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HomeMy WebLinkAbout0082 KETTLEHOLE ROAD - Health E82 KETTLEHOLE RD., W. BARNSTABLE t A = e e o Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 82 Kettle Hole Road 1-"L Property Address Fannie Mae ; Owner Owner's Name information is 3, West Barnstable MA 02668 7-2-18 required for every •"") page. City/Town State Zip Code Date of Inspection , ; U1 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 c5/# 1313 `���UtuttuttfnN�i� on the computer, ����� �.�•,....MqS �vi H F �i use onlythe tab .� 1,�'' `sq �''. 1. Inspector: ; ' °yam; key to move your cursor-do not -g; JAMES use the return James D.Sears =�: - key. Name of Inspector `*; :rn Capewide Enterprises plk moo:Q Company Name �i, lF .... . G 153 Commercial Street � '����,,,, itt00``�� Company Address rg Mashpee MA 02649 City/Town State Zip Code 508-477-8877 S1623 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 Q,,M�'R 7-5-18 spector'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 does not address how the system will perform in the future under the same or different conditions of use. t6ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System,(•-Page 1 of 17 n Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 0 �. 82 Kettle Hole Road Property Address Fannie Mae Owner Owner's Name information is required for every West Barnstable MA 02668 7-2-18 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: ® 1 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: The system is a 1000 Gal. Tank D Box and pit. Note: Outlet Tee has a zable filter. 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 ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 82 Kettle Hole Road Property Address Fannie Mae Owner Owner's Name information is required for every West Barnstable MA 02668 7-2-18 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 82 Kettle Hole Road V Property Address Fannie Mae Owner Owner's Name information is required for every West Barnstable MA 02668 7-2-18 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&IBM is less than 6" below invert or available volume is less than '/day flow P/7— 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 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 82 Kettle Hole Road v Property Address Fannie Mae Owner Owner's Name information is West Barnstable MA 02668 7-2-18 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 82 Kettle Hole Road Property Address Fannie Mae Owner Owner's Name information is required for every West Barnstable MA 02668 7-2-18 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ 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): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 15ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 c Commonwealth of Massachusetts p Title 5 Official Inspection Form Flo Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 82 Kettle Hole Road `J Property Address Fannie Mae Owner Owner's Name information is required for every West Barnstable MA 02668 7-2-18 page. Citylrown State Zip Code Date of Inspection D. System 'Information Description: 1000 Gal. Tank D Box and pit. Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): Well Water Detail: Sump pump? ❑ Yes ® No Last date of occupancy: NA Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form /a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 82 Kettle Hole Road Property Address Fannie Mae Owner Owner's Name information is required for every West Barnstable MA 02668 7-2-18 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: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts z Title 5 Official Inspection Form `Is Subsurface Sewage Disposal System Form - Not for Voluntary Assessments e 82 Kettle Hole Road Property Address Fannie Mae Owner Owner's Name information is required for every West Barnstable MA 02668 7-2-18 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: 1979 Permit# 79 -287. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 1' Depth below grade: 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.): Pipe ing is 4" PVC SCH -40. Septic Tank(locate on site plan): 4„ 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 Gala Precast H-10 211 Sludge depth: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form SSubsurface Sewage Disposal System Form - Not for Voluntary Assessments 82 Kettle Hole Road Property Address Fannie Mae Owner Owner's Name information is required for every West Barnstable MA 02668 7-2-18 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 28" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 8 Distance from bottom of scum to bottom of outlet tee or baffle 17" How were dimensions determined? asbult tape sludge judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank at working level. Tank at 4" below grade. In and outlet tee's. No sign of leakage or over loading. Note: Outlet tee has a zable filter. 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.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 82 Kettle Hole Road Property Address Fannie Mae Owner Owner's Name information is required for every West Barnstable MA 02668 7-2-18 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.