HomeMy WebLinkAbout0030 AUDUBON CIRCLE - Health 30 Audubon Circle
Centerville P F
A = 191 178
UPC 12534
No.2-
HASTINGS, MN
Ta
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS .
DEPARTMENT.OF.ENVIRONMENTAL PROTECTI9NED
/o IIIN 0 2 2004
CTOWN OF BARNSTABLE .
• HEALTH DEPT.
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL_SYSTEM FORM
PART A
CERTIFICATION
PARCE4 . 1 7�
Property Address: 30 Audubon Circle -
Centervi1.1e, MA LO ,,
O*ner'sName: cark Ra�mnnd
Owner's Address:
Date of Inspection:
Name of Inspector:(please print) W}11 jam F_ • Robinson Sr.
Company Name: William E. Robinson Septic Service
Mailing Address: P O Box 1 089
Centerville. MA
Telephone Number:- (5081 775-.8776_.-
CERTIFICATION STATEMENT
1 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 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 15340 of Title 5(310 CNIR 15.000). The system:
asses
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: c
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Healthvr.
DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies:Sent to the buyer,if applicable,and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page I
�n
Page 2 of 11
OFFICIAL INSPECTION FORM NOT"FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 30 Audubon Circle
Centerville,MA
Owner. Gary Raymond
Date of Inspection:.:
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. Syst 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 Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
rep fired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.'
Answ yes,no or not determined(Y,N,ND)in the for the following statements.If`not determined"please
expla'
e septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsoun exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the
existing is replaced with a complying septic tank as approved by the Board of Health.
•A meta septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicatin at the tank is less than 20 years old is available.
ND expla
Ob ervation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed ipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with
approval o" oard of Health):
broken pipe(3)are'replaced`
obstruction is removed
distribution box is leveled or-replaced
ND explain;
The sy cm required pumping more than 4 times a year due.to broken or obstrwed pipe(s).The system will
pass inspection'f(with approval of the Board of Health):
broken pipe(s),are replaced.
obstruction is rcmorod
ND explain:Plain:
Page 3 of I l
OFFICIAL'INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 30 Audubon Circle
Centerville, MA
Owner,
Date of Inspection: . �<
G Further Evaluation is Required by the Board of Health:
onditions-exist which require further evaluation by the Board of Health in order to determine if the system
is failin to protect public health,safety or the environment.
L S stem will pass unless Board of Health determines in accordance with310 CMR 15,303(1)(b)that the.
s tem is not functioning in a manner which will protect public health,safetyand the environment:-
Cesspool or privy is within 50 feet of a surface water
Cesspool or-privyis wit
hin 50 feet ofa bord
er
ing vegetated
lated wetland or a sa
lt marsh
2. Sys em will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system s 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
su ace 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 Goff 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 Gee from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered.A copy of the analysis must be attached to this form.
3. Other:
3
Page 4 of I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACESEWAGEDISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 30 Audubon Circle
Centerville, MA
Owner: Gary Raymond
Date of lnspection:. _! `
D. Sys em Failure Criteria applicable to all systems:
You mu indicate'jes"or"no"to each of the following for all inspections:
Yes N
Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool .
Discharge or pondin&of etllucnt 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
— esspool
iquid depth in cesspool is less than 6"below invert or available volume is'less`than Y,day°flow
equired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
f times pumped
— _ y portion of the SAS,cesspool or privy is below high ground water elevation.
y portion of cesspool or privy is within 100-feet of a surface water supply or tributary to a surface
rater supply.
— _ y portion of a cesspool or.privy is within a Zone I of a.public well.
— — y portion of a cesspool or privy is within 50 feet of a private water supply well.
