HomeMy WebLinkAbout0039 ISLAND AVENUE - Health r39 Island Avenue \`
Hyannis
A -265 - 031
No. ✓ Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
ftpliLation for MispoSal *pstrm Construction Permit
Application for a Permit to Construct(' Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
cation Address or Lot No. 5-4 a[Sloyet Owner's Name,Address,and Tel.No.
As essor's Map/Parcel 3
Installer's Name,Address,and Tel.No-7 CA �� '�, Designer's Name,Address,and Tel.No. ��` 'ftt
P
Ped
Type of Building:
Dwelling No.of Bedrooms Ip Lot.Size _ J ��® �� sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures BB
Design Flow(min.required) �Uin gpd Design flow provided 7 gpd
Plan Date iil d w Number of sheets Revision Date [. n 1 Z o it
Title
Size of Septic Tank L Type of S.A.S. Q A- ()e—
��
2.
Description of Soil. t
Nature of Repairs or Alterations(Answer when applicable) ��
Date last inspected:
Agreement: h
The undersigned agrees to ensure the construction and maintenance o eafore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmentre and not to place the system in operation until a Certificate of
Compliance has been issued by this Board e I -
lkSigned Date Vdou.
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. pW d—� ��.� Date Issued '��o Q
No. r �`. � Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: i/
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
Application for jBisposal 6pstem Construction 3pPrmit
Application for a Permit to Construct(V) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. C 1. Owner's Name Address and Tel.No.
lk
As2esso s Map/Parcel Z, l`• ;✓a ` , .�c. / t''
sa 7
Installer's Name,Address,and Tel.N0 ( t j Designer's Name,Address,and Tel.No.
��ny'_ �,�., �! �e.Q,i-i�.. �,�c.- 5 ter•t�� �
rf r . e Ito
Type of Building: • ,, r J "C K" u 4 - , r t
Dwelling No.of Bedrooms ] Lot Size 1 J,000 +"1m C"sq. t. Garbage Grinder( )
r
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures +
Design Flow(min.required) &14n gpd Design flow provided 117 gpd
f
Plan Date �(i„f_� Number of sheets . Revision Date ,I .,, )% 3 ;
Title
Y� Size of Septic Tank �-� f Type of S.A.S. 4 t` 9f r Q I A , A y ._.
Description of Soil (?' 01C4
Nature of.Repairs or Alterations(Answer when applicable)
ca ...-yr - W •d r
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 Environments Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board b T
lth.
( Signed s Date.- = - -t4N- - _
Applicatidr A-prol ved'b t7i ii.n ! x 6s s ( � Date /y /
Application Disapproved by Date
for the following reasons
Permit No. 'A -I.r Date Issued
------- ---°'-- --•-------------------------------------- -----------..- .- ._.
ij�v n J,A tril old j 4 J�M, THE COMMONWEALTH OF MASSACHUSETTS
di
�,l,( 2 n.�� BA NSTALE, USE
(C r ifB ate.D�fCompliance IASSAC TTS t
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed(V Repaired( ) Upgraded( )
Fbandoned( ).bye�. , t `1.. .an
at has been constructed in accordance
ance
-( v
with the 45��
" ix D,isposa11 y%stem Construction Permit No. C ated x ► , ( `),/ `�
� -
f'� Instal er1 Designer �4� �,�� n1 t; at,4wf arc y�
#bedrooms Approved design flow f gpd!; '<
The issuance of this permit shall not be construed as a guarantee that the system<will-functioh as designed.
Date �,/Q���- Inspectors
- - = --- ----------- ------- - ------ -------- ---------- - ----------------------
f< �
No. 'to s Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS
p
Disposal *pstem Construction Permit Via'
Permission is hereby granted to Construct( ) Repair(t/) Upgrade( ) Abandon( )
System located at
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:Construction mustbe completed within three years of the date of this permit.
Date / / a�� Approved by ,(i((iy /,� z, //
i
_ TOWN OF BARNSTABLE
LOCATION `.4CI ^— �Gp. ' SEWAGE#2-0� � P
VILLAGE ASSESSOR'S MAP&PARCEL
r
INSTALLER'S NAME&PHONE NO..
SEPTIC TANK CAPACITY
-' 4 ,--0.- 14 s 6
LEACHING FACILITY: (typ �_ '` (size) _ [ �
NO.OF BEDROOMS "�'�� C.4ce �e
OWNER � • !O�
PERMIT DATE: lliJ67142,1 COMPLIANCE DATE: 2
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist on
site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching facility) Feet
FURNISHED BY
qN.
41
_6ke�
C`twr� a(/^D
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i
Town of Barnstable
o Inspectional Services
W
Public Health Division
• HAEN6[ABM •
Jimn Thomas McKean,Director
1.� ,�
�o ° 200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fait: 508-790-6304
Installer&Designer Certification Form
Date: P�` Z Sewage Permit# � �-q� Assessor's MapTarcel Z�o>�
Designer: Installer: m,
Address: Address: 9v� r 'cY't
}-hp rw 1 C�, ®ram 1 4��, M 2
GV
c �� � _ -�
On 12t ` was issued a permit to install a
(date) (installer)
septic system at. °� l S 1, based on a design drawn by
(address)
IpAy 1 -t A Ir dated _L—
(designer)
V/ I certify that,the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral.relocation of the
distribution box and/or septic tank. Strip out (if required):was inspected and the soils
were found satisfactory.
I certify that the septic system referenced above was installed with major changes. (i.e. .
greater than 10' lateral relocation of the SAS or.any vertical relocation of any component
of the septic ystem)but in accordance'with State&Local Regulations. Plan revision or
certified as=built by designer to follow. Strip out(if required)was inspected and the soils
were found satisfactory.
erti at the ste referenced above was constructed incompliance with the to rms of
roV ,plicable) 03
R -
ristaller's Signature)
AAA
�0 Az
(Des n, 's Si nature (Affik.Desigr er`STMStamp Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE
OF COMPLIANCE WILL NOT B-E ISSUED UNTIL ;_BOTH THIS FORM AND AS
BUILT'CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH:DIVISION.
\ THANK YOU.
\Uoa\depulHEALTMEWER connecASEPTICOesigna Certification Form Rev:&14-11DOC
90°0'' 46.9'
29.3 x 34.3 (1/2) = 502.5 SF 34.3 x 31.9 (1/2) = 547.1 SF
Total SF = 1049.6 SF
1049.6 x 0.74 = 777 GPD
45.1'
Prepared by:
.39 Island Road Hyannis All Cape Septic and Survey
Leachfield Calc's
618 Route 28
West Yarmouth,- MA. 02673
(508) 771 —4200
allcapeseptic@gmail.com
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et 'u Avenu
twl, 1sl ��d ��ay� `-
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e
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Aa' ssor's Map 265 Parcel 31 n„'e
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I 194:D' _ —N 25 g� 2.) C175014
46.0 3.) LC Plan 13772-1J
J ` ^ Fxistin� — '►� 4. This property is not in the Zone 11
g --tom } p P Y o
Propane Tank 5- —" LOCUS°a °a Qad
co + , District ti5�o�d
t Water Protection
d- 5_) This property is in Flood Zone X
C I
fi� , Firm Asap 25001 CO564,.1 7/1£/14 /
den t i I 1 Lot, 52 Nantucket
ti 15,002f SF sound ,
4 ��• l l/ �y HYANNIS, MA ! 1
L 0 1'7' 1 ) SITE LOCUS
25 q S';2" I_ I water service _ ' NOT TO sCALZ
35
DB-6 — CD
I i ,► - / 1 A
ca — J
11 Maximum Feasible Compliance
1_eachfield 1 f — — W ...�_
1 / Deck w
Detail 1 _ Variances: 310 CMR 15.221 (7) General Construction I
NTS 1 / f LO Requirements for AIJ System Components: o
r� ee / r
i No 19 r 1 �p 1.) Variance to the 20' setback betwoon the edge at the SAS
# and the Foundation. An 10.0" setback is provided,
ce is
O 2.)1Var Variance the SAS Sd depth being qrc r lcr�thoii 3' A vent in propor.ied.
a
House �39 (.�10-c1vlJ� 'r5.22a(7)) _ _
�.
