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Home My WebLink About0147 LAKE SHORE DRIVE - Health 147 LAKESHORE qK MARSTONS MILLS A=030-084 i i r• Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 147 Lakeshore Drive Property Address Neila Neary Owner Owner's Name information is required for every Marstons Mills MA 02648 10/27/11 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 A. General Information filling out forms on the computer, I.T. use only the tab 1. Inspector: key to move your cursor-do not Ricky L. Wright use the return key. B & B Excavation,lnc. ray Company Name 14 Teaberry Lane Company Address Forestdale MA 02644 City/Town State Zip Code 508477-0653 S14595 Telephone Number License Number B. Certification _ c� I certify that I have personally inspected the sewage disposal system at this address and that-Yhe information reported below is true, accurate and complete as of the time of the inspection. The1insp@0ion 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'i40 oft Title 5(310 CMR 15.000). The system: 3 `CD ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 10/28/11 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•11'10 Title 5 Official Inspection Form:Subsurface 4Swagebi.posal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 147 Lakeshore Drive Property Address Neila Neary Owner Owner's Name information is required for every Marstons Mills MA 02648 10/27/11 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): 15ins•11'10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 147 Lakeshore Drive Property Address Neila Neary Owner Owner's Name information is required for every Marstons Mills MA 02648 10/27/11 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B System Conditional) Passes (cont.): y y ( ) ❑ 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-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 147 Lakeshore Drive Property Address Neila Neary Owner Owner's Name information is required for every Marstons Mills MA 02648 10/27/11 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 cesspool is less than 6" below invert or available volume is less than '/z day flow t51ns•1 M 0 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 147 Lakeshore Drive Property Address Neila Neary Owner Owner's Name mformrequired is Marstons Mills MA 02648 10/27/11 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. l5iis•1100 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 147 Lakeshore Drive Property Address Neila Neary Owner Owner's Name irfor every is irequequireded for Marstons Mills MA 02648 10/27/11 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 3 l5ins•11'10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 147 Lakeshore Drive Property Address Neila Neary Owner Owner's Name requredfo is Marstons Mills MA 02648 10/27/11 required for every page. Citylrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•1110 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 147 Lakeshore Drive Property Address Neila Neary Owner Owner's Name information is required for every Marstons Mills .MA 02648 10/27/11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•11;10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 147 Lakeshore Drive Property Address Neila Neary Owner Owner's Name iiion is required for every Marstons Mills MA 02648 10/27/11 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: 1998 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): ' Depth below grade: 1 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: > 20'feet Comments(on condition of joints, venting, evidence of leakage, etc.): At time of inspection, building sewer appeared to be in good condition. No sign of leakage Septic Tank(locate on site plan): Depth below grade: 6"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ® No Dimensions: 5'2"x 5'2"x 8'6" Sludge depth: 611 t5ins•11110 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 147 Lakeshore Drive Property Address Neila Neary Owner Owner's Name information is required for every Marstons Mills MA 02648 10/27/11 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 31" Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? scour stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): At time of inspection, septic tank appears to be in good condition. No sign of leakage 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•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 L_ Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 147 Lakeshore Drive Property Address Neila Neary Owner Owner's Name information is required for every