HomeMy WebLinkAbout0052 FOX RUN - Health 52 FOX RIJN, CENTERVILLE
A= 227152
i
UPC 12534
No.2_153 ORq� s
HASTINGS,MN
DATE:_2/jA:196 ,
PROPERTY ADDRESS: 52--F( x Run ,
Centerville ,
Mass'.
On the above date, I inspected the septic system at the above address.
This system conalsts of the following:
1 . 17-1500 gallon septic tank.
2- 1-Distribution box.
3. 1-1000 gallon leaching pit.
Based on my lnt�:,action, I certify the following conditions:
1 . This is a title five septic system. ' ( 78. 0ode• )
The Septie system is in proper workiMg ordv,
4t, t4R@ present time .
t '
SIGNATURE:
Name: J_P_M_acbmber Jr...
Company•_J.P_Macomber & Son_Inc .
Address:_-tie�c-�6-----=�--
Cente�rvill,eLMass ' 0.2.632 ' �4P ? -99
-- -- 6'
Phone:---SQ8,J75.-3338------- ., I
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
a
JOSEPH P. MACOMBER & SON,. INC.
Tanks-Cesspools-Leachtlelds
Pumped & Instilled
I Town Sewer Connectlons
P.O. Box 66' Centerville, MA 02632-0066
775-3338 775-6412
3 Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Department of
Environmental Protection
William F.WeldGovemor Trudy Coxe
LLArgoo,
Gm David B.Struhs Paul Celluccl 8-"Y
LL c3ov.mor • camr!"llorwr
•
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
PropertyAddreas: 52 Fox Run Centerville ,Mass .
Date of Inspection:2/14/9 6 Address of Owner.
Name of Inspeator.Joseph P. Macomber Jr. (If different)
Company Name,Address end Telephone Number.
J.P.Macomber & Son Inc . Box 66 Centerville ,Mass . 02632 508-7775-3338
CERTIFICATION STATEMENT
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 inspection. The inspection was performed based on sty+training and experience in the proper function and
mai:►tenance of on-site sewage disposal systems. The system:
Gc,:i:o:o wy Passes
?de^c'r }'ur er Evaluation By the Local Approving Authority
_ Fa:
Inspector's Signat l64:::_if'� Date:
V
The System Inspector sha'1 rah.—nit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspection. If the system L- a siLuTed 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 :'-:oral orice of the Department of Environmental Protection.
The original should be sent to ti,e system owner and copies sent to the buyer,if applicable and the approving authority.
INSPECTION SUMMAI'.';:
Check A,B,C,or D:
AJ SYSTEM PASSES:
have not found ar,• . f^r;nation which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure crit.er;a x,o: ..^'ti <cd are i,idicated below.
B] SYSTEM CONDITIGP:'z:_r-ILY F'taja: :
One or more conl,-onents need to be replaced or repaired. The system,upon completion of the replacement or repair,passes
inspection.
Indicate yes no,or not deterniinc:l (11, N, or ND). Describe basis of determination in all instances. If"not determined",explain.why not)
t The septic znss is metal, cracked, structurally unsound,shows substantial infiltration or exfiltration,.or tank failure is
imminent. b'he system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved
by the Sr,rd of iieaith.
(revised 11/03/95) I
One Winter Street a Bo.;ton, Masw chusetts 02108 a FAX(617)55&1049 a Telephone(617)292-SM
Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 52 Fox Run Centerville ,Mass .
Owner. Edward Lanzbom
Date of Inspection: 2/14/9 6
B]SYSTEM CONDITIONALLY PASSES(continued)
t
�O Sewage backup or breakout or huh static water level observed in the distribution box is due to broken or obstr%,t. pipe(,)
or due to a broken,,ettled or uneven distribution box. The system will peas 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:
A,D Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health,safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A
MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
ARw1� Cesspool or privy is within 50 feet of a surface water
.jJ Cesspool or privy is with:.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 ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a
surface water supply,
The system has 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 soil 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.
3) OTHER
(revised 11/03/95) 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 52 Fox Run Centerville,Mass .
