HomeMy WebLinkAbout0084 SWALLOW HILL DRIVE - Health 84 SWALLOW HILL DR. (BARNSTABLE)
A-336-069
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments:
84 Swallow Hill Drive 01
Property Address
Coulouras f
Owner Owner's Name ,
information is ✓
required for every Barnstable Ma 02630 7/1212019
page. City/Town State Zip Code Date oHnspection
*
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 �$q�3�-
filling out forms
on the computer,
use only the tab Sean M. Jones
key to move your Name of Inspector
cursor-do not S.M.Jones Title V Septic Inspection
use the return Company Name
key.
74 Company
A Lane
Co
„y Company Address ,
Centerville Ma 02632
City/Town State Zip Code
774-248-4850 smjonestitle5@gmail.com, SI4522
sean@smjonestitle5.com 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
7/12/2019
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
C Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
84 Swallow Hill Drive
Property Address
Coulouras
Owner Owner's Name
information is required for every Barnstable Ma 02630 7/12/2019
page. CitylTown State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
® 1.have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
The property located at 84 Swallow Hill Dr Barnstable is served by a Title V septic system consisting
of a 1500 gallon septic tank, distribution box and 2 1000 gallon precast leach pits. The system was
found to be in proper working condition at the time of inspection.
2) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system; upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N : ❑ ND (Explain below):
t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
Commonwealth of Massachusetts
s Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
84 Swallow Hill Drive
Property Address
Coulouras
Owner Owner's Name
information is required for every Barnstable Ma 02630 7/12/2019
page. Cityfrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
84 Swallow Hill Drive
Property Address
Coulouras
Owner Owner's Name
information is required for every Barnstable Ma 02630 . 7/12/2019
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
I
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
*' This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
84 Swallow Hill Drive
Property Address
Coulouras
Owner Owner's Name
information is Barnstable Ma 02630 7/12/2019
required for every
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 Y2 day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ . ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
El ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. (This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.)
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15:303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility,with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ 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
15insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18
i
6
Commonwealth of Massachusetts r
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
w 84 Swallow Hill Drive -
Property Address
Coulouras
Owner Owner's Name
information is required for every Barnstable Ma 02630 7/12/2019
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 a//inspections:
Yes No .
® ❑ - Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
El '® Have large volumes of water been.introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
11 El 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?
E 0 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 afthe Board of Health.
® ❑_ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18
M '
Commonwealth of Massachusetts
Title 5 Official Inspection Form
i Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
84 Swallow Hill Drive
Property Address
Coulouras
Owner Owner's Name
information is required for every Barnstable Ma 02630 M2/2019
page. City/Town State Zip Code Date of Inspection
D. System Information
1. . Residential Flow Conditions:
Number of bedrooms (design): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 gpd
Description:
Number of current residents: 4
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
Seasonaluse? ❑ Yes ® No
Water meter readings, if available(last 2 years usage (gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: current
Date
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
84 Swallow Hill Drive
Property Address
Coulouras
Owner Owner's Name
information is required for every Barnstable Ma 02630 7/12/2019
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
2. . Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection form:Subsurface.Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
84 Swallow Hill Drive
Property Address
Coulouras
Owner Owner's Name
information is required for every Barnstable Ma 02630 7/12/2019
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a,copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known)and source of information:
system installed 1974
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 1.feet
Material of construction:
❑ cast iron ❑ 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Joints in good condition, no leakage, vented through roof.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
84 Swallow Hill Drive
Property Address
Coulouras
Owner Owner's Name
information is required for every Barnstable Ma 02630 7/12/2019
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 1
feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: ''
1500 gallons
Sludge depth: 411
Distance from top of sludge to bottom of outlet tee or baffle
3'
Scum thickness
2"
Distance from top of scum to top of outlet tee or baffle 711
Distance from bottom of scum to bottom of outlet tee or baffle
10"
How were dimensions determined? Opened covers and took
measurements
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank does not need to be cleaned now but should be done soon and again every 2 years for proper
maintenance. water level was even with outlet, tank was not leaking and was structurally sound.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
84 Swallow Hill Drive
Property Address
Coulouras
Owner Owner's Name
information is required for every Barnstable Ma 02630 7/12/2019
page. Cityrrown 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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts
Title 5 Official , Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
84 Swallow Hill Drive _
Property Address
Coulouras
Owner Owner's Name
information is required for every Barnstable Ma 02630 7/12/2019
page. Cityrrown State Zip Code Date of Inspection
D. System information (cont.)
8. Tight or Holding Tank(cont.) ,
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
5
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened) (locate on site plan):
o„
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.):
Distribution box was level and in good condition with no major rot.Water level was even with 2 outlet
inverts with no signs of past backup. b
r
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
84 Swallow Hill Drive
Property Address
Coulouras
Owner Owner's Name
information is required for every Barnstable Ma 02630 7/12/2019
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in workingorder: *
❑ 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
❑ leaching chambers number:
❑ leaching galleries 'number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
^ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
V,. 84 Swallow Hill Drive .
Property Address
Coulouras
Owner Owner's Name
information is required for every Barnstable Ma 02630 7/12/2019
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
s.a.s. consists of 2 leach pits piped individually from d-box. Pit#4 on as-built was located and
opened. This pit was found with 2'standing water and a stain line 1'higher. Pit#5 on as-built is under
a stone wall and was located but not opened.
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
p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
84 Swallow Hill Drive
Property Address
Coulouras
Owner Owner's Name
information is required for every Barnstable Ma 02630 7/12/2019
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
I
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18
Commonwealth of Massachusetts
,p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
84 Swallow Hill Drive
Property Address
Coulouras
Owner Owner's Name
information is required for every Barnstable Ma 02630 7/12/2019
'
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
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t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
84 Swallow Hill Drive
Property Address
Coulouras
Owner Owner's Name
information is required for every Barnstable Ma 02630 7/12/2019
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: 12'+
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:
Groundwater was established by accessing town of Barnstable groundwater contour maps.
I,
1
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
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
84 Swallow Hill Drive
V
Property Address
Coulouras
Owner Owner's Name
information is required for every Barnstable Ma 02630 7/12/2019
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary: '
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
® D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included `
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18
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- Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�.' 84 Swallow Hill Road
Property Address
LouisColouras
Owner Owner's Name
information is Cumma uid �, tti MA 02673 08/02/08
required for q b l —
every page. Citylrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.
Important: A. General Information _
When filling out
forms on the
computer,use 1. Inspector:
only the tab key f
to move your Michael Kellett (Mi � ^D t09
cursor-do not Name of Inspector
use the return
key. Aardvark Environmental Inspections
Company Name
P.O. Box 896
Company Address
East Dennis MA 02641
r City/Town, State Zip Code
508-385-7608 S13742
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this a'ddtess and that the
information reported below is true, accurate and complete as of the time of the iqs pection I he:inspection
was performed based on my training and experience in the proper function and rbainten nce An site
sewage disposal systems. I am a DEP approved system inspector pursuantttt_ Secti 15.3V0 of
Title 5(310 CMR 15.000).The system: r t
co
® Passes ❑ Conditionally Passes ❑ lea Is -
❑ Needs Further Evaluation by the Local Approving AuthorityCO
c
.�
08/04/08
Inspectors Si a Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of Inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
bib
1 ��
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
84 Swallow Hill Road
Property Address
LouisColouras
Owner Owner's Name
information is Cummaguid MA 02673 08/02/08
required for
every page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.) j
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.
Answer yes, no or not determined (Y,N, ND) in the []for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent.
System will pass inspection if the existing tank is replaced with a complying septic tank as
approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate
of Compliance indicating that the tank is less than 20 years old is available.