Marstons Mills MA 02648 10/27/11 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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-1 VI Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 147 Lakeshore Drive Property Address Neila Neary Owner Owner's Name requir required is Marstons Mills MA 02648 10/27/11 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 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): At time of inspection, d-box appears to be in good condition. No sign of solids carryover or leakage 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 147 Lakeshore Drive Property Address Neila Neary Owner Owner's Name inquired for is Marstons Mills MA 02648 10/27/11 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: (2) 500 gal ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): At time of inspection leaching appears to be in good condition No damps soils or pondin m 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•1 N10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 147 Lakeshore Drive Property Address Neila Neary Owner Owner's Name information is required for every Marstons Mills MA 02648 10/27/11 page. Cityrrown 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•11110 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 147 Lakeshore Drive Property Address Neila Neary Owner Owner's Name information is required for every Marstons Mills MA 02648 10/27/11 page. Cityrrown State Zip Code Date of Inspection D. System Inform ation (cont.)Y ( 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 C y II 02 Ak- s6 ' 132. 22` 3 z3 ` C9 = � t5in;-11/1.0 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 L f Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 147 Lakeshore Drive Property Address p y Neila Neary Owner Owner's Name required fo is Marstons Mills MA 02648 10/27/11 required for every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: > 15'feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 r A Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ,M 147 Lakeshore Drive Property Address Neila Neary Owner Owner's Name information is required for every Marstons Mills MA 02648 10/27/11 for page. CityfTown 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 Commonwealth of Massachusetts Executive Office of Enviromnental Affairs Dept. of Environmental Protection Jitl One winter Street'Boston Ma. 02108 Septic D.L.P. "Titlee V S Seeptic Inspector 6 j 0 P.O. Box 2119 L Teaticket' MA 02536 WILLIAM F.WELD (508)564-6813 Governor ARGEO PAUL CELLUCCI Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ,PART A CERTIFICATION SFP 2 4 'I Property Address: 147 LAK HORE DR MARSTONS MILLS LOT 84 Address of Owner: !fit 1104 f 199(9 !/1 Date,of Inspection: 9117198 Name of Inspector: JOHN GRACI (if G EIfferent)G QUILTY h�[Ty�fP�TgB1F 1 I am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000) Company Name,Address and Telephone Number: CERTIFICATION STATEMENT I cer'ify 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: _ Passes This Inspection Is based on criteria defined In Title V Con ditio all Passes code31oCMR16.303.My findings are of how the system is performing at the time of the inspection.My inspection does _ Needs ur er Evaluation By the Local Approving Authority not imply any warranty or guarantee of the longevity of the X Faillubmit septic system and any of Its components useful life. Inspector's Signature: Date.: 9118198 The System Inspector shall a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A] SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B] SYSTEM CONDITIONALLY PASSES: !One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined(Y, N, or ND). Describe basis of determination in all instances. If "not determined",explain why not. The septic tank is metal, 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 04127197) One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 147 LAKESHORE DR MARSTONS MILLS LOT 84 Owner: GREG QUILTY Date of Inspection:9117199 _ Sew.aae backup or,hreakout or hiah.static water level observed.in.the distribution box is due to a broken. or obstructed pipe(s)or due to 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 leveled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface of water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and 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 presense of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method usedto determine distance (approximation not valid) 3)Other D] SYSTEM FAILS: You must Indicate either"Yes"or"No"as to each of the following: x 