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Home My WebLink About0226 GLENEAGLE DRIVE - Health 226 Gleneagle Drive Centerville A= 192-152 SMEAD UPC 12534 � smead.com • Made In USA nECYCLE rJ�A I� 2 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 226 Gleneagle Drive _ Property Address Harold and Miriam Robinson Owner Owner's Name Information is required for every Centerville MA 02632 May 20, 2011 page. City/town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way.Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector. �J key to move your cursor-do not David D. Coughanowr use the return Name of Inspector key. Eco-Tech Environmental ' as Company Name 43 Triangle Circle Company Address nma Sandwich MA 02563 Cityrrown State Zip Code 508 364 0894 1328 Telephone'Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of CD 1 i� rn Title 5(310 CMR 15.000).The system: L 0 Passes ❑ Conditionally Passes ❑ Fails f. ,'Needs Further Evaluation by the Local Approving Authority 0:1 r1 � w _ May 20, 2011 C) r r- 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. �h '5-1 I t5ins•09= Us,5 Offl6sl Inspection Form:Subsurface Sewage Dis System•Page 1 of 17 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 226 Glene_agle Drive Property Address Harold and Miriam Robinson Owner owner's Name information is required for every Centerville MA 02632 May 20, 2011 page. Cityfrown 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: ® 1 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: Inspector's Note==> A septic system is deemed to pass this Real Estate Transfer Inspection if it does not trigger any of the failure criteria listed below. The septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. 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): 15ins•09= Title 5 Otlidel Inspection Form:Subsurface Sewage Disposal System•Page 2 of» Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 226 Gleneagle Drive Property Address Harold and Miriam Robinson Owner Owner's Name information is required for every Centerville MA 02632 May 20, 2011 page. Cityrrown State Zip Code Date of Inspection B. Certification (Cont.) B) System Conditionally Passes(cunt.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Oealth): ❑ 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 t51ns•09= Idle 5 Official Inspection Form:Subsurface Sewage D g isposal System•Page 3 or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal,System Form -.Not for Voluntary Assessments 226 Gleneagle Drive Property.Address Harold and Miriam Robinson Owner Owner's Name information is requited for every Centerville MA 02632 May 20,_2011 page. 6tyrrown State Zip Code Date of Inspection B. Certification (cone.) 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 SASis within 50 feet of a private water supply well. ❑ The system has aseptic tank,and SAS and the S.AS.I is less than 100 feet buf 59 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, forcoliform 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 Ali 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 town overloaded or clogged SAS or cesspool ❑ 0 Liquid depth in cesspool is less:than.6"`below invert or available volume is less than.'/Z day flow t5ins•0g108 Title 5 OfFcial.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 226 Gleneagle Drive Property Address Harold and Miriam Robinson Owner Owner's Name information is Centerville MA 02632 May 20, 2011 required for every Y 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 ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone I I 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. 151n'090 TAIe 5 Official Inspe tEon Form:Subsurrace Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 226 Gleneagle Drive Property Address Harold and Miriam Robinson Owner Owner's Name information is required for every Centerville MA 02632 May 20, 2011 page. City/rown 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 an of the system components pumped out in the previous two weeks. ® Y Y R P P ® ❑ 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 facilityor dwelling inspected for signs of sewage back u ? 9 p 9 9 P ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components,excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 gpd tSins•09108 Title 5 Official Inspection Fort:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "f 226 Gleneagle Drive Property Address Harold and Miriam Robinson Owner Owners Name information is required for every Centerville MA 02632 May 20, 2011 page. Cityrrown 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?