HomeMy WebLinkAbout0047 MARASPIN ROAD - Health 47 Maraspin Road
Barnstable
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
47 Maraspir Road
Property Address
John Hardacrei. j
Owner Owner's Name l
information is r Barnstable MA 02630 06/07/14
required for every
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. General Information
filling out forms
on the computer,
use only the tab 1 Inspector:
key to move your
cursor-do not Trevor Kellett I
use the return Name of Inspector
key.
Aardvark Environmental Inspection
Company Name
P.O. Box 896
Company Address
ORO East Dennis MA 02641
City/Town State Zip Code
508-385-7608 S113744
Telephone.Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000).The system:
® Passes , ❑ Conditionally Passes ❑ Fails
- t
❑ Needs Further Evaluation by the Local Approving Authority 1
06/12/14
Inspector's ignature Date .
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP.The original should be sent to the system owner
and copies sent to the buyer,if applicable, and the approving authority.
• ***"This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•3113 Tdie 5 Olficiai inspection Form:Su da Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments `
a s 47 Maraspin Road
Property Address
John Hardacre
Owner Owner's Name
information i e
required for every Barnstable MA 02630 06/07/14
page. City/Town State Zip Code Date of Inspection
B. Certification (cunt.)
Inspection Summary: Check A,B,C,D or E/ahvays 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:
I
i
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired.The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Check the box for"yes", "no"or"not determined_"(Y, N,ND)for the following statements. If"not
determined,"please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of`
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
47 Maraspin Road
Property Address
John Hardacre
Owner Owner's Name
information is required for every Barnstable MA 02630 06/07/14
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational.System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(S) are replaced ❑. Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y '❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4,times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
6
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
. 47 Maraspin Road
Property Address
John Hardacre -
Owner Owner's Name
information is required for every Barnstable MA 02630 06/07/14
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cunt.)
2. System will fail unless the Board of Health(and Public Water Supplier,if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of.a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must
be attached to this form.
3. Other:
t
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® 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 day flow
t5ins•3113 rtle 5 Qtfidal Ins Fors::Sut—surface Lkpam—I&N--,-Rag A of 17
Commonwealth of Massachusetts
ug47Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Maraspin Road.
l -
Property Address
John Hardacre
Owner Owner's Name
information is required for every Barnstable MA 02630 06/07/14
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No ,-
❑ ® Required pumping more than 4 times in the last year RIOT 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.
El ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
I
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis,performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303,therefore the system fails.The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure. 4
Ef Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems,you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ El the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed.The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3l13 Title 5 Official Ins pedon Form:Subsurface Sewage Disposal System•Page 5 of 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�.' 47 Maraspin Road
Property Address
John Hardacre
Owner Owner's Name
information is required for every Barnstable MA 02630 06/07/14
page. City(rown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection? .
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
• ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located.on site?
i
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions,depth of liquid,depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field(if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330
t5ins•3/13 Title 5 Official insp
ection Fonn:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
47 Maraspin Road
Property Address
John Hardacre
Owner Owner's Name
information is required for every Barnstable MA 02630 06/07/14
page. City/Town State Zip Code Date of Inspection
D. System Information
Description: ,
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?(Include laundry system inspection El Yes ® No
information in this report.) l
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: 05/14
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available: _
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
r -
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
47 Maraspin Road
Property Address
John Hardacre
Owner Owner's Name
information is required for every Barnstable MA 02630 06/07/14
page. City/Town State Zip Code Date of Inspection
D. System Information (cunt.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank,distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy.
❑ Shared system (yes or no) (f 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
inspi lion of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Fora
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
47 Maraspin Road
Property Address
John Hardacre
Owner Owner's Name
information is required for every Barnstable MA 02630 06/07/14
page. City/Town State Zip Code Date of Inspection
D. System Information-(cont.)
Approximate age of all components,date installed (f known) and source of information:
35 years
Were sewage odors detected when arriving at the site? ❑ Yes ❑ No
Building Sewer(locate on site plan):
Depth below grade: 2.9
feet
Material of construction:
cast iron 40 PVC + other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade: 1.8
feet
Material of construction:
® concrete ❑ metal' ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
1000 gal
3"
Sludge depth:
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
47 Maraspin Road
Property Address
John Hardacre
Owner Owner's Name
information is required for every Barnstable MA 02630 06/07/14
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cunt.)
Distance from top of sludge to bottom of outlet tee or baffle
28"
Scum thickness
2".
Distance from top of scum to top of outlet tee or baffle
5"
Distance from bottom of scum to bottom of outlet tee or baffle
14"
How were dimensions determined?