32 G Bedroom
Map 265 I 1 $' ` Slab EL = 3C.5 Map 265
l f1 Parcel 30
Parcel 32 ST
a� \
J 01 G Top Corner Slate / * 1 ProposeCI SIte CII;C� Septic i��C1r1 I
10 1 ca TBM EL _ 30.
Slob / * + 10'�) �. L`7
+ island Avenue
39 d H
l Fa � � sae Hyannis � art MA
Seer� f tro x+ �- y , 3
Note 19 I Garage r + + �- o �N I
# 1 Slob EL - 30.2 '� + Prepared c
+ +
f C_i Prepared for: P y:
ro
Ali Cape Septic and Survey
r. ! �~' \ 'o• �T� + +.*� * ` ++•* **� rf .t� William ECgan 6 $ Route 28 f g
31
vent �;�� -� _ Griswold Rood
Rye, NY West Yarmouth, MA 02673
y (508) 771-4200 1.
- . . ` �t olicapesepticOgmoil.com I .
* art. $ „� , . November 8, 2021 Scale: 1" - 20'
of 84" —1�ti `J B ------�1 Revised: November 20, 202 i
2fi'
40 W ,
NOTE: 100. 3' TP1 Qc��rd,
: Jp 2/ GRAPHIC SCALE odded req,1 ""
LOCATION OF .UTILITIES" IS APPROXIMATE AND ALL
UNDERGROUND AND OVERHEAD: UTILITIES MUST 3E M:op 265 's 20 0 10 20 40 �0clqbah �- , so
DETERMINED IN: THE FIEND PRIOR TO -COMMENCEMENT O'
OF ANY WORK, THIS INCLUDES, BUT. NOT .LIM'ITED . TO,
Parcel 25
REQUESTS TO DIGSAF'E, ANY 'PRIVATE UTILITY COMPANIES IN FEET Sheet 1 of 2
AND THE 1_OCAL. WATER DEPARTMENT. i inch- _ 20 ft. w 396
U 9 #
® k
RAISE MIN. '20" DIAMETER COVER
TO FINISH GRADE
Proposed RAISE MIN. 20" DIAMETER COVER Vent
Clean
EL=30.8t Out TO WITHIN 6" OF FINISH GRADE /
CONSTRUCTION NOTES 4 30.0t EL=30.0t
1.) ALL WORK SHALL CONFORM TO THE STATE ENVIRONMENTAL CODE, TITLE 5 (310 CMR 15.000):
STANDARD REQUIREMENTS FOR THE SITING; CONSTRUCTION, INSPECTION, UPGRADE, AND *
EXPANSION OF ON-SITE SEWAGE TREATMENT AND DISPOSAL SYSTEMS AND FOR THE TRANSPORT
AND DISPOSAL OF SEPTAGE,.AND THE LOCAL BOARD OF HEALTH REGULATIONS. CONCRETE Inspection Pat m
2.) ANY SEPTIC SYSTEM COMPONENT INSTALLED IN A LOCATION WHERE THERE IS POTENTIAL FOR RISERS Box Cover v
VEHICLES OR HEAVY EQUIPMENT TO PASS OVER IT SHALL BE DESIGNED TO WITHSTAND AN H-20
LOADING. IF UNDER AN IMPERVIOUS SURFACE, SYSTEM SHALL BE 'VENTED TO THE ATMOSPHERE. 28.6f Inspection GEOTEXTILE
25.9 Port FABRIC
3.) TO MINIMIZE UNEVEN SETTLING, SEPTIC TANKS AND D-BOX SHALL BE INSTALLED ON A STABLE
MEHANICALLY-COMPATED BASE ON SIX
NCHES
F CRUSHED STONE
4.)CCOVERS OVER THECIN ET AND OUTLET(TEES OF THE SEPTIC TANK, THE DISTRIBUTION BOX; AND28.5t I 25.15
THE SOIL ABSORPTION SYSTEM SHALL BE RAISED TO WITHIN 6" OF FINAL GRADE. LEACHING t 3/4" to
FIELDS, TRENCHES, AND OTHER SOIL ABSORPTION SYSTEMS WITHOUT ACCESS MANHOLES SHALL r 27.45
HAVE AT LEAST ONE (1) INSPECTION PORT CONSISTING OF PERFORATED 4" PVC PIPE PLACED 27.7 O 25.97 25.8 1-1/2 Stone
VERTICALLY TO THE BOTTOM OF THE SOIL ABSORPTION SYSTEM WITH A CAP, TIED WITH MAGNETIC oo ','.` ,',•,'fit'`fatirlirizClr. . . (Double wash)
MARKING TAPE, ACCESSIBLE TO WITHIN 3" OF FINAL GRADE. v 25.4 `
Varies
5. PIPING SHALL CONSIST OF 4" SCHEDULE 40 PVC OR EQUIVALENT. PIPE SHALL BE LAID ON A GAS BAFFLE .. DB-6 H-10 I
) 24.6 � 6' to 49'• 24.6
MINIMUM CONTINUOUS GRADE OF NOT LESS THAN 2%FROM THE BUILDING TO THE SEPTIC TANK, D-B O X
AND NOT LESS THAN 1% OTHERWISE. 45'- 8" x 46'-10" x 61"-3" LEACHFIELD
... . ... .. . . . .. . . .. . . .
