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Commonwealth of Massachusetts
- F Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a
29 Otter Ln. a
Property Address
Peter Kanavos
Owner Owner's Name
information is Barnstable
required for every MA 02601 9/25/2018 , I„ .
page. Cltyrrown State Zip Code Date of Inspection
ED
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 n
p 33 U0
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.
Company Address
West Yarmouth MA 02673
Alf Cltyrrown State Zip Code `
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
10/1/2018
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.
t5insp.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
� .•' 29 Otter Ln.
Property Address
Peter Kanavos
Owner Owner's Name
information is Barnstable
required for every MA 02601 9/25/201 S
page. Cltyrrown State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
System 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):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 2 of 18
r
Commonwealth of Massachusetts
lg Title 5 Official 'Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
29 Otter Ln.
Property Address
Peter Kanavos
Owner Owner's Name
information is
required for every Barnstable MA 02601 9/25/2018
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (coat.)
2) System Conditionally Passes (cont.):
ElPump 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 P ❑ ❑ ❑ below):
❑ The system required pumping more than 4 times a,year due to broken or obstructed pipe(s). The.
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
� • 29 Otter Ln.
Property Address
Peter Kanavos
Owner Owner's Name
information is Barnstable.
required for every MA 02601 9/25/2018
page. Clty/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 aseptic tank and SAS and the SAS is Jess 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
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
29 Otter Ln.
Property Address
Peter Kanavos
Owner Owner's Name
information is Barnstable
required for every MA 02601 9/25/2018
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than %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. I have determined that one or more of the-above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ 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
r
Commonwealth of Massachusetts
in
Title 5 Official Inspection Form
Flo Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
29 Otter Ln.
Property Address
Peter Kanavos
Owner Owner's Name
information is Barnstable
required for every MA 02601 9/25/2018
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?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption.System.(SAS)on the site has
been determined based on:
® ❑ Existing information. For example,.a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc-rev.7/26/2018 Title 5 Ofric:al Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�� Ia Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
29 Otter Ln.
Property Address .
Peter Kanavos
Owner Owner's Name
information is Barnstable
required for every MA 02601 9/25/2018
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms(design): 7 Number of bedrooms (actual): 6
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 110x7=
770gpd
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system?(Include laundry system inspection Yes ® No
information in this report.)
Laundry system inspected? ® Yes ❑ No
Seasonal use?
® Yes ❑ No
Water meter readings, if available usage last 2 y g ears 2016=112gpd
( (9Pd))' 2017=55gpd
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Unknown
Date
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
29 Otter Ln.
Property Address
Peter.Kanavos
Owner Owner's Name
information is ry Barnstable
required for eve MA 02601 9/25/2018
page. City/Town 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 Z No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
l5insp.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
.` Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
29 Otter Ln.
Property Address
Peter Kanavos
Owner Owners Name
information is required for every Barnstable MA 02601 9/25/2018
page. Cityfrown State Zip Code Dated 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:
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 2111
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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18
Commonwealth of Massachusetts
ti (o Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
29 Otter Ln.
Property Address
Peter Kanavos -
Owner Owner's Name
information Is required for every Barnstable MA 02601 9/25/2018
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 10"feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑'polyethylene El 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:
2000Gal
Sludge depth: 3-411
Distance from top of sludge to bottom of outlet tee or baffle
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
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.):
2000Gal tank in good condition. PVC tees in place and clean. Tank at normal operating level. Covers
8" below grade.
t5insp.doc-rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection .Form
a Subsurface Sewage Disposal System form-.Not for Voluntary Assessments
29 Otter Ln.
Property Address
Peter Kanavos
Owner Owner's Name
information is required for every Barnstable MA 02601 9/25/2018
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
Design Flow: gallons per.day
15insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
. •°° 29 Otter Ln.
Property Address
Peter Kanavos
Owner Owner's Name
information is Barnstable
required for every MA 02601 9/25/2018
page. City/Town 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.):
* I
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert Oil
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.):
2-H-10 DB-Ts on this system. Both boxes clean and level with minimal solids carryover: Each box
feeds 1 Leach pit. No sign of overloading or hydraulic failure. Covers 1' below grade.
A
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
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
29 Otter Ln.
Property Address
Peter Kanavos
Owner Owner's Name
information is required for every Barnstable MA 02601 9/25/2018
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No"
Alarms irrworking 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: 2-6x8
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number,dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
I Type/name of technology:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 13 of 18
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
29 Otter Ln.
Property Address
Peter Kanavos
Owner Owner's Name
information is every
Barnstable
required for eve MA 02601 9/25/2018
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
2-6x8 Pits with stone. No standing effluent in pits during inspection. No evident staining. No sign of
overloading or hydraulic failure.
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
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
29 Otter Ln.
Property Address
Peter Kanavos
Owner Owner's Name
information is required for every Barnstable MA 02601 9/25/2018
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�" 4a Subsurface Sewage Disposal System Form -Not for Voluntary.Assessments
29 Otter Ln.
Property Address
Peter Kanavos
Owner Owner's Name
information is
required for every Barnstable MA 02601 9/25/2018
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
f
Commonwealth of Massachusetts
,p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form=Not for Voluntary Assessments'
29 Otter Ln.
Property Address
Peter Kanavos
Owner Owner's Name
information is required for every Barnstable MA 02601 9/25/2018
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: +141
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:
Hand auger 4' below bottom of dry pit with no water encountered. Max bottom of pits is 10'.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
r
Commonwealth of Massachusetts
,P Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
29 Otter Ln.
Property Address r
Peter Kanavos
Owner Owner's Name
information is required for every Barnstable MA 02601 9/25/2018
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
l5insp.doc•rev.7/26/2016 Tille 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
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Cape Cod Septic Services Inc. Invoice
350•Route 28
W. Yarmouth MA 02673
Date Invoice#
9/25/2018 5932
Bill Address Service Address
PETER KANAVOS PETER KANAVOS
106 HANCOCK BRGE PKWY D15-543 29 OTTER LANE
CAPE CORAL,FL.33990 BARNSTABLE,MA 02601
561-252-8526
P.O. No. Terms
Due on receipt
Description Rate Amount
Machine use to expose septic tank,distribution box,leach pit for inspection services.Install riser 944.00 944.00
onto all components to bring covers to within 6"of grade-$650.00
Title 5 septic inspection of system-$269+$25 Town fee =$294.00
An interest charge of 1.5%per month(18%per annum)will be charged on all invoices over 30 days.If any invoice remains unpaid
for more than sixty(60)days and is referred to Legal Counsel for collection;then,in addition to the unpaid billing and accrued Total' $944.00
service charges,the above signed further agrees to be responsible for all costs of collection,including all legal fees incurred by
Cape Cod Septic Services Inc.
