HomeMy WebLinkAbout0199 HARBOR POINT ROAD - Health id, Barnstable
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TOWN OF BARNSTABLE
LOCA'10N c l SEWAGE #
VILLAGE ASSESSOR'S MAP 6z LOT ,
INSTALLER'S NAME PHONE NO. A & B CANCO 775-6264
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) (size)
NO.OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u 199 Harbor Point Rd "
Property Address
Children of Haiti and Refugee Project
Owner Owner's Name
-u
information is :.a
required for every Cummaquid Ma 02637 4/22/19
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. Inspector Information Slit r 3 2
filling out forms
on the computer,
use only the tab Michael DiBuono
key to move your Name of Inspector
cursor-do not DiBuono Sewer And Drain
use the return Company Name
key.
35 Content Lane
Company Address
Cotuit Ma 02635
City/Town State Zip Code
508-364-9587 S113522
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ® Passes ~
2. ❑ Conditionally Passes R
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails ��
4/3/19
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 has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time.This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
199 Harbor Point Rd
Property Address
Children of Haiti and Refugee Project
Owner Owner's Name
information is uid Ma 02637 4/22/19 Cumma
required for every G
page. Citylrown State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
System contains a 1000 Gallon septic tank as well as a 1000 Gallon pump chamber and three flow
diffusers. Field was dry at time of inspection.
2) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
(/cis Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
4'
199 Harbor Point Rd
Property Address
Children of Haiti and Refugee Project
Owner Owner's Name
information is Cumma uid Ma 02637 4/22/19
required for every q
page. CitylTown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑-ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed • ❑ Y ❑ 'N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
la Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
199 Harbor Point Rd
Property Address
Children of Haiti and Refugee Project
Owner Owner's Name
required for
is every
Cumma uld
required for eve q Ma 02637 4/22/19
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
" This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
t5insp.doc-rev.712 612 01 8 P 9 P Y 9
Commonwealth of Massachusetts
Title 5 Official Inspection Form
is Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
199 Harbor Point Rd
Property Address
Children of Haiti and Refugee Project
Owner Owner's Name
information is required for every Cummaquid Ma 02637 4/22/19
page. Cityfrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/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 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.
El ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure,
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the'Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large-systems,,you must indicate either"yes" or"no"to each of the following,,in addition to the
questions in Section CA.
Yes No
i
❑ ❑ 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
l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
cam, Commonwealth of Massachusetts
,�.p Title 5 Official Inspection Form
to Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
199 Harbor Point Rd
Property Address
Children of Haiti and Refugee Project
Owner Owner's Name
information is
required for every Cumma quid
Ma 02637 4/22/19
page. Citylrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes"to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate "yes" or"no"for each of the following for all inspections:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
4l
199 Harbor Point Rd t
Property Address
Children of Haiti and Refugee Project
Owner Owner's Name
information is Cumma uid Ma 02637 4/22/19
required for every q
page. Cityrrown State Zip Code Date of Inspection .
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN.flow based on 310 CMR 15.203 (for example:•110 gpd x#of bedrooms): 330
Description:
Number of current residents: Vacant
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ 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 158 GPD
9 ( Y 9 (gP ))�
Detail:
Sump pump? - ❑ Yes ❑ . No
Last date of occupancy: Date
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
199 Harbor Point Rd
Property Address
Children of Haiti and Refugee Project
Owner Owner's Name
information is Cumma uid Ma 02637 4/22/19
required for every q
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: Not provided
Was system pumped as part of the inspection? ❑ Yes ❑ No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
199 Harbor Point Rd
Property Address
Children of Haiti and Refugee Project
Owner Owner's Name
information is required for every, Cummaquid Ma 02637 4/22/19
page. C'ityrrown State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
r .