— — y portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private uatrr
supply well with no acceptable water quality analysis.(This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
Indicates that the well is free.from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
(Yes/No)The system fails.1 have determined that one or more of-the above failure criteria exist as
described in 310 CMR 15.363,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 a considered a large system the system must serve a faci!ity with a`design flow of 10,000 gpd to 15,000
gpd
You ust indicate either"ycs"or"no"to each of the following:
(The ollowing criteria apply to large systems in addition to die criteria above)
yes 0
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 If of a public water supply well
if you 'e answered"yes"to any question in Scaim E the system is considered a significant threat,or answered
"yes"i ction D above the large system has failed.The or%m r or operator of any large system considered a
signific n threat under Section E or failed under Section D shall upgrade the system in accorda
nce with 310 CMR
15.304.T e,sy/stem owner should contact the appropriate.regional office of the Department.
d'
4
Page S of l l
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 30 Audubon Circle
Centerville, MA
Owner:
Date of Inspection: �-
Check if the following have been done.You must indicate''yes"or"no"as to each of the following:
Yes No i
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?Z_ _ as the system received normal flows in'the previous two week period?
✓/H 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?
_v Were all system components,excluding the SAS,located on site?
_ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:.
Yes no/
l 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)]
5
Page 6 of l l
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSALSYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 30 Audubon Ci rc-1 e
Centerville, MA
Owner: Gary R.
Date of Inspection:
— ' FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):. Number of bedrooms(actual):
DESIGN flow based on 310 CNIR 1 .203(for example: 110 gpd x ii of bedrooms):
Number of current residents:
Does residence have a garbage Oderfyes or no)
Is laundry on a separate sewage.system(yes or no) j [ifyes separate inspection required]
Laundry system inspected(yes or no):%
Seasonal use:(yes or no):A,
Water meter readings,if available(last 2 years usage(gpd)): 2 003 81 , 0 0 0
Sump pump(yes or no);4di 2002 - 99, 000
Last date of occupancy:6� �
COMMER IAL/INDUSTRIAL
Type of esc lishment:
Design flow based on 310 CMR 15.203): Rpd
Basis of desi .flow(seats/persons/sgft,etc.):
Grease trap resent(yes or no):_
Industrial w ste holding tank present(yes or no):_
Non•sant waste discharged to the Title 5 system(yes or no):
Water mete readings,if available:
Last date o occupancy/use:
OTHER escribe):
GENERAL INFORMATION
Pumping Records
Source of information: IS9 L `a,
Was system puumped as part of the inspection(yes of no);Z,,�)
If yes,volume pumped: gallons-=How was quantity pumped determined?
Reason for pumping:
fTYP F SYSTEM
Septic tank,distribution box,soil absorption system
Single cesspool
Overflow cesspool
Privy
_Shared system(yes or no)(if yes,attach previous inspection records,if any)
_Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
_Tight tank _Attach a copy of the DEP approval
_Other(describe):
Approximate age of all components�dale iclstalled(if known)and source of information:
Were sewage odors detected when arriving at the site(yes or no)-
6
Page 7 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 30 Audubon Circle
Centerville, MA
Owner. Gary R mond
Date of Inspection: — --Q�—
BUILDING /EE (locate on site plan)
Depth below Materials of cion:_cast iron 40 PVC other(explain):
Distance fromwater supply well or suction line:
Comments(oon of jousts,venting,evidence of leakage,etc.):
SEPTIC TA1\K.Zoocate: on site plan)
Depth below grade:
Material of construction: concrete_metal fiberglass_polyethylene
_other explain) —"
If tank is metal list age:_ is age confumed•by a Certificate of Compliance(yes or no :_(attach a copy of
certificate) , i
Dimensions:#topo
Sludge depthDistance froudge to bottom of outlet tee or baffle:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:,&F�
Distance from bottom of scum to bottom o utlei tee or�ba(Tle: M�,
How were dimensions determined: ' r✓ (4,
Comments(on pumping recommendatw s,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of I akaW.etc.):
� ® �
CREASE RAP: (locate on site plan)
Depth below ade:_
Matcrial of c nstruction:_concrete._metal fiberglass_polyethylene other
(explain): —.
