HomeMy WebLinkAbout2681 MAIN ST./RTE 6A(BARN.) - Health 2661 .Main Street/Rte..6A (,Barn);.,
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Commonwealth of Massachusetts o2 58 " b q�L
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
."� 2681 Main St. Barnstable; MA 02630 I
Property Address h
George Hill , PO Box 605
Owner t"
information is Owners Name
required for every Barnstable MA 02630 10/2/2018
page. City/Town State Zip Code Date of Inspection
�M+
01!
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 e
A. Inspector Information
filling out forms p
on the computer, f
use only the tab Paul C. Martin
key to move your Name of Inspector
cursor-do not Cape Cod Septic Services Inc.
use the return key. Company Name
350 Main St.
reb Company Address
West Yarmouth MA 02673
City/Town State Zip Code
"KI
508-775-2825 S15016
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
3. ❑ Needs Further Evaluation by the Local Approving Authority
A. ❑ Fails
10/12/2018
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.
t5lnsp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of.16
Commonwealth of Massachusetts
Title 5 Official Inspection Foam
�= Fio Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
46 Moss Place
` Property Address
Donna Atwood
Owner Owner's Name
information is required for every Marstons Mills MA 02648 10/5/2018
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
filling out forms
on the computer,
use only the tab Paul C. Martin
key to move your Name of Inspector
cursor-do not Cape Cod Septic Services Inc.
use the return key. Company Name
350 Main St.
,b Company Address
West Yarmouth MA 02673
Cityrrown State Zip Code
>eoro 508-775-2825 S15016
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
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
10/12/2018
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.
l5insp.doc-rev.7/26/2018 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
46 Moss Place
Property Address
Donna Atwood
Owner Owner's Name
information is required for every Marstons Mills MA 02648 10/5/2018
page. Cityrrown 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:
® 1 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 is in working condition.
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):
i
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
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
46 Moss Place
Property Address
Donna Atwood
Owner Owner's Name
information is required for every Marstons Mills MA 02648 10/5/2018
page. City/Town 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.712 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�= io Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
46 Moss Place
Property Address
Donna Atwood
Owner Owner's Name
information is required for every Marstons Mills MA 02648 10/5/2018
page. City/Town 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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts.
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
46 Moss Place
Property Address
Donna Atwood
Owner Owner's Name
information is required for every Marstons Mills MA 02648 10/5/2018
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
El ® 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 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 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. l 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
❑ ❑ 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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
c Commonwealth of Massachusetts
: Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
46 Moss Place
Property Address
Donna Atwood
Owner Owner's Name
information is required for every Marstons Mills MA 02648 10/5/2018
page. City/Town 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?
El ® 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?
® ElWas 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:
E. ❑ 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts
11? Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for.Voluntary Assessments
46 Moss Place
Property Address
Donna Atwood
Owner Owner's Name
information is required for every Marstons Mills MA 02648 10/5/2018
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): 110x3=
330gpd
Description:
Number of current residents: 2
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
=55gpd
Water meter readings, if available (last 2 years usage (gpd)): 2012016=55gpd
.Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: CurrentDate
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
46 Moss Place
Property Address
Donna Atwood
Owner Owner's Name
information is required for every Marstons Mills MA 02648 10/5/2018
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: No Records
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
i
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
Title 5 Official. Inspection Form
Flo Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
46 Moss Place
Property Address
Donna Atwood
Owner Owner's Name
information is required for every Marstons Mills MA 02648 10/5/2018
page. City/Town 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):
Approximate age of all components, date installed (if known) and source of information:
1989 Per BOH records
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):'
Depth below grade: 23"feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: +10'feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Line was checked with sewer camera and was found to be clean, properly pitched with no sign of root
intrusion.
t5insp.doc-rev.7/2 612 0 1 8 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
46 Moss Place
Property Address
Donna Atwood
Owner Owner's Name
information is required for every Ma�stons Mills MA 02648 10/5/2018
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 1211feet
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: 1000Gal
1"
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
Oil
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined? Estimated
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
1000Gal tank in good condition. PVC tees in place and clean. Tank at normal operating level. Inlet
cover 6" below grade with outlet 12" below grade.
l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
� 46 Moss Place
Property Address
Donna Atwood
Owner Owner's Name
information is required for every Marstons Mills MA 02648 10/5/2018
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 ❑ 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 ❑ other(explain):
Dimensions:
Capacity: gallons
A
Design Flow: gallons per day
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
ANI
Commonwealth of Massachusetts
Title 5 Official Inspection Form
= Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
46 Moss Place
Property Address
Donna Atwood
Owner Owner's Name
information is Marstons Mills MA 02648 10/5/2018
required.for every
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? 0 Yes ❑ No
9. Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
0"
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
H-10 DB-3 with 1 line in and 1 line out in good condition. Box is clean and level with minimal solids
carryover. No sign of overloading or hydraulic failure. Cover 6" below grade.
