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HomeMy WebLinkAbout0070 CARRIE LEE'S WAY - Health 70 Carrie Lee's Way, Centerville A= 1 i a d f S� I 4O'CLEDco UPC 12543 �a No. 53LOR HASTINGS, MN - Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 70 Carrie Lees Way Property Address Linda Panico Owner Owner's Name information is required for every Centerville MA 02632 March 2, 2012 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. Important:When filling out forms A. General Information on the computer, q use only the tab 1. Inspector: I I key to move your cursor-do not Mike DeCosta Jr. use the return Name of Inspector key. Wind River Environmental r� Company Name 1958R Broadway Company Address Raynham MA 02767 City/Town State - Zip Code 508-822-2003 13230 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 L cal A r ing Authority l ,L March 2, 2012 Inspector's Signature Date The system spector 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. t5ins•11/10 Title 5 Official Inspection r Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° M 70 Carrie Lees Way Property Address Linda Panico Owner Owner's Name information is required for every Centerville MA 02632 March 2, 2012 page. 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: Inlet cover is 30 inches below grade. Recommend installing build-up on inlet to within 6 inches of grade. Ouflet has riser to 6 inches below grade, no filter.Recommend installing filter on outlet. 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ' M 70 Carrie Lees Way Property Address Linda Panico Owner Owner's Name information is required for every Centerville MA 02632 March 2, 2012 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipes) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect-public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° M 70 Carrie Lees Way Property Address Linda Panico Owner Owner's Name information is required for every Centerville MA 02632 March 2, 2012 page. City/Town 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 .E] ® 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 '/z day flow t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 70 Carrie Lees Way Property Address Linda Panico Owner Owner's Name information is required for every Centerville MA 02632 March 2, 2012 page. 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 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 70 Carrie Lees Way Property Address Linda Panico Owner Owner's Name information is required for every Centerville MA 02632 March 2, 2012 page. City/Town 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 gpd t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments °wM 70 Carrie Lees Way Property Address Linda Panico Owner Owner's Name information is required for every Centerville MA 02632 March 2, 2012 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 207 gpd 9 ( Y 9 (gpd)): Detail: 2009 usage= 67,000 ; 2010 usuage=69,000 ; 2011 usage= 13,000. Total usage= 149,000 gallons. 149,000 divided by 24 months= 6,208 gallong per month. 6,208 divided by 30 days= 206.9 _round up) 207 gpd. Sump pump? ❑ Yes ® No Last date of occupancy: CurrentDate 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 70 Carrie Lees Way Property Address Linda Panico Owner Owner's Name information is required for every Centerville MA 02632 March 2 2012 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: Wind River Environmental record. Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1,000 gallons How was quantity pumped determined? Previous pumping records Reason for pumping: To check structural integrity of septic tank. 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): t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 70 Carrie Lees Way Property Address Linda Panico Owner Owner's Name information is required for every Centerville MA 02632 March 2, 2012 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: December 19, 1985 per plans. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 feet 6 inches feet Material of construction: ® cast iron ❑ 40 PVC ❑ other(explain): Distance from private water supply well or suction line. 0 11 feet Comments (on condition of joints, venting, evidence of leakage, etc.): All joints sealed. No evidence of leaking. Vent pipe on roof. Septic Tank(locate on site plan): Depth below grade: 2 feet 6 inches p g 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: 8 feet X 5 feet X 5 feet Sludge depth: 6 inches t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 70 Carrie Lees Way Property Address Linda Panico Owner Owner's Name information is required for every Centerville MA 02632 March 2, 2012 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 35 inches Scum thickness 5 inches Distance from top of scum to top of outlet tee or baffle 6 inches Distance from bottom of scum to bottom of outlet tee or baffle 18 inches How were dimensions determined? Tape measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet cover 6 inches below grade on a 2 foot riser. Outlet 30 inches below grade without a filter. Liquid level normal. Moderate solids and sludge. Tank is structurally sound and not leaking. Recommend installing riser on outlet to within 6 inches of grade and to install a filter on outlet to prevent sludge from entering distribution box. Also recommend to pump annually. 