HomeMy WebLinkAbout0046 BAYBERRY LANE - Health 46 Bayberry Lane, I
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
46 Bayberry Lane, Cummaquid P-335 P-46
Property Address L
Reid Christen
Owner Owner's Name
information is 56 Y2 Orange Street,Waltham MA 02453 December 8, 2015
required for every y}�
page. C,ityrrown State Zip Code Date of Inspection
I i•'Z'
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Inspect0h results must be submitted on this form. Inspection forms may"not be altered in arrly
way. Please see completeness checklist at the end of the form. r)
Important:When filling out forms A. General Information
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Troy Williams
use
key the return Name of Inspector
�►/&* - � Troy Williams Septic Inspections
Company Name
19 Hummel Drive
Company Address
r South Dennis MA 02660
Citylrown State Zip Code
(508) 385- 1300 S1682
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true,.accurate and complete as of the time of the inspection. The inspection
' was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
December 8, 2015
Inspector's Signatur Date
The system inspector shall submit a copy of this inspection report to the Approving Authority'(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
` and copies sent to the buyer, if applicable, and the approving authority.
****This report only.describes conditions at the time of inspection and under the conditions of use
S at that time.This inspection does not address how the system will perform in the future under
w the same or different conditions of use.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
(
46 Bayberry Lane, Cummaguid P-335 Pi-46 it
Property Address
Reid Christen 4
Owner Owner's Name
information is 1 I!
required for every 56 %Orange Street, Waltham MA 02453 December 8, 2015
page. CityrFown State Zip Code Date of Inspection
B. Certification (cont.) M
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes: 4
® 1 have not found any information which indicates that any of the failure Ocriteriadescribed
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluate ct are
indicated below. WW
a Comments: P
System meets minimum standards set by Massachusetts DEP at the time of inspection only.This
inspection is not a guarantee or warranty on the future working conditions of leaching, pipe',
components or the future structural integrity of said components and only represents conditions found 4
at the time of inspection only.
B) System Conditionally Passes:
1
❑ 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. '-�•.�, 0
*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): Q
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t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
46 Bayberry Lane, Cummaquid P-335 P-46
Property Address
Reid Christen
Owner Owner's Name :r
information is 56 Y2 Orange Street Waltham MA 02453 December 8 2015
required for every � ,
page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
6
❑ 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):
1'
U
❑ 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):
s
s'
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). Ae
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):
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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.
9 4
1.>'System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
z h
❑ 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-.3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Opage 3 of 17
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at Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
9 p Y rY
y�
46 Bayberry Lane, Cummaquid P-335 -46
$ Property Address
P.v
Reid Christen
Owner Owner's Name
information§is
56 /Oran a Street Waltham MA 02453 December 8, 2015.
re aired for eve 9
Q rY ..
a ye. Cityrrown State Zip Code Date of Inspection
P9 �
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment: i 4
❑ The system has a septic tank and soil absorption system (SAS)and the SAS's within
100 feet of a surface water supply or tributary to a surface water supply.
4 ❑ 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 analysismust
be attached to this form.
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3. Other:
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D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
4
Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
Static liquid level in the distribution box above outlet invert due to an overloaded
❑ ® or clogged SAS or cesspool b
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than %day flow
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments T
r` 46 Bayberry Lane, Cummaquid P-335 P-46 A
Property Address
Reid Christen
Owner Owner's Name w
information is Street Waltham MA 02453 December 8 2015
required for every 56%Orange � � j
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ,
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This'
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- .
