HomeMy WebLinkAbout0049 HOLLIDGE HILL LANE - Health '' rr ,°4g Flollidge Hi11 Lane '
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No. (� Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: n/
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
Application for Mi5po5a[ *y5tem Con5tructiou Permit
Application for a Permit to Construct( ) Repair(Y Upgrade( ) Abandon( ) ❑ Complete System X Individual Components
Location Address or Lot No. 49 tj0LLlDQ0C_ 141U— 4-406' Owner's Name,Address,and Tel.No.
�q 7C-kc, t40cUV_-,e_- OlLL,CL
Assessor's Map/Parcel 60V_ end
Installer's Name,Address,and Tel.No. —��7"O ��] Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms f Lot Size sq. ft. Garbage Grinder ( )
Other Type of Building P_4S9(h&JY I dL No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) A gpd Design flow provided /()I¢ 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) 3g5.T WO, cu tlu-1 RASA
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Hgtalth.
Signed Date —7"(3
Application Approved by Date FAl
Application Disapproved by Date
for the following reasons
Permit No. 2,012 22( Date T 13 ZA"
Feew
_� r.
THE COMMONWEALTH OF MASSACHUSETTS Entered in compute
PUBLIC HEALTH DIVISION - TOWN OF-BARNSTABLE, MASSACHUSETTS Yes
Apphcotion for Migo al *p!6tem Con0truction Permit �~
Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) ❑ Complete System [k Individual Components
Location Address or Lot No. 1 tjOLL(KC- (4 L CONE Owner's Name,Address,and Tel.No.
Ntj36§c HOc uNQc L4ILL.L(C
Assessor's Map/Parcel 16 .-.,®P, e - r taoz�v w
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building:
DwellingNo.of Bedrooms ?/'V�'" Lot Size sq. ft. Garbage Grinder ( )
'Oflier Type of Building P_arS(6e>JT 1 a-(,,, No.of Persons f Showers( ) Cafeteria
/ Other Fixtures
Design Flow(min,required) 1 �— gpd Design flow provided AM gpd
Plan Date Number of sheets Revision Date
6
1 Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) _jAUS j) [4,,,, )rc�"I •�(� ���,�( (�l Z L� Q��j�
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
+. Signed �'1 /. .,.. — (3 + o?-O' 7
Date �
Application Approved by Date 7,0 r3
Application Disapproved by; // Date i
for the following reasons .
t
`N
Permit No. ao 0 Date Issued *4' 1 f 3'ZA 1j
ii�t�+raww"�AY_+Yai�wa►wr�s.yr ea::r�ai4w��aeea'ori�;.iv�'��...+L.�:�—�_><,�—T,�-• 2' .,.� -
- THE COMMONWEALTH OF MASSACHUSETTS Y
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( x) Upgraded ( )
Abandoned( )by (2 4 rat)(n&
at qQ kow brn Wu_— r MA has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. �7�. 72� dated
Installer &(PEW U 6rn*2.LCE� Designer (V!A
#bedrooms Approved design flow A N� gpd
The issuance of this permit)shall not be construed as a guarantee that the system will function,,as designed.
Date r!'� f 1 1 Inspector
No. 7_,c)( " ZZ f Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS
Mi5po5a[ �§p.5tem Cott5trUction Permit
Permission is hereby granted to Construct ( ) Repair ( )0 Upgrade ( ) Abandon ( )
System located at qj 6(_t41)Q;& 4 1 LJ- LANE HM
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty
to comply with Title 5 and the following local provisions or special conditions.
Provided: Construction must be completed within three yeafs of the date of this r-m-i .