6.) DISTRIBUTION LINES FOR THE SOIL ABSORPTION SYSTEM SHALL BE 4" DIAMETER SCHEDULE 40 t 40.0 f WITH FIVE 4" SCH 40 PERF. PVC PIPE 5 5'
PVC (OR EQUIVALENT) LAID AT 0.005 FT/FT, UNLESS OTHERWISE NOTED, LINES SHALL BE CAPPED PROPOSED 50' Maximum SET AT 0.005 SLOPE ON-MINIMUM 6"
AT END OR AS NOTED. �---27't---� 2,000 GALLON H-20 2� 0.0 t L �-4' - 35't-� DOUBLE WASHED 3/4"-1 1/2" STONE
7.) LINES FROM THE DISTRIBUTION BOX TO BE LEVEL FOR THE FIRST TWO (2) FEET BEFORE SEPTIC TANK I LEACH CHAMBERS
PITCHING TO THE SOIL ABSORPTION SYSTEM, DISTRIBUTION BOX SHALL BE WATER TESTED TO
ASSURE EVEN DISTRIBUTION. (END VIEW)
8.) GROUT TO BE USED AT ALL POINTS WHERE PIPES ENTER OR LEAVE ALL CONCRETE STRUCTURES FLOW PROFILE
IN ORDER TO PROVIDE A WATERTIGHT SEAL. `' NOT TO SCALE EL=19.1 Bottom Test Hole-
9.) HEAVY EQUIPMENT SHALL NOT BE ALLOWED TO OPERATE OVER THE LIMITS OF THE SEWAGE
DISPOSAL FIELD DURING THE COURSE OF CONSTRUCTION OF THE SYSTEM. Test Hole 1 (EL=29.6t) TEST HOLE LOGS
10.) IN ACCORDANCE WITH 310 CMR 15.221, ALL SYSTEM COMPONENTS SHALL BE MARKED WITH SYSTEM DESIGN CALCULATIONS
MAGNETIC MARKING TAPE. Depth Elev. Layer Soil Class Soil Color
11.) THERE ARE NO KNOWN WELLS OR WETLANDS WITHIN 150' OF THE PROPOSED SOIL ABSORPTION SYSTEIV SEWAGE DESIGN FLOW- EXISTING SIX BEDROOM DWELLING 0 110 GPD/BEDROOM = 660 GPD
12,) FROM THE DATE OF THE INSTALLATION OF THE BOIL ABSORPTION SYSTEM UNTIL RECEIPT OF 0"-14" 28.4 A Loamy Sand 10YR3 2 (MINIMUM DESIGN REQUIRED 660 GPD)
THE CERTIFICATE OF COMPLIANCE, THE PERIMETER SHALL BE STAKED AND FLAGGED TO PREVENT I /
USE OF THE AREA THAT MAY CAUSE DAMAGE TO THE SYSTEM. SEWAGE DESIGN FLOW PROVIDED: 45'- 8" x 46'-10" x 61"-3" LEACH FIELD
13.) THE DESIGNER WILL NOT BE RESPONSIBLE FOR THE SYSTEM AS DESIGNED UNLESS 14"-44" 25:9 B Loamy ;and 10YR5/6 WITH FIVE 4" SCH 40 PERF. PVC PIPE
CONSTRUCTED AS SHOWN ON PLAN. ANY CHANGES SHALL BE APPROVED IN WRITING BY THE ENGINEER.
44"-126" 19.1 C Medium 'Sand 2.5Y6/6 Vt = 45.67 (1/2) x 46.82 = 1,050 SF x .74 = 777 GPD PROVIDED
14.) THE BOARD OF HEALTH REQUIRES INSPECTION OF ALL CONSTRUCTION BY AN AGENT OF THE 777 GPD PROVIDED > 660 GPD REQUIRED
BOARD OF HEALTH AND THE DESIGNER. THE DESIGNER SHALL CERTIFY IN WRITING THAT THE
SEWAGE DISPOSAL SYSTEM WAS INSTALLED IN ACCORDANCE WITH THE TERMS OF THE PERMIT SEPTIC. TANK CAPACITY REQUIRED: 660 GPD X 200 = 1320 (MINIMUM)
AND'THE APPROVED.PLANS. 48 HOURS ADVANCE .NOTICE IS REQUESTED. DATE OF TESTING: 10/24/21
15.).LOCATION OF UTILITIES IS APPROXIMATE AND CONTRACTOR SHALL BE RESPONSIBLE FOR SOIL EVALUATOR DAVID D. FLAHERTY JR. SEPTIC TANK CAPACITY PROVIDED: 2,000 GALLON H-20 SEPTIC TANK (PROPOSED)
DETERMINING THE LOCATION OF ALL UNDERGROUND AND OVERHEAD UTILITIES PRIOR TO
COMMENCEMENT OF ANY WORK. THIS.INCLUDES, BUT IS NOT LIMITED TO, REQUESTS TO DIGSAFE, WITNESS: DAVID STANTON, BARNSTABLE HEALTH AGENT A GARBAGE DISPOSAL IS NOT PERMITTED WITH. THIS DESIGN FLOW
ANY PRIVATE. UTILITY COMPANIES, AND THE LOCAL WATER DEPARTMENT. PERCOLATION RATE: LESS THAN < 2 MIN/INCH
16.) CONTRACTOR SHALL VERIFY THAT ALL WASTELINES ARE CONNECTED BY WATER TESTING PERC @ 62" (C Layer)
WITHIN THE DWELLING PRIOR TO INSTALLATION OF ANY SEPTIC COMPONENTS. NO GROUNDWATER .ENCOUNTERED v'
17.) CONTRACTOR SHALL VERIFY EXISTING INVERT ELEVATIONS PRIOR TO INSTALLATION OF ANY
SEPTIC SYSTEM COMPONENTS. NO MOTTLING ENCOUNTERED
18.) TEST HOLES COMPLETED PER STATE ENVIRONMENTAL CODE, TITLE 5. SOILS CAN BE Proposed Sewage D i s p o s a I System
VARIABLE AND TEST HOLE DATA IS NO GUARANTEE OF SOIL CONDITIONS IN OTHER AREAS. IF =29.6t TEST HOLE LOGS
3 9 Island Avenue H yd n n i s Port
SOILS DIFFER FROM THOSE SHOWN IN THE SOILS LOGS, DESIGN ENGINEER IS TO INSPECT THE Test Hole 2 (EL
SOILS PRIOR TO PROCEEDING WITH INSTALLATION OF ANY SEPTIC COMPONENTS. ) 1 : MA
Is,) EXISTING SEPTIC COMPONENTS TO BE LOCATED, PUMPED DRY, FILLED WITH CLEAN SAND AND Depth Elev. Layer Soil Class Soil Color Prepared for:
ABANDONED IN PLACE OR REMOVED AS REQUIRED. AREA TO BE COMPACTED TO MINIMIZE SETTLING. P
INCLUDING EXISTING SEPTIC TANK. 0"-15" 28 3 q Loamy Sand
10YR3/2 William Eagan
15"-44" 25.9 B Loamy Sand 10YR5/6 31 Griswold Road
I CERTIFY THAT I AM CURRENTLY APPROVED BY THE DEPARTMENT OF k
ENVIRONMENTAL PROTECTION PURSUANT TO 310 CMR 15.017 TO CONDUCT 44"-126" 19.1 C Medium Sand 2.5Y6/6 F,P�jN OF S Rye, NY
SOIL EVALUATIONS AND THAT THE ABOVE ANALYSIS HAS BEEN PERFORMED
BY ME CONSISTENT WITH THE REQUIRED TRAINING, EXPERTISE, AND EXPERIENCE ® Prepared by:
DESCRIBED IN 310 CMR 15.017. 1 FURTHER CERTIFY THAT THE RESULTS OF MY
SOIL EVALUATION AS INDICATED ON THE ATTACHED SOIL EVALUATION FORM F 'E'`- JR All Cape Septic and Survey
SOIL EVALUATION, AS INDICATED ON THE ATTACHED SOIL EVALUATION FORM, No. .-11
ARE A ATE AND IN AC RDAN WIT 310 CMR 15.100 THROUGH 15.107 p o 618 Route 28
West Yarmouth, MA 02673
l :� �P (508) 771-4200
DA D FLAHERTY JR, TIFIED SOIL ALUATOR ollcopeseptic@gmoil.com
Date: 11/08/21
Revised 11/20/21 Sheet 2 of 2
Project.No. AC-396-2
i
I�
-\ COMMONT _YE ALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS.
DEI'_ARTMENT OF.ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIA-L INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A oIGS aj/
CERTIFICATION h
Property Address: • � JX t'F� ' 7AC
P /
Owner's Name: "
Owner's Address.:
A- l
Date of Jnspecfion:
Name of 1nspecto pleas P3;int) , o eTt-2 .. . fi 1b9 e M
Company Name.
