HomeMy WebLinkAbout0515 MISTIC DRIVE - Health 55 Mistic Drive
Marstons Mills
080 ,019
i
f
Commonwealth of Massachusetts /
Title 5 Official Inspection Form ,
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments s
/ 515 Mistic Dr
Property Address .r
er Zito
Own „
information is Owner's Name +
required for Marstons Mills "� Ma 02648 10-7-19
every 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: A. Inspector Information
When filling out
forms on the
computer, use Douglas A Brown
only the tab key Name of Inspector
to move your D.A.Brown Inc
cursor-do not Company Name
use the return
key. P.o Box 145
Company Address
rL Centerville Ma 02632
City/Town State Zip Code
508-420-4534 S14297
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title
5(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
10-7-19
Znso
Signature Date
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 form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: 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.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
17 Commonwealth of Massachusetts
�v l Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
v
515 Mistic Dr
Property Address
Owner Zito
information is Owner's Name
required fcr Marstons Mills Ma 02648 10-7-19
every page. CitylTown State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) 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:
At time of inspection this system met or exceeded all minimum passing requirements. This system is
from 1994 and for at least the past 2 years has seen very little water usage. This report can not
predict the future performance under the same or incerased usage. System is 25 yrs old.
2) 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):
t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
Commonwealth of Massachusetts
ig Title 5 Official Inspection Form
1° Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
515 Mistic Dr
Property Address
Owner Zito
information is Owner's Name
required for Marstons Mills Ma 02648 10-7-19
every page. CityTrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ 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):
3) 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.
a. 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:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
�
lip Title 5 Official Inspection FormJA
_ p
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
515 Mistic Dr
Property Address
Owner Zito
information is Owner's Name
required for Marstons Mills Ma 02648 10-7-19
every page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ 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
b. 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.
c. Other:
4) 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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
r: ip Title 5 Official Inspection Form
(/ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
4'
515 Mistic Dr
Property Address
Owner Zito
information is Owner's Name
required for Marstons Mills Ma 02648 10-7-19
every page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® 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 'h day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
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 2000 gpd-
10,000 gpd.
❑ ® 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.
5) 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 CA.
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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
i
Commonwealth of Massachusetts
�m ►.? Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
4�
515 Mistic Dr
Property Address
Owner Zito
information is Owner's Name
required for Marstons Mills Ma 02648 10-7-19
every page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes"to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate "yes" or"no"for each of the following for all inspections:
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)]
t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18
Commonwealth of Massachusetts
r= l Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
515 Mistic Dr
Property Address
Owner Zito
information is Owner's Name
required for Marstons Mills Ma 02648 10-7-19
every page. Cityrrown State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
Description:
according to attached design plan this system consists of a 1500 gallon septic tank ,d-box, and 2
1000 gallon leach pits.
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ❑ No
Does residence have a water treatment unit? ❑ Yes ❑ No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection El Yes El No
information in this report.)
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes ❑ No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
2017--33 gpd 2018--24.6 gpd This system is designed for use with a garbage disposal.(See plan)
DO NOT RECOMMEND USING A GARBAGE DISPOSAL
Sump pump? ❑ Yes ❑ No
Last date of occupancy: Date
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18
Commonwealth of Massachusetts
rm - Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
515 Mistic Dr
Property Address
Owner Zito
information is Owner's Name
required for Marstons Mills Ma 02648 10-7-19
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. 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
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. 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:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
�u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
515 Mistic Dr
v�
Property Address
Owner Zito
information is Owner's Name
required for Marstons Mills Ma 02648 10-7-19
every page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
4. 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):
Approximate age of all components, date installed (if known) and source of information:
1994 per attached permit
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: feet
Material of construction:
❑ cast iron ❑40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18
Commonwealth of Massachusetts
Title'5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
515 Mistic Dr
Property Address
Owner Zito
information is Owner's Name
required for Marstons Mills Ma 02648 10-7-19
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 2
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: 1500 gallon
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
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
How were dimensions determined?
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
no pumping records were available at time of inspection. Tank was functioning properly. I recommend
pumping at time of transfer and at least every 2-3 yrs there aftre for maintenance.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
ip Title 5 Official Inspection Form
i9 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
515 Mistic Dr
Property Address
Zito
Owner Owner's Name
information is
required for Marstons Mills Ma 02648 10-7-19
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. 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
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. 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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts
�n l� Title 5 Official Inspection Form
I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
515 Mistic Dr
v
Property Address
Owner Zito
information is Owner's Name
required for Marstons Mills Ma 02648 10-7-19
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
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
9. 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.):
Box was functioning properly and looked typical with some corrosion due to age.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12.of 18
Commonwealth of Massachusetts
�n l Title 5 Official Inspection Form
SSubsurface Sewage Disposal System Form -Not for Voluntary Assessments
u
515 Mistic Dr
Property Address
Zito
Owner Owner's Name
information is
required fo- Marstons Mills Ma 02648 10-7-19
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. 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.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
® leaching pits number: 2 1000 gallon
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
�m l Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
515 Mistic Dr
Property Address
Owner Zito
information is Owner's Name
required for Marstons Mills Ma 02648 10-7-19
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
one pit was opened and was functioning properly with no clear signs of failure at time of inspection.
there was about 1ft of standing water.