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts 92 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments � 82 Kettle Hole Road Property Address Fannie Mae Owner Owner's Name information is West Barnstable MA 02668 7-2-18 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): "D Box is 16"x16"-2" below grade w/cover at 2". D Box is clean and solid Wone line out. No sign of over loading or solid carry over. 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 0 82 Kettle Hole Road Property Address Fannie Mae Owner Owner's Name information is required for every West Barnstable MA 02668 7-2-18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ 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.): Leaching is a 1000 Gal. Precast pit w/2'stone. Pit at 1' below grade w/cover at 2". Pit is dry w/no sign of over loading. No high stain line. 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 inflo w ow Yes No 9 ❑ ❑ t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 c Commonwealth of Massachusetts Title 5 Official Inspection Form j� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 82 Kettle Hole Road Property Address Fannie Mae Owner Owner's Name information is required for every West Barnstable MA 02668 7-2-18 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.doc-rev.6/16 Title 6 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 u 82 Kettle Hole Road Property Address Fannie Mae Owner Owner's Name information is required for every West Barnstable MA 02668 7-2-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 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 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection For Subsurface Sewage Disposal Systern Form-Not for Voluntary Assessments 82 Kettlebole Rd property Address Owner owners Name information is W.Barnstable MA 02668 required for CityfTovwn State Zp Code Date of ftpecdon every Paw- D. System information (cunt.) Sketch of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately Z.Ea2 �enc:z � c , } � � ►�GCS. r s , t i 1• D � Tine 5 oMew hVedion Form:$dnurfm Sewage Disposal System•pao 15 of 17 45ins•3113 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 82 Kettle Hole Road Property Address Fannie Mae Owner Owner's Name information is,required for every West Barnstable MA 02668 7-2-18 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells NO Estimated depth to high ground water: 20 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database -explain: .You must describe how you established the high ground water elevation: Rear of lot drop's off 204. Bottom of pit at 7' below grade. 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 c Commonwealth of Massachusetts 1 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 82 Kettle Hole Road Property Address Fannie Mae Owner Owner's Name information is required for every West Barnstable MA 02668 7-2-18 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 No. 20I3— Fee w/60 00 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ftpliLation for Misposaf *pstrm Construction Permit Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) ElComplete System individual Components Location Address or Lot No. / eHle,0/p 17,E Owner's Name,Address,and Tel.No. Assessor's Map/Parcel L✓> �4in$'gMe S IVMR IV Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. Tfpe of Building: Dwelling No.of Bedrooms /16 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) /W4 gpd Design flow provided /laq gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) �p�.nC°.7 GJN2� 1_..+e OA.- �t nik � D�,j4 1�'�—l3aX . 2PIAL� L'�+ -IROm �`SOX A, 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 de nd of t p s m in operation until a Certificate of Compliance has been issued by this Board of Health. S' d 44 to 3 /Y ✓3 Application Approved by Date 7 L!�Zol3 Application Disapproved Date for the following reasons Permit No. ZO 13 - 2 6 O Date Issued '' a�ZO P o No. 2O I3— Fee �W THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 2ppYication for Disposal *pstem Construction Permit Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ❑Complete System Individual Components Location Address or Lot No. �// Owner's Name,Address,and Tel.No. Assessor'sMap/Parcel (�. inS'4�i��. . i` 't ('�:'Ch�O�.� s ✓lr�e Installer's Name,Address,and Tel.No. _ Designer's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms NA Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) Alp gpd Design flow provided NA gpd Plan Date Number of sheets Revision Date Title t Size of Septic Tank Type of S.A.S. Description of Soil i Nature of Repairs or Alterations(Answer when applicable) CJa�-,,Wei tne 0,y ,,k Date last inspected: Agreement: ti 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 de and of to pl in in operation until a Certificate of Compliance has been issued by this Board of Health. Signed ate 3 Application Approved by h1 ,. Date �Zol3 Application Disapproved Date for the following reasons Permit No. 2011 - 2 6 o Date Issued Q, o 1,3 THl E COMMONWEALTH OF MASSACHUSETTS BARNSTABLE MASSACHUSETTS j t ?