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Commonwealth of Massachusetts
"u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
° M 139 Brentwood Lane
Property Address
Anthony Folino
Owner Owner's Name
information is every Cumma uid
required for eve 4 Ma 02637 8/7/2013
page. Cityrrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
on the computer,
use only the tab 1. Inspector: `n\ I
key to move your E� C� D
cursor-do not Sean M. Jones
use the return Name of Inspector
key.
dl--�� S.M.Jones Title V Septic Inspection
" Company Name
74 Beldan Ln.
Centerville Ma 02632
Cityrrown State Zip Code
774-248-4850 smjonestitle5@gmail.com SI4522
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 on4ite
sewage disposal systems. I am a DEP approved system inspector pursuant4o ection14.340W
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ is
❑ Needs Further Evaluatio 3e-fecal Approving Authority „
'y
8/7/2013 $9
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
This report only describes conditions at the time of inspection and under the conditions of use
p Y p
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•3/13 Title 5 Official Inspection Fo ff: bsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 139 Brentwood Lane
Property Address
Anthony Folino
Owner Owner's Name
information is
required for every Cumma quid
Ma 02637 8/7/2013
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
In 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
The dwelling located at 139 Brentwood Lane Cummaquid is served by a Title V septic system
consisting of a 1500 gallon septic tank, distribution box and 2 1000 gallon precast leach pits. The
system was found to be in proper working condition at the time of inspection
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•3/13 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
139 Brentwood Lane
Property Address
Anthony Folino
Owner Owner's Name
information is Cumma uid
required for every q Ma 02637 8/7/2013
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
El 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-Page 3 of 17
L
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
139 Brentwood Lane
Property Address
Anthony Folino
Owner Owner's Name
information is Cumma uid Ma 02637 8/7/2013
required for every G
page. Citylrown State Zip Code Date of Inspection
B. Certification (cont.)
2 System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ 0 Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y2 day flow
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection . Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
139 Brentwood Lane
Property Address
Anthony Folino
Owner Owner's Name
information is Cumma uid Ma 02637 8/7/2013
required for every q
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
El ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
. Commonwealth of Massachusetts
A - Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
ti 139 Brentwood Lane
Property Address
Anthony Folino
Owner Owner's Name
information is Cumma uid Ma 02637 8/7/2013
required for every q
page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no"as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system.components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example,a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 4+ Number of bedrooms(actual): 4
DESIGN flow based on 310_CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 gpd
t
t5ins-3r13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
I�
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 139 Brentwood Lane
Property Address
Anthony Folino
Owner Owner's Name
information is Cumma uid Ma 02637 8/7/2013
required for every q
page. Citylrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 2
Does residence have a garbage grinder? ® Yes ❑ No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® 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:
Sump pump? ❑ Yes ® No
Last date of occupancy: current
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
• Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°y 139 Brentwood Lane
Property Address
Anthony Folino
Owner Owner's Name
information is Cumma uid Ma 02637 8/7/2013
required for every q
page. CityrFown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
GM 139 Brentwood Lane
Property Address
Anthony Folino
Owner Owner's Name
information is uid Ma 02637 8/7/2013 Cumma
required for every G
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
original system installed 6/13/1989 per town records
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 5feet
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.):
Joint were ok, no leaks, vented through the roof
Septic Tank(locate on site plan):
Depth below grade: 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 gallons
Sludge depth: ---
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 139 Brentwood Lane
Property Address
Anthony Folino
Owner Owner's Name
information is Cumma uid Ma 02637 8/7/2013
required for every q
page. 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
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.):
Septic tank was structurally sound, water level was ok. Owner is having tank cleaned after inspection.
Tank should be cleaned on a regular schedule every 2 years for proper maintenance. Inlet cover is on
a riser to grade with a steel cover.
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
139 Brentwood Lane
Property Address
Anthony Folino
Owner Owner's Name
information is Cumma uid Ma 02637 8/7/2013
required for every q
page. City/Town State Zip Code Date of Inspection
D. System Information (coat.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete, ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
I_
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
139 Brentwood Lane
Property Address
Anthony Folino
Owner Owner's Name
information isequired for every Cumma uid
Ma 02637 8/7/2013
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
0"
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Water level in distribution box was even with both outlets. Stain line in box indicates that the box has
never been hydraulically overloaded. Box is h-20 loading and has a steel cover to grade.
