HomeMy WebLinkAbout0017 WHITE MOOR - Health 17 White Moor, Barnstable
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
17 White Moor 3>— �
Property Address
Geaoffrey Gray ~
Owner Owner's Name �
information is Barnstable Ma 02630 2/27/17
required for every _ _
page. City/Town State Zip Code Date of Inspection
�i
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 filling out forms A. General Information
on the computer,
use only the rtab 1. Inspector:
key to move your
cursor-do not Michael DiBuono
use the return Name of Inspector
Y
DiBuono Sewer and Drain
reb Company Name ---—------- -- -----------. _._
8 Johns path
Company Address
S Yarmouth _ MA_ 02664
City/Town T State Zip Code
508-364-9587 _ S113522
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
_ _ 2/29/17
I pec—to r'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 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•3/13 Title 5 Official Inspection Form_Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M
17 White Moor
Property Address
Geaoffrey Gray
Owner Owner's Name
G;,information is Barnstable Ma 02630 2/27/17
required for every --- _— ---_.
,page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
'indicated below.
Comments:
System contains a 1,000 Gallon septic tank as well as a new Distribution box and an existing 1,000
Gallon leach pit.
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 ieaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 17 White Moor
Property Address
Geaoffrey Gray
Owner Owner's Name
information is Barnstable Ma 02630 2/27/17
required for every --,—
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑. ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑, ND (Explain below):
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
15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
17 White Moor
Property Address
Geaoffrey Gray
Owner Owner's Name
information is Barnstable _Ma_ 02630 2/27/17
required for every _ _ _ _
page. City/Town 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 is functioning in a manner that protects the public health,
,safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance.
** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
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 '/2 day flow
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
— — it
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 17 White Moor
Property Address
Geaoffrey Gray
Owner Owner's Name
information is Barnstable Ma 02630 2/27/17
required for every _ _
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.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory, for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system-owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the
questions in Sectiori 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
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3/13 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 17 White Moor
Property Address
Geaoffrey Gray
Owner Owner's Name
information is required for every Barnstable Ma 02630 2/27/17
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?
® ❑ 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)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins•3/13 Title 5 Official 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
17 White Moor
Property Address
Geaoffrey Gray
Owner Owner's Name
information is Barnstable Ma 02630 2/27/17
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
System contains a 1,000 Gallon septic tank as well as a new Distribution box and an existing 1,000
Gallon leach pit.
Number of current residents: Vacant
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No
information in this report.)
Laundry system inspected? ® Yes ❑ No
Seasonal use? ❑ Yes ❑ No
Water meter readings, if available last 2 ears usage d 159 GPD
9 ( Y 9 (9p )):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203): Gauons per day(gpa)
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available: —
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
ac
17 White Moor _
Property Address
Geaoffre Gray
Y
Owner Owner's Name
information is Barnstable Ma 02630 2/27/17
required for every
Cit /Town State Zip Code Date of Inspection
a e. Y p p
p9
D. System Information cont.
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: None Provided
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
17 White Moor
Property Address
Geaoffrey Gray
Owner Owner's Name
information is required for every Barnstable Ma 02630 2/27/17
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:
Original to home
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 1.5
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.):
System vents at the roof
Septic Tank (locate on site plan):
Depth below grade:, 1
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
1,000
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: —
Sludge depth:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
17 White Moor
Property Address
Geaoffrey Gray
Owner Owner's Name
information is required for every Barnstable Ma 02630 2/27/17
page. Cityrrown 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 24
Scum thickness
3"
Distance from top of scum to top of outlet tee or baffle
42"
Distance from bottom of scum to bottom of outlet tee or baffle Sludge stick
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.):
Levels are normal
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•W3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
f
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,GSM 17 White Moor
Property Address
Geaoffrey Gray
Owner Owner's Name
information is required for every Barnstable Ma 02630 2/27/17
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:
❑ 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.):
a
Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
17 White Moor
Property Address
Geaoffrey Gray
Owner Owner's Name
information is required for every Barnstable Ma 02630 2/27/17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert New 2/27/17
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.):
New Dbox installed
Pump Chamber(locate on site plan):
Pumps in working order: *
p g El ❑ No
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
. Commonwealth of Massachusetts_
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 17 White Moor _
Property Address
Geaoffrey Gray
Owner Owner's Name
information is required for every Barnstable Ma 02630 2/27/17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number: .