Approximate age of all components, date installed (if known) and source of information:
4/7/86
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. -Building Sewer(locate on site plan):
Depth below grade: 1
feet
Material of construction: ,
f
® 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.):
System is vented at the roof line and field
- y
t5insp.doc-rev.7/26/2018 ' Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form =
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
199 Harbor Point Rd
Property Address
Children of Haiti and Refugee Project
Owner Owner's Name
isrequired for every Cumma Uid
Ma 02637 4/22/19
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 1
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
1000
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
r 1000
Dimensions:
Sludge depth: 3
Distance from top of sludge to bottom of outlet tee or baffle
24"
Scum thickness
3"
Distance from top of scum to top of outlet tee or baffle
4"
Distance from bottom of scum to bottom of outlet tee or baffle
30"
How were dimensions determined? Tape Measure
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 is at normal level
l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
;w Title 5 Official Inspection Form
I Subsurface Sewage Disposal System Form Not for Voluntary Assessments
199 Harbor Point Rd
Property Address
Children of Haiti and Refugee Project
Owner Owner's Name
information is required for every Cummaquid Ma 02637 4/22/19
page. City/Town State. Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete El metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene F ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
/ 199 Harbor Point Rd
Property Address
Children of Haiti and Refugee Project
Owner Owner's Name
information isequired for every Cumma uid
Ma 02637 4/22/19
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank (cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
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.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form-
�' .i1� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
199 Harbor Point Rd
Property Address
Children of Haiti and Refugee Project
Owner Owner's Name
information is Cumma uid Ma 02637' 4/22/19
required for every q
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) '
10. Pump Chamber(locate on site plan):
Pumps in working order: ® Yes []'No*
Alarms in working order: ® Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Chamber is functioning as designed, Steel cover to grade
Y
* If pumps or alarms are not in working order, system is a conditional pass.•
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Pump and floats are working as designed.
Type.
❑ leaching"pits, number:
❑ leaching chambers number:
® leaching galleries number: Flows 12' x 8'
El leaching trenches. number, length:
❑ leaching fields number, dimensions:
El overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
(/ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
4'
199 Harbor Point Rd
V
Property Address
Children of Haiti and Refugee Project
Owner Owner's Name
information is
required for every Cumma quid
Ma 02637 4/22/19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Flow diffusers. Field was found to be dry
z
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18
cam, Commonwealth of Massachusetts
Title 5 Official Inspection Form
la Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
199 Harbor Point Rd
Property Address
Children of Haiti and Refugee Project
Owner Owner's Name
information is Cumma uid Ma 02637 4/22/19
required for every q
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
le Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
0 199 Harbor Point Rd
Property Address
Children of Haiti and Refugee Project
Owner Owner's Name
information is Cumma uid Ma 02637 4122/19
required for every G
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference'
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
❑ hand-sketch in the area below
® drawing attached separately
t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
199 Harbor Point Rd
Property Address
Children of Haiti and Refugee Project -
Owner Owner's Name
information is required for every Cummaquid ' Ma 02637. 4/22/19
page. City/Town State Zip Code Date of Inspection
D. System Information,(cont.)
15. Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: : App 4ft below field
feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
4/7/86
If checked, date of design plan reviewed: Date
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:-
Original permit dated 4/7/86
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
V � 199 Harbor Point Rd
Property Address
Children of Haiti and Refugee Project
Owner Owner's Name
isrequired for every Cumma uid
Ma 02637 4/22/19
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
❑ A. Inspector Information: Complete all fields in this section.
❑ B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
❑ C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
❑ D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
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TOWN OF.BARNSTABLE $
LOCATION C r SEWAGE #
VILLAGE ASSESSOR'S MAP 6r LOT
INSTALLER'S NAME $i PHONE NO. A & B CANC O 775-6264
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) (size)
NO.OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
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COMMONWEALTH OF MASSACHUSE'ITS
z x EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
350 MAIN STREET
WEST YARMOUTH,MA
508-775-2$00
cc
TITLE S
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Properly Address: 199 HARBOR POINT ROAD
CUMMAQUID,MA 02637
Owner's Name: BROMAN,FORRES"f
Owner's Address: 199 HARBOR POINT ROAll hFO'cg ��Q
CUMMAQUID,MA 02637 q�T�Fp`rTq
Date of Inspection MAY 15,2001 T 6�
' F
Name of Inspector.(please hrin() ,IAM.I?S 1).SEARS
Company Name: A&B Canco
Mailing Address: 350 Main Street
West Yarmouth,MA 02673
'Telephone Number: 508-775-2800
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information
reported below is true,accurate and complete as of the time of the inspection. The inspection was
performed based on my graining and experience in the proper function and maintenance of on site selvage
disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(31.0
CMR 15.000). The system:
X Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date:
The system inspector shell submit a copy of this inspection report to the Approving Authority (Board of
Healtli or D.EP)within 3O days of completing this inspection. If the system isa shared system or has a
design flow of 10.000 gpd or greater, the inspcclor 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 tot
he buyer,if applicable,and the approving authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at
that time. This inspection does not address,how the system will perform in the future under the same
or different conditions of use.
Title 5 Inspection Form 6/15/2000 1.
L
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 199 HARBOR POINT ROAD
CUMMAQUID,MA 20637
Owner: BROMAN,FORREST
Date of Inspection: MAY 15,2001
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes: X
_ I have not found any information which indicates that any of the failure criteria described in 310 CUR
15.303 or in 310 CUR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes: N/A
One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.
