HomeMy WebLinkAbout0029 BEECHWOOD ROAD - Health 29 BEECHWOOD ROAD
CENTERVILLE 252-003
No. 4210 1/3 ORA
Pendaflex'
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COMMONWEALTH OF MASACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET BOSTON MA 02108(617)292-3500
TRUDY COXE
Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION -
Property Address: 29 BEECHWOOD DR CENTERVILLE, MA 02632 M262 P003 �.0''
Name of Owner WILLIAMSON
Address of Owner: 102 PALERMO PLACE THE VILLAGES FLORIDA 321259
Date of Inspection: 10/31100
Name of Inspector: JOHN GRACI r 6'
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)
Company Name: SEPTIC INSPECTIONS
Mailing Address: P.O.BOX 2119 TEATICKET,MA.02536
Telephone Number: 608-564-6813 FAX 508-564-7270 \
CFRTIFICATION STATEMENT `
I certify that I have personally inspectedthe sewage disposal system at this address and that the information reported below is true,accurate
and complete as of the time of inspectiop;,The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems.The system:
X Passes
_ Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: Date: 1116100
The System Inspector shall su mit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of
completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner
shall submit the report to the appropriate regional office of the Department of Environmental Protection.The original should be sent to the
system owner and copies sent to the buyer,if applicable,and the approving authority.
NOTES AND COMMENTS
"The inspection is based on criteria defined in Title V code 310 CMR 15.303.My findings are of how the system is performing at the time of inspection.M,.
inspection does not imply any warranty or guarantee of the longevity of the septic system and any of its component's useful life."
THE SYSTEM PASSES TITLE V INPECTION.RECOMMEND PUMPI
NG THE EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE.
THE SYSTEM WAS NOT INSPECTED UNDER NORMAL USE.
53 S a
revised 912198 Paoe 1 of 11
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
l' CERTIFICATION(continued)
Property Address: 29 BEECHWOOD DR CENTERVILLE, MA 02632 M262 P003
Name of Owner WILLIAMSON
Date of Inspection: 10/31/00
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
X I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not
evaluated are indicated below.
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 o
the replacement or repair,as approved by the Board of Health,will pass.
Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances. If"not determined",explain why not.
n/a 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.
n/a Sewage backup°or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)o
due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health).
_broken pipe(s)are replaced
_obstruction is removed
_distribution box is levelled or replaced
n/A The system required pumping more than four times a year due to broken or obstructed pipe(s).The system will pass
inspection if(with approval of the Board of Health):
_broken pipe(s)are replaced
_obstruction is removed
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revised 9/2/98 Paoe 2 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 29 BEECHWOOD DR CENTERVILLE, MA 02632 M252 P003
Name of Owner WILLIAMSON
Date of Inspection: 10/31/00
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 I:
NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
_ Cesspool or privy is within 50 feet of surface water
_ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER.IF ANY)DETERMINES THAT THE SYSTEM IS
FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH 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,
'itrt:
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 we,Ii,unless a well water analysis for coliform bacte.is and volatile organic compounds indicates that the
well is free from pollution ifrom that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm,Method used to determine distance n/a (approximation not valid).
3) OTHER
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revised 9/2/98 " Page 3 of 11
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 29 BEECHWOOD DR CENTERVILLE, MA 02632 M252 P003
Name of Owner WILLIAMSON
Date of Inspection: 10/31/00
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
X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool.
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow,
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped n/a.
X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
X Any portion of a cesspool or privy is within a Zone I of a public well.
_ X Any portion of a cesspool or privy is within 50 feet of a private water supply well,
_ X Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water
quality analysis.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic
compounds,ammonia nitrogen and nitrate nitrogen.
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:
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
X the system is within 400 feet of a surface drinking water supply
X the system is within 200 feet of a tributary to a surface drinking water supply
X 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 15.30412).Please consult the local regional office of
the Department for further information. j
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revised 912198 Paoe 4 of 11
y
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 29 BEECHWOOD DR CENTERVILLE, MA 02632 M252 P003
Name of Owner: WILLIAMSON
Date of Inspection: 10131/00
Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following:
Yes No
X - Pumping information was provided by the owner,occupant,or Board of Health.
X - None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that
period.Large volumes of water have not been introduced into the system recently or as part of this inspection.
X _ As built plans have been obtained and examined.Note if they are not available with N/A.
X _ The facility or dwelling was inspected for signs of sewage back-up.
X _ The system does not receive non-sanitary or industrial waste flow.
X - The site was inspected for signs of breakout.
X - All system components,excluding the Soil Absorption System,have been located on the site.