Comments(on pumping i recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert,evidence of leakage, etc.):
The tank was sound and tight with tees in place and liquid at outlet invert.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
r.y 47 Maraspin Road
Property Address
John Hardacre
Owner Owner's Name
information is required for every Barnstable MA 02630 06/07/14
page. Cityfrown state Zip Code Date of Inspection
D. System Information (cunt.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
i
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order. ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3/13 Title 5Official Inspection Form:Subsurface Sma a Disposal gSystem•Page 11 of 17
.r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�•' 47 Maraspin Road
Property Address /
John Hardacre
Owner Owner's Name
information is required for every Barnstable MA 02630 06/07/14
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
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.):
No box present
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 wonting order, system is a conditional pass.
Soil Absorption System(SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 ..
Commonwealth of Massachusetts
Title 5 official Inspection Fora
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M s 47 Maraspin Road
Property Address
John Hardacre
Owner
Owner's Name
information is required for every Barnstable MA 02630 06/07/14
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number,dimensions:
❑ overflow cesspool number:
❑ innovative/altemative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of
vegetation, etc.):
This system has a 6'x6' precast pit surrounded by a foot of stone. There was a foot of liquid with a
stainline 30'below the inlet invert.There was no sign of ponding or failure.
Cesspools (cesspool must be pumped as part of inspection)Qocate on site plan):
Number and configuration
Depth-top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Insp
ection Form:Subsurface Sewage Disposal System•Page 13 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
47 Maraspin Road
Property Address
John Hardacre
Owner Owner's flame
information is required for every Barnstable MA 02630 06/07/14
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cunt.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
,
t5ins:3/13 Title 5 Official Insp
ection Forth:Subsurface Sewage Disposal System•.Page 14 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
47 Maraspin Road
Property Address
John Hardacre
Owner Owner's Name
information is required for every Barnstable MA 02630 06/07/14
page. City(rown State Zip Code Date of Inspection
D. System Information (cunt.)
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
rear
16
47
�I
49
49
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
47 Maraspin Road
Property Address
John Hardacre
Owner Owner's Name
information is required for every Barnstable MA 02630 06/07/14
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
❑ Surface water _
® Check cellar
❑ Shallow wells
Estimated depth to high ground water. 20.0
feet
Please indicate all methods used to determine the high ground water elevation:
t
❑ 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:
USGS maps show an elevation of over 20.0 feet.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-3113 Title 5 Official Inspeclion Forth:Subsurface Sewage Disposal System-Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
47 Maraspin Road
Property Address
John Hardacre
Owner Owner's Name
information is required for every Barnstable MA 02630 06/07/14
page. CitylTown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary:A, B, C, D,or E checked
® inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
3
T i
I Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
47 Maraspin Road
Property Address
Estate of Paul Kelly
Owner Owner's Name
information is required for every Barnstable MA 02632 4/16/12
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 forma
Important:When filling out forms A. General Information ;
on the computer, I
use only the tab 1. Inspector: q
key to move your
cursor-do not Mike DeCosta Jr.
use the return Name of Inspector ,
key.
Wind River Environmental
Company Name
1958R Broadway
Company Address
Raynham MA 02767
City!Town State
P
Zi Code'
508-822-2003 13230
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal.system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection.
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5,(310.CMR 15.000). The system:
LIJ
® Passes ❑ Conditionally Passes ❑ Fails
E: ❑ Needs-Further Evaluation by.the Local Approving Authority
4/16/12
r sped is Signature Date
CC)
The system inspector shall submit a copy of this inspection'report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report.to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under .
the same or different conditions of use.
t5ins•11/10 Title 5 Off al Ins ion Form:Subsurface Sewage Disposal System.•Page:1 of 17
f
4
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not.for Voluntary Assessments
°M 47 Maraspin Road
Property Address
Estate of Paul Kelly
Owner Owner's Name
information is required for every Barnstable MA 02632 4/16112
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section.D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
Both inlet and outlet covers 16 below grade.No filter installed on outlet. Recommend installing 1'
riser on outlet and to install a filter on outlet.
B) System Conditionally Passes:
❑ One or more system'components as described in the"Conditional Pass" section need to be
replaced or repaired. The system,upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined,"please explain.
The septic tank is metal and'over.20 years old' or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial,infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank`will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ .ND (Explain below):
t5ins•11/10 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
-y 47 Maraspin Road
Property Address
Estate of Paul Kelly
Owner Owner's Name
information is required for every Barnstable MA 02632 4/16/1.2
page. CitylTown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.): -
❑ Observation of sewage backup or breakout or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ _ broken pipe(s) are.replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N `❑ ND (Explain below):
❑ The system.required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:_
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a.surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins-11/10 Title 5 Official Inspection Form:,Subsurface Sewage Disposal System-Page of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments,
47 Maraspin Road
Property Address
Estate of Paul Kelly
Owner Owner's Name
information is required for every Barnstable MA 02632 4/16/12_
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cost.)
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:
0 The system has a septic tank and soil'absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary.to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private,water .
supply well..
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria-indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or".No"to each of the following for all inspections:
Yes No
Backup of sewage into facility or system component due to overloaded or
El E .clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters
El ® due to an overloaded or clogged SAS or cesspool 11
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ E Liquid depth in cesspool is less than 6" below invert or available volume is less.
than '/z day flow
t5ins-11/10 Title 5 Official Inspection Form.'Subsurface,Sewage Disposal System•Page 4.of 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
47 Maraspin Road
,M Property Address
Estate of Paul Kelly
Owner
Owner's Name e s a e
information is required for every Barnstable MA 02632 4/16/12
page. Cityrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or,
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.,
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50,feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no.acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd'to 15,000 gpd.
For large systems, you must indicate either"yes"or"no" to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
:❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
El ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone 11 of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of'any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 5 of 17
of Massachuse
Commonwealth tts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 47 Maraspin Road
Property Address
Estate of Paul Kelly
Owner Owner's Name
information is required for every Barnstable MA 02632 4/16/12
page. City/Town State Zip Code Date of Inspection "
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
® ❑ Pumping Information was provided by the owner, occupant, or Board'of Health
® Were any of the system components pumped out in the previous two weeks?.
❑ Has the system received normal flows in the previous two week period?
® Have large volumes of water been introduced to the system recently or as part of
this inspection?
El N/A" 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.
® El Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Info;rmation
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 1.10 gpd x#of bedrooms): 330gpd
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
47 Maraspin Road
Property Address
Estate of Paul Kelly
Owner Owner's Name
information is required for every Barnstable MA 02632 4/16/12
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 0
Does residence have a garbage,grinder? ® Yes ❑ No
Its laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonaluse? ❑ Yes E No
Water meter readings, if available(last 2 years usage (gpd)):
Detail:
Unavailable, no one living in home.
Sump pump? ❑"F Yes ® No
Last date of occupancy: October 2011
Date
Commercial/Industrial Flow Conditions:
Type of.Establishment:
Design flow(based on 310 CMR 15.203):
per day d Gallons
P Y�9P )
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•11/10 Title 5 Official Inspection Form;Subsurface Sewage Disposal System Page 7 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 47 Maraspin Road
Property Address
Estate of Paul Kelly
Owner Owner's Name
information is required for every Barnstable MA 02632 4/16/12
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: Wind River Environmental
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped` 1000
gallons
How was quantity pumped determined? previous pumping records
Reason for pumping: to check structural integrity of septic tank
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):
Septic tank-Leach pit
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
47 Maraspin Road
Property Address
Estate of Paul Kelly
Owner Owner's Name
information^s Barnstable MA 02632 4/16/12 .
required for every _
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
1970's per owner
Were sewage odors detected when arriving at the site? ❑ Yes 0 No -
Building Sewer(locate on site plan):
Depth below grade:. 3
feet
Material of construction:'
® cast iron ❑ 40 PVC ❑ other(explain):
0.1
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
All joints sealed, no evidence of leaking. Vent on roof. ,
Septic Tank(locate on site plan):
16„
Depth below'grade: feet
Material of construction:
®concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) , ❑ Yes ❑ No
Dimensions: 8 x 5' x 4
4'
Sludge depth:
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form '
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 47 Maraspin Road
Property Address
Estate of Paul Kelly
Owner Owner's Name
information is required for every Barnstable MA 02632
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
30"
Scum thickness 2�"
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle 20'
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.):
Both inlet and outlet covers 16" bg. No filter installed on outlet. Liquid level normal with minimal
solids and sludge. Tank is structurally sound and not leaking. I Recommend installing two- 1' buildups
on inlet and outlet covers. Also,install'a filter.on outlet and tank should be serviced annually.
Grease Trap (locate on site plan): -
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑.fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System form - Not for Voluntary Assessments
,M 47 Maraspin Road
Property Address
Estate of Paul Kelly
Owner Owner's Name
information is Barnstable MA 02632 4/16/12
required for every '
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
_ V I
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete. . ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons-per day
Alarm present: ❑ Yes ❑ No
Alarm level.' Alarm in working order: ❑ Yes `❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches,etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes. ❑ No
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
47 Maraspin Road
Property Address
Estate of Paul Kelly
Owner Owner's Name
information is required for every Barnstable MA 02632 4/16/12 -
page. City/Town State Zip Code Date.of Inspection-
D. System Information .(cont)
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert
Comments (note if box is level and distribution to outlets equal, any,evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes . ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan;excavation not required);
If SAS not located, explain why:
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 47 Maraspin Road
Property Address
Estate of Paul Kelly
Owner Owner's Name
information is required for every Barnstable MA 02632 4/16/12
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: one-6'x 6'
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil,-signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Dry sandy soil, no signs of hydraulic failure. Pit has 2' of liquid in it. Staining in pit indicates that the
liquid level has been higher than 3'._Pit in good working condition.
Cesspools (cesspool must be`pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of,Massachusetts
Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
.,M
47 Maraspin Road
Property Address
Estate of Paul Kelly
Owner Owner's Name
information is required for every Barnstable MA 02632 4116/12
page. City/Town State Zip Code Date of Inspection
D. System Information (cont:)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, .
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure,,level of ponding;condition of vegetation,,
etc.):
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
� n
Title 5 Official Inspection Form
y a:
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
el� f 47 Maraspin Road
q Property Address
Estate of Paul Kelly
. :. Owner
Owner's Name
7s uiformation is
required forevery Barnstable MA 02632 4/16/12
f Ci rr page ty own State Zip Code Date of Inspection
` r D. System Information (cont)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
atleasttwo 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 z
K ❑ drawing attached separately
i 7 1 4Y
t
r
.. .... ...._..... .fit J
t
y' ,f r
I '
.. _ ...._ .. .
i
' ,b.,i - .. � ,.Gs 5 pC ii6'•,eprC•' . 1.:,.,rtlG.Sa,dy: s„+ Srs e a;;r.+...., ' -
f
L
r
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 47 Maraspin Road
Property Address
Estate of Paul Kelly
Owner Owner's Name
information is required for every Barnstable MA 02632 4/16/12
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: 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 USES database -explain:
You must describe how you established the high ground water elevation:
Approximatly 13' to the bottom of the leach pit. Pumped pit dry and observed no groundwater flow.
Before filing this Inspection Report, please see Report Completeness Cliecklist on next page.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 47 Maraspin Road
Property Address
Estate of Paul Kelly
Owner Owner's Name
information is Barnstable MA 02632 4/16/12
required for every
page. CttylTown &j3 State Zip Code Date of Inspection
E. Report Completeness Checklist'
® Inspection Summary- A,-B,.C, D,ror E checked .
® Inspection Summary fD (System Failure Criteria Applicable to All Systems) completed'
® System Information- Estimated depth to hgh:groundwater;
® Sketch of Sewage Disposal System either"drawn on page 15 or attached in separate file }.
.. a tl•
4
a
t5ins•11/10 Title 5 Official.Inspection Form;Subsurface Sewage Disposal System•Page 17 of 17
..
-THE COMMONWEALTH OF MASSACHUSETTS _
BOAR® OF HEALTH
f.U . __..._.......OF......... __'_ V_6 Y
Appliration for Ui_n giitti Workii Cnomitrurtion Prruid
r Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal
System at
Location_Ad ess _ or No.
---------------------------15-4---;---------------- �--- �y,� .. -�-•L•---
!taller --------_------------------ /C �� Address ...................................
-
Ins
UTypeof Buildin� Size Lot............................Sq. feet
Dwelling—No. of Bedrooms-------------7............................Expansion Attic ( ) Garbage Grinder ( )
P4 Other—Type of Building ............................ No. of persons---------4'f_'-------------- Showers ( ) — Cafeteria ( )
a' Other fixtures ------------------------------------------------------
w Design Flow_____________� ._.____.._..________gallons per person per day. Total daily flow.....2-�7:!a_p--___________-.------.-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..........i(--------- Diameter. 9n e t below inlet_:/000_ __4otal leaching area._-_____._--___sq. ft.
z Other Distribution box ( ) , '''1i77ostng tan c ( [�
Percolation Test Resul • 4em�*b _ -- ------------------------------------------------------------- Date- ---- P P gTest Pit No. 1 -__ F e th of Test Pit____________________ Depth to round water_..____________.-..__...
f14 Test Pit No. 2_::__+�rminutesper inch , Depth of :Test Pit____________________ Depth to ground water__.-_----__-._--____.---
�; ---------- ----------- ------------------------•-•--••-=-•---•-•--•--•---•---••-•--••-••--•...•------------•-------•-•-•-••------..-----------------------
O Description of Soil--------------- _Z=_------------ ----__--
- - ------------------------------------------------------------------------------------
x ------------- 1�� --------1
c, ------
w
VNature of Repairs or Alterations—Answer when applicable.-----------------------------------------------------------------------------------------------
--------------------------------------------------------------------- ---------------------------------------------- -------------
Agreement: -
The undersigned agrees to install the _aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article NI 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 o d of health.