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ® Yes ❑ No Water meter readings, if available last 2 ears usage 108 gpd 9 ( Y 9 (gpd)): Detail: 2009-2010 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: 15ins DO= Tine 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 o►17 Commonwealth of Massachusetts` Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Notffor'Voluntary Assessments y - 226 Gleneagle Drive Property Address Harold and Miriam Robinson Owner Owner's Name_ information required for every Centerville MA: 02632 May 20,2011 page.. Cltylrown 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-: owner Was;:system.purnped as part of the inspection? El Yes Z No If yes, volume pumped: gallons How wa&quantity'pumped determined? Reason for pumping: Type of System: 0 'Septic tank, distribution;box, soil absorption system ❑ Sin,gle cesspool ❑ Overflow cesspool ❑. Privy 0 Shared system(yes or no) (if yes, attach previous inspection records,if any) Innovative/Aiternative.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 VA system by system operator,under contract El Tight tank: Attacha copy of the DEP approval` ❑ Other(describe): 15ins•09108 Tile 5 Official Inspection Form:Subsurface Sawaga Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 226 Gleneagle Drive Property Address Harold and Miriam Robinson Owner Owner's Name information is Centerville MA. 02632 Ma `20 2011' required for every _y page. Citylrown State: Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Age 35+ years. Certificate of Compliance dated.:0/20/75 (Board of Health files). Were sewage odors detected when arriving at the site? El Yes 0 No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑`cast iron Z 40 PVC ❑ other(explain): Distance from.private water_supply well or suction line: feet Comments(on._condition of joints, venting, evidence of leakage, etc.). Sewer line appears structurally sound with no evidence of leakage or backup into dwelling. Septic Tank (locate on site plan)` Depth below:grade: 0.5 feet Material..of.construdtiod 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: 9:5 ft x,6 ft x 5 ft(1250 gal) Sludge depth: 6 in 15ins;•'09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal;System•Page.9 of 17 r`r Commonwealth of Massachusetts Title 5 Official Inspection Form +s Subsurface S.ewage Disposal System Form -Not for Voluntary Assessments — 226 Gleneagle Drive Property Address Harold and Miriam Robinson Owner Owner's Name= information forie Centerville MA„ 02632 May 20, 2011 required for every y page. City/Town State Zip'Code Date of Inspection D. Systern.Information (cant:); septic Tank (tong) Distance from top of sludge to bottom of outlet tee or baffle 28 in Scum thickness 2 in Distance:_from top of scum to top of outlet tee or baffle 9 in Distance from bottom of scum to bottom of outlet tee or baffle 13 in How were dimensions determined? As built.card Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence,of leakage, etc"): Pumping is not'required at this time but maintenance pumping is;recommended within and every two years. Tank appears structurally sound and functioning as intended. No evidence of leakage in or out was observed. Grease Trap (locate on site plan): Depth below grade: feet Material of construction': ❑ concrete El 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 15ins-09t08 Title 5 Offiicial.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 226 Gleneagle Drive Property Address Harold.and Miriam Robinson. Owner Owner's Name information is Centerville MA 02632 May 20, 2011 required for every _ page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations,;inlet and outlettee 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 [I metal ❑ fiberglass ❑ pplyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present. ❑ Yes ❑ No Alarm level Alarm in workingorder ❑ 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•09108 Title 5 Official Inspection Forth:Subsurface Sewage Disposal.Syslam-,Page 1,1 of 17. p. Commonwealth of Massachusetts Y- Title 5 Official Inspection Form _ - Subsurface Sewage Disposal System Form-Not for'Voluntary Assessments w 226 G.leneagte Drive Property Address Harold and Miriam Robinson_. Owner Owners Name information is Centerville MA 02682 May 20,"2011 required for every page. City!Town State Zip.Cbde Date of Inspection D. System Information (cont.). Distribution Box(if present must be opened) (lo,cat.e on site,plant Depth of liquid level above outlet invert at outlet invert Commen.ts.(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.);: D-box appears structurally sound with no evidence of leakage in or out. Some solids in sump. 