Mailing Address:
Telephone Number: �l
CERTIFICATION STATEMENT
1 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 DE.P
-approved system inspector pursuant.to Section 15.340 of Title 5(3.10 CMR 15.000). The system:
�✓ Passes
Conditionally Passes
Needs Further Evaluation by the.Local Approving Authority
Fails
Inspectors Sig111 tiire: Date:
f
The system inspector shall submit a copy of this inspection report to the Approving Authority(4icard of Wbalth or
DEP)within 30 days of completing this inspection.If the system is.a shared system or has a design flow of-.:10,066
gpd or;greater,the inspector and the system owner shall submit.the report.to'the appropriate ree48nal office'of the,.l
DEP.:The original should be sent to the system owner and copies sent to the buyer, if applicabler:and the kroviilk
authority. G`3
:3C u
Notes and Comments
r°
L11 M .
****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.
Title.5 Inspection Form E/15/2000 page 1
Page 2 of I 1 j
,.
OFFICIAL INSPECTION':FORM—NOT FOR VOLUNTARY A SSESStvIENTS
SUBSURFACE SEWAGE'DISPOS:AL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued).
Property Address:
Owner:. C,
s
Date of hispectt ni a
Inspection Summary: Check' A;B,C,D or E./ALWAYS complet,all.of Section D
A. System Passes:
I have not found any information which,indicates that.any of the failure criteria described in 310.CMR
15.303 or in 310:CNSR 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 pa
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 2.0 years old7 or the septic tank(whether metal or not)is structurally
d unsou n , exhibits infiltrations substantial infiltration 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 outor,hioh static water level in the distribution box due to broken or
obstructedpipe(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.pipe(s)..The-system will
pass inspection if(with approval of the.Board of Health):
broken pipe(s)_are replaced
obstruction is removed
ND explain:
Page 33 of 11
OFFICIAL IP SPECTION FORM -.NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEAEIDTSPOSAI;SYSTEM INSPECTION'FORM
PART A
CERTIFICATION(continued)
Property Address: Q P/3s/)
Owner.
Date of'Inspec ' n:
C. Further-Eva luation is Regidred by the Board.of Health:.
Conditions exist which require further evaluation by the.Board of Health in order to.determine if the system
is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b.) that the
system is not functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a'surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board.of Health (and Publie.Water Supplier, if any):determines that the
system is functionin-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 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 coliform
bacteria and volatile organic compounds indicates that the well is:free from pollution from that facili y.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 ofthe analysis must be attached to this form.
3. Other:
3.
` p
Page 4 of. I 1
OFFICIAL INSP7ECTIOiN:FORMI:...N.OT FOR VOILUNTAR ASSESSMENTS
SUBSURFACE•SE'WAGE DISPOSAL.SYSTEM INSPECTION:FORM
PART A.
CERTIFI CATI9N,(continued)
Property Address:
deOwner• x�
Date of Inspect' nc
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
A/ clogged SAS or cesspool
Static liquid level in the distribution box above.outlet.invert due to an.overloaded or.clogged SAS or
cesspool .
_ Liquid.-depth in.cesspool is less..than 6"below invert or available volume is less than %2 day flow
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.
V1. Any portion of.a cesspool.or.privy is within.a Zone 1 ofa.public well.
_ 71t Any portion of a cesspool or.privy is within 50 feet of a.private water supply well.
17 Anyportion of:a cesspool or"ptivyis: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'collfornz bacteria and volatile organic compounds
indicates that.the.well is free from pollution from that..facilityand,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 formij
/V0
(Yes/No)'The system fails. I have determined that one or more of the above failure criteria exist as
described in3.10 CMR 15.303, therefore-the system fails.The.system.ownershould contact the Board of
Health to determine what will be necessary to correct thefailure,
E. Large.Systems:
To be considered a large system the system must serve a,facility with a design slow of 10,000 gpd to 15,000
gpd.
You must indicate either"yes" or'"no"to each of the following;
(The following criteria apply to large systems:in addition to the criteria above)
yes no
_ 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 ill a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA) or a mapped
Zone I1 of a public water supply well.
If you have answered"yes"to any question in Section h the system is considered a significant tlireat,.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 3.10 CMR
15.304.The system.owner should contact.the appropriate'regional office of the Department.
Page 5 of I
OFFICIAL INSPECTION FORM—NOT TOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORK!
PART B
CHECKLIST
Property Address: =R9 --A/-),p A;�
Owner: — P. Q
Date of Inspect (�
Check if the following have been done.You must indicate"yes"or"no" as to each of the followins:
Yes o
. Purrping.information was.provided by the owner,occupant, or Board of Health
We any of the system components pumped out in the previous two weeks ?
Has the system received normal flows in the previous two week period?
— ZHave 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 ?
P
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
oft 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
he 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 issue approximation of distance
s unaccep
table)table) (310 CM11 15.302(3)(b)
P ]
5
s
Page 6 of I l
OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address, ):
m 4
Owner: `� C5 "✓
Date,of Inspe
FLOW CONDITIONS
RESIDENTIAL V"' V0
Number of bedrooms.(design): Number of bedrooms(actual): -
DESIGN flow based on 310 C�15.203xample: 11.0 apd x N of bedrooms):
Number of current residents: /
Does residence have a garbage grinder(yes or,no).-
Is laundry on a separate sewaae'system(ye or no): .[if ves separate inspection required]
Laundry system inspected (ye .or no):
Seasonal use: (yes or no):
Water meter readings, if available(last 2 years usage(gpd)):
Sump.pump(yes or no): .4
Last date of occupancy;
COMMERCIAL/INDUSTRIAL/ O
Type of.establishment:.
Design flow(based on 310 CMR 15.203): gpd
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):
GENERAL INFORMATION
Pumping Records
Source of information
Was system pumped as part of the i spec'' (yes or no ' (
If yes, volume pumped' aIlons- How tiv'as quantity pumped determined?
Reason for pumping:
TYPE -F SYSTEM
is tank, distribution box, soil absorption system
Single cesspool
_Overflow cesspool
_Privy
_Shared system (yes or.no)(if yes, attach previous inspection records,.if airy)
_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):,
roxim to age of all components, date installed(if known) and source of information:
Were sewage odors.detected when arriving at the site(yes or no):
Paee 7 of Y]
OFFICIAL INSPECTION FORM—NOT FOR''VOLUNTA.RY ASSESSMENTS
SUBSURFACE SE'WAGt DISPOSAL-SYSTEM INSPECTION FORM
PART .0
SYSTFM.INFORMATION (continued)
Property Address: _ QtAlj
Owner ( ) '
Date of Inspe on:
BUILDING SEWER(locate on site plan)
Depth below grade:
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: Zoocate'on site plan)
Depth below grade:&
Material of construction: ncrete_metal—fiberglass_polyethylene
_other(explain)
If tank is metal list age:— ".Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of
certificate)
Dim ens
Sludge depth:(
Distance from top of sludge to bottom of outlet tee or baffle:: 3� .
Scum thickness:
Distance fifrom 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: + &26
Comments(on pumping recomme dations, nlet and.outlet.tee or baffle condition, structural integrity,liquid"levels
elated to outlet invert, eviden e of leakage, etc.): t
Awo Q&_4V1A 1 AQ1ZP1tVA AA SO.A911P-0
dl <>1 g2 of ` 46 14
GREASE TRAP (locate on site plan) .✓� �J't� t;�/�; -� )T .
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 integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
7
Page 8 of I
OFFICIAL.INSPECTION FORM.- NOT FORVOLUNTARY ASSESSMENTS .