ND Explain:
❑ .Observation of sewage backup or break out or high static water level in the distribution box due,
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced
❑ obstruction is removed
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
84 Swallow Hill Road
Property Address
LouisColouras
Owner Owner's Name
information is Cummaquid MA 02673 08/02/08
required for
State Zip Code Date of Inspection
every page. Citylrown
B. Certification (cont.)
B) System Conditionally Passes(cont,):
❑ distribution box is leveled or replaced
ND Explain:
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced
❑ obstruction is removed
ND Explain:
C) , Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool,or privy is within 50 feet of a surface water
❑ - Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within
100 feet of a surface water supply'or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
Commonwealth of Massadhusetts
Title 5 Official inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
84 Swallow Hill Road
Property Address
LouisColouras
Owner Owner's Name
information is q
required for Cumma uid MA .02673 08/02/08
every page. Cityrrown State -> Zip Code Date of Inspection
B. Certification (cunt.)
C) Further Evaluation is Required by the Board of Health(cont.):
E` The system has a septic 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 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.s Other:
g
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections
Yes No
Backup of sewage into facility or system component due to overloaded or
® clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool _
Static liquid level in the distribution.box above outlet invert due to an overloaded
or clogged SAS or cesspool
Liquid depth in cesspool is less:than 6"below invert or available volume is less,
® than Y2 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.
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
84 Swallow Hill Road
Property Address
LouisColouras
Owner Owner's Name
information is Cummaquid MA 02673 08/02/08
required for State Zip Code Date of Inspection
every page. City/Town
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems(cone):
Yes No
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ Z Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 16,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
El Area
system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone li of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered yes in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
Commonwealth of Massachusetts
Title 5 official Inspection For
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
.y 84 Swallow Hill Road
Property Address
LouisColouras _
Owner Owners Name
information is q
required for Cumma uid MA 02673 08/02/08
every page. CityrFown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ 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)]
Commonwealth of Massachusetts
Title 5 Official. Inspection F®rrn
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
84 Swallow Hill Road
Property Address
LouisColouras
Owner Owners Name
information is q
required for Cumma uid MA 02673 08/02/08
.
every page. City/Town State Zip Code - Date of Inspection
D. System Information
Residential Flow Conditions:
Number of bedrooms(design)- 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440
. 4
Number of current residents:
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 years usage(gpd)):
Sump pump? ❑ 'Yes 0 No.
Last date of occupancy- current
. Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15,203): Gallons per day(gpd) `
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap,present?. ❑ Yes ❑ No
Industrial waste holding tank
prese
nt? ❑
Yes El No
Non-sanitary waste discharged to the Title 15 system? ❑ Yes ❑ No
Water meter,readings, if available: > .
Last date of occupancy/use: Date
Other(describe):
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
84 Swallow Hill Road
Property Address
LouisColouras
Owner Owner's Name
information is Cumma uid MA 02673 08/02/08
required for q _
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
General Information
i
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
HowWas quantity pumped determined?
Reason for pumping: —
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system(yes or no) (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:
04/26/74 per BOH
Were sewage odors detected when arriving at the site? ❑ Yes ®, No
Commonwealth of Massachusetts
mrRaN Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
84 Swallow Hill Road
Property Address
LouisColouras
Owner Owner's Name
information is Cumma uid MA 02673 08/02/08
required for q
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan):
Depth below grade: 1.
p g t
feet
Material of construction:
❑cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade: feet
0.8
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
--------------------------------------------------------------------------------------------------------------------------
Dimensions: 1000 gallons
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
28"
2"
Scum thickness
7"
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
14"
How were dimensions determined? measured
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
84 Swallow Hill Road
Property Address
LouisColouras
Owner Owner's Name
information is q
required for Cumma uid MA 02673 08/02/08
every page. Cityfrown 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.):
The tank was sound and tight with tees in place and liquid at outlet invert.
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
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:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain):
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
a °r 84 Swallow Hill Road
Property Address
LouisColouras
Owner Owner's Name
information is Cummaquid MA 02673 08/02/08
required for State Zip Code Date of Inspection
every page. Cityrrown
D. System Information (cont.)
Tight or Holding Tank(cont.)