The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y.N,ND)in the for the following statements. If"not determined"
please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,
exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing•
tank is replaced with complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval
of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system-required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health)"
broken pipe(s)are replaced
obstruction is removed
ND explain:
I ..
Title 5 Inspection Form 6/15/2000 2
Page 3 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
Property Address: 199 HARBOR POINT ROAD
CUMMAQUID,MA 02637
Owner: BROMAN,FORREST
Date of Inspection: MAY 15,2001
C. Further Evaluation is Required by the Board of Health: N/A
_ 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-salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone i of public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100'feet but 50 feet or more from a
private water supply well". Method used to determine distance
" This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility
and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided
that no other failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
i
Title 5 Inspection Form 6/15/2000 3
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
Property Address: 199 HARBOR POINT ROAD
CUMMAQUID,MA 2637
Owner: BROMAN,FORREST
Date of Inspection: MAY 15,2001
D. System Failure Criteria applicable to all systems: N/A
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded
or clogged SAS or cesspool
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool )
X Liquid depth in leaching is less than 6"below invert or available volume is less than%2 day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
X Any portion of the SAS,cesspool or privy is below high ground water elevation
N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a
surface water supply
N/A Any portion of a cesspool or privy is within a Zone 1 of a public well
N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well
N/A Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. (This system passes if the well water
analysis performed at a DEP certified laboratory,for coliform bacteria and volatile organic
compounds indicates that the well is free from pollution from that facility and the presence of
ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.)
NO (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails. The system owner should contact
the Board of Health to determine what will be necessary to correct the failure.
E. Large Systems: N/A
To be considered a large system the system must service a facility with a design flow of 10,000 gpd to
15,000 gpd.
You must indicate either"yes"or"no to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
Yes No
the system is within 400 feet 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 is 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.
Title 5 Inspection Form 6/15/2000 4
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 199 HARBOR POINT ROAD
CUMMAQUID,MA 20637
Owner: BROMAN,FORREST
Date of Inspection: MAY 15,2001
Check if the following have been done. You must indicate"yes"or"no"as to each of the following
Yes No
X Pumping information was provided by the owner,occupant,or Board of Health
X Were any of the system components pumped out in the previous two weeks?
X Has the system received normal flows in the previous two week period?
X Have large volumes of water been introduced to the system recently or as part of this inspection?
X Were as built plans of the system obtained and examined?(If they were not available note as N/A)
X Was the facility or dwelling inspected for signs of sewage back up?
X Was the site inspected for signs of break out?
X Were all system components,excluding the SAS,located on site?
X 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
X 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)has been determined based on: ..
Yes No
X Existing information. For example,a plan at the Board of Health.
X 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(3Xb)]
Title 5 Inspection Form 6/15/2000 5
Page 6 of 11 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 199 HARBOR POINT ROAD
CUMMAQUID,MA 02637
Owner: BROMAN,FORREST
Date of Inspection: MAY 15,2001
FLOW CONDITIONS
RESIDENTIAL
Number of Bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CUR 15.203(for example: 110 gpd x#of bedrooms: 330
Number of current residents: N/A
Does residence have a garbage grinder(yes or no): NO
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or no): YES
Seasonal use(yes or no): NO
Water meter readings,if available(last 2 years usage(gpd)): 1999 24,000/2000 29,000
Sump pump(yes or no) NO
Last date of occupancy: PRESENT
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203):
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: N/A
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: gallons—How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
X Septic tank,distribution box,soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no)(if yes,attach previous inspection records,if any)
Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight tank Attach copy of the DEP approval
X Other(describe): PUMP CHAMBER
Approximate age of all components,date installed(if known)and source of information:
PUMP CHAMBER 1986 PERNHT#86-630,LEACHING 1987 PERNUT#87-396
Were sewage odors detected when arriving at the site(yes or no): NO
Title 5 Inspection Form 6/15/2000 6
r
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued).
Property Address: 199 HARBOR POINT ROAD
CUMMAQUID,MA 02637
Owner: BROMAN,FORREST
Date of Inspection: MAY 15,2001
BUILDING SEWER(locate on site plan): N/A
Depth below grade:
Materials of construction: Cast iron _ 40 PVC _ other(explain)
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK(locate onsite plan): X
Depth below grade: 14"
Material of construction: X concrete metal fiberglass polyethylene
_ other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1,000 GALLON PRE CAST
Sludge depth: 2"
Distance from top of sludge to the bottom of outlet tee or baffle: 32"
Scum thickness: F,
Distance from top of scum to top of outlet tee or baffle: 12"
Distance from bottom of scum to bottom of outlet tee or baffle: 13"
How were dimensions determined: ASBUILT AND TAPE
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 IS AT WORKING LEVEL. OUTLET BAFFLE, 18"STEEL COVER AT GRADE.NO SIGN OF
OVERLOADING.