X - The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material
of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption System on the site
has been determined based on:
X _ Existing information,For example, Plan at B4O,H,
X _ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)1 5.302(3)(b))
X _ The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal
Systems.
revised 9/2/98 Paoe 5 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 29 BEECHWOOD DR CENTERVILLE, MA 02632 M252 P003
Name of Owner WILLIAMSON
Date of Inspection: 10/31/00
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 110 g.p.d./bedroom
Number of bedrooms(design): 3 `Number of bedrooms(actual):-ft-3
Total DESIGN flow: 330 gpd
Number of current residents:0
Garbage grinder(yes or no):NO
Laundry(separate system)(yes or no): NO If yes,separate inspection required
Laundry system inspected(yes or no): NO
Seasonal use(yes or no): NO
Water meter readings,if available(last two year's usage): n/a gpd
Sump Pump(yes or no): NO
Last date of occupancy: 10/17/00
COMMERCIALIINDUSTRIAL
Type of establishment: nla
Design flow: n/a gpd(Based on 15.203)
Basis of design flow:n/a
Grease trap present:(yes or no): NO
Industrial Waste Holding Tank present:(yes or no): NO
Non-sanitary waste discharged to the Title 5 system:(yes or no):NO
Water meter readings.if available: n/a
Last date of occupancy:n/a
OTHER: (Describe)
n/a
GENERAL INFORMATION
PUMPING RECORDS and source of information:
9128/93:6112198
System pumped as part of inspection:(yes or no):NO
If yes,volume pumped n/a gallow
Reason for pumping:n/a
TYPE OF SYSTEM
X 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 Copy of DEP Approval
Other:n/a �t�e
APPROXIMATE AGE of all components;date installed(if known)and source of information:
1975
Sewage odors detected when arriving at the site:(yes or no): NO
,.
revised 9/2/98 Paoe 6 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 29 BEECHWOOD DR CENTERVILLE, MA 02632 M252 P003
Name of Owner WILLIAMSON
Date of Inspection: 10/31/00 t
BUILDING SEWER:X
(Locate on site plan)
Depth below grade: 42"
Material of construction: _ cast iron _ 40 Pvc X other(explain)
Distance from private water supply well or suction line: n/a
Diameter: nla
Comments: (condition of joints,venting;,evidence of leakage,etc.)
TOWN WATER
S
SEPTIC TANK: X
(locate on site plan)
Depth below grade: 36"
Material of construction: X concrete_ metal_ Fiberglass_ Polyethylene_ other
explain: n/a
If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NO
Age: n/a
Dimensions: 1500G L 10'6"H 5'6"W 5'8""
Sludge depth: 1"
Distance from top of sludge to bottom of outlettee or baffle: 33"
Scum thickness: 1"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
How dimensions were determined: MEASURED
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.)
THE SEPTIC TANK AND ALL COMPONENTS_ARE STRUCTURALLY SOUND.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE
SYSTEM'S USEFULL LIFE.
GREASE TRAP:
(locate on site plan)
Depth below grade: n/a
Material of construction: _concrete_ metal_ Fiberglass _ Polyethylene_other
Explain: nla
Dimensions:n/a
Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle n/a
Date of last pumping: n/a
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.)
n/a
revised 9/2/98 Paoe 7 of 11
SJ'
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 29 BEECHWOOD DR CENTERVILLE, MA 02632 M252 P003
Name of Owner WILLIAMSON
Date of Inspection: 10/31/00
TIGHT OR HOLDING TANK: _ (Tank must be pumped prior to,or at time of,inspection)
(locate on site plan)
t•
Depth below grade: n/a
Material of construction: _concrete_ metal Fiberglass _Polyethylene _other
Explain: n/a
Dimensions: n/a
Capacity: n/a gallons
Design flow: n/a gallons/day
Alarm present: NO
Alarm level:,NIA Alarm in working order:NO
Date of pumping:umping: n/a
P
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
n/a
DISTRIBUTION BOX:_
i I(locate on site plan) ��v
Depth of liquid level above outlet invert: n/a
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.)
n/a "
i
PUMP CHAMBER:
(locate on site plan)
Pumps in working order:(Yes or No): NO
Alarms in working order(Yes or No): NO
Comments:
(note condition of pump chamber,condition of pumps and appurtenances.etc.)
n/a
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revised 9/2/98 Paoe 8 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 29 BEECHWOOD DR CENTERVILLE, MA 02632 M252 P003
Name of Owner WILLIAMSON
Date of Inspection: 10/31/00
SOIL ABSORPTION SYSTEM(SAS): X
(locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods)
If not located,explain:
n/a
Type:
leaching pits,number:(1)1000 GAL 6'X 6'
leaching chambers,number: (n/a)n/a
leaching galleries,number: (n/a)n/a
leaching trenches,number,length: (n/a)n/a
leaching fields,number,dimensions: (n/a)n/a
overflow cesspool,number: (n/a)n/a
Alternative system: n/a
Name of Technology: n/a
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.)