Date I o z-0 t-q Approved by
N Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�„ ,•' 49 Hollidge Hill Lane
Property Address
JGG Hollidge Hill LLC
Owner Owner's Name
information is required for every Marston Mills MA 02648 7-25-17
page. CityrFown 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
t5ins.doc-rev.6/16' Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
49 Hollidge Hill Lane
Property Address
JGG Hollidge Hill LLC
Owner Owner's Name
information is required for every Marston Mills MA 02648 7-25-17
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
Required pumping more than 4 times in the last year NOT due to clogged or
❑ ® q P P 9 Y 99
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
Commonwealth of Massachusetts
W Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 49 Hollidge Hill Lane
Property Address
JGG Hollidge Hill LLC
Owner Owner's Name
information is required for every Marston Mills MA 02648 7-25-17
page. Cityrrown 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 is less than 6" below invert or available volume is less
than Y2 day flow PiT
l5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
49 Hollidge Hill Lane
Property Address
JGG Hollidge Hill LLC
Owner Owner's Name
information is required for every Marston Mills MA 02648 7-25-17
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.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
wM 49 Hollidge Hill Lane
Property Address
JGG Hollidge Hill LLC
Owner Owner's Name
information is required for every Marston Mills MA 02648 7-25-17
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
The system is a 1000 Gal. Tank D Box and pit.
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.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts /002-'0?08
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
GSM 5 49 Hollidge Hill Lane
Property Address
JGG Hollidge Hill LLC
Owner Owner's Name /
information is required for every Marston Mills ✓ MA 02648 7-25-17
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
```��puunuuprp��
on the computer, �/# �a" ���` \(N OF fdgssO,,��
use only the tab 1. Inspector: .�`�#�'
key to move your O? yG
cursor-do not James D.Sears ; JA M E S m
use the return Name of Inspector s ;0z
key.
Ca ewide Enterprises
a :'
P p
r� Company Name
153 Commercial Street '�i,, INS? \QP'�
Company Address
�r Mashpee MA 02649
City/Town State Zip Code
508-477-8877 S 1623
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
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.
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Dis osal System•Page 1 of 17
710 VS
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 49 Hollidge Hill Lane
Property Address
JGG Hollidge Hill LLC
Owner Owner's Name
information is required for every Marston Mills MA 02648 7-25-17
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
The system is a 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
.Seasonaluse? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d 2015-0 Gal's
g ( y g (gP )) 2016-8,000 Gal's
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: NADate
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.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
wM 49 Hollidge Hill Lane
Property Address
JGG Hollid e Hill LLC
Owner Owner's Name
information is Marston Mills MA 02648 7-25-17
required for every State Zip Code Date of Inspection
page. City/Town
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
NA
Source of information:
p Was system pumped um ed as art of the inspection? ElYes ® 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
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 49 Hollidge Hill Lane
Property Address
JGG Hollidge Hill LLC
Owner Owner's Name
information is required for every Marston Mills MA 02648 7-25-17
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:
1984 Permit # 84- 726 / 7-2017 New D Box.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 4' 10"
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.):
Pipeing is 4" PVC SCH -40.
Septic Tank(locate on site plan):
Depth below grade: 4'
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is imetal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 Gal. Precast H-10
Sludge depth:
1"
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 49 Hollidge Hill Lane
Property Address
JGG Hollidge Hill LLC
Owner Owner's Name
information is required for every Marston Mills MA 02648 7-25-17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle 29
Scum thickness 01.
Distance from top of scum to top of outlet tee or baffle
12"
Distance from bottom of scum to bottom of outlet tee or baffle
18"
How were dimensions determined? Asbuilt- Plan -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 w/inlet cover at 10"and outlet cover at 27" inlet tee
outlet baffle. No sign of leakage or over loading.
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.6/16 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
c,M 49 Hollidge Hill Lane
Property Address
JGG Hollidge Hill LLC
Owner Owner's Name
information is required for every Marston Midis MA 02648 7-25-17
page. CitylTown 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.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
ro Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
49 Hollidge Hill Lane
Property Address
JGG Hollidge Hill LLIC
Owner Owner's Name
information is Marston Mills MA 02648 7-25-17
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D Box is 16"x16"-4' below grade w/one line out. Box in New 7-2017 w/cover at 6".
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.
not required):
Soil AbsorptionY System (SAS) (locate on site plan, excavationo
If SAS not located, explain why:
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
i7
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
c,M 49 Hollidge Hill Lane
Property Address
JGG Hollidge Hill LLC
Owner Owner's Name
information is required for every Marston Mills MA 02648 7-25-17
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 600 Gal. H-20 Pit. Pit at 5' below grade w/cover at 28". Pit dry w/stain line at 1'. No
sign of over loading or 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 inflow ❑ Yes ❑ No
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
49 Hollidge Hill Lane
Property Address
JGG Hollidge Hill LLC
Owner Owner's Name
information is required for every Marston Mills MA 02648 7-25-17
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction: .