GREASE TRAP(located on site plan) N/A
Depth below grade:
Material of construction: concrete metal fiberglass _ polyethylene other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as
related to outlet invert;evidence of leakage,etc.):
M �
Title 5 Inspection Form 6/15/2000 7
L
Page 8 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 199 HARBOR POINT ROAD
CUMMAQUID,MA 2637
Owner: BROMAN,FORREST
Date of Inspection: MAY 15,2001
TIGHT or HOLDING TANK: N/A (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/day
Alarm present(yes or no)
Alarm level: Alarm in working order(yes or no):
Date of last pumping
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: N/A (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.,):
PUMP CHAMBER: X (locate on site plan)
Pumps in working order(yes or no): YES
Alarms in working order(yes or no): YES
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
PUMP CHAMBER CLEAN WITH NO SOLID CARRY OVER.ONE PUMP,T STEEL COVER AT GRADE.
Title 5 Inspection Form 6/15/2000 8
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM y
PART C
SYSTEM INFORMATION(continued)
Property Address: 199 HARBOR POINT ROAD
CUMMAQUID,MA 02637
Owner: BROMAN,FORREST
Date of Inspection: MAY 15,2001
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:
X leaching chambers,number: 3
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.) C
LEACHING IS FLOWS,FLOWS ARE 34"BELOW GRADE. COVER AT 10"BELOW GRADE.FLOWS ARE
WET,NO SIGN OF OVERLOADING.
CESSPOOLS: N/A (cesspool must be pumped as part of inspectionXlocate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation etc.):
PRIVY: N/A (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.)
r
Title 5 Inspection Form 6/15/2000 9
I
Page 9 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT'S
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 199 1-IARBOR POI.N"I'ROAD
C1JMMAQUID,Mil 02637
Owner: BROMAN,FORRES"i'
Date of Inspection: MAY 15,2001
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two penuanent reference landmarks or.
benchmarks..Locate all wells within 160 feet. Locate where public water supply enters the building.
` I ,
tZ �`1 R-
50
Title 5 Inspection Form 6/15/2000 10
r
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C `
SYSTEM INFORMATION(continued)
Property Address: 199 HARBOR POINT ROAD
CUMMAQUID,MA 02637
Owner: BROMAN,FORREST
Date of Inspection: MAY 15,2001
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to no groundwater 7 feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
X Observation 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:
HAND DUG TEST HOLE IN FLOWS. BOTTOM OF FLOWS 4'4"BELOW GRADE. TEST HOLE
3' BELOW BOTTOM OF FLOWS,NO WATER.
Title 5 Inspection Forni 6/15/2000 11
s , COMMON\\'EALTH OF MASSACHUSETTS �
(F EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS a
DEPARTMENT OF ENVIRONMENTAL PROTEC ' I �
ONE WINTER STREET. i30STOTv. NIA 02108 (,l 292-Sj00 g ��
RECEIVED
WILLIAM F.WELD ,�,t T Y COXE
Govemof 350 MAIN STREET OCTC 20 1997 ccretar�
ARGEO PAUL CELLUCCI WEST YARMOUTH, MA TOWNOfgggNSTgBIE DAVI STRUHS
Lt.Governor
508-775-2800 HEAITHOFPT, o missioncr
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION 1`�+
PART A
CERTIFICATION 1
c Sty
PROPERTY ADDRESS: 199 Harbor Point Road,Cummaquid ADDRESS O N VEO
DATE OF INSPECTION: October 10, 1997 Forrest ror 20 19 NAME OF INSPECTOR : James D.Sears TO 9T . 46
I am a DEP approved system inspector pursuant to Section 15.340 of Title 10 Cn Q94
THDEPT. �f
COMPANY NAME: A& B Canco Gr
MAILING ADDRESS: 350 Main Street, West Yarmouth,MA 02673
TELEPHONE NUMBER: (508)775-2800 L
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:
X PASSES
CONDITIONALLY PASSES
NEEDS FURTHER EVALUATION BY THE LOCAL APPROVING AUTHORITY
FAILS
INSPECTORS SIGNATURE: Q=ZDATE: October 13, 1997
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, B, C, or D:
Aj SYSTEM PASSES:
X 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:
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 b the Board of Health,
will pass.
Indicate yes, no, or not determined (Y, N, or NO). 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 is failure is imminent. The
system will pass inspection if the existing septic tank is replaced with a conforming septic tank as
approved by the Board of Health.
