sew a e Dts osal S st¢tn ,
".stfeet _ _ rat
--
as shown on the application for Disposal Works Construction ,alit To------6=_ ........ Dated---.%, :a, _...._...
+.y.= t�� ._& ----------------------------------
=g�
DATE..................................................................................
Board of H th"
FORM 1255 HOBBS & WARREN. INC..PUBLISHERS