12. 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
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins .doc-rev.p 7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
�u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
515 Mistic Dr
Property Address
Owner Zito
information is Owner's Name
required for Marstons Mills Ma 02648 10-7-19
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
13. 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.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18
Commonwealth of Massachusetts
�v l,F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
515 Mistic Dr
Property Address
Owner Zito
informatio-i is Owner's Name
required for Marstons Mills Ma 02648 10-7-19
eve page.every P 9 City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. 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
t5insp.dcc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18
Commonwealth of Massachusetts
�v IF Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
515 Mistic Dr
Property Address
Owner Zito
information is Owner's Name
required for Marstons Mills Ma 02648 10-7-19
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: no water at 12 ft
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: attached
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:
attached design plan
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev 7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18
Commonwealth of Massachusetts
�m lF Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
/ 515 Mistic Dr
Property Address
Zito
Owner Owner's Name
information is
required for Marstons Mills Ma 02648 10-7-19
every page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria)and 6 (Checklist) completed
® D. System Information:
For 8: Tight/Holding Tank— Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc•rev 7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
Assessing As-Built Cards Page 1 of 2
TOWNdF BARNSTME
LOCATION !l.c;7CS r',ST� (),;y;? SEWAGE %'690
VILLAGE b7110)1n h,llf ASSESSOR'S MAP 6 LOT6040-0/i
INSTALLER'S NAME & PHONE NO. 01,'iS(p[I -77I-logo
a
?SEPTIC TANK CAPACITY
r+LEACHING FACILITY:07pe) L,e (sue) 1100)�,.Adk t
O.OF BEDROOMS Li PI PUBLIC WATE
RIVATE (WELL O
BUILDER Olt OWNER 97,Vj,cQ BU•Id;,�i G0. 771-02,-gy
DATE PERMIT ISSUED: Iz_Jt('q-1 /
DATE COMPLIANCE ISSUED: �� y lt7
VARIANCE GRANTED: Yes No /
In 6t16
1
c
7+r CL
https://town.bamstable.ma.us/Departments/Assessing/Property_Values/HMdisplay.asp?ma... 10/7/2019
Assessing As-Built Cards Page 2 of 2
https://town.bamstable.ma.us/Departments/Assessing/Property_Values/HMdisplay.asp?ma... 10/7/2019
No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEALTH
......._OF....... P .4 �.........................._......_.
Appliration for Digpoottl Yorks Ton>atrurtion rermit
Application is hereby made for a Permit to Construct ()r) or Repair ( ) an Individual Sewage Disposal
Sys o at: �....1�!4!9!l� . ..._.. / n/�1 z ----.. ............. _
Location-Address or Lot No.
Ul..v�—`�.-��..........� .......... ......................................................
tt Owner Address
W
Installer Address
Type of Build' Size Lot .?i. � c�...Sq. feet
U Dwellin No. of Bedrooms.............................. .....Ex anion Attic.+ g— ----_.... p (�I{U Garbage Grinder Q,_t<b
p`L, Other—Type of Building ............................ No. of persons......._................... Showers ( ) — Cafeteria ( )
p' Other fixtures --------------------_......_-------_........................................................................
d _ rr,,//,,
w Design Flow........................s ............gallons per person per day. Total daily flow..................T ..................gallons.
WSeptic Tank—Liquid capacityl`Le�. gallons Length................Width..........__._.Diameter................Depth................
�+ Disposal Trench—No 7.....................Width....................Total Length.......,.+...-. Total leaching area....................sq.ft.
Seepage Pit No....._.ceT...___. Diameter......F.....----- Depth below inlet_...t4_........Total leaching arm.. (1....sq.ft.
Z Other Distribution box Dosing.tank (�4 i _
aPercolation Test Results,q Performed by._. / ................ ___t..�'C................ Date.t- . .._- .. .............
M Test Pit No. I...........minutes per inch Depth of Test Pit......L;L....... Depth to ground water.a41��...�
Lr. Test Pit No. 2.........._....minutes per inch Depth of Test Pit.__ ------- Depth to ground water......I..t...._...`......
a ,................................................................. �......._.... ..............
0 Description of Soil.... _J ..4p1.9X.1�.. -. SL�LL........ ............. ... -/ - { lU...............
5r !t�...4f.. .... 1 _ lr � 1 .----.cA�r - r
_ ._ ...............................................................
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 TITLE 5 of the Stare
Environm cal Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compl' nc ha Mssued the board of health.
1^ .. ....._.......-
Application Approved y�.... . ....... .............
nn
Application Disapproved for the following;reaiont: ..................................._...... ._............................................_..........._............._............
-- .........._-...._........................�........._..._................................._....................................................._...............
................................
/�
Permit No. °'_....-....__........._!-.o' .._....... Issued ...f .......��.. r......�Tr�
I>�r
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Cer#ifirate of(gotttyliattrle
THIS IS TO CERTIFY,That the Individual Sewage Disposal System constructed( _ )or Repaired( )
by.................................................. .................................................................................................................................................................................................
mrr,uer
a[ ..........._............................I.......... . ... .. ......................................................`
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. ................................................ dated ................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. f'
DATE . f `.. - ............ InspecroB:3k.E ..��/�...//
................................
r ° J
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
................. .....
F ...
No......................... FEE........................
19ioltoottl Varkii Tonotrudian rprmit
Permission is hereby granted..............................................................................................................................................
to Construct (J ) or Repair ( ),an Individual SewagejDisposal em Syst r f•
atNo.. ........................._...................... .f....................
Street
as shown on the application for Disposal Works Construction Permit No_................... Dated..........................................
......................
---••----....-------------
....
............
............
............--_---
_
DATE. ................ Hoard of Health
FORM 125E HOBBS&WARREN. INC.. PUBLISHERS
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-\ COMMONWEALTH OF MASSACHUSETTS
_'EXECUTNE`OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTALfPROTECTION
TITLE.5..
OFFICIAL INSPECTION FORM=NOT.FOR.VOLUNTARY ASSESSMENTS,
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PARTAA
CERTIFICATION
' .1~ ,+... 4l .. .. r i .. f z;ia .:. •a',f r`«.}. V•,2 I r. . j �["I
Property Address: hs- / c. l/rlie.. . r "
Owner's Name: JS D a Yof
Owner's Address: .�/S. /N+s �� r�v .. ..
._... .._ M_ ...
Date of Inspection:
Name of Inspector: (please print) TeN da p
Company Name: Tvkv �u./ D $G.G,. iDc'S�Ot�+G,P•-, ; ,, ( _..•
Mailing Address:
Mue-� vtis � MI1
Telephone Number: S-OB -y2T! -7779
CERTIFICATION STATEMENT .