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
�= FII Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�u
46 Moss Place
Property Address
Donna Atwood
Owner Owner's Name
information is required for every Marstons Mills MA 02648 10/5/2018
page. Cityrrown 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.):
* 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:
Type:
® leaching pits number: 1-6x6
❑ -leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ 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
11. Subsurface Sewage Disposal,System Form - Not for Voluntary Assessments
46 Moss Place
Property Address
Donna Atwood
Owner Owner's Name
information is Marstons Mills MA 02648 10/5/2018
required for every
page. Cityrrown 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.):
1-6x6 Leach pit with stone. 2' of effluent in pit during inspection. No evident staining. No sign of
overloading or hydraulic failure. Cover 14" below grade.
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
i Commonwealth of Massachusetts
Title 5 Official Inspection Form
= Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
46 Moss Place
Property Address
Donna Atwood
Owner Owner's Name
information is required for every Marstons Mills MA 02648 10/5/2018
page. City/Town 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u
46 Moss Place
Property Address
Donna Atwood
Owner Owner's Name
information is Marstons Mills MA 02648 10/5/2018
required for every page. City/Town 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18
r
Commonwealth of Massachusetts
Title 5 Official. Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
46 Moss Place
V
Property Address
Donna Atwood
Owner Owner's Name
information is required for every Marstons Mills MA 02648 10/5/2018
page. Cityrrown 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: +14'
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:
Auger did not encounter water at 14'. Max bottom of pit is 10'.
I
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
l5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
46 Moss Place
Property Address
Donna Atwood
Owner Owner's Name
information is required for every Marstons Mills MA 02648 10/5/2018
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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18
tem Connecticut • Rhode Island
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COMMONWEALTH OF MASSACHUSETTS00
-� ExIXUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
z F DEPARTMENT OF ENVIRONMENTAL PROTEcf%, ,,�EIVED
m .l
FEB252003
TOWN OF BARNSTABLE
HEALTH DEPT.
TITLE 5
OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSEW 4 ILNTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM(
- . PART A
CERTIFICATION
Property Address: 2681 MAIN ST BARNSTABLE 02630 M258 P042 MAP �S g
Owner's Name: JACK HILL
Owner's Address: 2681 MAIN ST BARNSTABLE 02630 PARCEL ; 2
Date of Inspection: 2/3/03 LoT - - --
Name of Inspector: (please print) JOHN GRAC1, INC.
Company Name: SEPTIC INSPECTIONS
Mailing Address: P.O. BOX 2119 TEATICKET, MA.02536
Telephone Number: 508-564-6813 FAX 508-564-7270
CERTIFICATION STATEMENT
I certify 6-at I have personally inspected the sewage disposal system at this address and that the lifformation reported bek .v is
true, accurate and complete as of the time of the inspection.-The-inspection was performed based on my(raining and
experience in the proper function and maintenance of on site sewage disposal systems. I am a UEl'approved system
inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
_ Passes
-X Conditiona Passes
__-_.. Needs Fur er Evaluation by the Local Approving Authority
Fails
i
Inspector's Signature: Date: 2/3/03
The system inspector shall submi a copy of this inspection report to the Approving Authority(Board of Health or DEP) ,v ithin
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 ,e
sent to the system owner and copies sent to the buyer, if applicable, and the approving authority.
Notes and Comments
TI IE SYSTEM CONDITIONALLY PASSES TITLE V INSPECTION. THE.DISTRIBUTION BOX IS ROTTED AT i HE
KNOCK OUT AND HAS SOILD CARRYOVER FROM LACK OF PUMPING OF THE SEP iC TANK. THE
DISTRIBUTION BOX NEEDS TO BE REPLACED.
°"*This report only describes conditions at the time of inspection and under'the conditions of use at that time.'I As
inspection does not address how the system will perform in the future.under the same or different conditions of u:C.
