HomeMy WebLinkAbout0029 COACH LANE - Health 29 COACH LANE, BARNSTABLE
A=298 073
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TOWN OF BARNSTABLE
LOCATION C,@&, 11 SEWAGE #� S so
VILLAGE ASSESSOR'S MAP& LOT 2� — 3
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
'LEACHING FACILITY: (type) Y" (size)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMUDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and 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 b / ,(,J • t mow. S as
c�c.,�„
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L �u-`��'e S�`n
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3�
f �' �� /
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lbNo. � Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
ftpliLation for -MispoBaf opstem Construction permit
Application for a Permit to Construct( ) Repair X Upgrade( ) Abandon( ) ❑Complete System ,X Individual Components
Location Address or Lot No. a9 OoAeN LAAji✓ t341w. Owner's Name,Address,a�Ll A0.
BRUC,G t_0 rG
Assessor's Map/Parcel 019$ /Q?3 25CO &e 13 M
Installer's Name,Address,and Tel.No.508-477—88`7�1 Designer's Name,Address,and Tel.No.
CAPGusc'DG GW7-�Q►s�S l-.C.0 W A I1A
! . J✓j.4944oE2—:r
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures 1-4
Design Flow(min.required) rV gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Signetoef Date �` "
Application Approved by Date —(0 J0
Application Disapproved by Date
for the following reasons
Permit No. i5ld Date Issued (i6
No. Fee
THE COMMONWLtAL'TH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
application for ;Disposal *pstem Construction Permit
Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) ❑Complete System ,N Individual Components
Location Address or Lot No. a9 (2vQGt4 LAA.#F BA,-jw, Owner's Name,Address,and Tel.No.
Map/Parcel , BRuGG LOVG14L1V
Assessor's Ma
p a9 8 /o-t 3 -Z9 Co L.4A)g
Installer's Name,Address,and Tel.No. $Q$—477 a89-71 Designer's Name,Address,and Tel.No.
CA P6w,,D G
153 QQWU64 jq.t,S_r Mg614062Z
Type of Building:
Dwelling No.of Bedrooms F Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures 44
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title /•
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) AJ6 Ci Hi4��',,
3
L
Date last inspected:
Agreement:
The undersigned agrees to ensure:the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Signed Date
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. b( Date Issued ) —(0 v��
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance "
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( Upgraded ¢ ,
Abandoned( )by (2AV15U-4qr= C AJ76AAMSES LLC-.
n
at ,X 9 (I oAchf �•i�]V� ,.(�"j�Q�1�JS Z'f gG� -has been constructed in accordance ram,
with the provisions of Title 5 and thefor Disposal System Construction Permit No.aC4b`� dated
,
Installer 0105CCAD6 ENT02F126SS�; U C— Designer N 4
#bedrooms Approved design flow and
The issuance of this perAiit sh 11 not be construed as a guarantee that the system wi fun ti` as designed.
Date Inspector V ,- A n ,
------------------------------------------------------------------------ ---------------------------------------------------J--------------
No. �G( � 514 Fee l 5
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Bisposal 6pstem Construction permit
Permission is hereby granted to Construct( ) Repair
Upgrade( ) Abandon( )
System located at O�q �pr¢Gt-f &,4&),�
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions. —
Provided:Construction must be completedwithin three years of the date of this permit.
Date J`�G K� Approved by
AsBuilt - Page 1 of 1
TOWN OF BARNSTABLE
LOCATION QSEWAGE# S,o .
VILLAGE ASSESSOR'S MAP&LOT `l 9_7 3
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY f U U 0
LEACHING FACILrrY:(type)-- �' )� (size)
NO.OF BEDROOMS
�_
BUILDER OR OWNER
PERMTTDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and 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 b<-, t.(.w. a�
' r
y.
lro
LJ
http://issgl2/intranet/propdata/prebuilt.aspx?mappar=298073&seq=1 5/13/2016
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 29 Coach Lane
Property Address
Bruce Loughlin
Owner Owner's Name
information is Bar stable required for every MA 02630 5-13-16 N
page. City/Town State Zip Code Date of Inspection :4B
V7
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.
Im :when A General Information
fillingng out out forms A. a
orms /w& `��ptunuiuN���
on the computer, / ���"���1.ZN OF M4,,i,
use onlythe tab ��� �`••• S���i
1. Inspector: �.� .•• ;9p
key to move your 4 -
cursor : • y
-do not James D.Sears �:• JAMES ..:m
use the return Name of Inspector
key. Jim The Inspector Man
s �'•' �' ��N,.