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 _ -X_ Backup of sewage in facility or system component due to an overloaded or clogged SAS or cesspool. x _ Discharge or ponding of effluent to the Surface of the ground or Surface water§flue to an 001100ded 01 clugged cesspool. x_ _ SAS is in hydraulic failure. (revla ed OJ27197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 147 LAKESHORE DR MARSTONS MILLS LOT 84 Owner: GREG QUILTY Date of Inspection:9117199 D]SYSTEM FAILS(continued) Yes No x Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. x Liquid depth in cesspool is less than 6"below invert or available volume is less than 112 day flow. x Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). — Numbers of times pumped X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. —x- Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. x Any portion of a cesspool or privy is within a Zone 1 of a public well. —x_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. x Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: 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: The system serves a facility with a design flow of 10.000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No x the system is within 400 feet of a surface drinking water supply x the system is within 200 feet of a tributary to a surface drinking water supply _ x the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area(IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. Irevlsed 04,27197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: 147 LAKESHORE DR MARSTONS MILLS LOT 84 Owner: GREG QUILTY Date of Inspection:9117199 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: ,c_ — Pumping information was requested of the owner, occupant, and Board of Health. x None of the system components have been pumped for at least two weeks and the and the system has been receiving normal — flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. x As built plans have been obtained and examined. Note if they are not available with N/A. x — The facility or dwelling was inspected for signs of sewage back-up. x _ The system does not receive non-sanitary or industrial waste flow. _X— — The site was inspected for signs of breakout. x All system components, excluding the Soil Absorption System, have been located on the site. x The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees,material of construction, dimensions, depth of liquid, depth of sludge,depth of scum. x _ The size and location of the Soil Absorption System on the site has been determined based on The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal Systens. x Existing information. Ex. Plan at B.O.H. x Determined in the field(if any failure criteria related to Part C is at issue, approximation of distance is unacceptable)(15.302(3)(b)] (revised 04127)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 147 LAKESHORE DR MARSTONS MILLS LOT 84 Owner: GREG QUILTY Date of Inspection:9117198 FLOW CONDITIONS RESIDENTIAL: Design flow: 220 g.p.d./bedroom for S.A.S. Number of bedrooms: 2 Number of current residents: 4 Garbage grinder(yes or no): No Laundry connected to system(yes or no): Ye: Seasonal use(yes or no): No Water meter readings. if available:(last two(2)year usage(gpd): nfa Sump Pump(yes or no): No Last date of occupancy: nla COMMERCIAL/INDUSTRIAL: Type of establishment: nla Design flow:0 gallons/day Grease trap present: (yes or no) No Industrial Waste Holding Tank present:(yes or no) No Non-sanitary waste discharged to the Title 5 system:(yes or no) No Water meter readings, if available: nra Last date of occupancy: nra OTHER:(Describe) Ma Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: Na System pumped as part of inspection: (yes or no)No If yes,volume pumped:0 gallons Reason for pumping: nla TYPE OF SYSTEM x Septic tank/distribution box/soil absorptions system Single cesspool Overflow cesspool Privy Shared system(yes or no) ( if yes, attach previous inspection records, if any) I/A Technology etc.Copy of up to date contract? Other: APPROXIMATE AGE of all components, date installed(if known)and source information: 1978 Sewage odors detected when arriving at the site: (yes or no) No trevlaed 04117197) I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 147 LAKESHORE DRMARSTONS MILLS LOT 84 Owner: GREGQUILTY Date of Inspection:9/17199 SEPTIC TANK: x (locate on site plan) Depth below grade: 8" Material of construction:x concreate_metal_FRP_Polyethylene—other(explain) If tank is metal, list age nla . Is age confirmed by Certificate of Compliance No (Yes/No) Dimensions: L8'S"H5'T"W4'10" Sludge