Owner. Edward L. Lanzbom
Date of Inspection:2/1 4/9 6
DJ SYSTEM FAILS: e
s
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. _
A,D 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.
�VQ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
aQ/ Liquid depth in oesegocl is less than 6"below invert or available volume is less than 1/2 day flow.
�0 Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
j!�Q Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
AL4 Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Q� Any portion of a cesspool or privy is within a Zone I of a public well.
QfA Any portion of a cesspool or privy is within 60 feet of a private water supply well.
/lfl9 Any portion of a cesspool or privy is less than 100 feet but greater than 60 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:
N The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public
health and safety and the environment because one or more of the following conditions exist:
&),9 the system is within 400 feet of a surface drinking water supply
Q the system is within 200 feet of a tributary to a surface drinking water supply
lift' 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..
(revised 11/03/95) 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
PropertyAddreas: Edward L. Lanzbom
Owner. 52 Fox Run Cenete rville ,Mass .
Date of Inspection: 2/14/9 6
Check if the following have been done:
ZPumping information was requested of the owner,occupant,and Board of Health.
'None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
d that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
As built plans have been obtained and examined. Note if they are not av ' ble with N/A.
. The facility or dwelling was inspected for signs of sewage back-up.
ZThe system does not receive non-sanitary or industrial waste flow
ZThe site was inspected for signs of breakout.
, All system components,i6cluding the Soil Absorption System,have been located on the site.
-Al septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or
tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.
ZThe sue and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
7� facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 11/03/95) 4
1
5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 52 Fox Run Centerville ,Mass .
Owner. Edward L. Lanzbom
Date of Inspeotlon: 2/1 4/9 6
FLOW CONDITIONS
RESIDENTIAL• •
Design flow:EL—sal �r •
Number of bedrooms: '7
Number of current r•sia ate:o�
Garbage grinder(yes or no):-$
Laundry connected to system(yes or no):l�_'5
Seasonal use(yes or no):AJO
Water meter readings,if available:
Last date of occupancy-&6e
COMMERCIALANDUSTRIAL,
Type of establishment:
Design flow: )]!,R gallons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present:(yes or no)-)—L1R
Non-sanitary waste discharged to the Title 5 system: (yes or no)&! -
Water meter readings,if available: AI A
Last date of occupancy-.-ALA
OTHER(Describe) AJ
Last date of occupancy: AM
GENERAL INFORMATION
PUMPING REC RDS d so of i4forgiagon:
System pumped as part of inspection: (yes or no), e-S
If M volume pumped:_� '�)_� rs
Reason for Pumpi � i"4 TYPE OF SYSTEM
_-4GSeptic tank/distribution box/soil absorption system
_jQ Singie spool
4 Overflow cesspool
1*9 Privy
00 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: l0
Sewage odors detected when arriving at the site: (yes or no)t1b
(revised 11/03/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(oontinued)
Property Address: Edward L. Lanxbom
Owner. 52 Fox Run Centerville ,Mass .
Date of Inspeotion:2/14/9 6
SEPTIC TANKL-466o 41 Jz& 7'fN'C`' •
(locate on site plan)
Depth below grade: -
Mate w of Construction:SzC:ocrete_metal FRP_other(ezplain)
Dimensions: ly-kff'71 - 10'(a •
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle.
Scum thiclmess: 0
Distance from top of scum to top of outlet tee or baffle: 0
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.) Pump septic tank annually, Garbage disposal present, inlet. &
olltl Pt tPPs Are structurally sours S,F-.jD ti c tank is atr1irtnrn11 v Gniinrl tau t.h
GREASE TRAP:A
(locate on site plan)
Depth below grade:Al X
Material of constructionit1looncrete_metal_FRP�other(e:plain)
AJA
Dimensions:
Scum thickness:_
Distance from top of scum to top of outlet tee or bane: A)R
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.)
(revised 11/03/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 52 Fox Run Centerville,Mass .