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 bn site plan, excavation not required): if SAS not located, explain why: t5ins-OWN Tills 5 official Inspection,Form Subsurface Sawage,pisposat System•P.ago 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w 226 Gleneagle Drive Property Address Harold and Miriam Robinson Owner Owner's Name information is Centerville MA 02632 May 20,'2011 required for every Y page. Cityfrown State. Zip Code Date of Inspection D. System Information (cone.) Type: ID leaching-pits number: 2 ❑ 1eachipg 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 ofponding, damp soil, condition of vegetation,etc.);: Soils above leaching pits appear unsaturated. No evidence of surface ponding, breakout, lush .vegetation', or other evidence of hydraulic failure was:observed. A bucket of water was poured into the distribution box and was observed to pass through in a rapid and unobstructed manner,and could be heard s lashing down into both leach pits. Cesspools(cesspool must be pumpedI 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 l5ins•09108 -file 5 Official Inspection Fort Subsudace.Sowage Disposal Systom.--P.age.13_of 17 Commonwealth of Massachusetts _ Title 5 Official Inspection Form _ — — Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 226 Gleneagle Drive Property Address. Harold and Miriam Robinson Owner Owner's Name: .information fo is Centerville MA 026:3.2 May 20i 201`1 required for every page. Cityrrown State Zip Code. Date of-Inspection D. System Information (coat:;) 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.): t5in's t%09108 Title 5 Official Inspection FormrSubsuAace Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts _ UI _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 226 Gleneagle Drive Property Address Harold and Miriam Robinson Owner Owner's Name information is Centerville MA 02632 May 20,.2011 required for every Y page. City/Town State Zip Code Date of Inspection D. System Information (coat.) 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 welts 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 GLE WFA-6tf. z <)a , 5 36 ' 4-Z 1 Z2:G t a 00 `7WK 2 NT' � 5�t Q-fix 0 L9V_H Pt F t5ins•09108 Tille 5 Official Inspection Form:Subsurface;Sewage Disposal system-Page 15 o117 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage,Disposal System Form -Not for Voluntary Assessments 226 Gleneagle Drive Property Address Harold and Miriam Robinson` Owner Owner's Name information is required for every Centerville MA 026,32: May 20, 2011 page. City/Town state Zip Code. Date.of'Inspection D. System Information (cunt.) Site Exam: ❑, Check Slope: ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 25+ ft feet Please indicate all methods used to determine,the high groundwater elevation: ❑ Obtained front 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: Barnstable Gis Department records You must describe how you established the high,ground water elevation: Town of Barnstable GIS Department records indicate that the property is over 25 feet above groundwater table. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09108 The 5 Official Inspeclion,Form:;Subsufface Sewage:Disposal,System•Page 16 of 1.7 Commonwealth of Massachusetts -v Title 5 Official Inspection Form — - = Subsurface Sewage Disposal System Form Not for Voluntary Assessments 226 Gleneagle Drive Property Address Harold and Miriam Robinson Owner Owner's Name information is Centerville MA 02632 May 20, 2011 required for every Y page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Z Inspection Summary: A, B, C, D, or E checked Inspection Summary Q (System Failure Criteria Applicable to All Systems)completed 0 System Information - Estimated depth to high groundwater Sketch of Sewage Disposal System either.drawn on page 15 or'attached in separate file 15ins•09108 Title 5 Officiel Inspection Form:Subsurface Sewage Disposal Sysletn•Page 17 of 17 LO QT_10N _ _ :. SEW/J,C;E PERMIT 1J0, NALLAGE IWS-TaLLFER 5 U&NIE . ADDRESS 3 6, 5UI DER 5 . IME ADDRESS. DQT PERNA T ISSUED 7J- — e D ATE COMPLI &&ICE ISSUED : � -? r 6- 3 ( ^ THE COMMONWEALTH OF MASSACHUSETTS n BOARD O HEAL H .6 �' .. OF........... ...... . - .....-- ----- , pphration -for 43iiiVogal Workii Cnowitrurtion Vrrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Sys at if cation-/Address or -o. a Ow r ddr ess ----------- ------ . . ''..........----- -•---- -- - - --•..... ------------��iFL�.J_". .............................................. \ Installer Address dType of Building /, Size Lot-.l-_$_. .(....Sq. feet v Dwelling—No. of Bedrooms------------' ___________________________Expansion Attic Garbage Grinder ( ) Other—Type of Building ---------------------------- No. of persons_.___-_-_-_-_-__--___-_--- Showers —,Cafeteria ( ) Q' Other fixtures ----------------- ------------- - - ------------ ------------------------ W Design Flow-----------__ Mons per person per day. Total daily flow............. ....dom.........................gallons. -.-----;-.. WSeptic Tank I-Liquid capacity-)-S�gallons Length---------------- Width.._............. Diameter.-_-_..___._-.- Depth...---_-_.----. x Disposal Trench—No. .................... Width.__..__--__- _ _ Total Lit th._._ ____'_� . Total leaching area..---.-.-----_----_sq. ft. Seepage Pit No....... ---._._. Diameter.�� t _ e�y '.. Total leaching area-.._._-_._.__•--sq. ft. 7 Other Distribution box Dosin tank j ^ z ( ) g ( ) � yo aPercolation Test Results Performed by-------------- ----------------••------••----------------•--------...._... Date...