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate'and.complete asofthe time of the inspection:The inspection was performed based on my
-training and experience in'theproper fuiictidwand maintenance gfiC4site sewage disposal systems.I am a DEP
approved system inspector pursuant.to Section.15.340 of Title:5(310.CMR 15.000).,The system: .
!/ Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: _ , Date• St 12
The system inspector shall s116mit a copy of this"inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection:If the systemis'a shared system or has a design flow of 10,000
d or eater,the inspector and the s'stem owiieT'shall submit the re oft to the appropriate re ional office of the
gP P Y . Pg
DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority.
Notes and Co`mmentS' , t _ :`,T,... r:: . ! a• zt .., I. ;i c - ' _
},. .;.`i' y' 4 -,s. t Gar i•." . y
****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. ;
L�j
Y
01
Title 5 Inspection Form 6/15/2000 page I
r
• r
,
Page 2 of l l '
J !
OFFICIAL INSPECTION.FORM'-NO'!' 'OR'VOIUNTARYASSESSNFS
:,SUBSURFACE SEWAGE-DISPOSAL SYSTEII+I,INSPECTION FORM
_ PART A`
CERTIFICATION(continued) s.., •:.. :,`.'
Property Address:
a As; - s
Owner: N % M
Date of Inspection: y cl
Inspection Summary: Check`A;B,C,D or E''/'ALWAY complete >It ei'Sif
A. System Passes: , ;t
' . I have not found any information whicli 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 repaii,as.approved.by'the.Board of.Health,-will pass. .
Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please
explain.
Y,; .4 `The septic tank is metal-and over 20'"years old*,or'the septic tanlr:(whether.metal or not).is.structurally;
`!unsound,'exhibits substantial infiltration or,exfiltration or tank&ff=,1s imminem)System will pass inspection if the
existing tank,is replaced with-a complying septic tank'as approved by the Board of,Health.".,
•A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance.
indicating that the tank is less than 20 years old is available.
ND explain: ;<, _ . ;;< g. k .`�' #_.
Observation of sewage backup or breakout 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,mspection jf(with
f H approvafdBoard oealih): ..._ . ... . ._...,_.w.. ..__....._
broken pipes)anz�uepiaeed;� ..
obstruction is removed
distnbution box.is leveled or replaced `
!v
'W, ,,s�r.H3 S±:z?% + l.•}F , .3..J,;" L..:r; '`d`•t;.i.l :-k.t., ^r.� r'.'d ts. .:.r., ;ri li- f.r..; ":it"E i rF'.'.-i_ a`�.. s:-.
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Health): "
broken pipe(s)are replaced
obstruction is removed
t%1-u .xtr?',it:PtI.;I.!t>c1 L %{ SiX .. P rij^_..a ;,j iS:•�s<:f ljLl1T. :L,i :
3�?o�iai$i!i° f .i#j'y,, `::1j` ', w- «:ff ... it
- •� 'aI S t t.�f..
ND explain:;
Page 3 of 1 l
OFFICIAL:INSPECTIONFORM:.=NOT TORS VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM
' . .PARTI
CERTIFICATION#ontitiued)
Property Address: 5'/3�
Owner: Sh o e C.v Cr' a
Date of Inspectio : S= /2-o eJ
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order;to'deter►nine 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 theenvironment:.
"! .Cesspool.or privy.is;within 50.feet of asurface water
— Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
r< ,
i
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 publicbialth;-safety and environment:
• ,.,n .. .. �+1 ^., '• 7: '.1: • .;far,1� :�
The system has a septic tank and soil absorption.system(SAS)and the SAS`is within`100 feet.of a,-.
,surface,water'supply of tributary to a:surface water supply:.. 1 rt
... ,,. t.:a ._F':T',.. •. •,.;. r `.;.- �,5 !A.`. :_i:•_. "`., iF '�•a ,.,o-. ' ,k". '. S i;.:'i t::`. -
,. The system has a septic-tank and SAS and the SAS.is within a Zone a of a public water-supply.
• -+.:. r .S„r,r;_-."`1 ' ', • �:. i+t,itz e 3:�. ..tr ..?S �,. `. la+ ;.' i" •.. , ` ,", +.:.5 i. "`=w .!:. !
_ 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 frob a
private water supply well*' Method.used.to determine distance 14
"This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are riggeredr'A.copy,of the'analysis must:be-attached to this form. . i
3. Other: `
t.' C
1,3
Page 4 of 11 ;
;=.OFFICIAL INSPECTION FORM.=NQTtiFpR YOLUNTARY•ASSESSMENTS
:SUBSURFACE SEWAGE DISPOSAL:SYSTEM_Varw IVI N=FOR
,i PART A l: .
�1 CERTIFICATION(ooaoaued) .,.
Property Address: Jr'
Owner: Skoeago-ot 6'
Date of Inspectio ,Sr- "-4-a y
D. System Failure Criteria applicable to all systems:.
You must indicate."yes"or,"no'•,to each of the following for all ins pecU.oris!`.
...1 hrj, • .:.J ..�6 �.!.. .. .mot` '- .}. t.
Yes No ..
1Y Badwp.of sewage into facility- r system component due to`overloaded or clogged SAS or cesspool
v, Mischarge or ponding of effluent to the surface of the ground or surface:waters due 3o 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-,
V Liquid depth in cesspool is less than V below invert or available volume is lessthan h day flow
v Required pumping more than 4 times in the last year NQLdue to clogged or obstructed pipe(s).Number
of times pumped
V 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
° sa :water:sLlpPly:e c'_;• i` iv, 7
.i
V Any portion of a cesspool or privy is:within•a Zone T of a public well. , i., 1:.:«
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 bugreater than-'50 feerfrom`a`private water
supply well with no acceptable water.quality analysis-.[This system passes if the-"M. +ater analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
µ vindicates that,the well is'free from pollution from that`facility,and the:presence.of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other Maim criteria
are triggered:A copy.of.the analysis must lie attached t+v'"form:].
