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HomeMy WebLinkAbout0053 AUDUBON CIRCLE - Health 53 AUDUBON CIRCLE, CENTERVILLE A = 191 182 UPC 12534 No 2-1�5 OR �r � HASTINGS,MN w -- No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS ZIPPYication for Mioogar *potem Construction Permit Application for a Permit to Construct( . )Repair(,/)Upgrade( )Abandon( ) El Complete System O Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. S�'3 �U�t� lap n << � Assessor's Map/Parcel �21�T2fv.'�� ��-'d� �9A� Installer's Name,Address,and Tel.No. . o Designer's Name,Address and Tel.No. �3uM u�S Type of Building: Dwelling No.of Bedrooms— Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank \ Type of'S.A.S. Description of Soil! Nature of Repairs or Alterations(Answer when applicable) CepfA a- 74A_ AAd p 1 Ae. Date last inspected: y Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by is Board(�f Health. Signed tJIS Date 13 I Application Approved by Date _ Application Disapproved for the fol w' g reasons Permit No Date Issued "�1 No. d . ' Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION y TOWN OF BARNSTABLES MASSACHUSETTS 01pprication for Migogaf *pgtem Con5truction Permit Application for a Permit to Construct( )Repair(/)Upgrade( )Abandon( ) El Complete System ❑Individual Components Location Address or Lot No.S-3 /I �� l3� CI(� Owner's Name,Address and Tel.No. U n^ Assessor's Map/Parcel 'q Installer's Name,Address,and Tel.No. o 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( ) Other Fixtures r Design Flow gallons per day. Calculated daily flow gallons. Plan_Date Number of sheets Revision Date Title ' Size of Septic Tank Type of S.A.S.` Description of Soil Nature of Repairs or Alterations(Answer when applicable) Q_,0/8 0L.. % An(. 17/'A2 Ar-- Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by his Board of Health. Signed Date 6 It 3 r Application Approved by Date Application Disapproved for the fol w' g reasons Permit No. c9ol — 1-747 Date Issued �' 13` (1 ---------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired((pgraded( ) Abandoned( )by i at S3 A0 do bn,. C 1 r ctQ Ce.n i p ru, has been constructed in accordance Installer iththe provis ' Designer. ions of Title5 and the for Disposal Cons �t No. /l 1 dated Fig/3 l The issuance oJ t ' permit shall not be construed as a guarantee that the systlmlwll1function s designed•. Date I l l/ Inspector I l ��' «. ---------._ ----------------- ----- ---- - No.1201 1— 17 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS ~- Migogaf *pgtem Cong;truction Permit Permission is hereby granted to Construct( )Repair(XUpgrade( )Abandon( ) System located,at S? 4,)df I�n.4 C i rr (s (fit jo,IL 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. Provided: Construction must be completed within three years of the date of this t. Date:_. 3- Approved by L IX w i � OF THE TpjY Town of Barnstable Barnstable Regulatory Services Department j edcaC j l�• nARNSTnsLE. "Ass.059. Public Health Division rE0 MAt a 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 7006 0810 0000 3525 5255 May 17, 2011 Ms Laura Blair 53 Audubon Circle Centerville, MA 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system 53 Audubon Circle, Centerville MA was last inspected on 4/21/2011 by Robert Paolini a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system"Conditionally Passed" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • Outlet precast tee is soft and falling apart. New PVC S40 sanitary tee needs to be installed. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass: You are ordered to repair or replace the septic system within two (2) years from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH Thomas McKean, R.S., CHO Agent of the Board of Health QASEPTIC\Letters Septic Inspection Failures\53 Audubon Cir Cent May201 Ldoc I Commonwealth of Massachusetts ro Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments �^M 53 Audubon Cir. Property Address Laura Blair Owner Owner's Name information is required for Centerville Ma. 02632 4/21/2011 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in ary way. Please see completeness checklist at the end of the form. Important: ..,, .,. When filling out A. General Information