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.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
f
Commonwealth of Massachusetts
F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
139 Brentwood Lane .
Property Address
Anthony Folino
Owner Owner's Name
information is Cumma uid Ma 02637 8/7/2013
required for every q
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 2x1000 gals w 3'stone
❑ 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.):
Leach pits are located under pavement and are not accesible.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M ,. 139 Brentwood Lane
Property Address
Anthony Folino
Owner Owner's Name
information is Cumma uid Ma 02637 8/7/2013
required for every q
page. CityrFown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
f
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
,M 139 Brentwood Lane
Property Address
Anthony Folino
Owner Owner's Name
formation is
required for every Cumma 4uid Ma 02637 8L7/2013
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
c_ L ;
li
�1 _'z Z..I
C-2 ZY
a
C-Lf Z0'
IVY
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
F Title 5 Official Inspection Form
Subsurface.Sewage Disposal System Form-Not for Voluntary Assessments
139 Brentwood Lane
Property Address
Anthony Folino
Owner Owner's Name
information is required for every CumG
ma uid Ma 02637 8/7/2013
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 12'+
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Groundwater elevation was determined by accessing Town of Barnstable groundwater contour map.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 139 Brentwood Lane
Property Address
Anthony Folino
Owner Owner's Name
information is Cumma uid Ma 02637 8/7/2013
required for every q
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary:A, B, C, D, or E checked
® Inspection Summary D(System Failure Criteria Applicable to All Systems) completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
1
t
I
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
4
Page:
CERTIFICATE OF ANALYSIS
Barnstable County Health Laboratory
RECEIVED
Report Dated: 6/16/2004 UN
Report Prepared For: J 4�ooy
Greg Plummer Order No.: G04 5568
TOWN OF BARNSTABLE
Cape Cod Mechanical Systems,Inc. HEALTH DEPT.
8 Fruen Way
S Yarmouth, MA 02664
j
Laboratory ID#: 0425568-01 Description: Water-Drinking Water
Sample#: 25568 Sampling Location 139 Brentwood Dr Cummaquid MA Collected: 6/9/2004
Collected by: G Plummer Received: 6/9/2004
I I
Routine i
i
ITEM RESULT UNITS RL MCL Method# Tested
LAB: IC Lab
Nitrates 0.7 mg/L 0.1 10 EPA 300.0 6/11/2004
LAB: Metals
i
Copper BRL mg/L 0.1 1.3 SM 3111B 6/14/2004
I Iron BRL mg/L 0.1 0.3 SM 311113 6/14/2004
Sodium 17 mg/L 1.0 20 SM 3111B 6/14/2004
LAB: Microbiology
Total Coliform Absent P/A 0 Absent 309 6/9/2004
LAB: Physical Chemistry
Conductance 280 umohs/cm 1 EPA 120.1 6/9/2004
i
pH 7.4 pH-units 0 EPA 150.1 6/9/2004
Water sample meets the recommended limits for drinking water of all the above tested parameters.
Approved By:
Director)
1Af r �,�r.+ 9,, 4t��,�`fZa
1
t a,"
RL ='Reporting Limit
MCL=Maximum Contaminant Level
Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605
_ COMMONWEALTH OF MASSACHUSETTS y P
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET, BOSTON MA 02108 (617)292-5500 ;
TRUDY COXE
-x„«• Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Governor F' ,' Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 139 Brentwood Lane, Cummaquid, MA Name of Owner: Michael Fein
Address of Owner: same
Date of Inspection: March S, 1999
Name of Inspector: (Please Print) James M. Ford
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)
Company Name: James M. Ford
Mailing Address: P.O. Box 49, Osterville, MA 026SS-0049 f f Map. 333
Telephone Number: (508)862-9400 Parcel: 063
Lot: 4
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: '
✓ Passes ^
® Conditionally Passes ..
Needs Further Evaluati By the Local Approving Authority
Inspector's Signature: Date- ,March 7, 1999
The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(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 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.
