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HomeMy WebLinkAbout0366 CAP'N LIJAH'S ROAD - Health 366 Cap'n Lijah's Rd Centerville A=193 - 105 UPC 12534 No.215_3LOR_ ' wra��r 366 Cap'n Lijah's Rd Centerville A=193 - 105 oo UPC 12534 ILO.215_3LOR_ ' wra��r �� i �' �. �N E i I I I ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 366 Capn' Lijh's Rd. Property Address Cindy Hammond Owner / Owner's Name information is Centerville MA 02632 9-13-13 required for 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 any way.Please see completeness checklist at the end of the form. Importantfling out when A. General Information a��►ttitiiAIA filling out forms �� OF on the computer, �jN ASS°o use only the tab 1. Inspector: key to move your I _z: J A M E S cursor-do not = James D.Sears =O: use the return Name of Inspector key. — _ Ca ewide Enterprises,LLC Company Name 5►1 N SP� ````��z 153 Commercial St. Company Address Mashpee MA 02649 Cityrrown State Zip Code 508-477-8877 S1623 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 16.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 9-13-13 pector'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 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. �5 t5ins•3113 Titre 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 yZeaudayaw:0 L a M b i 1wr Gj Wn jua 7=41 LOU OL 11MM 00 Jaw ovate: VA: am, too! coin MO &I M Wv=w zMnuwVqw03 -my anoT .- W, Art 5w,"tr n'j I I i"Vi sm J b 9-ne 961 .0nuaw i OL %T I tells 0 Th"Cr V w MO t vwladt of Woplk'Z' is b 0.6 M.04 ail, CWWW M 1 1 70-V ':-tfv)h k C! one 0Iq%? 13 A ,1: SO (ir)-i :-;C?;4,7t if, ;ijp- 6( now am N , wN. un, Yj a, own,Ii OF lyn Ad ir v '0 WOwAK T �'-jV UnW rAf in Snatrbnn3 ardh3LDb &D r,Mpn Phil 1aw ff�' i s lon 63 'it; Ceu In -a Oubnoa fn OwIgh Ij wr= ids I ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 366 Capn' Lijh's Rd. Property Address Cindy Hammond Owner Owner's Name information is required for every Centerville MA 02632 9-13-13 page. City/Town State Zip Code Date of Inspection B. Certification (cunt.) 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•3113 Title 5 Official Inspection Fonn:Subsurface Sewage Disposal System•Page 2 of 17 ss { 1{ :� 21 Ga 1 rr +'vT ♦ [ tJ i t i S 7-� s 7 .i 71 n ? ' tJ l C; f c ri Syr t.. C1 V't � / � fT t✓- � � r C,? � .L' ,.. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ° 366 Capn' Lijh's Rd. Property Address Cindy Hammond Owner Owner's Name information is required for every Centerville MA 02632 9-13-13 page. Cityfrown 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(cunt.): ❑ 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•3H 3 Title 5 Orfidal Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 lr`f tr C, sub to! 0 11.10C. 3,yja ig,; 16 I,> Ayn, io ;jSZ 120",, In ri Us, w TaWYE YQ t',0,j1N"113Z!b I V%:!U IL WOOL T '-' vi M 1 SEPq V!,Old OF IF Oam&, f " ac L 8A I 0—to To -won Mon n ar Ic ww"I 1 o on 1, A JG saw,M W.,k ,! ;Kev ij Qw" Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �Y 366 Capn' Lijh's Rd. Property Address Cindy Hammond Owner Owner's Name information is required for every Centerville MA 02632 9-13-13 page. Cityrrown 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 Ay A- ❑ ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cNIUM is less than 6" below invert or available volume is less tan /:day flew /h ' 7S` t5ins•3f13 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 pp cvm—a we -wl-v tc- ir)A noWuMdU ti s%t et I Actic! low,) hNivi W T'yi fo"!. "a Is f- I t'v?'4"'M 1111,11, 0 q i T,13 i I o I")( WE; I Ka UM MAJ niq A' 0 FAA f WYL el; jmq lum 9-Ono? z Q VOW.1 :r- *-.1.L-' ":�cl' k,'?Fj N it r t'o J- is r'-N" - 02 am VaQ W cnz- '-illi40 "C`3"."Yd I M :}At; 3AO 10 r : A Do Nd ":F?t ztf: y !Ms ON Ono esn nll -' -q! WS: ALI is no vo st n2vq 71 m e LUT Oki p Asir co, ""W' wamnwt mysoc am p7s hoew co"Zon mwx- NW." h5'�;he 0, -ef -,� _; r - AM BYGOU st lqu A t- ";pr)1; z;-,;* J'Y 3 L A ox J-v:,Q: �Z' 0 :L c CIO to Was a; "am"lu Wy-us noon! vig US, 10 has la" n Sao we"Orm mQuem v W sy" -v-ax: sib 11 CL 9W MMAW 1:It! KI AMS 40 W a, -WV W VFW 'M !M/ A01 ,1 nvb P�a 4 0- Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 366 Capn' Lijh's Rd. Property Address Cindy Hammond Owner owner's Name information is required for every Centerville MA 02632 9-13-13 page. Cityrrown State Zip Code Date of Inspection B. Certification (cunt.) 