THE LEACH PIT APPEARS TO BE FUNCTIONING PROPERLY.SYSTEM SHOWS NO SIGNS OF FAILURE.THE PIT WAS EMPTY AT THE TIME OF
t .
INSPECTION.
CESSPOOLS:
(locate on site plan)
Number and configuration: n/a
Depth-top of liquid to inlet invert: n/a
Depth of solids layer: n/a
Depth of scum layer, n/a
Dimensions of cesspool: nla
Materials of construction: n/a
Indication of groundwater: n/a inflow(cesspool must be pumped as part of inspection)NO
Comments: a .
(note condition of soil,signs of hydraulic:failure,.level of ponding,condition of vegetation,etc.)
n/a
PRIVY:
(locate on site plan)
Materials of construction: n/a Dimensions:.n/a
Depth of solids: n/a 4�
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
n/a
revised 9/2/98 Paoe 9 of 11
;;i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 29 BEECHWOOD DR CENTERVILLE, MA 02632 M252 P003
Name of Owner WILLIAMSON
Date of Inspection: 10/31/00
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes into house),
PG
AA
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P3A ay
revised 9/2/98 Paae 10 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 29 BEECHWOOD DR CENTERVILLE, MA 02632 M252 P003
Name of Owner WILLIAMSON
Date of Inspection: 10/31/00
NRCS Report name: n/a
Soil Type: nla
Typical depth to groundwater: n/a
USGS Date website visited: n/a
Observation Wells checked: NO
Groundwater depth: Shallow_ Moderate_ Deep_
SITE EXAM _ Slope
_ Surface water
_ Check Cellar
Shallow wells
Estimated Depth to Groundwater 12 Feet+
Please indicate all the methods used to dete"/mine High Groundwater Elevation:
Obtained from Design Plans on record
Observed Site(Abutting property,observation hole,basement sump etc.)
t
Determined from local conditions
_ Checked with local Board of health
Checked FEMA Maps
Checked pumping records
_ Checked local excavators,installers
X Used USGS Data
Describe how you established the High Groundwater Elevation.(Must be completed)
USGS MAPS AND CHARTS-12+FEET
revised 9/2/98 Paae 11 of 11.
LOC SE jQ.CAE PER: T u0.
' �� -
VILLAGE — — —
AS
IWS LLE.RSW&ME ADDRESS
BUILD R 5 A E ADDRESS
Dt�,TE PER"VT ISSUED 7,Y — — —�
DATE COMPLI &16,dCE ISSUED ;
TOWN OF B TABLE
LOCATION �bC � SEWAGE #
VILLAGE \ SSESSOR'S MAP & L0
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO. OF BEDROOMS
BUILDER OR OWNER
PERMTTDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
NA
N. 9.5
......................... Fmc.... ........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF .E4
A L T
..OF................. ... ...... ......4...... . ... --
Appliration ----
-for Dispwial Works Tomitrurtion Vrrnift
plication is hereby made for a Permiti_to Construct or Repair an Individual Sewage Disposal
System at:
A?Ldtl......AO..... .........41.................. w..........J........ .................ke:a.....-_,,-Z ........................... C -------------- ...........
L!��-A_ e:s' e or Lot
------------1
Wool
. .............. ------ ..................................................... - ---------—-----
Owner Address
. ........
Installer Address
Type.�fu*ldmg Size Lot............................Sq. feet
Qwellin —No. of Bedrooms..------------------------------------------Expansion Attic Garbage Grinder ( )
a4 Other—Type of Building ____________________________ No. of persons_.______._____________-_-- Showers Cafeteria ( )
a4 Other fixtures -----------------------------------
--------------------------------------------------------------------------------
.14 - --------------------------------
W Design Flow--------------------------------------------gallons per person per day. Total daily flow--------------------------------------------gallons.
P4 Septic Tank—Liquid capacity------------gallons Length________________ Width_._.._._.._._-_ Diameter__.____.__.___- Depth-_________--.
Disposal Trench—No. ..................... Width._.._........___._.. Total Length__._.._.......__.._. Total leaching area--------------------sq. ft.
Seepage Pit No_____________________ Diameter______________-_._- Depth below inlet........_........... Total leaching area------- ----------sq. it.
Z Other Distribution box Dosing tank
Percolation Test Results Performed by-------------------------------------------------------------------------- Date-----------------------------------
1.4
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__._.__________.._____._
-------------------------------
----------------- ------------------
P4 -------- ------------- ----rV..........
0
Description of Soil------------ ------ .... ..........�xj .
---------------------------------------------------------------------------------------------------------------------------V........... --------------------------------------------------------
------------11------- ...................................................................................
�ti o, s er3Zn a.1picab fions A er 4-----------
U Nat e of lepairs or le. ---------
-- -------------------------------------------------- ----------------------------------------------------
Agreement: I -
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 undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee d th�, p issued b Y e b d oN-tcoth.
Sign -- - _- ............... ------------ - ----------------- Date
Application Approved By.._..... . . ......... .....= -- -- -----4444...4wft-------- ----------..----.._...ace--------------
----------------
Date
Application Disapproved for the following reasons:-----------------------------------------------------------------------------------------------------------------
........................................................................................................................................................................................................
Date
Permit No.-------................................................ Issued......
Date
----—-------------------------------------------------------
Fizz ...........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD Og S A LT
OF.................
r.
. ......
Appliration -for Bi!ipviial Works Tanstrurtion Vaunt
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at:
AkAl...... .. . . .. . ............. ..... ................. .. .................. .......................4------------
Le ST, or Lot No.......................................... ------------- --------------
. ...... ..............
Owner Address
. .... ...................................................... ..................................................................................................
Installer Address
TypS,21i. Qmg ..........................
K�
Size Lot ..Sq. feet
u
QZellino—No. of Bedrooms...'................. __,2±---........Expansion Attic Garbage Grinder
Other—Type of Building ______________________�'L !No.',j�,bf persons---_--__.................. Showers Cafeteria
Otherfixtures ------------------------------- ---------- -------_....................................................------------------- .......................
Design Flow............................................gallons'per:peff�,s^o,n per day. Total daily flow._._.____.____.__...__....._._. __gallons.
P4 Septic Tank—Liquid capacity............gallons Length________________ Width__-:_.....:._.. Diameter_._....._ ...... De
lift
Disposal Trench—No_ -------........�L. Width..._........._ ... Total Length___.....__........,. Total leaching area--------------------sq:frn
Seepage Pit No_____________________
Diameter.................... Depth below inlet__._.______________. Total leaching area----------------7 sq.
Z Other Distribution box Dosing tank
,4 Percolation Test-Results Performed by...................................................:....................... Date----------------------------------------
Test Pit No. I................minutes per inch. Depth of*Test Pit.................... Depth to ground water.--------------------
44 Test Pit No. 2................minutes per inch Depth of Test Pit......_..._......._. Depth to ground water--------------------------
............................
----------------- - ------ . ........................
0 ---------- ------------- -4----------------- ------- ........... -4
Description of Soil----- ......... �.-V_v- ---------7----------
'00 0
.. ........ ...........
----------------------------------------------------------------------------------------------------- -----------------------------
U -----------------------------------
------------------------------------ . ........................................................ ----- .........
N rs or Pilter4tion -7#As er Wn nap icable.- --------
U --------
A------------------------------------------------------------------------------------------------
-------
P
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate'of Compliance has bees issued by the tjffd oNtVth.
Sign ...... ------------- 3
Date
Application Approved BY.- . ......... ...... ..
1:4-t-4-or---------- .........................................
-7- Date
Application Disapproved for the following reasons:................................................................................................................
.........................................................................................................................................................................................................
Date
PermitNo....................7------------------------------- Issued.........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
... .........OF........ ... .......... ...................
rdifiratr oftiattr
I TO ER That the Individual Sewage Disposal System constructed or Repaired`t(Alr
......... .by....-T I ... ..... Y��Installer .........
------------------------------------------ -------------
#401
at---
has been installed in accordance with the provisions of Article Xeoif��The State Sanitary descr*,ede, the
40
application for Disposal Works'Contucti on Permit No.--_---_ IF-ja................... dated'-1-c Co012 T .. T ........
THE ISSUANCE OF THIS CERTIFICATE SHALLMO CONSTRUED AS A R E THE.
T BE.
SYSTEM MILL FUNCTION SATISFACZTORY.
DATE............................................................................... Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD. 0 1 HEALTH F
N ..... =-por.............
0... ...... 7 FEE..2.1.............
Permission is herebV granted--------
......... ........ ............................................
.... ...... ........
to Constr or it an nd' idu ew isppsal System
at . ..... ....... __#--- ---- - --- -- - --- . ........... .................
Street
as shown on the application for Disposal Works Construction P No.
,P .... . ....... ... . ......... .......................
............
o rd of aft
DATE..........................--------- ...........................................
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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