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 70 Carrie Lees Way Property Address Linda Panico Owner Owner's Name information is required for every Centerville MA 02632 March 2, 2012 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, j liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: - Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 70 Carrie Lees Way Property Address Linda Panico Owner Owner's Name information is required for every Centerville MA 02632 March 2, 2012 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 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.): Box size is 16 inches X 20 inches. Box is 42 inches below grade. Box has one outlet. Liquid level normal. Heavy carryover into box. Box will be pumped as part of inspection. Box is watertight and not leaking. Recommend installing riser on distribution box to within 6 inches of grade. 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 11 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 70 Carrie Lees Way Property Address Linda Panico Owner Owner's Name information is required for every Centerville MA 02632 March 2, 2012 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 at 6 feet X 6feet ❑ 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.): Dry sandy soil. Pit is 4 feet below grade with a riser to 6 inches below grade. Pit has only 15 inches of liquid in it. Pit has over 4 feet of available space. Pit is in good working condition. Pumped leach pit to check for groundwater infiltration. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth =top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -,Not for Voluntary Assessments 70 Carrie Lees Way Property Address Linda Panico Owner Owner's Name information is required for every Centerville MA 02632 March 2, 2012 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 70 Carrie Lees Way Property Address Linda Panico Owner Owner's Name information is required for every Centerville MA 02632 March 2, 2012 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 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 f I L0CAT10N SEWAGE PERMIT NO. i VILLAGE _ �tCIZ �o . INSILER'SAME i ADDRESS -VG. d U ILD E: R OR ' -:,OWNER DATE PERMIT l SSU,E0 D A T E COMPLIANCE ISSUED iv 2w LCX �_ Lmvi� ff-�C7 r. r:t t p� 1A wl a �y • v� tlr ( ` Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° 70 Carrie Lees Way M Property Address Linda Panico Owner Owner's Name information is required for every Centerville MA 02632 March 2, 2012 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 15 + feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Approximately 15 feet to the bottom of leach pit. Pumped pit and observed no groundwater inflow during a 15 minute period. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 • Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 70 Carrie Lees Way Property Address Linda Panico Owner Owner's Name information is required for every Centerville MA 02632 March 2, 2012 page. 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 All I� - Commonwealth of Massachusetts It Executive Office of Environmental Affairs )UN 1 2 1997 Department of TOWNOF N Environmental Protection HFA1HpEPjAB1f William F.Weld A Caovemor O y Trudy Coxe- -- Secretary,EOEA David B. Struhs Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 7 0 C--rc1 c L-crN t"AI C--E''"'`r%,"'``�.o Address of Owner: �a,j,(I CC, Date of Inspection:^j-•-J�"i-'�7 (If different) Name of Inspectors tGcrvj�..�ti?�� � (s Company Name, Address and Telephone Number: /Vh 0_Cr _k) CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reposed below is true, accurate on. The inspection was performed based on my training and experience in the proper function and and complete as of the time of inspecti maintenance of on-site sewage disposal systems. The system: VI-Passes _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority — Fails - Inspector's Signature: �� Date: j`� `l-v/ L/ The System Inspector shall submit a copy`of this inspection report to the Approving Authority 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 son; w tn(• <vsiem owner and copies senl to the buyer, if applicable and the approving au'l,ori;y. INSPECTION SUMMARY: Check A, B, C, or D: Al SYSTEM PASSES: V I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure.criteria not evaluated are indicated below. B) JSYSTEM CONDITIONALLY PASSES: / r One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. 