Page 1 of 10
(revised 04/25/97)
DEP on the World Wide Web:http://www.magnet.state.ma.un/d
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (CONTINUED)
Property Address: 199 Harbor Point Road,Cummaquid
Owner: Browman, Forrest
Date of Inspection: October 10, 1997
B]SYSTEM CONDITIONALLY PASSES(continued)
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 leveled or replaced
The system required pumping more than four times a year due to broken or obstructed
pipe(s). The system will pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
N/A Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect the public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS
NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER
SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A
MANNER THAT 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.
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 and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine
distance (approximation not valid).
3) OTHER
(revised 04/25/97)
Page 2 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 199 Harbor Point Road, Cummaquid
Owner: Broman, Forrest
Date of Inspection: October 10, 1997
D SYSTEM FAILS:
You must indicate either"Yes" or"No" as to each of the following:
N/A 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 over-
loaded 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 surface water supply or tributary to a
surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private
water supply well with no acceptable water quality analysis. If the well has been analyzed to be
acceptable, attach copy of well water analysis for 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:
N/A 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
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 treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of
the Department for further information.
(revised 04/25/97)
Page 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 199 Harbor Point Road, Cummaquid
Owner: Broman, Forrest
Date of Inspection: October 10, 1997
Check if the following have been done: You must indicate either"Yes" or"No" as to each of the following:
Yes No
X Pumping information was provided by the owner, occupant, or Board of Health.
X 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.
X As built plans have been obtained and examined. Note if they are not available with N/A.
X The facility or dwelling was inspected for signs of sewage back-up.
X The system does not receive non-sanitary or industrial waste flow.
X The site was inspected for signs of breakout.
X All system components, including the Soil Absorption System, have been located on the site.
X 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:
X The facility owner(and occupants, if different from owner)were provided with information on
the proper maintenance of Sub-Surface Disposal System.
X Existing information. Ex. Plan at B.O.H.
X 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)]
(revised 04/25/97)
Page 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 199 Harbor Point Road,Cummaquid
Owner: Broman, Forrest
Date of Inspection: October 10, 1997
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 330 g.p.d./bedroom for S.A.S.
Number of bedrooms: 3
Number of current residents: 2
Garbage grinder(yes or no): NO
Laundry connected to system es or no): YES
Seasonal use(yes or no) NO
Water meter readings, if available(last two(2)year usage(gpd): 1995-96 34,000/ 1996-97 33,000
Sump Pump(yes or no): NO
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow: gallons/day
Grease trap present: (yes or no):
Industrial Waste Holding Tank present: (yes or no)
Non-sanitary waste discharged to the Title 5 system: (yes or no)
Water meter readings, if available:
Last date of occupancy:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
9-97
System pumped as part of inspection:(yes or no) NO
If yes, volume pumped: gallons
Reason for pumping
TYPE OF SYSTEM
X Septic tank/oil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
I/A Technology etc. Copy of up to date contract?
Other WITH PUMP TRUCK
APPROXIMATE AGE of all components, date installed (if known)and source of information:
PUMP TANK 1986PERMIT 86-30, LEACHING 1987 PERMIT 87-396
Sewage odors detected when arriving at the site: (yes or no) NO
(revised 04/25/97)
Page 5 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 199 Harbor Point Road, Cummaquid
Owner: Broman, Forrest
Date of Inspection: October 10, 1997
BUILDING SEWER: N/A
(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: X
(Locate on site plan)
Depth below grade: 14"
Material of construction X concrete _ metal _ Fiberglass _ Polyethylene _ other(explain)
If tank is metal, list age Is age confirmed by Certificate of Compliance (Yes/No)
Dimensions: 1,000 GALLON PRE CAST
Sludge depth: 0"
Distance from top of sludge to bottom of outlet tee or baffle: 34"
Scum thickness: 0"
Distance from top of scum to top of outlet tee or baffle: 12"
Distance from bottom of scum to bottom of outlet tee or baffle: 14"
How dimensions were determined ASBUILT&TAPE MEASURE
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet
invert, structural integrity, evidence of leakage, etc.)
TANK HAS 18" STEELCOVER AT GRADE OUTLET BAFFLE
GREASE TRAP: N/A
(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:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet
invert, structural integrity, evidence of leakage, etc.)
(revised 04/25/97)
Page 6 of 10
• SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 199 Harbor Point Road, Cummaquid
Owner: Broman, Forrest
Date of Inspection: October 10, 1997
TIGHT OR HOLDING TANK: N/A (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:
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: N/A
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc,)
PUMP CHAMBER: X
(locate on site plan)
Pumps in working order: (Yes or No) YES
Alarms in working order(Yes or No) YES
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
PUMP CHAMBER CLEAN, NO SOLID CARRY OVER. ONE PUMP, 3 FLOATS 2' STEEL COVER AT GRADE.