NOTES AND COMMENTS ,
' 9 1
F MA R`,.1 ,8 1999
s Hft
� .
revised 9/2/98 Page i of 11
Pru¢ed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
i
Property Address: 139 Brentwood Lane, Cummaquid, AM
Owner: Michael Fein
Date of Inspection: March 5, 1999
INSPECTION SUMMARY: Check A, B, C, or D.-
A. SYSTEM PASSES:
✓ I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure
criteria not evaluated are indicated below.
COMMENTS:
B. SYSTEM CONDITIONALLY PASSES:
One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system,upon
completion of the replacement or repair,as approved by the Board of Health, will pass.
Indicate yes,no, or not determined(Y,N, or ND). Describe basis of determination in all instances. If"not determined",explain why not.
The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection; or
the septic tank, whether or not metal,is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
Sewage backup or breakout or high static water level observed in the distribution box 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
` ► ;�
rr
44 .
151
I�
revised 9/2/98 Page 2ofII
e
I
SUBSURFACE SEWAGE,DISPOSAL SYSTEM INSPECTION_ FORM
PART A .
CERTIFICATION (continued)
h Property Address: 139 Brentwood Lane, Cununaquid, MA .
Owner: Michael Fein
Date of Inspection: March 5, 1999
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:.
_ Conditions exist which require further evaluation by the Board of Health in order to detemrine if the system is failing to protect the,
public health, safety and 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 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 ANY)DETERMINES
THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND"
THE ENVIRONMENT:
The system has a septic tank and soil absorption system(SAS)and the SAS 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 the SAS.is within a Zone 1 of a public water supply well. A
_ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.,
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from at,
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. Method used to determine distance (approximation not valid). ,
3) OTHER
revised 9/2/98 Page 3of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
.PART A
CERTIFICATION (continued)
Property Address: 139 Brentwood Lane, Cununaquid, MA
Owner: Michael Fein
Date of Inspection: March 5, 1999
D. SYSTEM FAILS:
You must indicate either "Yes" or"No" as to each of the following:
_ I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this
determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
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 box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or available volume is less than'/z day flow.
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 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. If the well has been analyzed to be acceptable,attach copy of well water analysis for
coliform bacteria, volatile organic compounds,ammonia nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAILS:
You must indicate either"Yes" or"No" as to each of the following:
The following criteria apply to large systems in addition to the criteria 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:
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
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Department for further information.
revised 9/2/98 Page 4ofII
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B,
CHECKLIST
Property Address: 139 Brentwood Lane, Cununaquid, MA
Owner: Michael Fein
Date of Inspection: March S, 1999 ,
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:' p
Yes No
✓ _ Pumping information was provided by the owner, occupant, or Board:of Health. '
✓ _ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow '
rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
inspection.
✓ _ 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.
✓ _ The system does not receive non-sanitary of industrial waste flow.
✓ _ The site was inspected for signs of breakout.
✓ v All system components,excluding the Soil Absorption System,have been located on the site.:.
✓ s The septic tank manholes were uncovered,opened, and the interior of the septic tank was inspected for conditions"of baffles
or tees,material of construction,dimensions,depth of liquid,depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on:
✓ _ Existing information. For example,Plan at B.O.H.
✓ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)
[15.302(3)(b)].
,
✓ _ The facility owner(and.occupants,if different from owner)were provided with information on the proper maintenance of
SubSurface Disposal Systems.
revised 9/2/98 u Page 5oftt
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 139 Brentwood Lane, Cummaquid, MA
Owner: Michael Fein
Date of Inspection: March 5, 1999
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 110 g.p.d./bedroom.
Number of bedrooms(design): 4 Number of bedrooms(actual): 4
Total DESIGN flow n/a
Number of current residents: n/a
Garbage grinder(yes or no): No
Laundry(separate system) (yes or no): No ; If yes, separate inspection required
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings, if available(last two yearg,usage(gpd): 1998;15 000 gals.• 1997-52,000 gals.