Owner. Edward L. Lanzbom
Date of Inspection: 2/14/9 6
TIGHT OR HOLDING TANIi{:.&6&e, • '
(boats on site place) •
Depth below grade.N
Material of construction:,ghooncrete_metal_FRP_other(explain) -
A64
Dimensions: A/h
Capacity: AA gallons
Design flow: ona/day
Alarm level: A)
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert:_
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.)
PUMP CHAMBER.&a .
(locate on site plan)
Pumps in working orden(yes or no):
Comments:
(note oondion of pump chamber,condition of pumps and appurtenances,etc.)
Ala
(revised 11/03/95) 7
, . U
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 52 Fox Run Centerville,Mass .
Owner. Edward L. Lanzbom
Date of Inspection: 2/1 4/9 6
SOIL ABSORPTION SYSTEM(SAS)--,k-1
(locate on site Plan,it possible;excavation not require,but maybe approximated by non-intrusive methods) .
If not determined to be •
Pit,explain:
Type:
leacbln8 Pits,number.
leaching chambers,number
leaching galleries,numr:be
leaching trenches,nimber,length:
leaching fields,number,dime .ions:
overflow cesspool,number::
Comments:(note 004dition of soil of hydra c failure,level of ponding,condition of vegetation,etc.)
Loamy sando medi�"zm sana;no signs of hydraulic failure or pon ing;
_Vggq%&jQN JS r,nrmal TTn rar)aira raaHa(l nt the present time
CESSPOOLS:d&V4
(locate on site plan)
Number and configuration: Jt�t4
Depth-top of liquid to inlet invert: n)A
Depth of solids layer. N 14
Depth of scum layer.
Dimensions of cesspool:
Materials of construction:
Indication of groundwater._ 11}
inflow(cesspool must be pumped as part of inapediott) tiA
Comments:(pote condition of soil,signs of hydraulic failure,level of pondire condition of vegetation,etc.)
1VQ o r'1:�IertfTS
PRIVY:/11.0a/e
(locate on site plan) ,
Materials of construction: /1/w Dimensions:
Depth of solids
Comment (pots condition of soil,signs of hydraulic failure,level of pon&4n condition of vegetation,etc.) /
-441 om r
(revised 11/03/95). 8
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
property Address: 52 Fox Run Centerville ,Mass .
Owner. Edward L. Lanzbom
Date of Imp"Uon: 2/1 4/9 6
SKETCH OF SEWAGE DISPOSAL SYSTEM: e
include ties to at least two permanent references landmarks or benchmarks
locate aU wells within 100' -7,4-4r/v
moo!
• ^�� ' III
t
�,tifbr
DEPTH TO GROUNDWATER
Depth to Groundwater. + feet
method of determination or approximation: No water encountered at 12 ' when system installed
On file Board Of Heaith Town Ur Bar.ns a e .
(revised 11/03/95) 9
3
�n•rnnrn rr,rra•-•-rr:r+rrmr•nmrrnnrnrrrnr.:•++•'+ra'rr�rrrn•rrn Trrn,•sa rrat�crrss: .. •rn-r.r-it».•fs-:sr.-"..-r.i-••`
TOWN OF Barnstable BOARD OF HEALTH
SUBSURFACE SEWAGE; DISPOSAL SYSTEM INSi'ECTION FORM - PART D •- CERTIFICATION
�/ �»-seer»r:-::r nr.-.n�sntr..n•n.rr•rar.•es•rar.Rrrs•t psi.-r.-s:-mxr--errnc+.ar rr•-*:*rsmre rem n•,mr+rtsiv-•Trr.+ri•rrvnrs•r•rr--,>•-r•�
-TYPE OR PRINT CLEARLY-
PROPERTY INSPECTED
STREET ADDRESS 52 Fox Run Centerville ,Mass .
ASSESSORS MAP, BLOCK AfND PARCEL # 7
•
OWNER' s NAME Edward L. Lanzbom
PART' D - CERTIFICATION r
NAME OF INSPECTOR Joseph P. Macomber Jr,
COMPANY NAME J.P.Macomber & Son Inc.
COMPANY ADDRESS Box 66 Centerville ,Mass . 02632
Street Town or City state LIP
COMPANY TELEPHONE ( ) - FAX ( ) -
�08 775 �338 508 790 1578
eaa•n�atsss:rrestsrscs ..��a �a�•s» - m
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at
this address and that the information reported is true, accurate, and
� complete as of the time of .inspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems .
Check one:
XXXXXXX System PASSED
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
health or the environment as defined in 310 CMR 15 . 303 . Any faili►re
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form.
System FAILED*
The inspection which I have conducted has found that the system fails to
Protect the public health and the environment in accordance with Title
5 , 310 CMR 15 . 303, and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form .
Inspector Signature ' Z Date 2/14/96
,l
/ One copy of this c rtifieation must be provided to the OWNER, the BUYER
( where applicable ) and the BOARD OF HEAL1'it.
* If the inspection FAILED, the owner or,,,operator shall upgrade ' the system
within one year of the date of the inspection, unless allowed or required
otherwise as provided in 310 CMR 15 . 305 . '
z
Jos �C,
THE COMMONWEALTH OF M.A.SSACHUSETTS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BE IT KNOWN THAT i
Joseph P. Macomber Jr.
. P
. O
:.Has satisfied the..Department's qualifications as required and-is hereby
authorized to use the title
CERTIFIED TITLE 5 SYSTEM INSPECTOR
as provided in 310 CMR 15.340 and Section 13 of Chapter 21A of the
General Laws. Issued by The Department of Environmental Protection.
f June 8. 1995
' Acting Director of the '-ion, of Water Pollution Control
L G�-I b 0�p_ ,;,.7- �6
TOWN OF BARNSTABLE
LOf-TIUN ' LSEWAGE # Z AtZi0l)
VILLAGE ' ASSESSOR'S MAP & LOT.
INSTALLER'S NAME&P dONE NO.
SEPTIC TANK CAPACITY AC 2M'06
LEACHING FACILITY: (type) �� ` �r , fT (size) A10
NO.OF BEDROOMS
BUILDER OR OWNER y�
PERMIT DATE: I COMPLIANCE DATE: 6
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Fa ility(If any,wetlands a ist }
within 300 feet leachin fa it Feet
Furnished by
t
r
r'
e
o�
5� Rvn Ad G����rV ►'fig
LOCATJONG SEWAGE PERMIT N`0.
VILLAGE 9
er wc / l�
I N S T A LLER'S NAME i ADDRESS
3 U I L 0 E R OR OWNER � Y-G-? aeft-=
E I DA T P ERMIT SS U E D
DAT E COMPLIANCE ISSUED �o �3
ra
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
........... 0�..-. ------OF.:.........i .
ApplirFatiun for Disposal Works Tonunrtiun Vanfit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: }�vie#,,s.-"
ocation-Address or Lot No.
Owner Address
......� c.�... C�'. T-------�'-�'------------------------- ------------------- ----------------------------------------
Installer Address ,,5— ? 7 6
Q Type of Building Size Lot............................Sq. feet
V Dwelling—No. of Bedrooms...._7............. .Expansion Attic ( ) Garbage Grinder ( )
p., Other—Type 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 capacit ._�6.gallons Length................ Width................ Diameter---------------- Depth..._............
x Disposal Trench—No._ .._...._._.. Width.. _.... Total Length. ........ Total leaching area-----o __sq. ft.
Seepage Pit No-----------/........ Diameter........... Depth below inlet............... Total leaching area !2:9;�.....sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.__B_ 2... Z!� �------------------ Date___. __-_1_. __� /__..
Test 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........................
a ••-•-•••--•--------•--•---•---......-••-•...--•--••-•••---------•--••-•--•------•---....•-••-•.....•.........................................................
0 Description of Soil.......................................................................................................................................................................
W
U -•----
w
UNature of Repairs or Alterations—Answer when applicable._..............................................................................................
--•-•• --•-•----•--•••.. . ............•------•
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewa e Disposal System in accordance with
the provisions of'I'LL 5 of the State Sanitary Code—The and rs ne rther agrees not to place the system in
operation until a Certificate of Compliance has be is d by the oa aAh.
Signed_ ...... ------- -•-----9� .__ !.