(revised 04/25/97)
Page 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 199 Harbor Point Road, Cummaquid
Owner: Broman, Forrest
Date of Inspection: October 10, 1997
SOIL ABSORPTION SYSTEM (SAS): X
(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:
leaching chambers, number: 3
leaching galleries, number:
leaching trenches, number, length:
leaching fields, number, dimensions:
overflow cesspool, number,
alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
LEACHING FLOWS, BOTTOM OF FLOWS WET, FLOWS 34" BELOW GRADE WITH Z RISER, COVER
10" BELOW GRADE.
CESSPOOLS: N/A
(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: N/A
(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.)
(revised 04/25/97)
Page 8 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C .
SYSTEM INFORMATION(continued)
Property Address: 199 Harbor Point Road, Cummaquid
Owner: Broman, Forrest
Date of Inspection: October 10, 1997
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)
f
0
(revised 04/25/97)
Page 9 of 10
~ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 199 Harbor Point road, Cummaquid
Owner: Broman, Forrest
Date of Inspection: October 10, 1997
Depth to no groundwater 7' feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained fro Design Plans on record
X Observation of Site(Abutting property, observation hole, basement sump etc.)
Determine 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)
HAND DUG TEST HOLE IN FLOWS BOTTOM OFFLOWS 4"-4" BELOW GRADE, TEST HOLE 3' BELOW
BOTTOM OF FLOWS.
NOTE: NO GROUND WATER FOUND
(revised 04/25/97)
Page 10 of 10 ,
T
LOCATION s SEWAGE PERIA N0.
V I . L A G E ASSESSORS MAP NO: .2s;ng
PARCEL. NO.: -
-
INST LL R'S NAME A ADDRESS
J i
e U I L D E R OR OWNER
DATE PERMLT ISSUED
PATE COMPLIANCE ISSUED
11 Y
i
�s
44
?u r,,p
oic� c Awi Q
V j TOWN OF BARNSTABLE
LOCATION 1�o�c�oc Rc, �� ��SEWAGE #
VILLAGE ASSESSOR'S MAP LOT 3 �-
R
�. INSTALLER'S NAME & PHONE NO. K t \� C\�4;�
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) —(size)—
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED: L -S
VARIANCE GRANTED: Yes No
r
i
,nr
6SESSORS MAP NO:
No.. .7r... � 'AREL NO.: U 7 ''0N13i21t1d F�$.....a.. d..
THE COMMONWEALTH OF MASSAC'HU'S'ETTS'S+
BOAR® OF HEALTH
-.` '1U..................OF.... . ",2 ` 13t--------------------------------------
ApplirFation for Disposal Works Tonstrnrtiun 11amit
Application is hereby made for a Permit to Construct ( ) or Repair (�an Individual Sewage Disposal
System at: fit. A�
....1 ` ... :........................... D ....... ............. ..... .1 t'2.PLC_. S✓4 t ........ ..................................................
Location Address or Lot No.
....V±S"' ............................................................... ..........
--..............................................................................._.••-- -
Owner Address
---------------------------------------------------
Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
'4 Other.—Type of Building No. of persons............................ Showers — Cafeteria
Q' Other fixtures ..........-••-•-•-------•-•••--• .__
WDesign Flow..........:..........•...............•.._•._gallons per person per day. Total daily flow..................................I..........gallons.
1:4 Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................
Disposal Trench—No. _-__•--_- .... Width.................... Total Length.................... Total leaching area....................sq. ft.
3 Seepage Pit No.� ���!�f eter_/-'A?C 26_..... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
'-� Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------
fi, Test Pit No. 2................minutes per inch. Depth of Test Pit.................... Depth to ground water........................
a •-•-•-•. .. -••••••-•---•-•..........-•••••......•-•-•-------------- ....................................... ---....--••-
ODescription of Soil...... -._�..�..........••-..�.•.. (..•-•••--••- .-------- ....------�......I.......................
U .....•-•••----•-••--•----••-••••---••-••...•-•---•---••••••••......--•••••••--•-••-••••.......--••--•----•-•-•--•--...•••.....---•---,---•......••--•---••--.••-•••-•••••-•-•---•-•..............••-----
w
x •-•--•••••-•••---...•...
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 LiT;.: 5 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 board of health.
Signed..-- ?. ^`_... t -•-•-------•--••--------------•--
p _..........._-•- Date--•-
Application Approved BY----•-•• '._"� •-------•----•-------------------- .