Sump Pump(yes or no): No
Last date of occupancy: Unknown
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow: Qvd(Based on 15.203)
Basis of design flow
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 RECORDS and source of information:
None on file per treatment plant. -
System pumped as part of inspection(yes or no): No
If yes,volume pumped: gallons
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)
I/A Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components,date installed(if known)and source of information: June 1989-per as built card.
Sewage odors detected when arriving at the site: (yes or no) No
revised 9/2/98 Page 6of11
I
SUBSURFACE SEWAGE, DISPOSAL"SYSTEM INSPECTION FORM
PART,C
SYSTEM„INFORMATION (continued)' `
r
Property Address: 139 Brentwood Lane, Cununaquid,AMA
Owner: Michael Fein M
Date of Inspection: March S, 1999
,
BUILDING SEWER:
(Locate on site plan)
Depth below grade: • Y
Material of construction: —cast iron —40 PVC other(explain) =-
Distance from private water supply well or suction line
Diameter
,sr
Comments: (condition of joints, venting,evidence of leakage, etc)
SEPTIC TANK: ✓
Y
(locate on site plan)
Depth below grade: 4'
Material of construction: ✓concrete °metal Fiberglass Polyethylene —other(explain)
If tank is metal, list age_ Is age confirmed by Certificate of Compliance_(Yes/No)
Dimensions: 10'6" x 5'8" x 5'8" 11500gal.)
Sludge depth: 1
Distance from top of sludge to bottom of outlet tee or.baffle '�28 "
Scum thickness: 1
Distance from top of scum to top of outlet tee or baffle: 10""='
Distance from bottom of scum to bottom of outlet tee or baffle:., 12" � '
How dimensions were determined: Measuring stick
Comments: _ `" <• '- . � �.:, ,
h�
,..
(recommendation for pumping, condition of inlet and outlet tees'or baffles,depth of H4 _id level in relation to outlet invert,structural integrity,' ' • ',"
evidence of leakage,etc.) The tees were present. The liquid level was'even with the outlet invert. There were no signs of leakage. `
GREASE TRAP: None "` #
(locate on site plan)
�. F'
r a
Depth below grade: 'F r
s.F
Material of construction: —concrete metal Fii;&dasg,_Polyethylene other(explain)
a :
q 4F`
Dimensions:
Scum thickness: A,
Distance from top of scum to top of outlet tee or baffle: IM
Distance from bottom of scum to bottom of outlet tee or;baffle:
Date of last pumping: _ ¢r
Comments., a �,4 ak A. 3
(recommendation for pumping,condition of inlet and otitlet tees`or baffles; depth of liquid level in relation to outlet�mvert, structural integnty:
evidence of leakage, etc.)
�&u
revised 9/2/98 Page 7of 11
P ,
,�;.
,I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 139 Brentwood Lane, Cunvnaquid,MA
Owner: Michael Fein
Date of Inspection: March 5, 1999
TIGHT OR HOLDING TANK: None (Tank must be pumped prior to, or 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/day
Alarm present:
Alarm level: Alarm in working order: Yes_ No_
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches,etc.)
DISTRIBUTION BOX: ✓
(locate on site plan)
Depth of liquid level above outlet invert: 0° (even)
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.)' The box was level and there
were no signs of solids
PUMP CHAMBER: None
(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.)
revised 9/2/98 Page 8ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR_ M
PART C
SYSTEM INFORMATION (continued)
Property Address: 139 Brentwood Lane; Cummaquid, MA
Owner: Michael Fein
Date of Inspection: March S, 1999 ,
SOIL ABSORPTION SYSTEM(SAS): ✓
(locate on site plan, if possible; excavation not required, location may be approximated by non-intrusive methods)
If not located,explain:
t
Type:
leaching pits,number: 2-1000 gal. w/3'stone-per desi_Zn plans
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions: j
overflow cesspool,number:
Alternative system
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation, etc.) -
An asphalt driveway covered the pits and the pits were unaccessible:
CESSPOOLS: None
(locate on site plan) A
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(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: None "
(locate on site plan)
m
Materials of construction: Dimensions:.