� Certif icate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired) Upgraded( ) Abandoned( )by ate/xile 1) („L��.� �i has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No2oi 3 -J&0 dated *4 11 9, 12 O t :5 —• Installer Designer #bedrooms Approved design flow NIQ / l gpd The issuance of thi permit 1hall not be construed as a guarantee that the system will ettiionpy as de�nc��)drj,/F .,ci ., FXE, � FIv1�{L-'1 �II Date 7 Inspector - 1111((J i )1 � ------ - ------ ----- - ------------------------------ ----- No. - 7D�3- (od - - Fee • �oo THE COMMONWEALTH OF MASSACHUSETTS i PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS )Disposal 6pstem Construction Permit Permission is hereby granted to Construct( ) Repair(� Upgrade( ) Abandon( ) System located at R_ke+410 ,1. /3Q and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Co struction must be completed within three years of the date of this permit. Date 7013 Approved by I I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 82 Kettlehole Rd Property Address Richard Spinney Owner Owner's Name information is required for every W.Barnitable MA 02668 7/15/13 page. Cityrrowni 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 forms A. Gelneral Information �`J ' v on the computer, use only the tab 1. Inspector: o 057 key to move your i cursor-do not Jason P Burnie use the return key. Name of Inspector Neighborhood Waste Water LCompany Name 350!Main St Company Address Yarmouth MA 02673 City/town State Zip Code 508-775-2820 S15011 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 1he time of the inspection. The inspection was performed based on my training and experience in the proper function and mgrT-tlltenance often site t sewage disposal systems. I am a DEP approved system inspector pursuant t S'ction 15 310 ofp Title 5(310 CMR 15.000). The system: , ZE i ❑ Passes ® Conditionally Passes ❑ Fans f`,o 0 ❑ Needs Further Evaluation by the Local Approving AuthorityCD '•;, %� 7/15/13 Inspector's Sign Date I 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. i V\ t5ins•3113 Title 5 OflidaVhspmlonrn ace Sewage Disposal System•Page 1 of 17 I I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 82 Kettlehole Rd Property Address Richard ISpinney Owner Owners Name information is required for every 68 W Barnstable MA 026 7/15/13 page. CityrrownI 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: ❑ 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: i Th&system is a conditional pass. The outlet line from the tank to the distribution box is broken. The distribution box is rotted and needs to be replaced. The line from the distributon box to the pit is broken. i 1 i B) System Conditionally Passes: i ® 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 Co f pliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): Thesystem is a conditional pass. The outlet line from the tank to the distribution box is broken. The distribution box is rotted and needs to be replaced.The line from the distributon box to the pit is broken. i i i i t5ins•3/13 ! Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 82 Kettlehole Rd Property Address Richard Spinney Owner Owner's Name information is required for every W.Barnstable MA 02668 7/15/13 page. Cityrrowna 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. I 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): I® broken pipe(s)are replaced ® Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ® distribution box is leveled or replaced ® Y ❑ N ❑ ND (Explain below): The;outlet line from the tank to the distribution box is broken. The distribution box is rotted and needs to be replaced. The line from the distributon box to the pit is broken. i i ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): i i I I C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect 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: i ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 i I f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 82 Kettlehole Rd Property Address Richard Spinney Owner Owner's Name information is required for every W Barnstable MA 02668 7/15/13 page. City/Town; State Zip Code Date of Inspection B. Certification (cont.) i I System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: i **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or, less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. i 3. Other: I j i I I D) System Failure Criteria Applicable to All Systems: You;must indicate"Yes" or"No"to each of the following for all inspections: Yes No 1� ® Backup of sewage into facility or system component due to overloaded or l 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❑ ® Liquid depth in cesspool is less than 6"below invert or available volume is less. than Y day flow I l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 I i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 82 Kettlehole Rd Property Address Richard';Spinney Owner Owner's Name information is required for every W Barnstable