HomeMy WebLinkAbout0139 ALTHEA DRIVE - Health g:
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
files, Z�
Property Address-
Owner Owner's Name
information is. /
required for gild V 1 e"sc�,fa k ► "� t r (••-S / Q �r
every page. City/Town State Zip Code Date of rnspe6tion
i
Inspection results must be submitted on this forma Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
j When flung out A. General Information
,i i forms on the
I computer,use
�t 1 Inspector:
only the tab key ,/• J ,.
to move your
cursor-do not Name of Inspector _ 1 use the return 0 . —
key.
Company Name J }3
Company Address
r City/Town , State Zip Code
17
Telephone kumber License Number
I i ,
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
�i information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site -
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
IFI-p-a's—ses ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
Inspector's ignature Dates
i. he 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
�,►'� ;�I 'I�' has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
' I 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.
� I
****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•09108 Tide 5 Official Inspection Forth:Subsurface Sewage isp lSys tam Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form -
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Property Address - ---- ------
Owner Owner's me
information is
required for �! !'� /�s GZ�t i c-6
every page. City/Town State Zip Code Date of nsp6ction
Bo Certification
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:
i Eq
11
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13) 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.
y 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
j' 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
k Board of Health.
�.\
{ A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
C
{ ompliance indicating that the tank is less than 20 years old is available.
? 1
❑ Y ❑ N ❑ ND (Explain below):
t5ins•09/08
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Pace 2 ci 17
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Commonwealth of Massachusetts
Title 5 Official Inspection' For
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
i
Property Address op rty
�C
Owner Owner's NFee
_
information is required for 4'i'1{M st (, Nr e ri' . 0:)-tip /0
every page. -City/Town State Zip Code Dat4 of Inspection
B. Certification (cont.) .
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
t
1 broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ `Y ❑ N ❑ ND (Explain below):
):l
❑ distribution box is leveled or replaced ❑ VY ❑ N ❑ ND (Explain below):
❑ The system required pumping more than`4 times a year due to broken or obstructed pipe(s). The
i system will pass inspection if,(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y : ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
I�i
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
i 15.303(1)(b)that the systein is not functioning in a manner which will protect public health,
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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•09i08 Title 5 Official Inspection Form:Subsurface Sewage Disoasal System•Pace 3 of 17
i 1 Commonwealth of Massachusetts
Title 5 Official Inspection Forte
' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Property Address `
Owner Owner's Name"
information is // / r
¢ required for l�"� V40'!G saL4
every page.a e. Cityfrown State Zip Code Dao of spection
B. Certification (coot.)
2. System will fall unless the Board of Health (and Public Water Supplier, if any)
I I determines that the system is functioning in a manner that protects the public health,
Ii safety and environment:
I `
I t ❑ The system has a septic tank and.soil absorption system (SAS)and the SAS is within
!l 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: .
s
This system passes if the;well water analysis,performed at a OEP certified laboratory, for 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.
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j 3. Other.
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fD) System Failure Criteria Applicable to All Systems:.
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i 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 orY
it ❑ clogged SAS or cesspool
❑ Discharge or ponding of effluent to the surface of the ground or surface waters i
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 %day flow
15ins•09i08 - Title 5 Official inspection Form:Subsurface Sewage Disposal System.Page w of 17
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�{{ Commonwealth of Massachusetts
S
'l Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
Property Address
I i II
Owner Owner's Name,,")
II information is ( �d 01�'v7G,' � l '
required for � ' ` (7
every page. City/Town `State Zip Code Date o insp ction
B. Certification (coat.)
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.
Lt
�I Any portion of cesspool or privy is within 100 feet of a surface water supply or
i, tributary to a surface water supply.
i•
❑ Any portion of a cesspool or privy is within a Zone 1 of a public well.
1 ❑ 12- 'Any portion of a cesspool or privy is within 50 feet of a private water supply well.
�s ❑ 0� Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
s 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.]