(Yes/No):The system fails!I have determuied"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 toot the failure.
i
fir . . r .. ii. .aS_ {{ fit ..i"w*ppii .-tir.. iJ' �.' ,i:'ix ..}: 1S >w>=. .. ;,�.._•�: ..
L` :Large.Systems: s: a, ' '. s. `a ; - �:• 1_ =
To be considered a large system the system must serve a-facility with a'design-flow of`10,000 gpd to'15,000
gpd•
You must indicate either"yes"or"no"to each of the fallowing:
(The following criteria apply to large systems in addition to the aita$above)
yes no
— the system is within 400 feet of a surface drinking water supply
.the system.is within 200'feet of a tnliutary to a surface.drinlcing water supply
the system is located in a nitrogen sensitive area(Lnterim Wellhead Protection Area-IWPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"Yes"in Section D above the large.system has failed.The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The system owner should contact the appropriate regional office of the Department.
4
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL:SYSTEM INSPECTION FORM
PART B
'CHECKLIST
Property Address:
Owner: kve cf u r
Date of Inspectio
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' _
_ _Z 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.?
V 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?
n
V _ 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?
_V`_ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
Existing information.For example,a plan at the Board of Health.
Determined in the field(if any of the failure criteria related to Part Cis at issue approximation of distance
is unacceptable)[310 CMR 15.302(3)(b)j
r
5 '
1
Page 6 of 1 l
OFFICIAL INSPECTION.FORM=NOT R�OLi.FO MAY ASSESSMEN°rS .
SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM
_-;PART C
SYSTEM.-ROORMATION •
Property Address: /1 �s�ji f�rr d�
[ ar s
Owner: SJf- •v ergard
Date of Inspection.
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): r Number of bedrooms(actual): S' 2 . Y.. ;�; . ,,
DESIGN flow based on 310 CMR 15203(foi eiiample: 110 gpd x#of bedrooms): .5�ra ` ` Z• '
Number of current residents: 0
Does residence have a garbage grinder(yes or no): V.PS
Is laundry on a separate sewage system(yes or no): v [if yes separate inspection required]
Laundry system inspected(yes or no):
Seasonal use:(yes or no):jLe f 0�7-; !23 ��d �2 8� �Pv�
Water meter readings,if available(last 2_years usage(gpd)):
Sump pump(yes or no): 11/o x
Last date'of occupancy: /l/v v�100 4`
COMMERCIA ANDUSTRIAL r
Type of establishment:
Design flow(based on 310 CMR 15203):_ faad -
Basis of design flow(seats/persons/sq%etc.): ,
Grease trap present(yes or no):_
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 system(yes or no): `
Water meter readings,if available: ,
Last date of occupancy/use:
OTHER(describre):
z :GENERAL INFORMATION +
Pumping Records -
Source of information:
Was system pumped as part of the inspection(yes or no):
If yes,volume pumped: I S'" gallons»How_was quantr�umped determined? 5%Ze o
,Reason for pumping:- ai 01- eN 4 nczi
TYPE OF SYSTEM
LSeptic tank,distribution box,soil absorption system ,
Single cesspool
=:Overflow cesspool _ _G, ,. _ ,+
_Privy . n,. {,
_Shared system(yes or no)(if yes,attach previous inspection records,if any)
_Innovative/Alternative technology.Attwb4 copy of the cu=o operation and maintenance contract(to be
obtained from system owner)
_Tight tank Attach a copy of the DEP approval
_Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Sta
Were sewage odors detected when arriving at the.site(yes or no): LVO
6
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C '
SYSTEM INFORMATION(continued)
Property Address: t/S- M I� -ti
Owner: Sko,e and G �44
Date of Inspectio - -o
BUILDING SEWER(locate on site plan)
Depth below grade: .30
r
Materials of construction: cast iron _40 PVC other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc): T w
SEPTIC TANK:_(locate on site plan)
Depth below grade:
.Material of construction: oncret metal fiberglass polyethylene
other(explain)
If tank is metal fist age:— Is age confirmed by a Certificate of Compliance(yes or no)-_(attach a copy of .
certificate) fi c T tik
Dimensions:
Sludge depth: l'' 3 " • ,;s ;.
Distance from top of sludge to bottom of outlet tee or baffle: 3
Scum thickness: 2''
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle: /0'i
How were dimensions determined., Hri�� 911W
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence ofleakage,etc.):�uyk ,r�irr»t� -A r Asaec ie,a I
S�rac .�1 Xti1"e�r^ efbc -
GREASE TRAP: (locate on site plan)
Depth below grade: -
Material of construction:_concreteµ metal fiberglass polyethylene=other
(explain): «
Dimensions:
Scum thickness:
Distance from top,of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
7
Page 8 of l l
,'OFFICIAL'INSPECTION FORM.=lea i: 70R� UNTARY ASSESSMENTS ,
SUBSURFACE SEWAGE DISPQSAL.SYSTEM_IPOEMON FORM:.
SYSTEM INFORMATION continued)
Property Address: l� A9ist� A"' s' _. o �"- _ .;. ,+ +•; ;�; .
urs aHs r' s H _ - •
Owner. sko@ Yard. G, 4- M,
Date of Inspection:
TIGHT or HOLDING TANK: (tank must be p»mped at time of iespaetate on site plan)
Depth below grade: -
Material of construction: concrete _ metal 'fiberglass polyethylene other(explain):Dimensions:
Capacity: aallons�
Design Flow. aallondday
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping: t.
Comments(condition of alarm`and`float switches;etc:):._
r -+
DISTRIBUTION BOX:,!eL(if present must be opened660cate-ori site plan) n
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.): p zc r._d +,I.'
- -PUMP CHAMBER: - (locate on site plaII).
Pumps in working order(yes or no):
Alarms in working order(yes or no): .'