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
No signs of failure
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth —top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^' 17 White Moor
M
Property Address
p Y
Geaoffr e Gray
y
Owner Owner's Name
information is required for every Barnstable Ma 02630 2/27/17
page. Cityrrown 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
. Commonwealth of Massachusetts
Title 5 Official Inspection Form
lSubsurface Sewage Disposal System Form - Not for Voluntary Assessments
17 White Moor
Property Address
Geaoffrey Gray _
Owner Owner's Name
information is required for every Barnstable Ma 02630 2/27/17
page. City/Town 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:
❑ hand-sketch in the area below
® drawing attached separately
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
>GSM 17 White Moor
Property Address
Geaoffrey Gray
Owner Owner's Name
information is required for every Barnstable Ma 02630 2/27/17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 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 indicate ngw at 14'
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
TOWN.OF BARNSTABLE
LOCATION �J ��,/L,',' /► / SEWAGE# .
VILLAGE 3C.r.4. -.fia-4l e- ASSESSOR'S MAP&PARCEL
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY �� 0 bd
LEACHING FACILITY(type) Ca c Z Tl�,`� (size)
NO.OF BEDROOMS 3
OWNER CsCo ����i (f—t �
PERMIT DATE: 'Z'Z 7 I ) COMPLIANCE DATE: 7
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist on r .
site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching facility) Feet
s
FURNISHED BY
I
4 s 13C`tA
o
2 1
s,/
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
17 White Moor
Property Address
Geaoffrey Gray
Owner Owner's Name
information is Barnstable Ma 02630 2/27/17
required for every _
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
I
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
TOWN OF BARNSTABLE
LOCATION 17 /i�f,' �c��i./ SEWAGE#
VILLAGE Q>a,g+a,41e— ASSESSOR'S MAP&PARCEL
INSTALLER'S NAME&PHONE NO. �)r t,,-nO 5CO QT <.J I.7�e ,'•�
SEPTIC TANK CAPACITY ®O�
LEACHING FACILITY:(type) �°�'�C,� �i d- (size)
NO.OF BEDROOMS-
OWNER &Q27
PERMIT DATE: Z'Z 7"/ ) COMPLIANCE DATE: -7
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist on
site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching facility) Feet
FURNISHED BY
;:;
1.
L
i3��� �
� �
�- �1 2� '
z 3�-'6°'
' 3 � �' � 2
. � __ i z 2' ,�.
— � �s
_ 3 3�
f
TOWN OF BARNSTABLE
LOCATION SEWAGE#
VILLAGE q��, .ram l,-%� ASSESSOR'S MAP&PARCEL
INSTALLER'S NAME&PHONE NO. _��;Q6t Sri y Scw Q t <,,,y
SEPTIC TANK CAPACITY I, Ud
J
LEACHING FACILITY(type) eA(,� !�,`�- (size)
NO.OF BEDROOMS
L 3
OWNER
PERMIT DATE -z'Z 7 I COMPLIANCE DATE: '7
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist on
site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching facility) Feet
FURNISHED BY
211
r 3 3 5' 1�
2_ �s� 3�
,3 �s
No. Fee /
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Ye
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
01pptiration for -Misposal *pstrm Construction Permit
Application for a Permit to Construct( ) Repair(�) Upgrade( ) Abandon( ) ❑Complete System ndividual Components
LAation Address or�L t No. )7 u h.�t Q +'� b C Owner's Name Address,and Tel.No.
Asses or s Nlap/Parcel 3 %2 C 6
Installer's Name,Address,and Tel.No. J o1.rS P Designer's Name,Address,and Tel.No.
wNOnc SC��0� �i`n
Type of Building: J
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 Type of S.A.S.
Description of Soil
1
Nature of(�epairs or Alterations(Answer when applicable) I C Q)a G e? C, k- f`o•�. O1C
Date last inspected:
r
Agreement: ,'Y
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 plac t m in operation until a Certificate of
Compliance has been issued by this Board of Heal
Si ed Date —1 -'Z `/—/7
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No.— 1 17 — 0 L/ Date Issued 7
No = f D! Fee / J
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Ye*
PUBLIC HEALTH DIVISION"- TOWN OF BARNSTABLE'MASSACHUSETTS
application for Mispo8al 6pstem Construction PPrmit
Application for a Permit to Construct( ) Repair(J) Upgrade( ) Abandon_( ) ❑Complete System P<ndividual Components
Location Address or L t No. 17 - h t)O"/'1°°1 \.j 4 j Owner's Name Address,and Tel.No.