El 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 cor,rect 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
El Area
system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area- IWPA)or a mapped Zone 1.1 of a public water supply well
f If you have answered "yes"to any question in Section E the system is considered a significant threat,
j or answered "yes" in Section D above the large system has failed. The owner or operator,of any large
ij system considered a significant threat under Section E or failed under Section D shall upgrade the
to i system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•09108 Title 5 Official Inspection Form:Suesurface Sewage Dspcsal Svstem•Page 5 of 17
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I 1 Commonwealth of Massachusetts
Title 5 Official Inspection Fora.
4
l Subsurface Sewage Disposal System Form 7 Not for Voluntary Assessments
Property Address
Owner Owners Na
information is
required for
every page. City/Town State Zip Code Date f Inspection
C. Checklist
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
r
Yes 'No
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f ❑ 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?
El Has the system received normal flows in the previous two week period?
Li E�' 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)
L ❑ Was the facility or dwelling inspected for signs of sewage back up?
i ❑ Was the site inspected for signs of break out?
I�
L>✓� ❑ Were all system components, excluding the SAS, located on site?
1 q ❑. 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,
I( dimensions, depth of liquid, depth of sludge and depth of scum?
- r❑ Was the facility owner(and occupants if different from owner) provided with
t information on the proper maintenance of subsurface sewage disposal systems? .
t 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 js at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
i`
Residential Flow Conditions:
I t
Number of bedrooms (design): Number.of bedrooms (actual):.
li DESIGN flow,based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):
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tsins•09i06 _ Tiue 6 Official Inspection Form:Subsurface Sewage Disposal System•Pace 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal Systee/m Form Not for Voluntary Assessments
3. 9 'XI '
Property Address
r �
Owner Owner's Nam /
I!i informa�ion is CGsv�t/►-j �yi t ^� /� ` /
I� required for [G v�
R I every page. City/Town State . Zip Code Date Inspection
D. System Information
Description: s /y
/"r�
y<
Number of current residents:
Does residence have a garbage grinder? ❑ Yes No
Is laundry on a separate sewage system? [if yes separate inspection required) ❑ Yes L_f No
Laundry system inspected? ❑ Yes No
Seasonal use? ❑ Yes ❑` No
{E '
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
. ,i
Sump pump? ❑ Yes D"No
Last date of occupancy: oaf
4 Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
I Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.): --
Grease trap present? ❑ Yes ❑ No i
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available: —
Sins•09i0B Title 5 Official Inspection Form:Subsurface Sewage Dispcsal System•Page 7 of,7
1: ,
Commonwealth of Massachusetts
Title 5. Official Inspection dorm . _
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
j Owner Owner's Nam _
{ information is / %'
required for
every page. City/Town State- Zip Code Date df Ins ection
D. System Information (cont.)
Last date of occupancy/use:
Date
Other(describe below):
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General Information z
Pumping Records:
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Source of information: 1
Was system pumped as part of the inspection? ❑ Yes-moo
If yes, volume pumped:
gallons
,4
How was quantity pumped determined? -
Reason for pumping:
i Type of Sy
peptic tank,distribution box, soil absorption system
❑ Single cesspool ,
i ❑ 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
kEl Tight tank. Attach a copy of the DEP approval
I t
❑ Other(describe):
Sins•09i08 Title 5 Official Inspection Form:Subsurface Sewage.Disposal System•Pace 8 of 17
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Commonwealth of Massachusetts
4 Toe 5 Official.Inspection Form
Subsurface Sewage Disposal:System Form - Not for Voluntary Assessments
°mow ���� ✓ ���c: �T' •
Property Address
Owner Owner's Name
information is I 014.r C4 I �6 !6' /0 "
i required for
` every page. Cityfrown State Zip Code Date/of in, pection
D. System Information (coat.)
VII
Approximate age of all'components, date installed (if-known) and source of information:
( ! Were sewage odors detected when arriving at the site'? ElYes No
t
Building Sewer(locate on site plan); ✓X
Depth below grade:
feet
Material of constructi�40
❑ cast iron �PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
i
Comments (on condition of joints, venting, evidence of leakage,etc.):
I�
!