Comments(note condition of pump chamber,conditim-apumups and appurtenances,m):. .:
lu#yE.. ��:,r�''l�3Tyw`+4r r, 1' ts'.e-•`..:'1 � ..�i ,r3��+iv�._ �' .4 :..t':r, .r r � - .� ,�
i
Page 9 of l l -
OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGEDISPOSAL SYSTEM INSPECTION FORM
. PART C-.
SYSTEM.INFORMATION(continued)
Property Address: 513' A.f 1,C
-
Owner: SAW M, `h
Date of Inspectio S—l 2—0 9 _
SOEL ABSORPTION SYSTEM(SAS):Yj5 (locate on site plan,excavation not required)
If SAS not located acplain why:. o
Type
/i leaching pits,number.'
leaching chambers,number.
leaching galleries,number,
leaching trenches,number,length:
leaching fields,number,dimensions.:
overflow cesspool,number
innovative/alternative system Typefiame of technology.
Comments-(cote condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.):
evYep i� �'.y 0,ela� ra,•e �Ilm ei"u:of at �e "I" 9' Aa,..ti
stack iai y # ConeP d 4`1o10 '900 `-d e . No L«®.�� ay Ro -*' 9``"pown
CESSPOOLS: (cesspool must be pumped as part of inspectionxlocate on site plan)
Number and configuration:
Depth—top of liquid to.inlet invert:
Depth of solids layer. .
Depth of scum layer.
Dimensions ofoesspook
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)-
PRIVY: (locate on site plan)
Materials of construction:
Dimension's:
Depth of solids-.
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,ate.):
9
Page to of 11
FFICULINSPECTION.FORM NO .FO]k V`Ot=AY ASSESSM0ffS
_. :SUBSURFACE.SEW AGE DISPOSA` -SYftEM INSPECTION FORM '
PART:C
• << SYSTEM VMRRVATION(continued)'`=
Property Address: 325,
owner. kole
Date oflnspectio : — 99_ :��: z • • . ,x:,_,.;.. _ - : �.-, - •.,:; :;;,•�a _•
SKETCH OF SEWAGE DISPOSAL.SYSTEM
Provide a sketch of the sewage disposal system inch*g ties.to at least two permanent refemce landmarks or '
benchmarks.Locate aU wells within 100 feet.Locate wempube ter sWp
-_._.. - __ . _ ... f
� .- _Lcath b water_ _.- _ _ . _ ._ _ _ lyententhabuildin&
,1 v
4: ?-. -�„ ,7 'ice -"V ..T •'-'�i �� }3 _ f'. �
t g a :t• S Al-t1• t
± /8" Tip ®f�
Aim
f 30', 30�
{✓o/lvhi O �O� f
,� ... / rf.. CouQr j O .. •�ti .� y
Page 11 of 11 '
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACES;WAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
-
Owner. Sko e ga r G,si iVl,
Date of Inspecti n: —/2,—09
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water r!.h- feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation)
v Accessed USGS database-explain: /17 g s
You must describe how you established the high ground water elevation:
��nd /evkroa �r,t 'J?. $3' rind dot /l�,ctn.� oT 60
There.jv,,e o A. o
11
COMMONWEALTH OF MASSACHUSETTS
z z EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
J
C DEPARTMENT OF ENVIRONMENTAL PROTECT ION
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY:ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A FRECEIVEDCERTIFICATION
Property Address: / N 2 4 2002
�y TOWN OF BARNSTABLE
Owner's Name: HEALTH DEPT.
Owner's Add res s�,% -�2aiL-
l/�3Cor/� MAP D%®
Date of Inspection: --A PARCEL
Name of Inspector: please print) J !'11U,Od�"t LOTI Ala -
Company Name
Mailing Address:
Telephone Number: !�30efL- 7-7/•
CERTIFICATION STATEMENT _
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuantX.P
ection 15.340 of Title 5(310 CMR 15.000), The system:asses
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
� ails - I
Inspector's Signature: /' Date: a0a
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,
Notes and Comments
****This report only describes conditions at..the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/20.00 page 1
1
i E Y
. Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE`SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: l�
Owner:
Date of In ection: C—"Viez n
Ins.pection'Summary: Check A,B;C;D or E[ALWAYS complete.all of Section D .
A. System Passes:
:j 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>Cond.itionally Pa ses:
One or more system components as described in the"Conditional Pass".section need to be replaced or
repaired. The system,upon completion of the replacement or repair; as approved by the Board of Health,Will pass.
Answer yes,no or not determined(Y,N;ND)in the for the following statements. If"not determined"please
explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound,exhibits substantial infiltration or exfiltration or.tank failure.is imminent.System will pass inspection if the
existing tank is replaced with-a_complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND`explain:
Observation.of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass.inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced .
ND`explain:
The system required pumping more.than'4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
..Page 3.of 11
OFFICIAL.INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
Owner: r-A
Date of I ection: 0 0,
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 C.MR 15.303(1)(b)that the
system is not functioning in a manner which will protect.public health,safety.and the environment:
Cesspool or privy is within 50.feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier, if any).determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water'supply.
The system has a septic tank and SAS:and the SAS is within 50 feet of a private water supply well-
- The system has a septic tank and SAS and.the SAS is less than 100 feet but 50 feet or more from a,
private water supply well".Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified.laboratory,for coliform
bacteria and volatile organic compounds indicates that the well.is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
3
Page 4 of I 1
OFFICIAL.fiNSPECTION FORM-NOT FOR YOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Add'ress: �j/ pfse�� ld�
A
Owner:
Date of spection: aa-
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes N
Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
_ Dischar6e 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 invertdue to an overloaded or clogged SAS or
1 cesspool
Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow
_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
/ of times pumped
1/V Any portion of the SAS,cesspool or privy is below high ground water elevation.
7j 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 ofapublic 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 coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence:of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm; provided that no other failure criteria
/�/ are triggered.A copy of the analysis must be attached to this form.]