Depth of solids:
Comments:
(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation,°etc.)
revised 9/2/98 Page 9of11 '
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 139 Brentwood Lane, Cummaquid, MA
Owner: Michael Fein
Date of Inspection: March 5, 1999
Map: 333
Parcel: 003
Lot: 4
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
/ FeonT '
Qae�
1 I�
as
.20
aye T
W4/1
lao /
revised 9/2/98 Page 10of11
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 139 Brentwood Lane, Cununaquid, MA .h
Owner: Michael Fein
Date of Inspection: March S, 1999
NRCS Report name
Soil Type
Typical depth to groundwater
USGS Date website visited ,
Observation Wells checked
Groundwater depth: Shallow Moderate Deep
SITE EXAM Slope
Surface water
Check Cellar '
Shallow wells '
Estimated Depth to Groundwater Feet
Please indicate all the methods used to determine Higli Groundwater Elevation:
— Obtained from Design Plans on record
— Observed Site(Abutting property,observation hole,basement sump etc. F
) - .
Determined from local conditions
✓ Checked with local Board of Health
Checked FEMA Maps
Checked pumping records
Check local excavators, installers w
✓ Used USGS Data '
r
Describe how you established the High Groundwater Elevation. (Must be completed)
Using the Barnstable water contours and topographic maps, the maps were showing approximately 115'to groundwater at
this site.
. R
This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a.warranty
or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed,
written,or implied, relating to the system, the inspection'and/or this report '
revised' 9/2/98 Page llofll
L
J
J TOWN OF BARNSTABLE °
LOCATION__
VI.LLAGIA � ASSESSOR.'S MAP & LOT_
INSTALLER'S NAME & PHONE NO.&, ptap
r
SEPTIC TANK CAPACITY 1.900
LEACHING FACILITY:(type.) (si�P�1l/GYJe �3:sivv�l
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER�Z/e>
BUILDER OR OWNERr� '�/�
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED_
VARIANCE GRANTED: Yes/ � �—AIo
0
f
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
�... pliliration for Dispati al Marks Toustrurtion rrmit
r .--- ,Application is hereby made for a Permit to Construct (✓r or Repair ( ) an Individual Sewage Disposal
Location-Address or Lot No.
................................................. ........•-----.........._-•.....-•----...._._.._._....----•-•----••-••--......•----•-••--•---•----
Owner Address
W
Installer Address
U Type of Building ,�,,AA Size Lot. -----Sq. feet
Dwelling—No. of Bedrooms..............4......................... Attic ( ) Garbage Grinder ( )
aOther—Type
of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
d Other fixtures -----------------------------------•------------•-----------:.1..------•---•-----••-------------_
W Design Flow.............-.6-3.......—
.. ..................... per person per day. Total daily flow.............................................gallons.
WSeptic Tank—Liquid capacity lra..gallons Length/eJ `'-_, Width.4.' '. Diameter________________ Depth.7:`�7�
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area--------------------sq. ft.
Seepage Pit No--------------------- Diameter....__.! '.... Depth below inlet.............. Total leaching area..15Z 9..sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by..... ...�s...._ � ......... Date...!4,9 5 ..
W
Test Pit No. 1..G.,�__.minutes per inch Depth of Test Pit..� y._._ Depth to ground water...'^_____________
f3, Test Pit No. 2...G¢...minutes per inch Depth of Test Pit_._-":5...."..... Depth to ground water.___------____-_--___.
-------------••-••-----•-•-------------•-------•....---------•....-----....---------........._-••----•••••-•----............----•-------. ----------
O Description of Soil........a`-._3a -__li✓O"V&,VV KS'vC'-Sai�---------•-'3° -/,J '•...............................................................' `
x
W
UNature of Repairs or Alterations—Answer when applicable_______________________________________________________________________________________________
---------------------------------------------------------------------------------------------•-------------•----•-••-----------------•-•--------•-••--------••--•••--•••----•-------•---•-•----•----•••.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iIT:.:L 5 of the State Sanitary Code—The undersigrfifurther agrees not to place the system in
operation until a Certificate ofZZ
as be i su by the oard health
b
d.-----•-- ..
................................
A Application Approved B D
PP PP Y ------------- ------ --•...---------------------......_-------- ••--.----6 ..........
at
Application Disapproved for the following reasons:...............................................................................................................