MA 02668 7/15/13 page. City[Townj 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. I❑ ® 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. f 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 i ❑ 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 i 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 I Tide 5 OffiaaTlnspedon Form:Subsurface Sewage Disposal System•Page 5 of 17 1 j I A I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments i a 82 Kettle'hole Rd Property Address Richard;Spinney Owner Owner's Name information is required for every W Barnstable MA 02668 7/15/13 page. Cityrrown i State Zip Code Date of Inspection C. Checklist i Chel k if the following have been done. You must indicate"yes"or"no"as to each of the following: i Yes No I 0 ❑ 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? Z ❑ Has the system received normal flows in the previous two week period? O ® 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) i ❑ 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? i ❑ 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 i 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 d x#of bedrooms): SAS@ p 9P ) 550gpd t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 I I I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t 82 Kettlehole Rd Property Address Richard Spinney Owner Owner's Name information is required for every W Barnstable MA 02668 7/15/13 page. CityfrownI State Zip Code Date of Inspection D. System Information i Description: The!system consists of a septic tank, distribution box and a leach pit. i i I i Number of current residents: 0 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 None available- ( y g (gpd))' well water Detail: I I I Sump pump? ❑ Yes ® No Last date of occupancy:- Early summer 2013 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 I Water meter readings, if available: I 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 I 82 Kettlehole Rd Property Address Richard;Spinney Owner Owner's Name information is W Barnstable MA 02668 7/15/13 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): i i I I General Information Pumping Records: Last pumped 2009- Barnstable BOH Source of information: Was system pumped as part of the inspection? El Yes ® No i If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: i Septic tank, distribution box, soil absorption system Single cesspool El Overflow cesspool I Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) I ❑+ Innovative/Alternative technology.Attach a copy of the current operation and } maintenance contract(to be obtained from system owner)and a copy of latest 1 inspection of the I/A system by system operator under contract El I Tight tank. Attach a copy of the DEP approval. Other(describe): I t5ins-3/13 I Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 i I i • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 82 Kettlehole Rd Property Address Richard;Spinney Owner Owner's Name information is required for every W.Barnstable MA 02668 7/15/13 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: i 1979 per permit on file at the Barnstable BOH Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 3 2 feet Material of construction: i ❑cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: 100'+ feet Comments(on condition of joints, venting, evidence of leakage, etc.): We ran a sewer camera up the line and it was ok at the time of inspection. i I I Septic Tank(locate on site plan): Depth below grade: Inlet cover- 1" Outlet cover-grade . feet Material of construction: i i ®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) ! I 1 I If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000gal Sludge depth: 2 I t5ins•3/13 j 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 i 82 Kettlehole Rd Property Address Richard'Spinney Owner Owner's Name information is W.Barnstable MA 02668 7/15/13 required for every page. CitylTowni State Zip Code Date of Inspection D. System Information (cont.) i Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 2+ I V. Scum thickness 4"+ Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 1'+ tapemeasure How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The;tank was at a normal level. Both baffles were in place. The outlet line going to the distribution box is broken. i i I I i Grease Trap(locate on site plan): i 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 4 Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 I Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 i 1 i i I i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 82 Kettlehole Rd Property Address Richard!Spinney Owner Owner's Name information is required for every W.Barnstable MA 02668 7/15/13 page. Cityrrown, 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.): I I li Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): i Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑polyethylene ❑other(explain): Dimensions: I Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): i 1 i *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No i t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 l i i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 82 Kettlehole Rd Property Address Richard;Spinney Owner Owner's Name information is W Barnstable MA 02668 7/15/13 required for every � page. City/Town 1. State Zip Code Date of Inspection D. System Information (cont.) I 1 Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 i 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.): The;box was rotted and needs to be replaced.The outlet line going to the SAS is broken and needs to be replaced. The box cover was 1'2"deep. I i Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* i 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): I. If SAS not located, explain why: SAS was located. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 I i i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 82 Kettlehole Rd Property Address Richard Spinney Owner Owner's Name information is I required for every W.Barnstable MA 02668 7/15/13 page. Citylrown 1i State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1-6x6 with stone ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: i ❑ 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.): The;pit was found to have 1'of standing water in it at the time of inspection. There was a stain line at 2'.The cover of the pit was 6"deep. 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 I Dimensions of cesspool Materials of construction I Indication of groundwater inflow ❑ Yes ❑ No I t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 82 Kettlehole Rd Property Address Richard;Spinney Owner information is Owner's Name required for every W.Barnstable MA 02668 7/15/13 page. City/Towi; 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, i i i i Privy(locate on site plan): Materials of construction: Dimensions i I Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): j t j i j y 9 � i t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 I Commonwealth of Massachusetts b Title 5 Official Inspection Form Subsurface Sewage Disposal System Fonn-Not for Voluntary Assessments 82 KetUebole Rd Property Address Richard S inns Owner Owners Name information is W Bastable MA 02668 7115/13 required for drn Static Zip code Date of rrrspec�n every page. own D. SWOM lnfOrMation (cunt.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks Or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately EVIR, � c t ® n ��t:,►C t r i i� C - 91 T3 t� . C . at 0 ► ari D • 7tt s 5 0maw htspeoWn Form:SubvxfacO Sewage DiV-W SY"'page 15 017 t5ins•3r13 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 82 Kettlehole Rd Property Address Richard Spinney Owner Owner's Name information is required for every W Barnstable MA 02668 7/15/13 page. Citylrown;, State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water i ® Check cellar ® Shallow wells 30,+ Estimated depth to high ground water: feet i Please indicate all methods used to determine the high ground water elevation: ® j Obtained from system design plans on record i If checked, date of design plan reviewed: 1979 on file at the Barnstable BOH Date ® i 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: SDW-252 Zone B water level 46.7 1.2x12= 17'adjustment I Youlmust describe how you established the high groundwater elevation: By observing the yard there is a 30+drop off where no water is found. From grade to bottom of SAS it is 7'i This give you a seperation of 23'+between bottom of SAS and where groundwater is known not to be. I Before filing this Inspection Report, please see Report Completeness Checklist on next page. I t5ins•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 16 of 17 I i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 82 Kettlehole Rd Property kdress Richard;Spinney Owner Owner's Name information is required for every W Barnstable MA 02668 7/15/13 page. City/Town: State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked i I ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file i i E t f r i i 1 t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 17 of 17 Commoriiwea th of Massachusetts Jolm Grad Executive Office of Environmental Affofrs D.E.P. Title V Septic Inspector department of P.O. Box 2119 Environmental Protection Teaticket,MA 02536 ► (508) 564-6813 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A Cz� � CERTIFICATION Property Address: 82 KettleHole Rd.W. Barnstable Address of Owner: AN m Date of Inspection:1122197 (If different) fn 19g� f� Name of inspector:JohnGracl carpenter (k Company Name,Address and Telephone Number: y lam - 1'fi c.,L 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: X Passes This inspection is based on criteria defined in Title y _ Conditionally Passes code 310 CMR 15.303.My findings are of how the system is performing at the time of the Inspection.My inspection does _ Needs Further E aluation By the Local Approving Authority not Imply any warranty or guarantee of the longevity of the Fails septic system and any of its components useful life. Inspector's Signature: / ✓ Date: 1123197 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B,C,or