Ile (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR.15.303,therefore the system-fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a.facility with a design flow of 10;000.gpd to 15;000
gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
_ the system is within 400 feet ofa:surface drinking water supply
— the system is within 200 feet of a tributary to a surface drinking water supply
the system.is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"Yes"in Section D above the large system has failed.The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15:304.The system owner should contact the appropriate regional office of the Department.
- 4:
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 61,.$' ?r�J
Owner-
Date of pection: Q;IL4 e— /,3 no
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
_� Pumping.infcrmation 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.vclumes 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 sept:.c 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:
`f
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(3)(b)]
5
Page 6 of 11
OFFICIAL INSPECTIONTORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
1
Property Address: .�
Owne
Date " spection:
t/.
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design)::. Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203 (for example: 11.0 gpd x#of bedrooms):
Number of current residents:
Does residence have a garbage grinder(yes-or no)/yt,(j—
Is laundry on a separate sewage system(yes or no .[if yes separate inspection required]
Laundry system inspected(yes or no): �
Seasonal use: (yes or no):��
Water meter-readings, if available(last 2 years usage(gpd')),:
Sump pump(yes or no): 2 b' /��ri�C�
Last date of occupancY V� ''�
COMMERCIAL/INDUSTRIAL�
Type of establishment:
Design flow(based on 310 CMR.15.203): gpd
Basis of design flow(seats/persons/sgft;etc.):
Grease trap.present(yes or no):_
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 system(yes or no):_
Water meter readings, if available:.
Last date of occupancy/use:
OTHER(describe):
. GENERAL INFORMATION
Pumping Records
Source of information: ,
Was system pumped as part of the inspection{yes or 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)
Tight tank _Attach a copyof the DEP approval
Other(describe):
pproximate age of all co .pon nts, date installed(if known)and source of information:
Were sewage odors detected when arriving at the site(yes or no):14 --
6
Page 7 of l I
OFFICIAL INSPECTION FORM'NOT FOR.VOLUNTARY A.SSESSMEITTS
SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM
PART C
SYSTEM_INFORMATION.(continued)
Property Address: ���� ;�,,
Rio a v�YrA16yY1,,1,64
Owner:
Date of pection• a
BUILDING SEWER(locate on site plan) 60-
Depth below.grade:
Materials of construction:_cast iron _40 PVC.—other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK:✓(locate on site plan)
Depth below grade:
Material of construction:_concrete_metal_fiberglass_polyethylene
—other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions: ' Q.
Sludge depth: 9 i' ,,
Distance from top of sludge to bottom of outlet tee or baffle: �9
Scum thickness: '3 `
Distance from top of scum to top of outlet tee or baffle: 3 >�
Distance from bottom of scum.to bottom of outlet tee or baffle:
How were dimensions determined:. , ,naz � ? raj
Comments(on pumping recommend ions, ' et and outlet tee or baffle condition, structural integrity, liquid levels
s related to outlet invert, evidence of leaka e, etc.):
/SDc� h,
GREASE TRA��(locate on site plan) _
Depth below grade:
Material of construction:_concrete_metal fiberglass___polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:.
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert, evidence of leakage,etc.):
7
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C .
SYSTEM INFORMATION(continued)
Property Address: ✓� .�
Owner•.
Date of pection: /
TIGHT or HOLDING TANI�(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
Desien Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes'or no):
Date of last pumping:
Comments(condition of alarm and float switches, etc.):
DISTRIBUTION,BOXi (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
akage'into or out of bo ,ete.): •
PUMP CHAMBERJ&�-(locate on site plan)
Pumps in working order(yes or no).:
Alarms'in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
8
Pace 9 of 11
OFFICIAL INSPECTION FORM.—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM.INFORMATION(continued)
Property Address:
Owner:
Date of�spection:
SOIL ABSORPTION SYSTEM (SAS): (/(locate on'site plan,excavation not required)
If SAS not located explain why:
Type
_,.
leaching pits,number:
leaching chambers,number:.
leaching galleries,number:
leaching trenches, number, length:
leaching fields,number, dimensions:
overflow cesspool,number:
innovative/alternative system .Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure, level of ponding, damp soil,condition of vegetation,
etc):
_7406--
I ri
CESSPOOLS:/V �_(cesspool must 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:
I-ndication of groundwater inflow(yes or no):
Comments(note condition,-of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc_):
PRIVY(locate on site plan)
Materials of construction:.
Dimensions:-
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation, etc.):
9
Page 10 of 11
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY'ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM
PART C.
SYSTEM INFORMATION(continued)
Property Address:6'/6— ��
,A
Owne .
Date o - spection: , ��
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the buildin1g.
r'
e
a
t
q4 .
10
Page 1 I of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART.C
SYSTEM INFORMATION(continued)
Property Address:1C Id
Owner:
Date of ect►on. d r ,
SITE EXAM
Slope
Surface.water
Check cellar
Shallow wells ,
Estimated depth to ground water 1 feet
Please indicate(check)..all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked, date.of design plan reviewed:.
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
_ Ahecked with.local excavators, installers-(attach documentation)
ccessed USGS database-explain:
You must describe how you established the high ground water elevation: t
Il
Permit Number: Date:
Completed by:.
HfGH GROUND-WA.T,E•R :EVEL COMPUTATION
Site Location,: J /,5— S �'L ��- ,
Owner:_.. %zqqz 9,o,� if Addres
s--
:.
Contractor: ,address: ���
Notes:.
STEP" 1 Measure depth to-water table
to nearest.1116`ft......_................
_...._.....,.:_...... .......... .DateL�3�L
month/day%year. 1
STEEP 2 Using.Water-Level.Range Zone
and Index 1NeII:M.a.p locate
site anal"determine:
OAApro.priate.i'ndex wel-L...................