I irlr.5 Immortino.1-ni'm AEI snnnn
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 2681 MAIN ST BARNSTABLE 02630 M258 P042
Owner: JACK HILL
Date of Inspection: 2/3/03
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 CONDITIONALLY PASSES TITLE V INSPECTION. THE DISTRIBUTION BOX IS ROTTED AT
THE KNOCK OUT AND HAS SOILD CARRYOVER FROM LACK OF PUMPING OF THE SEPTIC TANK.THE
DISTRIBUTION BOX NEEDS TO BE REPLACED.
B. System Conditionally Passes:
X 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.
n/a 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.
ND explain: n/a
46a 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 — CW- -\�o Cokr V-���
ND explain: n/a
n/a 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: n/a
Page 3 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 2681 MAIN ST BARNSTABLE 02630 M258 P042
Owner: JACK HILL
Date of Inspection: 2/3/03
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
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water
supply or tributary to a surface water supply.
_ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
_ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water
supply well". Method used to determine distance n/a
"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:
n/a
f
Page 4 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 2681 MAIN ST BARNSTABLE 02630 M258 P042
Owner: JACK HILL
Date of Inspection: 2/3/03
D. System Failure Criteria applicable to all systems:
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 cesspool is less than 6"below invert or available volume is less than Y2 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 nLa.
_ X Any portion of the SAS, cesspool or privy is below high ground water elevation.
X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
X Any portion of a cesspool or privy is within a Zone 1 of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
X 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 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.]
_ Ni- (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:
To be considered a large system the system must serve a facility with a design now 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
X the system is within 400 feet of a surface drinking water supply
X the system is within 200 feet of a tributary to a surface drinking water supply
X 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.
A
I
f Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 2681 MAIN ST BARNSTABLE 02630 M258 P042
Owner: JACK HILL
Date of Inspection: 2/3/03
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)on the site 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(3)(b)]
5
Page 6 of 11
OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 2681 MAIN ST BARNSTABLE 02630 M258 P042
Owner: JACK HILL
Date of Inspection: 2/3/03
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
Number of current residents: 2
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): NO
Seasonal use: (yes or no): NO
Water meter readings, if available(last 2 years usage(gpd)):m4a � 4(3 I Oc
Sump pump(yes or no): NO
cco
Last date of occupancy: n/a - �r
COMMERCIAL/INDUSTRIAL
Type of establishment: n/a
Design flow(based on 310 CMR 15.203): n/agpd
Basis of design flow(seats/persons/sqft,etc.): n/a
Grease trap present(yes or no): NO
Industrial waste holding tank present(yes or no): NO
Non-sanitary waste discharged to the Title 5 system(yes or no): NO.
Water meter readings, if available: n/a
Last date of occupancy/use: n/a
OTHER(describe): n/a
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: n/agallons--How was quantity pumped determined?n/a?
Reason for pumping: n/a
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 a copy of the DEP approval a
Other(describe):n/a T
Approximate age of all components,date installed(if known)and source of information:
1987 COMPLIANCE
Were sewage odors detected when arriving at the site(yes or no): NO
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 2681 MAIN ST BARNSTABLE 02630 M258 P042
Owner: JACK HILL
Date of Inspection: 2/3/03
BUILDING SEWER(locate on site plan)
Depth below grade: 18"
Materials of construction:_cast iron =40 PVC other(explain): n/a .
Distance from private water supply well or suction line: n/a
Comments(on condition of joints,venting,evidence of leakage,.etc.):
TOWN
SEPTIC TANK: X(locate on site plan)
Depth below grade: 12" -
Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a .
If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate)
Dimensions: 1500 GALLONS"
Sludge depth: 3"
Distance from top of sludge to bottom of outlet tee or baffle:31"
Scum thickness: 3"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: 15"
How were dimensions determined: MEASURED
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related
to outlet invert,evidence of leakage,etc.):
SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIOING PROPERLY.
RECOMMEND PUMPING NOW AND EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE.
GREASE TRAP: _(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
Date of last pumping: n/a
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
to outlet invert,evidence of leakage, etc.):
n/a r
I
7
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 2681 MAIN ST BARNSTABLE 02630 M258 P042
Owner: JACK HILL
Date of Inspection: 2/3/03
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Capacity: n/a gallons
Design Flow: n/a gallons/day
Alarm present(yes or no): N/A
Alarm level: N/A Alarm in working order(yes or no): NO
Date of last pumping: n/a
Comments(condition of alarm and float switches,etc.):
n/a
DISTRIBUTION BOX:X(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE
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.):
THE DISTRIBUTION BOX IS ROTTED AT THE KNOCKOUT AND HAS SOLID CARRYOVER.
PUMP CHAMBER:_(locate on site plan)
Pumps in working order(yes or no): NO
Alarms in working order(yes or no):NO
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
n/a
F .
R
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 2681 MAIN ST BARNSTABLE 02630 M258 P042
Owner: JACK HILL
Date of Inspection: 2/3/03
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
n/a
Type
6' X 4' leaching pits, number: 2
n/a leaching chambers, number: n/a
n/a leaching galleries, number: n/a
n/a leaching trenches, number, length: n/a
n/a leaching fields, number: n/a
n/a overflow cesspool, number: n/a
n/a innovative/alternative system
Type/name of technology: n/a
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.):
THE PITS WERE VIDEO INSPECTED.LEACH PITS ARE STRUCTURALLY SOUND AND FUNCTIONING
PROPERLY. SYSTEM SHOWS NO SIGNS OF FAILURE.ONE PIT HAS 2' OF WATER AND THE OTHER PIT IS
EMPTY.THE BOTTOM IS ESTIMATED AT 10'
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: n/a
Depth—top of liquid to inlet invert: n/a
Depth of solids layer: n/a
Depth of scum layer: n/a
Dimensions of cesspool: n/a
Materials of construction: n/a
Indication of groundwater inflow(yes or no): NO
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.):
n/a
PRIVY: (locate on site plan)
Materials of construction: n/a
Dimensions: n/a
Depth of solids: n/a
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a
4
f
Page.I@ of I I rtA
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSM ENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 2681 MAIN ST BARNSTABLE 02630 M258 P042
Owner: JACK HILL
Date of Inspection: 2/3/03
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchma;ks.
Locate all wells within 100 feet. Locate where public water supply enters the building.
T �
1
I(1
Page.l I of 1 1
OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued) .
Property Address: 2681 MAIN ST BARNSTABLE 02630 M258 P042
OiNw is JACK HILL
Date„['Inspection: 2/3/03
SITE EXAM
_Sur!ace water
_Chc�.:k cellar
Shallow wells
Estimated depth to ground water 12+ feet.
Pleasc indicate(check)all methods used to determine the high ground water elevation:
NO Obtained from system design plans on record- If checked,date of design plan reviewed: n/a
YE5 Observed site(abutting property/observation hole within 150 feet of SAS)
NO Checked with local Board of Health-explain: n/a
NO Checked with local excavators, installers-(attach documentation)
NO Accessed USGS database-explain: n/a
You must describe how you established the high ground water elevation:
GIt!3UNDWATER DETERMINED FROM HAND AUGER- NO WATER AT 12'
A
TOWN OF BARNSTABLE
LOCATIONS G ;�7`/V?P/,, S l' SEWAGE #,F 6 %�J
VILLAGE ASSESSOR'S- MAP & LOTaS7,�- O I A
INSTALLER'S NAME & PHONE NO.�&�g
SEPTIC TANK CAPACITY%re''O G ,4
LEACHING FACILITY:(type �4,< (size)
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER/ GA
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED: � r'
f VARIANCE GRANTED: Yes No /
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iASSESSORS MAP NO:
No.---- - -- Fes$................: ..........
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
..........................................OF.....................................
Apphration for Disposal Works Tonstr�r!" rruti#
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System at:
� Lo ation-Address or Lot No.7.�!..C�_ .......................................... ----•- --•..................................
-- -•.••-.---•.----•••- •--...................................._.....
Owner Address
a ti
Installer Address
UType of Building f Size Lot-___-_--------------------Sq. feet
Dwelling—No. of Bedrooms........... _------•---_--___..__Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons............................ Showers — Cafeteria
Q' Other fixtures ----------------------------••-- .
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
Gd Septic Tank—Liquid capacity............gallons Length................ Width.................. Diameter---------------- Depth................
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--------................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P4 --•--------------------•---------------------------------..........-------------•-••------•----..............................................................
0 Description of Soil........................................................................................................................................................................ 1
V ..•••-••-•-•----•--•--•-•-•---••-•----•--••-------------•---•-------------••••••------•------••--••----------------...-•••--•----•-------•-•-•---•-•----------•••-•--•.................•-------------
W
U Nature of Repairs or Alterations—Answer when applicable-.:° __. g^d _? `" !-_-'�----�Z_C __�G"�
-•- ,.