depth:V Distance from top of sludge to bottom of outlet tee or baffle: 22" Scum thickness:e" Distance from top of scum to top of outlet tee or baffle:6" Distance form bottom of scum to bottom of outlet tee or baffle: 10" How dimensions were determined. MEASURED Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,etc.) SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING NOW AND THEN MAINTAINED EVERY TWO YEARS. GREASE TRAP: (locate on site plan) Depth below grade: rda Material of construction: _concrete_metal_FRP_Polyethylene_other(explain) Dimensions: rda Scum thickness:rda Distance from top of scum to lop of outlet tee or baffle:nla Distance from bottom of scum to bottom of outlet tee or baffle: nla Date of last pumping;,,a 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.) n!a BUILDING SEWER: (Locate on site plan) Depth below grade: 14° Material of construction:_cast iron_40 PVC_other(explain) Distance from private water supply well or suction line•TOwN Diameter: nIa_ Q1*1mments: (conditions of joints,venting,evidence of leakage,etc.) (revleed CARD97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 147 LAKESHORE DRMARSTONS MILLS LOT 64 Owner: GREG QUILTY Date of Inspection:9117199 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: rda Material of construction:_concrete_metal_FRP_Polyethylene_other(explain) Dimensions: nra Capacity: nla gallons Design flow: rva gallons/day Alarm level:_nla Alarm in working order?_Yes_No Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) rda DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: nla Comments: (note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box etc.) rda PUMP CHAMBER: (locate on site plan) Pumps in working order:(yes or no)No Alarms in working order(yes or no)_Yes Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) rda (revised 04727)97) i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 147 LAKESHORE DRMARSTONS MILLS LOT 84 Owner: GREG QUILTY Date of Inspection:9117199 SOIL ABSORPTION SYSTEM (SAS):x (Iccate on site plan, if possible;excavation not required, but may be approximated by non-intrusive methods) If not determined to be present,explain: Na Type: leaching pits, number: 1000 GALLON LEACH Prr leaching chambers,number:Na leaching galleries, number: Na leaching trenches, number,length: n1a leaching fields,number, dimensions:Na overflow cesspool,number:n1a Alternate system: Na Name of Technology:_Na Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) THE LEACH MIS IN HYDRUALIC FAILURE,THE LIQUID LEVEL IS OVER THE INVERT,PR WAS PONDING TO THE SUFRACE. CESSPOOLS:_ (locate on site plan) Number and configuration: Na Depth-top of liquid to inlet invert: Na Depth of solids layer: Na Depth of scum layer: Na Dimensions of cesspool: Na Materials of construction: Na Indication of groundwater: Na inflow(cesspool must be pumped as part of inspection) Na Conments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) Na PRI'":_ (locate on site plan) Materials of construction: Na Dimensions: Na Depth of solids: Na Corments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) Na (revised 04127)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 147 LAKESHORE DR MARSTONS MILLS LOT 84 GREG QVILTY 9117198 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) C �c-vk l° °1 V AA A y9 Ac P,A n Cc Papa 9 of 10 pevmed 04n7197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 147 LAKESHORE DR MARSTONS MILLS LOT 84 GREG QUILTY 9117199 Depth of groundwater 12+ Please indicate all the methods used to determine High Groundwater Elevation: Obtained from design plans on record. Observation of Site(Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of Health Check FEMA Maps Check pumping records Check local excavators, installers X Use USGS Data Describe in your own words how you established the High Groundwater Elevation.(MUST be completed) USGS MAPS AND CHARTS p.vm.dw127197► to#* 10 a[ 10 TOWN OF BARNSTABLE (, LOCATION ' `�-��(L1�� SE AGE # ® � ASSESSOR'S MP & OT 0 � VP;'LAGEM'"SM INSTALLER'S NAME&PHONE NO.m"oa 4a6Je_ 4+11-62,314 SEPTIC TANK CAPACITY I COO t LEACHING FACILITY: (type) 100 f Ls)"size) '13 2-X NO.OF BEDROOMS OL BUILDER OR OWNER PERMITDATE: S COMPLIANCE DATE: 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"oi 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 ^ AS q9 � 6A d® g 14 i$'� �I � cI.r — o33 � (w� Z- 1- 9� r �`f 7_ .=-L��S'G-�-tee..._��,,we , _�r o„�.�-v�•,,,.�- ,,�r�l s __ _ _ _--__ _ -- - - �„3Ip-��/^VV' �' t � _ — - - - -�"O�o_(st_.w� :T:�S��-c=�^•- _o-.e9� 2 sGLeweti� �,�`� _a-�-_��.��!(.