BJWater-level"range zona;, ........ '........................... . C
STc`:P:;:3:: Usin -monthly .re ,, o - I"
g Y poi "'Corr n•�
Water R.esources"Conditions"
determine current-depth-to /
water Invef for index well ......................... ®S`®� �j13 r
month/year
J.T•.t 7. 1. Using.T able.o.f VVater-Jexel Adjustments
for index"well (S•TEP'2A),.current depth
to water1extel for.•index well ('STEP 3-)•,
and"water-level zone (STEP"2B)
determine water-level adjustment ................. :....... . ........................ ........ _ r
STEP. S stimate de th p• . to:'
high water
by subtracting th.e water
--
level adjustment.(STEP 4`)
from measured-.depth to.water
level-at.size.(STEP'1)",_........
...... .................................... ................ J
Vible
v„ I�ri
�. n el
I '
�o oil
No.- - --- ---- Fee------- ------------
BOARD OF HEALTH
TOWN OF BARNSTABLE
App[icationArlVe1C Con0ructionpermit
Application is hereby made for a permit to Construct (1,1, Alter ( ), or Repair ( )an individual Well at:
-------------------------------------------------
Location — Address Assessors Map and Parcel
J1 Qu/J_ — — — — —----------— -- S�S. M U-/d _f"
Owner Address
-----------------------
Installer — Driller Address
Type e of Building
Dwelling--- ----——--------------------------------------------
Other - Type of Building ---------------- No. of Persons--------------------------------____
Type of Well-y"-&C ----- -- ----— ---- Capacity-------------------——--- -
Purpose of Well!�i-b_c� "`t- ----- ------—
Agreement:
The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The
Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to
place the well in operation until a Certificate .of Compliance has been issued by the Board of Health.
Signed ---— — -p v _�� �'--------
date
Application Approved By m
— ---------
---
date
Application Disapproved for the following reaso--n—s:- _--__-----_-_--_-_--_----_-_—_-_-_-_-_-_--_-_--_— -----
Permit
No. Issued----- - / _--------
date
te --
—_--_---__--___-__-
--
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certificate Of Compliance
THIS IS TO CERTIFY, That the Individ a�Well Constructed (—), Altered ( ), or Repaired ( )
by----- ---------�-�-'SCu t�+cuc-------------------
Installer
at— —S�f M L-01 ' 61- M4✓S owshas been installed in accordance with the provisions of the Town of Barnstable Boar of enated
vate Well Protection
Regulation as described in the application for Well Construction Permit No.THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE-------- - —-- Inspector-- - —---------------- ------- ----
6 10
No.- - -- --- ---- Fee------- ------------
BOARD OF HEALTH
TOWN OF BARNSTABLE
applicationArMelt Construction ihnnit
Application is hereby made for a'permit to Construct ( vl, Alter ( ),.or Repair ( )an individual.Well at:
iS.r/G Q/ n1 nLj
�bcahon s',Address Assessors-Map and Parcel — ----
3t�Kt �lPu/clo..J S/I M14I`/ t10/ /i.i ►l`v, S /mot �lS
/� A (� / Owner Address
-- ------_J__Lli-.wr-/`---- ----- --------- -=---------- ---��-----�--gGo vb,ufCi-P----------------���-1�f
K —
Installer — Driller Address
Type of Building
Dwelling-----—------- '• ---------------------------------------
Other - Type of Building - - No. of Persons--------------------
Type of Well A %°�
YP Capacity-----------------------------------------=--
Purpose of Well--i_��i� `i -- --— - --=—-
Agreement:
The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The
Town of Barnstable Board of Eeakh Private Well Protection Regulation — The undersigned further agrees not to
-� place the well in operation until a Certificate .of Compliance has been issued by the Board of Health.
Signed -D ,~ as ---
te
Application Approved By
date
Application Disapproved for the.following reasons:
o.
- --- ---------------------- --------- ------- ------------------
-
5
Permit'No.
- —--— Issued----- - -------
ate
-.•. = .�>- Ul��!ti^1vuWli4ili!!�'RaK�d!itilRirK'Si!del9Tifiw�JFP6.:i1Ki@6R61d't3Yb+R6@�YY1�TbY�'NTY+!'AMb1iTiMTiltilb'S'AN'+N'.�l���Tilii9eT4a��'qt�lGl6!GR6'.��4K3Ymfila�bTili!@Y]8►T'e�
BOARD OF HEALTH
TOWN .OF BARNSTABLE
Certificate Of Compliance
1 /
THIS IS TO CERTIFY, That the Individual
Well Constructed Altered ( ), or Repaired ( )
X' bY--------— —_ u ti c.x—
Installer _---- 'at S/SS A, 1rT.c d/ /LA41,1ywf M l l<S
/ has been installed in accordance with the provisions of the Town of Barnstable Board of ealt rivate Well Protection
Regulation as described in the application for Well Construction Permit No. --')]Dated----- ______
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION.SATISFACTORY.
DATE-------------— - Inspector-- - ------
..
BOARD OF HEALTH
TOWN OF BARNSTABLE
Well Conotruct ion Permit
No. ----- Fee—
Permission is hereby granted ScG"'�'` // --- -- ------ ---------
to Construct ( I<Alter ( ), or Repair ( ) an Individual Well at:
No. 5l S • AA �S�`r 0� UPS 4;4 n•c, //r
------------------ ----------------------------
Street
as shown on th q p' do Well Construction Permit
No.---- ----- Dated— (--
�I Board of Hea
DATE
P J. i
J
THE�COOMAO�N®ALT�Fu TS
BOARD HEALTH
�CJ�V.........OF.......
..... / .............................................................
Appliratiou for Diipoii al Workii Tumitrurfinxt ramit
Application ereby made for a Permit to Construct A' ) or Repair ( ) an Individual Sewage Disposal
system at:
.. 4. ..... .......`s..�1 C.....P .:.....I5 rz�5..p /_5--------.-------------.------.--------------..-..------•---.--.----
Location-Address or Lot No.
�r� -'�____------- ------------- --------------- ..........---•--------------------...............--
Owner Address
W
Installer' Address �/
UType of Buildi15_ Size Lot.. ?x_ �v...Sq. feet
a Dwelling l—�N`o. of Bedrooms............................................Expansion Attic (�4> Garbage Grinder �16
04 Other—Type of Building ............................ No. of persons............................ _Showers ( ) — Cafeteria ( )
a' Other fixtures -----•......•-••-••-•-••--•••--- .
