HomeMy WebLinkAbout0035 AMES WAY - Health 35 Ames Way
Centerville
A= 189--006 - 003
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UPC 12534
.2.153L.O � •
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COMMONWEALTH OF MASSACHUSETTS
�� EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS .
DEPARTMENT OF ENVIRONMENTAL PROTECTION
( C)
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 35 Ames Way
Centerville / _ �, _ 00--�
Owner's Name: Rebecca Ames
Owner's Address: -1 5
Date of Inspection:- 1)
Name of inspector:(please print)',— Sean Jones
Company Name: William E. Robinson Septic Service
Mailing Address: P O Box 1 089
Centerville, MA
Telephone Number: (S08) 77 -8776
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my r
training and experience in the proper function and maintenance of on site sewage disposal systems.Iam a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system,
1 � 3
"/ Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authgn',
Fails
Inspector's Signature: Date: l l as O r"
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board Healthy
DEP)within 30 days of completing this inspection.if the system is a shared system or has a design now 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 approxing
authority.
Notes and Comments
""This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of I 1
OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 35 Ames Way
Centerville
Owner: Rebecca Ames
Date of Inspection: t 14 2 JOG
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes: '
JI 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: 1
One or mores stem co ���y components as described in the� Conditional Pass"section need to be replaced or
repaired.The system,upon completion of the replacement or
explain. repair,as approved by the Board of Health,will pass.
Answer es no or I
y not determined(Y,N,ND)in the Cor the following statements.IC"not determined"please
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 tartk 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 structurallylsound,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 pipes)or due to a broken,settled or uneven distribution box.System will pass inspection if(with
approval of Board of Hcalth):
broken'pipe(s)are replaced
obstruction is,removed
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 Hoard of Health):
broken pipe(s)are replaced
obstrUc6m isrtm ud.
ND explain:
l _
Page;'rof I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 35 Ames Way
Centerville
Owner: Rebecca Ames
Date of Inspection: .
C Further Evaluation is Required by the Board of Health: Al J
Conditions=ist 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(i)(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 of 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 front 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 and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence.of ammonia nitrogen and nitrate.nitrogen is equal to or less than S.ppm,provided that no other
failure criteria are triggered.A copy of the analysis must be attached to this form.
3. Other:
i
3
Page 4 of 11 .<
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 35 Ames Way
entervi e
Owner• Rebecca Ames
Date of Inspection: 1 Ob,
D. System Failure Criteria applicable to all systems:
You must indicate"yi s"or"no"to each of the following for all inspections:
Yes No/
Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
— Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged`SAS or cesspool
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
— cesspool
Liquid depth in cesspool is less than 6"below invert or available volume is less than%day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
J 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 oPa 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 coliform bacteria and volatile organic compounds
indicates that the well is free.from pollution from (fiat 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 must be attached to this forma
(YeslNo)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:,. N,I
To.be considered a large system the system must serve a.,facility with aAcsign-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 criteria above)
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 Prolection Area—IWPA)or a mapped
Zone 11 of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered .
"yes"in Section D above the large system has fatted.The owner orr 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.
4
Pape 5 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 35 Ames Way
Centerville
Owner: Rebecca Ames
Date of inspection:
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?
—ZHave 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?
J _ 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?
-Z_ 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)[310 CMR 15.302(3)(b)]
S
Page 6 of l l r
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 35 Ames Way
Centerville
Owner: Rebecca Ames
Dale of Inspection: I 06
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x N of bedrooms): 330 6 b
Number of current residents:
Does residence have a garbage grinder(yes or no):
Is laundry on a separate sewage system(yes or no): .-v [if yes separate inspection required]
Laundry system inspected(yes or no):�LA
Seasonal use:(yes or no): /P 2005 — 5 3 , 0 0 0
Wa
ter meter readings,i available
f 1 last 2 ears usage d
g � ( Y g (gpd)): 2004 _ 68,000
Su
mp mp pump(yes or no): nio
Last date of occupancy: CVrr I A+
COMMERCIAL/INDUSTRIAL N 4
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 system(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(yes or no): %pc,%
If yes,volume pumped: t000 Qallons--How was quantity pumped determined? S -zc a F
Reason for pumping: u o • cr 1-c a„rs t.
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)
_InnovativdAltemative 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:
Were sewage odors detected when arriving at the site(yes or no):iw
6
I;a6c 7 of I I
OFFICIAL INSPECTION F0161 —NOT FOR VOLUNTARY ASSL;SS111ENTS
SUBSURFACE SENVAGE DISPOSAL SYSTEM INSPECTION F011111
PART C
SYSTUI INFORMATION (continued)
ProptrtyAddrew 35 Ames Way
Centerville
Owner: Rebecca Ames
Dale of Inspeetlon:
BUILDING SLNVEll(locate on site plan)
Dcpdt below grade:_2.��&Joy ?�r
Materials of eorlstrucljolt:_cast irun __v/40 PVC_Odlcr(explain):
Distance from private%%.atcr supply%Vcll or suction line:_
Cununents(oil condition of juurts,Venting,Evidence of Icakagc,c10:
JOv }1 p.c �J I Ca lCL e—
SEPTIC TANK: ✓(locale oil site plan)
Dcpth below Bradt: )'?"
Material of eonstruaiun:✓vncrcre metal fiberglass pulyctltylcne
_uthcr(txplain) — —
If tank is metal list age:_ Is age cunfirmed•by a Certificate of Compliance().es or nu):_(attach a Cully of .
ccnifrcatc)
Dimensions: 1000
Sludge deplb:
Distance front toll of sludge to bottom of vutict tcc or bafllc: ^—
Sctult thickness: —
Distance front toll of scum tv toll of outlet let or ballle:
Distance Gotn bvttunt of scum to button,of vutict,cc,or bafllc:
lose were dimensions determined: .-4x W l e.S !�v V
w fer a j`w+C Q r. .ia cy�e
Curnmcnts(urt pumping recomuncndativns,inlet and outlet Ice or bafllc cunJilicn, siructwal intc6rity,liquid IcvNCls
as rclalcd to oullcl ulvcrt,es•idcncc pf leakage,etc.):
t7>'IA�—_ 84 /r
lPti lci�s
GREASE TRAP:Al catc un site plan)
Dcpth below grade:_
Nialerial of construction:`cuncrcle metal fiberglass`pulyelllylene _other
(explain): — —"
Dimensions:
Scun1 lhickr,css:
Distance (torn Iup of scull,10 101)of uuticl lee or bafllc:_
Distance 50111 bottom of`scurn to butlun,of uuticl Ice or bafllc:
Date of last pumping:
Conunenls(on pumping rccununendalions,inlet and outlet(cc or bafllc conditiu:t,sltuctural inlcgilly, liquid ICN-Ch
as Iclalcd lu oullcl inVcrt,cVidcncc of Icakagc,c1c.).
7
,'age 8 of
OI.I.ICIAL 1NSPECUON FORM NOT FOR VOLUNTARY ASSL••SSNJENTS
SUDSUKI-ACE SLWAU DISPOSAL SYSTEM 1NSPEIC-1-ION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 35 Ames Way
_Centerville
Owner:
llAlc of lospcclloo: 1.( a, 0�
TIGHT or 110LUlNG TANK: AI1A(lank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
hlalerial of eonstrvction:__concrete_ntcial_fiberglass_lrulyethylene____otl�ct(explain):
Dimensions:
Capacit}:_ ralluns
Design Flow: galluns/da}•
Alarm present(ycs or no):
Alarm level: Alann in wolkin urdcr
Date of last pumping: 6 (des or tw):
Conuncntsdit'con
(condition of alarm and f1oa1 switches.etc.
DISTRIBUTION BOX:Zif present must be opcncd)(Iocatc on site plan)
Depth of liquid level above uutic( invert: 0`'
Conuncnts(note if bvx is Revel and distribution to outlets equal,an}•evidence of solids cairyovcr,any evidence of
Icaka c into or out of box,ctc.).
�..:
S ,
PUAW CIIAMBElt:N'Ilucate on site plan)
Puutps in working order(yes or no):_
Alamos in working order(yes or no): _
Comments(note condition of pump chamber,cunditiun of pumps and alipurtenan(es,cle.):
Page 9 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 35 Ames Way
Centerville
Owner: Rebecca Ames
Date of Inspection: t i/a.110!o /
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation'not required)
If SAS not located explain why:
Type
leaching pits,number:_
leaching chambers,number:
__,leaching galleries,number:
�/leaching trenches,number,length: 'la ' 301 x I icl...r 'Ta)so.rr
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/altemative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.): C �po 1
Sol ( wA I G/�� e nJ... wC ND
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 or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY:NI 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.):
9
Page 10 of 1 l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 35 Ames Way
Centerville
Owner: Rebecca Ames
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
benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building.
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10
Page L ofll
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS .
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 35 Ames Way
Centervi e
Owner: Rebecca Ames
Date,of Inspection: _ I a Db
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 5}lrfeet
Please indicate(check)all methods used to determine the high ground water elevation:
JObtained from system design plans on record-if checked,date of design plan reviewed: 1 9 0 S 3
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: f
ri�lc9 sz �la.s C a 1!� o-q bAXt-can f 'L",i k e� rr�c
C� qw Crlc c �� f}a f SA.r is Aflpryx 3
ruder.
'beS P c_ (JU 4-J I 11S SA�
ll
No.......E?...L. 1. Fins..........................._
THE COMMONWEALTH OF MASSACHUSETTS y'7 Z
BOARD OF HEALTH 7
'n�...✓.....-----... .....OF i�.:'9 --'sf-�.F3--L=�---------------
Appliration for Disposal Murks Tuntrur#iun rrntit
Application is hereby made for a Permit to Construct ('boor Repair ( ) an Individual Sewage-Dispoiil
System at: M -e W
65ZV'1 ILL
................_... ..........---•--:----.........---------•----•---.......•....••. .---------------•-------- -- - . ...._....
Locatio 2 Addre s . � 3 or No.
G --- / ` :� .-- •--
Owner Address
(sl
Installer Address 0� 9�
Type of Building Size Lot..... .................Sq. feet
U Dwelling—No. of Bedroom .................:.......................... ns
p Gage Grinder
Cafeteria �r
per, Other—Type of Building l'- '`s� -...... No. of.personsi&Attic Showers (
dOther fixtures ....
W Design-Flow......................��....�........._gallons per person day. Total daily floes......_...__ 3®.____......._... Ions.
W Septic Tank—Liquid capacityk®'O�gallons Length--m__L'`_. Width-Z.5�... Diameter..................
............... Depth.. ............
x Disposal Trench—No......./........... Width_-`z...._._._.. Total Length._-_-_®....... Total leaching area..'`I........sq. ft.
Seepage Pit No..........-�._. Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box Dosing t Jnk (
aPercolation Test Results Performed by...... 1........ !z T.__. '�C............. Date....j...__ �
Test Pit No. 1.....!k+minutes per inch Depth of Test Pit.....13�'� Depth to ground water.._._...��s.�..
fT4 Test Pit No. 2...... Minutes per inch Depth of Test Pit.....1.11--- Depth to ground water._......
Description of Soil..................... 1�J v� y--- ...................... .........
x ------------------------- ------------------ 4E__ - �s
V- 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 iITU 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been i su d bv board of health.
Sined. ..... .. ......................-................
Application Approved By......................... �../• -•---- ---- •--•--...--••--•---•-•--......--•• ---.----Z -1) ........
Ie
Application Disapproved for the f ollowi reasons-..............------••----.....-----...-----.._..--•-•------....--•------•-----...---------...Y......•--...._
.........................•--------------.. ..--------- --.....••---•---•-••-•---...... _...._....-----------••------- - ......---••---•-
Date
PermitNo................................................... Issued........................................................
Date
t ,
No................_....... Fims.............................
THE COMMONWEALTH OF MASSACHUSETTS Z
BOARD OF HEALTH
. .........OF.....�..:..j' i'T/\/ : =--;---. ' '..�:_—ti°........... ..
Allp iraation for Disposal Works Tonstrurtion Vprrmit
Application is hereby made for a Permit to Construct ( /<r Repair ( ) an Individual Sewage Disposal
Systemat: .............................. .......................................................
Location Address or Lot No.
W owner Address
a _..._.....
Installer Address
UType of Building Size Lot--- Y �'_....Sq. feet
.., Dwelling—No. of Bedrooms................. -�-_......................Expansion Attic Garbage Grinder •(--��
aOther—Type of Building .` _` :___.__. No. of persons...._&................. Showers ( - Cafeteria (�
Other fixtures .---•-•--•--: -•---•----------•------•---
�T
W Design Flow..................... _ .............gallons per person per day. Total daily flow............. ................gallons.
R: Septic Tank—Liquid*capacity P Pl gallons Length..2...L . Width _'.!.�.`r Diameter________________ Depth_` '_--__--
Disposal Trench—No. ...... ........... Width............. Total Length.._ ?.t____ Total leaching area_. _ _ __sq. ft.
Seepage Pit No.......... - Diameter.................... Depth below inlet.................... Total leaching area......_...........sq. ft.
Z Other Distribution box ( c Dosing tank (62 _
`-' Percolation Test Results Perforr}ped'by. .._..fi-.^... ... .......�...'Y......`'�.. __........ Date.....
......... ��
a
Test Pit No 1 .minutesrinch Depth of Test Pit._._.. 2,. Depth to ground water...._._ � .
f� Test Pit No 2 r ' utes per inch Depth of Test Pit..._. ..` �f_f Depth to ground water.___._.. _._
----------- ------••--•-
O Description of Soil........ " -` ' ^� r ���` 5-r h,t�7
..................................
W --------------------------------------------------------------- `� "---"�---` -"'''�r' -'-!``/ ---------- ------------------ --------- ------- -
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
--•-••-••••---•••-----------------•----------.-•--------------------•------------•--•------•--•-•---••----••---------------------------.....-------•---------------.._..------------.....------••---
Agreement
CW
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Sined.. - ------------•----•-----•--------------•••...------........_...-•----•--•...---
'� D'te
Application Approved By----•-•-------••......1 . •---•---•-------------••--•-----• --------
D to
Application Disapproved for the f ollowi y reasons-------------------------•--- _... ..........................................................
.......-•-•-----------------•----•--•---...---•------•-••-----..••••--
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Tnrtifiraatr of Toutpliaattu
THIS IS T ERTIFY That he Individual Sewage Disposal System constructed ( /� or Repaired ( )
by--------------------_-- .-•=G✓iv'�- c.....
,, ��• 'per-----
�` ......... Jastal;p
at_..-1" J / C r - ,� '�' � i
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as d scribed in the
application for Disposal Works Construction Permit No....... ( r_�!.'__._....... dated....W1%-/,----------------------------
THE
ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL NIN5T.ION SATISFACTORY.
DATE........... � Inspector.........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
................. am ,f? s Cr
FEE........................
Disposal Works ToWnstrurtion frrmit
Permissionis hereby granted..........................-...................................................................................................................
to Construct ( if-ror Repair ( ) an Individual Sewage Disposal-System
at No....... -`" r G ✓� r i r f1/r:�—` / rs �� . ✓2/.a� G /.%i.! rr'�Wit,
Street-^ ---••------- --•- ------ ----•...........
' �(1
as shown on the application for Disposal Works Construction Permit No_______ ________ _ Dated..._..... ......_. .................
-------------------
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Board of Health
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'GROUND TAHLE T, PROFILE OF
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SANITARY DISPOSAL SY STEM
NOT TO SCALE DESIGN DATA
BEDROOMS
• COIVSTR UCTfON OF SANITARY DIS POSA'L»
A�l ,; ., DESIGN F `tOW ; GAL . D AY
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LEACH RA
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ENVIRONMENTAL (REV SED 7- t
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AND THE E TOWN N O F PROPOSED LEACH CAPAC
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HEALTH EG U LATI ON R S.
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GAL. DAY -,
MtN. CONCRETE STRENGTH 3000 F'St
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MIN. STEEL.. STRENGTH 20,OOOPS1
H .10 DESIGN LOADING
• DRIVEWAYS NOTTO BE LOCATED OVER SYSTEM
UNLESS H- 20 DESIGN LOADING ISi USED.
A PIP. TIN A R I• ALL ES AND FlT GS TO BE W TE T GHT AN D
TO BE OF CAST IRON OR S, CHED 40 P.V. C:
L A N KOWING PROPOSED CONSTRJ TIO � SH .;L0F ._—S'HSS TE P
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- LEGEND
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, BOAR OF
5CA1` E. ' r D HEALTH
.___. __�� R E F E R E N C a- ��, �c�vtt f� ,
t3UILDCNG 'SETBACK REGULATIONS PER EXISTING CONTOUR t6 _ E �,. �3 ter'
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BUILDING 'INSPECTO:R OR -BU ( L,Dt<NG F;
> COMMISSIONER .
PROPOSED CONTOUR { 6 DATE. AGENT
E XISTING SPOT ELEVATION 17. 6
MIN. FRONT SETBACK
PROPOSED WATER SERVICE
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MIN. SIDE SETBACK _� t�s @� 4'Sc
TEST HOLE LOCATION
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MIN. REAR SETBACK
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PROFESSIONAL LAND SURVEYORS ,b ENGINEERS GIS
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1586 MAIN'. .STREET RTE.°6A EAS DENNI ' MASS
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