D: A] SYSTEM PASSES: x I have not found any information which indicates that the system violates any of the failure criteria defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: _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.) _ The septic tank is metal,cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 11115195) One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 82 Kettlefte Rd.W.Samstable Owner: Carpenter Date of Inspection:1122197 _ Sewage backup or breakout or high static water level observed in the distribution box is 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 leveled or replaced _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 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 system has a septic tank and soil absorption system and is within 100 feet to a surface of water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone 1 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 volatile organic compounds indicates that the well is free from pollution for that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm. 3) OTHER 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 In 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 cesspool. SAS Is in hydraulic failure. (revised 11115195) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 82 KettleHole Rd.W.Samstable Owner: carpenter Date of Inspection:1122197 D] SYSTEM FAILS(continued) 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 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Numbers of times pumped Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria;volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria: _ The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area (IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall 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 11115195) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: 82 KettteHole Rd.W.Samstable Owner: carpenter Date of Inspection:1122197 Check if the following have been done: X Pumping information was requested of the owner,occupant, and Board of Health. x None of the system components have been pumped for at least two weeks and the and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. 21aAs built plans have been obtained and examined. Note if they are not available with N/A. X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout. X All system components,excluding the Soil Absorption System,have been located on the site. X The septic tank manholes were uncovered,opened,and the Interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions, depth of liquid, depth of sludge, depth of scum. X 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. X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11115195) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 82 KettleHole Rd.W.Barnstable Owner: Carpenter Date of Inspection:1122197 FLOW CONDITIONS RESIDENTIAL: Design flow: 330 gallons Number of bedrooms: 3 Number of current residents: 2 Garbage grinder(yes or no): Yes Laundry connected to system(yes or no): Yes Seasonal use(yes or no): No Water meter readings,if available: n1a Last date of occupancy: n1a COMMERCIAL/INDUSTRIAL: Type of establishment: n<a Design flow:0 gallons/day Grease trap present:(yes or no) No Industrial Waste Holding Tank present: (yes or no) No Non-sanitary waste discharged to the Title 5 system: (yes or no) No Water meter readings,if available: nla Last date of occupancy: n1a OTHER:(Describe) n1a Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: Septic tank was pumped in April 1996 System pumped as part of inspection: (yes or no)No If yes,volume pumped: 9 gallons Reason for pumping: n1a TYPE OF SYSTEM X Septic tank/distribution box/soil absorptions system Single cesspool Overflow cesspool Privy Shared system(yes or no) ( if yes,attach previous inspection records,if any) Other(explain) APPROXIMATE AGE of all components,date installed(if known)and source information: 1978 Sewage odors detected when arriving at the site:(yes or no) No (revised 11115195) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 82 KettleHole Rd.W.Barnstable Owner: carpenter Date of Inspection:1122197 SEPTIC TANK: X (locate on site plan) Depth below grade: 1' Material of construction:X concreaie_metal_FRP_other(explain) Dimensions: L 8'0'H 5'7"W 4'10- Sludge depth:1' Distance from top of sludge to bottom of outlet tee or baffle: 20' Scum thickness:0 Distance from top of scum to top of outlet tee or baffle:0' Distance form bottom of scum to bottom of outlet tee or baffle: 0 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.) Septic tank and all components are structurally sound.Recommend pumping system every one to two years for maintenance. GREASE TRAP: (locate on site plan) Depth below grade: n1a Material of construction: _concrete_metal_FRP_other(explain) Dimensions: rda Scum thickness:n1a Distance from top of scum to top of outlet tee or baffle:n1a Distance from bottom of scum to bottom of outlet tee or baffle: n1a 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.) nla (revised 11115195) 6 