Date
Application Disapproved for the following reasons-------------•----•--------------...------------....------------••--------------------------------._............
•-••••----•-•••••••-••-•---•--••----••-•......_...•••••-••••..................••••-•...---•--••••--....---••••-•-••--••••-•--•-•-•-••-•••---•---•--•-------------------•••-•------------•---••-----•--•-
Date
Permit No-----?-7.....3.?4......................._ Issue(L................... ........................--------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
7
,Z Yv T✓t0�
tJ. OF .:.r. ...... .....s......... -
Appliration for Di-4panl Workii Totuitrnrtiun Permit
Application is hereby made for a Permit to Construct ( ) or Repair (,eT`an Individual Sewage Disposal
System at:
Location Address or Lot No.
.�A Nay 2......_----...--- .............................•---------------- -----------.....-----------...-------•---......---
Owner Address
W k 01........ I C�.`T....-----•-----_•----•------------------------------ --�LCt:Aj,—744'f .......
Installer Address
d Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ------------------_---_--- No. of persons..........--................ Showers ( ) — Cafeteria ( )
d Other fixtures ....................... -------------•----....--•--.....
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter--.--.--.------- Depth................
Disposal Trench—No. .........�..q....... Width .................. Total Length.................... Total leaching area....................sq. ft.
Seepage Pit ------- Depth below inlet.................... Total leaching area..................sq. ft.
z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by...................................................•___•----•---_•-------- Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit................---. Depth to ground water.---.....................
f34 Test Pit No. 2................minutes per inch Depth of Test Pit.--................. Depth to ground water........--..---.........
----_---•--•...............••_-_---•-•-•------•---•-----•----•-------............--------------••-•---...----...----------.... -•-_-
O Description of Soil..... .................................................................tLI1fyl
U •-•-------------•------_---------_---•-_•___---_-----•_--------•---------•_-------•--........---•--......._•••-•---_--......-----•-_---_•_-------_•__•---_-•---------_--
W
Z. -------------- -------_----------- ••_---------•----------------------•-••----------_---••-_•---_----•-------•--------_--_---•••-------------------_•_-_-•---•----••----_--.........................
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'TT
LE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued
-b�-y the board of health.
-------------•-----------•--•--•--
Date
Application Approved By.......a...---~-j�.---��c-r�-�---�-•--•-----------•------•------•------- ........................................
Date
Application Disapproved for the following reasons:.............................................................................................................
-•-•-------------------------------•-----.....--...------------_----------•__---.....•__--.....____-••-----__•••-•__--•-_-_•----•_•---_•-•-•••--....------_--•-_------••...------•-----.....•_-••-......
Date
Permit No.51--3--516--------------------------- Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..............of..... .............................
Qwrtif iratr of Tomplianre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaireddl-)-
byC.c.,:q i_N---• --------------------------------------------------------------------------•------------........------.....-------•----..........------------------.....
_ Install�j
at...1.1-�5--------------1=t R��--------?0 r N- --fz�..-_--_------------�n.V.y`'�1` ---.............................................................................
has been installed in accordance with the provisions of TiTIE 7 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No..f.S.7_..'�` .............. dated_.............................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT YHE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.................... ....... .7..................... Inspector.... -.
5..1-mac.............. ----------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
NO - .- '••- -- ..�`�...................OFJ��F-� v.. FEE..;k�.2...:�....
Diapnoal Workg Tuan�s, #.rnr#inn :"permit
Permission is hereby granted......... j�.__ .......11.... _:4 ........------------------------------------------•------.........................
to Construct ( ) or Repair I��n Individual Sewage Dispo a System
at No.--- ..............4 n -------2 w ................
.............................................................................................................
Street
as shown on the application for Disposal Works Construction Permit N4 3�.6.... Dated..........................................
----------------------------
Board of Health
DATE................................................................................
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......aW�.........OF....A* 1A, -.--.....
Appliratiun for Uiupuual Works C9unstrur#iun Frrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
----------------•-.----- ----..-------.--...................-----
- - _ -- ------------
---.--_. L ati d ess _ _--.--..--•-....or Lot No.
+� ----------------------------- - ----.------------- -----------.-----------------.------------------------
O n r Address
a --------------------------------- ----..
Installer Address
4 Type of Buildin Size Lot............................Sq. feet
U Dwelling No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—Type e of Building __........._ No. of persons............................ Showers — Cafeteria
G4 YP g ---------------- P ( ) ( )
a' Other fixtures ..................................
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Li, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
04 •---••--•----------------•-••-•-•-••---•••...................._....................-------------_............................................................
0 Description of Soil.....................•--•--------•---•--.......-•----............................................ ......................................................................