�y Company Name .�," `�77.....*
P.O.Box 784 °NSF 5�I N S?*- 0���\
Company Address
West Yarmouth MA 02673
City/Town State Zip Code
508-364-4398 S 1623
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
Leos 5-13-16
spector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
�0�gtw
4 Commonwealth of Massachusetts
. Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
29 Coach Lane
Property Address
Bruce Loughlin
Owner Owner's Name
information is required for every Barnstable MA 02630 5-13-16
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 system is a 1000 Gal. Tank and pit.
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
G v Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,.•''- 29 Coach Lane
Property Address
Bruce Loughlin
Owner Owner's Name
information is required for every Barnstable MA 02630 5-13-16
page. City/Town 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
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
'~ 29 Coach Lane
Property Address
Bruce Loughlin
Owner Owner's Name
information is required for every Barnstable MA 02630 5-13-16
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
functioning in a manner that protects the public health
determines that the system is
Y p
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance;
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
El ❑ Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in 91118W is less than 6" below invert or available volume is less
than '/2 day flow ei-r
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 29 Coach Lane
Property Address
Bruce Loughlin
Owner Owner's Name
information is required for every Barnstable MA 02630 5-13-16
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.
❑ ® 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 16,000 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
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
29 Coach Lane
(Property Address
Bruce Loughlin
Owner Owner's Name
information is required for every Barnstable MA 02630 5-13-16
page. City/Town 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): NA Number of bedrooms(actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
u Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
29 Coach Lane
Property Address
Bruce Loughlin
Owner Owner's Name
information is required for every Barnstable MA 02630 5-13-16
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
The system is a 1000 Gal. Tank and pit.
Number of current residents: 1
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 ears usage d na
9 ( Y 9 (gP ))�
Detail:
Sump pump? ❑ Yes ® No
Present
Last date of occupancy: 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
w W Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
29 Coach Lane
Property Address
Bruce Loughlin
Owner Owner's Name
information is Barnstable MA 02630 5-13-16
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
NA
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:
I
Type of System:
® Septic tank, VS29=012=11 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 29 Coach Lane
Property Address
Bruce Loughlin
Owner Owner's Name
information is required for every Barnstable MA 02630 5-13-16
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
NA
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 30"
feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Pipeing is 4" PVC SCH 40.
Septic Tank(locate on site plan):
Depth below grade: 20"
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: 1000 Gal. Precast H-10
Sludge depth:
1"
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
u u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
29 Coach Lane
Property Address
Bruce Loughlin
Owner Owner's Name
information is required for every Barnstable MA 02630 5-13-16
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
29"
0"
Scum thickness
Distance from top of scum to top of outlet tee or baffle,
8"
Distance from bottom of scum to bottom of outlet tee or baffle
18"
How were dimensions determined? Asbuilt-Tape
Sludge Judge
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank at working level. Tank and outlet cover at 20" below grade w/inlet cover at 2". In and
outlet tee's No sign of leakage or over loading
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
W Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
'Y 29 Coach Lane
Property Address
Bruce Loughlin
Owner Owner's Name
information is required for every Barnstable MA 02630 5-13-16
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
.rz Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
29 Coach Lane
Property Address
Bruce Loughlin
Owner Owner's Name
information is Barnstable MA' 02630 5-13-16
required for every
page.e. CityrFown 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
No Box.
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.):
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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
w v Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Y
29 Coach Lane
Property Address
Bruce Loughlin
Owner Owner's Name
information is Barnstable MA 02630 5-13-16
required for every
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1
❑ 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.):
Leaching is a 1000 Gal. precast pit. Pit and cover at 26" below grade. 1'water in pit w/stain line
at 30" No sign of over loading or solid carry over. No high stain line.