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORNI
PART C
SYSTEM I1'eTI+ORIV AT ON(continued)
Property Address; < ?
49
Owner: e
Date of I pec
_ es�'
TIGHT or HOLDING TANK,,/ (tank ni,ust be pumped at tinge of inspection)(loc.ate.on site plan)..
Depth;below grade:
Material of construction. concrete metal fiberglass polyethylene other(explain):.
Dimensions:'
Capacity: gallons
Design Plow: gallons/day
Alarm present.(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Cornmenm(condition of alarm an&float switches, etc.):
DISTRIBUTION BOX: (if present must be opened)(locate on site.plan)
Depth of liquid lever above outlet invert��r�, Z� ��
Comments (note if box is level and distribution to.outlets��t�al,,an.y evrdence of solids carryover, any evidence of
je ale i Ito pr out box, etc. .
4
"
PUMP CHAMBER:. (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.):
I
Page 9 of l I
OFFICIAL INSPECTION FORM.—NOT FOR'VOLUNTARY ASSESSMENTS
SUBSURFACE, SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART`G
SYSTEM INFORMATION(continued)
Property Address: "gl
Owner: _ C? `
Date of Insp on: 7
SOIL!ABSORPTION SYSTEMS (SAS):tZlocate on site plan, excavation not required)
If SAS not located explain why:
T�ea'c,lhing
pits,number:
ing chambers,number:
leaching.galleries, number:
leaching trenches, number, length:
leaching fields,number, dimensions:
overflow cesspool,number:
__.innovative/alternative system. T,,ype/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,
etc.)- r
J L-- r
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 conditiorrof soil; signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
PRIVY:/Ik(locate on site plan)
'Materials of constriction:
Dimensions:
Depth of solids:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc,):.
i
9
Page 10 of 11
OFFICIAL INSPEC'TIONUORM. --.NOT FOR VOLUNTARY ASSESSMENTS
SUBS RFACE SEWAGE DISPOSAL SYSTEM-INSPECTION FORM
PART-
SYSTEMJNFORMATION(continued)
Property Address:
14-
Owner C
Date of Inspec on.. 1Qs
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 publicg water supply enters.the building.
° V B .
. 0 c� 1
1000
i ��
Page. I I of I I
OFFICIAL INSPEC'CION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: r 9 �
' r
Owner.:
Date ofTnspe n:
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to•ground water.-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)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation: 9
1
d ..
.. ._�
. � ��
t � L
��
., � 9 � � }
-�
+'���,,.
.. .�
_-=
-
.. ..
.. y i
�.
�' � �
• i 7
�. ��
. � ,
�1 :.
�.
. �
�-
• � ��
�, r ,�.
~=l � . .
��
f.
..
. � ._.J�
��
�.�
� .
Permit Number: Date:
Completed by: i
HIGH GROUND-WATER LEVEL COMPUTATION
Site Location: Lot No.
Owner:_ Address:
Contractor: ��•�� Address:STEP 1 Measure depth to water table ---- Ip�to nearest 1/10 ft. .............................................................................. ..D'ate. = �Z /4 7
month/day/year
STEP 2 Using'V1later:=Level Range Zone
and.Index:.Well Map locate
site an&determine:
O.Ap.Propnate index well..........:.................... . ............... 7iG3
OB Water-level range zone .....................................................
STEP 3 Using monthly report"Current
Water Resources Conditions"
determine current depth to
Water level for index well ...........................
month/year
STEP 4 'Using Table of Water-level Adjustments
for index well (STEP 2A), current depth
to water level for index well (STEP 3),
and-water-level zone (STEP 2B)
determine water-level adjustment ..........................................................................................
STEP -5 Estimate depth to high water
..by subtracting the water-
level-adjustment (STEP 4)
from measured depth to water
level'atsite (STEP"1)
Figure 13.—Reproducible computation form.
15
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
y
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 9 /514, rfP /09�/Z
' RECEIVED
Owner's Name: Wil ll, r~
Owner's Address: -39 /�4,,,, 1�,.� f✓y�H.�•f rT
M161 SEp 4 2001
Date of Inspection: $— 2-O/
/ TOWHEALTH DEP7OF BLE
Name of Inspector: (please print) jo /?G I fa
Company Name: 17.�� ��P Pv✓� y
Mailing Address: $2 w /•1•4 t 5 A�
Telephone Number: SO - 412a- 7 279
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
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date:
The system inspector shall stf mit 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,ifapplicable, and the approving
authority.
Notes and Comments
""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.
Title 5 Inspection Form 6/15/2000 page 1 `�''
Page 2 of 11
r
OFFICIAL INSPECTION FORM—Nd 'VOR'Vt)tUNTARY:ASSESSMgNTS;
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ,k '
PART A
CERTIFICATION(comtinued)
Property Address: 39 h A'l, «}
/yyA
Owner: ���� ,.- G�+�.
Date of Inspection: `2— D 1
Inspection Summary: Check A,B,C,D or E/ALWAYS completAIi 4SsCt6 p P
A.-
A. System Passes:
I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
µ .,w
t
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)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank faiha+e is anmineaL 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(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 thad 4 times a year due to..broken or obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM
PART .;
CERTIFICATION-(continued)
Property Address:
Nyu ti�%s �°o•'f �
Owner: bl/•�l u.+^ G�, l•,
Date of Inspection: - --O/
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health,safety or the environment.
1. System will pass.unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
_ Cesspool or privy is within 50 feet of a surface water
_ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and.'%yironment:
.
_ 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 ismithin 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 frort 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 coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered.A copy of the analysis must be attached to this form.
3. Other:
3
r
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT IF OR
VOLUNTARY ASSESSMENTS �.
SUBSURFACE SEWAGE DISP05Ai�.9YS`I'EM:INSPECs"ITOMFORIV
PART.A . . . Y:.
CERTIFI CATIOM(continued)
�a
Property Address: 39 /7vt
Owner: ���,G,..TtiuD/s�a►.�,
Date of Inspection: 1—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
_ tl 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
j_/ Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow
V 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.
_jl 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. .
_ _LZ 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'3016etfrom a-private water
supply well with no acceptable water quality analysis. [This system passss if the-vvell water analysis,
performed at a DEP certified laboratory,for coliform bacteria and V'W ile 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 fail=criteria
are triggered.A copy of the analysis must be attached to this form.]
NO (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems: }
To be considered a large system the system must serves facility with a design flow of.10,000 gpd to 15,000
gpd•
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
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.
4
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM
PART
CHECKLIST
Property Address: we
/7`9L�HNiS Aif MIR
Owner: i liar
Date of Inspection:
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
r/ Were any of the system components pumped out in the previous two weeks?
c� Has the system received normal flows in the previous two week period?
r/ Have 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?
Was the site inspecte&for signs of break out?
Were all system components,exehidiag 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:
Yes no
f/ _ Existing information.For example,a plan at the Board of Health.
_V_ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)[310 CMR 15.302(3)(b))
LIloc nc fariliry nwnf'r IAr,rl nr.CnnnntS if diffr.r tit from owner)A7Yovided with information on the 7:`C)f;cr
rr..ly
5
f
Page 6 of I I
OFFICIAL INSPECTION.FORM—NOT FOR YOLUNTAkV ASSESSMEN3'S .
SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: -3q /f -I'kilt Awe
Owner: e�/��G•.• �,QdLr�an
Date of Inspection: $-1 lol
FLOW CONDITIONS
RESIDENTIAL
a 14
Number of bedrooms(design): Number of bedrooms(actual): •,•yyo
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x tt of bedrooms):
Number of current residents: `L e'.+,r
Does residence have a garbage grinder(yes or no): 416
Is laundry on a separate sewage system(yes or no): A b [if yes separate inspection required]
Laundry system inspected(yes or no):
Seasonal use:(yes or no):—
Water meter readings,if available(last 2 years usage(gpd)):
Sump pump(yes or no): It/a
Last date of occupancy: v�C 1 -�
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sqft,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
pgmpmg)Records
Source of information:
Was system pumped as part of the inspection(yes or no):
,y
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/Alt�mative technology.Attach'a copy of the current operation and maintenance contract.(to be
obtained from syst,e.m owner)
Tight tank Attach a copy of the DES'appraYa1
Other(describe):
Approximate age of all components,date installed if knownla d source of information:
S 3ts•-� yfs� 7 3'�c1 %Own o /3arns ah l� �.�rr+: 1� 77-
Were sewage odors detected when arriving at the site(yes or no): Ala
.+
Page 7of11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE'DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 'f9 jSJoN� eve
of MAI,
Owner:
Date of Inspection:
BUILDING SEWER(locate on site plan)
Depth below grade: `!.s' ►
Materials of construction: cast iron 40�VnCl
_other(explain):
Distance from private water supply well or ne:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK:_(locate on site plan)
Depth below grade: 3'
.Material of construction: concret _metal_fiberglass polyethylene
_other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions:
Sludge depth: t-Pu Au„ ?"
Distance from top of sludge to bottom of outlet tee or baffle: . 22
Scum thickness: .loss ytiu„ z"
Distance from top of scum to top of outlet tee or baffle: 7
Distance from bottom of scum to bottom of outlet tee.or bade: -$S''
How were dimensions determined: ra 10 � rihy s
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of.leak�age,etc.):
' fir'
sld� c �H� 7HHG��v�'1 !H4 SGo'/JTL����y
GREASE TRAP:,yA (locate 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 integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
7
Page 8 of I 1
OFFICIAL INSPECTION FORM-NOTTOR VOLUNTARY.,ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM:INSPECTION FORM:
SYSTEM INFORMATION'(continued)
Property Address: 51u ve '. :. . .
Owner: W/0114-ft 6 t. Y
Date of Inspection:
TIGHT or HOLDING TANK: (tank must be pumped at time of �r}j(Skvte an site plan), Y,;.:, ,• ;,
Depth below grade:
Material of construction: concrete metal fiberglass L{ polyethylene` other(explain),
Dimensions:
Capacity: 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: (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: O :+
Comments(note if box is level and distribution to outlets equal,any evidence of solids ca.rryover,any evidence of
leakage into or out of box,etc.):
:6 %s a��s i"br,�7�,ri re as l ' .. Goy'�� 2 y' bye ps
PUMP CHAMBER: (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.):
8
Page 9ofII
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 3cf
Owner:
Date of Inspection: O I
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,numbed,2,
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.):
BO 4 . C4 {auvP_ T cfvu Ze
A-/ S'., [,caOr:o� �lc►C d�1 6 has 3" 4/ c�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 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: (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.):
9
Page 10 of 11
OFFICIAL INSPECTION FORM-N0T,;FOR V-OJWNTAItY ASSESSMENTS
SUBSURFACE'SEWAGE DISPOSAL"SYSTEM INSPECTION FORM
i t PART C-
SYSTEM INFORMATION.(continued)
Property Address: �vs—t
Owner'
Date of Inspection: $=2-0�"
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. .
r ,
a. � err. x,s:'. `Y r• sYd n�
. A VA
m
.,F 1 .,/`i/ .,.�. .. a try• .. - .
2
y i,
D
10
r
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACESEWAGE DISPOSAL.SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 39 A�.c•�� h�✓�
rrvr�s p✓�
Owner: W,/�ilrrso C/�pD v�+
Date of Inspection:
SITE EXAM ',►};
Slope
ace water
Check cellar
Shallow wells
Estimated depth to ground water 31 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 ievirewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
w"Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation)
_k/Accessed USGS database-explain:
You must describe how you established the hi h round water elevation: ,
CA he Mk s at yvwn ?a HIICA 5fik-fe /-A4 5 tof Fl• i5 3/,
I%-Gvu 41 Ir l r'- y A,' 4 Ti' -e / * L
, o
et.' Ort 7T,ff^' I h / WO" e ,-ew I- / --
w ., pLu7/ N
A
rL I 3 y;
l �
' 12
1 1
�-� COMMONWTALTH OF MASSACHUSETTS �& a
�lip EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS � ���L 1 1998 w
DEPARTMENT OF ENVIRONMENTAL PROTECTION I jo
�l ONE WINTER STREET. BOSTON. MA 02108 617-292-5500 � 44
X
WILLIAS' T F.WELD RUDY CORE
Govemo: Secretar.
ARGEO PAUL CELLUCCI
` DAVID B.STRUHS
Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner
PART A
CERTIFICATION
Property Address: G �v�/ ������ �rf
�y S� '^� Address of Owner:
Date of Inspection: 6--3--98 � (If different)
Name of Inspector: 1OLiA, 17 `a 1/y-
I am a DEP approved system inspector purs ant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: GC*tioe
Mailing Address: 57
Telephone Number: 5,419 - y2 -• 93-9s '
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:
asses
_ Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
_ Fails
Inspector's Signature: �G�r�2� Date:
The System Inspector s all submit a copy of this inspection report to the Approving Authority within thirty (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 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:
t, I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
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.
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, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or
the septic tank, whether or not metal, is 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 04/25/97) Page 1 of 10
DEP on the World Wide Web: http:ltwww.magnet.state.ma.us/dep
i Printed on Recycled Paper
o �
CIO
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
C ` t+• CERTIFICATION (continued)
P•,'roper�tyiAdd'ress: 3 /y'7*/-7 �� �� '7 AV4
/ O✓
Owner: hO s� 1?, 7� TrH Sfi Co.�3tirc< r✓rah/�y
'Date of Inspection: 7
B) SYSTEM CONDITIONALLY PASSES (continued)
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the
Board of Health). Describe observations:
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled 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 privyi 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 PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or
tributary to a surface water supply.
The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that
the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate equal nitro en is to or
g
less than 5 ppm. Method used to determine distance (approximation,not valid).
3) OTHER
(revised 04/25/97) Page 2 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 3 9
Owner: �ots� /QPui/7 r/Ny� s/fHtJ ✓HNP�/ Tr�s7r.r
Date of Inspection:
D) SYSTEM FAILS:
6 ' 3-ib
You must indicate either "Yes" or "No" as to each of the following:
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.
Yes No
_ Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or ck=ed SAS or
cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 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 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 I 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 wmer analysis for
cohiorm bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
El LARGE SYSTEM FAILS:
You must indicate either "Yes" or "No" as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significam threat to
public health and safety and the environment because one or more of the following conditions exist:
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 fl 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 treatrwent program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 04/25/97) page 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 3� �S�uH(/ �"� �y/hs7v�i�y DOr���A,
Owner: �otS `1 lPf�.� �INS� CohS •� C.r d�.ahnpu, /�S ✓
Date of Inspection:
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No
JZ _ Pumping information was provided by the owner, occupant, or Board of Health.
_ None of the system components have been pumped for at least two weeks 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.
_ As built plans have been obtained and examined. Note if they are not available with N/A.
y The facility or dwelling was inspected for signs of sewage back-up.
