HomeMy WebLinkAbout0074 PALOMINO DRIVE - Health 4
74,Palomino Drive
Bai7istable
A = 316 - 089 I
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No. / 0 v Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
2ppfication for disposal 6pstem Construction Permit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
pez on_71-7v ,Qo Owner's Name,Address,and Tel.No.
Location Address or Lot No. 7Y
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
o&
Type of Building.
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank ZAR Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) C'2
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Si ned Date
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. ��`�� U Date Issued
---------------------------------------------------------------------------------------------------------------------------------------
�j
No.Vim-' / Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
Opplitation for bispoBal *pstem Construction Permit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. Y U XP 7 phi�7 Owner's Name Address,and Tel.No.
Assessor's Map/Parcel � fS
Installer's Name,Addr ss,and Tel.No Designer's Name,Address,and Tel.No.
Wo ��_0 8)
Type of Buildin :
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
i Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title }
Size of Septic Tank AW Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with thprovisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by t�B. and of Health.
Signed / J L Date / 5-
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. � Date Issued C-}
f
____________________________________________ _
(� THE COMMONWEALTH OF MASSACHUSETTS
VJ CJ BARNSTABLE, MASSACHUSETTS
Certificate of (Compliance
THIS IS TO CERTIFY, t/then-site Sewa Dis osal system Constructed( ) Repaired( (/�pgradedAbandond( )bn a S���
at �/ ,� G f"!i/!O /� has been coast ucted in accordance / / 1
with the provisions,4 Title 5 andfthe for Disposal System Construction Permit No � "ddlated
Installer L410 l C/� Designer
#bedrooms Approved design flow gpd
The issuance of this permit shal not be e construed as a guarantee that the system ilv ll fug cti-dC�2s"designed.
Date ! ( Inspector t
---------------------------------------------------------------------------------------------------------------------------------------
No. � dj Fee .
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Misposal 6pstem onstruction 11'ermlt
Permission is hereby granted to C struct( ) Repair( Upgrade( ) Abandon( )
System located at , '4 ( O
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty.to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction 'ust b co eted within three years of the date of this permit.
r
Date Approved
' s
Commonwealth & Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
° 74 Palomino Road
M Property Address
Ian Ives
Owner Owner's Name
information is required for every Barnstable MA 02630 11/15/11
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 Mik DeCosta Jr
use the return Name of Inspector
key.
Wind River Environmental
rab Company Name
1958 R Broadway-
Company Address
rerun Raynham MA 02767
City/Town State Zip Code
508-822-2003 13230
Telephone Number License Number'
B. Certification
0:
tit 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
ci Title 5`(310 CMR 15.000). The system:
®:Passes ® Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local A rovi thority
q
11/15/11
Inspec is nature( Date
The system inspe or shall submit a copy of this inspection report to the Approving Authority (Board
of Health or D 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 Official Inspection form:Subsurfa ;ewage Disposal System•Page 1 of 17
• 1
T Commonwealth of Massachusetts
W Title 5 Official Inspection, Form
Subsurface Sewage Disposal System.Form - Not for Voluntary Assessments
M 74 Palomino Road
Property Address
Ian Ives
Owner Owner's Name -
information is required for every Barnstable MA 02630 11/15/11
page. CityFrown State Zip Code Date of Inspection
B. Certification (coat.)
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:
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
f
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form.- Not for Voluntary Assessments
M 74 Palomino Road
Property Address
a
Ian Ives
Owner Owner's Name
information is required for every Barnstable MA 02630 11/15/11
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
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):
El obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
® distribution box is leveled or replaced ® Y ❑ N ❑' ND (Explain below):
Distribution Box has completely rotted away and needs to be replaced, all sides on box are gone.
Dirt has infiltrated the box and the box is not properly functioning.
❑ 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•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
f
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments,
°M 74 Palomino Road
Property Address
Ian Ives
Owner Owner's Name
information is required for every Barnstable MA 02630 11/15/11
page. Cityrrown state Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board'of Health (and Public Water Supplier, if any)
determines that the system isjunctioning 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:
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 a y
El [A or
liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than6 below invert or available volume is less
than '/2 day flow
t5ins•11/10 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage'Disposal`System Form - Not for Voluntary Assessments
°M 74 Palomino Road
Property Address
Ian Ives 1
Owner Owner's Name
information is required for every Barnstable MA 02630 11/15/11
page. City/Town State Zip Code 'Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number,of times pumped:
® Any portion of the SAS, cesspool or privy is below high ground water elevation.
El Any portion of cesspool or privy is within 100 feet of.a surface water supply or
tributary to a surface water supply.
❑ Z Any portion"of a cesspool or privy is within'a Zone 1 of a public well.
El ® -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,
a provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
7 ® 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 slarface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to'a surface drinking water supply
El El Area
system is located ina 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 sigriificant 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
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 74 Palomino Road
Property Address
Ian Ives `
Owner Owner's Name
information is required for every Barnstable MA 02630 11/15/11
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 available
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 breakout?
® ❑ 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.
® L 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): 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
^M 74 Palomino Road
Property Address
Ian Ives
Owner Owner's Name
information is required for every Barnstable MA 02630 11/15/11
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ .Yes ® No
Water meter readings, if available last 2 ears usage d n/a
9 ( Y 9 (gP ))�
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: May 2011
Date
Commercial/Industrial>Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gauons 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 74 Palomino Road
Property Address r
Ian Ives
Owner Owner's Name
information is required for every Barnstable MA 02630 11/15/11
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
El Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•11/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
° 74 Palomino Road 1M
Property Address
Ian Ives
Owner Owner's Name
information is Barnstable MA 02630 11/15/11
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:
Approximately 25 yrs per owner
Were sewage odors detected.when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: feet
Material of construction:
® cast iron ❑ 40 PVC ❑ other(explain):
0"
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 pipe installed on roof.
Septic Tank(locate on site plan):
Depth below grade: feet
Material of construction:
® concrete ❑ metal. ❑ fiberglass El,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
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form.
Subsurface Sewage Disposal System.Form -,Not for Voluntary Assessments
74 Palomino Road
Property Address
Ian Ives
Owner Owner's Name
information is required for every Barnstable MA- 02630 11/15/11
page. CitylTown 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
36"
Scum thickness 4„ `
Distance from top of scum to top of outlet tee or baffle
8"
Distance from bottom of scum to bottom'of outlet tee or baffle 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.): m
Inlet cover under deck, could not open. Outlet cover 2' below grade Baffle is starting to deteriorate.
No filter installed on outlet. Recommend installing riser/filter on outlet. Liquid level normal, minimal
solids and sludge. Tank is structurally sound and not leaking. Recommend.to service tank yearly.
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal El-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
W Title 5 Official Inspection" Form'
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 74 Palomino Road
Property Address
Ian Ives
Owner Owner's Name
information is required for every Barnstable MA. 02630 11/15/11
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) -
Comments (on pumping recommendations, inlet and-outlet-tee or baffle condition; structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
El 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
r
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
°M 74 Palomino Road
Property Address
Ian Ives
Owner Owner's Name
information is required for every Barnstable MA 02630 11/15/11
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on.site plan):
0,
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.):
Box size is 16"X 20",-box is 36" below grade and has three outlets. Box is completely deteriorated
and needs to be replaced. Both sides of walls of Distrubution box are gone and dirt is falling into box.
Box has been leaking for some time, needs to be replaced.
Pump Chamber(locate on site plan):
t
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 a 74 Palomino Road
Property Address
Ian Ives
Owner Owner's Name
information is Barnstable MA 02630 11/15/11,
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information-(cont.)
Type: .
❑ leaching,pits number:
❑, leaching:chambers ,,3 ' number:
leaching galleries - number:
z leaching trenches' number,length: 3@40'
❑ leaching fields'.." number;'dimensions:
a
overflow cesspool number:
innovative/alternative system
Type/name of'technology: -
Comments (note condition of soil, signs of hydraulic failure,rlevel of ponding damp soil, condition of
vegetation, etc.): .
Dry sandy soil, no,ponding showing`no signs�.of.hydraulic failure. -Vegetation is normal.
Cesspools (cesspool must be pumpedas 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 ofbesspool
Materials of construction
Indication of groundwater inflow _ ❑ Yes E] No
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
f ,
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 74 Palomino Road
Property Address
Ian Ives
Owner Owner's Name
information is required for every Barnstable MA 02630 11/15/11
page. Cityfrown 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
f
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments `.
Property Address
Owner Owner's Name
information is
required for every City/Town
page. State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
E nand-sketch in the area below
❑ drawing attached 'separately ,
6
tL
_aL�,C
• �e
D
A D :3b�
'gym
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
f
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 74 Palomino Road
Property Address
Ian Ives
Owner Owner's Name
information is required for every Barnstable MA 02630 11/15/11
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: _ ' e +.
fee4,
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: pate
® 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:
Wetlands off property, property slopes down.,Leaching area is raised. There's 6' + between bottom _
of leaching and wetlands.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
F-
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
'M 74 Palomino Road
Property Address
Ian Ives
Owner Owner's Name
information is required for every Barnstable MA 02630 11/15/11
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D,or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information:--' Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
Q
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
s .
COMMONWEALTH OF MASSACHUSETTS
= EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
t
•
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL. SYSTEM FOI;LM
PART A
CERTIFICATION
Property Address: 7 IWD,Owner's Name v Owner's Address:Date of Inspection: f '
Name of Inspector: lease print) i'�4.ae k1w, (1( '/
Company Name: A(Ar4 16di ! asPe r i
Mailing Address: Id ~c:
Telephone Number:—S�j3 .�P,q-•Z66R
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
Passes
Conditionally Passes -
Needs Further Evaluation by the Local Approving Authority
Fails
t
Inspector's Signature: �_/� Date: 8 r'B
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.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that '
time.This inspection does not address stow the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/M00 page I
Page 2 of I 1
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL'SYSTEM INSPECTION FORM
PART A
// CERTIFICATION(continued)
Property Address: 46- r&O
�nA6
Owner: �' � YA ly
Date of Inspection: a
Inspection Summary: Check A;B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
AI 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:
B. System Conditionall
y ly Passes:
One or more system components as described in the"Conditional Pass"s 'on need to be replaced or
repaired.The system,upon completion of the replacement or repair,as approv by the Board of Health,will pass.
Answer yes,no or not determined(Y,N;ND)in the for the fol ing statements.If"not determined"please
explain.
The septic tank is metal and over 20 years old*or a septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or enfiltration tank failure is imminent.System will pass inspection if the
existing tank is replaced with a complying septic as approved by the Board of Health.
*A metal septic tank will pass inspection if it is s aurally sound;not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years of is available.
ND explain:
Observation of sewage bac or break out or high siatic water level in the distribution box due to broken or
obstructed pipe(s)or due to a bro en,settled or uneven distribution box. System will pass inspection if(with
approval of Board of Health):
broken pipe(s)arereplaced
obstruction is removed
distribution box is.leveled or replaced
ND explain: r
The sys m required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspecti if(with approval of the Board of Health):
broken pipe(s)are replaced ,
obstruction is removed
ND explain:
2
Page 3 of I 1
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 7
Owner:
Date of Inspection: 0�
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.
I. System will pass unless Board of Health determines in accordance with 31 R 15.303(1)(b)that the
system is not functioning in a manner which will protect public health fete P P � 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 etland or a salt marsh +.I
2. System will fail unless the Board of Health(a Public Water Supplier, if any)determines that the
system is functioning in a manner that protects a public health,safety and environment:
_ The system has a septic tank and soi bsorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a s ace water supply.
— The system has a septic tank d SAS and the SAS is within a Zone I of a public water supply.
— The system has a septic t and SAS and the SAS is within 50 feet of a private,water supply well.
_ The system has a sep c tank and SAS and the SAS is less than 100 feet but 50:feet or more from a
private water supply we *. Method used to determine distance
"This system passe if the well water analysis,performed at a D.EP certified laboratory, for coliform
bacteria and volati organic compounds indicates that the well is free from pollution from that facility and
the presence of a monia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria e triggered. A copy of the analysis must be attached to this form.
3. Other
3
I
Page 4 of 11
• . Y +
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL'SYSTEM INSPECTION FORM
PART.A-
CERTIFICATION(continued)
Property Address: 4l'al1`lrtt+to �r}v{
ai-ns 4
Owner: CazS�
Date of Inspection: a US ,
A System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No n
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 ov
cesspool erloaded or clogged SAS or
Liquid depth in cesspool is less than 6"below invert or available volume is less than 1'/z day flow* y
D( 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.
4)(- Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis.(This system passes if the well water..-analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic.compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is.equal-.to or less than S ppm,provided that no other-.f"ure criteria
are triggered.A copy of the analysis must be attached to this form.]
/VQ(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure'.
E. Large Systems:
' v To be considered a large system the system must serve.a fac
gpd• with a design now of 10,000 gpd to 15,000
You must indicate either"yes"or"no"to each of the owing:
(The following criteria apply to large systems dn. ition to the criteria above) "
yes "no
— the system is within 400 feet a surface drinking water supply
— the system is within 200 eet of a tributary to a surface drinking water supply "
_ the system is locat in a nitrogen sensitive area(Interim Wellhead Protection Area'—IWPA)or a mapped
Zone II of a pub ' water supply well
If you have answered" es"to any question in Section E the system is considered a significant threat,or answered
"Yes"in Section D a ve the large system has failed. The owner or operator of any large system considered a '
significant threat er Section E or failed under Section D shall upgrade the system in accordance with 310 CUR
15.304.The system owner should contact the appropriate regional office of the Department.
Page 5ofII
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART
CHECKLIST '.
Property Address: 791 j A-V s H
Owner: Clis�y < u a
Date of Inspection:
Check if the followin have "yes" y <• ,�
g 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'
d 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 NIA)
_ 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?.'
A� Was the facility owner and occupants if different from owner( p . )provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil+Absorption System(SAS)on the site has been determined based on: .
Yes no
- 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)[31.0 CNM;l 5.3 02(3)(b)]
n
7
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C `
SYSTEM INFORMATION .
Property Address: 71Y U O=('k'h i/1 p Je CAJ
r
Owner: an<P
Date of Inspection: (.5 16A
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):__�K Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Wa
Number of current residents:
Does residence have a garbage grinder(yes or no):
Is laundry on a separate sewage system(yes or no):_ [if yes separate inspection required] -
Laundry system inspected(yes or no):
Seasonal use: (yes or no): N0
Water meter readings, if available(last 2 years usage(gpd)):
Sump pump(yes or no):jV�
Last date of occupancy: G G .•P
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): __gpd
Basis of design flow Z
ns/sgft,et . :
Grease trap present Industrial waste hold t(yes or no):_Non-sanitary waste o the Title 5 system(yes or no):Water meter readinge:Last date of occup
OTHER(de ribe):
GENERAL INFORMATION .
Pumping Records `
Source of information;
Was system pumped as part of the inspection(yes or no):
If yes,volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM f
C Septic tank,distribution box,soil absorption system
_Single cesspool
_Overflow cesspool
_Privy
_Shared system(yes or no)(if yes,attach previous inspection records, if any)
_Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight tank _Attach a copy of the DEP approval
_Other(describe): "
Approximate age of all components, date installed(if known)and source of information:
too 4 firs
Were sewage odors detected when arriving at the site(yes or no):Nd
6
Page 7 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
r '
Owner: Ca
Date of Inspection: g f 06
BUILDING SEWER(locate on site plan) .
Depth below grader
Materials of construction: cast iron 40 PVC
Distance from private water supply well or line;other(explain):
Comments(on condition of joints, venting, evidence of leakage,etc.):
SEPTIC T A- ,
TANK:_(locate on site plan)
Depth below grade: ?6-0
Material of construction: o_(concrete `_metal_fiberglass Polyethylene
_other(explain)
If tank is metal list age:— Is age confirmed by a Certificate of Compliance certificate) p (yes or no): (attach a copy py of
Sludge depth: 4/
Distance from top of sludge to bottom of outlet tee or baffle:Scum thickness: ]1 0?8,
Distance from top ofScum totop of outlet tee or baffle: _
Distance from bottom of scum to bottom of outlet tee orb e:How were dimensions determined:
Comments(on o— `surer
pumping recommendations, Inlet and outlet tee or baffle condition, structural integrity,Iiquid levels
as related to outlet invert,evidence of leaka-e, etc.). '
GREASE TRAP: .
_(locate on site plan)
Depth below grade:
Material of construction:— -
c oncrete metal fiberglass Polyethylene_other
(explain): —
Dimensions:
Scum thickness:
Distance from top of scum to p of outlet tee or baffle:
Distance from bottom of m to bottom of outlet tee or baffle Date of last pumping:
Comments(on pu mg recommendations, inlet and outlet tee or baffle condition,structural integrity,
'
as related to out invert, evidence of leakage; etc.): h>liquid levels
7
Page 8 of 11
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address i it o �rtV..r
Owner: 525
Date of Inspection:'_. 1 O 6
TIGHT or HOLDING TANK: (tank must be pumped at time of ins tion)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fi glass_polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallo ay
Alarm present(yes or no):
Alarm level: Alarm in rkin order
Date of last pumping: g (Yes or no):
Comments(condition of and float switches,etc.):
DISTRIBUTION BOX:—Y—(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:_ew '
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover; any evidence of
leakage in o or oqt of box,etc.): DD
. 1wt
rc� 4s c o�
PUMP CHAMBER: (locate on site pla
Pumps in working order(yes or no):.
Alarms in working order(yes or
Comments(note condition o ump chamber,condition of pumps and appurtenances,etc.):
_ 4
i
8
Page 9 of I I
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSUkFACIf SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 7
r
Owner: CA s�4 —
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Type
p( leaching pits,number: t
leaching chambers,number:
leaching galleries,number:
leaching trenches,number, length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovativefaltemative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,
etc.):
6 6 a Tft
4
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 groundw er inflow(yes or no): `
Comments(note co ition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
PRIVY: (locate on site plan)
i
Materials of construc 'on:
Dimensions:
Depth of solids:
Comments(not condition of—soil, of hydraulic failure, level of ponding, condition of vegetation,etc.): t
9 ,
Page 10 of I 1
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: �� '
Owner: CCc e
Date of Inspection: (p
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent benchmarks. P reference Locate all wells within 1 landmarks or
00 feet.Locate where _
• ere public water supply enters
PP y . the building.
g
_ eC4,V-
' _ ✓ • -
�� 3a
l -
'Page 11 of 11
OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued) •
Property Address: 7 K t�
Owner:_
Date of Inspection: (a p
SITE EXAM
Slope N
Surface water 00
Check cellar Y�
Shallow wells `
Estimated depth to&round water feet
Please Lndicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked, date of design plan reviewed:
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-
US ktaw ci
11
L0•CATION � ' SEWAGE P 'R"13 N0.
L.
VILLAGE
z�,Q NJ - je!S 'R L E M. tq
INSTALLER'S NAME & ADDRESS
M b, A) MA F,9 1
:2j L, Y Co Al
B UILDE R OR A N E R
DATE PERMIT ISSUEDy � `/
DATE COMPLIANCE ISSUED
rAe*l r .
r
�� ,�
�:
��
,�
���-� _
No.- ...... Fps.. 5..............
�D gCJ THE COMMONWEALTH OF MiASSACHUSETTS 1
L3 </ _, BOAR® W HE4LTV
- ,j7-1101...........OF.
Appliration for Uispoiial Works Towitrurtion ramit
1 Application is hereby made for a Permit to Construct ( or P
Repair ( ) an Individual Sewage Disposal
PP
Y
................. ---
Location-Address t No.
r
Owner Address I
W c
Installer __���'"ddress
dType of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
`4 Other—T e of Building ............................ No. of persons........................ Showers — Cafeteria
p' Other fi tures .._.
- -------------------
W Design Flow..... -�. .:..........................gallons per per a . Total da'I flow----........._. __.............gall�s.
W Septic Tank—Liquid capacity/A00tallons Length_..._ Width.---' .___ Diameter................ Depth _._
P *e------
x Disposal Trench—No................•.... Width ......Total Length------- ........... Total leaching area____.___ sq. ft.
Seepage Pit No.............�----- Diameter-__�l�l._ Depth below linlet.... .�_. _. Total leaching area_ i�e__ q. ft.
Z Other Distribution box ((40"' Dosing-tank ( )
Percolation Test Result Performed by.. d_.lell0"e._._. ,i ........ .... ....... Date.........................................
Test Pit No. 1....Z A....minutes per inch Depth of Test Pit-___-_--•-._.-____-• D pth to ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit._____-_._______-_•- Depth to ground water........................
--------------------------- ---- -----------•• ...........................................................................
O 1 Description of Soil•52S ._ — y� ___ ...... ..... ..
W •------------ --------------------------------------------------- --------------------•-----------------------------------------------------..........................................................
UNature of Repairs or Alterations—Answer when applicable................................................................................................
e
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITS 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance h is ed the boa; of heal h.
Date
Application Approved By.... •• ..... •-• • .....Gvl/....
----------------------- ---L7.-.'? `1..
Date
Application Disapproved for the following reasons---- --------------------------------------------------------------------------------------------••--------_...--
••--------------------------------•-•------------ •------------------------------•--.........---------------•••..................-•---- ------•......................................................
Date
PermitNo......................................................... Issued-.......................................................
Date
1
u THE COMMONWEALTH OF MASSACHUSETTS,
el' -7 BOARD OF -HEALTH
............OF............. . ... i.................................................
THIS I TO CE TIF hat the ividt�l e 'a e Dispos ster��onstructed ( Zor Repaired ( }
bY-.--... = ----------------------------------------------------------
Installer ......................... c
i
at.... ......! +1r._.•••• • . •••• -4-.----.... --
has been installed in accordance with the provisions of T�..:l 5 of The State Sanitary Code as described- in the
application for Disposal Works Construction Permit No. .__....,�,��............... da.ted----�_-:__��_____7�"_r_..........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector.........................................................-..........................
{
v
Fss..............................
THE COMMONWEALTH OF MASSACHUSETTS
#.- 6
BOARD OF HE I--'-
z ppfiratiun for 11iipmat Mirko Tomitrurtiun Prrutit
Application is hereby made for a Permit to Construct (' )1 o Repair ( ) an Individual Sewage Disposal
Syst at• �
--- ... !ya...........���J G. -----... ................ ='•�--------
! Location-Address �` / o"r It No. / y
........ f.- ... ..-_•___-..._.._ L ...... ................ �........--
Owner �C`
A / Address
Installer 11 Address f
Type of Building ________ Size Lot............................Sq. feet
aDwelling—No. of Bed *rooms Attic ( ) Garbage Grinder ( )
p,l Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Other fixtures ...................................
W Design Flow....____ __________________________gallons per-persan per day. Total daily flow.............. __ ._tQ.............gallons.
WSeptic Tank—Liquid capacity�e%Qgallons Length....V.... Width.... ___ _ Diameter................ Depth.._! `_____..
x Disposal Trench—No..,................... Width......... Total Length...._................ Total leaching area--- ___......sq. ft.
Seepage Pit No_____________/_...... Diameter...��<._�--- Depth below inlet....��.P..�... Total leaching area'�."�t_•-{�q. ft.
Z Other Distribution box ( Dosing tank ( )
�7
a Percolation est Result Performed by... __ .$� '' ____ ``: . ''' '.._-. •__-= �_______ Date........................................
Test Pit NO. 1___ ..._.minutes per inch Depth of Test Pit____________________ Dpth to ground water_____________._____.._..
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
.....-- .................................................................................
D Description of SoiL:5LZ. _ - t,/...-•-•-_.. ...... .............
..••-•----•----------------••---------•-----•-•••---•------__...--------....._..•-••----•-•--•----••-----.........-•••---•--------•-•-•-•....._..__.•-•--•-•-•---------•--•••....--•--•-•-....---.------
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 TIT p 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.
Si ..........
........................................................................ ..........................
Date
1 ! /APPlication Approved BY �= - ..----- ✓. ---�/ � ••----------------••--•-- ----�..............................
.
' Date I
Application Disapproved for the following reasons:..............................................................................................................
.................................•-•--------------••--------......--•-•-------------------------------------•-•-•-------•---•••------••--•-•----••-------------......--- ...............................
Date
PermitNo......................................................... Issued......---•--------- ...----------------------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...... .G.." . !.:r.............OF............ j ._..............................................
Tprtif iratr of Tuizt li nrr
THIS ;S T� TIF That the aivid lwage isposa 'stem constructed or Repaired ( )
by....
✓ �. .;---------------------•-------•--••-----....._......•----.....--•-----
-
Installer
at.. D a _ J�_ y �L L::�r.�, it----------------------•--•-•--•-------••-•------------------------•-----------
has been ins.alled in accordance with the provisions of `p i L�� j of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No . ... ............... dated__..-.__2_%-___7�:_:_._._.._...
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.........•...---•...........................•-----.......----------------------- Inspector.........................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
7� .... G. > :a.......-....OF............. ................................................
...............
Difilu al or o #r to
�exnii#
Permission 's hereby granted..•••••-- ..... -•----•--......••-•---•...................................... ....
to Cons-trr Ct (�or Repair (,//I an Individual wa -Disposal
atNo.:�• y (�r-- 7....... 1...1.L. 1 Q - ----....................................................
Street
as shown on the application for Disposal Works Construction Permit_No.______ %-.______ ted._.a......•1.'.7�.............
Board of Health
DATE.................................................................................
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS
L j
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