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, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the'exisfing•septic tank is replaced with a conforming septic tank as approved by the Board of Health. - 1 (revised 8/15/95) One Winter Street • Boston,Massachusetts 02108 • FAX(617)5WI049 • Telephone(617)292.5500 `~,Printed on Recycled Paper e • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 17C) Cs•-r r' Owner: Date of Inspection: ..._ B] SYSTEM CONDITIONALLY PASSES (continued) 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 pipe(s) are replaced obstruction is removed distribution box is levelled or replaced 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 C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: kiConditions 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 THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRON!s1ENT: l hP c,Stem nay a septic tanti anu so�i aUSUf�llUli S)'bieni anu is witirii1 103 icci iiu a Suliauc 'vo ci supp") Gr trib' ;'Iar f'tU a surface water supply. _ The wstem ha! a septic tank and soil absorption system and is within a Zone I of a public water supply well: The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. _ The system has a septic tank and soi; absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a'well water'analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm• D] SYSTEM FAILS: I have'determined that the system violates one or more of the following failure criteria as defined 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: Backup of sewage into facility or system component due to an 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. (revised 8/15/95) .2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A Propertyy'it, D C..r r e-s Owner: l ,ij'�(.[) Date of Inspection: D) SYSTEM FAILS (continued): Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. 6-/ Liquid depth in cesspool 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. 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. fy Any portion of a cesspool or privy is within 50 feet of a private water supply well. /y Any portion of a cesspool or privy is less than 100 feet lbut 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. El LARGE SYSTEM FAILS: - The following criteria apply to large systems in addition to the criteria above: _ The design flow of system is 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: 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' The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. �x (revised 8/15/95) 3 SUBSURFACE�SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property, ddress: 70 Cc rriN, L -+� w Y, C •�i.T , Owner: "wi co Date of Inspection:. Check if the following have been done: Pumping information was requested of the,owner, occupant, and Board of Health. 1- 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. /`A"'As built plans have been obtained and examined. Note if they are not available with N/A. vThe facility or dwelling was inspected for signs of sewage back-up. ZThe system" does not receive non-sanitary or industrial waste flow the site was inspected for signs of breakout. III system components, excluding the Soil Absorption System, have been located on the site. .,�iThe septic lank 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. _,_-We size and location of the Soil Absorption System on the site has been determined based on existing information or approximated_bnj non-igyusiye methods.. _ hcfaCi;i;� .•r. ; ;! occ ,p�:;>, i d f'cre f•n-r ov.nc' were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 8/15/95; 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property. ddress: '70 �t�;;r r... L r. e- L,.rv-y Owner: Date of Inspecti9ru FLOW CONDITIONS RESIDENTIAL: Design flow: -5JO sallons Number of bedrooms: _....