..............•--•-----------•-----------------......--------....------------------------....----------.....-•-•--------•-----......--------------•------------•--•-----------------...................
Date
PermitNo..... ._2_73............................ Issued.......................................................
Date
�O....e-.c.---d..KJ Fin$.............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..................r�r✓�/ .....OF......----------------
Appliration for Disposal Works Tunitrurtiun Vrrutit
Application is hereby made for a Permit to Construct ( v)'-or Repair ( ) an Individual Sewage Disposal
System at:
...... . ....... .... .....----•..............•-----...-•4.7
-- ...------••-•-•-•..........---------......
Location-Address or Lot No.
Owner Address
W
Installer Address
dType of Building Size Lot._`' g --...Sq. feet
U Dwelling—No. of Bedrooms...............`........................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
a Other fixtures ............................................
W
Design Flow.............. ....._.._._............gallons per person per day. Total daily flow............................................'� ' gallons.
WSeptic Tank—Liquid capacity_/_ -P.C?.gallons Length./?:!�-'-/... Width._-.,1'.S?:r. Diameter---------------- Depth__4__/Z''-.
x Disposal Trench—No.................. . Width.....................Total Length.................... Total leaching area__-____•--..._--_-sq. ft.
Seepage Pit No........2---------- Diameter.......ZZ....... Depth below inlet........ ......... Total leaching area...G �"G._sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
`-' Percolation Test Results Performed by......4Zk^l % ......L._....... Y......... Date-__---- 'Pl
,aa Test Pit No. 1---4._�_ri'inutes per inch Depth of -Test Pit___/ ``__.. Depth to ground water_-_--_---_--_-_.
w Test Pit.No. 2....i5��.'..minutes per inch Depth of Test Pit.... ....... Depth to ground water------------------------
P4 -------------------------------------------------- ---------••-----------------------------
---------------------------------------------------------
O Description of Soil---------a I-- -70 k 11,ia�C��/.!r-i. � 5��-_so.,- 3n`"1J�,. �7�i>.. SA P
U --•---------------•---••••••-----•-•.........--••-•••------•---•••-•••---•...••-••--•-------------•--•---•--••--•-•-•-•-•-----••-•--•••-••-----•---••••-•---------••--•----•-•---•----•-•......--••-
W
U Nature of Repairs;/or Alterations—Answer when applicable................................................................................................
r
--___...-•..................::..................................................................................•.•-----••-•----•----•------•-••------.........._.......--••-•----__....................
Agreement
i The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
t•1:IE--�
the provision TT:
s of 'T 5 of the State Sanitary Code—The undersign further agrees not to place the system in
operation,-:until a Certificate of Compliance has bee su t by the board health.
2' Signed-•-- ......... . •. ...... � /-------• ---•-•.
/ �%� DF.
Application Approved By---••----•• �= f'9 .•-- '-- ---- ------....� l-r �
Application Disapproved for the following reasons------------------------------------------------------------------------------------------ ---------------•-----
--•-•-•-------------------------------•-•----•--•-•-•••-•-•--......-•---•••---••........-•-••-•---•-•••-••••--•••--•••--•••••---•••------------•-----•--••-----------•------•-••-------•--------•--•--•-
Date
PermitNo.......��`�- --------------------------- Issued_.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
i
BOARD OF HEALTH
................7D X!!1.:�........OF...... ' Tie4&...................................
Trrtif iratr of Tnm pliFanrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( 4e<or Repaired ( )
by............j f./eq..a t�..����-s)-.....................................................................................................................................................
i Installer
at � ¢`� (Jt frJ D� L/{ry l ..._. _C�f_ l2 _l.D
has been installed in accordance with the provisions of TITIE 5 of he State Sanitary Lode as described in the
application for Disposal Works Construction Permit No.__.f :�'�................. dated_...�� ��? --_-----_--__--------_
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE1 ARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. 0
DATE...... •--....•---.....----•-•-•---.... Inspector •••--- ez% oL -C� ..�...........
77_� . .....:....... -
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
7 L,�,�✓.......0F.........'
of�.�� ..................... .....................--•--........