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 regional office of the Department. t5ins•3113 Tits 5 Official Inspection Forth:SubsuAace Sewage Dis posal System•Page 5 of 17 y , ?!aT VICTIM vy r T 4,$1 .. $#S.l.3 tJ • .:U Yryp+ .[r r..I :3 L !Ztt t et O.i l -ET°'oli OW 2 :at.. ;4,.;C ,l nC data,OR ,bruojQ On in tt..' ty�?. � _ i :+•..•����r�: �E:` � .t",F .'?� r>a '.i`". � �. �.E3 �•p•� f..f t:...[T`"i L. (.a �„�.#r.`J�. ,_. i;i 1' ago v tit`t`';so ... '':t in ont is si ld . '(: ', ":J!L'1v'::7:..,., Fi:•f'.0 t t; _ 4J=u7 u to y to Yr ''i�r�''.-C): :J `iC7'1•r"LS , �:� t'�_. :�..[ I L ' ,'�'.`1t +.3+". F. `•?� r+,.� t ii.,:.a 4r r (ri�� ,t'. ."F " +?fS Fit/ct".�G^,n � 4`i t )st...tt n-� ( . =n �!; Pe�;4 €`f€:.,:.flt)set� ,�S} =.'r` CK�f` . ?• e;dr' O+w'�.'.�)s� t � t, "y ."?'1. :°� ._. d!1 ?•..j`.ait., —X, ,1A+iaw'' Y.)fsat:, .' 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Property Address Cindy Hammond Owner Owner's Name information is required for every Centerville MA 02632 9-13-13 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): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 A'�,'iHr (` r `� ,.. .'t r• rl,7 , t -s'. •ti'3 ?' .)�''�"�'! �-, t3` _ ,. ,t!` ..,ti ._ t-, V.6 wi fz 'Ju;r I i L I r-"(7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 366 Capn' Lijh's Rd. Property Address Cindy Hammond Owner owner's Name information is required for every Centerville MA 02632 9-13-13 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: The system is a 1000 Gal.tank and two pits. Number of current residents: 2 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)): 2011-26,000Gais 2012-9,000 Gal's Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Present 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•3/13 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 ,e•''.:��.,tfz Nfx»»�',wr _. �,� �5��!• �'••r�{�'S!S'�iis.'.?v , s , "A x i a !t " '4 U, ,s'•' ±t/?! '�: .. 1 1.'tc.• !err, ii yr •t ..J - -.f a :�. -7..�-i^!i i�`r.. r,w •J,i ve[.e. - L'i ..•:CL :hr ..`rt:: .tfi 7C' 5 ►t .,t..t ... _ �`�..JLy �"..�:N G" ), •^a.''_ ''F'•r� i-.:'ie .r'�FS{."... 3, ,,,r�.tti, � 3:," f �, '>;'t� '.'.^.,';;;1f'iri9.,:.,L..J .t�:tF:x if.t�..�i'.'.a�:Stl1''l�ta i;;ti•'tl:+. .�4 I •J F'i t 1.,''\':..1�i.�!a~..DrA.. t7: �� � ifl` a�3. . '. �••7 '✓; 1. t?:: f � ,'"�%: t'� ..t.. . .,�: •' 1y _E �i's"...� :i;�� i.'. !-i'i_•.,'lf�Ci. .'r :si<.>;j1� `�1";�;f�t Commonwealth of Massachusetts Rome Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 366 Capn' Lijh's Rd. Property Address Cindy Hammond Owner Owner's Name information is required for every Centerville MA 02632 9-13-13 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: NA 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,41102NOW 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): t5ins•3113 Title 6 official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 f r )",n i lzv ii T4 C nt-,,.:oj VA, V kjL e to "I A,S,. !1,.;'�-,,6­1,5 T l , 1 EA ; , 0.;n,,A , On ;zIl L) o-jrj;jt4')!jt C_I71 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 366 Capn' Lijh's Rd. Property Address Cindy Hammond Owner Owner's Name information is Centerville MA 02632 9-13-13 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Tank and older pit 1979 permit#79-786. new pit instaled 1994 permit#94-500 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 20"feet Material of construction: ❑ cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Pipeing is 4" PVC SCH 40. Septic Tank(locate on site plan): Depth below grade: 9"feet 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 Gal. Precast Sludge depth: 1" t5ins-3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 9 of 17 1517 FT110-9 FWARCeam, 'ills MIJ 1: 1121 - 1q. wh - frmus"4 .