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•3113 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
29 Coach Lane
Property Address
Bruce Loughlin
Owner Owner's Name
information is required for every Barnstable MA 02630 5-13-16
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
t
29 Coach Lane
Property Address
Bruce Loughlin
Owner Owner's Name
information is Barnstable
required for every MA 02630 5-13-16
page. City/Town 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
th n 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
Brick
A n
�A �
IQ�1 y 0 0
C
r
'06
O
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
29 Coach Lane
Property Address
Bruce Loughlin
Owner Owner's Name
information is required for every Barnstable MA 02630 5-13-16
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
® 13'+
Estimated depth to high ground water: 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:
Past report 7-8-98 no G.W. at 13'. Lot High no G.W.problem seen.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
29 Coach Lane
Property Address
Bruce Loughlin
Owner Owner's Name
information is required for every Barnstable MA 02630 5-13-16
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
A - 27�5'
TROY WILLIAMS
SEPTIC INSPECTIONS
Certified by MA Department of Environmental Protection (508) 385-1300
19 Hummel Drive
South Dennis, MA 02660
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFF - COPY
r DEPARTMENT OF ENVIRONMENTAL P
ONE HINTER STREET. BOSTON, MA 02108 617- 0
ticv v�
WILLIA
GovcmoM F.WELD tAy yy0� 0 UDY CORE
OSccrctan-
ARGEO PAUL CELLUCCI FA
fc� �VI B.STRUHS
Lt.Govcmor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPE 'I', FORM f�� �� �' Commissioner
PART A
CERTIFICATION
Property Address: g v�� �^r^• &rH spa 6 jc Address of Owner: y Z v br i ., 5 k i
Date of Inspection: 7�8 �I 8 (If different)
Name of Inspector: T r 0y W i 11 i am s
1 am a DEP approved"em inspector pursuant to Section 1S.340 of Title S (310 CMR 1S.000) J
Company Name: Troy .Williams Septic Inspections
MailingAddress: 19 Hummel Drive , South Dennis , MA 02660 c.Zi ��
Telephone Number: (5 0 8) 38 5-13 0 0 S
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 Evaluation By the Local Approving Authority
_ Fails
Inspector's Signature Date: $
The System Inspector shall submit a copy of this inspection report to the Approving Authority 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.
INSPECTION SUMMARY: Check A, 8, C, or D:
Aj SYSTEM PASSES:
I 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.
COMMENTS: '
Bj SYSTEM CONDITIONALLY PASSES: I 11
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 rnetal, is cracked, structurally unsound, shows substantial infiltration or exftltration,or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced whh a conforming septic tank
as approved by the Board of Health.
(—i—d 04/25/97) 7.q• 1 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
(
29 Coach Lane,Barnstable,MA CERTIFICATION continued)
Property Address: Eugene Zubrinski
Owner: July 8, 1998
Date of Inspection:
BI SYSTEM CONDITIONALLY PASSES (continued) /v//9.
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). Describe observations:
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
CI FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: A/1A
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 THAY
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 I of a public water supply well.
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 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. Method used to determine distance (approximation not valid).
3) OTHER
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 29 Coach Lane,Barnstable,MA
Owner: Eugene Zubrinsld
Date of Inspection: July 8, 1998
DJ SYSTEM FAILS: IV1
You must indicate ei;,.er "Yes" or "No" as to each of the following:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303' The basis
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
Yes No
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 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 front 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.
El LARGE SYSTEM FAILS: All/
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 heallth 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 bring the system and facility into full compliance with the groundwater treatmentiprogram
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(r—vial 04/25 91) ,
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
29 Coach Lane,Barnstable,MA
Property Address: Eugene Zubrinsld
Owner: July 8, 1998
Dale of Inspection:
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes i 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.
N10 As built plans have been obtained and examined. Note if they are not available with N/A.
�L = The facility or dwelling was inspected for signs of sewage back-up.
_ The system does not receive non-sanitary or industrial waste flow.
_ The site was inspected for signs of breakout.
/ _ All system components, excluding the Soil Absorption System, have been located on the site.
�L _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of
baffles or tees, material-of construction, dimensions, depth.of liquid, depth.of sludge,depth of scum.
—The size and location of the Soil Absorption System on the site has been determined based on:
The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of
Sub-Surface Disposal System.
/L(q Existing information. Ex. 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)]
(—iud 04/25/97)
L -
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 29 Coach Lane,Barnstable,MA
Owner: Eugene Zubrinsld
Date of Inspection: July 8, 1998
RESIDENTIAL: FLOW CONDITIONS
Design flow: 306 P.d./bedroom for S.A.S.
Number of bedrooms::
Number of current residents:
Garbage grinder (yes or no):_"
Laundry connected to system (yes or no): YES
Seasonal use (yes or no): NO
Water meter readings, if available (last two (2) year usage (gpd): _97 78 = aZ� �oO �4�( S cj C „Z6 vo 0
Sump Pump (yes or no): NO /
Last date of occupancy:,«—•.+`ore .� .
COMMERCIAUINDUSTRIAL• A/(//
Type of establishment:
Design flow: aallons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non-sanitary waste discharged to the Title S 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:
7.�W%.C- a3 V8 L, Ia
System pumped s Pan of insFje ction: (yes or no)�(O
If yes, volume pumped:
gallons
Reason for pumping:
TV7F SYSTEM
Septic tan Wd404yeSea-bWsoiI absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
VA Technology etc. Copy of up to date contract?
Other.