___. ...._.,.w. .. Number of current residents: Garbage grinder (yes or no):_ Laundry connected to system (yes or no):—YL Seasonal use (yes or no):t Water meter readings, if available: i✓�W Last date of occupancy: vc�c,( COMMERCIAUINDUSTRIAL: Type of establishment: Design flow: zallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no),. Non-sanitary waste discharged to the Title S system: (yes or no)_ Water meter readings, if available: Last date of occupancy: ' OTHER: (Describe) Last date of occupancy. GENERAL INFORMATION PUMPING RECORDS and source of information: / s -ter)c:; C/2 -= System pumped as-parr•of-inspection:-(yes or no)_ If yes, volume romped. gallons 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) Other (explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: /(�T� Sewage odors detected when arriving at the site: (yes or no)L7 (revised 8/15/95) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property- dress: 7 r> L r�'r c.S L r e Owner: \ �kt.A t.:�) Date of Inspection: SEPTIC TANK:_ (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP —other(explain) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: 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: 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:( (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP —other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom hnttor^ O! OU!�P! tee O, bailie' 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.) (revised 8/=5195) 6 SUBSURFACE SEWAGE DISPOSAL. SYSTEM INSPECTION FORM 1'Alil 1' 1`VI IM IIVl.t1IlMAlIl11V (iunlfi�uidJ t Property Address: 70 C<<rV, Owner: t c�r�1 c.p Y Cw i i —Date of,Inspection: .._._....__...___......_.. - S. OSAI qRT t TIGHT OR HOLDING TANK:— (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP_other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm.level: Comments: ' (condition of inlet tee, condition of alarm and float switches, etc.). DISTRIBUTION BOX: l� ' 01 (locate on site plan' Depth of liquid level above outlet invert: I 1/0P.2tS t� Comments: mote it ievei and dtstributiw: tq,, cI1dlcnCE Of iul-J., evidence of leakage into or out of box, etc.) PUMP CHAMBER: (locate on site plan) Pumps in working order.(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 8/15/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property A dress: 70 Cci/l�`t- L-e c`it..�,. s`'�'•`:�, Owner: r-, -I ".(:) Date of Inspection:,- �. �• SOIL ABSORPTION SYSTEM (SAS):L� (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number: leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) nl%QD 62 CESSPOOLS: (locale on Sit(- 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 groundwatc inflow (cesspool must be pumped as part'of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: r (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.) (revised 8/15/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 7 0 Cc: r r I L-e- co Y I I l p Owner. lr�i„�l Dale of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or,benchmarks locate all wells within 100' I DEPTH TO GROUNDWATER Depth to groundwater: /d feet method of determination or approximation: ^��C%7`Z, '! i < n'i r:' (revised 8/15/95) 9 THE COMMONWEALTH OF MASSACHUSETTS BOARD�jOF HEALTH \� - Oln!--..N-...-.-:..-.OF.-.....4�c^.r 0"'..✓���'�................................. Appliration for Diipoottl Works Tonstrur#inn Vamit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: _�>o Location((Address-1 or Lot NQ- .................... Q...f�..........r f JC{\2.t 3.�, -_-___---•---------- ------_-_-•-••------•- �' ✓ Cs.......�.................................. -- -- `Q�f-- ._._� 5. w w c S=-- -------------- ---------------- Installer Address d Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms.__ ________________________________Expansion Attic ( ) Garbage Grinder ( ) Other—Type T e of Building C?___.___._.. No. of ersons____________________________ Showers — Cafeteria a yP g ----�- - P ( ) ( ) aOther fi�x�t -- --------- . --------------------------- -------•-•---------------____--•----•--•--------•--•••-•------------------------- - - - Design Flow____._.__ __________________gallons per person per day. Total daily flow..__.-�_ _�..................gallons. WSeptic Tank—Liquid capacity............gallons Length__________ _____ Width------_-------- Diameter................ Depth................ x Disposal Trench—No_ ____________________ Width_______j_.__........ Total Length.................... Total leaching area....................sq. ft. Seepage Pit No........(............ Diameter_____..k_0....... Depth below inlet_...(a.......... Total leaching area..................sq. ft. Z Other Distribution box:(. ) Dosing tank ( ) Percolation Test Results Performed by-------------------------------------------------------------------------- Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ G4 ----------------------------------••--•-----------------•-----•---•---•--------......--•----•--.............................................................. 0 Description of Soil.........................................................--•---•-•---------------•---------------------------------....----•-----------------------------•------_••---- U •-••--•--•--••-•----•-•••-••--.._..--•--•-••----•--•••-•-•.............•-------•--•-----•-•••-------•--...