Dimensions:
Scum thickn ss:
Distance fro top of scum to top of outlet tee or.baffle:
Distance fro bottom of scum to bottom of outlet tee or baffle:
Date of last umping:
Comments(i n pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to utlet invert,evidence of leakage,etc.):
7
Page 8 of 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 30 Audubon Circle
Centervi11e. MA
Owner:
Date or laspectlom :Jil-64-7
TIGHT or HOLD TANK: (tank must be pumped at time of inspection)(locate on site.plan)
Depth below grade:
Material of constructio :—concrete metal fiberglass polyethylene other(explain)::.
Dimensions:
Capacity. —gallons
Design Flow: allons/day
Alarm present(yes or o):
Alarm level: Alarm in working order(yes or no):
Date of last pumpin
Comments(eonditi of alarm and float switches,.etc.):
DISTRIBUTION BOX: r/(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: _
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,ctc.):
PUMP)( 1c
ER: (locate on site plan)
Pumpsg order(yes or no):
Alarmsg order(yes or no):
Commcondition of pump chamber,condition of pumps and appurtenances,etc.):
8
Page 9ofII
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 30 Audubon Circle
Centerville, MA
Owner' c;arY RaYm� Ld
Date of Inspection:
SOILABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
r
ching pits,number:ching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
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.):
6
CESSPOOLS: ( esspool must be pumped as part of inspection)(locate on site plan)
Number and configuratie
Depth—top of liquid to' let invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater nflow.(yes or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: (locate on to plan)
Materials of construction
Dimensions:
Depth of solids:
Comments(note condit on of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
Page 10 of 11 ..
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 30 Audubon. Circle
Centerville, MA
Owner: Gary Raymond
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.
e
0
10
Page 11 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS .
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 30 Audubon Circle
Centerville, MA
Owner: Gary Raymond
Date:of Inspection: :2 Zj7" /
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
ecked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
h-A a,v A0,0-7-
11
ASSESSORS MAP N0:
No. "" 0- 01) PARCEL NO`_ / / rfi Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
ZippIication for Miooml 6raem Construction Permit
Application is hereby made for a Permit to Construct( )or Repair( )an On-site Sewage Disposal System at:
Location Address or L t No. Owner's Name,Address and Tel.No.
�a � v� C���/'e ve -�5�� 00 ke
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
s;*/f '.
Type of Building:
Dwelling No.of Bedrooms Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Description of Soil
Na�ree airs or terations(Answer w4m -applicable)
_eop —
Date last inspected:
Agreement:
The undersigned agrees to ensur onstruction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of itle 5 o e Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued b is Bo f H�
Signed v"'^��— Date~�J�
Application Approved by
Application Disapproved for the following reasons
Permit No.��� ��� Date Issued ��
No. ^' / 7 1 Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
01pplitation for Miopool 6potem Cou!6truction permit
Application is hereby made for Permit to Construct( )or Repair( )an On-site Sewage Disposal System at:
Location Address or L t N . Owner's Name,Address and Tel.No.
42 rrr `7 7S- 7sS�s
Installer's Name,AddreV,and Tel.No. Designer's Name,Address and Tel.No.
P /'7 v /�
�/t �OG /C 1 ;X,
Type of Building:
Dwelling No.of Bedrooms Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
" Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Description of Soil
i
Ni}ture o e airs or terations(Answer w4i . applicable)
r
Date last inspected:
Agreement:
The undersigned agrees to ensur -he-construction and maintenance of the afore described on-site sewage disposal system r
in accordance with the provisions of it
5 o tote Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued b is Boa} of He th. )
U"'^�""� f� 6
Signed Date �Y
Application Approved by X
r
Application Disapproved for the following reasons
Permit No. '° �� Date Issued 1pq
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLEs MASSACHUSETTS 3
Certificate of (Compliance
TF
S IS TO CERUFY, .at the On-sitg Sewage Disposal System insled(, or re red/replacedn
by J for VA L//� k%e
as ltJ 2 — Q, has been constructed in accordance`
with the provisions of Title 5 and the for Disposal Systemleonstruction Permit No. Z� dated
Use of this system is conditioned on compliance with the provisions set forth below:
r
` .•� 4gL4.e
—�
No. --------------------------Fee &4_;4.�
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLEs MASSACHUSETTS
- 'fi6pozar *p5tem Cougtruction Permit
Permission is hereby granted to M v '
to construct( )repair( "' an On-site Sewage System located at v oft/ C, -e
t
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
i
} All construction must be completed within two years of the date below.
Date: �^✓" " � '' � Approved b ✓
i
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS)
l'
P
he certify that the application for disposal works
construction permit signed by me dated ,4T 1 Y /2 coning the
property located at �� �,10�y Cis C/�, C e y tt� all of the
following criteria: *'
There are no wetlands within 300 feet of the proposed septic system
• There are no private wells within 150 feet of the proposed septic system
The observed groundwater table is 14 feet or greater below the bottom of the leaching facility
• There is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
•t
SIGNED
G�+�' DATE:
LICENSED SE ff
SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NLIMER
[Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan,
this plan should be submitted].
y`f �
� ty
} r c
at
r
< t
r TOWN OF BARNSTABLE 1
LOCATION Sb Au 0/1, La>,J SEWAGE
VILLAGE` Gew7z/• ASSESSOR'S MAP & LOT
INSTALL-ER'S NAME&PHONE NO. T l`"n M 6 k e(
SEPTIC TANK CAPACITY o o ® A
LEACHING FACT LTTY: (type) (size) �� 5(/K1-F/f� �ZS
NO. OF BEDROOMS L Ldd-X —<546-e
BUILDER
OR OWTNER �J/— yy_-
PERMIT DATE: �COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Z Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) ft/G/�/`e Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of ac ' acility) �GN`� Feet
Furnished by -/�"
r
c
e, r
TO
No......A...�...y.t 9 �. Fic$ ................
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF' HEALTH 'A 0,�, JJJ
........._..-- ..........................OF.............................._........------------.._...------•---......................
Apli iration for Dispnsn1 ' .arks Tonstrnrtiun thrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
...............------------•-----......o----•----------
nn Location-Address or Lot No.
- Q ELVZ �Y 5� Y�cSl�1 11� W............................................
- — ....... .C. �.......................................... ............
Owner Address
"! "" �� e�v�.�CS a�
a --- . ------------------•------------- --------.............-------------------- �--- . ....................--------------....
Installer Address
U TypeDwellinNo. of Bedrooms___________________________________ Size Lot...__...........___._...._._Sq. feet
Building of
a g— .___.__..Expansion Attic ( ) Garbage Grinder ( )
p, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
C4 Other fixtures ------------------------•-•--•--•---•----••....... ..._
W Design Flow................1.I.Q..................gallons per person per da� Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity.k.V.wgallons.l—Length.�s�la•.7Width................ Diameter................ Depth................
x Disposal Trench—No._ Width.................... Total Length.........._..........Total leaching area...._...............sq. ft.
Seepage Pit No..................... iameter..(a .----_--__- Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
a' Percolation Test Results Performed by.......................................................................... Date........................................
aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.......................
VA Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P4 ........................•----•••••---•------•-••-••--••••.....-•-----•-•••--•----------
•-•-----
-----
----------------•----------------------------------------
0 Description of Soil..........................................................................................---------•-----------------...----------•-------------------.._.....-•--•----
W
U •••••••••-•--••••-••--------•-••----•..............•---•••----.....--••-••-•--••--•-•-----...--•••----••...••--••••••••----••••••-•---•-•----•-•---•••-•••••-••••--••--•--••-......----••......-•••--••.
W
•••-•------------------------------------------------------•------•-------------------•---------------------------------------------------..........-----------.......................................
U Nature of Repairs or Alterations Answer when applicable... 4_____1
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TI TALE 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 bpmLdlealt .
Signe r •....... . ...
Date
Application Approved By.___.__.._._ :c..__ . ........... --••••..............Da.-•-•.....
Date
Application Disapproved for the following reasons---------------------------------•---------------------------•------------------•------------------•-•••.........