APPROXIMATE AGE of all components, date installed (if known) and source.of information:
% � Cr
Sewage odors detected when arriving at the site: (yes or no) /fib ;
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 29 Coach Lane,Barnstable,MA
Owner: Eugene ZuMnsld
Date of Inspection: July 8, 1998
BUILDING SEWER: /V 119
(locate on site plan)
Depth below grade:
Material of construction: _cast iron_40 PVC _other (explain)
Distance from private water supply well or suction line
Diameter
Comments: (condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK:
(locate on site plan)
Depth below grader
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:_ ,5 "�r 2 lx% �obo Sc4 /��•�.
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness:
Distance from top of scum to top of outlet tee or.baffle: ,yo S C-'�
Distance from bottom of scum to bottom of outlet tee or baffle:A& 3
How dimensions were determined:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in elation to outlet invert tructural
integrity, evidence of leakage, etc.) LIL c r n /c 4:� dl o✓�-��
�rL. N _ 1 GL� v-1 �•L. � ri•- � �
GREASE TRAP: /4
(locate on site plan)
Depth below grade:
Material of construction: _concrete_metal _Fiberglass _Polyethylene —Other(explain) .
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments: t
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid
integrity, evidence of lea P q d level in relation to outlet in structural
leakage, etc.)
(r.vis.d 04/25/97) a _
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 29 Coach Lane,Barnstable,MA
Owner: Eugene Zubrinsld
Date of Inspection: July 8, 1998
TIGHT OR HOLDING TANK:A//(Tank must be pumped prior to, or at time, of inspection)
(locate on site pVan)
Depth below grade:
Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
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: `—
Comments: CC
(note if level and distribution is equal, evidence of solids carry/over, evidence of akage into or out of box, etc.)_ ✓h
: r r ".oP "I N U Sl \ u
v L, GL►-`f—
PUMP CHAMBER:-- //4
(locate on site plan)
Pumps in working order: (Yes or No)
Alamo in working order(Yes or No)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(rwia.d 04/7S/97i ~ -
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 29 Coach Lane,Barnstable,MA
Owner: Eugene Zubrinski
Date of Inspection:July 8) 1998
SOIL ABSORPTION SYSTEM (SAS):z
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type:
leaching pits, number:/.,L b �!; Le--
leaching chambers, number:_
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions;
overflow cesspool, number: '
Alternative system:
Name of Technology:
Comments:
(no a cpndition of soil, si ns of hydr ulic fa i ure, level of ponding, condition of vegetation, etc.)
G/C+ k G •� � / r t a i.•� W / G,l � 4 T tv
CESSPOOLS: �1//i�f
(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(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 on site plan)
Materials of construction:
Depth of solids:
Dimensions:
Comments: t
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revl..d 04/25/97) Page 0 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 29 Coach Lane,Barnstable,MA
Owner: . Eugene Zubrinski
Date of Inspection: July 8, 1998
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water Supply comes into house)
6
qLw //o•,
1
14
(ravia.ad 04/25/97) Pao. 9 or 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 29 Coach Lane,Barnstable,MA
Owner: Eugene Zubrinski
Date of Inspection: July 8, 1998
Depth to Groundwater - Feet ndjuAcd high groundwater level
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observation of Site (Abutting property, observation hole, basement sump etc.)
IDetermine it from local conditions
Check with local Board of health
Check FEMA Maps
Check pumping records
Check local excavators, installers
Use USGS Data
Describe in your own words how you established the High Groundwater Elevation. Must be completed) a:•; -.
1.-�r"'t,� � r /o �w�c �J► �-� �:�C,`.. S vt�v�.,J �-+. ell .
S �a�d�.�` �d (✓w f�.� pur.� (�L�f'D1�, o!� /LE�.c �. 5
a+1 CJ` h o C_K C.C/� / h [�. S 4 v�o.�+-�cQ t��+' - ✓�
In L G.J Yaw f-.c A t C J v `•
J�.a L r�,., t �.�. `o v s f JS
cam-.-. S i^
z'
ev4.� a �ja..s. v� 5 yS
No.__/13. ' F�$a....ay...........
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH_
® � ........-OF.....! 19.1 7/9yJLi
�( Appliration for Miposal Works Tatotrurtivn Urrutit
Application is hereby made for a Permit to Construct (k() or Repair ( ) an Individual Sewage Disposal
Syst at
70
atio._.._ddr s / or Lot No. j
Owner Address
111C.U/------ -
Ins al r Address
Q Type of Building F2�-,..�.�— Size Lot_I.I.S. ........Sq. feet
U Dwelling—No. of Bedroom(__. ______________________________Expansion Attic ( ) Garbage Grinder ( )
`4 Other—Type of Building No. of persons............................. Showers — Cafeteria
Otherfixtures ......................................................----------...---...------.....---------------------------------------------•-------------.-----
W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons.