-----••-••--------•••-------•------•---------•-•------••---•..._.._•---•-•-...••---•--•_•-•- W -•--•--------------------- ----•-----•--•--••-----------------••---•---•--------------•--•-•-•-------------•--•----------•----•----.._-----•-•••---•----•-•---•--••..__._...-----•------•-••------•- , VNature of Repairs or Alterations—Answer when applicable__ ......N= ..:_.:_.L -._ �. 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 ham b t boar aft Signed .......... ---•----_._.. ` ('O � Date ApplicationApproved By.................................................................................................. ........................................ Date Application Disapproved for the following reasons:.............................................................................................................. .................•--•---.___....---•-----•--•-----•--•----------...--------•-•---•--------......------....__....---------•-•----...-•-------•--------•------•----•-•-----...--•••---- •----•------- Date PermitNo......................................................... IssuecL....................................................... Date l-- ----- ----- ��_�__��-------------- --- ----_-- ---- - ----------------------- ------ J f' s No......................... FIc$.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...................... ............----....OF............................. Appliratiun for Diuyuual Works Tonotrurtiun :.ermit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: �Location-Address i or IfotNo. ..... ............ ............................. 1 .V Gr.�!.. .. .�.,..... ......................... O n Address Installer Address Type of Building Size Lot............................Sq. feet 0-4 Dwelling—No. of Bedrooms..... .................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) < Other fixtur ----------- -------------------------------- ••--------- I----------- •----------•-------------------- -----------..... ------- w Design Flow.......... .................gallons per person per day. Total daily flow--•_---�_ .. .................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. l Seepage Pit No_____________________ Diameter.....�0_....... Depth below inlet.....a............ Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by---_-----------_- ..................................................... Date........................................ 1--.1 Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ fs, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a --••--•-•-------------- ................................................................................................................................. O Description of Soil.........................................................---------------••----•-----------------•--------......----...----------------...-••-----...........-•--•---•• x w U Nature of Repairs or Alterations—Answer when applicable..__. ------N_ ..... ..... '= a ' , .------DQ------�p------------------------------------------------------ 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 Complia a as been iss t board f Signed •--- ---•............. I�..........................l � --•... Date ApplicationApproved By.................................................................................................. Date Application Disapproved for the following reasons----------------•-•-••----------•----....----•-------------....--------------•--------•----•-••----......_....._ -•---•------------------------------------------------------•----•--•-••--------•--------.........--•---.••------....--•--------------••----•-••---•-•-------------•--•---------------------.....__.._._ Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 1 �` ........� O La-?.�........OF............. c�y..r .7 F. C' ................... Tntifiratr of Tomplianre THIS O CERTIFY, Tha*-tl�n ,vidual Sewage Disposal System constructed or Repaired ��CC g P �' ( ) ( ) G.__......e. -----.G...----.•--•- -----------------•.......•=---------------••-.........._..-•-----------•------.....----•---•-•-.... by....................... -•••-•. Installer C at...... ....••---..`..0........C.—C 1 c� O.S�cu �:, '?,............................................. has been installAd in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......................................... dated-------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................. ) ................................ Inspector......... THE COMMONWEALTH OF MASSACHUSETTS -•�-- BOARD OF HEALTH �5—IJ7� `... ... ............OF..... .�^ 5 .................................... No......................... FEE........................ Disposal Works To U In Permit Permission is hereby granted...