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
Distribution Sox(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
even
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
The box was level and tight with no sign of carryover.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Commonwealth of Massachusetts
lam Title 5 Official Inspection form
Subsurface Sewage Disposal System Form.-Not for Voluntary Assessments
84 Swallow Hill Road
Property Address
LouisColouras
Owner Owner's Name
information is Cummaquid MA 02673 08/02/08
required for
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (coot.)
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:
Type:
I
leaching pits number:-
2
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
El leaching fields number, dimensions:
overflow cesspool number:
innovative/alternative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
This system has two 6'x6' precast pits surrounded by two feet of stone. There was 30"of liquid in the
first pit while the other was half full.
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Foam-Not for Voluntary Assessments
,.•'' 84 Swallow Hill Road
Property Address
LouisColouras
Owner Owner's Name
information is umma uid MA 02673 08/02/08
required for C 4 _ _
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
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.):
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.):
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
84 Swallow Hill Road
Property Address
LouisColouras
Owner Owner's Name
information is required for Cummaguid MA 02673 08/02/08
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (coot.)
Sketch Of Sewage Disposal System: Provide a sketch 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. l
J" i
. Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Forma-Not for Voluntary Assessments
84 Swallow Hill Road
Property Address
LouisColouras
Owner Owner's Name
information is required for Cummaguid MA 02673 08/02/08
every page. Citylrown State Zip Code Date of inspection
D. System Information (cont.).
Site Exam:
® Check Slope
❑ Surface water
®, Check cellar
❑ Shallow wells
20.0
Estimated depth to round water: feet
p g 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:
USGS maps show an elevation of over 20 feet.
r2� '�J✓ti l.�- a h �I..e .� — 3 3 6
�ECEIVEn
+ E
TROY WILLIAMS MAY 7 20 �
01
SEPTIC INSPECTIONS rO1" �� �;�ti�HE ,TW'
Certified by MA Department of Environmental Protection 8) 385-1300
19 Hummel Drive
South Dennis, Iy,(A\02660
�� COMMONWEALTH OF.MASSACHUSETI'S
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
a DEPARTMENT OF ENVIRONMEN'I'AI, PROTECTION
y TITLE 5
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
ProperiN Address: 84 Swallow Hill Drive
Cummaquid,MA
O%%ner's Name: Edward Younis
Owner's Address: 86 Gay Street
Needham,MA 02492 Q
Date of Inspection: April 27,2001 O
0
Name of Inspector: TroyM. Williams
Company Name: Troy Williams Septic Inspections
Mailing Address 19 Hummel Drive
Telephone Number: South Dennis,MA 02660
(508)385-1300
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal systern at this address and that the information reported
below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system-
Passes
Conditionally Passes
Needs I urther Evaluation b) the Local Approving Authors)
Fails
Inspector's Signature. �/ 2J Date: y/27 /Dl
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
Although system meets the minimum requirements set forth by the Massachusetts Department of
Environmental Protection,certification is not to be construed as a guarantee of future working condition
of system,piping or components. This inspection represents the conditions of the system on the Date of
Inspection noted above.
"This report only describes conditions at the time of inspection and under the conditions of use at that
time. I his inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 pace
Page 2 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE'DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
84 Swallow Hill Drive
Property Address: Cummaquid,MA
Owner: Edward Yotmis
Date of Inspection: April 27, 2001
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
V // 1 have not found any information which indicates that anv of the failure criteria described in 310 CNIR
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 a replaced or
repaired. The system, upon completion of the replacement or repair,as approved by the Bo of Health, will.pass.
Answer Nes. no (it not determined(Y,N,ND) in the_ for the following stateme s. if"not determined"please
explain.
The septic tank is metal and over 20 years old* or the septic tank ether metal or not)is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure ' imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved the Board of Health.