10,000gpd. ? 0
❑ ® 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
i system owner should contact the Board of Health to determine what will be
necessary to correct the failure'.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply Y
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well,
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
t Subsurface Sewage Disposal System Form -Not for Voluntary Assessments j
46 Bayberry Lane, Cummaquid P-335 P-46
Property Address
Reid Christen
Owner Owner's Name
iequir dfo is 56 %Orange Street, Waltham MA 02453 v December 8, 2015
required for every
page. Cityrrown State Zip Code Date of Inspection
C. Checklist
4 Check if the following have been done. You must indicate"yes"or"no"as to each of the�ollowing:
Yes No
i 4 ® ❑ 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?
e
® ❑ 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 QMR 15.302(5)]
t4
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 2 Number of bedrooms(actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 gpd
2
!j t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
46 Bayberry Lane, Cummaquid P-335 P-46
Property Address
Reid Christen
Owner Owners Name
information is required for every �56 /z Orange Street Waltham MA - 02453 December 8, 2015
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
a
Number of current residents: 0
Does.residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes E No
information in this report.)
Laundry system inspected? ' ® Yes ❑ No
I Seasonal use? ® Yes ❑ No
Water meter readings, if available last 2 ears usage d 14=14,000 gals.
g ( y g (gp ))' 13=13,000 gals.
Detail
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Sump pump? ❑ Yes ® No
Last date of occupancy: occasional use
Date
a�
Commercial/Industrial Flow Conditions:
;Type of Establishment: N/A
'
Design flow(based on 310 CMR 15.203): N/A
Ganons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.): N/A f
Grease trap present? ❑ Yes ❑ No
+ Industrial waste holding tank present? ❑ "Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
e Water meter readings, if available:
N/A i
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 11
tr
Commonwealth of Massachusetts
Title 5 Official Inspection Forme
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
46 Bayberry Lane,Cummaquid P-335 P-46
Property Address
Reid Christen
Owner Owner's Name
required for
is 56 '/Orange Street,Waltham MA 02453 December 8, 2015
requited for every
page. « City/Town State Zip Code Date of'Inspection
D. System Information (cont.)
P Last date of occupancy/use: N/A
Date
Other(describe below):
f
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General Information
4 Pumping Records: �J
Source of information: No pumping info was available.
8
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
0
Reason for pumping:
A
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
t
❑ 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
9 ❑ Tight tank. Attach a copy of the DEP approval.
q ❑ Other(describe):
6
15ina 3/13 Title 5 Official Inspection Fond:Subsurface Sewage Disposal System-Page 8 of 17
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Commonwealth of Massachusetts
Title tbfficial Inspection Form t
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
!'r
46 Bayberry Lane, Cummaguid P-335 P-46
9 Property Address
Y Reid Christen
Owner Owner's Name
information is required for every 56 /Orange Street, Waltham MA 02453 December 8, 2015
page. Citylrown State Zip Code Date of Inspection
i D. Systei "Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
ii $ , Tank,d-box and leaching were installed on 6/4/84 per compliance.
t
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
111
AI �
7 Depth below grade: e8t+
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
3
b Comments(on condition of joints, venting, evidence of leakage, etc.):
s Flushed lines and found clear at the time of inspection.
b �
Septic Tank(locate on site plan): '
1 it
Depth below grade: feet
i Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain)
If tank is metal, list age:q years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
' Dimensions: 5'X9'X6' 1000 gallon
411
Sludge depth:
t5ins-3/13
�y; Title 5 Official Inspection Fond:Subsurface Sewage Disposal System-Page 9 of 17
1
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
46 Bayberry Lane, Cummaquid P-335 P-46 ,
Property Address
Reid Christen
Owner Owner's Name
information is g
required for every 56 %Orange Street, Waltham MA 02453 December 8, 2015
page. f Citylrown State Zip Code Date of Inspection ` "
D. System Information (cont.) " .
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
2'8" '
Scum thickness none
Distance from top of scum to top of outlet tee or baffle 611
Distance from bottom of scum to bottom of outlet tee or baffle 14'
How were dimensions determined? probe/measured
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pvc inlet and concrete outlet tees were found present and in working order. No evidence?f leakage
or damage was found. Tank was not in need of pumping at this time.
d
Grease Trap(locate on site plan):
Depth below grade: N/A
feet
Material of construction: $
❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions: N/A
Scum thickness N/A
a Distance from top of scum to top of outlet tee or baffle N/A
Distance from bottom of scum to bottom of outlet tee or baffle N/A
Date of last pumping: N/ADate Q
`:5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
n
rl�
Commonwealth of Massachusetts
Title 5 Official Inspection Form
4 �
i Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1 46 Bayberry Lane, Cummaquid P-335 P-46
Property Address _
Reid Christen
Owner {. Owner s=Name
information is)
required q 56 '/z Orange Street, Waltham MA 02453 December 8 2015
for
page.' 4r,I every!