}-n �0 Cy no or z w L m w up 14 1,-0 epy na Mao -I wN YPIRUS, FYA401 IM07 IV, [n a Psi 'C- I " : 1 iv L. .%,.. -.- )jd 1, .on "I Olt. jw ,:, Inviv Q my ?xT 1 fawlwya.0 a MAd is n ye cc,-'G)a kto A if m r1q144, r it W,? Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "t 366 Capn' Lijh's Rd. Property Address Cindy Hammond Owner Owner's Name information is required for every Centerville MA 02632 9-13-13 page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Septic Tank(cunt.) 29" Distance from top of sludge to bottom of outlet tee or baffle Scum thickness oil Distance from top of scum to top of outlet tee or baffle 81 Distance from bottom of scum to bottom of outlet tee or baffle 18„ How were dimensions determined? Asbuilt-TapeSludge Judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): Tank at working level. Tank and cover's at 9" below grade. In and outlet tees. No sign of leakage or over loading. 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Ch Sam I f!NOS Sit t't nvo nal r u AT ic, 7. 'c.") 7 C) Lyn lotion 3 NOW nom 1 w" (A": wA =40 w m SAM WC550 1c as, w POP 0 j WA r Mtn jus'm .1 wNS14 snlu one% W wou Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 366 Capn'tijh's Rd. Property Address Cindy Hammond Owner Owner's Name information is required for every Centerville MA 02632 9-13-13 page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) 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•3/13 Tile 5 official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 —t;Cl'I t4 i��'1(�•i rti' c:. .. ' 1r `JES,t£;:.+� �_' L-. �::_.t'' f`":+I: ', r'_ }�} .. ?...rC: r, ♦'t7 -1:`,'L`._. tJ•':; "if. '.i r �r r'�ti i�."�; r. 13°- r.. 1 �;�i',•.? :`'i:�?•1 .� f > r '�{arr,.l`;`, `,.36', k? _.i -ir". "t�ltFV �! t.�'.1)'.a'tii '�� Ir...�? .r __I C. ., '-'1't:':3 S._,.• t . �..�, .'�it r_ i 1,. .' d4a�:S�.S y`�d. , ". ..'� .#r•-1 n,,.�.,. ���,r.•r� i., .,,,i; ,�..i{� Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 366 Capn' Lijh's Rd. Property Address Cindy Hammond Owner Owner's Name information is required for every Centerville MA 02632 9-13-13 page. 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 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.): 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•3113 Title 5 Official Inspection Form:Subsurlace Sewage Disposal System•Page 12 or 17 a a m!T Ya's'�� ?t> ����a :3 f'}• `'L yr� {� a,. a r � �,+m�r o- r s`��'�` � � �. ^"`"' ^ i. nk c, rj V. ,:'5r..: A ki- 44 Ir" Ic pt no Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "< 366 Capn' Lijh's Rd. Property Address Cindy Hammond Owner Owner's Name information is required for every Centerville MA 02632 9-13-13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2 ❑ 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.): Leaching is two precast pits. Older pit dry. Note: Cover under large bush. Newer Pit at 1' below grade w/6"water in pit. Stain line at 18". Note: Tank out let piped to newer pit w/outlet line and outlet tee piped to older pit. No sign of over loading or solid carry over. 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 t5ine-31 3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 4-F at moi u Foe, 1 1 PP00,7, CT !u !Jf P C. Z,-" `:-O Av Ir sr' ! ..it t - rw r�; n 0." , 0 1 C U5 hit) I OC2 '46 lr� 001 Oi W6, Sz� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Foam-Not for Voluntary Assessments 366 Capn' Lijh's Rd. Property Address Cindy Hammond Owner Owner's Name information is required for every Centerville MA 02632 9-13-13 page. Cityrrown 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.): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 4 0 1-17 P lo- rn!A­z I. oc t5't"' ic '�c "�Z� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "t 366 Capn' Lijh's Rd. Property Address Cindy Hammond Owner Owner's Name information is Centerville MA 02632 9-13-13 required for every page. 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 J ry W A17 BAR ° , ° o ° ` 3 t5ins•3/13 Title 5 OMdal Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 51� � JIM? "71.1 d 10A 1 �Qli '01V iTT'r.-,Tl MOSS ire'4x;.0 fc too?a Ir eF U Ol 10 wz j 3 TNUM qvc MAIO 7 nrux;a An Oc -sr man.WR 1 q "'!s,r 4% Ann is -0. 11 V, E u'm Oque lsomy to a WeV Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 366 Capn' Lijh's Rd. Property Address Cindy Hammond Owner Owner's Name information is required for every Centerville MA 02632 9-13-13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells /V0 12'+ 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 P design Ian reviewed: 10-26-79 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: You must describe how you established the high ground water elevation: T.H. on Design plan 10-26-79. No G.W. at 12'. Bottom of newer pit at 7'. Bottom of newer pit at 5' above T.H. Depth. Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Lit 40 I v f4 IT., IQ I, 76 lit, V, 14 11 1, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "t 366 CaP n' Li'h's Rd. 1 Property Address Cindy Hammond Owner Owner's Name information is required for every Centerville MA 02632 9-13-13 page. Cityrrown 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Ail Sj°}}+ir�1..1"•i�'t4}wo �... �� #'..� .. �s t`:...#k s,� ..�w:�ea.F`css,.a'a :s:., �c _.�i k. .• .•.rf 'st:z": ^.✓i,n{ .. ' 7C' io.4. r��,o :?�, rc ,_. �. 'ia :�r?Ca j,� .)C#"3f.'.�d_ -,•, vt , Q i i. ^�� +'S�)i li�r ...ii`it .,'Ii,f i.c. r:n_ :.. '�s i*i :,�::t• ` -;r`.i ucs i') +a9;..ert,l(} r• , 3' r C,� 'iJfx�'C` U .iCY3 'Ca,�;ft'^}f1. 1± s�3c� .i •.L �`t i 'J f1J .I w No. 0/ / s 3151 Fee (`, ) THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 4pliCAtion for Disposal 6pstem Construction permit Application for a Permit to Construct( ) Repair(A Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 3 fe( GA-e�N LI.TA!-I`S K 1�o Owner's Name,Address,and Tell.No. Assessor's Map/Parcel 40 (C gA,> PLACE R o � Installer's Name,Address,and Tel.No. -?SS Y7 Designer's Name,Address,and Tel.No. G4tgGC�im£ �1�'-�I�LtStsS ,� Type of Building: j� Dwelling No.of Bedrooms / Lot Size � sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd 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) �ti L OL97rt-12fi- I L 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 Certificate of Compliance has been issued by this Board of Health. Signed Date —�(�� Application Approved by 2 Date �� -0 Application Disapproved by Date for the following reasons Permit No. �o 1 3 S Date Issued fl�� 5 NO. a G 13 ' 351 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS M 01ppfitation for Disposal 6pstem construction Permit Application for a Permit to Construct Repair Upgrade Abandon ) ❑Complete System El Individual Components ( ) P Pg ( ) ( Location Address or Lot No. 3�� GAR,,o Ll_TAWS Rn Owner's Name,Address,and Tel.No. Assessor's Map/Parcel �i ' I D 5 G�epTw .Ci C Yellb�H/A C Akw 0 Installer's Name,Address,and Tel.No.5rM-(J'77.76T7 Designer's Name,Address,and Tel.No. <GAo6wl oaE f-�KrStS L -G 0 Type of Building: Dwelling No.of Bedrooms / t/ 4— Lot Size 4 sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd'' is Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. t Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: "" The undersigned agrees to ensure the const5otion 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 Certificate of Compliance has been issued by this Board.'of Health. Signed '� Date r((� Application Approved by �~ Date Application Disapproved by Date for the following reasons Permit No. U 3— ?2 Date Issued Th COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Com'rianre THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(x) Upgraded( ) Abandoned( )by at C. C has been constructed in accordance Q E _�—Lf_ �P�l I'f�Q I� S r�A D �� ��``/� c� with the provisions of Title 5 and the for Disposal System Construction Permit No.p'yl/—17` dated Installer — i Designer #bedrooms Approved design flow R gpd, i �- The issuance oft 's permits all not be co strued as a guarantee that the system will Indft4ion-as.]-Signed Date } Inspector i '� i. --_------ --.----_--_----- -- ----------.--r_--.-----.--'-,' _---.--.--------------:.-- --------------------------------------------- No. 3 S 1 Fee A THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS ' Misposal 6pstem CDnstruction permit 4' Permission is hereby granted to Construct Repair(� UPgrade Abandon ( ) � System located at 3W,�(l n 'AI c—I ,TA N I:S ADD and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with f Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date t9—f I— 177 Approved by i TOWN OF BA%NSTABLE a LO ATION 04,L C,'a,PAJ SEWAGE # �Y—SAW VILLAGE j PEE ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. �cn -ue� SEPTIC TANK CAPACITY /C(fcj LEACHING FACILITY:(type) %� J ��) (size) cp NO. OF BEDROOMS PRIVATE, WELL O PUBLIC WATER-� BUILDER O DATE PERMIT ISSUED: �o�yAPy DATE COMPLIANCE ISSUED: 7 VARIANCE GRANTED: Yes No i .27 0 (i e L✓ No.. f-j� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliratiou for Divi-pw3al Worko Touitrurtion 11 amit Application is hereby made for a Permit to Construct ( ) or Repair LN,4' an Individual Sewage Disposal System at: /" O option Address 7 or Io ---•--. -•--•---•---.............-----•---••--......--.-&-4-----......C-'-� .. ........ .... •--•--•---•--•.-......................................... owner ddress �40 •• --------• -- --- -- ---- 5'-- Installer Address QType of Building Size Lot............................Sq. feet U Dwelling— No. of Bedrooms________________v?_---------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) a Other fixtures _______________________________ _ _ W Design Flow...................��_�..........._____.gallons per person per day. Total daily flow_..___.....a-76...................gallons. WSeptic Tank—Liquid capacity/40----gallons Length________________ Width---------------- Diameter................ Depth___-___-__--__-- x Disposal Trench—No. .................... Width--_-___�__-__.____. Total Length.................... Total leaching area....................sq. ft. Seepage Pit No......�-------- Diameter........E®___.___ Depth below inlet..__...1....... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) ►- Percolation Test Results Performed by------------------------------........................................... Date........................................ 14 Test Pit No. 1________________minutes per inch Depth of Test Pit_____.._...__....... Depth to ground water------------------------ Gx Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ CY -------------------------------------------•------•-------•--------------•-•---•-•-----•--•----••............................................................ 0 Description of Soil........................................................................................................................................................................ W --- --------------------- --------------•------------------------ -----------------•--------------•----------------------------------------------------------•------------••-----•-----•---------•.•--- UNature of Repairs or ?alterations—Answer when applicable------/3.0:Q........e!q-_-------!'__00-_ 0..4t--____1,-,! Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code —The undersigned further agrees not to place the system in operation until a Certificate of Compliance s en i s d by board of health. _._ Signed .. -----e ... .._.. _.................. Dare Application Approved B PP PP Y .......... )Nr_�� -a ------------------------------------------------------------------- ..... Application Disapproved for the following reasons- ------------------------------------------------------------------------------------------------------------------------ -------- ........................................ PermitNo. ...... _'—s- -C)--------------------- Issued --------......-----------....-.............------------------------- Dace No...—(... 5.UO Fes$....-3�! '..... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Dili-p 3al Works C omitrnrtion ramit Application is hereby made for a Permit to Construct ( ) or Repair (>-,) an Individual Sewage Disposal System at: .------•-------------------- -- - ---- ----------------------------------------- -•-----•------------------•--•--• •--____•-- -- .._...._.._�_________----__....__-••--- Lo anon-i\ddress ` or Lot N _ n 1 Gr.JL� Owner Address •-------------------•-••••-•------------------- ---....---•------------------------•---..._..... •. Installer Address d Type of Building Size Lot.................... q. feet U Dwelling— No. of Bedrooms_________________ ---------------------Expansion Attic ( ) Garbage Grinder ( ) aOther —Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther 'fixtures --------------------------------------------------------------------------------------- ------------------------------------------------------------- W Design Flow----------------5_-�4................_._gallons per person per day. Total daily flow...........37.L1_...................gallons. W Septic Tank—Liquid capacity-/-!.Ut?____gallons Length---------------- Width---------------- Diameter................ Depth................ x Disposal Trench—No. .................... Width-------------------- Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..__-__,z-7......... Diameter-------- �:-:---_ Depth below inlet......j�t.�......_. Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test. Results Performed by----------------------.................................................... Date........................................ W ,.� Test Pit No. I................minutes per inch Depth of Test Pit-------------------- Depth to ground water-..___._.____-__--__._.. 444 Test Pit No. 2................minutes per inch Depth of Test Pit._____--_.______---- Depth to ground water......................... a' ---•---------••----------------------•-------•-------------•---•--------------......----------_•-_........................................... •---------_----- ODescription of Soil........................................................................................................................................................................ x U ---------••-••--•-•----••-•--------•--•------•-------------------------------------------••-------------•---....._...--------------------•--•-----------•----•--•-••-•-•---------------................ W UNature of Repairs or �lterations—Answer when applicable._____ n________ _........1..U6I?___ Q._.____---- -----�-----_-. ------------ T"-•----5-;'Zi i..3r ---•............. ......�=`-1- ------ �-_.sT�'a_c.�J...F:---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliances een issu d by rho board of health. Signed _... --lJ�' .-/� . ~.. ------ ....����� �G Date Application Approved B �' ------------------------------------------------------------ Application Disapproved for the ollowing reasons: .. . ....................... ..... . ................................ ._................... ......._..........................................--------------------------.........---------------------------....----------------------------------------------------------------------------- .............-------------------------- Permit No. l L I r�........................ Issued r Dare THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE C'Iertifirate of Toraptianee THIS IS TO CERTIFY That the Individual Sewage Disposal System constructed ( ) or Repaired (X ) by ......... - G>/L—rG.LOTTZ ---------�' -^�'=S-T'`1'`�...-r.1 U_._j.. ....... . . hsrdler f at ..............................................` .Lv..l�s. ... t ,i" -1. f.+` .4:�''/.5...------------4� ......1i ._ : ................. . .......... has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ----7.-If.. 6)-------- dated ---------- ---------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE------------ ..— .._L----- 1. 4 Inspector --------- ...- - -- -- ------------ THE COMMONWEALTH OF MASSACHUSETTS q BOARD OF HEALTH TOWN OF BARNSTABLE Ropnout Worho Tuntrurtinn "omit Permission is hereby granted.....___._..._,.� GAL- ._�!_!______________�.._�� f��.. U tJ --------•---------••.. ...... ........... to Construct ( ) or Repair (.`) an Individual Sewage Disposal System _ at No. . -•--.......--3.6 �^' 'A-q�-------_.(-__� 4-1`J------- ...... .... ! ....................... Street gg �— as shown on the application for Disposal Works Construction Permit No.l-�/-_,5-Q-) Dated____...._... .-�._Y.----91.1 ............................................... ..... .j�_-- ------------------------------- p� Boar of ealth DATE Z - f f FORM 36508 HOBBS 6 WARREN,INC..PUBLISHERS, t J No............7....... O5 0 1 , `„ Fps............................. �' THE COMMONWEALTH OF MASSACHUSETTS I BOARD OF HEALTH �4..7..........OF...... mow...........:............... „ 11VIiration for UisVniiai larks Tonstrurtiun rruti# Application is hereby made for a Permit to Construct J or Repair ( ) an Individual Sewage Disposal System at / .• 'on-Ad or�j°t N Ow er Address- W . . . . .....-�... ..... ..................................... ..... Installer Address (..... .......... � - d Type of Building Size Lot...�45�/-3/------Sq. feet Dwelling—No. of Bedrooms.............. ................Expansion Attic Vva Garbage Grinder.141- Other—T e W yp of Building �} _ No. of persons........4............... Showers �j ) — Cafeteria�j�jj Otherfixtures --------------- -------------------------------•---------•------•-----------•-------------------- W Design Flow............../l.O....................gallons per person per day. Total daily flow.......- ..............................gallons. WSeptic Tank—Liquid*capacity/az'. 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 ch }g area..................sq. ft. Z Other Distribution box �) Dosing a ( 0�— ram' Percolation Test Results Performed by.., -. ...'... •......... Date..I�.:.�_L:' j........... a ,..1 Test Pit No. 1..�..�____minutesper>nch Dephl of Test Pit______lo?_.__.__. Depth to ground water...lycli!�, Test Pit No."2................minutes per inch Depth of Test Pit_ - Depth to ground water..... a ---•---•-----•--------•-....•--.._..••--._...... .. .......... 0 Description of Soil.......................................................a-y. !n... x V ------------- ----------------- -...... ------- ------------------- --------- ;.. 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 has bee issued by the board of h lth.. Sign —............. .................................. .....l Application Approved BYz2�� -•. -� I -" ate 7�' Date Application Disapproved for the following reasons:------•--------------------••--•------------------------------•-----------------------------•--•......-----•--•- ----•----••-----•---.....:•-•-......--•......-••...................•--•-------•----•---•--••--•------------...•-•----•••---•-•-•-------- •--- e � Date IIY Permit 1\�. .. Issued.--- ..................................... Date � � f t PF 7 No.......... (-o....... Fps.. ............... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Y� �' r..., re, ;r r , Appliration for Di"as al Works (fnnstratrtinn Prrutit Application is hereby made for a Permit to Construct,�*) or Repair ( ) an Individual Sewage Disposal System at: r f .......•••••------•.....------••--------• .......... ..... ... r Location Add e s (.•, or�Lot No. Owner L/Addres s �!?1 ��t!` 7l /f t 11�'e .£ c....� ./a .... sir_, mi. .:.. .'C, :.. ............ ..... ......... .,••-•......_.............-•--.._.......... •. =-. Installer Address dType of Building / Size Lot... ......Sq. feet V Dwelling—No. of Bedrooms.._.. °1- ..................Expansion Attic ,(4L(1 Garbage GrinderJ(�'�) Other—T e of Buildin r� ;+✓' No. of persons ................ Showers C Cafeteria dOther fixtures .:.................................................................................................................................................... Design Flow..............e�✓.CZ..................^t_gallons per person per day. Total daily flow....... -7. '._..._....•._.....__......gallons. WSeptic Tank—Liquid'capacity/�-cCAC�'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,�ch' g area..........._......sq. ft. Z Other Distribution box�) ' Dosin a ( CJ6- �" ' `" Percolation Test Results Performed by._ .� .: ^_.. +.. ...Pt.._...... Date._ d_'.i `_ .._____..... Test Pit No. 1_<_�__._minutes per inch Dept of Test Pit...... ?_........ Depth to ground water..kl,AE_ Test Pit No. 2................minutes per inch Depth of Test Pit..... Depth to ground water......._...._.._........ // r ,! O Description of Soil........... . f� "" - A , r :!y �'�.� ," r .................. -•---•-•-•_._ ...•-•-••-------------------•-••--•----------••••-•----••---••----•-•-----••--•--•-----•---- ......---------•------••. -•----•-----------------------•--.----•-� = 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 TIT x5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of Health.. cSign :.._ 1 c__• _�-:.«:-..........-�' f .-= `-- ....... ate Application Approved By......... . �'t . _-- ---.............r f •� ,------. --••••-- Date Appkcation Disapproved for the following reasons------------------------------------------------•----•---------•--•----------•--------------•--------------•-.._ 1! - .............................•-•------•-----------......._....-----------._...---•---------•---••-----------------•--•----•••- ----------------------------------------------- :. +` Date Permit No......................................................... Issued...............................= = - Date THE COMMONWEALTH OF MASSACHUSETTS rM BOARD OF HEALTH THIS IS TO CERTIFY',,That the Individual Sewage Disposal System constructed O,j or Repaired ( ) Iller............................ . I_ /nsta t- 4s 1 z. C has been installed in accordance with the provisions of 5 of The State Sanitary Code as described in the application for Disposal Works Construction`_Permit N .-_... &_�............ dated---I .-y'.7t.................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOS BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE....................fL 1 /�-----•--•-------•--------•--- Inspetor....... 1� THE COMMONWEALTH OF MASSACHUSETTS ter �+'� BOARD,-,OF H/EALTHf ,(p �w� �(./♦ 7(f�/. ...........................0 F...... 40 No........:................ FEE........---............. Owposa ork.6 To idr inn rrani# Permission is hereby granted......!..... .......... :c.. _ tr to Construct ,° or Repair ( ) an Individual Sewage Dispos Sy�s�tem C at No................ f �'• .._ Street` as shown on the application for Disposal Works Construction Pe t No.. ,._ _.. Dated..;�_'�__'__'y-7.p'.............. ((//�//,���ff-- i Board of Health DATE----- ............................................. FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS '; r:,iL } _ c.• (=.Qc:"�,;L�G.E L�f21 I..IL7'C�Z. V � �e� ..5��� Tow t Ib � 3 � ';,3U G.P•t7 ` U Ste- t OOC� 6A.L-. ��JSPoS Dt_ PiT • USE 1000 GAL. , .- �.w1s�L AZZA . tso S-t". IG�o St= ,c 2.S • 3 IS 6..P.T3. T'7'C�NI AzeA- =-4> So S•�. � 1 .o - SO c•�.P�. '� fij .ri TOTAL TJ irSIGtJ = .¢25 G.RD• h TOT41_ b,dl L_,-( Fww = 330 &M. - A � 34 • + Pat?, a 4 ,; Ae�it TOT rt4o =�oo.o ,,... . �xtRd'.p11, 4�PP� MKT 1w. &AL. 44.7- -Box U-0 Sepric IWV. TiahtK i DOO �•4 t IW. 3 �uv, =' Cynt.. ct ,G q�g .C. Dicta 'A j PIT TO w' ` Curt°� was►+aa mod- PtzoT=-t LE L oCATI O" it I llj1 ,r I� tJbA ©t4 51•.itau I t E G G tZ T t t-�( T 1-t A T T t-1 E. �p U T� 4-1F_i�'t=L5h3 G<�Pl_�(S i�l/ITF-1 TWE:• �ji D� t_INE: ` � t i AWt> SC.TOAC4 WC-QcJ1QeA,4E- jTS OP TW -Tow►J 0t= 7JF2;,AtZ�N� S r PL 2VI la g UATC t0 't �✓ ` u� �f�'"u t! 1 1� 6 a,�CTC tz. �... c IQC_ tZEGIS t'V--i:r--D 1 A Wo 5UZVa'(oc:s OSTE��/�LLG • c� MASS• 1tJSfC':J:✓ti�.W; �,U1,�1t=�{ Tt�C: c�Fc.;Ft'�, Sl40wt� APPL- i k:,r CE U5Ut? T•4, t�rz Tt��MI►Jit 1.o'"C' t_►h1�: _ LJri'-CIG ' ';� .. _ l,0 CAT ION ' S E W A G E PERMIT NO. VILL KGE INSTA LLER'S NAME i ADDRESS S U I l D E R R OWN ER z DATE PERMIT ISSUED -79 DATE COMPLIANCE ISSUED l7� s