�,c k - - Lai,l�V �( Allc� - - kCA"U- 6-7 - b IeacL-Ova d d -v µVS Ovv7 c/7 Kt f 0 r'l c4 e� L c 9,`Fe �vt; S - v t�rw-l09- la-e �`--° y 0 (11ve.4- _p; _ c S_ A Iola(lk _" C-�kCl/ /,6f •-- -- -- - --- 1 S`c�C.`„i,,Qi(��?�_ ;_�._..71�.c,c---�"�`� - -t�=�� ,cz�'.t�= -S�.e�� - v'" `hf'c� 5=�¢,�..�i�_.. . r lakeyz -`O�� i � f 1� t M �r f' ._-�.�--.�--•-»+.-_.�`�... �� _- v._..,_...��-fir..,..- w � --'�� ....� �__._. .�.._ r T OF BARNSTABLE LC :A`i ION LPS SEWAGE # ` ,i,LAGE r_4SAM'- I t',S ASSESSOR'S MAP& LOT S INSTALLER'S NAME&PHONE NO. 0,3d �lI SEPTIC TANK CAPACITY 006 LEACHIAiG FACILITY: (type) lll�S. (�l (size) NO.OF BEDROOMS BUILDER OR OWNER _ 1 PERMTTDATT:: _COMPL CE DATE: i 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 • ��-'1 �,..r ��'',� , .) � . ,�� e I .. TOWN OF BARNSTABLE Y Y•l! LOCATION 141 ","GrC 1� lUt� SEWAGE # 7d k VILLAGE M"SLfn YYl" ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO.M"OJ SEPTIC TANK CAPACITY 1000 t LEACHING FACILITY: (type) �` [ l,t�PJ�(size) 13'2 X a%si IL V NO. OF BEDROOMS 0 BUILDER OR OWNER <OrQC, PERMTTDATE: COMPLIANCE DATE: l2-l —y 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 L> tf i Ci 9'a 4fi o v Ce W Id V9 1 No. A Fee 1 THE COMMONWEALTH OF ' A ACHUSETTS Entered in computer: Yes -TOWN OF B STABLE MASSACHUSETTS PUBLIC HEALTH DIVISIONO s 01ppYication for ;i-4po.5al 6peum Cow6truction 3permit Application for a Permit to Construct( )Repair( )Upgrade( )A and D ❑Complete System ❑Individual Components Location Address or Lot No.I � � ) p r_� Owner's Name,Address and Tel.No. Assessor Map/Parcel ' 2's'� m/`"bA�{ . "� u ��✓ — 1 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Z` Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil N ture oTRep#irs or Alterations(Answer when applicable) n g2g 3 l7- r W 1 N, N t4l Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has be ed by B and of ealth. Signed Date Application Approved b Date Application Disapproved for the following reasons Permit No. Date Issued Fee !! 11 THE COMMONWEALTH OF AS ACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BA STABLES MASSACHUSETTS 01pplication for Mi5po5ar *pgtem Construction i3ermit Application for a Permit to Construct( )Repair( )Upgrade( )A(anD( ) ❑Complete System ❑Individual Components Location Address or Lot No.I� f y� Owner's Name,Address and Tel.No. Assessor's�p/P rc l 4\ 1114 1�'S`�R LA 11M' ` �C —I O S� Installer's Name,Address,and Tel.No. - Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil N ture of Repairs or Alterations(Answer when applicable) �- d r LU k 4° S Date last inspected: r Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has bee. issyedd by t Band f ealth. Signed 60 Date a 1 ~ Application Approved by Date Application Disapproved for the following reasons r Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS 11 Certificate of Compliance/ THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( Repaired( )Upgraded( ) Abandoned( by t L h - L r3,6 C� at 1 y1 L a k<a Sk has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No ated /.7 Installer ,Designer The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date Inspector No. � �--`�—A---------—-----------------Fee —,:g � THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS ` Mi0pogal 6,vMem Congtructton hermit Permission is hereby granted to Construct( �Repair( )Upgrade( )Abandon System located at 1—Y��<e-S 4F 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 years of the date of t ' it. Approve Date:1 .- y� �+ ! � I i 10/9197 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT ENGINEERED PLANS) f wLpw I, Y%L 61,J P` �-io'b LIR , hereby certify that the application for disposal works construction permit signed by me dated L -c W , concerning the property located at I `4-1 ('` 16CS Le PC ue— meets all of the pw"1 following criteria: There are no wetlands located within 100 feet of the proposed leaching facility There are no private wells within 150 feet of the proposed septic system /• There is no increase in flow and/or change in use proposed There are no variances requested or needed. • If the proposed leaching facility will be located within 250 feet of any wetlands, the bottom of the proposed leaching facility will=be located less than fourteen (14) feet above the maximum adjusted groundwater table elevation. Please complete the following: A)Top of Ground Elevation(according to the Engineering Division G.I.S.map) _ B)Observed Groundwater Table Elevation(according to Health Division well map) SIGNED : DATE: LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. q:health folder.ccn s .� �J .