�•�— tt rrll ,, ••----.
W Design Flow........................Q13 ..........gallons per person per day. Total daily flow..................�` .................gallons.
WSeptic Tank—Liquid capacityl. gallons Length................ Width---------------- Diameter................ Depth................
x Disposal Trench—No..................... Width.................... Total Length.._......--._-•---- Total leaching area....................sq. ft.
Seepage Pit No...____9....... Diameter.....,F.......... Depth below inlet...:........... Total leaching area...��J....sq. ft.
Z Other Distribution box (� Dosingtank ( 0 V , ``_
'-' Percolation Test Results Performed by :_'` `'� t��" Date_1k5�•--:q_.----._
al .. ._ ._ ......
Test Pit No. 1........ _._minutes per inch Depth of Test Pit......1_2....... Depth to ground water.,5V
(i Test Pit No. 2................minutes per inch Depth of Test Pit... ....... Depth to ground water.........__..__.`.._...
a f .....•-- -----------------•---------------
---------- - ------
O Description of Soil �--3.....� -f... -1 j��3LL+ � .��a��U� ---------------------
� % .-.
. r ---
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 TITLE 5 of the State Environm tal Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compl' nc ha e •ssued the board of health.
Signed ........................ .... ........ --- .................................................... .......................................
Date
Application Approved ✓p � - .. �. -
..... ........................ .. ..-...-..
Date
Application Disapproved for the following reasons: ........................................... ................................................. .............. ................
-------------------- ---------------------------- ------------------------ - ---------------------------------------------------------------------------------
to
Permit No. b� Issued ... ` ��-i ..
......
Date
No------------------------- Fizz..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD fOF HEALTH
.......... l%Gi .---.....OF........`.. /rl�f)�r���l(.
Applirtaffou for Utsp i al Vork,5 Cnnnwunrtilan rrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
..._.._ -•.............. ......................................... .
Location,-Address„ - or Lot No.
z- Qt
�''" (1 . .. , ... '......-----•......:...... ..................................................................................................
( Owner Address
W
Installer Address t
g .....................Ex Expansion Attic �1 e' Garbage� G nderq ,J -1
Q Type of BuildingSize Lot............................wS feet
Dwellin �No. of Bedrooms.................�� p ( ) � E);
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
QOther fixtures ..•-------------------------------------------------------------------------------------------•----------.r
W Design Flow......................4?.��............gallons per person per day. Total daily flow____....._....... L e--)...........gallons.
WSeptic, Tank—Liquid capacity/`J/Qgallons Length---------------- Width................ Diameter---------------- Depth................
x Disposal Trench—No..................... Width................. Total Length------�.......... Total leaching area....................sq. ft.
Seepage Pit No.--________._o.-------- Diameter.................... Depth below inlet.................... Total leaching area...l�Z2!` ...sq. ft.
Z Other Distribution box ( f.)- Dosing tank
Percolation Test Results Performed by.._ 'X-1.�=_A 4-Pile le 1 �a c'
W - ----------------------------------•------ Date ------`------......-------------......
Test Pit No. I.........4__.minutes per inch Depth of Test Pit------A.?_...... Depth to ground water.
44 Test Pit No. 2................minutes per inch Depth of Test Pit....)__?........ Depth to ground water_.__._..-...............
Per `
" ..... t
O Description of Soilrf `=� �"•+ � `S t= "�U(Z, 4� Rl lJ '" 'r —/.1 �:_�jioi /
--- ----------------
(> ..................~ ................................................................�r. -I-
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 TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has been issued by the board of health.
Signed ............................. ........................................................................ ........................................
Date
ApplicationApproved By ................................................ ... .. ...................................................................................
Date
Application Disapproved for the following reasons- ---------------------------- -- -- -- -- ---- ---------------------------------------- ------------------- ----------------
................................................ ................................................. .. .................................................................................................... ........................................
Dare
PermitNo. .................. .......... . .... ................. Issued ..........--------------------....................................
Date
! THE COMMONWEALTH OF MASSACHUSETTS
i
--- BOARD OF HEALTH
....-- ------------- OF ---- , 21� =1YT i �(= -----------------------------------------
(112difiratr of Tompliana
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by ........... ..... ..... ......... ................................ ........................................................................./.:J�..................
Installer
at
.--.----- .......... a• ....... ---- ---- ----: - .. ----- ----------------- ---------- - ------------
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. ................................................ dated ................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
-� / ................................ Ins ecto ..-.__.._ ..../� .. T {..
DATE__....... .---- ---- 15....................................................... p ":.. -............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD 12OF HEALTH
.....................................OF....................................................................................
No......................... FEE........................
"ispmal Works Tnntrudion amit
Permissionsris hereby granted..............................................................................................................................................
to Construct ( ^ ) or Repair ( ) an Individual .Sewage Disposal System c
at No..........................�_``�....--•---..�../_....li" 1' 1l e''- -b'-�h._'u--�'-._.....�fII1__ leJ) �1 �1/��
•------•-•.......
Street
as shown on the application for Disposal Works Construction Permit No..................... Dated..........................................
•......................•------------------ ............................................................
Board of Health
DATE.
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
TOWN OF BBARNSTABLE
LOCATION ��'� �: m`; Sd k52 SEWAGE #9+ 690
VILLAGE_W`1� 0 Mills ASSESSOR'S MAP & LOTO,000`019
INSTALLER'S NAME & PHONE NO. a.7, -7-71- t0q o
;SEPTIC TANK CAPACITY l �UU h�lIo✓s
O LEACHING FACILITY:(type) �.2��� �� (si e) �, 006�pvlto-(►s
�r,-NO OF BEDROOMS '7 PRIVATE WELL O PUBLIC WATE
BUILDER OR OWNER e(Jl'id'i1n5 CO. -771-0S;9�
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No ���
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