forms on the computer,use I > only the tab key 1. Inspector: . to move your Robert Paolini cursor-do not Name of Inspector ;' use the return key. Capewide Enterprises,LLC. Company Name P.O.Box 763 Company Address r"' Centerville Ma. 02632 City/Town State Zip Code (508)477-8877. S14454 Telephone Number License Number 4, B. Certification F 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 CM 15.000). The system: ❑ Passes ® Conditionally Passes ❑ Fails :f ❑ Needs Further Evalue by the Local Approving Authority 4/21/2011 Inspector's Ign re LY Date a 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. I t5ins•11/10 Title 5 Official Inspection Form:Subsurf a Sewage Disposal Sy tem•Page 1 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form . Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 53 Audubon Cir. Property Address Laura Blair Owner Owner's Name information is required for Centerville Ma. 02632 4/21/2011 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: 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): Outlet precast tee is soft and falling apart.New PVC S40 sanitary tee needs to be installed. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 53 Audubon Cir. Property Address S Laura Blair Owner Owner's Name information is Centerville Ma. 02632 4/21/2011 required for every page. City[rown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ 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 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 • Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments M 53 Audubon Cir. Property Address Laura Blair Owner Owner's Name information is required for Centerville Ma. 02632 4/21/2011 every page. CitylTown 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 f ❑ ® 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 .11 El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than,1h day flow t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 53 Audubon Cir. Property Address Laura Blair Owner Owner's Name ' information is required for Centerville Ma. 02632 4/21/2011 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) R Yes No Required pumping more than 4 times in the last year NOT due to clogged or El ® 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 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 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments �M •y° 53 Audubon Cir. Property Address Laura Blair Owner Owner's Name information is required for Centerville Ma. 02632 4/21/2011 every page. CitylTown 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 witl ® El 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. El ® 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)] F° D. System Information Residential Flow Conditions: T 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 4. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 'G M 53 Audubon Cir. f Property Address ' Laura Blair Owner Owner's Name information is required for Centerville Ma. 02632 4/21/2011 I every page. City/Town 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? [if yes separate inspection required] ❑ .Yes ® No Laundry system inspected? ® Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 2009:42,000 g ( y g (gp ))' 2010:42,000 Detail: Sump pump? ❑ Yes ® No Last date of occupancy: NA 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 J Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: L,5ins11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments M 53 Audubon Cir. Property Address Laura Blair Owner Owner's Name information is required for Centerville Ma. 02632 4/21/2011 every page. City[Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: date Other(describe below): . General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons t How was quantity pumped determined? T Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption systemA. ❑ Single cesspool y ❑ Overflow cesspool 3 ❑ 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): t, t5ins•11/10 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System•Page 8 of 17 F t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ,M 53 Audubon Cir. Property Address Laura Blair Owner Owner's Name information is required for Centerville