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 82 KettfeHole Rd.1N.Samstable Owner: carpenter Date of Inspection:1122197 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: n1a Material of con struction:_concrete_metal_FRP_other(explain) Dimensions: n1a Capacity: n1a gallons Design flow: n1a gallons/day Alarm level: n1a Comments: (condition of inlet tee,condition of alarm and float switches,etc.) nla DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: nla Comments: (note if level and distribution is equal,evidence of solids carryover, evidence of leakage into or out of box etc.) nla PUMP CHAMBER: (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber,condition of pumps and appurtenances, etc.) n1a (revised 11/15195) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 82 KettleHole Rd.W.Bamstable Owner: Carpenter Date of Inspection:1122197 SOIL ABSORPTION SYSTEM (SAS):X (locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: n1a Type: leaching pits,number: 1,000 gallon leach pit leaching chambers,number:n1a leaching galleries, number: n1a leaching trenches,number,length: n1a leaching fields,number,dimensions:nla overflow cesspool,number:n1a Comments:(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) The leach pit is structurally sound and functioning properly.It was 112 full at the time of the inspection. CESSPOOLS:_ (locate on site plan) Number and configuration: n1a Depth-top of liquid to inlet invert: n1a Depth of solids layer: n1a Depth of scum layer: n1a Dimensions of cesspool: n1a Materials of construction: n1a Indication of groundwater: n1a inflow(cesspool must be pumped as part of inspection) n1a Comments:(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) nla PRIVY:_ (locate on site plan) Materials of construction: n1a Dimensions: n1a Depth of solids: ►ya Comments. (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) n1a (revised 11115195) 8 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 82 KettleHale Rd.W.Barnstable Owner: Carpenter Date of Inspection:1122197 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' Ct(k h' r 0 � Ab 15 CAA �q (�C 3 DEPTH TO GROUNDWATER Depth to groundwater:12 feet method of determination or approximation: USGS Maps and Charts (revised 11115195) t) i As6 - l©g 30 LOCATION SEWAGA PERMIT NO. VILLAGE I N S T A L L E R'S NAME a A D 0 R E S S J. CRAIG MEDEIROS Trucking. & Bulldozing 2 Corporation treet Hyannis, Mast 775-0828 BUILDER OR OWNER, DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED l� r ,, �� . _ � �� ���� �� ° �,a ��� ����� �v5"G} .. 'k t 4 Fj '� �/� ��� �s�Ll -• yam► � �, No............z� � ............. _ THE COMMONWEALTH OF MASSACHUSETTS DV_" BOAR® OF HEALTH Appliratiun for Bilivas al Works Tonstrnrtiun Errant Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at:................_... :,c .....:..... -- '-`-e - ..... Location-Address ` or Lot No. .._.... `.. ._o'� 3..!'�_.._..... �. ....................•.. ............ �. 4�t. - P.."`-r! ............................... Owne� A dress a ..................... ................... ..----•---• Installmf Address d Type of Building Q-l� y Size Lot............................Sq. feet Dwelling—No. of Bedrooms..........a...........................Expansion Attic ( ) Garbage.Grinder (Allo Other—T e of Building No. of persons............................ Showers — Cafeteria Q' Other fires -----•-••-•-•---------••----••..-• • W Design Flow..................................gallons per person per day. Total daily flow.... _ ...........................gallons. WSeptic Tank—Liquid*capacity/!�.5Lgallons Length................ Width__.``............ Diameter................ Depth................ x Disposal Trench—No..................... Width.....li......... Total Length___...(.......... Total leaching area_.;2_..t/e.t//,__sq. ft. Seepage Pit No.....C_........... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box Dosing tank ( ) Percolation Test Results Performed by........... .... ... .. ! .......... -......... Date..I .. ,tea Test Pit No. 1__,,� .____minutes per inch Depth of Test Pit.................... p ground --------------- Depth to ater........................ 1-4 ( Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ _•-----. .-- -- .Y.�._�..l-......................................................... ir 0 Description of Soil.................. - ------------ ----------------------- ------------•---------------- ------------------------......------- ------------------------------------2 .. .l�—..........C..4-u hs� ��.�,.�....�-:.� . ............... w -•--••-----------------------------••-------•--•--------•---------------•---•-•--•--••......•--•------••-----•--•-.-•--------------•-----•-•••••--•••---••--•--•................--•-••------------•---- UNature of Repairs or Alterations.—Answer when applicable................................................................................................ -•---------------------•----•---•--...............-----------------------------.......--•----•-•--•-----••--------------•------------------ ............................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of LI`.IZ 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been • ued by the board of health. n . �/ Date Application Approved By•-•-•........ ------- c1.�. ��� Date x, Applica 'on Disappr9yed for the following reasons:----------•-------------------------------------------•--------------------------------------------....-•------ .... h7............. . .................. ...................�tom.. ........... .._..... --------------•-----------._..._._..------------------• ------------•------------- � � .. � Date O PermitNo....................................................... Issued-------t..-------------•------•--•-•------•---•-----•-- Date w'4 �r k •4� O �, �`� No �...'ri Fxs.. 1i '. • THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH HHo-.t``....---.....OF..... ....Z...4'......... Appfiratiun for Disposal Works Tuntrur#tun erutit-, Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Iiisposal System at .,. .. ............... .... ` . :: ..� .......... ... : ' .------------. ..................................... . Location-A}d ess " or Lot No. /f��f _. .... . ........................... �:. ... �w.�'.+l�Y.d�d."�.�"��3 a'q._!!�T.!3. ..................._ Own L� .� +4"'+''�!.. :' lslr t b�•a '�.. T Ark ."�... a .......................... ! ... •..... ......•... Installer •ddress - d Type of Building �/:-d'y ,, Size Lot_..-------------------------Sq. feet. U Dwelling No. of Bedrooms.... ......... ..............Ex Expansion Attic� g= ------,-- p ( ) - Garbage Grinder (d rt Other—Type Type of Building No. of persons............................ Showers Other fix res •••... -•--••...---------•--.-•--••••--•-•.......:.•--••----••---••---•--••--•---•••. •.--•-••-••....--••.--•_. — Cafeteria ( ) p., ( ) W Design Flow_...... ..�.........................gallons per person per day. Total daily flow....1. .4.0. ....................gallons. R; Septic Tank—, Liquid capacitylq° '.gallons Length................ Width__ Diameter______ ..... Depth_ x Disposal Trench—No.................... Width... ..... Total Length._... Total leaching area...A . sq. ft._. Seepage Pit No..... ........... Diameter.................... Depth bel w inlet.. ............... Total leaching area..................sq. ft. Z Other Distribution box O Dosing tank ( ) f' aPercolation Test Results Performed by...........x' �"�i •......... Date.. !" ' ,.a Test Pit No L. .....mmutes per inch Depth of Test Pit .................. Depth to ground ater _................... fi t Test Pit No �2................minutes per inch Depth of Test Pit........... .... Depth to ground water r � ...ram^ $ lr O Description of Soil -------•-• ............................. U --------------------- ....................................... W t U Natur-e.of Repairs or Alterations—Answer when applicable................................................................................................ .{ q, ...•.....................................c-.--.___.......•............................................................._.....---_ Agreement The undersigned pagrees, to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 AAhe 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. Sin .'............... _+ ............... Date Application Approved By...-...... . ....... ._.. �• ............ .......�f"� °i at8 Application Disapproved for the following reasons-------------•------------------•----------------------•-------------------=-=------=--=---••-•---=------------ g 4 .............. ,..-.................--........•..........................--..........--.•.............••........................._..........•...•....._...__...........__.................... Date Permit`"No................................... ..................... Issued....................................................... Date' • THE COMMONWEALTH OF MASSACHUSETTS BOARD .OF HEALTH C�rrttfictt�le of �u�t�r�i�nr.� CIS Is TO ERTIFY, That the Inu vidull Sewage Disposal System constructed Oe) or Repaired ( ) by............... !... 1 ........ --------- . ---•-----........----_-I--------.......-----••--•------.......................--------- I staller at.......... /' _1 _ ts3 " ► ! " ........ ' '_` _ _ .! *.... .' has been installed in accordance with the provisions of TI 5 of The State Sanitary Code as described in the' application fpr Disposal Works Construction Permit No... dated-.- ` .,.:., :.___ THE ISSUANCE OF THIS:CERTIFICATE SHALL.NOT=BE CCiNSTRIIED AS A,G.UARANTEE;: AT..THE SYSTEM WILL FUNCTION SATISFACTORY. � `� DATE.......Jll. . L-.T............................................. Inspector......... -- =--------- -------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .� .yr OF.. ..- ................................................. N ..11... FEE.Z?.. "' I +<J. ............ i "I Works Tunstr ' n ramit Permission a hereby granted_._..'. t.:.° :- -- ---- - ------- ------------------------•-•----.- -------------...... to Construct Lw Repair ( ) an Individual Sewage Disposal yst or at -- r - Street pp p rks Construction Permit No.. ........ ...... 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