Sign d_..ld!_! `� `d( �./ 1 ✓ / 7T
D to
Application Approved By--...._ ..., -_ -- - .................. /y_ �
Date
Application Disapproved for the following reasons:..........................
---•---._._..---••-•--•-•-••.....................•--•--------•--•---------•---•-•---•--------•-------•--•-----------------------------------------------------------•--------------------------------
Date
7 � �
Permit No......................................................... Issued.....�C- E.•----- -- .....................
Date
L------------------------------------------------------------------
' r o.- v FEE...I'd...............
,�-.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
------ OF... .... ........ ......
Appliratiun for :11!ivuiittl works To'witrnrtinn Vrrmft
Application is hereby made for a Permit to Construct ( or Repair ( } an Individual Sewage Disposal
System at
r3� �/f:xs�' 'f,i1 - ' ------------------------•-----..._..-------...------•----...
�f Location Address or Lot No
gas
_C ;�P --------------- --•---------1( -........
Installer• ' Address
UType of Building Size Lot-..-..........................Sq. feet
Dwelling= o. of Bedrooms............. Attic ( ) Garbage Grinder ( )
A., Other—Type of Building ____________________________ No. of persons........... --------------- Showers ( ) ,Cafeteria ( )
QI Other fixtures --------------•----------------- -- -- - - - - -- - -
Design Flow................ -__S ____________________gallons per person per day. Total daily flow...... '_t .......................gallons.
WSeptic Tank—Liquid capacity_1 ._gallons Length---------------- Width................ Diameter------.......... Depth__...-_--_---
x Disposal Trench—No- ____________________ Width.....--------------- Total Length--____-__-_______--- Total leaching area--------------------sq. ft.
Seepage Pit No..........I........ Diameter...... t �Depth below inlet---fl0"OP _��etal leaching area------------------S . ft.
z Other Distribution box ( t t 1!
a Percolation Test Ri tVP tD Date-----------==-
Test Pit No. I__�4:5--__m ma e inch Depth of r in "Pest Pit.................... Depth to ground wate-...-------_--.--_------
(.Tq Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water-_.----.--_-.---..._.. -
O Description of Soil-------_--------- :! ________.__
C.
V ._..... *_
a•-• - - ------
------------------------------------------------------------ ---__;-----------------------------------------------------------------------------------------------------------
U Nature of Repairs or Alterations—Answer when applicable---------------------------------------------------------------------------------------------
----------------------------:-----------•-------••-------------_-------------•-----------------••----------_----------------------•-------•----------•....------•--------------------------------__-----------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article aI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Com liance has been issued byWtheoad of health ��S ,��•��Yy9� r,•s . .. i&t4s /�A:-- /' I _
Gtil�t• • I -
Application Approved B ---•-------------•-----•--= -•=-=•------••--
.
...................
.....
Date
Application Disapproved for the following reasons--------------------------------------............................................................................
-Date
PermitNo......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.................OF..... �f2:5 r
QIrrtif iratr of TlImplianrr
TIT6,�S_T,O CER Y F the Individual Sewage Disposal System constructed (- or Repaired ( ).
by...._..l '"�'` �.,. /.} ----- ----------------------- ----------
�T ,?P Installer .w E'
at ------------------------- a
has been installed in accordance with the provisions.of Articles JI f.The State Sanitary Code as described in the
application for Disposal Works Construction Permit No...... .......:...................... dated..._.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUAZA TEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.. Inspector C-- •,, _
.L
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
p... ...yi.....of...... �t. � .......................
No.- ►� -•-•-••-- FEE.--)4..............
Di� nett n k,i Ln strurtion Vrrmit
Permission is reb ranted__._. /
Y g 7� L�{ --------------------------------- ---------------------------
to Construct or epair M an Individual Sewa tsp ys
at No:b" v$ r ..���/¢ i Z
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Street
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FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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V �,, TO THE tNSPECTOR ' f 'BUILDINGS x `� ,vt. `f . ,
.;,, Tfie undersigned hereby applies fora permit. according-to the following information:
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