State Zip Code Date of Inspection
D. System Information (cont.)
Comments�(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
I T
+�IJ v
s
+ , Tight ol,Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
t Depth below grade: N/A
Material of construction: '
' 0 concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other Axplain):
Dimensions: N/A
N/A
Capacity:
gallons
Design Flow: N/A
4 = gallons per day
Alarm present: ❑ Yes ❑ No
:p 3•
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Alarm level: N/A Alarm in working order: El Yes ❑ No
ih N/A .
t,Q Date of last pumping: Date
�. Comments(condition of alarm and float switches, etc.):
N/A� i
• I
R .Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
4�
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
46 Bayberry Lane, Cummaquid a P-335 �;46
Property Address
Reid Christen
Owner Owner's Name
information is required for every 56 Y2 Orange Street, Waltham MA 02453 December 8, 2015 '
page' City/Town State Zip Code Date of Inspection 'Pit
i D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
level � A
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.): G+
D-box was found level and in working order.
l
g
A Pump Chamber(locate on site plan):
D
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ �No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
N/A
�a
o .
a
o •
*If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
r
If SAS not located, explain why:
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
a
{� 'Commonwealth of Massachusetts
f Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
'46 Bayberry Lane, Cummaquid P-335 P-46
Property Address
Reid Christen
Owner Owner's Name
information
forie 56'/z Oran a Street Waltham MA 02453 December 8 2015
re uited for�eve 9 � � -•
page!,,," ry City/Town State Zip Code Date of Inspection '
D. System Information (cont.)
N '
Type: i
s 1 -6'X6' pit with
leaching pits number: 2'of stone
❑ leaching chambers number:
❑ leaching galleries number:
' ❑ leaching trenches number, length:
4, �; : ❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑i innovative/alternative systemi
h Type/name of technology:
4 Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leach pit was found with little water present dry with no evidence of hydraulic failure or problems in
the past were found at the time of inspection. Checked stone and found dry and clean.
{ j
on
Cesspools(cesspool must be pumped as part of inspection) (locate on site plan):
0
st 'Number and configuration N/A
Depth—top of liquid to inlet invert N/A
' Depth of solids layer N/A
Depth of scum layer N/A
I Dimensions 01;cesspool
Materials of construction N/A
I
Indication of groundwater inflow ❑ Yes ❑ No `h
t5insry 3/13 t's' Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Pad"13 of 17
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Commonwealth of Massachusetts .
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments o
46 Bayberry Lane, Cummaquid P-335 P-46
Property Address too
Reid Christen r ;! `•
Owner Owner's Name ` I
information is
56 /Z Oran a Street Waltham MA 02453 December 8 201.5
required for every 9 , � i
page. CitylTown State Zip Code Date of In§ection
4 D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of yegetation, i
etc.):
i
.� N/A ,
Privy(locate on site plan): 4
Materials of construction: N/AI,
Dimensions N/A
NIA
Depth of solids 79• v
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.): '
N/A
A
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1
4
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I'
A �
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t5ins-3/13 Title 5 Official Inspection Form:s$ubsurface Sewage Disposal System•Page 14 of 17
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Commonwealth of Massachusetts
- 'Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
w 466FBayberry Lane, Cummaguid P -335 P -46
_
Property Address
Reid Christen _
Owner Owner's Name
information is required for every �56 /2ran9 Street,O a Waltham MA 02453 December 8, 2015
page. Y City/Town State Zip Code Date of Inspection
11). System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
q at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
. c- .5 P.w Go✓Nw✓'r
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0 3 0 0
S
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t5inl*3/13 f � Me 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts `
Title 5 Official Inspection Form :