_ The system does not receive non sanitary or industrial waste flow.
_/ _ The site was inspected for signs of breakout.
_ All system components, exc d the Soil Absorption System, have been located on the site.
✓. _ 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.
The size and location of the Soil Absorption System on the site has been determined based on:
_ The facility owner (and occupants, if different from owner) were providedwith information on the proper maintenance of
Sub-Surface Disposal System.
Existing information. Ex. Plan at B.O.H.
_ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) [15.302(3)(b)J °
(revised 04/25/97) Page 4 of 10
}
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
/ SYSTEM INFORMATION
Property Address: 3�/ S� 'IV A,*7his p,, �Q
Owner: ),j-.S$
Date of Inspection: cyQ
Z,'3—/v FLOW CONDITIONS
RESIDENTIAL:
Design flow: 010 e.p.d./bedroom for S.A.S.
Number of bedrooms: 4
Number of current residents:,
Garbage gn:der (yes or no): 411
Laundry cor:nected to system.(yes or no):�
Seasonal use tyes or no): Ala
Water meter readings, if available (last two (2) year usage (gpd):
Sump Pump Ives or no):—A-141
Last date of occupancy: .P1�14
COMMERCI.AUINDUSTRIAL:
Type of establishment:
Design flow: Qallofis/day
Grease trap present: (ves or no)_
Industrial `Paste Holding Tank present: (yes or no)_
Non sanitary Aaste discharged to the Title 5 system: (yes or no)_
Water meter readings, if available
Last date of o•cupancy:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and sourceet.' iniormation:
}� /I c 7—,)c
System pumped as pan of inspection: (yes or no)
If yes, volume pumped: eallons
Reason for pumping
TYPE OF SYSTEM
�Septfc tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
VA Technology etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all compon nts, dat. installed (if known) and source of information:
Sewage odors detected when arriving at the site: (yes or no)—Al
(zeviied 04/25/97) Page 5 of 10
• .a
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 3 4 N/ A- s�o✓�
Owner: 4,v �-5-.2 Rz4l"� TI'vr 57� Cv�s ae% T'�hh�y Tress ,�
Date of Inspection:
6-.3-9 �
BUILDING SEWER:
(Locate on site plan)
Depth below grade:
Material of construction: _cast iron _ 40 PVC _other (explain)
Distance from private water supply well or suction lir-4-
Diameter y,,
Comments: (condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK:_
(locate on site plan)
i
Depth below grade:
Material of construction: concrete metal _Fiberglass _Polyethylene _other(explain)
If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No)
Dimensions: SIle
Sludge depth: O
.: �.�
Distance trom top of sludge to bottom of outlet tee or baffle:
�Scum thickness: 2n
Distance from top of scum to top of outlet tee or baffle:_
Distance from bottom of scum to bottom of outlet tee or baffle: 2S
How dimensions were determined: tw Cr 4 ^/lpafswJ j>`i�k
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.) �c T•�� -f'a rcn N lids lruc ✓
GREASE TRAP:
(locate 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:
(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.)
(revimed 04/25/97) Page 6 of 10
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: •3g ��/un� 171-e �-
Owner: ,[ofS1 �1ti�r Tp�r S� �✓!S/`uroc i ���'lhey 7/NI/�c
Date of Inspection:
-
TIGHT OR HOLDING TANK: ,Tank must be pumped prior to, or at time, of inspection)
(locate on site plan).
Depth below grade:
Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain)
Dimensions:
Capacir\: .gallons
Design floes': gallons/da�
Alarm level. Alarm in working order _ Yes; _ No
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:_
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and distribution is�lqual, evidence of solids carryover, evidence of leaks a into or out of box, etc.)
p •S/ ij p l So�r�! C�iY C'V-1e- G ' Nl�l� ? ? ! 6� �Y�bH// H 3 e4 z
Co i,-e,- i:s 2 V" �f o rsr c
PUMP CHAMBER:—
(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.)
(zavisAd 04/25/97) Page 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:vf 3 �5�ar,� I�v-e /�r,��tihl��Jo✓1� *G•
Owner: k -51Z Zr
Refill: r75 t'i,
r as/l�svc,o 7-Phh'!7J
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS):
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type: 2
leaching pits, number:_
leaching chambers, number:__
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) y / e
Q4Gli i+a Z9 J /1/N/s� lYr.� S o H S k!/C� ,:5 lv as �/ w,14 !. 9:•�d" �l�f y �d••
LP J4 f
C I
n � c a ✓r 1 61'rt' r� * c/I"•i+ -� /.v 1i �r /ry t+
CESSPOOLS: _
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet inven:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow (cesspool must be pumped as part of inspection)
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.)
(revised 04/25/97) Page 8 of 10
l
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 3 9 /S�s,H ��Q ��c �a vt Mti.
Owner: Lot
Date or Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
k"a f" n v
AI
6
Y,
;6 s
(revised 04/25/97) Page 9 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
Depth to Groundwater Feet
Please indicate all the methods used to determine High Groundwater Elevation:
[/Obtained from Design Plans on record
k-'Observation of Site (Abutting property, observation hole, basement sump etc.)
Determine it from local conditions
heck with local Board r of health
Check FEMA Maps
Check pumping records
V/Check local excavators, installers
Use USGS Data
Describe in your own words how you established the High Groundwater Elevation. Must be completed)
l�
TLi.t,.r .�. d �j¢. �j r lti v �:�. I�/ ' a �a�e
i
(revised 04/25/97) Page 10 of 10
Make application to local Fire Department.
Fire Department retains original application and issues duplicate as Permit.
0/9 411�
� � rim
CJp�x�ts — ✓ oag4a/ rixe
APPLICATION and PERMIT Fee:
for storage tank removal and transportation to approved tank disposal yard in accordance with the provisions
of M.G.L. f: hapter 148, Section 38A, 527 CMR 9.00, application is hereby made by:
•
Tank Owner Name(please print) �Pr�/-iLj X
ignature i apilying o•pennit
Address P- (/C 1-1 ;11✓1.JJJ PC7? /1//1
Street City state Zip
• - HOISTING LICENSE #
Company Name �.t_��� ,L - 5 F'= C ct2� Co. or Individual
Print Print
Address _I"6 3 G A 3o--) Address
Print G Print
i I in for per it /'� �o
.:Signature ( Y 9 P ) Signature(if applying for permit)
5Q IFCI Certified Other ❑ IFCI Certified ❑ LSP# Other
Tank Location ��. --
Y�___ Sleet Address
City
Tank Capacity(gallons) —Substance-Last-Stored
Tank Dimensions(diameter x length)
Remarks:
Disposal • •
E)J✓(20
Firm transporting waste "" 5:�1 r� State Lic. #
Hazardous waste manifest# ��Y.� E.P.A. #
Approved tank disposal yard Tank yard# O 6
Type of inert gas LJ;-9, Tank yard address C��"✓� �'� 2C %? S J,_)
City or Town / FDID# �f��,r`� Permit#
Date of issue Date of expiration
Dig safe approval number: -1 70 G,P -� Dig Safe Toll Free Tel. Number-800-322-4844
Signature/Title of Officer granting permit
------0a
After removal(s) send Form FP-29OR signed by Local Fire Dept.to UST Regulatory.Compliance Unit, One Ashburton Place,
Room 1310, Boston, MA 02108-1618.