*A metal septic tank will pass inspection if it is structurally sou r,not leakins and if a Certificate of Compliance
indicatine that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break t or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled uneven distribution box. System will pass inspection if(with
approval of Board of Health):
br en pipe(s)are replaced
bstruction is removed
distribution box is leveled or replaced
ND explain:
The system quired pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass,inspection ' (with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
Page 3 of 1 I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 84 Swallow Hill Drive
Cummaquid,MA
Owner: Edward Younis
Date of Inspection: April 27, 2001
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require funiier 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 v,ill pass unless Board of Health determines in accordance with 310 CMR 15 03(l)(b)that the.
system is not functioning in a manner which will protect public health,safety and a 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 It marsh
2. System will fail unless the Board of Health (and Public ater Supplier,if any)determines that the
system is functioning in a manner that protects the publi ealth,safety and environment:
_ The system has a septic tank and soil absorpti system (SAS)and the SAS is within 100 feet of a
Surface <+ater supply or tributary to a surface w- r supply.
The system has a septic tank and S and the SAS is within a "Lone I of a public water supply.
_ The system has a septic tank SAS and the SAS is +ithin 50 feet of private eater supply well.
The system has a septic nk 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 pass if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria and vol a organic compounds indicates that the well is free from pollution from that facility and
the presence ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure cri ria are triggered. A copy of the analysis must be attached to this form.
3. Other:
3
Page 4 of I
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
84 Swallow Hill Drive
Property Address: Cummaquid,MA
Edward Younis
Owner: April 27, 2001
Date of Inspection:
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 clo,_,ed SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
Liquid depth in cesspool is less than 6"below invert or available volume is less than %day flow
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.
N/q Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply. '
At/a 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
k;,9 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 eater quality analysis. (This system passes if the well water analysis,
performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria
are triggered. A copy of the analysis roust be attached to this forma
/yb (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
de�crihed in 310 CMR 15 303. therefore the s.vStem fails. The system owner should contact the Board of
Ilealth to determine "hat will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a d ign flow of 10,000 gpd to 15,000
gpd
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the crit a above)
yes no .
the system is within 400 feet of a surface.drinkii water supply
the system is within 200 feet of a tribut o a surface drinking water supply
the system is located in a nitrogen nsitive area(Interim Wellhead Protection Area—I WPA)or a mapped
Zone 11 of a public water suppl ell
If you have answered"yes"to any estion in Section E the system is considered a significant threat,or answered
"yes" in Section D above the la r system has failed.The owner or operator of any large system considered a
significant threat under Secti E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The system owne hould contact the appropriate regional office of the Department.
4
Page 5 of 1 I
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 84 Swallow Hill Drive
Cummaquid,MA
Owner: Edward Younis
Date of Inspection: April 27, 2001
Check if the following have been done. You must indicate"yes"or"no"as to each of the followine:
Yes No
information was provided by the owner. occupant, or Buard of I leahl,
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:
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).[3 10 CMR 15.302(3)(b)]
5
Page 6 of
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 84 Swallow Hill Drive
Cummaquid,MA
Owner: Edward Younis
Date of inspection: April 27,2001
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): I/yy
Number of current residents: 0
Does residence have a garbage grinder(yes or no): Yr'S
Is laundn on a separate sewage system (yes or no):Aro [if yes separate inspection required]
Laundry system inspected(yes or no): „/A
Seasonal use: (yes or no): Ye S
Water meter readings, if available(last 2 yearsluage(gpd)): 0o ' S'39,yvr o T
Sump pump(yes or no): ,Vo
Last date of occupancy: p c w, t u I..-w t 14,;
COMM ERCIAL/INDUSTRIA L
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 syst (yes or no): _
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part of the inspection ono): Nu
If yes, volume pumped: gallons-- How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
Septic tank,distribution box, soil absorption system
_Single cesspool
_Overflow cesspool
_Privy
Shared system(yes or no)(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:
�hs �aIItA `l/a-6 /7Y lag
Were sewage odors detected when arriving at the site(yes or no): Aw
6
• Page 7ofII
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 84 Swallow Hill Drive
Cumntacluid,MA
Owner: Edward Younis
Date of Inspection: April 27, 2001
BUILDING SEWER(locate on site plan)
Depth belo�N grade: IS f
Materials of construction:_cast iron ✓40 PVC_,/other(explain):
Diqanc, fron. priv ate water supply well or suction line: _A,/,7
Comments(on condition of joints,/vlenting, evidence of leakage, etc.)-
/ r
SEPTIC TANK: ✓ (locate on site plan)'
Depth below grade: 1
Material of construction: concrete_metal_fiberglass_polyethylene
_other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Sludge depth: 3
Distance from top of sludge to bottom of outlet tee or baffle: a �o "
Scum thickness: Doti
Distance from top of scum to top of outlet tee or baffle: &o S c►�w,
Distance from bottom of scum to bottom of outlet tee or baffle:
Hogs were dimensions determined: A-t�t6.,. .
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
W•-S Te } Tc�r t� L-a c—I-
GREASE TRAP:_(locate on site plan)
Depth below grade:
Material of construction:_concrete—me tal_fiberglass_pol ylene ._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 r baffle:
Date of last pumping:
Comments(on pumping recommendations,in and out tee or baffle condition, structural integrity,liquid levels
as related to outlet invert,evidence of leak e,etc.):
7
Page 8 of 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 84 Swallow Hill Drive
Cummaquid, MA
Owner: Edward Younis
Date of inspection: April 27, 2001
TIGHT or MOLDING TANK: (tank must be pumped at time inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fibe ass_polyethylene other(explain):
Dimensions: -- — -
Capacity: gallons
Design Floe. gallons/day
Alarm present(yes or no):
Alarm level: Alarm in worki order(yes or no):
Date of last pumping:
Comments(condition of alarm a float switches, etc.):
DISTRIBUTION BOX:-,Z(' )(locate on site plan)
Depth of liquid level above outlet invert:
Continents(note if box is level and distribution to outlets equal,any evidence of solids caM,Qver, any evidence of
leakage into or out/of box, etc.): [ n n
1�—lJ-1F t cs syy 1 i .� .r� I V c �. + < ✓� .� Jl c✓y/�o..G< f 77i�.< �/c. /I .+ t t s�Q <A. . c s -S
(Y' S �'✓/_`'12t� U�. W•a I.I•----w Y-'�w�- r...i^---_:1._S..i1... G��_=-�__S�-r�....i ��_ �o� t7a:+'�
) �^+,• �u.i'j" c:bs 7•Y✓cj•oc�. l�'-:3�}•. /vJ...Si•-.� .-ti w•:.��YC. •.. o✓-„� µ�- ',L
if't✓�.e. c, i L.j�t c.../7.:.�• -'..��.. p G •.,o ..- ci I� `� �� we.,'1 w� {).c. n r .i....6_.!t✓.S•... 5.�.-.•C:�
PUMP CHAMBER: (locate on site plan) f
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,co ttion of pumps and appurtenances,etc.):
8
Page 9 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 84 Swallow Hill Drive
Cummaquid, MA
Owner: Edward Younis
Date of Inspection: April 27, 2001
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required)
If SAS not located explain wh):
T
leaching pits, number: '. � X G �LG��� r" f � w;11. a '5�uN t-.
leaching chambers,number:
leaching galleries,number:
leaching trenches,number, length:
leaching fields,number, dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure, level of ponding, damp soil,condition of vegetation,
etc.): 1 )
G�.✓�T� , .}- � l t,,,,J w y ��lc.� C/� y �:.•ti N � -� c 17 c-c-c W %l t:� V s L, �-�
a6v.t j7g. ., 1..,� �.`f 01 ✓�- f � /so .-7
. Ci'T Y1 �r�A-✓ (�•L .�. I Jr� p.�� O!'t.`1} Il•1 �,� �oc. f T GEC-✓'a_ ��/,:�� OI1�S t.1 / wt
CESSPOLS: (cesspool must be pumped as part of inspection)(]ocate on site plan)
Number and configuration: _
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer: _-- —
Dimensions of cesspool _
Materials of construction:
Indication of groundwater inflow(yes or no
Comments(note condition of soil,signs 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 hydr tc failure, level of ponding,condition of vegetation,etc.):
9
Page 10 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
84 Swallow Hill Drive
Property Address: Cummaquid,MA
Edward Younis
Owner: April 27, 2001
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
I benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. (,Gr
- y
42ro
I�L
Pk
W:tL
10
r
Page 11 of 1 I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 84 Swallow Hill Drive
Cummaquid,MA
Owner: Edward Younis
Date of Inspection: April 27, 2001
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells Q
Estimated depth to ground water 15t• feet Adjusted high ground water elevation — feet
Please indicate(check)all methods used to determine the higli ground eater 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: ltc 1i4 7 -2 G • `
You must describe how you established the high ground water elevation:
11
THE COMMONWEALTH OF MASSACHUSETTS
�, BOARD F HEALTH
Vtt...........OF...... ..................
Apphra#gnn -for Uitipnittt Worko Cnnnuarnrlinn Punift
Application is hereby made for a Permit to Construct ( ') or Repair. ( ) an Individual Sewage Disposal
System at: 1 I
r'
�r�s
Location-Address f c or Lot No.
- `
.?I = s� .. --------- --------------------.((.9_t _�_�. :� ASS._._...
n b ner `Address
r- V.%..(-,S...............................................
Installer Address
Type of Building Size Lot.._`����_4qn_°_Sq. feet
Dwelling—No. of Bedrooms..... ....:...................:..........Expansion Attic ( ) Garbage Grinder (k)
per, Other—Type of Building ---- ....................... No. of ---------------- Showers ( / ) — Cafeteria ( )
Otherfixtures .......................................................
W Design Flow------------- d..:...:: gallons per person per day. Total daily flow___--__-__y0 0.....--___-.----_--.gallons.
9 Septic Tank—Liquid capaci _ gallons Length________________ Width__......_--__-. iameter---------------- Depth.__.__-____---
xDisposal Trench—No- ____._�_ '� _ Width______________ _ T tal Le °'�..... ...... tal leaching area......_.-___-_._---sq. ft.
'Seepage Pit No... ,,LBiameter__.___.if_xT in el"t----------------_- Total leaching area------------------sq. ft.
Z Other Distribution box (V Dosing tank ( )
aPercolation Test Results Performed by------- ------------------•--------•-----------------•--•-----........_.. Date---------------------------------------
Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water..-------_--.._----__._.
(X Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground water_--__-_------_.__-
( -----------------------------•---- ----•--•---•-- -----•--••------------•--•-----•---------------.........................................................
0 Description of Soil--------------------------------------------------------------------------------------------------- ---------------------- ----------- ---------------------------------
U _...------.�a /t r .. S'��``p=--------------------------------------------------------------------------------------------------------------------
------------------------ --------------------------------------- - -- - - ----------------------------------------------------------------•--------------------------------------------------
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 provis ion s of Article \I of the State Sanitary Code— The undersigned further agrees not to place the system in
operation"until a Certificate of Compliance has been ' ed by the board of h.
Sign .. '' - - -•------
--�% ----- ---
Date
Application Approved By-- - •••-- ----- -- -------------- . ....... . .......---- ---•-�
Application Disapproved for the following reasons------- ---------------••- ----•--,--------------------•--------.........-•-----------------Dat-----------•---
-••-•-•-•---------------•------••--•---•--••---••-••••---------•••---•--•------------•----•-•------------•---------•----•----------•-•--------------------••-••••----•-------••--------------------.....
j Date
Permit No........................................................ Issued.----- °'___._4_.
r Date &
L—
.............
No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF FALTH
77.... , OF........:...... ................................
ApVftraflon -for Uispoiitti Works Tiltilq#r rtion Vrrmft
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System
ocation- ss - .- ..__� or o.