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No. J o1,�5 + }h Designer's Name,Address,and Tel.No.
Type of Building: '
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
/ e
Other Fixtures / f
Design Flow(min.required) gpd Design flow provided ` gpd
Plan Date Number of sheets Revision Date
Title '3
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Re or or Alterations(Answer when applicable) { F' P)c.c E �, S't'(r(.J k4 to'— 436y,
fl P S ..:... y
y
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 t e-system in operation until a Certificate of
Compliance has been issued by;ed
B�ofHealt
Si Date Z._ 7 17
Application Approved by Date 7
Application Disapproved by Date
for the following reasons
• � r
Permit No. /)-0 7 --"d 51 Date Issued
----------------------------------------------------------------------------------------------------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
f ) trrtificatP Of Complianct
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( pgraded( )
Abandoned( )by l� /� � v� S e-w-c_/- 6 =,f (!,. \^--
at )7 W 4 , 4-T Y!'1 o J w a.Y has been constructed in accordance l
with the provisions of Title 5 and the for Disposal System Construction Permit NoPZ17 Q 5 ) dated a ��-�/%-2
Installer ���z h a G /JI /,� k '7 -� Designer
#bedrooms Approved design flow gpd
The issuance of thisl permit shall not be construed as a guarantee that the system will fun ti n as designed., Q
Date Inspector G`
r V
---------------------------------------------------------------------------------------------------------------------------------------
No. 05 Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS
Nsposal *ps onstrUction-J)Prmit
Permission is hereby granted to Construct( ) Repair Upgrade( ) Abandon( )
System located at ' 7 �/✓`►, �f'� 4 u 7
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 must be completed^within three years of the date of this permit.
Date ` '-2 / Approved by `�-� �
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Roy Stewart
Property Address ,
17 White Moor way {
Owner Owner's Name
information is required for every Barnstable Ma 02630 . 6/18/2014
page. Cityrrown 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 filling out forms A. General Information
-
on the computer,
use only the tab 1. Inspector: S�
key to move your V cursor-do not Sean M. Jones VVV tJ
use the return
key. Name of Inspector'
S.M.Jones Title V Septic Inspection
Company Name
74 Beldan Ln.
Centerville Ma 02632 w
City/Town State Zip Coder.
774-248-4850 smjonestitle5 I' ""@gmail.com. SI 4522 rY'
Telephone Number License Number r�.J
X
73
' f "•may f
1 � ,
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as,of the time of the inspection. The.inspection,.
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 16.000).The system:
® Passes ❑ Conditionally Passes ❑• Fails
❑ Needs Further Evaluation by the Local Approving Authority
6/18/2014
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 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.
t
i5ins•3/13 Title 5 Official InsVSbe Disposal System-Page 1 of 17
Commonwealth of Massachusetts
.dTitle 5 Official
a Inspection Fora
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M Roy.Stewart
Property Address
17 White Moor way
Owner Owner's Name
information is required for every Barnstable Ma 02630. 6/18/2014 ,
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete'all of Section D
A) System Passes:
Z I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria_ not evaluated are
indicated below.
Comments:
The dwelling located at 17 White Moor Way Barnstable is served by a Title V septic system consisting
of a 1000 gallon septic tank, distribution box and a 1000 gallon precast leach pit. The system was
found to be in proper working condition at the time of inspection.
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M Roy Stewart
Property Address
17 White Moor way
Owner Owner's Name
information is required for every Barnstable Ma 02630 6/18/2014
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms.not operational. System will pass with Board of Health approval if,
pumps/alarms are repaired.
B) System Conditionally Passes (cont:):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑-N ❑ ND (Explain,below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
obstruction is removed .❑ Y ❑ N ❑ ND (Explain below):
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 r ri❑ ss o0 o v is within 50 feet of a surface water
P privy
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3/13 Title 5 Official Inspection Fonn:Subsurface Sewage Disposal System'-Page 3 of 17
Commonwealth of Massachusetts
F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Roy Stewart
Property Address
17 White Moor way
Owner Owner's Name
information is required for every Barnstable Ma 02630 6/18/2014
page. City/Town 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 is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other.