Dat
Application Approved BY ---- x � ---•..................•-- ,/
Date
Application Disapproved for the following reasons-----------------------------•--•--------...------------•------•------•------•--•------------------•-••-------•--
----------------------------••---............---------------...-----------------.....-----------•--••---•----••-•----•-•--••----•--•------------••----••-•••••--•---------------•---••••--------•-•-----
Date
PermitNo......................................................... Issued.......................................................
Date
..............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......... ,.. ...---....OF.......-41"
; .... .. ..................................................
Appilration for Bhipasal Works Tonstrurtwit lirrmit
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at:
.............. sr
... IV Cr
............. ......... ..................... ..................................................................................................
cation-AddWAk or Lot No. Cc2i��_dl
.......................
......... ......
....1.4 ......................... J3_x......w-9
.... ..............................
Owner Address
,C
............ :2
...............
f. ..............t.. S.1........................................ ..................................................................................................
Installer Address
00 ;L4_
Type of Building Size Lot............?...........% 70
U ..Sq. feet
0-4 Dwelling—No. of Bedrooms......3.................................Expansion Attic Garbage Grinder
a Other—Te of Building IejP
..S............. No. of persons..........T..T ............. Showers Cafeteria
yp Other fixtures ...........................................................................................................
el - , _--- ------------------*-------------
low.........I.X .'�
Design F ................ ..........gallons per person per day. Total daily flow---------
W Width .......... ................gallons.
C4 Septic Tank—Liquid capacit .....gallons Length................ Width___.........._ Diameter---------------- Depth.._......._..._.
IV Disposal Trench—No. .40-5.......... Width.AW....... Total Length_..4100...... Total leaching area... ft.
.I
Seepage Pit No..........I--------- Diameter........... Depth below inlet........v.......... Total leaching area '�......sq. f t.
Z Other Distribution box Dosing tank
W..................
Percolation Test Results Performed byad -----n ... Date....
14 Test Pit No. I................minutes per inch Depth of Test Pit.__................. Depth to ground water...._._............_.__.
44 Test Pit No. 2................minutes per inch Depth of Test Pit.___..........._._.. Depth to ground water......._............__..
........................................................................
0 Description of Soil........... ...........................................................................................................................................................
.W .........................................................................................................................................................................................................
U
W
Z -
......................................................................................................................................... ..............................................................
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
.......................................................................................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewa sal System in accordance with
Disposal
the provisions of TILTILS 5 of the State Sanitary Code—The and rs lief
j,e tj_jer agrees not to place the system in
operation until a Certificate of Compliance has be' i d by the o d h.
. ............. ....... .......
Signed.-
. .............
Da
Application Approved By..... ..........
------------------------- ------
Date
Application Disapproved for the following reasons:................................................................................................................
.........................................................................................................................................................................................................
Date
PermitNo........................................................ Issued.......................................................
Date
THE.COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........ .. ..............OF....... .... . ... ..........
At
Qwrtffiratr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired
b ......................<�� ........4
y be. ................................................................................................................................
Installer"0 V .0
at.................. .............e... ...........C.... ... ...................................................................................
has been instilled in accordance with the provisions of TLITIZ 5 of The State Sanitary Code as described in the
application for Di, osa ors Construction Permit o..
T I k Ct i P i N
/W ? _e>............. d ....._.._._._____...______......___......•._...
THE ISSU F THIS CERTIFICATE SHALL NOT BE CO AS A GUARANTEE THAT THE
SYSTEM VW'
ION SATISFACTORY.
DATE....... ................ ................................................. Inspect .......... .......................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEAL
.................OF s .Wrff:3
FEE��.V................
Raposal Morkii Tonstrudivit "pantit
Permission is hereby granted........ . ...... .......................................................................................
to Construct air an Indivj!�4 Sewage Sys em
atNo............. ........I.. .... ......
........ .... . .... ..........................................................................
Street
as shown on ap cation for Disposal Works Construction Permit No..................... Dated..........................................
rISSU E C Bo of ealth
... ...... �o ...
-----------------------------------
DATE................................................................................
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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