___________fin__
Ow i Addres�
..a -y mil- � -•-- -------------•------___..---------
s er _ .., Address
UType of,Bt ild nw' "< Size Lot----------------------------Sq. feet
Dwelling!v—No. of Bedrooms._-_____...._____ ............ _--Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ---------------------------- No. of,persons---------------------------- Showers ( ) — Cafeteria ( )
Q' Other fixtures
W Design Floiw__ _____________ """:.._.__. �ons per person per day. Total daily flow------------ __ _-j.gallons.
9 Septic Tan -�Liquid capacity- _--galIons Lehgth................ wwtf,................ Diameter...------------- Depth.._--.._-.-----
W Disposal Trench—NO. ............... .... VVidtfi-:__._.. _ ngth----__ __. _ __ tal leacl • g area-------------------- ft.
x
Pit No " iameter_ _ _: e t elow I let a hin area----
Seepage _.__ _____sc it.
-2--- g1
,
z Other Distribution.box: ( ). Dosing tank ( )
a Percolation
Test Pit Test
NoRlsults-•------nPn tes pea mch Depth of Test Pit.................... Depth----------------------------- Date_._._.____..___:._:_...._._______.._..
�. .>,...
epth to ground water------------------------
(� Test Pit,No. 2:•______________minutes per inch Depth of Test Pit.---_---_.________-_ Depth to ground water--.-.--_-______.__-____.
._..--'---_............ -•------'---_----- -'-------- --•------------------------------ -
O Description of Soil.......
--------------------------------
V ------------------------------------------------------------ -. ------------ ----- - -- :'---- -- -- -----------------------------------------
------------------------- -------------------------------- - -- :- ---------------------------:---------------------------=-----------------------------------------
V Nature of Repairs or Alterations` Answer when,ap li ble-------_------_-------------_............ .........,._._..-----------------._._--____-.__-__ .
I •
__________________________________________________________________________________________________________________________________________________________________________________----------------------
Agreement:
The undersigned agrees to,install the aforedescribed"Indiuidual'Sewage Disposal:System in accordance with
the provisions of Article XI of-the State,Sanrtar `Code-T1ieundersi ned further a trees not to lace the system in
P Y g g P Y
operation until a Certificate.'of Compliance'ha's been•issued by the board of health.
•
S., d - - ------ -- - --------------------
Date
a { Date
t� j
Application Approved B., •------
Date
Application Disapproved for the following reakbnsr :_-___:__ `
---.._...---'- ------------------------- --- '-- -__..._..- - '...-- --• .........
te'
Periirit No. ==-'•--•. '•--'• -- Issued. --_------
r.•,.. Date
4;
5
kw THE COMMONWEALTH OF MASSACHUSETTS
BOARD O EALTH
OF..... ..... .:. . ..........................................................
err#i�ir�fr-'�rf�'�f�nnt�li�trtrr
TXHIf IS TO CE I_FY, Tha -th ndividual Sewage Disposal`System constructed ( ) or Repaired ( )
by----- '-•--- ----------- -- ------•------- .............................
- = ---
¢ +�" --+ ...---
has been installed in accordance with the provisions of �lrtic e XI of The`State Sanitary Code s describe in the
application for Disposal Works Construction Permit No___ dated_..__
.- -
THE ISSUALV,CE...OF-.THIS"(CERTIFICATE SHALL. NOT BED CONSTRUED AS A G ARANTEE FIAT THE
SYSTEM WILL FUNCTION SATISFACTORY.,
DATE......................---- --------------......................... Inspector-- �'• => - `'' f '
j :
THE COMMONWEALTH OF MASSACHUSETTS
BOARD HEALTH
�y PP......OF....
&e,� • FEE -
�i��:��
Permission iiss -hereby granted.- ------ _-- ----------................................................................................
to Const ct (F' ) or :pair ( Individual w g. is o 1 Sy tem
atN'o -"f' `— ' ------------------------ -------- •- ----------------
Street
as shown on the application for Disposal'Works Construction Permit o.... .......... ►ated__.__._..:_____.___._....__..._..__.__.__
Board of Health
DATE.--- f ---=- ---------------------•--
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS - / .+
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