HomeMy WebLinkAbout0279 GLENEAGLE DRIVE - Health 279 Gleneagle Drive-
Centerville P
A = 192 140
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Ill1
UPC 12543 �a
NN o.�.OR
HASTINGS. MN
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COMMONWEALTH OF MASSACHUSETTS
Z EXECUTIVE.OFFICE OF ENVIRONMENTAL AFFAIRS
a
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION.FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM 9= ry
PART A MAP
CERTIFICATION PARCEL '
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LOT
Property Add.ress:. �"!f �� <
Owner's Name: _ Q 4
Owner's Address: O
X/A 045-0 0
Date of Inspection: D
Name of Inspect jr��please .rint): �^rt'� �
Company Name'�/ r� ,t', G�Cr, Gt
Mailing Address: -&- ��p� TpN1H�AFTH pEPT-
Telephone Number: /- 9 q
CERTIFICATION STATEMENT
I certify that 1 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 ection 15.340 of Title 5(310 CMR 15.000). The system:
Passes
Conditionally Passes
Needs.Further Evaluation by the Local Approving Authority.
ails
Inspector's Signature: 7Date:
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 oftlie.
DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving
authority.
Notes and Comments
****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.
Title 5 Inspection Form 6/15/2000 page 1
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Page 2"of l I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: Ac. 9p
Owner:._�/l �A �/?./,&P e
Date of Inspection:W ,� 2('
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
TAM
A. S stem Passes•
iRAq
I have not found any information which indicates that any of the failure criteria described in 310 CMR
15303 or in 310 CMR T5 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.
Answer yes,no or not determined(Y,N,ND) in the 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.H.ealth.
*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.
ND explain:
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
obstruction is removed
distribution box is.leveled or-replaced
ND explain:
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
obstruction.is removed
ND explain:
2
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Page 3 of I'l
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued).
Property Address: Q7
Owner: n�E�.
Date of Inspection: 7
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.(l)(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
Z. 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..s.oil.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 I00,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 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,provided that no other
failure criteria are triggered.A•copy.of the analysis must be attached to this form:
3. Other:
3
Page 4 of 11
OFFICIAL.INSPECTION FORM—NOT FOR.VOLUNTARY'ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: c�
Owner:
Date of Inspection:
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes Nql
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
7 clogged SAS or cesspool
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
_ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow
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.
_ V Any portion of.a cesspool or privyis within a Zone I 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 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,provided that no other failure criteria
are triggered.A copy of the analysis.must be attached to this forma
(Yes/No)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•
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
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—I WPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any questibn 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.
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Page 5 of 1.1
OFFICIAL.INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
CHECKLIST
Property Address: `7 Q�)Z
Q
Owner: PJ7//v li
Date of Apection: J '2 3QQ 0
Check if the following have been done. You must indicate"yes"or."no"as to each of the following;
Yes o
Pumping.information.was provided by the:owner,occupant,or Board of Health
r/ Were.any of the system components pumped out in the previous two.weeks?
_t'Has the system received normal flows in the previous two week period?
— I,' 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).
f/ 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?
V _ 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 Soit Absorption System(SAS)on the site has been determined based on:
Yes no
— 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(3)(b))
5 .
Page'6 of I I
OFFICIAL LNSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM[INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: ,�?�q As",
Owner:
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(.design): . Number of bedrooms(actual):.
DESIGN flow based on 3I 0 Cv1R 15.203(fore ample: 11.0 gpd x of bedrooms): jd
Number of current residents:
Does`residence have.a garbage grinder(yes or now->
Is laundry on a separate sewage`system(yes or-n0�,cif yes separate inspection required] .
Laundry system inspected(yes or nom�
Seasonal use: (yes or no):
Water meter readings, if av (last 2 years usage(gpd)): 0/-
Sump pump(yes or no
Last date of occupancy:
COMMERCIAL/INDUSTRIAL
Type'of establishment:
Design flow(based on 310 CMR.15.203): gpd
Basis of design flow(seats%persons/sgft,etc,): : ..
Grease trap present(yes or no):_
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 system(yes or no):_
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information:. ,
Was system.pumped as part of the inspection( s.or no);
If yes, volume_pumped: gallons--How was quantity pumped determined?, -
Reason'for_pumi ping: .
TYPE OF SYSTEM
_Septic tank,distribution box,soil absorption system
_Single cesspool
Overflow cesspool
_:Privy
_Shared syste'm.(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')
Fight tank _Attach a copy:of the DEP.approval
✓Other'(describe):apgntge;
Approximate age of all comZY;2
ents,date install d(if known and source of information`.
Were sewage odors-detected when arriving.at the site(yes or no):��
F
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL-SYSTEM INSPECTION FORM
PART--C
SYSTEM INFORMATION(continued)
Property Address: .79
Owner: _
Date of Iris ection: G
BUILDING SEWER-(locate on site plan)
Depth below grade:
Materials of construction:_cast iron 40 PVC_other(explain):- _
Distance from private water supply well or suction line:
Comments(on condition of joints, venting, evidence of leakage,etc:):
SEPTIC TANK:Zoocate on site plan)
Depth below grade: �
Material of construction: ; COnCrete_metal_fiberglass_polyethylene
—other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):—(attach a.copy of
certificate) /
Dimensions: ����x�®` k 5
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:341,
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: nr►�J� G�l/�L!/t/I
Comments(on pumping recommend ions,Inlet and outlet tee or baffle condition,structural integrity,liquid levels
s� related to outlet invert,. vidence of leaka-e,etc.)
VGREASE TRAP locate on site plan)
Depth below grade:
Material of construction:_concrete_metal_fiberglass_polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations, inlet and outlet,tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage;etc.):
7
Page 8 of 71
OFFICIALINSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 07C 64,
Owner:.
Date of In pection:. ff X 0 000
TIGHT or HOLDING TAN (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass Uolyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches, etc.):
DISTRIBUTION BON` "` if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
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.):
PUMP CHAMB1ER`�locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):.
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
8
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Page 9 of 1 I
OFFICIAL,INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM_ INFORMATION(continued)
Property Address: ,
Owner:
Date of In pectjon:
SOIL ABSORPTION SYSTEM (SAS):._--(Focate on site plan,excavation not required)
If SAS not located explain why:
Type
reaching,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,
tc.l D .
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 Hof cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,.signs of hydraulic failure,_level of ponding;condition of vegetation.,etc.):
PRIVY-jt0'(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.):
9
Page 10 of 11
OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
:PART C .
SYSTEM INFORMATION(continued)
Pro*perty.Address: 7
Owner•
Date of Inspection: ` �>�OQ
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch 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.
6�)✓mil
0
& 0 9�i
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Page I 1 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
6,f" ° �✓
i'Owner: n Q,Q„
Date of rispection: 02
SITE EXAM:
Slope
Surface water
Check cellar.
Shallow wells
Estimated depth to ground water �®feet
Please indicate(check),all methods used to determine the high ground water elevation:
Obtained from.system design plans on record-If checked,date of design.plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with-local excavators, installers-(attach documentation)
Accessed USGS database=explain:
You must describe how you established the high ground water elevation:
��
11
Permit Number: Date:
• � Completed by:.
HIGH GRO•UND-WATER LEVEL COMPUTATION
Site Location: �i7 J �i �/`�/! Lot N'o.
Owner: Address-
Contractor: 44r'd 9. ' / �/'S Address:_ �`'�y _/"
Notes:
STEP. 1 . Measure depthto water table.
". to nearest.1110--t........................ . .
............ .Date �Z
month/day/Year
STEP 2 Using.Water-Level.Range Zone
-and In.de.x WeII:,:M:a.p:locate
site anal determine:
O Appro.'
priate.index well.................... .. Z
OWater-level range zone;_.........._. (/
S.a E Using monthly.repo.rt:"Current
Water Resources Conditions"
determine current depth to
water level for index well ........................... ��" �Z 17,E
month/year
STEP 4.. Using.Table.o.;•Water-Level Adjustments
for index well (STEP 2A),..curr.ent depth
to waterlevel fo.r index wel.l (STEP 3):,
and water-level zone (STEP 2B) "
determine water-level adjustment ............................
........... �i
STEP:. 5 Estimate depth to:high water
by subtracting th.e'vvater
level adjustment.(STEP 4)
-From measured.depth to.water
level-at site.(STEP'1) ..........
Figure. 1I--•Repro-du ible computation fori.Ti.
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LOCATION ` SEINAG PERMIT NO.
aXlz� .2(5
VILLAGE
INSTALLER'S AME & ADDRESS
B U I'L DE R OR OWNER
DATE PERMIT ISSUED ZZ 17 7
DATE COMPLIANCE ISSUED �j
n
43.4
i
1'
No............ Fas. .................-
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F H��� H
............OF...... .=......... _....--- .....
- ...........................
Appliration -fur Ui,ipuuttl Morkii Tonstrurtion Vrrulit
Application-i-g-he4y`made for a Permit to Construct ( ) or Repair ( } aa Individual Sewage Disposal
Sys at: P" I � .4 P J_
Locate n• 6 - or No.
w O 'er ddress
0-',C A - ....lZT.. —---------------------------------------------------
staller Address
T e of Building Size Lot,/_S;..4'?_l 3.__-____Sq. feet
V Dwelling—No. of Bedrooms------ak................................Expansi n Attic (f� Garbage Grinder
aOther—Type of Building ..____......-(.�.......... No. o Pei oats....:. .................. ShowersCafeteria ( �
d Other fixtures --•,e�i�/`va�2ly �--4�`-_-. iu✓ - -
w Design Flow......SO.............................gallons per person per day. Total daily flow....... .;2®-------------------------gallons.
W Septic Tank/2 Liquid capacity/..� allons Length---------------- Width................ Diameter.......--------- Depth----------------
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area__--.--_-___.-----sq. ft.
Seepage Pit No..--4/............. Diameter.. 1"`--- Depth below inlet_... Total leaching area---_____.-_.--._--sq. -t.
z Other Distribution box ( ) Dosing tank ( ) Q — ��� �-- /W
a Percolation Test Results Performed by.......................................................................... Date-•-•---•------------------------••------
a Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water....---..--.---._.------
LT, Test Pit No. 2................minutes per inch Dept of Test Pit-------------------- Depth to ground water------------------------
-----------
G Description of oil = �- --- /.� j _x.U'lc`� -
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 Article \I 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�h. .
'
Signe . . . . ..............` a - ..........
� Date
Application Approved By------- ------ - - ------- ....... -- . ------"--- ----•--------------- h--= )----d ...
e
Application Disapproved for the following reasons:---•---•---•-------------- ------------•-------•------------------•-----•-•--•---•-------------------•----------
---...-•-•-•-•--------...-•--•-••-•-•------------------------••----.....-----------------.-----------------------...-----------------•----•-------••----••-----•---•--------------_...__•...............
Date
PermitNo.................... Iisued........................................................
Date
1
i
No.........`•'_............. FRiz ..................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF......._/._.. •ail .....:.�'Y/.•�'�:;^.�.
App iration -fur 43WVuiitt1 Works Tunutrurtiun Prrntit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
Systerrii at:
f t•�/�/�tnn.: l•/ii _t-----�if /s.- —................................... /.hsr...w n an ,1.- 1 .I1�a f_= ............................` ..... - .... _ w r
Location-Address- r/�� / 1 ! or Lott No.
lr/1!1 /�. ....s.b7, Ns`7 �!!.!J . l J�� 1-it t''n�.t, ' /iw.s/. ...........................
; I�G!,,��... /_:__.._:_ddress
taller Address Q (J ',Tye ,---of Building Size Lot_ =----------------Sq. feet
Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic Garbage Grinder
per, Other—Type of Building .-.------- No. of persons..-4 - ---------------- Showers (� ) — Cafeteria (�>—
a �. �!
dOther fixtures ..-::a ll�<i!:-,"-M-------_------------n��.r�r2. (A--------------•------•-•---------------•------••-----------_------------
W Design Flow_.-._.-`� .._____________________________gallons per person per day. Total daily flow-------n_e")n--------------------....gallons.
WSeptic Tank•-Liquid capacity__..P!�:gallons Length................ Width-.----.-..----.- Diameter---.-_-------_ Depth.-__.._--.---
x Disposal Trench—No- -------------------- Width-------------------- Total Length-------------------- Total leaching area-------.---_--_---sq. ft.
Seepage Pit Na.;___ _____________ Diameter_./.-"' Depth below inlet---__-___-__-_-_--_- Total leaching area.---._----..-_---sq. ft.
Z Other Distribution box ( ) Dosing tank ( ) Of- ✓G _ 7- 2
Percolation Test Results Performed bY--------;>----------------------.......................................... Date---------------------------------------
Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water---.---..--.---.--.-_-
rZ4 Test Pit No. 2----------------minutes per inch Deptl} of Test Pit-------------------- Depth to ground water------------------------
---------------------- ...........................................--• --
O Description of'77Soil ----- .............................................t�/tJ-J G/} Gl_vct - d / .. r/.: t(..-f ...,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 been issued by the board of health.
./ t
Signed- - --------- -
Application Approved B 1•:�^ ..........r '• �/ --1��-f --- ,f�-� �/ace j
PP PP Y / .I -_'' ------. t Deft ---- --
",....
Application Disapproved for the following reasons:-------------------------C_.-_.................................................................................
-------•-------------------------------•-----•-------- ---------------------------•----------------------
Date
Permit No. Issued..............
Date' .
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
,.............
uIrrtifiratr of filompiiatta
THLS IS'TO CERTIFY?That t In i Sewage Di osal System constructed ( or Repaired ( )
by..'--'` :;--`--/-� d�4i -- -------------- ---------
V ! Installer /
has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the
application for Disposal Works Construction' Permit NoC� -'-._-A?_ __._...--. dated' �-_--/-.7-j........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSYRU D AS A GUARANTEI�THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE....-•--•----- f? --------------••---'-.. Inspector------- -----------------------------
THE COMMONWEALTH OF MASSA ETTS
BOARD OF HEALTH
Tf f......-.
/ - �zf. ..t.............O F... ✓ /'L. ;_:�_<. +................... f L_
No...................•---- FEE./'--•---......-•--
�t��u�tt� urk�-�un�trixrtt n err it
Permission is hereby granted_-_ 1 - - - --_-_�� -.- �- �.
•.
to Construct1( or Repatrf(� )man Individual Sewage Dtsposal ` stetrl��
at No. /� f`ol
f;,,� /,,=' /. ..�.I - , / ��5--.f %• /..4°s a J,
r Street
as shown on the application for Disposal Works Construction Permit No._,:�---------- lDated-_ ?'--. l-y.----_-r
--=- = - - s=-
�"�`"� •' Board of Health '
DATE ..................... --------------------------------- i
FORM 1255 HOBBS &'WARREN• INC.. PUBLISHERS
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