--------------------------------- a Test Pit No. I................minutes per inch Depth of Test Pit......_------------- Depth to ground water..------..----.._.--.._- G14 Test Pit No. 2----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water-_---.-.-------.--_----. P; - ------- ............ 0 Description of Soil �`. U -= W -•----•--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------••--••--- U Nature of Repairs or Alterations—Answer when applicable._---------------------------------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee issued by tl,,Vd of health. Signe --- - ------- -----------•--------•- Date Application Approved By-.- � - ----- ---• - 4 7 Date Application Disapproved for the following reasons-------------------------------- ..... ............................................... ..............•-••-----••--------•--•------•-------------------------------•-•-----••--•--•-••---•--------------------------------••----•-•-------------...-•--•--•----•......_----•------------•---•-- Date { Permit No......................................................... Issued.• .. .. Date - •. : Finc .. ..No ..._ s THE COMMONWEALTH OF MASSACHUSETTS BOARD OA HEAL H Zle �►'t 1---...OF........... .: f ...... .---- Appliratiun -fur 11opuottl Works Cnunotrurtion Vrrunit Application is hereby made for,a Permit to Construct ( ) or Repair ( ).'an Individual Sewage Disposal Sys at:. -: dress = ..................................... f cation-(Ad or o. 4 --- -•---- �..-•-•-- • _. . . .................................... .2_ _ -_ .-.�'.' ... t.ust. '- '-...... Ow r ddress W Installer Address d Type of Building Size Lot---/�__6._-!____Sq. feet- U Dwelling—No. of Bedrooms____________ ___________ Expansion Attic Garbage Grinder ( ) Other—Type of Building ____________________________ No. of persons_-_:__---_•_-______________ Showers (*..+ — Cafeteria ( ) Other fixtures ................ ----------- W Design Flow___________ ___ _,_�-_ allons per person per day. Total daily flow-__________: -----------__----------------gallons. WSeptic Tank-t Liquid capacity/i. ---gallons Length................ Width................ Diameter_----..._.-___-_ Depth.._.-____..__..- x Disposal Trench—No_ ____________________ Width__. ___ Total L th.... ....... ..... Total leaching area--------------------sq. ft. Seepage Pit No...... Diameter_��. ' Total leaching area... sq. It. T Z Other Distribution box ( ) Dosing tank ( ) f .►:�?,' "+'Y• aPercolation Test Results Performed by-------------------------------------------------------------------------- Date....................................... a Test Pit No. 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water.-___-_----_-.-.-.._._.- (_, Test Pit No. 2................minutes per inch IDepth of Test Pit____________________ Depth to ground water-_.-_-_--____-_----_.__. a -----------•--- - ----- --'------ ------ D Description of.Soil. "�' > +�'D70► t '� x !j �` U F + J ----- =' 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 Article XI of the State Sanitary Code— The undersigned further agrees'not to place t!-(&system in operation until a Certificate of Compliance has beAi issued by t4&4Q2xd of health. Signe --- -- ----------------•- � -"y-.. --------------------- ------------------ D w to _ Application Approved By------ . ------ --- r --- -- ---------- ---- -- _. .. Date Application Disapproved for the following reasons:................................................................................................................ l i ---•------------------••---•-••----•---•-•-•------------------------_------•----------- j Date Permit No.f--•'=--•-•----•``- Issued---------------•-- Date i THE COMMONWEALTH OF MASSACHUSETTS 1 BOARD F HEALTH OF.... Trrtif irate,of f.Tompliaurr 4--_- T I IS TO CERT F Tlia t e Individu ewage sposal System constructed ("') or Repaired ( ) b ---- y - '� -----•- �, i { `? 5t has, een installed in accordance with the provision- f.Ar' e I of T e State Sanitary Code as described in the application for Disposal Works Construction Permit No. .._.__..SY_.__ __. ._._. dated...... '`.: `...`...�_�""___--__ THE ISSUANCE OF THIS CERTIFICATE SHALL. NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL. FUNCTION SATISFACTORY. {" DATE................................................................................ Inspector..........................................1 THE C'QMMONWEALTH OF MASSACHUSETTS, 01 3- BOARD OF HEALTH,wrp FE v %spofia ork,i �tr f it err it • Wiz%��{ Per fission hereby granted - -----•-- -------- to Cons uct ' or Repair (_ In idual Se1. w t posal Sy m ,- TM'#� at No. t � .3 ` .:: � -`- - • Street as shown on the application for Disposal Works Construction P it No .:__.. _ .. . Dated-_:7"' -----_-- ....._ oard of ealt H h' � DATE...�----•-� ( , FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS -