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HomeMy WebLinkAbout0071 CENTERBROOK LANE - Health 71 CENTER BROOK LN. Centerville A = 172 — 244 I �w N SMEAD KEEPING YOU ORGANIZED No. 12534 n 2-153LOR `YJ��iR�� MIN.RECYCL' E-p- 7 CONTENT10%® Certified FiberPOST-CONSUMER �nvwsfiprogrem.org SFh014G0 MADE IN USA GET ORGANIZED AT SMEAD.COM Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 71 Centerbrook Ln. 3> Property Address t <: Patricia Menieil ' OMmer Owner's Nameirrfor required y Centerville MA 02632 12/16/2016 Pap- City/Town state Zip Code Date of Inspection W t?7 Inspection results must be submitted on this form.Inspection forms may not be altered in any way.Please see completeness checklist at time end of the form. 'mom When filling ad foils A. General Information ts on the computer, use oNy the tab 1. InspedOr key to move your cursor-do not Paul Martin use the return Name of inspector key. Cape Cod Septic Services VQ 350 Main St Company Address W.Yarmouth MA 02673 Cityrrown state Zp Code 508-775-2825 S15016 Telephone Number License Number B. Certification 1 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 ❑ Fads ❑ Needs Further Evaluation by the Local Approving Authority 12/20/2016 Inspe Ws 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. t5ins•W 3 Title 5 Of el kqWWW Form Stbasrace Sewage Disposal System•Page 1 of W f f Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments G M ,•''� 71 Centerbrook Ln. Property Address Patricia Merriell Owner Owner's Name information isequired for every Centerville MA 02632 12/16/2016 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: System in.working condition. 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 Form:Subsurface Sewage Disposal System•Page 2 of 17 r Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "t 71 Centerbrook Ln. Property Address Patricia Merriell Owner Owner's Name information is Centerville required for every . MA 02632 12/16/2016 page. Cltyfrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed . ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board'of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 5.0 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3N3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 1 1 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 71 Centerbrook Ln. Property Address Patricia Merriell Owner Owner's Name information is required for every Centerville MA 02632 12/16/2016 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 aseptic 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 ❑ Z. Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invertdue to an overloaded or clogged SAS or cesspool 0 ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments V•y'. 71 Centerbrook Ln. Property Address Patricia Merriell Owner Owner's Name information is required for every Centerville MA 02632 12/16/2016 page. Cityfrown 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 ❑ D 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•3/13 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal$ stem Form Not for Voluntary Ass essments 71 Centerbrook Ln. Property Address Patricia Merriell Owner Owner's Name information is required for every Centerville MA 02632 12/16/2016 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? Z ❑ 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):' 11 Ox3= 330gpd t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Officiale Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 71 Centerbrook Ln. Property Address Patricia Merriell Owner Owner's Name information is required for every Centerville MA 02632 12/16/2016 page. Cylrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection information in this report.) ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): 2014=208gpd Detail: 2015=288gpd Sump pump? ❑ Yes ® No Last date of occupancy: Current 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 r Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 71 Centerbrook Ln. Property Address Patricia Merriell Owner Owner's Name information is required for every Centerville MA 02632 12/16/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: No Records Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system, ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System+Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,.•'°� 71 Centerbrook Ln. Property Address Patricia Merriell Owner Owner's Name information isequired or every Centerville MA 02632 12/16/2016 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: 1985 Per BOH records. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer,(locate on site plan): Depth below grade: 34"feet Material of construction: ❑cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: +10' feet Comments (on condition of joints, venting, evidence of leakage, etc.): Line checked with sewer camera and was found to be clean, properly pitched with no sign of root intrusion. Septic Tank(locate on site plan): Depth below grade: 25"feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene El 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: 1000Gal Sludge depth: 6-81' t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ' M 71 Centerbrook Ln. Property Address Patricia Merriell Owner Owner's Name information is Centerville required for every MA 02632 12/16/2016 page. Clty/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 A Scum thickness 2-Y,1 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Estimated Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 1000Gal H-10 tank in good structural condition. PVC tee in place on inlet with concrete baffle in place and solid on outlet. Tank at normal operating level Covers 6" below grade. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene El 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 71 Centerbrook Ln. Property Address Patricia Merriell Owner Owner's Name information is required for every Centerville MA 02632 12/16/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ` ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level.' Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches; etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 71 Centerbrook Ln. Property Address Patricia Merriell Owner Owner's Name information isequired for every Centerville MA 02632 12/16/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): H-10 DB-3 with 1 line in and 1 line out in good condition. Box is clean and level with minimal solids carryover. No sign of overloading or hydraulic faiure Cover 24"below 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.): * 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 Forth:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 71 Centerbrook Ln. Property Address Patricia Merriell Owner Owner's Name information is required for every Centerville MA 02632 12/16/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1-6x6 ❑ 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.): 1-64 Leach pit with stone. 1' of effluent in pit at time of inspection. Stain about 2'. No sign of overloading or hydraulic failure. Cover 28" below grade. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer ' Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3l13• Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,.•�''r 71 Centerbrook Ln. Property Address Patricia Merriell Owner Owner's Name required fo is every Centerville required for eve MA 02632 12/16/2016 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14of 17 Commonwealth of Massachusetts. . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 71 Centerbrook Ln. Property Address Patricia Merriell Owner Owners Name information equir for is every Centerville required for eve MA 02632 12l16/2016 page. Cityfrown 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 71 Centerbrook Ln. Property Address Patricia Merriell Owner Owner's Name information isequired or every very Centerville MA 02632 12/16/2016 page. C4rFown 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: +12' 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: Hand auger to 12'with no water encountered Bottom of pit at 8' i Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 71 Centerbrook Ln. Property Address Patricia Merriell Owner Owner's Name information is required for every Centerville MA 02632 12/16/2016 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 + w �.� � Z �¢ y �� �3/ �G 1 � l � �_�� . _ �,_~ � .. ;...,,. . �...,.. ._,. .. sr�.. .�...�.. e ��,�-cb�cc �- �ir,� � L 4 4,Lq No ............... THE COMMONWEALTH OF MASSACHUSETTS ,------BOARD F HE LTIJ ---------------------------- Appliration for Dispatial Works Timotrurtion Famit Application is hereby made for a Permit to Construct ( L,).,6r Repair an Individual Sewage Disposal System PLA.- Loc.at' Add s ......... lt_O 11Y.1 1C .. ........... ------------------------------------ ... �wne1 Address ................. !t�.c.........................................0--------- Installer Address qq aY Type of Building ize Lots[_ --- Sq. f e ?ag Grinder U Bedrooms__.___ ________________________________Expansion%I................................Expansion Attic e Dwelling—No. of Bedroo Ga:rf Other—Type of Building ............................ No. of persons............................ Showers Cafeteria Other fi=rtL----------------------------------------------------------------------------------------------------- 'l ---------------------------- Design Flow............. ................gallons per person per day. Total daily flow........ —T ..I.........&.....................gallons. IY4 Septic Tank—Liquid capacitY4.60Ziallons Length________________ Width_.___._._-_.__.. Diameter__.__-_-______-_ Depth______.______._. Disposal Trench—No_.................. Width.._.._.__._._-._.._. Total Length.___._______...._.__ Total leaching area....................sq. ft. Seepage Pit No_____________________ Diameter.____.__._....__._._ Depth below inlet___.._______________ Total leaching area .......sq. ft. Other Distribution box Dosing Percolation Test Results Performed by...Dosing 4-j5 ZZW. 1— /7. Date---- Test Pit No. llle3� minutes per inch Delj�' Fest D to ground water 5-------- PtIM, s 44 Test Pit No. 2 rk&l.,�Lniinutes per inch Depth of Test Pit_/�------­ Depth to ground water-- P4 .......... y ..................... ......... .............................................................................................. 0 Description of Soil.. --- .................................................... ............................................ V%/I _ '0­ jirr4, ..... .. ;�w-------------------------------------------- .......................... 2�5K. . .... . .... , U ................................................................................... ----------------­----- 70... . ........ -- ----- U Nature of Repairs or Alterations Answer when applicable................................................................................................ ......................................................................................................................................................................................0............. 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 be issued by th and of heal,D 4-:t!jW- ­ ------------------------------- Signed ate=49 Application Approved By............j<SAAAQ %5 ...........0...................... ........ Dale Application Disapproved for the 9ollowing reasons:................................................................................................................ ......................................................................................................................................................................... ............................... Date Permit No.......q�!GS..................o.......... Issued_____________ ............. .............. Date THE COMMONWEALTH OF MASSACHUSETTS �0AR® F HE LT . .............OF.. :. .. .......................... Appliration for Uhipas al Works ( omitratrtion JIrrutit Application is hereby made for a Permit to Construct ('L,).-or Repair ( ) an Individual Sewage Disposal System t 6. ------- Of Locat�pm•Addresse Noj r t'^ �wn Address !t?'�e.4._0�:-��-W1.................................. ------••--------------- e`� •-----•--••----------••--•--------------•- Installer Address qq 33 d Type of Building Size Lotz _t_..�._ __Sq. feet U Dwelling—No. of Bedrooms_._...................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building No. of persons............................ Showers a YP g ---------------------------• P ( ) — Cafeteria ( ) A4Other fi--$jures .........................•-•-•••--•--...••-----•-•--..•-•------•-••-•---•••-••-•-----------•---•----••--- ------- W Design Flow............. .. ................gallons per person per day. Total daily flow------- 4.....................gallons. WSeptic Tank—Liquid capacit�.4b—Gallons Length________________ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area.................sq. ft. Z Other Distribution box ( ) Dosing a Percolation Test Results Performed by__ .._. _ l �_ ... _.`?`. t/l.C:'�f-1,t7_ _._. ..Date.... .� __ r� _._____.... Test Pit No. $' � minutes per in Deptl't- f Test 'lit tt -1..... De i to ground water.____..____ LL, Test Pit No. f�ok4_ _"_"minutes per inch Depth of Test Pitf. ......_.. Depth to ground water... .......... ..........................................................I....---.....-•----.....--------•----- Description of Soil. tJ - r 4 !F _ ----------------- ----- ------------------- --- -- V „ _fC ----------------•........------•---------••. '. W -- f�/ c ------- / C'f,,lf_1' . -t4�' c,� t�a� ------------------------------------------- UNature of Repairs or Alterations—Answer when applicable................................................................................................ . --•-- -----•••----•••••-•.........•••....•-•------------•-•-••-•--•-•-•---------------- Agreement: The. undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITIE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be issued by the and of heal p t Signed . . _ ._ D to Application Approved By-•••-•-••-• -'I _.---- Date Application Disapproved for the f .lowing reasons:----•------•••---•------------•---------------•-.....-•---•-•------••-•......•-•----••-•---•--------------•---- -•.......•------•---•.................•-------•-----••--•••••....-------------••......-------••...----•-. r ................................................................................... Date Permit No. � `` � y-------------------------_.. Issued_:----------�`�. _t..�'. ................. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEA TH r.1................oF.... tl! �/ / ...........------•............. Tatifiratp of Tutttpliattrr s IS TO,� RTIFY, h t the Individual Sewage Disposal System constructed (4006r Repaired ( ) G .................................................. , .. ........... ._.._.. l InBE$Iler has been installed in accordance with the provisions of TIT F 5 of The State Sanitary Code s d cribed in the application for Disposal Works Construction Permit No.................... .......... dated___..._. ► �f THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL UNCTION SATISFACTORY. . -- DATE......... ...� al......................................... Inspector.............• � �-•----•-----•---•- i f THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HE T 0 F ,,,C�d` ! ................... l" .. �'r.................................... No........5='D3�S' FEE-•YZ............ Dispopal Work . VIM/T wit rrattit Permission is hereb ranted_ _ _+Lt_ 'P ':�.. 1.. --------•------•-------------•------•-•-•.......---------........................ y g LT to ConstrYt or p )fan Individual S wage Disposal System Street C, 115 as shown on the application for Disposal Works Construction Permi .e�-t N _1�� __ Dated.._... _"'.1.5'� ........ --------------------------------------------------- DATE oa f Health �-�� ------------- FORM 1255­A. M. SULKIN, INC., BOSTON fz. Jh, I lop 51 ;v sr s� a Y S A' �(,\ Et- �/� 17 �',�"w.,V."i '. 'rv:f' S /"..•'^`.F'"4rys'� A t j Ykr,:�P�y' tEs:� }aYl,f �' '! d� _ �v [� � � .!•4 .i iA � •t A; .�7rP�.Y�r 4 .�I 5� cy J ti rz lGJ-t�/77 oNS Fb/L Sa. F.r�, y�rrk 1 " 61 Zrt 2 19 i -re T L n TD4O,,t7—. 3 T �. 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