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HomeMy WebLinkAbout0047 LONG POND CIRCLE - Health 47 LONGPOND RO�CFNNTERVILLE E an �� UPC 12534 No. 2 "bsrca '' HASTINGS,MN TOWN OF B STABLE LOCATIONHI LZSEWAGE # VILLAGE � ASSESSOR'S IMAP & LOT 09 D INSTALLER'S NAME&PHONE NO. DP PQ u-. ( R 0 u e r Pa L r44_ SEPTIC TANK CAPACITY I C� LEACHING FACILITY: (type) Q (size) NO. OF BEDROOMS t DtLnner,man YY1t�cV BUILDER OR OWNER C PERMIT DATE: _. COMPLIANCE DATE: J 1 9 9 Separation Distance Between the: Maximum Adjusted Groundwater Table to the 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 Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by MA Ag 36 AD Vl COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS John Graci DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119 TeaTicket,Ma. (508)564-6813 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION � 8 Property Address: 47 LONGPOND RD. CENTERVILLE Name of Owner MRS.CARDULLO <6 Address of Owner: BOX 631 CENTERVILLE Date of Inspection: 5121199 Name of Inspector:(Please Print)JOHN GRACI I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.00,) ,%_ Q� 0 Company Name: n/a � o � Mailing Address: n/a low, Telephone Number: n/a fit+ 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 inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.The system: X Passes The inpection is based on criteria defined in Title V Conditionally Passes code 310 CMR 15.303.My findings are of how the system is Needs Further Evaluation By the Local Approving Authority performing at the time of the inspection.My inspection does _ Fails not imply any warranty or guarantee of the longgevity of the septic system and any of its components useful life. Inspector's Signature: Date:6/21/99 The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(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 Department of Environmental Protection.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING SYSTEM EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. revised 9/2/98 Page 1 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 47 LONGPOND RD.CENTERVILLE Owner: MRS.CARDULLO Date of Inspection:6/21199 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: _ I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. COMMENTS: System passes Title V inspection B. SYSTEM CONDITIONALLY PASSES: Wa 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. Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not. Wa The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of_ Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. n1a Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health). _ broken pipe(s)are replaced _ obstruction is removed distribution box is levelled or replaced Wa 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 revised 9/2/98 Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 47 LONGPOND RD.CENTERVILLE Owner: MRS.CARDULLO Date of Inspection:5/21/99 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 the public health,safety and 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 ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water _ Cesspool or privy is within 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 ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well, _ The system has a septic tank and soil absorption system and the SAS 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,Method used to determine distance n[a_(approximation not valid). 3) OTHER Wa revised 9/2/98 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 47 LONGPOND RD.CENTERVILLE Owner: MRS.CARDULLO Date of Inspection:6/21/99 D. SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: I have determined that one or more of the following failure conditions exist as described 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. Yes No X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet Invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow, X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped n&. X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well, X 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.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic ompounds, ammonia nitrogen and nitrate nitrogen. X The liquid level in the SAS is over the invert pipe,is in Hydraulic Failure. E. LARGE SYSTEM FAILS: 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: 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: Yes No X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X 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 upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 47 LONGPOND RD.CENTERVILLE Owner: MRS.CARDULLO Date of Inspection:5/21/99 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No X Pumping information was provided by the owner,occupant,or Board of Health. X None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that period.Large volumes of water have not been introduced into the system recently or as part of this inspection. X As built plans have been obtained and examined.Note if they are not available with N/A, X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout, X All system components,excluding the Soil Absorption System,have been located on the site. X The 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.The size and location of the Soil Absorption System on the site has been determined based on: X Existing information,For example,Plan at B4O,H, X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) [1 5.302(3)(b)) X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 9/2/98 Page 5 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 47 LONGPOND RD.CENTERVILLE Owner: MRS.CARDULLO Date of Inspection:6/21/99 FLOW CONDITIONS RESIDENTIAL: Design flow:-440 g.p.d./bedroom Number of bedrooms(design): 4 Number of bedrooms(actual):4 Total DESIGN flow: 441? Number of current residents:-1 Garbage grinder(yes or no):YES. Laundry(separate system)(yes or no): NO If yes,separate inspection required Laundry system inspected(yes or no):M Seasonal use(yes or no):JLQ Water meter readings,if available(last two year's usage(gpd): n/a Sump Pump(yes or no): MQ Last date of occupancy: Wa COMMERCIAL/INDUSTRIAL Type of establishment: Wit Design flow: n/a gpd(Based on 15.203) Basis of design flow: n& Grease trap present:(yes or no):�LQ Industrial Waste Holding Tank present:(yes or no): NO Non-sanitary waste discharged to the Title 5 system:(yes or no):1)Li2 Water meter readings.if available:n& Last date of occupancy: n& OTHER: (Describe) n& Last date of occupancy: n& GENERAL INFORMATION PUMPING RECORDS and source of information: SYSTEM HAS NOT BEEN PUMPED IN TWO YEARS. System pumped as part of inspection:(yes or no):YES If yes,volume pumped 1000 gallons Reason for pumping: MAINTENANCE TYPE OF SYSTEM XSeptic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes.attach previous inspection records,if any) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other: n& APPROXIMATE AGE of all components,date installed(if known)and source of information: SYSTEM IS 14 YEARAS OLD. Sewage odors detected when arriving at the site:(yes or no) NQ revised 9/2/98 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 47 LONGPOND RD.CENTERVILLE Owner: MRS.CARDULLO Date of Inspection:6/21/99 BUILDING SEWER: (Locate on site plan) Depth below grade: 1C Material of construction:_ cast iron X 40 PVC _ other(explain) Distance from private water supply well or suction line: TOWN Diameter: nLa Comments: (condition of joints,venting,evidence of leakage,etc.) Wa SEPTIC TANK: X (locate on site plan) Depth below grade: J Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain) Wa If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NQ Wa Dimensions: L 8'6"H 6'7"W 4'10" Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle: M Scum thickness: Distance from top of scum to top of outlet tee or baffle:St Distance from bottom of scum to bottom of outlet tee or baffle: 1E How dimensions were determined: MEASURED 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.) SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND,RECOMMEND PUMPING SYSTEM TWO YEARS. GREASE TRAP: (locate on site plan) Depth below grade: Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain) Wa Dimensions: Wa Scum thickness: nLa Distance from top of scum to top of outlet tee or baffle:-n& Distance from bottom of scum to bottom of outlet tee or baffle nta Date of last pumping: n& 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.) nla revised 9/2/98 Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 47 LONGPOND RD.CENTERVILLE Owner: MRS.CARDULLO Date of Inspection:6/21/99 TIGHT OR HOLDING TANK: MQ (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: Wa Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain) nLa Dimensions: nLa Capacity: Wa gallons Design flow: Wa gallons/day Alarm present: NO Alarm level:jiLa- Alarm in working order:Yes_No_: NO Date of previous pumping: Wa Comments: (condition of inlet tee,condition of alarm and float switches,etc.) nLa DISTRIBUTION BOX: X (locate on site plan) Depth of liquid level above outlet invert:LIQUID LEVEL WITH BOTTOM OF PIPE Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) DISTRIBUTION BOX IS STRUCTURALLY SOUND SYSTEM IS FUNCTIONING PROPERLY PUMP CHAMBER: MQ (locate on site plan) Pumps in working order:(Yes or No): NO Alarms in working order(Yes or No): MO Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) n& revised 9/2/98 Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 47 LONGPOND RD.CENTERVILLE Owner: MRS.CARDULLO Date of Inspection:5/21/99 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: nta Type: leaching pits,number: ONE PIT UNDER DRIVEWAY leaching chambers,number: _n/a leaching galleries,number: j]La leaching trenches,number,length: Wa leaching fields,number,dimensions: nta overflow cesspool,number: nta Alternative system: n& Name of Technology: -n& Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE LEACH PIT APPEARS TO BE FUNCTIONING PROPERLY,SAS SHOWS NO SIGNS OF FAILURE.PROBED AREA,IT IS DRY CESSPOOLS: - (locate on site plan) Number and configuration: Wa Depth-top of liquid to inlet invert: nta Depth of solids layer: nta Depth of scum layer. Wa Dimensions of cesspool: nta Materials of construction: n& Indication of groundwater: n/a inflow(cesspool must be pumped as part of inspection)n& Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) Wa PRIVY: _ (locate on site plan) Materials of construction:n& Dimensions:nta Depth of solids: Wa Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) nta revised 9/2/98 Page 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 47 LONGPOND RD.CENTERVILLE Owner: MRS.CARDULLO Date of Inspection:6/21/99 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) n/a I JcI, �c QO Pb 3b AC 11 AD0 AA �sa3� bA �6 revised 9/2/98 Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 47 LONGPOND RD.CENTERVILLE Owner: MRS.CARDULLO Date of Inspection:6121/99 NRCS Report name: Wa Soil Type: Wa Typical depth to groundwater: n[a USGS Date website visited: D& Observation Wells checked: NO Groundwater depth:Shallow _ Moderate _ Deep _ SITE EXAM _ Slope _ Surface water _ Check Cellar Shallow wells Estimated Depth to Groundwater 12 Feet Please indicate all the methods used to determine High Groundwater Elevation: _ Obtained from Design Plans on record X Observed Site(Abutting property,observation hole,basement sump etc.) _ Determined from local conditions _ Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators,installers X Used USGS Data Describe how you established the High Groundwater Elevation.(Must be completed) USGS MAPS AND CHARTS revised 9/2/98 Page 11 of 11 r 7/7 LOCATION SEWAGE PERMIT NO. ``VILLAGE I-o tv Ao►ti �' 2�l 1 INSTALLER'S NAME i ADDRESS 3--Z 7-t w vU� C-S P A-V to d U 1 L D E R OR OWN ER C9 DATE PERMIT ISSUED _ DATE COMPLIANCE ISSUED F r 5 9 10oo gn6cri Pv'e `qs7 SE P ia� Ws T 13cvr, t000 CIAO, pre cR p4 aT I..E ci+ P;r Board of Health •v. . r G Town of Barnstable No.... y:. P.O. Box 534 F: . . ........ HYan �li1 MASSACHUSETTS BOARD OF HEALTH ..........OF............ r liration for Uhi Mal Works Tonstrurfiutt Prrutit Application is hereby made for a Permit to Construct �v' or Repair ( ) an Individual Sewage Disposal ySystem at: �;" 5;, 49 "1......r,�. !`?. ..----r' q�7. .....�.J. .............1 o ,_ �c.�T UiL�.. A.>................! Loa n•A dr ss or t No. !®'f ner ddr s a ....................... Installer� Address � Type of Building d 'l Size Lotg�_0'�7"®.......Sq. feet Dwelling—No. of Bedrooms......... .............................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures .----------..-----------------------•--------------"-----------"......,--•------------•---•---....••-•-•-•-- W Design Flow............ 7i57......................gallons per person,per day. Total daily flow........3.5.!?_.....................gallons. WSeptic Tank—Liquid capacity/�GLgallons Length._..:.`.. Width....°.... Diameter________________ Depth... .`-__. x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No._.....I....._....._ Diameter.../a e_s Depth below nlet..._....fea...inlet ......Total leaching area..v`�.;6�.s. .:sq-•fit.C-PZ> Z Other Distribution box (P'} Dosing tank ( ) '-' Percolation Test Results Performed by.BAX 7..a Fes...... 6... ......../joa...... Date...... .......... � � .. . Test Pit No. 1----.5___�minutes per inch Depth of Test Pit...i k.�.a_-- Depth to ground 44 Test Pit No. 2..... 'minutes per inch Depth of Test Pit___ . .. Depth to ground wateraQQ . O Description of Soil................6—ii-rZ.......... G ........ r9 J V --••••••••••••---•••-----••--•••-----•----....---•-----•--•--•---------•--•-...----•-----•...._--•--•--•----••-•---•-•------•-----------------•-•------ x .......................................................................................................--•-•--------------•---...•--••------•-•----•--••---••-•......•---............................ U Nature of Repairs or Alterations—Answer when applicable._.............................................................................................. --------------- ""-------------------- ------------------------------------------------------------------------------ Agreement: The undersigned agrees to install the afQredescribed Individual Sewage Disposal System in accordance with the provisions of TITLE; 5 of the State Sanitary Code— The undersi ned further agrees not to place the sys m/i.n operation Cer ifica of CoE��Ign been i d y the b d of ealth. -_ ••-•------••- •--- ------ -- ----------- . •- /�' ate //<Application Approve By....................... •--•• -- ----•:�•.. -• • .................................... ........ 1 o D t Application Disapproved for the following reasons---------------------•----•""----•------------------"-----7--..--------------------------------------------------- - ------------------•----------------•------•--...---•-----------•--•-----------•--•---------... .....................-_-...................---------- ••----••--•--- .................. Date Permit No. ..-•--...�.��...--•---....... Issued-------------� � ' No... FEB........... ............... THE COMMONWEALTH OF MASSACHUSETTS ` BOARD OF HEALTH r .----......OF........--4519_2x .S ?`F7-r�L . ApplirFatiou for Disposal Works Tonstrnritun Permit Application is hereby made for a Permit to Construct (; ) or Repair ( ) an Individual Sewage Disposal System at: l-0� e i7r.}� � C I IG c_C. E Ct:,(J TG7!.v i L L�.. ... •-- ��� ,v �f3AZ a ---......... - - _..... -----------------------------•---•------......--------_. ....-•-----••---. Location-Address or Lot No. ......................—.......................................................................... ..........--...................................................................................... Add W Owner ress Installer Address Type of Building Size Lot____________________ _____Sq. feet .-� Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) a Other—T e of Building ............... No. of persons............................ Showers ( ) — Cafeteria ( ) a Other g P Otherfixtures ---------------------------------- -- - --------------------------------------•---------------....---•---.._.. W Design Flow...........` _A .......................gallons per person per day. Total daily flow------- ......................gallons. 9 Septic Tank—Liquid capacity;/ra% gallons Length_..... Width.._f4'.__. Diameter................ Depth..4__,..... W FDis`osal Trench—No............... x , p Width____________________ Total Length__._..._•....._.___. Total leaching area....................sq. ft. Seepage Pit No......`------------- Diameter...�A!.5_'__ Depth below inlet.......(a......... Total leaching area; :��_sq-ft:G'�A Z Other Distribution box { ) Dosing tank ( ) a Percolation Test Results Performed by' k�_..___ .__!'J_?�(F.... +'`��_...... Date......8ry_.......� ` � -- -•-•• ,.a Test Pit No. 1----<._ :.minutes per inch Depth of Test Pit.. _G. '_''___ Depth to ground water--A )Q 77 (-.- Q fZ4 Test Pit No. 2......:�—.7-.minutes per inch Depth of Test Pit__ 4 4:' Depth to ground water" O Description of Soil..............~` T � c.....�.r� P�.� -j x --------------------........................................................ 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 T ITLE 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. Signed ••-------:.. - �9 Date Application Approved By--••... •�------._. `= i � Sys ....... .......................... Application Disapproved for the following reasons---------------------------•----------------------------•---•-----------------------•--••-----••.............--- .........•-•------------------•-------•••-•-••-•....•••--•-•...•-••--••-••-•--•--•----•-•-•••••-----••-•-•-••--•----••-----•--•----•-----•---••-•--•. •----- •••------••......--•--•--••-------- Q ._ Date Permit No.•-•-- -- ©•_0-------------- Issued._..----------- - --j ----------- ate THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF........ ............... Trrtifiratr of Tompfianrr THIS IS TO CERTIFY That the Individual Sewage Disposal System constructed or Repaired ( ) by �> --------------------------------------- -----------------------••-------•---•-- .......r................................. �/n �^ Installer at.................................... ............""`�'r�"�----•-L- :?_ = ------------C.... has been installed in accor-d'ance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No..____ l.'. '.f1�l�)__...... dated_......--------------------------------------,_. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONST E® S A 7RANTEE THAT THE SYSTEM WILL F CTION SATISFACTORY. DATE---------••--•--.---- -- • ... .....---------... Inspector.. ............................. — THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .....................OF....................... FEE....... ....-....... Disposal Works Tonstrnrtion Permit Permission is hereby granted-------------------------- ! ` .,.sr� %:_-------------------------------•-----•-----......------.........................--- to Construct ( ) or%Repair ( ) an Individual Sewage Disposal System i atNo.- ...........0 ....e.e- .......................... Street as shown on the application for Disposal Works Construction Permit No..................... Dated.......................................... ---- ..:..�•-•--•......•--------------•••--•-••---...•---.........•...............-•-•- v Board of Health DATE................• -•-- Q FORM 1255 A. M. SULKIN, INC., BOSTON 4 r Q 41 ff , .,Aa_ S I r q , D , i t t i 1 I I 1( , { a F& E x J 6:'11✓ c:/9 L E i " = i c�" — - 5 �. 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