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 49 Hollidge Hill Lane
Property Address
JGG Hollidge Hill LLC
Owner Owner's Name
information is
required for every Marston Mills MA 02648 7-25-17
page. Cityrrown 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
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t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
49 Hollidge Hill Lane
Property Address
JGG Hollidge Hill LLC -
Owner Owner's Name
information is required for every Marston Mills MA 02648 7-25-17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
N�
12'+
Estimated depth t high ground water: feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: 5-3-83
Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
El Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
T.H.on Design plan 5-3-83 12'+ no G.W.. Bottom of pit at 9' below grade. Bottom of pit at 3'+
above T.H. Depth.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
49 Hollidge Hill Lane
Property Address
JGG Hollidge Hill LLC
Owner Owner's Name
information is required for every Marston Mills MA 02648 7-25-17
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
doa -ao8 _ 726
,J0CAT10N 61�o/y� h/f %/ „� SEWAGE PERMIT NO
'VILLAGE.
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I N S T A LLER'S NAME i ADDRESS
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I U I L D E R 0R OWNER
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED
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No.............. 4
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® F HEALTH
1..0L}..0.............OF.........- .. - .............................
`•'J �PjppiirFauon for Btip.va al Workii Tonstrnrtiorn ratuff
ID Application is hereby made for a Permit to Construct (�) or Repair an Individual Sewage Disposal
PSystem at:
... .. ... ........� ....................... .. ---...1lb..................................................
Loca��Address or Lot No.
L•!l.ik .-. = c�v e�► .-- - ��� _ ...............................................
a s 10,&I....AAAM--O- ---wner ress
------------------------------------------- w-,JO �4✓�,���.,9 ................................................
Installer Address
Q Type of Building Size Lot. �.3�__..Sq. feet
v Dwelling�of Bedrooms___......•...'..__ ._...Expansion Attic ( Garbage Grinder (IJb
PL4 Other—Type of Building ............................ No. of persons............................ Showers ( ) Cafeteria ( )
Q' Othe`r fixtures ..._.
Q ---•------••=•---------------•--- ---------------------------------------••-------•--........•••---------------
W Design Flow..........................S............gallons per person Delr day. Total djily flow............... .���--------------gallons,,
WSeptic Tank—Liquid capacity.t��?gallons Length__ ..--�ea. Width_4-_=.L�. Diameter________________ Depth_A_._.(i.
x Disposal Trench—No..................... Width ....... Total Length............ ... Total leaching area............
__....�Sq. ft.
Seepage Pit No.....____I._.____--- Diameter-___-__L_�__. Depth below inlet.:�J: __.... Total leaching area...Z,._4,Ssq. ft.
Z Other Distribution box ( L)--' Dosing tank �j GG,
a Percolation Test Results Performed by..i,�� G�.... ........... Date--- .�.....b3.......
0
Test Pit No. l....----.__minutes per inch Depth of Test Pit_____2..._.._ Depth to ground water..o�-,P_V— .��
Test Pit No. 2................minutes per'Ai&h Depth of Test Pit....�2..._... Depth to ground water-___
•
O Description of Soil.......... --' A2-......1............-------- ----U(5 501----....... -0
x
V .............................................................--•••••------------••-•••-••--••------------------------•-••-••----•••-----•--•-------•-----•-•---•-----•-•--.........---•••-•••--......---
W ----•----••--------------------•----•---•-••-----------------•---•------------------•--•-•--•-••--••-----------•------------------•----•---- ...........................................................
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 TLEHE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has beea issued by thebVrd of health.
ed.,
C�'G f/ Date
ApplicationApproved •----- ----- --•---........-•••-•••••••------•-•-•--•-•---•...................•-•.-•-...
Date
Application Disapproved for the owing reasons-...............................................................................................................
.................••••--••----•••••-••--•...•-•---•�---••.................._--••------•----•--............••-••-•-•--......•-•--•-•----••••-•----••----••-----•--•-•--•-•-----•---- -•-•-•--......
Date
PermitNo..... '--_.�--4-.'6..-•-•-•-•............. Issued.......................................................
Date
1
No.. ��;.. rr ,` FEs..0 .�,?.............
THE COMMONWEALTH OF M 4SSACHUSETTS
BOAR® F• HEAL`fH
LC
1... . _ ,--.............0. .................................................
ApplirFatiun for Disposal Works Tonstrnrtiun ramit
Application is hereby made for a Permit to Construct (K) or Repair ( ) an Individual Sewage Disposal
System at
...
Locatiolr-Address c or Lot No.
t.l No.
i\.lq_l o.y w ... `" .... ...............
Owner
af V r.. / F - y Address7----- •------------- •--•_-.---------
Installer o- g = Address
Type of Building Size Lot 4_.Z t.�.«.---Sq. feet
ll��
Dwelling of dfoorl , . ;?� ....._Expansion Attic ( sa Garbage Grinder (IS
Other—Type of Building ............................ No. of persons_...._.._:__.....•......_.._ Showers — Cafeteria
Otherfixtures .... s •... -_••-•--•------------------------------------------ ; .................................
W Design Flow..........................4-.
........gallons per person�ptlr day.` Total daily flow.............✓.A-� �__.._____._.. allons..
W Septic Tank—Liquid capacity�_r�(?galIons Length__ .-( . Width.: .')._. Diameter................ Depth.."...___ ..
_. ..
x Disposal Trench—No. .................... Width..._._._..._..... �Totar ength..._........a-...... Total leaching area---------------------sq. ft.
Seepage Pit No_________ ___________ Diameter........ .___. Depth below inlet..........:.._... Total leaching area..... _11_��sq. ft.
Z Other Distribution box ( Dosing-tank ( f z ._...
Percolation Test Results Performed by._�._.:L:/! �-::Q=.Q.....�_j-- t- ........... ' .� .
Date `'-•-- 1
MTest Pit No. 1...Z..:� minutes per inch Depth of Test Pit---- Depth to ground water..C?---_--':....... V
44 Test Pit No. 2................minutes per inch Depth of Test Pit----- ....... Depth to ground water----<_>'4'5D f j Z
<x •••• `
D Description of Soil......... . �~'.......:...........I'hY... � �...11._�-C,JL�. / rf.-� �;yc ".... ...�� .
x
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 TITU 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the, and of health.
Sign d. :.'�._. ........fir`' /5� y
Date
Application Approved B .......-
Date
Application Disapproved for e f o wing reasons-------------------------------------------------------------•------------------------------•••••-•••••........
i
................................................................................................................................................_......................_............_....................
Date
PermitNo.......... ? Z: -------------------- Issued.....................................................
Date
i
` THE COMMONWEALTH OF MASSACHU5ETTS
BOARD OF HEALTH
/4t�/�......: .......o F...., /c/V , � ' 4C ....................
Trtifiratr of fP�unt li�anr�e
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (4_� or Repaired ( )
by-•-••-••J201.1.IV.....•..,4-fJ--.42-0-------------------------------------------------------------------------------------------------------------------------------------------
at. �� �r� Installer
15� 1l C .......................................
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the.
application for Disposal Works Construction Permit No..__ -__ _�'I............. dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNFTIOJ SATISFACTORY.
DATE.................... ... . J� .... Inspector.....----••••.
ello-_'k$JMAO---------�' - ----- ------ ........
THE COMMONWEALTH OF MASSA�HU65ETTS
BOARD OF HEALTH
....................OF.Jf� 1!S. L=.--........... r
No.... :4t-' FEE.:
Disposal Workii Tonstrur#iun Vprrmit
Permission is hereby granted....J!J&/V....4``."1/1.2_0...............................................................................................
to Construct (� ) or\Repair ( ) an Individual Sewage Disposal System
at No. _ Q 7 .` .-- /.--40_4L-! 'A _h,//,,,L--. �M. J f Frs 11 '-.,/V /-/' S
f Street
as shown on the application for Disposal Works Construction Permit No--------- _- __- ated..........................................
If# Board of Health
DATE-------------------••-••--••• •--••••-• --------••••--•-••............••....
FORM 1255 A.M. SULKIN. INC.. BOSTON
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