Phone# Fax# Payments/Credits $0.00
508-775-2825 508-775-0424 Balance Due $944.00
f
Cape Cod Septic Services Inc. Invoice
350-Route 28
W. Yarmouth MA 02673
Date Invoice#
10/3/2018 5933
Bill Address Service Address
PETER KANAVOS PETER KANAVOS
106 HANCOCK BRGE PKWY D15-543 29 OTTER LANE
CAPE CORAL,FL.33990 BARNSTABLE,MA 02601
561-252-8526
P.O. No. Terms
Due on receipt j
Description Rate Amount
DISTRIBUTION BOX REPLACEMENT. . 975.00 975.00
BACKFILLED WITH ONSITE MATERIALS
An interest charge of 1.5%per month(18%per annum)will be charged on all invoices over 30 days.If any invoice remains unpaid
for more than sixty(60)days and is referred to Legal Counsel for collection;then,in addition to the unpaid billing and accrued Total $975.00
service charges,the above signed further agrees to be responsible for all costs of collection,including all legal fees incurred by
Cape Cod Septic Services Inc.
Phone# Fax# Payments/Credits $0.00
508-775-2825 508-775-0424 Balance Due $975.00
A ;
0
BORTOLOTTI ,
765 WAKEBY ROAD,MA STONS MILLS, MA 0 MAY 1 3 1
9g=7
508-771-9399 508-428-8926 FAX: 508-428-9399 rO"AR8AR4grAB
tlH pEpT (E
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIO
PART A
CERTIFICATION
Property Address;-
Date of Inspection: '— / Insp ctor's ame:
nees Namq and Address
�sr
CERTIFICATION STATEMENT:
I certify that I have personally inspected the sewage disposal system at this address and that the informa-
tion reported below is true accurate and complete
p as of the time of inspection. "fhe inspection was per-
formed based on
Pe
my training and experience in the proper function and maintenance of on-site sewage
disposal
po stems. The System:
Passes n
Conditionally Passes
Needs Further Ev anon B t e Local Aproving Authority
Fails
Inspector's Signature: Date:_
The System Inspector shall submit a copy-of this inspection report to the Approving authority within thir-
ty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000.
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional
office of the Department of Environmental Protection. "fhe original should be sent to the system owner
and copies sent to the buyer, if applicable and the approving authority..
INSPECTION M ARY•
A)SYSri
PASSES:
have not found any information which indicates Ihat the system violates any of the failure
criteria as defined 310 C*."R 15.103. Aay failure criteria riot evaluated are indicated -
below.
B)SYSTEM CONDITIONALLY PASSES;
One or more system components need to be replaced or repaired. The system,upon comple-
tion of the replacement or repair,passes inspection.
Indicate yes,nor,or not determined(Y,N,OR ND). Describe basis of determination in all instances. If
not determthedse septic is metal cracked structurally unsound
explainy
p y ,shows substantial infiltration or,
r exfiltration,or tank failure is imminent. The system will pass inspection if the existing sep-
tic tank is replaced with a conforming septic tank as approved by The Board of Health.
Sewage backkup or breakout or]nigh static water level observed in the distribution box.is due .
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. The
system will pass inspection if(with approval of The Board of Health):
r.
P .
C 0
Y
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
,.+� CERTIFICATION (continued)
. Broken pipe(s)replaced
.o;, W&struction is removed
Distribution Box is levelled or replaced
The System required pumping more than four times a year due to broken or obstructed pipe(s).
The systemP Pe will ass inspection if(with approval of The Board of Health):
Broken pipe(s)are replaced
Obstruction is removed
C)FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by The Board of Health in order to determine if
the system is failing to protect the public health, safety and the environment.
1)SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE
SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE
PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 Feet of a surface water
Cesspool or privy is within 50 Feet of a bordering vegetated wetland or a salt marsh.
2)SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER
SUPPLIER,IF APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTION-
ING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 Feet to a surface
water supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and is with a Zone I of a public
water supply well.
The system has a septic tank and soil absorption system and is within 50 Feet of a private
water supply well.
The system has a septic tank and soil absorption system and is less than 100 Feet but 50
Feet or more from a private water supply well, unless a well water analysis for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from
the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm.
D)SYSTEM FAILS:
I have determined that the system violates one or more of the following failure criteria as defined
in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health
should be contacted to determine what will be necessary to correct the failure.
Backup of sewage into facility or system component due to an overloaded or clogged SAS
or cesspool.
Discharge or ponding of efluent 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 clog-
ged SAS or cesspool.
Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2
day flow.
Required pumping more than 4 times in the last year N-01 due to clogged or obstructed
pipe(s). Number of times pumped
-2
;t
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
.PART A
CERTIFICATION (continued)
Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater
elevation.
Any portion of a cesspool or privy is within 100 Feet of a surface water supply or tributary to
a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 Feet of a private water supply well. ; t
Any portion of a cesspool or privy is less than 100 Feet but greater than 50 Feet from a private
water supply well with no acceptable water quality analysis. If the well has been analyzed
to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic
r.. compounds,ammonia nitrogen and,nitrate nitrogen.
E)LARGE SYSTEM FAILS:
The following criteria apply,to a large system in addition to the criteria above:
The design flow of a system is 10,000 gpd or greater(Large System)and the system is.a significant
threat to public health and safety and the environment because one or more of the following
conditions exist:
The system is within 400 Feet of a surface drinking water supply
The system is within 200 Feet of a tributary to a surface drinking water supply.