WSeptic Tank—Liquid capa�cityOgq_gallons Length________________ Width-----------..--. Diameter---------------- Depth-.----_-__---._
x Disposal Trench—No. ��_____. W th.................... Total Length.................... Total leaching area--------------------sq. ft.
Seepage Pit No.,/l�00.__.*Aameter.................... Depth below inlet............_------- Total leaching area------------------sq. ft.
z Other Distribution box ) Dosing tank ( )
Percolation Test Results Performed
a by--------------------------------------------------------------........... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water---..--.-_--____-------.
f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.--_--_---__-_-___-_-.-.
---------------------------------------------------------------------------------------------------..........................................................
0 Description of Soil-------- .
------------ -------------------------------------------------------------------------------------------------------------------------------------------
U ----------------•--------------------------------------------------------------•--••---------------------------•-•------------------------------------------••--------------------------.......---------
W
---------------------------------------------------------------------------•---------------------------------------- _._.....-------------------•----....----------------------------------------------
U Nature of Repairs or Alterations—Answer when applicable--------------------------------.-_-____---_____-_-_----_---_-._--_.-_-_-----------_--___-_-.--.
------------------------------------------------------------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issu d by the oi
r of health.
i o
. ��� _Signed - ----------------------------------------- ----- -----D_ •----
�� Date'• - ---
Application Approved By C'. ..= _ 5--- --------
O Date
Application Disapproved for the following reasons-..............................................--------------------------------------------------------I---------
-------------------- •----------------:----•----------------•--------------------•-----------------
.� Date
PermitIVo. /..t .......................=-----•--•........ Issued.------ --------------- ...............
Date °
----------------------------
No.... .. Fxa't...... ...........
THECOMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..-.......OF.....•:. •..el �,..r(y.f.... ........................................
� ation for Ropmal Vorkii Tonstrnrtion Wrnfit
Application is hereby made for a Permit to Construct O or Repair ( ) an Individual Sewage Disposal
System at:
' ------------------
Location ddress � or Lot No
Installer Address
Type of Building ` Size Lot__ _ 8 _ Sq. feet
U 4_0 'r
Dwelling—No.`of Bedroo�..._ ,�_______________________________Expansion Attic ( ) agage Grinder ( )
aOther—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria. ( )
a' Other fixtures -------------------------------------------
d ---------------------------------------------------------------
W Design Flow............................................gallons per person per day. Total daily flow_______._.____._____..____.._._..•_._.._....gallons.
WSeptic Tank—Liquid capacity f gallons Length................ Width._...._...-.__._ Diameter____.._._..._... Depth_._____._-._.-..
x Disposal Trench—No. x .._. Width.................... Total Length--------------_..... Total leaching area--------------------sq. ft.
Seepage Pit No. ?,y'- Iiamtei ............... Depth below inlet___._._-____________ Total leaching area------------------sq. ft.
Z Other Distribution box f ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date----------- ------------------------....
aTest 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---_-------------------
P4 ----------------------------------------------------------•-----------------.................................................................................
0 Description of Soil__________________________
x
U .--'----------•-'--------------------- = =
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 Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the boar of health.
Signed-- .,2- =-----------------.........
�• Date
Application Approved BY ";�'° �° tr,� y •--- '°
Date yea
Application Disapproved f r the following reasons------------------------------------------------------------------------------------------------------------•-•-
---------- t------------
ae
Issued.------..Permit No. f' -- ------
-, Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.. ...
OF. .........................
Cnrdif iratr of Tout�rlittnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal 'System constructed ( )/or Repaired ( )
bY--------------------------------------------------------------- ------ -
J
Installer
ii; t •
at Fl F. � �- aF_ c _ `._.__...__ A t�_' x ..',;:4
has been installed in accordance with the provisions o£ Article XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No. .--'� ___________________________ dated.__. ,'_: .._ _ } .....................
,,..r%,
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARkkTEE THAT THE
SYSTEM WILL FUNCTION S TISFACTORY. '
DATE l " Inspector -------1......c .------- =
�b
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH--
No. ' ' "----------
Permission .is hereby granted-----------------
to Construct,(-:' ) or Repair ( ) an Individual Sewage Disposal System '
w tr'
Stree .. -x.-...-r-%#,•..--�••'.
as shown on the application for Disposal Works Construction P.ornlit Noy',� �- � �-- Dated_ ?l'fws
,.
o
''ter• _3� ____________________
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FORM 1255 #GOBBS &- WARREN. INC.. PUBLISHERS -