Septic Tank(locate on site plan):
Depth below grade: feet
Material of construction:
concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
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If tank is metal, list age: , Years
iI ! Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) . ❑ Yes ❑ No J
Dimensions:
_4
` Sludge depth:
t5ins•09i08 Title 5 Official Inspection Form:Subsurface sewage Dispo<_a! o
S System•Page..or 17
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System !Form -Not for Voluntary Assessments
12.2 1-114//A�C-
Property Address ' !�
{ Owner Owner's Na .e
I information is
required for V�?E%V1 f�"�.,�' .� (�2�G � _ L f j)
_.
f every page. City/Town State. Zip Code Date of inspection
l
D. System Information (coat.)
Septic Tank (cont.)
Q l'
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness
� l
i 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?
Il ;li i •
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
1 F liquid levels as related to outlet invert, evidence of leakage, etc.):
� 1 ,
0 _ P
Grease Trap locate on site Ian
;9 P ( plan):
in i
Depth below grade: feet
` Material of construction:
1 ❑ concrete ❑"metal'' ❑ fiberglass ❑ polyethylene ❑ other(explain):
f
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 -----
4i l t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 70 of,7
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Commonwealth of Massachusetts
, Title 5 Official Inspection Form
t .M Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address 7l
Owner Owner's Name
information is
required for n 01lAla
every page. City/Town Sate 'Lip Code Date d Insp ction
D. System Information (cone.)
Comments (on pumping recommendations, inlet and,outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert evidence of leakage, etc.q 9 )
I `
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€ 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
t Alarm present: ❑ Yes, 0 No
I 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
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t5ins•o9io8 Tilla S Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 7 7
I`
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Property Address
i
.G &1 c ��
Owner Owner's Nam
I' information is >_• C
• required for fif 111y7�C ` /41/
every page. City/Town State Zip Code that of Inspection
D. System information (cont) ,
Distribution Box (if present must be opened)(locate on sittplan):
i�
1 Depth of liquid level above outlet invest
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.):
✓ k-S
i
Pump Chamber(locate on site plan):
I► Pumps in working order: Q Yes ❑ No
Alarms in working order: 0 Yes R No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
I
Iijl $I R
' + Soil Absorption Systems (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
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t5ins•09/08
Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Paoe 12 of 17
t
Commonwealth of Mass
achusetts
Title 5 Official Inspection I _
p F®r
a _ &I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Property Address r
Owner Owner's 7!�information isrequired for Ut 1Mu2?G�2 N. r
every page. City/Town State Zip Code Date ofj(nsp'ection
Do System Wormation (coot.)
Type: •
leaching pits number: /
❑ leaching chambers number:
❑ leaching galleries number:'
t
❑ leaching trenches number, length:
i ❑ leaching fields number, dimensions:
® overflow cesspool number: I
❑ innovative/alternative,system
Type/name of technology:.
Comments (note condition of soil, signs of hydraulic failure, level of pohding, damn soil, condition of
vegetation, etc.):
it 0-5
is /'
4 Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top or liquid to inlet invert
Depth of solids layer
II't Depth of scum layer
i
Dimensions of cesspool
Materials of construction
i
Indication of groundwater inflow ❑ Yes ❑ No
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' t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disc
osal System•Pace 13 of 17
t i
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Commonwealth of Massachusetts