I
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
El Discharge or ponding of effluent to the surface of the ground or surface waters
® due to an overloaded or clogged SAS or cesspool
❑ ® v Static liquid level in the distribution box above outlet invert due town 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
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
F Title 5 Official Inspection Forme.,
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M Roy Stewart
Property Address
17 White Moor way
Owner Owner's Name
information is Barnstable Ma 02630 6/18/2014
required for every -
page.. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the.SAS, cesspool or privy is below high ground water elevation.
❑ ® ' Any portion of cesspool or"privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
-❑ ® Any 'portion'6f a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool servingYa facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility,with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone Il of a public water supply well,
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M Roy Stewart
Property Address
17 White Moor way
Owner Owner's Name
information is required for every Barnstable Ma 02630 6/18/2014
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?
® El 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 backup? .
® ❑ 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.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of.Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M Roy Stewart
Property Address.
17 White Moor way
Owner Owners Name
information is required for every Barnstable Ma 02630 6/18/2014
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection El 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: , ' 1/2014
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): ,
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present?' ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings,if available:
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
L
Commonwealth of Massachusetts
Title 5 Official Inspection Form,
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M Roy Stewart
Property Address
17 White Moor way
Owner Owner's Name
information is required for every Barnstable Ma 02630 6/18/2014
page. Citylrown 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:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes,volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy,
❑ Shared system (yes or no) (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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M Roy Stewart
Property Address
17 White Moor way
Owner Owner's Name
information is required for every Barnstable Ma 02630 6/18/2014
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and�source of information:
original system 1979
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 20"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.):
Joint were ok, no leaks, vented through the roof
Septic Tank(locate on site plan):
15,
Depth below grade: ' feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ .No
Dimensions:
1000 gallons
Sludge depth:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 117
f
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Roy Stewart
Property Address
17 White Moor way
Owner Owner's Name
information is required for every Barnstable Ma 02630. 6/18/2014
page. Cityrrown 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
Y
3" H F
Scum thickness
611.
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle 10
11,
How were dimensions determined? opened covers, 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.
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑,fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
.Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins-3/13 Title 5,Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
l
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Roy Stewart
Property Address
17 White Moor way
Owner Owners Name
information is required for every Barnstable Ma 02630 6/18/2014
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumpingrecommendations, inlet and outlet tee or baffle condition, structural integrity,
� 9 tY,
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):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order:. ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.): ,
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official 'Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M Roy Stewart
Property Address
17 White Moor way
Owner Owner's Name
information is required for every Barnstable Ma 02630 6/18/2014
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
0"
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Distribution box was functioning as intended
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No"
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
*If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
Title 5 OfficialInspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,
M Roy Stewart
Property Address
17 White Moor way
Owner Owner's Name
information is required for every Barnstable Ma 02630 6/18/2014
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.) ;
Type:
® leaching pits w number: 1 x1000 gallons,
❑ 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.): I '
Leach pit was found to be dry with no sign of past hydraulic overloading.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Roy Stewart
Property Address
17 White Moor way
Owner Owner's Name
information is required for every Barnstable Ma 02630 6/18/2014
page. Cityrrown 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Roy Stewart
Property Address
' r
17 White Moor way
Owner
Owner's Name
information is required for every Barnstable Ma , 02630 6/18/2014
page. Cityrrown 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: ;.
® hand-sketch in the area below .
" ❑ drawing attached separately
1>
• : V. FoDl
t
A_z 33
3 3�
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Roy Stewart
Property Address
17 White Moor way
Owner Owner's Name
information is required for every Barnstable Ma 02630 6/18/2014
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑' Shallow wells
Estimated depth to high groundwater: 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 elevation was determined by accessing Town of Barnstable groundwater contour map.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M Roy Stewart
Property Address
17 White Moor way
Owner Owner's Name
information is required for every Barnstable Ma 02630 6/18/2014
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® inspection Summary:.A, B, C, D, or E checked
® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
® �1 TROY WILLIAMS '�, o
F -Pee, p
SEPTIC INSPECTIONS ro c1 ",
Certified by MA Department of Environmental Protection cad `9�ryggy ,�j8) 1300
2",
19 Hummel Drive
South Dennis, MA 0.2660
COMMONWEALTH OF 1VIASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET. BOSTON, MA 02108 6I1.292.5500
WILLIAM F.WELD
Governor
TRUDY CORE
Sccrctzn-
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner
PART A
tom/ CERTIFICATION
Property Address: 17 �� ' �Q 1400� �`'r^�"-(,�_Address of Owner:
Date of Inspection: I I /12 Y �y 7 /Z r! /1/l
� (If different) o.��-✓ o v s c
Name of Inspector: Troy Williams
1 am a DEP approved s��sslem inspector pursuant to Section 15.340 of Title 5 (310 CMR 1S.000)
Company Name- _Tro_y .Williams Septic Inspections i3c�r� S� l ��
Mailing Address: �9 HUmmPl Hriva _ Cntlth ppnniS MA 02660 r
Telephone Number: T5 08T3 8 5-13 0 0 0-2 C ?o
CERTIFICATION STATEMENT
I certify that 1 have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
asses
— Conditionally Passes
— Needs Further Evaluation By the Local Approving Authority
_ Fails
Inspector's Signature:— Date: I y L/C(7
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit
the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
INSPECTION SUMMARY: Check A, B, C, or D:
A) SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
COMMENTS:
BI SYSTEM CONDITIONALLY PASSES: /K
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.
Indicate yes, no, or not determined (Y, N,or ND). Describe basis of determination in all instances. If"not determined", explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty(20)years prior to the date of the inspection; or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exftitration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic talk
as approved by the Board of Health.
(r igad 04/2S/97) Paq• I of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 17 White Moor Way,Barnstable, MA
Owner: Robert Morse
Date of Inspection:November 24, 1997 B1 SYSTEM CONDITIONALLY PASSES (continued) /"//iI
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the
Board of Health). Describe observations:
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
C1 FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Alll�
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IT APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or
tributary to a surface water supply.
The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that
the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method used to determine distance (approximation not valid).
3) OTHER
(rwiwed 04/25/97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 17 White Moor Way,Barnstable,MA
Owner: Robert Morse
Dale of Inspection: November 24, 1997
DJ SYSTEM FAILS: nor 4
You must indicate ei;,.er "Yes" or "No" as to each of the following:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
Yes No
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
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 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped _.
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone 1 of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water,supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
El LARGE SYSTEM FAILS: A114
You must indicate either "Yes" or "No" as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
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)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(rovi ud 04/25/97) Page 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
17 White Moor Way,Barnstable,MA
Property Address:OwnRobert Morse
Date of Inspection: November 24, 1997
Date o
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes, No
Pumping information was provided by the owner, occupant, or Board of Health.
None of the system components have been pumped for at least two weeks and the system has been receiving normal
flow rates during that period. Large volumes of water have not been introduced into the system recently or
/ as part of this inspection.
V ,— As built plans have been obtained and examined. Note if they are not available with N/A.
�G _ The facility or dwelling was inspected for signs of sewage back-up.
_ The system does not receive non-sanitary or industrial waste flow.
J _ The site was inspected for signs of breakout.
✓/ _ All system components, excluding the Soil Absorption System, have been located on the site.
JL _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of
baffles or tees, material-of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
/ The size and location of the Soil Absorption System on the site has been determined based on:
The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of
Sub-Surface Disposal System.
_ Existing information. Ex. Plan at B.O.H.
Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) [15.302(3)(b))
(revised 04/25/97) Page 4-of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 17 White Moor Way,Barnstable,MA
Owner: Robert Morse
Date of Inspection: November 24, 1997
RESIDENTIAL: FLOW CONDITIONS
Design flow: 13' s.p,d./bedroom for S.A.S.
Number of bedrooms: .3
Number of current residents:
Garbage grinder (yes or no):Ny
Laundry connected to system (yes or no):
Seasonal use (yes or no): No
Water meter readings, if available (last two (2) year usage (gpd): /G �q7 = ��/orb 4w/lam , 9S/�L = 6;, °o C' 4i40^ S
Sump Pump (yes or no): 7�5
Last date of occupancy: < < e
COMMERCIAUINDUSTRIAL•
Type of establishment:
Design flow: Qallons/day
Grease trap present: (yes or no)_�
Industrial Waste Holding Tank present: (yes or no)
Non-sanitary waste discharged to the Title 5 system: (yes or no)_
Water meter readings, if available:
Last date of occupancy:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information: /
J 5S �oZ 1 �9/� ., T7-O 0- G- a-1 c y wh z✓
System pumped as part of inspe ion: (yes or no) il(v
If yes, volume pumped: gallons
Reason for pumping:
TYPE 07 SYSTEM
_I 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)
VA Technology etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information: _—as S i/t 11(
Sewage odors detected when arriving at the site: (yes or no) nib
(revised 04/15/97) page S of 10
L
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 17 White Moor Way,Barnstable,MA
Owner: Robert Morse
Date of Inspection:
November 24, 1997
BUILDING SEWER:
(Locate on site plan)
Depth below grade:
Material of construction: _cast iron _ 40 PVC _other (explain)
Distance from private water supply well or suction line
Diameter
Comments: (condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK:
(locate on site plan)
Depth below grade:
Material of construction: ✓concrete _metal _Fiberglass _Polyethylene _other(explain)
If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No)
Dimensions:_
Sludge depth: "
i i
Distance from top of ludge to bottom of outlet tee or baffle: o� 7
Scum thickness: w
Distance from top of scum to t p of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
How dimensions were determined: Pra
Comments:
(recommendation for pumping, condition of inlet and outlet tees or boes, depth of liquid level in relation to outlet invert, s ructural
integrity, evidence of leakage, etc.) 4-e a u L (c . ! „ S � ��jA
l i— 1
w c r�. �.�✓t r.� o.--,2 <<-. o r-u(,t o .S 7-� �e�_Gc y Z-
Z7 c. t cR .
- H u a �4n l l t c ,}.7`40 d
J
GREASE TRAP:
(locate on site plan)
Depth below grade:
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:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.)
(revised 04/25/97) 'ry Page 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 17 White Moor Way,Barnstable,MA
Owner: Robert Morse
Date of Inspection: November 24, 1997
TIGHT OR HOLDING TANK:A//4 (Tank must be pumped prior to, or 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/day
Alarm level: Alarm in working order_ Yes; _ No
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX: y/
(locate on site plan)
Depth of liquid level above outlet invert: 2 c I
Comments:
(note
(` if level and istributtion is_equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)
PUMP CHAMBER:
(locate on site plan)
Pumps in working order: (Yes or No)
Alamo in working order (Yes or No)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 04/25/97) Page 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner: 17 White Moor Way,Barnstable,MA
Date of Inspection: Robert Morse
November 24, 1997
SOIL ABSORPTION SYSTEM (SAS):4z
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type: ,
leaching pits, number: b1� - XC ter% c..G �� /'� r (-S ��
leaching chambers, number:_
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
Alternative system:
Name of Technology:
Comments:
(note condition of soil, s• ns of hydraulic failure, level of ponding, condition of vegetation, etc.)
-----------------
L r .i t v ^�. l5✓
CESSPOOLS:
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow(cesspool must be pumped as part of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:
(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.)
(raviaad 04/25/97) Page ! of 10
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:Owner: 17 White Moor Way,Barnstable,MA
Date of Inspection: Robert Morse
November 24, 1997
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
3
3 ' �6
i
3`6
eJ
(revised 04/25/97) Page 9 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 17 White Moor Way,Barnstable,MA
Owner: Robert Morse
Date of Inspection:
November 24, 1997
Depth to Groundwater — Feet — adjusted high groundwater level
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
,Observation of Site (Abutting property, observation hole, basement sump etc.)
Determine it from local conditions
Check with local Board of health
Check FEMA Maps
Check pumping records
Check local excavators, installers
Use USGS Data
Describe in your own words how you established the High Groundwater Elevation. (Must be completed)
Inc, S c.b 1 P e—o S o �..� '5
IL S a 7" �✓°` C 7�" t c�
�J
�r� l../'^ T C"✓ � cJl v ) 7 µ.,cc-. f
c-) a /
(revised 04/15/97) o Pager 10 of 10
y
t!
LO CAT N1� SEWA PERMIT NO.
% • /� �����a� . �� / off
VILLAGE /� jig
�0 7�-�i L A h I �-e leg®l-6t
INSTA L L E R'S NAME & A D D RE S S J. CRAIG MEDEIROS
' Tiucking-42
�' Br�lldoZiug
rporo ion Street
Hyannis. Mass -27S-Oa28
B U I'l D E R OR OWN ER
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED
6i/f g
`l
fo o ie`-@
t
� 3
5 k-s-tc Jr # �/
,40"d717 0 0 ' It
73�'
-J
No........... V ---- t Fxs.. ..........
THE COMMONWEALTH OF MASSACHusETTS
BOAR® OF HEALTH
u ..............._0F.....?.. , XA S.�? t.�-:.
Applira Lion for EliopooFal Workti Tomitrnrtion ramit
Application is hereby made for a Permit to Construct (x) or Repair ( ) an Individual Sewage Disposal
Ztem at
Location-Address or Lot No.
n� S:
owne . Addre s _
....................•-•---•.......
. 1' '?"' ......---------•...--....
M Inst er Address
U Type of Building Size Lot.ztiA!�•.....Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder WO
aOther—Type of Building ............................ No. of persons.....................--.--.. Showers ( ) — Cafeteria
Otherfixtures -------------------------------------------------------•••--------•------------------------------•-•-•••••--•••••--••------••-•......•-•-•-...-••---•.
W Design Flow.........-r ...................••--gallons per person per day. Total daily flow..---.-�tea...®......................gallons.
WSeptic Tank XLiquid capacity..IPO..gallons Length---------------- Width-.-:-..----.---. Diameter................ Depth................
x Disposal Trench—No. .................... Width.................... Total Length..........e I..... Total leaching area....................sq. ft.
Seepage Pit No.......I............ Diameter.......V ------ Depth below i t..... .... ...... Total leaching area.� .�....sq. ft.
Z Other Distribution box ( X) Dosing tank ( ) f OV- �e % /7-,2 7- 7 7. C-5`4p
Percolation Test Results Performed b 5.1.!.l! K......1 "�.�J............. Date....I 1;1 7 1..•........
Test Pit No. 1 .-5-_2 ...minutes per inch Depth of Test Pit.----- Depth to ground water.A&V!4F--4��C_
44 Test Pit No. 2................minutes per inch Depth of Test Pit...----............. Depth to ground water...----.................
0+ ---••-••••-•----------------••-••••••••-•••---•••••-•-•-•-..........-•---•.........------------..._..........................................................
O Description of Soil--••-4......Dor...P --� , 4"' fc� S4.L!A
x .y -
U •--••---••••-•-••-••---••••----•-•••••---••-----.....••••••----••-•--•••-••--•••-••••--•......-•--•--•--•••-•---•-•-•-••--•••-•---------•--•---••-••----•-.............................................
w
------------------------------ -----------------------------------------------------------------------------------------------------------------------------------------------------------------------
U Nature of Repairs or Alterations—Answer when applicable................................................................................................
-------------------------------------------•---------------------...----------------........•••••••--•--•--•-•---•••••--•------•••-••------•-••--•--------------•-----------------•-•--••----......-•--
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITL% 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. r
Application Approved By.•••. 1� +--� K 3'�3.�. .......
Date
Application Disapproved for the following reasons-----------------------------------------------------------------------------------------------------------------
--------------------------
•-----------
•---------------------
..-.----------------------------
----------•---------------------------------•-------------------------------------------------------
Date
PermitNo......................................................... Issued- ....�oz6- ......................
Date
{� M
N ......... ,S
THE COMMONWEALTH OF MASSACHUSETTS
` BOARD OF HEALTH
7a-f t-l")..................OF.... 1 ?fL:llJ �/`:F1- ...•.
Appliration for Biopos al Works Tonstrnrtion ramit
Application is hereby made,for a Permit to Construct O or Repair ( ) an Individual Sewage Disposal
System at: '
L �Z j4 E' Hoo jZ (VP I✓- �7-P.1 fl v y E —VZL 3 A 2 A)[TAg4.E '>/ 11116 4
..._..VJ ......... ----------------------------- - -----.._..---............ ... .-----•--.........__......-
--
Location-Address —Or Lot No.
--1� , 17DvT/�n
.f . -. =.._ tic
--- 0 <s.. .
Installer Address
Type of Building Size Lot.24d'`'O-----Sq. f
Dwelling-No. of Bedrooms....... ................................Expansion Attic ( ) Garbage Grinder, (
Other—T e of Building ............... No. of ersons_....._........._.......__.. Showers
W YP g P ( ) — Cafeteria
dOther fix�res --------------- - ------•----------•--------------------._.....---------------------....--------....--••---•----
w Design Flow.......... ............................gallons per person per day. Total daily flow......J ��_......................:gal Ions.
WSeptic Tank Liquid capacity.17VO.gallons Length................ Width................ Diameter---------------- Depth................
x Disposal Trench—No_____________________ Width.................... Total Length........ ._t------ Total leaching area....................sq. ft.
Seepage Pit No....... ------------ Diameter ....... Depth below inlet....... __........ Total leaching area _ sq. ft.
S `•�z Other Distribution box ( ) Dosing tank ( ) f _ i ( q l P;4y
a Percolation Test Results Performed by. �
I P a'(__ (_� ,{' ._e_�_T:.7Date � { ..7_ _________..
Test Pit No. 1'C ......minutes per inch Depth of Test Pit.......Z-_..... Depth to ground water_ _._F-�L
(T Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water...................
a •-••._..... . -• ........................................
Description ofSoil.._.. � i
.....----- ..... . ------
w
--------------------------------------------------------------------------------- ---------------------------------------------------------------------------
U Nature of Repairs or Alterations—Answer when applicable..............................................................................:...............
---------•-•----••......••.---••-
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITiL 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.
'gn yd 13 �Q�STit �_ t ...............•--------•...._. - � ��
Application Approved By....... C.�' dG.`y'/ . •---•---•••----------------- - -�3 Y
Date
Application Disapproved for the following reasons___________...... ....�
--•---------------------------------•-------•--------------.........---...----------...----•---------•------•--•----••---•----•-------••...-•---•••---•-----•--•-------••••...............................
4 Date
PermitNo......................................................... Issued_.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
^� BOARD OF HEALTH
.. t).1r.1}-.L)....................OF...... J .!�5. 1"I :. L=..........................
Trrtifiratr of Tootplionrr
T,H T �TIFY, T idu z i% System constructed ( ) or Repaired ( )
by..... ............. ..•-- = �� ... ---••--- --•--------------•-------------......---.....---......------------------------......-•------•--
h C '� /� 1�� r Installer t
at f ' i ,� J � z+vl�vl; f,�': c�i s ls� f +--------------
has been installed in accordance with the provisi n. of TI 1& >of The State Sanitary Code as described in the
application for.Dis osal Works Construction Permit No.. _ __ _&. ................. dated__.. -7 ..................
THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................... ........... �f ..... Inspector......... ..- . ---• •--- ..................................
THE COMMONWEALTH OF'MASSACHUSETTS
BOARD OF HEALTH
a� Toy OF.. t��. R.n�sz: a � .
.... .. ............................
No.... �.�.} FEE........................
Dispos Works Tongr Urt
r
Permission is hereby granted..____,_. -'.._... �?. AJ �T/?.v C_T i v N `
-----•-• ....... ...................................
to Constr1uct ( � or Repair ( ) an Individual Sewage Disposal System
at No........C2�_.......: -. .._... .. ..............•... ._.5, = a.. & �y t
Street
as shown on the'application for Disposal,.Works Construction Permit No__________________ Dated..
r
44
Pa . / / Board of Health
DATE ;
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS /
ft i Soil__Log 1
2 L�yY - ^—. -- 2' f
3 --; --- q
,-- 4 ;4
Ijap _. _ _ 5
EE A _ iMF D 5 ,
2 % SLOPE OVER LEAC14ING AREA F -
_ 7
1 8" Q(A. G �1V C P E T E COVERS SAan, ,
_ ,--•18'' DIA. C ONCRETE COVER fs94: r ATI C
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W A L L F!/P E S, S HA I L BE S L OFF r D l 4'' PER F O J T . M I N. : E`XC EPT
FOR THE FIRST 2 FEET OUT OF_ HE DB WHICI•-` SHALLSE LEVEL
3 - DESIG 1V FL CAW-3 B t0P,0 �M;; AT. 1/0 GAL DJ v PER- la c/nAY c,ne��,�
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SYSTEM : USE L E�c����v _f?`�� 'G�r, p �,,, :__. ` ,F } � _
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