The system is located in a nitrogen sensitive area Interim Wellhead Protection Area
(IWPA)or a mapped Zone II of a public water supply well.
The owner or operator of any such system shall bring the system and facility into full compliance with the
groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local
regional office of the Department for further information.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM'..
PART B
CHECKLIST
Check if the following have been done:
I/' Pumping information was requested of the owner,occupant,and Board of Health.
_None of the system components have been pumped for atleast two weeks and the system has
been receiving normal flow rates during that period. Large volumes of water have not been
t/ introduced into the system recently or as part of this inspection.
As-built plans have been obtained and examined. Note if they are.not available with N/A. `
The facility or dwelling was inspected for signs of sewage back-up.
_, The system does not receive non-sanitary or industrial waste flow.
_ fXhe site was inspected for signs of breakout. `
All system components,.excluding the Soil Absorption System, have been located on site.
The septic tank manholes were uncovered,opened,and the interior of the septic tank was in
spected for condition of baffles or tees,material of construction,dimensions,depth of liquid,
/depth of sludge,depth of scum.
The size and location of the Soil Absorption System onthe site has been determined based on
existing information or approximated by non-intrusive methods.
-3-
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST(continued)
le The facility owner(and occupants, if,different from owner)were provided with information on
the proper maintenance of Subsurface Disposal System
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM,INFORMATION
FLOW CONDITIONS
RESIDENTjA. Io�
Design Flow: gallons Number of Bedrooms: Number of Current Residents
Garbage Grinder: Laundry Connected To System:/ .G_ Seasonal Use:
Water Meter Readi s, if ailable- �/
Last Date of Occupanrya -e��
CO MERCLAI I NDUSTRIIAL:
Type of Establishment:
Design Flow: gallons/day Grease Trap Present: (yes or no)
Industrial Waste Holding Tank Present:
Non-Sanitary Waste Discharged To The Title V System:
Water Meter Readings, If Available: Last Date of Occupancy:
OTHER: Describe)
Last Date of Occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System Pumped as part of inspection: A)0 1_f yes,volum umped: gallons
Reason for pumping:
TYPFj OF SYSTEM:
J�Septic Tank/Distribution Box/Soil Absorption System
Single Cesspool
Overflow Cesspool
Privy
Shared System(If yes,attach previous inspection records, if any)
Other(explain):
ROX04ATE AGE of all components,date installed(if known)and source of information:
9Sew a odors detected w n arrivingat
-4-
B SU SURFA E C SEWAGE
W GE DISPOSAL
S OSAL SYSTEM INS
PECTION
S ECTION FORM '
PART C
GENERAL INFORMATION (continued)
SEPTIC TANK:
Depth below grade:-,, Material of Construction:✓ concrete metal FRP_Other
(explain)
Dimisions:_./Z SXd,t`5" Sludge Depth: Scum Thickness:s�3
Distance from top of sludge to bottom of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle: /O "
Comments:,(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid
19TI in lation jopoutlet invert structural integrit ,evidence of leakage,etc. aC;Q 0— �CID
//
YA
ij
GREASE T
RAP. ,
Depth
pt Below Grade: Material of Constnuction: concrete metal FRP Other
(explain) — — — —
Dimensions: Scum Thickness:
Distance from top of scum to top of outlet tee or baffle:
Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid
level in relation to outlet invert, structural integrity,evidence of leakage,etc.) -
TIGHT OR HOLDING TANK: c)
Depth Below Grade: Material of Construction:_concrete. metal FRP_Other(explain)
Dimensions: Capacity: gallons Design Flow: gallons/day
Alarm Level:
Comments: (condition of inlet tee,condition of alarm and float switches,etc.)
DISTRIBUTION BOX: (�
Depth of liquid level above outlet invert:
Comments: (note if 19yel and distribution is equal,evidcKcc of solids carryover,evidence of leakage into
or out of box,etc. -,z
PUMP CHAMBER:
Pump is in working order:.
Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.)
-5-
4,0
v
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
SOIL ABSORPTION SYSTEM(SAS): !l*"�
(Locate on site plan, if possible;excavation not required,but may be approximated by non-intrusive
methods) If not determined to be present,explain:
Type:
Leaching pits,number:Leaching chambers; number: Leaching galleries,number:
Leaching trenches, number, length:
Leaching fields,number,dimensions:
Overflow cesspool,number:
Corn ts: (note condition of soil,signs of hydraulic failure level of pending,condition of vegetation,
etc) 2�o GL►� /hr a _a/rin n osvi�Yh
CESSPOOLS:
Number and configuration: Depth-top of liquid to inlet invert:
Depth of solids layer: Depth of scum layer: Dimensions of Cesspool:
Materials of construction: Indication of groundwater:
Inflow(cesspool must be pumped as part of inspection)
Comments: (note condition of soilk, signs of hydraulic failure, level of ponding,condition of vegetation,
etc.)
PRIVY:
Materials of construction: Dimensions:
Depth of Solids:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,
etc.)
-6 -
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C -
SYSTEM.INFO11MATION (conlimicd)
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include ties to atleast two permanent references, landmarks or benchmarks.
Locate all wells within 100 Feet. _
DEPTH TO'GROUNDWATER:
Depth to groundwater: feet /
Method of Determination or Appro 'oration: ni1! 5 ��
-7-
-,-'--y 'Inclk -y p He R Rc--�a I E�-:-+.',+. a r-1 e,r
1 01 Ne J.cl Ii Ll unt-h I-,oc -'.S B ED' i r e 1[1 J s t
L'o 11'. S:1. z ez, 17 Pi-C.'res,
u r r...n t: D LALIF-ZLAL.-C M a t-I-? C 1 Ct 1.
4 .71
I 1\1 CAI'D'L.D I.-"t.N D Al No. _. .I.d g A{"`ela
43. y e (I cl d e d tt
I STNI
. 1.4 T
1 .1, • E TP- GD - !--I c IF D : ed 744S .. ,I , (I . Y l `1H _ P 1. 0
4 zi
(_Aj 1::' T.I-jE; 1-e-0.L(C,s. L.a it
I nid e I _11.90 r in t..g
V-I cJ •5 0 a1........NE"T (.'OVEE L Ar\1E Fr,l-,t g
l `o S utc jpd, 0: k C cintron -1cA L :J ) us, 1st
Land R; v i e Iw e I-All 31 t,.x A....e Ok"I(Y) BlcJlg'_:i Revio.n,.jecil Ely�;' t 9::'
C; 4-Lt,.::
Ta:,.- 'Tit. Le," A c c c)u n t 1". F 1 A c.c c)t_t r,-c. s,,:
L-*?n c: i
XIVIT Fcir d t'a
Nk -rl L
c)a d e,ill 2 oac n di e
Commonwealth of Massachusetts �Rfe/��EQ
Executive Office of Environmental Affairs ggpp
Department of
o RP� ? 2 1997
Environmental Protectio q AB
Wllllam F.Weld
Governor
Trudy Coxeg b
Secretary,EOEA
David S. Struhs
Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
\� CERTIFICATION �.
`y Property Address:pact 0 1 1 'c'Z 1_IAP4 F C Vy� Address of Owner: �1 "� GOL .
Date of Inspection: y�p..ce-7 (If different)
Name of Inspector'_Za�z�6�
Company Name, Address an Telephone Number.
JY\,tJ�(Ap�SF_ 7-o;R<�kq- koAl& bey 4►pa 'S
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was Performed based on my training and experience in the proper function and ,
maintenance of on-site sewage disposal systems. The system:
Passes
_ Conditionally Passes
_ Needs Further Evaluation By the local Approving Authority
Fails
Inspector's Sign Date: 4i(`0-6-7
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this
inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and.the system owner shall submit
the report to the appropriate regional office of the Department of Environmental Protection.
The original should be sen; ic, :ne system owner and copies sent to the buyer, if applicable and the appro ing authority.
INSPECTION SUMMARY:
Check A, B, C, or D:
A] SYSTEM PASSES:
•r I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
B] SYSTEM CONDITIONALLY PASSES:
f
_ One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,'
passes inspection.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not)
The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is -
imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as
approved by the Board of Health.
(revised 8/15/95)
One Winter Street • Boston,Massachusetts 02108 • FAX(617)W6-1049 • Telephone(617)292-5500
%V* Printed-on-Recycled Paper
L
� r
,,r \\
UBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
r t1, + PART A
r,•�� t CERTIFICATION (continued)
R
Proper,4ty Addressl o Gl Ou t t, v�{f Cu t y O&I&vs-o
Owner �Q �Nd�
Date of Inspeitt .
B]SYSTEM CON DITIONA-"Y>►PASSES (continued)
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the
Board of Health):
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
_ The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
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 the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
_ Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
_ the ,v�tem has a sermc tanK ano soil absorption System and is wilhiii 100 feel iv a suliaCc 'wdiri Supp:j o. tributary to a
surface water supply.
The wsten; ha, a septic tank and soil absorption system and is within a Zone I of a public water supply well.
_ The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
_ The systen-, has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water
supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is
free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5
ppm.
D] SYSTEM FAILS:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
(revised 8/15/95) 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: D 0(�'�v �c�� CvVY1
.Owner: Q.1A&;►ob.olQ t�A 0.",c a
Date of Inspection:
D) SYSTEM FAILS (continued):
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
LLiquid depth in cesspool is less than 6 below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of.a cesspool or privy is within a Zone I of a public well..
/y Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
EJ LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above:
The design floe- of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety
and the environment because one or more of the following conditions exist:
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 11 of a
public water supply well:
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the,local regional office of the Department for further information.
�t
Y
(revised 8:/15/95) 3
r Cj
C
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property/A� %%dress: oC 9 D �%L Ltin9__'C ft vi�
Owner: �tl p 10 I
Date of Inspection
�-10-�7
Check if the following have been done:
V Pumping information was requested of the owner, occupant, and Board of Health.
None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
V As built plans have been obtained and examined. Note if they are not available with N/A.
,The facility or dwelling was inspected for signs of sewage back-up.
ZThe system does not receive non-sanitary or industrial waste flow
r/The site was inspected for signs of breakout.
(/AII system components, excluding the Soil Absorption System, have been located on the site.
,The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or
tees,
es, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
` The size and location of the Soil Absorption System on the site has been determined based on existing information or
proximated by non-intrusive methods.
_I he faci;i.� c.,r,C ;3 .�' occupa11- i.d'ere.. from owner) were provided ��ith information on the proper maintenance of Sub
Surface Disposal System.
1
(revised 8/15/95) 4.
•' fi
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: a0\ O 1 11 C�,— -Gv,2, G-)QKAA,"-�-v t C>
fv Owner: %e`a wt o\Q
Date of Inspection:
y-tiO,;7
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 710 Gallons
Number of bedrooms:
Number of current residents: I
Garbage grinder (yes or no):,
Laundry connected to system (yes or no):y
Seasonal use (yes or no):-Y—
Water meter readings, if available: /Y 114
Last date of occupancy:Ot
COMMERCI AUI N DUSTRI AL•
Type of establishment:
Design flow: gallons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non-sanitary waste discharged to the Title 5 system: (yes or no)_
Water meter readings, if available:
Last date of occupancy:
OTHER: (Describe)
Last date of occupancy.
GENERAL INFORMATION
PUMPING RECORDS and.source of information:
"r-e- f�co r ►�S
System pumped as part of inspection: (yes or no)_
If yes, volume primped. gallons
Reason for pumping:
TYPE O�SYSTEM
V 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)
Other(explain)
APPROXIMATE AGE of all components, date installed (if known) and source of information: k Y j
Sewage odors detected when arriving at the site: (yes or no)
(revised 8/15/95) S
L ----
�i
a
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property �dd"ress: 0�C,
Owner: �r1QTN816V
Date of Inspection:
L4-1 6-q7
SEPTIC TANK:
(locate on site plan)
f(
Depth below grade:
Material of construction: :concrete _metal _FRP —other(explain)
Dimensions: D-
Sludge depth: y't /
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: 7 11 -
Distance from top of scum to top of outlet tee or baffler_ �t
Distance from bottom of scum to bottom of outlet tee or baffle:_
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid lev I in relation to outlet invert, structural
integrity, evidence of leakage, etc.) ZTW -- -io S-`z V,5
► Gac,
GREASE TRAP:,L)
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _FRP —other(explain)
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle:
Dktance from bottom ro Fri— 1- hoarrn of otjtlot tee or batlle'
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.)