Tide 5 Official � specflon Form
Subsurface Sewage Disposal System Form m Not for Voluntary Assessments
Property Address 4,
Owner Owner's Name
information is A� f a
required for 61.1 VI i4lo'62 L, f _ d% ( 14J _ l L, / 016
every page. CitylTown State Zip Code Date of Inspection
D. System Information (cons.)
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.):
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t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1:of 17
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Commonwealth of Massachusetts
Title 5 Official Inspection Forte
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Property Address 1
I ( Owner
Owner's M
Name r
information is
required for C•4t l ,`41,, QH J r/
E
every page. City/Town State Zip-Code Date of VspE4ion
I De System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate'all wells within 100 feet. Locate ;'
where public water supply enters the building. Check one of the boxes below`
hand-sketch in the area below
❑ drawing attached separately
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15ins-09/08 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Pace 15 of 17
Commonwealth of Massachusetts 4
Title 5 Official
i - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Property Address
Owner Owners Name
information isC:f —
required for
every page. Citylfown State Zip Code Date of Inspection
D. System Information {cons.}
Site Exam:
c
c ❑ Check Slope
d ❑
Surface wafter �'- -----=
I' El Check cellar
i ❑ Shallow wells
i
Estimated depth to high groundwater: 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: pate
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
i{ [ Checked with locaj.poard of Health explain:
i ❑ Checked with local excavators, installers - (attach documentation)
}
{ ❑ Accessed USGS database-explain:
1
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You must describe how you established the high ground water elevation:
/cl (4.,l
'fill
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•09108 +
{ I rdie e orraal rnspection Form:Subsurface Sewage Disposal System•P3gg?5 of 17 p
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I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address .�
I Owner Owner's Name
information is
i required for
every page. City/Town State Zip Code Date of s ction
E. Report Completeness Checklist
Inspection Summary: A, B-, C, D, or E checked
{ Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
21-�System Information— Estimated depth to high groundwater
etch of Sewage Disposal System either drawn on page 15 or attached in separate file
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t5ins•09/08 Title 5 Official.ln;pection Form,Subsu�ace Sewage Disposal System•Page 17 of t7
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TOWN OF BAR.NSTABLE
OCATION
VILLAGE Cvtw,- Jj Y ASSESSOR'S MAP si LO' �
INSTALLER'S NAME & PHONE NO. J'7• Dosezli 771 ` Jv�O
SEPTIC.TANK CAPACITY 1, 000 5.1110"5
LEACHING FACILITY:(type)_(.e`i6� 'r (size) Ly00e:j�
NO. OF BEDROOMS _ PRIVATE WELL O PUBLIC WATE
BUILDER OR OWNER
DATE PERMIT ISSUED: 7— 9 2- _
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes �_ _No_
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yr'
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3y�
6`�
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No... ..: Fxs..... i .............
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
2 TOWN OF BARNSTABLE
�7 Appliration for Dispnsa1 Works Tonstrurtion Vamit
Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal
System at:
I-OF a V �L7&4F4 7)iZ Cv 1W 044 uI-D
............ ............................•-----......----------------------..•..._....... ....._..-••---••••-•••----••-•••••----•...--•••••••--•••....._.....-••-•-•..•_.•.........••....._.
oc Address Lot No.
' -•-•-- ------------------
- •--••--•---•--•--........---•-------•-••-- ------._.._....................... .. ..__ .
--•-----------------------
W O er �M Address
Installer Address �// ��f�
.I- (� ..9.S
Type of Building Size Lot_______________ __ _ _ q. feet
U Dwelling No. of Bedrooms._.dx�;
Ex ansion Attic
g— ,'> ------------------ p ( ) Garbage GrinderOther—Type of Building _CN _.___ am` No. of Expansion Attic
Showers ( ) — Cafeteria
Other _____.__
fixtures ----------------------------•-•-
g ________________gallons per peermn per day. Total daily flow............. _ ._.g
W Design Flow____________________ _ .�3 D_______._______..._ allons.
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 ( ) Dosin tank )
Percolation Test Results Performed by � _____y__.v .................................. Date........................................
a
,.� Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
�%4 Test Pit No. 2................minutes per inch Depth of.Test Pit.................... Depth to ground water........................
W -- .
—
O
Description of Soil------. - -- - --------•-•-•--•-•--•-----•---•-------------------------------------------------------------------------
U •--••------------------•--------------•-•-•-----/---•----------•---•---•---------•-------._....._.----•-••-------•------------------•----------------------------•-••----•-•-••-•-••••---••-••--•-••-••-
W
x --•••-•---•----------------------------•-•--•-----------------•----•-----------••••••------•-•••-•••-•--•-•-••-------•---••••••-••••--•--•-••-•••--.._••-•-•-•••••••-•-•••••••-•----•..................
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
•••-• ••••-••-••--•-•••-••--••--•-........................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sew-age Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code— he rsigned further agrees not to place the
system in operation until a Certificate of Compli c has been iss t e board th. p,
Signed----- C
e
Date q
Application Approved BY --------- --- ----e I. _'.1....'3-.
Due
Application Disapproved for the ollowin reasons: .................................................. .... ... ...
........................ ................—...................---------------------..............------............................--.--...------------------------------------ .....- ------'------ .................
Dace
PermitNo. IT. . ..-- ................... Issued ..---------------.......------. --------......-----------------
Dace
No.._ FzS
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Applirtttion for Uiiivusttl Works Tonstrurtion Vamit
Application is hereby made for a Permit to Construct ( X) or Repair ( ) an Individual Sewage Disposal
System at:
� ......oc......Address.-•............................... .............. ... ..-or Lot No. ............................
..
-O fi r
a n� ---)� �- Address
tijl`/.. ........... •--•- ----- .......•
Installer Address `/ V G /�
`-r (Q Q 9 S feet
Type of Building Size Lot•................... ....
q•
I-, Dwelling—No. of Bedrooms...........................................Expansion Attic ( ) Garbage Grinder ( )
a`4 Other—T e of Building G! = No. of,persons ersons............................ Showers
YP g -��� ---• p ( ) — Cafeteria ( )
Otherfixtures ---------------------------------------------------•------------------------------•---
WDesign Flow......................11 U-------------gallons per person per day. Total daily flow..._....... ..7....U....._......___._.__.gallons.
Septic Tank—Liquid'capacity.....__.....gallons Length................ Width................ Diameter................ Depth................
0.4
W 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 ( ) Dosin tank ( )
0-4Percolation Test Results Performed by Gt . ..............
sC-------_---------------•-_ Date........................................
a
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
fs, / 'Test Pit No. 2................minutes per inch Depth of.Test Pit.................... Depth to ground water........................
t� •----------------------------••------•-•--------•--•-------.......------...-----•---._..._..--•••---------•--••-•--•-----------•--•--•----••----•-•--
x . Description of Soil------.� � 4+...-js ....................................................-•-•-------------------------.......................................
�N
U ....................................................................................................................................................................1...................................
W
........................................................................................................................................................................................................
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
k�
-•------••-•-----------------------------------------------------------------------------------•--.........-------------------------------------------------------------------------••.....----•-•-----.
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—� he undersigned further agrees not to place the
system in operation until a Certificate of Complia• ce has been issu d<Vvy the board d ealth.
/�
Signed . .... � ±' L.{' / ------------ ...... -------� . '2-
I/ Date
Application Approved BY ---- 4 ------- -� ----'7--1 ...
�c
Da[e
Application Disapproved for the following reasons- --- --------------------------------------------------------------------------------------------------------------------------------
Date
PermitNo- -------- -- ---------— .................... Issued ............---------_-----_---- ......~..................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
(fe>r#tfirate of Tontylian e
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ' �C) or Repaired ( )
by ---
at ._...: �/ C/! C/-...... .............1ns[alier
_.....-_._- ...............................
has been installed in accordance with the provisions of T lI'LE 5$f 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. �.._
DATE...................................--=- .. .'..4_ Inspector ----------- - >�.�
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
No._._.�Z...:._�.�6 FEE__��.�.r)...........
i �trr tt rk a� #r ivit Trutt#
Permission is herebygranted...... .... -
to Constr ct ( K) or Repair ) an nd vidua.-Sewage Disposal System
atNo.. r �1.._ ............................... ! -- - --------------------••--•-----------•---•---•-------•--••----------..........--
t/ t
as shown on the application for Disposal Works Construction Permit No..?4 3�b-_ Dated..........................................
_ ---------------------------- --------------------------------------•-----•--------------
DATE. �_-�_I : n 7 Board of Health
FORM 38808 HOBBS Q WARREN.INC.,PUBLISHERS
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