Ma. 02632 4/21/2011 every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line. 10'+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of Ieakage.System vented through the house vents. Septic Tank(locate on site plan): Depth below grade: e6t 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 gallon Sludge depth: 3° t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments i 53 Audubon Cir. I Property Address Laura Blair Owner Owner's Name information is required for Centerville Ma. 02632 4/21/2011 every page. City/Town 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 29" Scum thickness Distance from top of scum to top of outlet tee or baffle 8" 14 Distance from bottom of scum to bottom of outlet tee or baffle Measured. How were dimensions determined? Measured. Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural intgrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump tank every two years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears structurally sound. -i 1 Grease Trap (locate on site plan): t 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments °M 53 Audubon Cir. Property Address Laura Blair Owner Owner's Name information is required for Centerville Ma. 02632 4/21/2011 every 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.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 53 Audubon Cir. Property Address . f: Laura Blair Owner Owner's Name information is required for Centerville Ma. 02632 4/21/2011 4- every 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 No D-Box present Comments (note if box is level and distribution to outlets equal, any evidence of solids carryove�r`, any evidence of leakage into or out of box, etc.): t F ny S Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No t Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): n Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments °M 53 Audubon Cir. Property Address Laura Blair Owner Owner's Name information is required for Centerville Ma. 02632 4/21/2011 every 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.): Sandy dry soil.No signs of hydraulic failure.Leaching pit was dry at time of inspection.Stain line observed 18" below invert. 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page`13 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments wM 53 Audubon Cir. Property Address Laura Blair Owner Owner's Name information is required for Centerville Ma. 02632 4/21/2011 every page. City/Town 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.): 15ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 I Map Page 1 of 2 1 Town of Barnstable Geographic Information System Parcel Viewer Custom Map Abutters Map Size ® ® Zoom Out 1 1 1 1 JIn de. - - 1 1 - . -2- 36 16 9 4, 3' ,A ty_ l tir 0, 20 Feet. t .x - II _. _ I.. I Set Scale 1 20 Aerial Photos MAP DISCLAIMER r.-,rinhf 90r)r-91110 T--of P.—O.W. hAA All rinhfe 65.h" , http://66.203:95.236/arcims/appgeoapp/map.aspx?propertyID=191182&mappaiback=191182 5/5/2C"`11 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 53 Audubon Cir. Property Address Laura Blair Owner Owner's Name information is required for Centerville Ma. 02632 4/21/2011 every 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: Bottom of LP 22' 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: As-built ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: USED:USGS Observation Well Data.USED:Technical Bulletin 92-0001 plate 32 annual ranges of groundwater elevations. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ^M 53 Audubon Cir. Property Address Laura Blair Owner Owner's Name information is required for Centerville Ma. 02632 4/21/2011 f every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist r ® 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 F, Y 3 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 COMMONWEALTH OF NiASSACHL•SETTS ExECCTIVE OFFICE OF FwRONMENTAL AFFAIRS DEPARTNIEIT OF E��ZR0�;1E1TAL PROTECTION r iv O%E WINTER STREET. BOSTON. MA 02106 tl r--S.•5:@( , Al 40WIV 1 F.VVELD• .. "'�+; . H (Ty�NST� 9�8 CG> i .. ... 6' _ q 'iD t: • ARGc4 PALZ��t LCCl B STR ,,L''LeeGovc-nor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 8 Conurissior. PART A - -:�- CERTIFICATION Property Address,5 �� t� C\P`I Cr u< Nut t Lt . Address of Owner: Date of Inspection: AA 2 :Of different)r. Name of Inspecto 1 am a DEP ap roved system inspector pursuant to Section 13.340 of Title S G10 CMR 13.000) Company Name:�� o A"4- 4577ov Y•i'a_-i.+ Mgt o Mailing Address: -P O e 37P 4.4 . H 1KAIOesz_ /Y I-O 2-C4_47 . Telephone Number: r CERTIFICATION STkTE?NE\T I certIN that I have pe•scnally inspected the Sewage d!S;aSal system a: this address and that the information reaerted below' IS true. accurate and complete as of the time of tnspec::p-. The inspec::pn was pe-�ormed based on my training and experience to the proper funcicn and maintenance cf on-site Sewage disposa: systerm. The rs:err:: Pastes _ _ Concit-onaiN Passes �eec; Furthe- E.•a!uaro^ Ey the Local A;-roving Authorit% Fa.!! Inspector's Signature �J Date: kA 7:ie Ins:e-::o- shag' submi: a cc,y of this inspe::,on re_cn to the Aperoving Authcnn• within (301 dat•s Cf Ccr..pie:ing this inspection. It the sv:tem is a Share--: s\•stern a• has a de!-In flow. of 10,000 g_+d or greater• the inspe:or and the sys:em owner ShZ!l subrnl; the repo- to the acorocriate regional o-+ce of the De,a-ment of Envirenmenta' Frotec:ton. The crig:na! should be se-tt tc the intern ow.-, and copes .--n to the buyer, ii applicatle. and the approving authorit\ INSPECTIO\ SUMMARY: Check A, E, C, or D Al SYSTEM PA55E5: „I have not found any information which indicates that the system violates any of the failure criteria as dc,ned in 310 C.MR 15.30: Any failure criteria not evaluated are indicate-d below. . COMMENTS: MS Vft _ �a -c I �, Or c:1UT o NwP ,V--\ t 0 7-v_Z U U 81 SYSTEM CONDITIONALLY PASSES: - One or more system components as described in the 'Conditional Pass' section need to be replaced or repaired. The systern, uc completion pf the replacement or repair, as approved by the Board of Health, will pass. Indicate yes• no. or not determined (Y, N. or NDj. Describe basis of determination in all instances. If'not determined-, explain why not. The septic tank is metal, unless the owner or opmtor has provided the system tnspec.or with a copy of a Certificate of Compliance (anachedt indicating that the tank was installed within twenty (201 years prior to the date of the inspection: the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiitratton, or tag failure is imminent. The system will pass inspecion if the existing septic tank is replaced with a conforming septic =k a! approved by the Board of Health. PART A , CERTIFICATION (continued) e ` Property Addaus: Owner: Date of Inspection: 81 SYSTEM CONDITIONALLY PASSE5 (cont:n.i�' Sewage backup or'breakout or high static water level observed in the distrib/cn-boue to broken or obstructed p:pe:s► or due to a broken, se*tied or uneven distribution box. The system wction if(with approval of the Board of Healthi. Descnbe observations: _ broken pipe(s) are repiamd _ obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken orpesl.:The system will pass inspection if twith approval of the Board of Health): / brc!— pipets; are replace: obstruction is removed C1 FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require furthe•evaiuzion by the Board of Health in order to de:ermine if the system is failing to protect the Public health. safer-and the environment. 1) SYSTEM WiLL PASS UNLESS BOARD OF HEALTH DE U MINE5 T14AT THE SYSTEM 15 NOT FUNC71ONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFtiY AND THE ENVIRONMENT: Cesspool or prn't is within 50 fee: of a surface water/ Ce:spooi or prnti. is within 50 fee: of a bordering vegetated we:land or a salt marsh. Z! SYSTE.M WILL FAIL UNLESS THE BOARD OF H1:ALTH (,, D PUBLIC WATER SUPPLIER, IF APPROPRiATFj DEiERMINES THA THE SYSTEM 15 FUNCTION ING.IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFt:;Y AND THE ENVIRONMENT: The systern has a septic tank and soil abso ion systern (S15i and the SAS is within 100 fee:to a surface water supply a tnbutary to a surface water supply. The sys tern has a septic tank and soil erpt:en system and the SAS is within a Zone I of a public water sup:ily we!l. _ The syste^n has a septic tank and soil sorption system and the SAS is within 50 fee: of a private water supply well. The system has a septic tank and sail absorption system and the SAS is less than. 100 fee: but 50 fee or more from a private water supply well, uniess a e!1 water analysis for colifcrm bacteria and volatile organic compounds indiates th. the we-'I is free_ from pollution fro that facility and the presence of ammonia hitrageh and nitrate nitrogen is equal to c less than 5 ppm. Method used t determine distance (appraximation not valid). 3) _ OTHER page 2 of 10 • w SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR.NA PART A CERTIFICATION (continued) Property Addross: Owner: Date of Inspection: D] SYSTEM FAIL5: You must indicate either -Yes- or -No' as to each of the following: have determined that the system violates one or more of the following failure criteria as defined in 310 MR 15.303 The oasis for this determination is identified below. The Board of Health should be contacted to determine what ill be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged.SAS r cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to a overloaded or clogged SAS or cesspool. Static !ieu,d level in the distribition boi. above outlet. invert due to an overloaded or clogged SAS or cesspool lieuid depth in cesspool is less than 6- below invert or available volume is less t n 1/2 day flog. _ Reeu'red pumping more than 4 times in the last year NOT due to clogged or obstrueer pipe s . ►.urnoer o;times pumped Any portion of the Soil Absorption Syste-r, cesspool or prri}• is below the high groundwate• eieyatior. An, por:on o:a cesspool or privy is within 100 feet of a sur,•ace water supply or tributa-y to a surface water supply And porion of a cesspoo' or pri.-�• is w ithir a Zone I of a public well. An\. pe-io- et.a cesspool or privy is within. 50 feet of a private water supple well Any por,,or. o:a cesspool or privy is less than 100 fee: but greater than 50 fee: from a private water supoh• well with no acceo;abie -ate- qualir� analys s. If the we!) has been analyied to be acceptabie. arach copv of well water analysis for cohiorm. bacteria yolat.ile organic eor„pounds, ammonia ni�ilrogen and nitrate nitrogen. q LARGE SYSTEM FAILS: 'rou must indicate either -Yes` or -No- as to each of the following. The ioliow:ng criteria app;% to ,arge systems in addition to the criteria above: The system serves a facilin 'with a design flow of 10,0001gpd 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 suppiv the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area - IWPA) or a mappr' 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 31-; CAAR.5.00 and 6.00. Please consult the local regional office of the Department for_further.iniormaiiocti:-- trw�%sed 04i:si97t �' PA91,3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: -5.3 ��NC't� Owner: Date of Inspection: 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 pan of this inspection. As built plans have been ootained and examined. Note if they are not available with N,A. L _ The facrlic. or d..eihng ..as inspected for signs o:sewage back-up. The system does not receive non-sanitan• or industrial waste flow. L _ The site was inspected for signs of breakout. _ All 5.sterr. co-nponents, excluding the 50-1 Aosorpt,on System, have been locate✓ on the site. ✓ The septic tank manhoies were uncovered. opened. and the interior of the septic tank was inspected for condition of baffies or tees. mater,a`. o'constructoon. dimensions, depth of liquid, depth of sludge. depth of scum. i The size and location of the Soil Absorption System on the site has been determined based on The fac.l,n o%.ne• ,anc occupants. r:difteren: from ow•neft were provided with information on the prope, maintenance of —\ r Sub-Suriace Disposal Svstem. �(A Existing information. Ex Plan at 6,0 H. Determined to the field !tf an. of the failure'criteria related to Pan C is at issue, approximation of distance �s unaccexabie (15.302t3iti] 04/25/5'i r.q. 4 at 10 ' i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Propert% Address: 5 3 PKA')�pp•J Owner: C IN C Date of Ihspection:► tk. -1 4 C) FLOW CONDITIONS RESIDENTIAL: Design p.d..bedroon: for S.A,.S Number of bedrooms OJ Number o7.current residents Q Garbage g•.� der (yes or nol: f�-2i Laundry co-r—ected to system (yes or no! Seasonal use (yes or no-:l=L Water meter readings. if available (last two ;2 year usage igad): Sump Pump Ives or nor Lac da:e 0:occupancl- COMMERC;,kL'I VDL.'STRIAL• Type of establishment Design fro%% eahons/oa\ Grease trap present ryes or no_ Indus:na! \',ante Holding Tani; present ves or no_ ':o-saarta'1 waste d-scnargec to ine T:;ie 3 S\•s-,ern tees or no_ \\ater meter readings if avallabie Las.Pa:E .0' 0 :;,,^,2'% '. OTHER: .De:cribe L25t cafe of occuoanc. GENERAL INFORMATION PUMPING RECORDS and source of mformatior. System pumped as par, of Inspection. (ves or no. Out If yes, volume pumped gallons Reason for pumping TYPE OF SYSTEM _ Septic absorption system Single cesspool Ovenlow cesspool Prny Shared system (yes or no) (if yes, attach previous inspection records, if any) 1/A Technoiogv etc. Copy of up to date contract? APPROXIMATE AGE of all components, date Installed (if known) and source of information: t4V'?-Q Sewage odors detected when arriving at the site. Eyes or not (� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORA PART C � SYSTESA INFORMATION (continued) Property Address:Ss/ dusk/ Owner:5F, Date of Inspection: BUILDING SEWER: (Locate on site plan) Depth below grade. 'Lb Material of construction. _cast iron _40 PVC _other (explain! Distance from private water supply well or suction li-t Diameter Comments: (condition of joints, venting, evidence of leakage. etc.) SEPTIC TANK: S locate on site pi n tl Depth below grade material of construcno concre:e _me-.a _Fiberglass _Polyethylene _othertexplain If tan( is metal. Ins: age _ 1; age confirmec o% Ce-:.iica:e c: Compuance IN es.-No Dimensions Sludge depth 'X1 M Disiance from top o: s:ucee to bono-n o: ou!;e: tee o• ba-;e 'l\ Scum thickness %t Distance from top o: scum to top o- outle: tee or bade �_ l t Distance from bonom of scurn to bo-o-n o;outie: tee c• bane Hoy- dimensions \ere determined Comments trecommendation for pumping. Londiti n o, rniet and outlet tees or baffles. 4epth of liquid level to reiatt n to outle invert, stru ral integrity, evidence of leakage e:c i r �. V O GREASE TRAP: V (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 baffie: Date of last pumping: _ Comments: -- trecommendation or pumping,-condition of i•flet and outlet tees or baffles. depth of liquid level in relation-te-outlet-invert,�structural- tntegrtq•, evidence of leakage, etc.: - tz•�•_..d 0�/2::97) Page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIO% FORM PART C - SYSTEM INFORMATION (continued) Propert% Address: OM ner: Date of Inspection: TIGHT OR HOLDING TANK: ?ahk must be pumped prior to, or at time, of inspectiont (locate on site plan, Depth below grade. Material of construction _concrete _metal _Fiberglass _Polyethylene _other(explain) Dimensions: Capacir, gallons Dessg- floe galiorsda. Alarm level Alarm in corking oroe•_Yes. No Date of previous pupping Comments (condition of inlet tee. condition o- a`a•m and float s�,%•itches. etc.) DISTRIBUTION BOX:_ _ ilocate on site p a- De::!i o'licuid le%e' aoo�e ouite: in�e- Cornmenu mote leve! and distrib.t-or is eaud' evidence of solies urn•o.•er, e.i rice of leakage into or out of boa, etc.) PUMP CHAMBER:_ (locate on site plan. Pumps in working order: (Yes or No, Alarms in working order (les or No Comments: (note condition of pump chamber, condition of pumps a appurtenances, etc.) t ?.q. 7 of 10 y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Addr-ss: KlJ bol"i , Owner: Sri (flat- c.� Date of nspectton:q( &(i SOIL ABSORPTION SYSTEM (SAS): (locate on'site ti possible: exca, ion not required. but may be approximated by non-intrusive methodsi If not determined to be present, explain. Type: leaching pits. number. �� leaching chambers, num r._ leaching galleries, number: leaching trenches. number,length: leaching fields. number ci.rnensrons overflow cesspool, number Alternative system Name of Tecnnotog% Comments mote condition of Ill. s! r.s of hydraulic failure, leve' of p riding. rtion of vegetation, e!c.t m j� CE5SPOOLS: (locate on site plan. Numbe, and config-ira:,on Depth-top of liquid to inlet rnver, Depth of solids lave, Depth of scum laver Dimensions of cesspoo: Materials of constructior Indication of groundv,ate- inflow tcesspool must De pumpec as par, of rnspection� Comments: tnote 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.): Page a of 10 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued. Propem Address: 3 � Owner.�E, vtnl�— Date of ln,peeiion. 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? • A-- �, J Z r.yq 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIO-N FORM PART C SYSTEM INFORMATION (continued) Properi% Addres-•S3 Owner: /1, Date of Inspection: Depth to Groundwater,�3`feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation o-' Site lAbuning property. observation hole, basernent sump etc.) Determine It from local conditions Cnec" %•uh local 5�arc o• nea!:- Chec: F:.MA Macs Chect, purnp,ng recores Check loco' irs:alle•s use Da-a Cescnhe in o rc-.. ,c_ es:ac;:spec the Crounc�Aate• Eievallon (Must be cornpiete--� UPS. Ca�fc� 4 L� ( ���`c`ll �'-NVeg'�c�✓ Zd,��' ` 44, A, v I , Page 10 of 10 TOWN OF BARNSTABLE 1 LGCATION ��� �r �' SEWAGE # VILLAGE C&t-2'T<"I IX--- ASSESSOR'S MAP &LOT r ' `L INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) Q1 l (size) 1bOf�a�°4 NO.OF BEDROOMS A BUILDER OR OWNER , PEMRITDATE: tiy kaij . COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and 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) 6' Feet Edge of Wetland and Leaching Facility(If any wetlands exist Ri Ih Feet within 300 feet of leaching facility) Furnished by. �� r LA ` o �^L.Cj�— AS y G it m _ b P���3P '� 6b A No.�1_.7-------_. Fxs..., ..:U.U.......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...................OF..........`�. /�w� f -77 Apphra#ion for 15isposal Works Tomitrurtion Vrrmff Application is hereby made for a Permit to Construct ( ) 'or Repair ( ) an Individual Sewage Disposal System at: G C-X "I y� /G G ............................... .............. ----..D.d .l.�:....�5 °.:... L ¢�-----..--.�.-- Location•Address or Lot No. ........... .....f1..f I`.......�_ .......... ............ .,.............,.....,..,................... Owner Address Installer Address dType of Building . Sq. feet U J' � — /✓�i��00�9� OTC Size Lot a Dwelling—No. of Bedrooms .........................................Expansion Attic ( ) Garbage Grinder ( ) `4 Other—T e of Building ---------------------------- No. of persons............................ Showers — Cafeteria 04 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. 1.................minutes 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•------.--- --.--- tx -------------------------------------------------------•-------.............................................................. ........................... O Description of Soil--...... .......................................... lei.f;�............... -------•..............••-••--•------------•........---•-•--------••--..........-•i-�---------... . .. . o �y i fro V lai r LW .... . d _ �_ a --•--•-•-----------------••------•-- w . rc U Nature of Repairs or Alterations—Answer when applicable------------------ --------------------------------------- --------------look.S:r: —..:.... ._........._._....... /T...S- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—?.)v e undersig further agrees not to place the system in operation until a Certificate of Compliance has bee issuar lth. Signed...- : ...... -----••--•-••••------•----•...............•• ................................ Date Application Approved By..... A -- ...'...... -- Date Application Disapproved for the following reasons:---------•--------------------------------------------------•--------------------------••-••-•-•---------------- .................••--•------•-------------------------•----•---------......----------...••••---------------•••-•--•-=--••-•-•-----•••----••------••---•--. •.......................................... ✓ Date PermitNo. :.................................. Issued -------.---................. � Da No.... •--•----- ......... �:.f�...._ THE COMMONWEALTH OF MASSACHUSETTS BOARD HEA LTH ALTH .--------- ---- -- ©F...........t ................................. Apphrativat for Ui5 oga1 Norkii Tous#rurfiun Pumit Application is hereby Trade for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: .................z �..[i.s..... .. ..................`; s : Location-Address of Lot No. .................... :'t,j�:, .. ......., .y?..iS.j.J;g.�:�.�.'�a ...._........,......_.,.......................................................................... wner� Address � ........................ ..... .......Instal?er.........,................,........ ............_.......,...........,,..........Address................................._....----- d Type of Building Size Lot................ Sq. feet Dwelling—No. of Bedrooms.._ `. `el f c. . . —xp nsion Attic (� ) Garbage Grinder( ) `4 Other—Type of Building No. of persons............................ Showers a g --•-•...................•-•- P ( ) — Cafeteria ( ) POther fixtures ------------------•----------------•------------•-------•--•-------------•-•--•--•------......---•••-•-••••••---.....--••••......--•-••--••--••_...-- WDesign Flow,.,'.-..........................•..........__gallons per person per day. Total daily 1fow............................................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. 1................minutes per inch Depth of Test Pit-................... Depth to ground water-----____.____-.__.--_-. fi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water......................... P' •-•••••••••--••-----•---•.......................................•.._• ..............................•-•-•••-•••-••••--•••••:••_.............................. O Description of Soil 4 1-11u < vE ------------- x r - /.. -•••-•--•••......-• -•••••. V • .__...... W •-••-•-•-------------------- fJ d;` /� f ..fs P l �� / �✓ _Z(Jz ----- G U Nature of Repairs or Alterations—Answer`/when applicable....._`.. . .................__ _.._......._......... f F- zc _,.,____.__r___..1_. ..._,:._.......................>._..........__...__........,.. :. � -•rEer fa -17 Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersign further agrees not to place the system in operation until a Certiiica.te''of Compliance has been issue the board " health. Signed -- ,' .................... ............................, Date Application Approved BY----i-- ---- ----- Date :- "d {` ea �f -- .Application Disapproved for the following reasons:_............................................................. ...... .......... ........................•--•--•------........._...............................---•-•--•-••-----------•-----••---------••••-••---•-•--..........-••••................................................... Date " '' ? ': ................. Permit No...... ' ....................... Issued... - , THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH THIS IS TO CERTIFY, That th't"Individual Sewage Disposal System constructed ( ) or Repaired ( ) by.......... ................... 's- w°w...................................-..............................."` - Installer at.............fir :-� - t!:.r r� • E •-----•-----•------------ '+_ has been installed in accordance with the provisions of Article KI oe_Yle St�te Sanitary' ode.as described in the application for. Disposal Works Construction Permit I\o------ ____ ______________________ dater--- ............................................ THE ISSUANCE OF THIS CERTIFICATE SMALL NOT EE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION,SATISFACTORY. a '.DATE .. ;._.. - Ins ector 4K f r - r n..........� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF.,,:HEALTH r ...............�-:..«...:;�..........O F............._!?.f�-J��'�,.-e:;�--fit'" °.��•��•..� ....._.................. No.. :.. ..f..-•-•- w. r `%` ....................... FEE. Permission is hereby granted...... ............... f ti�------------------------------•-----------------------•---•------•----•----------,_,_,,--,-.-,_,,, to Construct (..�) or Repair ( ) an Individual Sewage Disposal System atNo.. �s�i�? `, =!�-.:'r .t=.�a.j �- ------------------------------•-•--------..........---.....................••-•-•--•--..................... r Street as shown on the application for Disposal Works Construction Permit No........ `:...".7f... Dated_____f� tT3uar''d -o' •alt,, .�-...... / }} --•• ----•-•--........ /' FORM 1255 HOBBS & WARREN, INC., PUBLISHERS -�-- C, - 3 L&C AT ION S E W A PERMIT NO.. V LL A GE �2 A /; � LBIC. INST A LL ER' �1���& ADDRESS (Jr i � Od B UI'LDE R OR OWNER DATE . PERMIT ISSUED 0 y,,, -7- 7 OAT E COMPLIANCE ISSUED -, �-�- , , i �� „i ��' � � �� �;