FP-292(revised 9P96)
TOWN OF BARNSTABLE
i
y UNDERGROUND FUEL AND CHEN41CAL STORAGE SYSTEMS_
NAME �_�i /PLC S Gt/• �r/ I�iP�//�y— S �s _r' i2 t�r�/✓/D�✓{L��}cOaO�/ �,
� ADDRESS 3q ys ��� 44rZ"q
VILLAGE
LOCATION OF TANKS: CAPACITY: TYPE OF FUEL AGE: TYPE:
OR CHEMICAL
r
}
(Give same information for any additional tanks on reverse side of card) t
DATE OF PURCHASE OF EACH: 1
2. 3. 4. Ig
i
i
DATE OF FIRE DEPARTMENT PERMIT:
TESTING CERTIFICATION SUBMITTED: h
PASSED DID NOT PASS
;
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mom
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c07 73 Y
LQCATION S E WGE PERMIT NO.
ct
VILLAGE
I N S T A LLER'.S AME i ADDRESS
B UI'LL,DEE RqI ORR /OWNER
DATE PERMIT ISSUED.
DATE COMPLIANCE ISSUED -3- ��
-�/� CAL� ��� � ��� ,,,`r
C-1711)
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...............
Apphration Jor Uiivuiitt1 Works ( omitrurtion Vrrutit
Application is hereby'made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at:
-------- ---
... -.4-��-�e---------....................................
® Location_Address ) or Lot No.
Owner Address
,
Installer Address
Type of Building Size Lot. 1_:? -Sq. feet
Dwelling—No. of Bedrooms---------7-----------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type
of Building ___________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) !
dOther fires ------ --- -------------------------------------- ----------------- ---------------------------------------------------------------------
W Design Flow............. r45---________--__-..gallons per person er day. Total daily flow-------,r�_70______. _ _ _-_gallons.
WSeptic Tank—Liquid capacity/i,_ 'gallons Lengt __..' &._ Width.S0._-" Diameter................ DepthAO."��Xt'
x Disposal Trench—No. ..........:......... Width-------------------- Total Length--------- Total leaching area.._._.-____---___--sq. ft.
Seepage Pit No...._!..________ iameteU&7'_,6 __ Depth below 'nlet_&�...,,!70.._ Total leac h;�g' trea. , —�____sq. ft.
Z Other Distribution box ( Dosing tank �y�J
Percolation Test Results Performed by. ,r4 - __. > Pe Date, . ______._._
Test Pit No. _____minutes per inch Depth of "Pest Pit... Depth to ground water______________________.
f=, Test Pit No. 2-.=r...1?-....minutes per inch Depth of Test Pit._/+_ *". p g.... De Depth to round water________________________
-------------------------------------------------•-•-•----•--•---------------- ......-.......-----------------------------------------------------
O Description of Soil---:- �s� ."..._ _ a4 ------ = ��, c� 4` ��. -------------
t ---------- �---......'' s�r�-- - -I--7----•-- crr'i.��f��_�..�-eP._C__ ---------- -•-----------------------------------------
WV Nature of Repairs or Alterations—Answer when applicable.._________________________________________________y:__._...._..__._...._..__._._..._.____.
3
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article \I of the State Sanitary Code— The undersigned further rees fiot to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signe-2�� -----------
J- f � �� - Date
Application Approved B __..:.___' _�C_gr.._/____.__ � _ /L'r.l.�
PP PP Y- ---t�------ - -- ----//mow%=�--�---=-------
Date
Application Disapproved for the following reasons---------------------------------------------
--------------------------------------------------------------------
------------------------------------------------ -------------------------------------------------------------------------------------------------------------------------------------------------------
7 F Date
PermitNo.. -------------------------------- Issued. ] . -----------------------•--
Date
No = Fas....../...5...... ......
THE COMMONWEIAI+TH OF MASSACHUSETTS
BOARD OF HEALTH
y5 ,,fie
Applirtt#inn -for 13itipaaiittl Workii (f omitrnr#inn Vantit
Application is hereby'made for a Permit to Construct (!'f or Repair ( ) an Individual Sewage Disposal
System at:
...............
Location-Address or Lot No.
Owner Address
Installer Address
d Type of Building Size Lot_:w34k5v7 .Sq. feet
U Dwelling—No. of Bedrooms__._______-_-. _.__.Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons..::____.__ __ ____ __ ____-_ Showers ( ) Cafeteria ( )--- ------ —
Other fixtures :_---------- ------ --------•. ----------- --- --
W Design Flow_____________ :: allons per pet son e-i day. Total daily flow w -.._._gallons.
1 / --�g g .� t? Diameter------- Depth_40- .
� Septic Tank—Liquid ca�lcity._ ___ allons Len th ..___''x_ Width_. '
xDisposal Trench—No. .................... Width............3------ Total Length--------- srTotal leaching area..._. __sq. ft.
_Seepage Pit No------' ---------- Djameter�s __ Depth below •nlet,A�'.:"`'42 Total e cl in area. sc t
z Other Distribution box (. Dosing tank
Percolation Test Results Performed b
a Y-•� ,�.+4'�r°�'�._._ ��-+si0:e�'VZ4477 Date.r.'�,f _- ---------
a Test Pit No. 1. �°-___minutes per inch Depth of Test Pit._ ' ° _ Depth to ground water _____________
f14 Test Pit No. 2.49::"_Z....minutes per inch Depth of Test Pit-_—/* +____- Depth to ground water--- --
0 Description of Soil........ C.1Q`j s !'• � �.,' / _fir
"'U �..-- " . � '' --------------- a_ t•'1�� .t -7r ;"rC.`7. '°"crt�'s 'e' � x�c/ •'P ` ��i�' Y
U Nature of Repairs or Alterations—Answer when applicable:_______________________'`"-____.-._________------._______-___-_.__.__:-:.....____-..-____--
---•--•---------------•-------------- .._..-----------------------------___----------------------------------
Agreement:,
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned further rees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health �� 1
o
g
Date
Application Approved BY fT I��'21 ' --------
Date
Application Disapproved for the following reasons_________________________ - ---------
-----•-----------------•--•-•-------------•-------------............................................................................------------•----- --•--------------•--_- ----------------------•-•
Date
PermitNo........................................................ Issued......... .....•.
Date
e`
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....OF.. .., � ... c�-.................
Tntifira#r of 109amplittnrr
THIS IS TO CERTIFY That the Individual Sewage Disposal System constructed ,( 'j�or Repairedby ( )
..._ . F 4:5 .___._ ._ ___...._.___ _..:.__. __
/ Installer w,d
has been installed in accordance with the provisions of : i XI of The State Sanitary Code as described in the
------------- dated------.
application for Disposal Works Construction Permit No. _.._..7L `_Z___ .........
THE ISSUANCE OF THIS CERTIFICATE SHALL, NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE-------• 7 Z Inspector !/'
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
< 1
N .--•-•--•-���---- .. FEE-----=S-••-----•-••--•
�i��n,�ttl nrk,� �nn�#rtYr#intt �rrnti#
Permission is he�zeby granted.-, � 4'=t��`� = 0-0. 7� -4 ..................................................
to Construct ,( or Repair ( ) a] It dividual Sewage Disposal System
at No._- _014-Q ..........1 ---••
r Street
as shown on the application for Disposal Works Construction P r it .'�!f___ _--____ Dated_______ ...............................
/�r �1 .TI� 6i�/i'✓ ----------------------
x P��;;•`
DATE------------------------------------------------- Board of (((/// :,
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REFERENCE : Q� .-�' 'G'O' ' ' S},/`U`{'''4'
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