A
M
a Subsurface Sewage Disposal System Form Not for Voluntary Assessments
46 Bayberry Lane, Cummaquid P -335 P:4A�
Property Address { *z
Reid Christen i
Owner Owner's Name
information is
required for every 56'/2 Orange Street, Waltham MA 02463 December 8, 2615,
page. City/Town State Zip Code Date of Inspectidn rg
D. System Information (cont.)
Site Exam:
® Check Slope 0
s
x
❑ Surface water
® Check cellar `
i
❑ Shallow wells LI .i
Estimated depth to high ground water: 13.0'+
feet
Please indicate all methods used to determine the high ground water elevation: d
❑ 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) .
❑ Checked with local Board of Health:-explain:
❑ Checked with local excavators, installers- (attachidocumentation) @ .
EI
® Accessed USGS database-explain: p a
AIW 247 Zone B 25.3' 4.6' adjustment
IP —
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You must describe how you established the high ground water elevation:
Hand augered 5' below bottom of leaching at lowere elevation with no water found.at a depth:of 13.5'.
Groundwater adjustment at the time of inspection was 4.6'. Bottom of leaching at 8.5' wasiound not I
to be located in the high groundwater elevation at the time of inspection.
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Before filing this Inspection Report, please see Report Completeness Checklistbon next page.
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•'Page 116 of 17
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
5 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
p
�< 46 Bayberry Lane, Cummaguid P-335 P-46
Property Address
$ Reid Christen
Owner Owner's Name I
information is
required for every 56 '/z Orange Street,Waltham MA 02453 December 8, 2015
page. , ' 011 d Cityrrown State Zip Code Date of Inspection
E Report Completeness Checklist
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® inspecti6q'Summary: A, B, C, D, or E checked '
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Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ,
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. ® System information—Estimated depth to high groundwater
I ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
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It5ins•3/13 1 { Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
TOWN OF BA NSTABLE
LOCATION Z(O _ SEWAGE#
,VILLAGE A SSOR'S MAP&PARCEL
INSTALLERS NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS
OWNER
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
FURNISHED BY = & � o7/a�//4
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Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Department of 2
Environmental Protectio To 4 1997
William F.Weldp pTTABjudy
Goremor
Argso Paul Celluccl �� David B
u.oaernor
s 8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
property Address: 46 Bayberry Lin, Cummaquid Address of Owner. Ann Canedy
Date of Inspection: .L'1 (If different) PO Box 23
Name of Inspector. W.E. Robinson, SR Cummaquid, -MA 02637
Company Name,Address and Telephone Number. ( 5 0 8) 7 7 5-�8 7 7 6
W.E. Robinson Septic...Bervice ( 70 Vanduzer .Rd,Barnstable
P.O. Box 1 089 -Centery ll''e,, MA
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
asses
Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
_ Fails
Inspectoe's Signature: 4%) V Date: ✓ —
The System Inspector shall submit a copy of this inspection report to the APPe��gAuthoritY within Y(30)days of completing this
inspection. e system is a ahared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the
report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY.
Check A,B, C,or D:
A] SYSTEM PASSES:
L STI have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
B] STEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes
inspection.
yes,no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain why not)
_ The septic tank is metal,cracked, structurally unsound,shows substantial infiltration or enfiltration,.or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a ponforming septic tank as approved
by the Board of Health.
(revised 11/03/95) 1
One Winter Street is Boston,Massachusetts 02106 a FAX(617)556-1049 a Telephone(617)292.5500
�A1 Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 46 Bayberry Ln,, Cummaquid, MA
Owner. Ann Canedy
Date of Inspection: ,�,—i �' fl
B)SYSTEM CONDITIONALLY PASSES(continued)
Sewage backup or breakout or high static water level observed in the distribution boa is due to broken or obstructed pipe(s)
or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed.
C) THER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health,safety and the environment.
