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HomeMy WebLinkAbout0118 ELIJAH CHILDS LANE - Health 118 Elijah Childs Lane Centerville A= 171-248 SMEAD No.2453LOR UPC 12534 amead.com • Made in USA W wwwwiHSFROO alm S�URONCt S[I MEfT51FESW10CN0�J�M905 f OFMSRFMOAM CFRfIFIED No. � 66 FEE 1 COMMONWEALT14 ®F MASSAC14USETTS l Board of Health, �d�sd/cam MA. APPLICATION'FOR DISPOSAL SYSHM CONSTRUCTION PERMIT Application for a Permit to Construct Repair( ) Upgrade( ) Abandon( ) - ❑Complete System ❑Individual Components Location 'G Owner's Name Map/Parcel# j Address >d h^c Lot# Telephone# Installer's Name '. b- Designer's Name Al Address �/�^WA4, 14 Address Telephone# r Telephone# Type of Building /' i C/l°w iG Lot Size sq.ft. Dwelling-No.of Bedrooms Garbage grinder ( ) Other-Type of Building No.of persons Showers ( ),Cafeteria ( ) Other Fixtures y� r Design Flow (min.required) gpd Calculated design flow X?C? 40/) Design flow provided I�r1V1G gpd Plan: Date Number of sheets Revision Date Title Description of Soil(s) Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS iCe/ l—e ems,/ o,;& �ad- The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to goL49 place the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date 0% l Q)c Inspections J"'�'" .. yq�'"''�"""►,•'" ^-,"yer,x'r••r;«..-�sr,'+,.�-+sc a+* w ,1�+- ,,.,�,�;,�'*� +� r, Y�6„t.`;, ,,,.,, w q�M.f'k'j�;�''tiR� �'l►'�`�,....i"`y" rt;,..p+``^"'cr"r• No.,?vIt ( 60 Y're I �'I IG FEE CO I� ,r , Bard of Health,�S��i��P MA. i APPLICATION F® DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct Repair( Upgrade( Abandon( - ❑Complete System ❑Individual Components R Location P �'1� t d Owner's Name 3 ►M e Map/Parcel# O -� Address Lot# Telephone# Installer's Name / Designer's Name Address o4 A Address Ilr d. 1 w rG/ADD✓�� Telephone# Telephone# Type of Building /��c�!'vtTidf �.� Lot Size sq.ft. Dwelling-No.of Bedrooms -rkv eig Garbage grinder ( i Other-Type of Building No.of persons Showers ( ),Cafeteria ( ) Other Fixtures Design Flow (min.required) gpd Calculated design flow 40 Design flow provided e1~1 Sf l It Plan: Date Number of sheets Revision Date j Title Description of Soil(s) j �i Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation ; DESCRIPTION OF REPAIRS OR ALTERATIONS i= The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to n .t t place the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed ...,- Date Qt I .20)C Inspections b _ -.� _ _ ,. <-�-�- .-a�'�•�_.�--._ - ,.._.ate-e-,-.a-.� y--¢�-a r>-4-..t �..-s-a. ,a .� _ _..-� -� t---— -.. _.-..,_�--�._------J No. O J U 66`( FEE I COMMONWEALTH OF MASSAC14USETTS Board of Health, Ra/11,S - ,MA. CERTIFICATE '®F COMPLIJ -7..----- Description of Work: ,E ndividual Component(s) ❑Compel te-S`ystem I The undersigned hereby certify that the Sewage Disposal System; Constructed O;Repaired ( ),Upgraded ( ),Abandoned ( ) by: �;l�f��r / an/� �'zr✓J .T� A t_ • �' • u v y Y at I has been installed in accorda ce with the provisions of 3 0 CMR 15.00 title 5 1. /the approved design laris/a-built plans relatin to �y� ��( `o,�•) '� � pP t ,g P� s` P g. application No. a�fJ �{" dated '( Ap,�rovedesign/Flow i. (9pd� t Installer A t'lcP_.r k 1 ,..�r { /j Y j � � CCU e fib /. � A Designer: Inspector: ` (ArO/4 /�E (fLL' i, _ _Date:. /" W The issuance of this permit shall not be construed as a guarantee that the system will function asAesigned. / �^ No.,p O' C(—bc tl.. 4, 4--•- . ..�_, ..—.,.-__.R..F =�._�. _�_ yj O � FEE A V l/ r COMMONWEALTH OF MASSACHUSETTS Board of Health, J3�,�S�`X/J/� 114 1 'u �DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Rep Upgrade( ) Abandon( ) an individual sewage disposal system at �� ` �;, A rA . d _/ Asa ,. as described in the application for J Disposal System Construction Permit No. a©►uo'e , dated Provided: Construction shall be completed within three years of the date of this permit. = local conditions must be met. Form 1255 Rev.5/96 A.M.Sulkin Co.Boston,MA Date 1- ( �f Board of Health r ' � I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 118 ELIJAH CHILDS LANE Property Add ------__------��--- -- Owner JOHN DEM_E_LLO_/ ED_G_A_R FOU_ L_T_ON R_EALTORS information is Owner's Name _ required for every page. C_ENTERVILL_E ____ _ -- _ MA_ 02532 O_C_TOBER 3, 2013 _ 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: A. General Information When filling out forms on the computer, use 1. Inspector: only the tab keyG to m move your MARK L WHITE cursor-do not ---- _------.- use the return Name of Inspector key. BOUSE HOUSE ENTERPRISE Company Name reb 14C JAN SEBASTIAN DR Company Address — SANDWICH MA 563 ; --a City/Town State -- ,.,� 1 Code 508-962-0819 _ S_113381 Telephone Number — — — License Number "' CI. zo (.+') 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: ````` NoFi ��s�'fh �,.• S r ® Passes ❑ Conditionally Passes ❑ Fails 9'C �% o?' MARK yc�,, �c WHITE :0-4'_. ❑ Needs Further Evaluation by the Local Approving Authority No.S13381 CT , � F 5R NSp� OOBER 3 2013 ii CT - ----------- imm�uuua�--- Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system 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. 1"04V1 s3 t5ins•11/10 Title 5 Official Inspection Form. ub rface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): B. Certification (cont.) B) System Conditionally Passes (cont.): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh B. Certification (cont.) t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 T Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1h day flow B. Certification (cont.) t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a/ 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. 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 t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ❑ ® 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)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 3 Number of bedrooms (actual)-3 (design): DESIGN flow based on 310 CMR 15.203 330 (for ---------- example: 110 gpd x #of bedrooms t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments D. System Information Description: A 1000 GALLON TANK, 1- DB-3 DISTRIBUTION BOX & 1-6X6 LEACHING PIT Number 0 of current ---------- --- - residents: Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? [if yes separate inspection ® Yes ❑ required] No Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes No Water meter readings, if available (last 2 years usage (gpd)): 2011- 31000 2012-26000 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Sump pump? ® Yes ❑ No Last date of occupancy: 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? El Yes El No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: ------- - - D. System Information (cont.) Last date of occupancy/use: -- ---- - Date Other(describe below): General Information t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Pumping Records: 2012 , BOUSE HOUSE Source of information BOUSE HOUSE 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): D. System Information (cont.) l5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Approximate age of all components, date installed (if known) and source of information: 3/25/82 PLANS ON FILE AT B.O.H. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 26"— Material of construction: ❑ cast iron ® 40 PVC ❑ other (explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): INLET AND OUTLET TEES ARE IN PLACE AND MAIN LINE IS CLEAR Septic Tank (locate on site plan): Depth below grade-17" Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) INLET COVER AT 4" AND OUTLET AT 10" If tank is metal, list age: — years Is age confirmed by a Certificate of Compliance? (attach a copy of ❑ Yes ❑ No certificate) Dimensions: - - - Sludge depth: — -- ---- t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments t D. System Information (cont.) Septic Tank (cont.) 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 ' How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.) TANK IS IN GOOD SHAPE WITH NO SIGNS OF LEAKAGE AND VERY LITTLE SOLIDS Grease Trap (locate on site plan): Depth below grade: - ---- — feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: -- -- Scum thickness ----- -- t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 " Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 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 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.):. TEES ARE IN PLACE AND LIQUID LEVEL IS GOOD 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 ❑ Yes ❑ No attached? t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 ' <L\� Commonwealth of Massachusetts - W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert JUST BELOW INVERTS 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.): 1 INLET AND 3 OUTLETS IN D BOX, BOX IS STRUCTURALLY SOUND 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 13 of 18 • Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments D. System Information (cont.) Type: ® leaching pits number: -- ❑ 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. NO SIGNS OF HYDRAULIC FAILURE, NO DAMP SOIL. 28 inches to invert t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 • , Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 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 Ind ication of groundwater inflow o Yes No 9 ❑ ❑ 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 15 of 18 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 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 16 of 18 l Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 13+ --.-_. 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 PLANS DATED 12/24/80 ❑ 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: t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments You must describe how you established the high ground water elevation: TEST HOLE DATA PERFORMED ON 12/24/80 STATED NO GROUNDWATER AT 13 FEET Before filing this Inspection Report, please see Report Completeness Checklist on next page. 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 18 of 18 n c� �i kN C No.�.... Fns 9D .......... THE COMMONWEALTH OF MASSACHUSETTS BOAR® F HE TH .......... ............. OF...... ........................................ ( I Applirution for Uiipusal Workii Tomitrurtinn lirrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System ........ .-•----....... .................................. ........._..-- ---•-4�'•-. '. ....-----••-•-----.............•--- •. cation-Address or Lo �F! Address .------...... . -... ner --------------- --------•-----............. - --.....------------....--------.............. Installer Address PQ 14 Type of Building �_ Size Lot../ ...Sq. feet J�.. Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( V Other—Type of Building No. of persons............................ Showers — Cafeteria Q' Other fixtures ;_-----------••-•-••......-•-------- . ------•-••----•---•-........... W Design Flow...........L�� .`�..............gallons per person per day. Total daily flow.................. V.......gallons. 04 Septic Tank—Liquid capacity/ allons Length................ Width................ Diameter________-___-._. Depth................ Disposal Trench—No.................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No-------&X_ iameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ aTest Pit No. 1................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........................ P4 •-••-------•---•••••••-•••----•------•.............................................................•.......................................................... 0 Description of Soil........................................................................................................................................................................ --------------------------------------------- -------------=------------------------------------------------- -------------------------•----•--------------------------------•-----••-•-----•----._... V Nature of Repairs or Alterations—Answer when applicable............................................................................................... -------------------------------------------•-------•---------------•--------------------....------------•-----------------------------------......--•------------•--....----------------......••-••..--- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'T:S,id. 5 of the State Sanitary Code— The undersi ned further agrees not to place the sy tem in operation until a Certificate of Compliance has been iss ed by t oar of health. ,�r� igned. _ .. ems. ate ApplicationApproved By.... • •-• --•�......................••------...--••-----------------------•- 3 ... -- Date Application Disapproved f o th following reasons----------------------------------------------------------------•--------------------------------------••_••---- ------------------•------••••---------...----•-•-••--•----------•-----•--------•--------••-•----••.....•.-----------•-•---------------------•---•-•------------•-••-----••------••-•--------•--._....... Date PermitNo......................................................... Issued...................................................... Date NO S ,� .��.�. Fms.. ............ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..-......................_....._...........OF...................................-•.------..................................---------•- Appliratiaan for Uispm al lovrks Tonotratrtiaan ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ................__.............................................................................. ..........---••---•---••-•----•---...........-------•---------------------•------.........---••--- Location-Address or Lot No. ......-•.............._»...........---•-----------....-------•----••............................ ..........--...................................................................................... Owner Address W Installer Address dType of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) '_lPL4 Other—T e of Building _ No. of persons............................ Showers — Cafeteria a' Other fixtures ...................................................... 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. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ •---•------------------------------------•----------------------•------............-•-------.----••......................................................... 0 Description of Soil........................................................................................................................................................................ x �., w .......-----••-- UNature of Repairs or Alterations—Answer when applicable..............:................................................................................ ------------------------------------•-----•---•-•------------.........----------.............•-•-...................------------•-•--•--••-•......_..--------•---------•--•--•••......•............----- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT11.Z 5 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. gned........................................••----••----...........-----•-----•......•--• ---•- ---------- •---.---- to Application Approved B `" Date Application Disapproved fo th following reasons:............................................................................................................... --•..........................•-•-----••-......__.....•------•--------•-...---•---------•--•---•---.....--••-------------•---•-•-•--•--•---•-------••••--••-•-----•--•-------------------•--••--••••-•--- Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALT . i(,G�.........................OF... ! ................. (Irr#ifirtttr oaf Tuntph anre T 0 TIFY That the Individual Sewage Disposal S;stem constructed ((,,Yr Repaired ( ) -- - X •---•----- nsta�lef� --------------- has bee' nstalled in accordance with the provisions of TIT L 5 of The State Sanitary�od as�l gibed in the application for Disposal Works Construction Permit No.._ _"' ." ............ dated- ... _.. .. .�s..' ............... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE. .................................. Inspector...............S:71/ ................................................. THE COMMONWEALTH OF MASSACHUSETTS -- BOA OF LTH ..................... No.................... .kii Tomitrn#iaan aeranit Permissio i reby granted f `� to Constr ( or R�ep,�,lr ( ) �vidual ew po yO p� � 6 at No.. ........ ..... - ---- Street / as shown on the application for Dispo atl corks Construction Permit No...AA-d Dated...., .. .1�.. ._. !�":....... .............. 1 ...................................................... Board of Health DATE. ����$i FORM 1255 HOBBS & WARREN, INC., PUBLISHERS xadlL�( F'l�W 110 +� 3 • 'S=:O G•PV. i. .. ��'tc -f'C•►.114 ' =33o,r (r7C %•_.� ��?6.P.D. �a,p•P�. ; ' .; . .. (oa4 Gd_..: r'F•.•A ti l50 Ste. ,t�-r• i Ir�p •gF .c 2 s� • 3ZS 6.P-X% ! ; $OTTt7l(•t AZ eA s ,r:A sr-. i �9 t �' . . i•F„ 05'. i6t1 ,o r - • � TOTAL 'L'�t�S � d25 �..p n. -- -r-cTA t_ GmGOL.dT1O4l It ttJ 2.�r(ItJ•OR LESS. l Of N_ ' RtCHAFO r1!i. :A Ary S, A. S8.S ToP F•+o IL t jcX. Wrr. RG.N ... .. G.SB-O �.., 4• i�� f • 7 - i 4 / -eo Y. • SG I Inc t o e; I SAND�/ 1000 55 i5 �wK t�M. . t• ' _ FT • MC-ate �. . . . . .. . • .. _ � 1 • Pcw�•t Lam . . . . LoGATto� :NT�Q:�111-�E- 13 44Sl" _pd .Qa..-TM ( -�gZ WAS R� raV-s WcE GGCXTiF�f THAT' TOG- Fo�NT�l�T1laN5t.low►J t-1C:P_trnt,l GcaMPt_�l5 W ITIA TI ;Z; '51 DE-: Lt►-t� l--G+T'GZ..• ' ; . A/.lt� SCT��CIG VC-a .lt�.'CMcuTS OF T GEN' WILL �IGN1rI1 -To w v Or nAQN�ABt_� a•ub ! ECT; .'� .. 57 LOGA,TEb• WI 0,4 `C4X-- t✓L.0Ob PLAW. XT C-.�Z . u�lE t�JG. RG6j1;*MRED l•AwD 6UeVcYo2: "('t-Il5 t7t_A►-! t5 UOT k'�ASC� 064 AN INs�etJMc_wT 'W1Z'1t7-Y Ytac:. o�c,�t'% ,t tc,ww Apr>t_I -n.►--j-r &.L t-J X-L- 1 NG• LOCATION SEWAGE PERMIT N.O. L �-v : - 13 VILLfAOE I N S T ER'S NAME i ADDRESS l 92 GUILDER OR OWNER S If DATE PERMIT ISSUED DATE COMPLIANCE ISSUED 7 A��