--.....--•-----------------------•---------------...---•-------•-•--•-----------......---------------------••••••-•---•-•---••-••-•-•••••••••••••------- ................................................
Date
PermitNo...............•-------•--------•-•---------------•----. Issued...................D .................................
ate
F
No....r09_:.4 L. . .' .. Fps..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
I
ApplirFation for Disposal Workii Tonitrnrtion ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
-•..........................................................................•-....----••---...... --•-----•••••----------------......_.....-----•••-•------•----•---......-•----------•••-•--------•
Location-Address or Lot No.
......................--•-•----....----......-----........-_--•---------------_---------------
W Owner Address
Installer Address
UType of Building Size Lot............................Sq. feet
t-, Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
a I Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
Other fixtures
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No_____________________ Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No_____________________ Diameter.................... Depth below inlet.................... Total leaching area.__...............sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date-----------........................................
Test Pit No. L_______________mmutes per inch Depth of Test Pit.................... Depth to ground water........................
(� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
=---------•-------•--- .............................................................................................................
0 Description of Soil________________________________
x
w I
UNature of Repairs or Alterations—Answer when applicable.
----------------------------•-------------------------------------------------------------_•---------•------------------------------------•------------ ---------------•----•-----•---••-•....----
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITIE 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.
Sig ----•.-.-------•---- � D Dat----------------•-------------------------------•--- ------------ a•e---•-•---------
....................�
Application Approved By---•---------•---------------•-=-a
Date
'Application Disapproved for the following reasons______________
-•---•---------------------------------------------•-------•---------•-------- --------------
.........-•----------------------•--•----=•-----•-----------•-------------•------•----•----------------- ----------------------------------------------•-----------`=----------------------------------
Date
Permit No.... ---------•---•= Issued.......................................................
Date
THE COMMONWEALTH'OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF..............................................................
Tntif iratle of TonapliFanrr
F` THIS IS TO CERTIF , That e Individual Sewage Disposal System constructed ( ) or Repaired ( )
by--------------- -- --.. ";. .............................................................................................................
....................
I�as aver�as aver+at------•-•--_---
.}�
has been installed in accordance with the provisions of TI T L'E 'C'5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No------ __"_. .___ ___ dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSThUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.......................................... '.t 3J�............... ,Inspector.......t .. v•.............................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Q ..........................................OF
....NO............ .........! EE........................
E io�ro gal work ' n rrmff
Permission is hereby granted............ ........................................................ ..............4--
to Construct ( ) or-Repaird ( In i ual Sew grt` `' osal S*st rt
g,.,.r_
atNo...............................................................................................................................................................................................
Street l .1„
as shown on the application for Disposal Works Construction Permit - Dated...
J!_.............. .....................
---------------•-----------•------------ -------- --- -------
DATEr - :
I;-- _..._
- --• Board of Health ,.
h ----------------------------------------�--a-----•-•------.....•---•---......
FORM 1255 HOBBS & WARREN, F�C�.. PUBLISHERS
. Original installer:Delta Crane
for Alan Small Permit #176
,,1974
A
c-
-LOCATION SEWAGE PERMIT NO.
VILLAGE
Gr���
I N SST A L L,E•R IS, ,N A, MU... i ADDRESS "
- _—��`ea�r-►.ate- �_. .��`..�.���<.`
B U I L D E R OR OWNER' y
DATE, PERMIT' IS,SU-ED
DATE 'COM-PLIANCE ISSUED
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'L CA_ SEW fl,G E P_ER.MIT�U O.
Lot 12 Audubon Circle 176
_Centervil_le, pjess.
Delta Crane Service
.off Airport Ad. $yannis, N(ass.
e
5-U_l_L-D-E—R-5-1.1-LL
Alan E. Small, Inca
Box 536 Centerville, Mims.
DATE—RE R-NAI-T 1_S-SUED�-
D AT_E-CO N/l_P L._tm&t,- 1 CE-I SS U EC>-,_ -
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