1 SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES.THAT THE SYSTEM IS NOT FUNCTIONING IN A
MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or-privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)
DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a
surface water supply.
The system has a septic tank and soil absorption system and is within a Zone I of a.public water supply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water
supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free
from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm.
9) THER
(revised 11/03/95) 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 46 Bayberry Ln, Cummaquid, MA
Owner. Ann Canedy
Date of Inspection:
Dl SYSTEM FAILS:
I ban determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for
his determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution boa above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coli.form bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen.
El LAR SYSTEM FAILS.
e following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public
health and safety and the environment because one or more of the following conditions exist:
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)
The owns or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirem nts of 314 CMR.5.00 and 6.00. Please consult the local regional office of the Department for further information._
I
(revised 11/03/95) 3
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B _
CHECKLIST
Property Addrew 46 Bayberry Ln, Cummaquid, MA
Owner. Ann Canedy
Date of Inspection: a Qt
Check if the following have been done:
/Pum ' information was requested of the owner,occupant, and Board of Health.
�L Pmg
None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
Ong that period. Large volumes of water have not been introduced into the system recently or as part of this invpection.
_As built plans have been obtained and examined. Note if they are not available with N/A.
The facility or dwelling was inspected for signs of sewage back-up.
Me system does not receive non-sanitary or industrial waste flow
�fhe site was inspected for signs of breakout.
system components,excluding the Soil Absorption System, have been located on the site.
e septic tank manholes were uncovered, opened;and the interior of the septic tank was inspected for condition of baffles or
t of liquid,depth of sludge,depth of scum.
tees,material of construction,dimensions,depth q d, P dg'e� P
11The site and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 11/03/95) 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
property Address; 46 Bayberry Ln, Cummaquid, MA
Owner. Ann Canedy
Date of Inspection: )--12—9 n
FLOW CONDITIONS
RESIDENTIAL
Design flow: 3 0 ,gallons
Number of bedrooms:_
Number of current residents: 0
Garbage grinder(,yes or no):&p
Laundry connected to system(yes or no):)&- S
Seasonal use(,yes or no): A 1994 - 1995 36 , 000 gals.
Water meter readings,if a ble:
5 - 1996 4 , 000 gals.
Last date of occupancy:,
COMMERCIALANDUSTRIAL:
Type of establishment:
Design Dow:_gallons/day
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:
OTHER(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORD of information:
77
System pumped as part of inspection: (yes or no)_L.#
If yes,'volume pumped: pUons
Reason for pumping:
TYPE OF STEM
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)
Other(explain)
APPROXIMATE AGE of all components,date installed(if known)and source of information:
Sewage odors detected when arriving at the site: (yes or no) d
(revised 11/03/95) b
� 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
property Address: 46 Bayberry Ln, . Cummaquid, MA
Owner. Ann Canedy
Date of Inspection:
SEPTIC TANK.L
(locate on site plan)
t
1
Depth below grade: /
Material of construction:_r/concrete_metal_FRP_other(explain)
Dimensions: 3?
Sludge depth: 9-1
r
Distance from top of sludge to bottom of outlet tee or bade: y 0
Scum thickness: 0
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle: Jyt-
Comments:
(recommendation for pumping,condition of inlet and outlet t9es or baffles,depth of liquid level in relation9 to outlet invert,structural integrity,
evidence of leakage,etc.) 1, �, /lli ���c L Ae LG Gl! l o ham// &IS C 1
11ocaten
P.
lan)
ade:struction:_concrete_metal_FRP_other(ezplain)
fi om top of scum to top of outlet tee or bafn
from bottom of scum to bottom of outlet tee or baffle:
Co uts:
( endation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,
nce of leakage,etc.)
(revised 11/03/95) 6
+ y
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
PropertyAddrese: 46 Bayberry Ln, Cummaquid, MA
Owner. Ann Canedy.