-_ �.. �'� Y....... . to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at Nod Z�......... �-(L.. ......C ............. —..................... 5`i ev c..�� 2 f Street ZS I J1�. l ::'� •a �..... as shown on the application for Disposal Works Construction Permit No........ Date ......................................... ............................... .....L.................................................. ... Z Board of Health DATE..... •. ...............•-----... FORM 1255 A. M. SULKIN. INC.. BOSTON LOCATION SEWAGE PERMIT NO. _ . '7 O w!�f 7 ems- I 1 � 0 VILLAGE ��-� A -• � �, � b0 � O�� <, INST ILER'S CN_AME & ADDRESS R U I L D E R OR OWNER -q v DATE PERMIT ISSUED t �l� 7S DAT E COMPLIANCE ISSUED lZ _ �� _ �• At Z � 1 1p � r Fosb . I � 8 ` ' G � C 7T f r' No......................... .............................. V bIV, THE COMMONWEALTWbO MASSACHUSETTS .v BOARD OF HEALTH _ Appliration -for Bitipmal Workii Cnnnitrnrtion Vrruift Application is hereby'made for a Permit to Construct "Q or Repair ( ) an Individual Sewage Disposal System at: S--•--_l�)( ....... ...... Ek. 'A x .......................................... Location.Address jP or Lot No. -> --E--c--.... ........................................... 5.[_ .4 _.......... ........................................... Address VET©rz.-N4--- °zxi f?.S_------------------------------- ..... .................... Installer Address d Type of Building Size Lot_.NC 9'_13--------Sq. feet U Dwelling—No. of Bedrooms-----------5______________ _____________Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Q' Other fixtures _______________________________ __ W Design Flow................... -...5-.-gallons per person per day. Total daily flow............. --_--_._--.-_-_.-gallons. WSeptic Tank—Liquid capacitAPPP--gallons Length________`_f----- Width...$......... Diameter__,---_.-.-.---_ Depth---------------- x Disposal Trench—No- ____________________ Width..--___-_-_-_-_-_--- Total Length.................... Total leaching area-----.-.............sq. ft. Seepage Pit No................... iameter-------------------- Depth below inlet-------- _ T tal leaching area---_a�._- ----sq. ft. Z Other Distribution box (' ) Dosi tank ( ) — L '—' Percolation71P— Test Results Performed b �--!.-. !FFD___________________________________ Date____. .�-�`' Y-- - - `�a Test Pit No. I...;�.........minutes per inch Depth of Test Pit.._l'�i.°....._. Depth to ground water.-1.)O►,E----_--- (i Test Pit No. 2................minutes per inch Depth- of Test Pit-------------------- Depth to ground water.-.-.-.--_.-------_-.--. 9 ---------------------- -----------------------------------------------------------------------------•-------------------------------------------------------- 0 Description of Soil--------G' ..------. ....4,---zUEU .-?1-L--------- ...... -f. e----- aob-------------------- x V W VNature 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 Article XI 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. \� 4 Signe ..... ----•-----------•--•------------------- ------------Da----------------- !fie Date pplication Approved BY---- ------- - 1� . ....---------•--•-- -- � . Application Disapproved for the following reasons:............................ -•----••------•.............................................. Date ......------. ------•--.....-----•----------------- Date PermitNo......................................................... Issued...N__Y�........................................ Date No............ r+�` Flnc...................::..:..... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ....... Af� .�...R-. ................. Applira$ion -for Bi,ivagttl Workii Totti5$rur$iott Vrrtlii$ Application is hereby'made for a Permit to Construct ) or Repair ( ) an Individual Sewage Disposal System at: Location-Address or Lot No. Owner Address Installer Address Type of Building Size ::-ate_9-13 9- ._-____-Sq. feet Dwelling—No. of Bedrooms..----------5.'_____________________________Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ____________________________ No. of persons...___-__--_________-__--.-_ Showers ( ) — Cafeteria ( ) 44 d Ott-ier fixtures ------------- ------------------------------------ .................................................... W Design Flow_________________________________M __gallons per person per day. Total daily flow............ ----_--_-__-.-.--.-..gallons. WSeptic Tank—Liquid capacity k-�_=_ ---gallons Length--------14..... Width---8.. ...... Diameter---------------- Depth__._-__---.... x Disposal Trench—No--------------------- Width-------------------- Total Length----___-_--__-_--- Total leaching area--------------------sq. ft. Seepage Pit No.................... aDiameter._.___-______..__-__ Depth below inlet_..G________ � 4 _TQtal leaching area. � ----sq. ft. Z Other Distribution box ( ) - Dosin tank ( ) ( - - - , Percolation Test Results Performed by.__ .__ ►'� ------- Date Date-----el, - ;z_-' 71- -------------------- Test Pit No. I---�---------minutes per inch Depth of Test Pit.._I_ �!-"....__. Depth to ground water...090-_--.----- fZq Test Pit No. 2................minutes per inch Depth of Test Pit_----------------- Depth to ground water------------------------ Ix --------•---------- .................................................... Description of Soil--------`�' ....60 !iQAkj...A...-. -------- -- I ..... i rU Q�------------------ x U --------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------- 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 Article XI 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. Sign--',,.... /.................... -.,,:_ •--------------------•--------•-------------CDate Application Approved BY----- � �� �<.�s�( '._c -=------ -`-- = Date - Application Disapproved for the following reasons__________________________________ ---•_-•-••---••........................................... _______....... ...................................................... --•----------•--•---------------------------------•---------------- .....................------------------------------------------------------- Date Permit No......................................................... Issued...... 27 Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...... .l�s..........OF.... 3E��1 . T ..................................... OVITrr$ifira$r of TOmpliaurr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( V<or Repaired ( ) at. Installer �----- F;� ' t ..�� �_���_���.�-r,.�------•------------------•-----------•- has been installed in accordance with the provisions of : r iii X� of The State Sanitary Code as described in the application for Disposal Works Construction Permit No__ ________ __ __-`3__.:...._.._:. dated- ........................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WIL4 FUNCTION SATISFACTORY. DATE....... -•••--•-•-••-•--•--_..... Inspector----- -----f/. � f --------•--------•-•---------•--•---•--------•--- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH � ., No.............r'......... FEE........................ Permission is erebY granted_.._._��job Iu- ----_ -- -.._ -' .. : --------------------------------------------------------------------- to Construct ( or Repair ( ) an Individual Sewage Disposal System ------------------------------------------- at No-------LJOT.._ '. ._ ...... •A.' e�-"-- - Street as shown on the application..for Disposal Works Construction Per. -'t No____ ___________ _ Dated- �� ?� Board of Health DATE-------_----- -------------------------------------------------------- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS - LOyCATION `� SEWAG PERMIT NO. . 1,07 02 Q C4f�/1 VILLAGE /_ INSTA LLER'S NAME ADDRESS L/LjLD�2I%v 'k d 5 F B UILDE R 0 OWNER 6m ti 11 DATE PERMIT ISSUED `as --7 DATE COMPLIANCE ISSUED �.z - 7 - 37 0 w TE -,V 7 I SU050/L • G' �� i c A N JrTEsr ,�;r� 5+� , RESERYL ®wi�'Mi(�l '�{�" is"44 _1 ELe V /(D 7 0/57 QOr No WATER ENC_J )NTER":D � TOWN WATER 15. AVAILA3: r A4/iv/1L4w._11. ✓. /3 u/LD/nrG S ETL-3�1C� � ram - SC�4 L E — qO P2 0,ao SE.D SE P T/C 5 Y5 T&M 'DONS T2 UC T/ON . E3 E'D�OoMS SHALL CONF02M TO .v/,q 5•S FL O!,t/ EN✓/,20n/n4E/�/T,4L COOS. T/rLL ]� � GAL/L7A Y �EYISEJ 7--/ - 77 r I-{f;»'n, � .. :; r., LEACH 2.4TE C 2 1 M/n/. //VCR,/ 70P OF HEAz_T/L/ )2z CULA,T/OHS RE UI.eED•LEEICN A4254(3��� .02 O.po S U------------- 2 ..OF pE xt STOVE MA�/f1OLECo✓�Iz TO T �MpE2V/OC/S C t/ X E A!D TO O E " W/ TN//V / OF F/^//SyE-17 GT'A D TO..a2E✓ENT /A/C • F20i�-1 /�/F/L T2A T/it/6 .r•" 13 ; Z¢..GO✓GrZ,S _ rD/57" STO/vE i0 I / 3 Co ov,�,�,� ✓E.Z 2% G�pE. at/E 6"nn i wJ Pi r M/N/MUD - -—-✓ 3"M/Ai 4�. D/A. VATF.Z, 'A ��� r�/TCf/ FLO/u Lin(E^�` Al/N' RiTCf/ / T 4' 01A. _ t.C, /O LL- gc,ci � 4 MOOT 2.. Aloc /n/ �/re //vv�r GA L�O�/. . , -�-- G i S ro/vE /NVf..2T CA PAC/ 7 )C /.V✓E eT (9 ,4 SE oT/G AA/•e AJZDUNO 1 5. 3 CWATG TIGN?/ /Nt/E.�T Q� $027bi4 OF, NO GA,e,5AGE' iMUA4. Lam" ✓' ��j pf Loc�tTlo/v a + ?► ��A' 3`t �CERf]' RViLL E) M A 2EfE2EAfCE ,- A p7r/G TAA/.� S .2iBUTiOA/ 80X �/ T �/T T E TE 3000 .as/ 7. dry` r' 20000 E3.Y' �. l'C'-�-' ':• .. T,�t '�t;." ' h/-!'O L OA D IliG - ., , `rye v� OVA Y NO T TO 5 G.0C.A 7-E,D .4 �/v1 Q U 7��7.-77"/ '.A-),4- : - O I/E.e S YS TE M Un/L�5 5 �/- 2O .UE S/GAJ L.OAL_)//vG' /S USE ID, T CERT/FY THAT THE 0UILDliVCr' Si�'p; J!�. ON r.1 ,16.��xir N; Tfli.S PL Hf� 7S ' LOCA'TEI� CAN THE - GR: f,=N1? ,�_ , rJR -_ '75Sf/t i,J/11Nt1. 1T DiZ5�7_ r OUIL IN& S,cTJ3 s tC ?tQw`/tt'fi/�E�,y,7sTHc TOWN O r. QA:�t'1V$7All"L �'� D� TE. AI E.,4 L TA/ 4<3 7-