(revised 8/15/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION-FORM
PART C
SYSTEM INFORMATION (continued)
PropertyAddress: v'Z�i D i i 1=12 �,c�`�-e-CO'^^YV�--@vZ 0
Owner. ���"'�`�
Date of Inspection: R
k
TIGHT OR HOLDING TANK:/ _
(locate on site plan)
Depth below grade:
Material of construction: _concrete_metal _FRP_other(explain).
Dimensions:
Capacity:-gal Ions
Design flow: gallons/day
Alarm level:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:_
(Locate on site plan,
Depth of liquid level above outlet invert:
Comments
(note if ievei and distributi� : > ryua , e� Bence of.solid_ ca:n"o,,er, evidence of leakage into or out of box, etc.)
PUMP CHAMBER:
(locate on site plan)
Pumps in working order.(yes or no)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 8/15/95) 7
1,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: oLq t t �� �_�v ✓►ti���v`�
Owner:
Date of Inspectio : U
SOIL ABSORPTION SYSTEM (SAS):_
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type.
leaching pits, number:A
leaching chambers, number:_
leaching galleries, number:
leaching trenches, number,length:
leaching.fields, number, dimensions:
overflow cesspool, number:
Comments: (note condition of soil, signs of hydraul1'c failure, level of ponding, condition of ve etation,etc.)
S vv►r p L7i� �.�z-�
C, i 6� �1�I r9va.�-civ
CESSPOOLS:
(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 grounds%ate .
inflow (cesspool must be pumped as part of inspection)
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY: T
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised 8/15/95) 8
T
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: vw M V-Qv p
Owner:
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
,a
a
�o
6
DEPTH TO GROUNDWATER
Iv b�vi�jz✓�
Depth to groundwater: U feet �T O CA
method of determination or approximation: r
(revised 8/15/95) 9
r
_ TOWN OF BARNSTABLE
IOCA"1IaC2 7Q C SEWAGE#`"
VILLAGE�/p /�'/� /-�� ASSESSO .'S MAP & L T�S�'
S®E TO7Q�"NAME&PHONE NO
SEPTIC TANK CAPACITYQl) ���io/h� r, s .( /yam ✓1G
v
LEACHING FACILITY: (type) ?�/ ( i, (size)
NO.OF BEDR 7
BUILDER O OWNE
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
c �
�_
Q.i
..
,«j
Y
':
n •I a 1.
J
TOWN OF BARNSTABLE
LOCATION <=;�9 677,, SEWAGE #
VILLAGE cVoi i>f0 1,D ASSESSOR'S MAP Sk LOT
INSTALLER'S NAME & PHONE NO..,F ZZ-� l ('CfV- 771- 9,?9,9
i
-SEPTIC TANK CAPACITY ff4®U w i t
LEACHING FACILITY:(type) i�J 7r (size)v2x�46
LEACHING
NO. OF BEDROOMS --'S— PRIVATE WELL OR LIC WATER "
`'BVILDER OR OWNER �W— Z - �� �
DATE PERMIT ISSUED:
'DATE COLIPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
�t
� e
�� � ��
_�,
,.r
��.ti
.� � ✓� _
,. ��
.. S f
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
, pplirFation for Elhipmal Work i T mitrurtivat Prrutit
Application is hereby made for a Permit to Construct ( ) or.Repair (X) an Individual Sewage Disposal
System at:
.2 9 ®�� '/!/� �vM W,4o°&i Loss i
•.--•-•----•..............1G�...--------------.....--•------------------------...... _..._ ......-----......
Location-Address or Lot No
'�
-4 '
ow Address
7 L� .
--- ... ... ---- .... -------------------- -----..- - ----. 00r t1
..........
Installer
� Address
Type of Building Size Lot_.__...&.%.ktoo...Sq. feet
Dwelling—No. of Bedrooms........FiV.6.........................Expansion Attic (/✓o) Garbage Grinder (.1/)
Other—Type T e of Building No. of persons............................ Showers
a YP g ------•-•----•-------------• P ( ) — Cafeteria ( )
Otherfixtures --------------•-----------------------------------•---.................. -------------------••-----------•--•------------------•-••••............•.
W
Design Flow...................................SS__gallons per person per day. Total daily flow......................5.Z .........gallons.
9Septic Tank—Liquid capacity-MiQ9.gallons LengthJQ�. `�Width.5_�.. ��._ Diameter__.___ Depth_sS 8 ii-.
Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area-___----_-_---.--•sq. ft.
Seepage Pit No....7wc)___-___ Diameter...../.'� Depth below inlet.3�S......_.. Total leaching area. �?.sq. ft.
coy e,t.s n C4�L rusA j/S Six 2 /r
z Other Distribution'�ox ( "j Dosing tank ( ) OF
'~ Percolation Test Results Performed by._:T�.�Jtc.11.,,.y-..lZ�?s?�79..t. JZ.sI � .. «�1sLDate.......•....... . ...........
-_
W
Test Pit No. l.... .......minutes per inch Depth of Test Pit.................... Depth to ground wat _ ___S-TEPHEN
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground wa X ....MLLYN
ESON
Ix ••--•-•------••..................•-----•••••----•-••••••-••-•-•--••-•.....-••••••-•-......----...---..............................