Date of Inspection: a,_12.`4 7
GHT OR HOLDING TANK_
( on site plan)
below grade:
of construction:_concrete_metal_FRP—other(explain)
Dime no:
Ca ty: ¢allons
flow: aallona/day
level:
Cc nts:
(co n of inlet tee,condition of alarm and float switches,etc.)
DISTRIBUTION BOX:C/
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if-level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.)
PUM CHAMBER:_
(locate n site plan)
Pumps working order:(yes or no)
ta:
(note co n of pump chamber,condition of pumps and appurtenances,etc.
(revised 11/03/95) 7
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(oontinued)
Property Address: 46 Bayberry Ln, ..Cummaquid
Owner. Ann Carledy
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS):_
(locate on site plan,if possible;excavation not required,but may PP be approximated by non-intrusive methods)
If not determined to be present,explain:
Type:
leaching pits,number:1 02
leaching chambers,number:_
leaching galleries,number:
leaching trenches,number,length:
leaching fields, number,dimensions:
overflow cesspool, number:.
Comments: (note condition of soil,s' of h oleic failure, level of ponding,condition of vegetation,etc.)
6 a c . �, L Ild s 5 A a, / 6 ' , ,—
ro
C LS:
(locate site plan)
Number ead configuration:
Depth- of liquid to inlet invert:
Depth solids layer-
Depth
scum layer.
Dime ' ns of cesspool:
Mate ' of constriction:
wn of groundwater:
iulLow(cesspool must be pumped as part of inspection)
Comments.(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.)
PRIVY:
(locate site plan)
Material oonstruction:
Depth of so' Dimensions:
Comments: note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.)
(revised 11/03/95) 8
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(oontinued)
PropertyAddrese: 46 Bayberry, Ln, Cummaquid, MA
Owner. Ann Canedy
Date of Inspection: ' —! 'L—pleo L q7,
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
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DEPTH TO GROUNDWATER
Depth to groundwater: )7---' feet
method of determination or approximation:
(revised 11/03/95) 9
L 0 C Al ION SEWAGE PERMIT NO.
VI'ILAGE
.33S= 6 y�
INSTA-LLE S NAME ADDS'
t U I L D E R OR OWNER
DATE PERMIT ISSUED 2,Z
DAT E COMPLIANCE ISSUED
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No..... ....._._.. Fps...........!.. ........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF......................................
Appliration for 11Wposa1 darks Tonstrurtion Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
• Lo lion.A ess or Lot No.
Owner ................................Address
Installer Address
Pq
� Type of Building Size Lot___________________________S q. feet
Dwelling—No. of Bedrooms.................... ----------------Expansion Attic ( ) Garbage Grinder (�p�
Other—T e of Building No. of persons............................ Showers )
a YP g -------------•----------••-- P ( )_.— Cafeteria----------
dOther fixtures -------------------------------------------------------------------------------------------------•---••------------
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No_____________________ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
a
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water--___--______-_--.-.._..
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
W ----•-•--•-....-•-------•-----•••-••--•-••-•-••......-•••-•-•--•-••..........-•------...•-•--•....••.........................................................
0 Description of Soil.....................................................................................................-----------------•------....-------•-•••......--•-.......•........
x
V -•---••••-••••••••••---...-•--•••••••-------•-•-•••...••••-••--•--•••-••-•--...•••-••-----•••---•-••-•-•...-•---••---•-•----••-•-•--•--•••-•---•-••••••••-•-•-••-••-•••---•..............••......•..--•-
W
----------- - - ------------ --- ----------- ---- ----- ------------ --------- --- ------------- ---
Nat
ure of Repairs or Alterations—Answer he�gplicable_..__ ®0_Q_______ _t�.�___..__�S'�. '� .. ... .!v.
...................••-••-••••- _.e�_ �'.:._. a ,e .....�i-.--•-•--•---•-----•--------------------------------------•------------------------------------..............-----•
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITIS 5 of the State Sanitary Code— The un ersigned further agrees not to place the system in
operation until a Certificate of Compliance has b t sued by thqvoard ohealth
Sig . - • • -• . _.. .. .......... ................................