--•--••--•...._-----••--
U N�ure of Repairs�o Alterations—A er when applicabl .. .. . .1 .. .__ .: _ :_ >�________ _ _________
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System.in accordance with
the provisions of iITIE 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee issued by he and of ealth.
Signed �... �......... I .....--- .
ApplicationApproved By..-••- =< �E........... ...........................•---•---....---............--- ----•--•----------Date --------•---
Applieation Disapproved for the following reasons:..........................................................................................................._
--.........-•--------•-....-•--•-------------•----•------------•----------•------.............---------....------------............-•------•-----•---------------------------------......••••--•••--••---
Date
PermitNo........... ----------- Issued.......................................................
Date
Pr
Now:.».�..:..L F;�s..:�: ._............_
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............. J'',':� � ..........OF.. '�`✓. A f '.. �'�.i.}..,ki ..,od...................................
. pphratinn for Disposal Works Tonotrurtion Frruti#
Application is hereby'made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System^ at:
p' .............................................................................
L�cation r s ft or Lot No.
ty �Ir ®� ........................ .............................................
........... ........................ ._.»..........................................
{ r 01wner r Address
............. ..................................
Installer Address
Type of Buildings Size Lot............................Sq. feet
Dwelling. No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other=T e of Building No. of persons............................ Showers
p.I YP g -------------------••--••-•- P ( ) — Cafeteria ( )
QIDesign ............................................
Other fixtures :......-•--•--•- -------- ---- .-.......- ---........------------------- --------•-..........---------------•--------...-•---�-......
d ...............gallons per person per day. Total dailyflow............................................gallons.
Desi Flow.._..--.. --.-•- - - . 1� g P
Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Dept
x Disposal Trench—No........:..:........ Width.................... Total Length.................... Total leaching area...................sq. ft.
3 Seepage Pit No..................... Diameter.................... Depth below inlet--.................. Total leaching area.................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by....................................'..................................... Date........................................
Test Pit No. I................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........................
�Y .....---•............. .......
....•----......-----•-- ........ -.........
-.-.......
-.--..----•- ---------
ODescription of Soil......................................=---•••••--•---•-•----------•--•-•••-•--------------•-----------...-------•-----•---•..._..-••---........---••-•--•-------••----
--....-•--------------------------------- ------------------ ---•--------•----...---...-- ---- --- ------.---------•------.
U N ure of Repairs Alterations Answer when applicabl /.7.- sd � r 11 ¢t � ........ :.............
`� '------- -• ✓ f d!1........ - r4).-- .. L�°` %1%t. ....................�f.'.:.........
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System.in accordance with
the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued b the P7"and of health.
Signed . ........, `s > '. r'r `; - ✓�.
a` ..t�._......•... ....... .._ .... .........
Zte
Application Approved BY..... .. . .. . . . ...................................•• ..
----
Application Disapproved for the following reasons:..........................................................................................................---
........•-•--•.....---••-----•-•................•-•...----•---..........••----...----....--•-------....»...---•--......---....._.....•----•---.......---•-•...---------••-----------._............_..»
Date
Permit No.........."�---- .-- _.` _1.•...»..» Issued......-•-----------------------•-----•-•----..........
Date
THE COMMONWEALTH OF MASSACHUSETTS
a„ BOARD OF HEALTH
,r
............ ...
.f!• .�.�,�.......OF........+ ° ... .�. ............................
Tatif irat a of Tomplitturr
T, lS hAi T ,CERTIFY, !hat the Individual Sewage Disposal System constructed ( ) or Repaired
Y
at........................ ' . °' l-/
... .. .......................... ----------I—*
has been installed in•:accordance with the provisions of TITLE 5 of The State Saniy Code s described in the
application for Disposal:Works Construction Permit No... ._':_�.[........ dated........ ��7��.�..................
THE ISSUANCE. OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE......... . .............................. Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD PF HEALTH , PVm�
� mod! ° %Y�............OF....: Ef` e ................. �r
No 4� ..
Fss...: ..........
Disposal No!* Tons#rttr#io,n rrruti#
Permission is hereby granted..._ � r``'' `�'��—' �
....... .............................................................»»....
to Construct ( ) orl epair bran Indivi Sewage Dis o S stem '2?at No....- � JI, --------- - ..� _122! ......�: ,!'.' �..1 �r j " � '.............
.•-•-.-.
Street r �
as shown on the application for Disposal Works Construction Permit N.o.�................l ated......__� ?/ ................
4
...............t »� - - ..... _. -----. ------•... .......»
Board of Health
. ..... ...
DATE:.............. >
FORM 1255 A. M. SULKIN, INC., BOSTON
v�
y�
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