------------------------------------•-------------------•--•---•-----•--------------............--------•------------------------------------------------------------------------ ...................... v f
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of T T CIE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance ha�bn sued b e boa It
Signe .. ---•-- - t l
Application Approved BY........
2
Date
Application Disapproved for the following asons:............................................................................................Da--............
_
--•----•--•---------------------------••----•------------•--•--------------•-------------....-•-------•--I---•-------•------••••-•----•-----•-•---•-----•-••••--•-•---------•------•••-••---•-•----------
9 -77 Date
// ' ISSIlt't1 J v'��
Permit No..... . ....... ••. • --••- f
Date
No.... :.. :? FEs............._............_.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
-------....................................OF..........................................------.••-•-•---..............................
Appliratiaan for Uh4paaal Works Tnnstxnrtiaan rumit
Application is hereby made for a Permit to Construct ( ) or Repair (� Individual Sewage Disposal
System at: I
----••-•-•-..._..•-••••••••--•---- -•-•••••-•.....- _ -...----•---- ••.....-•-•••-•-•-... ..--•------ -------- ` .. •--••--••-••-
• L9cation-Address or Lot No.
................................................................................................. .........._................_...__._..........---••--...._.._'_____......_..._.._._......_..__...__
/ Owner Address
Installer Address
Q Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms.._......_�..........................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building ........... No. of persons............................ Showers — Cafeteria
a Other fixtures -----------------•-------------- -
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................
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........................
G Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-.-______._-___•-_••_---
W' •--------•••---•••---•--------•-•-••••••••-•-•-••----••-••••-•-••--•••-•---•-••-••--•-•-•.._..•••.........................................................
0 Description of Soil........................................................................................................................................................................
x
W -•••-•-•----------------•------•••--•-••-••--•-------------------••--•--•---•-----•-......•-••-••--•--••-----------•----•---•_------••-•-•-•••--•--•-•••--••---- ••. -------•••-•-
UNature of Repairs or Alterations—Answer when applicable_ '__.... ..`. `.. ..
------------------------------------------------------------------------------------------•---•--------•-•--...---•-------------------------------------------------------------------------------•----
Agreement:
The undersigned agrees to install the afor edescribed Individual Sewage Disposal System in accordance with
the provisions of TiT�..7 ;of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has beef,issued by-the boa ealth.
�!
Signefl �:-----�..... '--•-------------••--------•--- ,�-----••---------•--
�— D to
Application Approved B 1 /-- f� C-
Date
Application Disapproved for the following �easons:.............................................................................................................----•••-------•-•----•-••-•.............••••......._.__
..........................................
-----------------------•--------•------•---------•-•-•----......--••-•---------•--------•--------------...---------------------------........................
....................
r Date
Permit No..•.(:..� -----`-=-- - Issued r��..: z=Z,- 0
Date
THE COMMONWEALTH OF MASSACHUSETTS
�� BOARD OF HEALTH
.....0 ......._................0F........... .f..:.'.`'f 1' ..............................................
Tnrtifiratr of TI-Implianrr
THIS IS TO GFR IFY, That the Individual Sewage Disposal System constructed ( ) or Repaired }
> Installer
CLvra 11�ram,at •-•-------•----•---•--•-•••-•-•--•--•--•••-•----•--•...-•-•---•••-••-•----•••--•. .
has been installed in accordance with the provisions of TI_T 1E 5 of he State Sanitary Code as describes}' in the
application for Disposal Forks Construction Permit No...
................ dated_._` _`._._c.C._::_.............................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT YHE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................. -�r--•-- i.. ..----.••.... Inspector------------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
FE - •...
Dispaasa1 Work,Tonstrnrtiaan Upamit
Permission is he by granted..........t-r_ i .�_....t, i t - ---•_-----••................................•---•---.........---•--.........................
to Construct ( ) or epair ,, ).an Individual Sewage Disposal System
atNo................?_..............._............. .�_.____•/-_-,....I.._...... A_. ._.. ._ .—I.................................... _._._...___. _._._. ..._....
Street
as shown on the application for Disposal Works Construction Permit No. _....._ :..-.__. Dated,._.._........ .z..................b
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'f � . ,>� BTard of Health
DATE......t Z1.�'•-- ......."`
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
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LOCATION 46:70 -- SEWAGE PERMIT NO.
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01. LAG E
INSTAL/L/E/R'S NAIME & ADDRESS
R U I L D E R OR OWNER
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED 4 /„ M
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