O So l-•--•lc s----`"1 g�No:3d'Zl6
Description of Soil-----�t�'• -�- -- ��.�.�s.�---'�l-�"-'-'t------------------•------------------------------ -
V ......................................................I............................................................................................... 0
'c
QUAL
i U Nature of Repairs or Alterations—Answer when applicable....!S�117/act-_.-_/moo.--fk/.._-r5�07,64_-- _4,,,_�,----_•-
•e 20. sA !__ rnh_�.__ c�___._v}!�_.. . 'c i_hMJ....Icircic►--- ' _uj ._�_�flcc�cl---GcQc�d�7cFns.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of'T T L ;
p 5 of the State Sanitary Code— The undersigned further er agrees not to place the system in
operation until a Certificate of Compliance has been i e by the b r health.
Signed...... �L ` 'L� .........
TDa e
Application Approved By....... (J V .�a.�,..�;*- ...-•----
Date
Application Disapproved for the following reasons:--------••--------------------------------------------------------------------------------•---•-•.............
..............................•-••---•--••---:•---••-•-•-••-•---•••••-•--••-•••-•-•----••--•.....-•••----•-••-••-••............--•-----•••••....
Date
Permit No.•-•...61. JY•2- -
�' Issued.......� ---�-�1--- --- ---._...---
Date
Fim........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
... Gcatil --.....................I........................
. pplirFation for Uiipagtal Works C mitratrtivat ramit
Application is hereby made for a Permit to Construct ( ) or Repair ()() an Individual Sewage Disposal
System at
,,1,7 17 e r P I.F' r"�I ' G /;/d1 r� i' L-7-s I . Z
. ` • -
Location-Address i�' or Lot No.
�.� t•-.• --i�11 C Ii kC�Ui GY .X 1-% Q /. �crr7 C.
.............................. J --•--•_-_------------•--•----------------- ..........____......------- ....._._....._.............------_.............._........._.....
Owner Address
Installer Address
Type of Building Size Lot...._`6_`x.l_.16.00...Sq. feet
Dwelling—No. of Bedrooms.........F1 t.........................Expansion Attic (Alo) Garbage Grinder (,VD
aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
a' Other fixtures ..................................
W Design Flow....................................� __gallons per person per day. Total daily flow.......................S.S.D.........gallons.
WSeptic Tank—Liquid capacity.!rS-2.gallons Length_/Q_:_�"Width-a`'--.�_.Ff.. Diameter..._..==_--_- Depth-S_�-8._.`.
x Seepage Pit No......! ?v. Diamete`r----- ......._. Depth below inlet.15 �....... Total leaching�ar�.k_3.0_.S% ft.
Dis osal Trench—_No. ... ................ > t ..._..............._ of en t ..__......_._.._..._ ota eachln area..._.._.._._.__._____s
P - g g q
z Other Distribution box ( Dosing tank ( ) OF
P 1
Percolation Test Results Performed by._.T__�=_!_�_CLs.lr_.!. t2uJ�`L_ _Lr _ ►«a f ��/ �ate....•........•. . . � ..........
aTest Pit No. 1....4'.......minutes per inch Depth of Test Pit.................... Depth to ground wat ��---STEPHEN
Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground wat ALLY N �0
a, WILSON y
--•-----•-•----------------------•--.......---..............--••-----••-•--•---•---._.........•••---_.._................_...---
O Description of Soil.....� -`-�`n... ' s`' `�`�5 ``== •sc P 1�h No:3021h Q
_ t� `�------------------------------•--------------------------- ..•...
x
x ------ --- --•---•••-- . •-•----•-•----------•-------------•----•--•--•--•----•-•-----•-•---•------•-•---------------•-•---•-••------ -----------------------
U Nature of Repairs or Alterations—Answer when applicable.....1�'`1z AK5;.....ZQ.v0. sly/r.__r_�1- .._.... ��d�
`.....`.. .=... G.....
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of T I T TLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health. ,
Signed...................................................................................... ................................
t Date
Application Approved By.............. --------------------------
Application Disapproved for the following reasons----------------•-------•------------------------------------------------------...-----•.._..............-••-----
i -••----•--------- •••----------------•---•----•-•---••---•------•-------•....--••-..........-•-----••-..............._...-----•--•---•---•-------•--------•----•----•--•-•••-•--•-••---•--•-•---------•.
i Date
Permit No----- .::..�21
_.5.. �
- Issued-------�- == r /--•------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
fL..............oF.............. .....................................
Tuff if iratr of TnmpfiFaatrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired )
by....... .... ......• •••.............
Installer
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No....!g7SL...._ '__�!'._. dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.. ... �..................... .-• --•---•--.. Inspectors:... '1 ? .; ' .- --------------
' - f
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
j
c . .. ��7..............OF.. '
.- .
N&. ........T .
,..G . s �. - .......... FEE.`. _...:.....
{� �i���a��a1 �rk,� C��at��ratr#uaat �erZYti#
Permission is hereby granted --•------••---------------------------- --------.........
�/ .........
to Construct ( ) or Repai ) an Individual Sewage Disposal System
at No`.. ......... �7�- ..I r-
............t-,--Lan ..-y:` 'I! ----------------------•----------•-----------------------•---------.------••--
Street I
as shown on the application for Disposal Works Construction Permit N@7�__ Dated..........................................
........................•--...----. ..-r •-•.....................................................
rp---- Board of Health
DATE------------------------•-------------------•----------------------------1--
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
BAXTER & NYE, INC. L[EUTEQ OF UII MEUUUL
812 Main Street
CISTERVILLE, MASSACHUSETTS 02655
(508) 428-9131
DATE JOB NO.
i 7 Mfrs e��G
ATTENTION
.. Tyr' 1�unni.r
RE:
TO -Swhc
7- (5 r ",R-
Cr LA
yci�nnis
WE ARE SENDING YOU Attached ❑ Under separate cover via the following items:
❑ Shop drawings ❑ Prints A Plans ❑ Samples ❑ Specifications
❑ Copy of letter ❑ Change order ❑
COPIES DATE NO. DESCRIPTION
12 i s/l G /£SS s� h e s sod. l> r:zet°e
fs !to T)is o i Wor Cc- sfrudun Pcrrni>`
73
THESE ARE TRANSMITTED as checked below:
❑ For approval ❑ Approved as submitted ❑ Resubmit copies for approval
I& For your use ❑ Approved as noted ❑ Submit copies for distribution
❑ As requested ❑ Returned for corrections ❑ Return corrected prints
❑ For review and comment ❑
❑ FOR BIDS DUE 19 ❑ PRINTS RETURNED AFTER LOAN TO US
REMARKS
COPY TO 77r L. Y\�C�K-G1eS
SIGNED: a
PRODUCT 240-2 n e Im,cmmn,ores 0leo. 1f enclosures are not as noted, kindly notify us at once.
L 0 A,T 10 Id �2� S E W A G E PE RUIT NO.
Caj!2�/4 Q U 112
VILLAGE
INSTA LLER'S NACIE 8 ADDRESS.
®X I ICJ, ��/1//11fS. /72a9 • ����'� !�
GUILDER OR OW93 ER .
DATE PERMIT 'ISSUEO 61a9l9-Z
DATE COMPLIANCE ISSUED �� I
6- 7
®-19
s ,"
qk
No-... ........
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
0-W.4................oF..... ' ,G ......................................
Appliration for UhivaaFal Workii Cnomitrurtion Famit
Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal
System at:
c� �' .r�
-- ............... s Ge '.---•----------------- ......................................... ....................................................
Location-Address p or Lot No.
a Owne Address
L�
� Installer Address
UType of Building Size Lot._ ,.�P.i�t......Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
pa., Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( .
P4Other fixtures •------------------------------•------------------•---------••---•--•----••-••----•-•--...-•••••................_.........
W Design Flow.............. . .................gallons per person per day. Total daily flow---_.__..---:�_-�-._�.....................gallons.
WSeptic Tank—Liquid capacity!e .gallons Length._A_K.". Width .' `'... Diameter---------------- Depth. -T..".
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area---------------------sq. ft.
Seepage Pit No......./----------- Diameter......�.!f....... Depth below inlet:... Total leaching area.. !P....sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
'—' Percolation Test Results Performed by--G, - .. _ �:............................ Date-Z �.. ../ �
o4 Test Pit No.$A.F9YP minutes per inch Depth of Test Pit---- Depth to ground water......Y..._........
(i, Test Pit No.. ...............minutes per inch Depth of Test pit--- Depth to ground water........................
P4 --•-•-•-•••-••-•-•-•••-•---•••.....................•---••---••-------.....•••---.....:.._.....................................................................
O ��
Description of Soil ®•-� L--- ��'`� _---- ��-..`/Z e......`sue= �1�[ = is ?�7�'
V ?^7... - .A.
W
UNature of Repairs or Alterations—Answer when applicable................................................................................................
-----------------------------------------------------------•-----------------------.................--•-•-••-------•-•--....-----------••-•-•----•••----•-----•-----•---•--......•----•.........---.-•--
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITI.E4 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been i su b the oard of health.
Signed........
-••--- ---------------/--------------------------------•------------------
Date
Application Approved By...... = %�� % .. 6 L..��'�
Date
Application Disapproved for the following reasons-----------------------------•---------------------.----...-----------------------------------------•-•••-----•...
--------------------------------------------------------------------------=---------------------------------•----•-•--•-••-•-••-••---•----•-•--•----••----•----••-••----•••......•--•--••-•----•--..--•-
Date
PermitNo......................................................... Issued_......................................................
Date
Fimic .......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
T1^/A/...............OF...... ► .......................................
Appliration for Di_qpviial 1Vvrko,. (finuitrurtion ramit
Application is hereby made for a Permit to Construct L,-ror Repair an Individual Sewage Disposal
System at:
Z4AIeV- Z07
.................................................................................................. .................................................... ..........................................
W
Location-Address or Lot 0.
V,e, Z,9-,,leC
7f" -�77 F47— - 57M/_-7 161,14-�Al/-S
................................................................................................. ...................................7--------y.....................................
Address
....................... .Ownclr, .......... 4caoale�) ..................................................................................................
6 At
Installer Address CIO Type of Building Size Lot______... ...Sq. feet
U
Dwelling—No. of Bedrooms____.._.___...............................Expansion Attic Garbage Grinder (
0 —Type of Building .................. ... No. of persons........................ Cafeteria (Other Showers
Other fixtures
-----------------------------------------------------------------------------------------------------------------*-------***-------------------
Design Flow............................................gallons per person per day. Total daily flow...._..______..._..._ __._.__________.___gallons.
1:4 Septic Tank—Liquid capacity.! b!?_gallons Length...9-14--- Width.2g'A.i Diameter________________ Depth..6
... .............
x Disposal Trench—No_ .................... Width.................... Total Length___._._-_______.._._ Total leaching area....................sq. ft.
Seepage Pit No......../----------- Diameter______- Depth below inlet...... Total leaching area__t3®g...sq. ft.
Z Other Distribution box ( ) Dosing tank ( )1.4Percolation Test Results Performed by.-. r.,...Pe..� ............................. Date._ , "cM/?
_ -------.......
Test --
I
Pit No. +:��.&�44�_minutes per inch Depth of Test/Pit..... .......... Depth to ground water_--_____- —--------
Test Pit No. ;r..............minutes per inch Depth of Test Depth to ground water_-_________--_._._...
............................................................................................................................................................
0 Description of Soil_.._ 7Z.......6"et7...y_ '7 4 7 "e,r Z:,, —
...... ................................................................................................
?%6" & e " �'rG P- - , I.
U ................................ .................Ir ---------------_.........................................................................................................
...................... .................................................................................................................................................................................
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 TITLE 5 of the State Sanitary Code The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been iEpj-eby the and of health.
Signed..:7ry I ?_3 Tv w v_-
................;,......................................................... ..........................
ate
Application*Approved By...... -------
--------------------------------
Application Disapproved for the following reasons:...............................................................................................I.................
...........................................---------------------................................................................................................................................
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
75 IA/,k/ 619170^1-:5 7A I36 C-
..........................................OF..............................................................I......................
THIS IS TO CERTIFY t_-ror Repaired
.eT41at the Individual Sewage Disposal System constructed
by...................... - ---------------------------------------------------------------------------------------------------------------------7----------7-
_Jnstaller
at---------- "I"
.............. .................................................V1...... ................. ................
has been instilled in accordance with the provisions of TLITIE, 5 of 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 GUARANTEE THAT THE
SYSTEM WIL F 41CTION SATISFACTORY.
DATE.._.. ................................... Inspector.—.—.— ...... ...................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
0 F............
..........................................................................
N 0. FEE.._... ........
DWposal Worh TUInstrndion "pumit
PermissioniVlereby granted-------_; .....................................................................................................
to Construct L__;�,or Repair an,�'Individual Sewage D' al System
.41 0 ys em
...!�-n........... . ......;44-
at No............... ..............2C- ----------------------------------------------------------------*-----------------
Street
as shown on the application for Disposal Works Construction.Permit No._id`�..... Bated..........................................
----------------------------------------
t
DATE........ Z:�.F'j............................................
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
_t
r/+ : TE=;T NOL E LF�Ta
UNOE.�'�FlOU/Vd OT/L /T/ES WE/lE COrlIA--"/L 7.D /W047 I e Dc.- ,•,� 0 , /979 L.l,tr, •:.. r?; ,� c. //i/,,.,•,., T ,r r Id, 1 182. L,/�„c s : /�o., G- ✓
1l&W14A).434E" //Vlw"01j14770n/ A/10 oqilg- rINN/z�x/✓�IrtTE ^ - � Tr_sf G>J, %hn,.,>; 4 Mc/r<y 4,y
ONL V, Z3 e,-0 k L£ CD/tl T✓,e UC T7 O/V CALL //L/G 54 FE ' \ TN .1 TN '�� 7a y.3 Tf1�g Tf-/0.�
/- 800-32z•- 4844
(SOS) �l,o 2- 64 9 8
/ /oar/ �4.3A/ s•n.,i„
6,00
N.
01
\\ .rc rlllacl.-
tea, i G/i7�
�o''`
� ti. I1fJ - lillcc�i.i•.,
(,Ui ozkr)
(No CJa 1n )
z ,
1 32.•
ads 1�, 1 GENERAL NOTES: A107_e
�e•� asap: ad �„
1. THIS PLAN IS FOR DESIGN AND /, Tc: n,ic ihr.,ia rs,,/ fio„ / f;. ys %•,/
33.5 .� iH9 CONSTRUCTION OF THE SEWAGE /E, EG/.✓ .._/ E. /�- � / r. �,�< i'' �.><-
n Zr3f�/Y A1,c Aj /500 Ga//o+� 31 /600 Go7jori S:w/rc Tank DISPOSAL FACILITY ONLY. P�. .,..r '6`8?_-322,
IQ
U \ �L e O ii W 2. ALL CONSTRUCTION METHODS AND 2. L o c a 1�.r,, c N,
` THZ I MATERIALS SHALL CONFORM TO MASS.
\ \ .\ r A 32 Gonr�<c• _ .�JccuAs��lfc t�n/ac -h, D.E.Q.E. TITLE 5 AND LOCAL BOARD 3. �xls Frr,S ': c tic. y�tcw
N \ �!� 3 c+. s" cx/s vol/may q/.Ist, box OF HEALTH REGULATIONS. Sc-phe- ia�k - loco Sa 11,„IL,
\ \ bL
ca rh r f — c1'v r .. ��� or.�0 ew 4 S
3. ALL PIPES SHALL BE SCHEDULE 40
.Gcs/• .r
U 1^ \ \ \\ 31 4 T N 4 T H 5 OR PVC EQUAL.
1\ \ T 3
z_' a, str// 4cu> lcc�O
CONSTRUCTION NOTES: t
IF ENCOUNTERED, ALL UNSUITABLE SOIL
n,r,PFr_ 7"D WITHIN' '. IO
ZONE AROUND THE LEACHING FACILITY
AND SHALL BE REPLACED WITH CLEAN
cp
a SAND AND GRAVEL IN ACCORDANCE WITH
TITLE V.
rl
,
, RY
T.
•a
_ -
T TC
;.. .
� 2. THE EXISTING SEPTIC SYSTEM, WHEN
FOUND, IS TO BE PUMPED DRY & FILLED
I WITH SAND.
_ . I
OF
+ aJ'
S a T E' L._A K) STEPHEN
S rr- 40' � � RICE! 1�� : ALLYN
cr,I� I - C. A.
QAXIE WiLSON
R "' tto.3Q216
Io No.2404£i �' •G P�
ICON AT DAC►STEQ��`
ONA :.
,`,/'•�7wocl' 4Jd''i/X./s- 2 bcd'rcx,.>s � g'ICo�Bq fs' /� /�S''f`
Deily Flew S x AID
/Jo GG LJGyc Gr,,r c.1c r
SF,t,c
J 74Es.//c cu> /C-00 ,1 o//ors t4n✓{C
c y r � ���� > ; - Errai� SEPTIC SYSTEM UPGR�IDE
:cccli .'y Vi / iL 0�/u �o:c
� /cx,sfi.,5> �c�cs� ,�,C �9.36Z/,, 2 O-n-�R LArvE
Ad 4 ' clao���l. ) pr+ w/4rs+vnc - --- �
3063pcP Pcas na o d ;: . p• .,D.P'r� +ZZas�on� l�UwrnA�
1 . , p.r , � 1 c?urn , MAss .
(9cnm/Inch /5"'1S1- x0,$3Jv?4/.3r = /2B JPR 2"
4,?6
IVi'' P,el-act<- .� t/Jast1<� D . lr<tWREK10E I�IIEII�IGO �L�
Y Z.
872 GPCv Isle;6,c! S Fe nc
S+o n la•,/'c ^
/.cc A' S
a
BAxr R NYE , INr_
-- Rc�rs+crccQ l-av�c( S�r.re�/p,S
q -- - Co -�- -� �} C r v 1
O£.'re R v l%_L._E M Ass,
VJ
MM� —
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