No..... i�l FEE......?�
Disposal Works Tonstrudinn rruti#
Permissionis hereby granted..............................................................................................................................................
to Construct ( L ror Repair ( ) an Individual Sewage Disposal System
at No...... -----
Street
as shown on the application for Disposal Works Construction Permit No.....�?s6�.-i&Dated------�/f�/-I ..............
•........................•--..... v...,. ---•-. f .
p -------•---•---•............................... oard of I*
DATE.-----b--�3��-f---
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
D
3
TOP OF FOUNDATION - � �•Sa � �
CONCRETE COVER
A. CONCRETE COVERS
o
E�
CAST IRON 12 MAX.
12"MAX, � \
ap
OR SCHEDULE 40
P.V.C. 4"SCHEDULE 40 P.VC.(ONLY)
PIPE
o P
LEACH 1 \
PITCH 1/4"PER. PIPE MIN.
PITCH I/4 PER.FT. PIT o PRECAST \
1
INVERT o a LEACHING
,o EL... •�/-Zo INVERT INVERT o . w o.: PIT OR
SEPTIC TANK DIST. EQUIV. ` �3L
a 3 7 /33,4Is :•: / /
EL. ....'. . .
,•o INVERT /.Soo BOX EL........- :: ,F-•F-- 0: t'• $'� � LoT �'¢ I
/ GAL. INVERT c>n 8 3/4'�T0 1 l/2
o; EL..-3�.7Z. /33S f/-2-c, INVERT w w V•
o e EL0 \: WASHED
' lat.
w STONE
'
I
PROFI LE OF GROUND WATER TABLE ` / / 0r, 10
SEWAGE DISPOSAL SYSTEM \ / -10Q00
�a ► D�
NO SCALE ro/� / / !, N^
�— 7Z -7� PLAN 1 ,� ° o
SOIL LOG WITNESSED BY :
�
DATE .A�.¢!G ./y8� TIP,1 :�-70/ :/INN/!-!G BOARD OF HEALTH t 1p / Pr' 03 �
TEST HOLE I TEST HOLE 2 / \ N V,�i`G7� /R. �' �.�?Ley. ENGINEER N
ELEV. .0 Zo. . ELEV.
7�tl
.�90' B-Sp�C. jai) , S�`,s Soi C- DESIGN DATA _ �2• �' � � �� �� f
Ez.�s/7o Wit. is/.90 ) \ �� -•�- ' �a
NUMBER OF BEDROOMS V+ 7-Mr ;
Pont. s i� \ / \ �� /-/PcE II
Ssv-&s TOTAL ESTIMATED FLOW ��''rb GALLONS/DAY �� s/
7z" A-Z I28.Zo BOTTOM LEACHI NG AREA >/3, /o SO.FT. /PIT�G,p77• / ,� / �� /
S6��D SIDE LEACHING AREA . . . 2z�• 7r0 SQ.FT./ PIT 4-6Z- ��� i \ '� 1 �1 ' ��Je �/
/7eA./ /a.P. D. \� \ \ 0 1 i9�. . /
Awc GARBAGE DISPOSAL NoN6 - .(50% AREA INCREASE) 4k, \ .\
Si�r/D TOTAL LEACHING AREA . . 678,�+. . SQ.FT \ ^i \ \�e�� P°
gC
PERCOLATION 42zz.zo RATE LS. �?`! Fa'!��. MIN/INCH
144- 1 is i 2
EZ. Z/-`/o
i
Z / Rio,
LEACHING AREA PER PERCOLATION RATE ./.o.g . . . SQ.FT. 6:P .D
.No. .WgTER ENCOUNTERED �i
NUMBER OF LEACHING PITS ^/� .P� .�lT'� . 8_,� \ �'�' �/ \ - led..
APPROVED . . . . . . BOARD OF HEALTH ;It
DATE . . . . . . . . . .
AGENT
OR INSPECTOR a \
�TH Of
Lo7
o EILLEY o p _ R
'
2�7V7-/A/0o D Z~,!E %0. 2E100
• SANRAR�IJ�
•� PETITIONER � . . .`E7N . . . JJ "he4n