�� . �, rt- � P�o'�c� �o THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH A -------------OF........06. �_ .. t tj Application is hereby made for a Permit to Construct (V) or Repair an 1ndividual Sewage Disposal Sys t: . 7------- .... ...... -- -- ----- .......4..... ................................ --------------------------------- :�.�L 0 K7 ----- Owner Address Other Distribution box ( ) Dosing tank ( ) U Nature of Repairs or Alterations—Answer when applicable--_----------1NaTAUED__1K__C.0MPLIA1NGF------------------------- Agreement: SANITARY CODE AND TOWN The undersigned agrees to install the aforedescribed IndividuF4Q%" -S- -in in accordance with the provisions of Article XI of the State Sanitary Pjde— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has lb iss d b t2h7erd of h li.�� Date Date ___ Date ~ Permit '-- _ ' ""u /---'---''—' '— ''' ' —'''' ' '— ''' — — —'— --' —' —' ' — ' —'—' ----'-----' No:_. �...._..._. FEs.. ..................... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ^. al ..._.........OF.:.. -. r � .:a:... "- Applirativia for Biuvviia1 Works Tomitrurtion ramit Application is hereby made for a Permit to Construct O or Repair ( ,) an Individual Sewage Disposal SY s ,at.* �-- ' e ocatw Tess r Lo r TT Owner _ { Address W !/ Installer Address Q Type of Build Size Lot----------------------------Sq. feet U Dwelling-No. of Bedrooms---------------------------------------_-----Expansion Attic ( ) Garbage Grinder ( ) a Other—T e of Building No. of persons____________________________ Showers — Cafeteria a' Other fixtures __________ W Design Flow.............................................gallons per person per day. Total daily flow.............................................gallons. WSeptic Tank—Liquid capacity------------gallons Length................ Width_-________--_-_ Diameter____-______.___ Depth---............. x Disposal Trench—No_____________________ Width____________________ Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by-•-:--=---------------------•-•••-•-•----•--•---•----• .................. Date........................................ Test Pit No. 1................minutes°per inch Depth of Test Pit____________________ Depth to ground water__-____________________- �, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water____________________--_- Q'+ -- - r Description of Soil_________________________ ----------- x U .•---------------=------------------------------------------•-•---•---•---------------•---•-----------•--------------•--------•-----•------------•-------------------------------------••--•------------- 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 Article XI of the State Sanitary de The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b enfisr d b, th bard of health. /( �. //4 / Signe ._._._ = D r c:• '�-`` _.----•------- o Date Application Approved BY c .------------------- +�--- ........ Date Application Disapproved for the following reasons:................................................................................................................ ......................................................................................................................................................................................................... Date Permit No Issued. ................................................. Date y,. t .-m yr �'^ �',. r<.{(+' s+ �f w«�v�i-_�.3""_��..`57's#.��.-...._a..._ ..� �.�. .,___'.>..x•_...._� *� �._�',..:��"^�`#£"u_;.NSF=rrL"�_A8'Lb'•'ld�i-�d?$C'-_f'�+-I�F_..�• —THE COMMONWEALTH OF MASSACHUSETTS BOARD F HEALTH f ..OF........... .:{�,� ,w..........: ...... of (Ijampliattrr T II IS TO CERTI Y at the Individu wag Disposal S- in constructed or Repaired ( ) by w. Installer at _._ ';et ------------- has been installed in accordance with the provisions of Article XI of The State Sanitary Code as d scribed in the application for Disposal Works Construction Permit No...................t l.Y`_______ dated__'_ _ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CFTAS A ARA E THAT THE SYSTEM WILL F NCT N SATISFACTORY. 01/ /�. DATE-------- -' - --- ----------•---•---- ............ Inspector----- --------- -------.-�.�'� r.�• THE COMMONWEALTH OF.'MASSACHUSETTS BOARD OF; HEALTH :.. ....:. . OF... . i No._f........................ FEE- .................. Urt i Permission is hereby granted'- t to Construff Ok or Rep ' ) a --- -Indivld Sewage posah steri3` t �' N� - / - •,-, • .. Street - s,.,E. as shown on the application f r Disposal Works Construction -Per lit'N �/ S Dated__. ; _ _.. M r _�___ Board of e DATE FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS