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HomeMy WebLinkAbout0059 BAY LANE - Health 59 BAY LANE, CENTERVILLE A=186.079.002 r� to t Ito • • �'e� ,oNSVJ HASTINGS,MN y Commonwealth of Massachusetts �86-ate ooa� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments iG M 59 Bay Ln. gat Property Address "tea 7 Ce Schoenherr Owner information Owner's Name is required for every page. Centerville '� MA 02632 4/11/18 { _:• Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information 25"/# t.2 1. Inspector: Frank Nunes III Name of Inspector saa Company Name Box 841 Company Address East Falmouth MA 02536 City/Town State Zip Code 508.272.6433 13010 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 4/11/18 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 ^O0d u f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 59 Bay Ln. Property Address Schoenherr Owner information Owner's Name is required for every page. Centerville MA 02632 4/11/18 Citylrown 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): t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 59 Bay Ln. Property Address Schoenherr Owner information Owner's Name is required for every page. Centerville MA 02632 4/11/18 City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 59 Bay Ln. 4M Property Address Schoenherr Owner information Owner's Name is required for every page. Centerville MA 02632 4/11/18 Citylrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins.doc-rev.6/16 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 M 59 Bay Ln. Property Address Schoenherr Owner information Owner's Name is required for every page. Centerville MA 02632 4/11/18 City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 16,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ 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 L,5.nsdoc-rev.6/16regional office of the Department. doc•rev.6l16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 59 Bay Ln. Property Address Schoenherr Owner information Owners Name everyage.ed r Centerville MA 02632 4/11/18 every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 59 Bay Ln. Property Address Schoenherr Owner information Owner's Name is required for every page. Centerville MA 02632 4/11/18 Cityrrown State Zip Code Date of Inspection D. System Information Description: Per engineering plan on file 373 gpd provided Number of current residents: 1 Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Occupied Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins_doc•rev.6/16 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 59 Bay Ln. Property Address Schoenherr Owner information Owner's Name everyage.ed r Centerville MA 02632 4/11/18 every page. Cityrrown 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: No recent pumping per owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Lt5m.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 59 Bay Ln. Property Address Schoenherr Owner information Owner's Name is required for every page. Centerville MA 02632 4/11/18 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1983 per BOH record Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 2'6" Depth below grade: 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.): Septic Tank(locate on site plan): 2' Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) H-10 septic tank appears to be structurally sound If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000g Sludge depth: 4" t5ins.doc-rev.6/16 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 M 59 Bay Ln. Property Address Schoenherr Owner information Owner's Name is required for every page. Centerville MA 02632 4/11/19 Ci mown 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 >12 Scum thickness trace Distance from top of scum to top of outlet tee or baffle >2" „ Distance from bottom of scum to bottom of outlet tee or baffle >2 How were dimensions determined? measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping suggested every 3 years to prolong the life of the system Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins.doc•rev.6/16 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 5•�'' 59 Bay Ln. Property Address Schoenherr Owner information Owner's Name everyage.ed r Centerville MA 02632 4/11/18 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 59 Bay Ln. Property Address Schoenherr Owner information Owner's Name is required for every page. Centerville MA 02632 4/11/18 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box is 2' below grade and in average condition for its age Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments < 59 Bay Ln. Property Address Schoenherr Owner information Owners Name is required for every page. Centerville MA 02632 4/11/18 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2 Flo Diffusors � ❑ 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.): 2 Flo Diffusors per BOH record, they were video inspected and no indication of hydraulic failure was present, top of chambers is 30" below grade 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.doc-rev.6/16 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 M 59 Bay Ln. Property Address Schoenherr Owner information Owner's Name is required for every page. Centerville MA 02632 4/11/18 Citylrown 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.): Soils are compact and dry Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 59 Bay Ln. Property Address Schoenherr Owner information Owner's Name is required for every page. Centerville MA 02632 4/11/18 City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately V kzPIT L C_ LA\ G ,- t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 59 Bay Ln. Property Address Schoenherr Owner information Owner's Name is required for every page. Centerville MA 02632 4/11/18 CityrFown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells 8' Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 1983 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: TOPO mapping You must describe how you established the high ground water elevation: 1983 engineered plan has 2 test pits with ground water at 48" and 78". TOPO mapping places the site at approximately 10' msl. Previous septic inspection in 2000 states GW at 10'. 1 augered a hole at the time of inspection and found groundwater at 8' giving the SAS approximately a 4' seperation without flucuation SAS is within 300' of a tidal water body Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 } Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 59 Bay Ln. Property Address Schoenherr Owner information Owner's Name is required for every page. Centerville MA 02632 4/11/18 City(Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 D AT E:_.J151DU---- PROPERTY A D D R E S S: -19-•j1a-jt. I a D a ----------- ----------------- On the above date, I Inspected the septic .system at the above address. This system consists of the following: // y 1 . 1-1000 gallon septic tank. ` � (9 OFF F 2 . 1-Distribution box . 3 . 2-4 ' x8 ' flow diffussors packed in 3 ' of stone . Based on my Inspection, I certify the following conditions: 4 . Th-is is a title Five Septic System. ( 78 Code ) 5 . The septic system is in proper working order at the present time . 6 . The flow diffussors are presently dry . SIGNATURE:'j Name: Company: Joseeh P. Macomber & Son, Inc. Address*_ Box_66 ------------- CentervilleL Ma- --._02632-0066 ---------- -- - Phone:_ 508 775_3338_______ d THIS CERTIFICATION GOES NOT CONSTITUTE A GUARANTY OR WARRANTY • {I � JOSEPH P. MACOMBER & SON, INC. Tanks•Cesspools•l.eachflelds Pumped & Installed � Town Sewer Connections ! RENEO P.O. box 66 Centerville, MA 02632-0066 775.3338 775.6412 TOV34 OF BAPP+STABLE HC APT f I , COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE.WINTER STREET, BOSTON MA 02108 (619) 292-6600 TRUDY Cc Secre ARGEO PAUL CELLUCCI DAVM B. STRI Governor Commissi, SUBSURFACE SEWAGE DISPOSAL SYSTEMA•WSPECTION FORMA PART A CERTIFICATION Property Add,.,: 59 Bay Lane N„tte of owner D r Barry J. Benjamin Centerville ,Mass . Address of owner: Dart,of Y"peadon: 1//5/a aName of Inspection(PL"Wnti Joseph P.Macomber J r . I am a DEP oved system Inspector pur uant s to Section 16.340 of Tide 6(310 CMR 15.000) ComwryName: J.T.Macomber. & Son Inc . Maary Addrass: Box 66 C P n t a r v i 1 1 a r M n c c _ 02632 Telephone Nurraber: S O R 7:7 5 3 3 3 A 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 Inspection. The Inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Falls 4upectoes Slgrurume: y Dats: J�z The System Inspecto shall submit a copy of this Inspection report to the Approving Authority(Board of Health or DEP)withtn thirty(30) days c completing this inspection. If the system Is a shared system or has a design flow of 10,000 gpd or greater,the Inspettor and the system own shall submit the report to the appropriate regional office of the Department at Environment l Protection. The original should' o.sent tots system owner.and copies sent to the buyer,If applicable,and the approving authority. NOTES AND COMMENTS revised 9/2/98 Page I of 11 C,Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property address: 59 Bay Lane Centerville ,Mass . Owner: Dr . Barry J. Benjamin Date of Inspection: 1/5/9 9 WSPECTION SUMMARY: Check A, B, C, or A A. SYSTEM PASSES: 1 have not found any Information which Indicates that any of the failure conditions described in 310 CMR 16.303 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,.at approved by the Board of Health,will pass. Indicate yes,no, or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain why not. The septic tank is metal,unless the owner or operator has provided the system Inspector with a copy of a Certificate of Compliance(attached)Indicating that the tank was Installed within twenty(20)years prior to the date of the Inspection;or the septic tank, whether or not metal,is cracked,structurally unsound, shows substantial Infiltration or exfiltration, or tank failure Is Imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box Is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box. The system will pass Inspection if(with approval of the Board of Health). broken pipets)are replaced obstruction Is removed distribution box Is levelled or replaced - The system fequired pumping-Tnam than-four-times s yeardue to broken or obstructed pipets). The system will-Vows— inspection if(with approval of the Board of Health): - broken pipe(a)are replaced obstruction is removed revised 9/2/98 Page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) n v' llMass . Property Address: 5 B Bay Lane C e ter i e , owner: Dr . Barry J. Benjamin Data of Inspection: 1/5/9 9 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 the public health, safety and 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 WHICKWILL.PRO.TECT THE PUBLIC HEALTH.AND SAFETY AND THE Efi1MONIMENTz Cesspool or privy is within 50 feet-of surface water Cesspool or privy is within 60 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 AND SAFETY AND THE 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 soil absorption system and the SAS Is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS Is within 50 feet of a private water supply well. 410 The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for col)form bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the pr`ejo,nce of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distanc (approximation not valid).- 3) OTHER la revised 9/2/98 Page 3of11 i SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECTION FORM PART A CERTIFICATION(confined) Property Address: 59 Bay Lane Centerville ,Mass . Owner: Dr . Barry J. Benjamin Data of Inspection: 1/5/0 0 D. SYSTEM FAILS: You must Indicate either'Yes'or"No" to each of the following: _ I have determined that one or more of the following failure conditions exist as described In 310 CMR 15.303. The basis for this determination is Identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of eewags iMofeciReyor•sTetem ootnponent•due cto an overloaded orclagged-SiA&ot•cesspod. 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 al�w tribution box b a tiet Invert due to an overloaded or clogged SAS or cesspool. JrZdAb.� Liquid depths�I-s CAy� in,eesspod is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times In the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. v Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to,a surface water supply. Any portion of a cesspool or privy is-within a Zone I of a public well.. Any portion of a cesspool or privy is within 50 feet of a private water supply well. f� Any portion of a cesspool or privy is less-than 100 feet but greater than 60 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for »coliform bacteria,volatile organio-compounds, ammonia nitrogen•and nitrate nitrogen. - E. LARGE SYSTEM FAILS: 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: N// The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No , the system is within 400 feet of a surface drinking water supply the system•Is-witiwn 200 faet*f-*4ributary to-•a-*urfaoe drink!Ag waW4UPPIr.••• - - —•- _ _ ._ the system is located In a nitrogen sensitive area(Interim Wellhead Protection Area=IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4of11 1 . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 59 Bay Lane C e n t er v i 11 e ,Mass . Owner. Dr . Benjamin Barry J. Data of Inspection: 1/5/0 0 Check if the following have been done:You must Indicate either"Yes" or"No" as to each of the following: Yes N Pumping Information was provided by the owner,occupant,or Board of Health. f - •None of the system compos&A&kaaa bewt hssbaeowca[9iwg"mosal 11ow rates during that period. Large volumes of water have not been Introduced Into the system recently or as part of this Inspection. _ As built plans have been obtained and examined. Note If they are not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up. 41 The system does not receive non-sanitary or Industrial waste flow. _ The site was inspected forsigns of breakout. _ All system components;4uding the Soil Absorption System,have been located on the site. _ The septic tank manholes were uncovered,opened,and the Interior of the septic tank was Inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum. The size and location of the Soil Absorption System orrthe site has been determined based on:- _ Existing information. For example, Plan at B.O.H. _ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) [15.302(3)(b)1 _ The facility owaar.(and.^^ant=.H differaat froaLomuml wou p auW& wlth.rn+nr•,,Arioavn•hs proper megaton& ."f SubSurface Disposal Systems. i i revised 9/2/98 Page 5of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION PropartyAd&e": 59 Bay Lane Centerville ,Mass . Owner: Dr . Barry J. Benjamin Data of Inspection: 1/5/0 0 FLOW CONDITIONS RESIDENTIAL: Design flow: /it g.p.d./bedro Number of bedrooms desigf�): Number of bedrooms(actual): Total DESIGN flow .� 2v— Number of current residents: Garbage grinder(yes or no): _is Laundry(separate system) ( es o Ad If yes,separate inspection.required Laundry system inspected J e�jor no) Seasonal use(yes or no): Water mater readings,If available(last two year's usage(gpd): b�i Sump Pump(yes or no): j ij/d C r0K., Last date of occupancy:461K CO M M ER CIA LAN D U STR IA L: Type of establishment: Design flow: A)d apd ( Based on 16.203) Basis of design flow Grease trap present: (yes or no) Industrial Waste Holding Tank present:(yes or no),W Non-sanitary waste discharged to the Title 6 system:(yes or no)A# Water meter readings,if available: ,64 - Last date of occupancy: A,A OTHER:(Describe) Last date of occupancy:^A1,4 J" GENERAL INFORMATION PUMPING RECORDS ar%d sore of information: AI ;r A AP%1!4 System pumped as part of inspection:(yes or no)_ If yes, volume pumped: 6 gallons Reason for pumping: AM TYPE O YSTEM 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) I/A Technology'etc.Attach copy of up to date operation and maintenance contract Tight Tank i(Jd Copy of DEP Approval Other � APPROXIMATE AGE of all components, date installed,{if known)-and source of,information:—• J -� - Sewage odors detected when arriving at the site: (yes or no) revised 9/2/98 Page 6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 59 Bay Lane Centerville ,Mass . Owner: Dr. Barry J. Benjamin Dace of Inspection: 1/5/0 0 BUILDING SEWER: (Locate on site plan) Depth below grade: Material of construction:AA cast iron_1e140 PVC d4other(explain) AAA Distance fro.private water supply well or suction line /W _ Diameter Comments:(condition of joints,venting,evidence of foak"o,-etc.) - — —- Joints appear tight No evidence of leakage S TANK: .� (locate on site plan) r Depth below grader Material of construction:�oncrete4knotallkFlberglasa4P Polyethylene 4other(explain) If tank Is(natal,list age_4)A JJss.age_confw;ned by Certificate of Compliance_(Yes/No) Dimensions: n" etn Sludge depth:; Distance from top of sludge to bottom of outlet tee ortoffle• � Scum thickness:_�� Distance from top of scum to top of outlet tea or baffle: Distance from bottom of scum to bottom of outlet t or baffle:�,C✓ How dimensions were determined: Comments: (recommendation for pumping,condition of inlet and outlet tees or-baffles,depth of liquid level in relation to outlet invert,structuralintegrity, evidence of leakage,etc.) 'Pump tank annually . Garbage disposal is present . I Tnl et R njitl et tags ar'a is place Li quid depth at the niitl et invert! is fifty one J • ea age . (locate on site plan) 77 Depth below grade: Material of consuu.t onY�concreteGa' metal4/,9Fiberglasa Polyethylene) other(explain) Dimensions: IVA Scum thickness: ,/d Distance from top of scum to top of outlet tee or baffle:.6lL Distance from bottom of scum to bottom of outlet tee or baffler Date of last pumping: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level In relation to outlet invert,structural integrity, evidence of leakage,etc.) Grease trap is not present . revised 9/2/98 Page 7of11 I , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(cont)rwed) Property Address: 59 Bay Lane Centerville ,Mass . Owner: Dr . Barry J. Benjamin Date of trnpection:1/5/0 0 TIGHT OR HOLDING TANK•,Lt. O9.(Tank must be pumped prior to, or at time of, inspection) (locate on site plan) Depth below grade: NA Material of construction:Nfconcrete dmet&14 Rberglass4APolyethylene,&other(explain) Dimensions: Capacity: gallons Design flow: AZ& gallons/day Alarm present Alarm level: Alarm in working order:Yes&A NoA),# Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) Fight or holding tanks are not present DISTRIBUTION BOX:- (locate on site plan) Depth of liquid level above outlet Invert:— Comments: (note-if level and distribution is equal, evidenoe of solids carryover,evidence of leakage Into or out of box, etc.) — - Distribution box has nno lntpral ' No avideare of solids Gar- :'-y-9irE}� � No Pvi dpnrp of 1 enkaneJ pto op ou,t of the bex PUMP CHAMBER: ,l A a (locate on site plan) Pumps in working order:(Yes or No) AA Alarms in working order(Yes or No)_-A[h Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) Pump rhamhpr ig not nrp�pnr revised 9/2/98 Page 8of11 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(corrtinued) Property Address: 5q Bay Lane Centerville ,Mass. Owner: Dr . Barry J. Benjamin Data of I m4 cfo` 1/5/0 0 SOIL ABSORPTION SYSTEM(SAS): —Z (locate on site plan,If possible:excavation not required,location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits, number: leaching chambers,number:-k-/2-4 x 8 ' flow d i f f u s s o r s . Packed in 3 ' of stone . leaching galleries,number:_IW 2 2 ' x 10 ' leaching trenches,number,length: leaching fields,number,dimen Ions: [� overflow cesspool,number: Alternative system: Name of Technology: T7� Comments: (note condition of soil, signs of hydraulic failure,level of ponding, damp soil,condition of vegetation, etc.) Loamy sand to meth nm canrl . N _S,i._8n s of 4ydraul ;Lc fa1-jd-1=e or- are . CESSPOOLS e, (locate on site plan) Number and configuration: Depth-top of liquid to Inlet invert: AN- Depth of solids layer: Depth of scum layer: Dimenslons of cesspool: Materials of construction: Indication of groundwater: AIR Inflow(cesspool must be pumped as pan;of Inspection) eSSDools are not nresPnt Comments: (note condition of soil, signs of hydraulic failure..level of Pending,-condition of-vegetation,etc.) essi)oo s are not present - (locate on site plan) Materials of construction: /V� Dimensions: Depth of solids: A&L Comments: (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation;etc.) rive is not present . revised 9/2/98 Page 9of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(condmied) Property Address: 59 Bay Lane Centerville ,Mass . Ownw: Dr. Barry J. Benjamin Data of lrtspecdon: 1/5/0 0 SKETCH OF SEWAGE DISPOSAL SYSTEM: Include des to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes Into house) revised 9/2/98 Page 10of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION kRM PART C SYSTEM INFORMATION(continued) Property Address:5� Bay Lane Centerville ,Mass . Owner: Dr . Barry J. Benjamin Date of trupection1/5/0 0 NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep _ SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater 10 Feet Please indicate all the methods used to determine High Groundwater Elevation: —1—Atained from Design Plans on record 09 served.Site(Abutting props bservation hole,basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps ✓ Checked pumping records --L/-Checked local excavators,installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) Used water contours map . Gahrety & Miller Model 12/16/94 J revised 9/2/98 Page 11of11 • >•..RT{T.—n.Ts'•-.TT� esrrmr•nsPla�Tn nrRlsrnr.�+T7f►f1►e*�++1A.nR+.7.�'�ntr1�T ,. '�� 'I'UWN OF Barnstable BOARD OF HEALTH SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CEItTIFICATIUN I •.•rrt-r••.-: .—r..,r.^.-rnm r.+n•n.�rsTre•a�r>+r^nrrrx•t^turn-�srnan•^t+�+a�wr.�+wrn�et+n� ant •m�s-r•r.-ter—..A -TYPE OR PRINT CI.EARLY- PROPERTY INSPECTED STREET ADDRESS _ 59 Bay Lane Centerville ,Mass . ' ASSESSORS MAP, BLOCK AND PARCEL # OWNER' s NAME Barry Benjamin PART D - CERTIFICATION NAME OF INSPECTOR Joseph P.Macomber Jr . COMPANY NAME J. P.Macomber & S-0ii' Inc . COMPANY ADDRESS Box 66 Centerville ,Mass . 02632 Street Town or City State LIP COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX ( 508 ,1 790 - 1578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposall system at this address and that the information reported is true , accurate, and omplete as of the time of ,inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one: Ft 1 `At:�f'Systeni PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 16 - 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. System FAILED* The inspection which I have con cted has found that the system fails to protect the public health and the environment in accordance with Title 5 , 310 CMR 15 , 303, and as specifically noted on PART C - FAILURE CRITERIA of this inspection form , r Inspector Signature Date O( ne copy of this c rtification must be provided to the OWNER, the BUYER where applicable ) and the BOARD OF HEAL'TIi. * If the inspection FAILED, the owner or operator shall upgrade ' the system. within one year of the date of the inspection, unless allowed or required otherwise as provided in 3.10 CMR 16 . 305 . partd.doc LO W & WELLER, INC. 477 Main Street - P.O. Box 119 Yarmouth Port, Massachusetts 02675 362-6868- 362-8131 Registered: George Low, Jr., R.L.S. Land Surveyors Everett H. Hinckley, P.E., R.L.S Professional Engineers William G. Weller, Consultant December 14, 1983 Mr. John Jacobi, Health Agent BOARD OF HEALTH Town of Barnstable Town Hall Hyannis, MA 02601 RE: Lots 40 and 41 - Bay Lane, Centerville Dear Mr. Jacobi: Please be advised that we have located the constructed sewage systems for the above referenced lots. The invert elevations for these systems were found to be as follows: Lot 40 - Inlet septic tank 11. 20 ' Outlet septic tank 10. 65 ' Inlet at flowdiffusors 10.45 ' Lot 41 (water lot) - Inlet septic tank 10. 0.01- Outlet septic tank 9.58 ' Inlet at flowdiffusors 9. 20 ' If you have any questions, please do not hesitate to contact us. Very truly yours, Everett H. Hinckley,P.E. EHH:dlw cc 2-- ' f to 1 ry � /.7. ;aj .�wl Ic P.1 , ,�OG•�4T/O.V. NG'C�QY C�GT/FY T/�/4T TL1 BtJ/LD��./F �s 4j C Y :S.NCk►N.V O.tJ TN/S OL QA. l '/:5 LOCOQT'ED C.V r/5/� t r�flti^sC_eY t-'�7uc/tt� A3 �NOW�I NeG�"oa/ A�va 7�N.�iT iT �`z, 1133 r:o ` e co.v,#VoA-as ro 7-s,'4C- t3Y L.4*wz y✓,c��.v. cooia reuc�'�n. ��� s��. YA�eM0U7H , N!/955. /p /,, ',ft. R ¢~ N THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ................. ....................OF ........................................ Application for Biipooal Workii Ton,itrnrtton rprutit 4? JApplication is hereby made for a Permit o Construct ( ✓)or Repair ( ) an Individual Sewage Disposal System at: o $ �/� */0 .. .....� ..N:e....................... ..---•---•....-•••••----.••..-------•--------•...•--••••.-------•--------..._.___._.------•----••. �/ lion--fir ss. _..-•---•-•---....--•--------------or Lot No. ---•........... ................. -. ...-••---... ......------.................... W �► Owner Address ,� lye{----•-----�1or.��d........................... Installer Address d Type of Building Size Lot............................S V Dwelling—No. of Bedrooms.....3..................................Expansion Attic ( ) Garbage Grind aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria Q, Or xtures ...................................................... Design Flow....... ......................gallons per person per day. Total daily flow.......... __..J.._...........gallons. WSeptic Tank—Liquid ca citylOV.7..-galIons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .r......... 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 Percolation Test Results Performed by.. Date........................................ aTest 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........................ ----•-•---•------------------------------- --- - Description of Soil.... L5 ...�4 .... . ? .--•---------------------------------------•-••---------------- U •----•••------•------------•---•--•---•------------••----------------•----••------............_..........•--•----------•--•......---••-------.-- .................................................................................................................................................:..----------•-----------...--•--•-------•....---•----- U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ----------------------------•-----------------------•----------.....-----•----•-------....................---...---------------------------••-•••-------------•-••••--•...........................:•---. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance s been issued by the boar o 1.ealth. q ned.. --- . ------- -• -• ----------•------ -- E Application Approved By........ --••- ----••---- ..�.....--•---•-•----••-•---•---••........-•-•••..--•-•--•-•--.._. .... :.....�.�-- ..... Date Applic atation Disapproved f th f ollowing reasons:-------•-------------•--........----......---...........------...--•--------......--------=-----............•... ...........I_. .....M",r.............•-••- ---.............----................---............................-•-•----•---.......................... ......... - ......---------- Date PermitNo......................................................... Issued........................................................ - D - ------ --- ............... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ....... _ ..............OF.. ................................. __.......------.. •• - ........I............ Appliration for Uhgpo,ittl Work,i Tomitrurtion Permit Application is hereby made for a Permit to Construct ( �or Repair ( ) an Individual Sewage Disposal System at: ..04 .... '/ .. ► ------------------------ -------------------------------------------------------------------- ................. AJA f•_ �•_.� ' r •.- E or Lot No. ........................... ........ - Owner •-•-----•----• ------------------•----Address Installer Address QType of Building Size Lot............................S U Dwelling—No. of Bedrooms.._.....................................Expansion Attic ( ) Garbage Grinde Q, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria P-1 O%r 4xtures .............•• --•---••----••. w Design Flow........... ©......................gallons per person per day. Total daily flow.......... ..... ...J...............gallons. W Septic Tank—Liquid cap cit)/��gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. ._.___ .r......... 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 to ( / ~" Percolation Test Results Performed by.. lj� _*.�8.�"------ Date........................................ Test Pit No. I................mmutes per inch Depth of Test Pit.................... Depth to ground water........................ f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ----•-----------------------•------------- -------- ODescription of Soil---�0.�--.o ..-------••------------------- ----------------------•-----.......-----•-•-••----..... x U .........--•---•---•-----•••---••-••--••------•---------•----••.........--•-•......•-----•-------•--••--•---------•.....................•••-----•--•-••-••-••----------••----•---....................... w 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 TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance s been iss ed by the boar o health. gned.- ....... ........... ....ems`_ r ..._ Application Approved By........ ••... .. .•• ... ------•......................•-•--.----- Dat-e Application Disapproved f r th f ollowing reasons:---------•-------------------------•------------------•------••-•----------............................._-•---- '.I��Tac�arrati T� f;L- - ------ -------------••--------._..... ------••-------•-------•---------------•-----•---- _Date-------------- PermitNo...................................................... Issued..................................................... D �Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... Trrtif iratr of T amplittnrr T TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired ( ) by..- Installealle --..__.. --------- ---------•-••--•------•---•------- --- -----------------.-.-•----•--------..._..-------- •---------------------------- ----------------- Xr at... •--- ••--•---•---•---•--•------------------------•----------•-•-------••-•-•.......--••............................----- has been i all in accordance with the provisions of Tjj..,5.s e State Sanitary�o as-'rd ��^rib d in the applicati n Disposal Works Construction Permit IVo.. .................................... dated_-r .. _Y.. ..._1-•-. ..._........... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A UAR NTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ¢ ----------------- �....O F.............. .. . .. Eliopos rko Tondration Permit Permission is h y granted...../ �ual ......--•-••......••---------------------•---•-•...-•-•-•-----••----•--•--.......------_.................-•-.. to Construct ( epair ( ) a Indiviewage Disposal System at No.... .. ..._.... ..._..:... ------ -------••---•-------------- ---- ---------•-•------ •.. .................. Street t as shown on the tion for Disposal Works Construction Permit ._.- ---- ___..Dated. .. . _ _. ..��/................ .••. .........•......................................................... •• - � Board of Health DATE---.......-•----fit • ---------------•-••••--•---- FORM 1255 A. M. 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