Date
Application Approved BY ..�..... - - ---------------------- --------5
Date
Application Disapproved for the following reasons:..........-••-•••-•••------••---•--•---•---•-•••-•-•-••---•-•••••---•-••---•--•--•---•-•-••-•-••---•••.......
--•-••••--•-••--••••---••-•--••••-------••-•••-•••-••---•••-•-----•-•---•-••--••--•----------------•------•••-•-•---•••-•-••-••••••-••--••-•••-•--•--••--•-•---•••------•••--••---•---•••-•-••••--------
Date
PermitNo......................................................... Issued.......................................................
Date
No... .. �. ' Fps........ ...
THE COMMONWEALTH OF MASSACHUSETTS 4
BOARD '"OF- HEALTH �� ` '
Appliration-for Disposal Works Tonstrnrtiun Vrrmi# ` ..._
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
.......... ...�.. ..... .....__..._- ----------------------------------.'
Lo ation ress
Lot No.
- --�`---------• --:. ... ............................................. ......--------.....-------.............._....
W Own Address
a -------_... er -•--•
Instal Address
UType of Building Size Lot............................Sq. feet
I—I Dwelling—No. of Bedrooms___________________ „---______________Expansion Attic ( ) Garbage'eGrinder _
a'4 Other—T e.of Building "'
YP g ,,:: No." of persons ==--•-•••• Showers ( ) — Cafeter )
Other fixtures ----------------------------='-•-••--••••-
...........................................................
W Design Flow............................................gallons per person per day. Total daily flow.............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter________________ Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No-----------_------- Diameter.................... Depth below inlet,.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) f Dosing tank ( )
aPercolation Test Results Performed by........................................................................... Date........................................
Test Pit No. 1.....:..........minutes per inch Depth of Test Pit.................... Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
0 Description of Soil....................................................................................................................................-•-•••--•-••••-• =
V ................•------••-•-•••-•---•----•--•-•-•---........---=••-=----•-----•--...--..................................................-------••-•----•----•s.........................................
W
UNature of Repairs or Alterations Answer he pplicable J��p'® 0� 4 h" /'y �' "
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE: 5 of the State.Sanitary Code— The u ersigned further agrees not to place the system in
operation until a Certificate of Compliance has b sued Lyth oard healt
Si �""``.".--•---- ----- -•- ................................
Date
Application Approved BY •----•--••- •-•- � 'a'�" 2_/- ---8
Date
Application Disapproved for the following reasons__________ _________________________________________________
-•----------------- -
......----•••--••-•-•-•-••-----•••-----••-••---••--•---•-••...----•••••-•....-••-•-•-----•---------------.---•-•-••-•--••-••••••---•----••--••... .......................................................
Date
PermitNo:.:. =•=•-----------------•--•. Issued.........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF............................................................................-_.......
(9rr#if irtttp of f ompliFanrr
THIS IS T C RTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by----------------- ----,... .�_G/ - ..... ----------------------------------------------......----------........--- .....................................................
staller
at. -
has been installed in accordance w provisions of TIT F 5 of The S ate Sanitary Code as described in the
application for Disposal Works Construction Permit No.__. _ .. -___.___ dated________________________________________________
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTIO1 SATISFACTORY.
DATE----._:=.t_._................... �'t -V------------------------- Inspector........................ .....................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
0
No ✓'' ...........................................OF...........-------••._....___..._......._•--•-------••---•-...__-__.._......_........ r
FEE....._..................
Disposal Workii Tnn#r ion "anti#
Permission is hereby-granted •-- •--•• -•--•--------------------...•---------•-.....------.._..-•--•.......................
to Construct ( �)�or�2epair an Individual Sew ge Disposal S stem
atNo..................
� t. ------•--- - -------------------------------•---------•---
Street
as shown on the application for Disposal orks Construction Permit No..................... Dated..........................................
_ ._ -•a---•_ -•• ..........................................................
Board of Health
DATE................................................................................
FORM 1255 A. M. SULKIN, INC., BOSTON
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