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0081 MONOMOY CIRCLE - Health
81 MONOMOY CIRCLE, CENTERVILLE A= 190 213 BY UPC 12543No. 53LOR �a HASTINGS. MN LOCQTIO EWoC4E PERMIT 1J0. VILLAGE — — — — II�JSTQL 5 QPJ� ADDRESS 5 U I L D E R- 5 Q Qt./lE QDDRE SS .ANTE PERNKIT ISSUED '- - 7WI DATE COMPLI &l ACE ISSUED ; r . . . n r� � t. �� .2 �� � � - ��o �� 1 S�M , TOWN OF BA"R�NSTABLE Ii,OC:�TIOIv~ �L SEWAGE # 'Tx:{.AGE l'e ASSESS S MAP & LOT O 7�VSP �14 5.NAME&PHONE NO: SEPTIC TANK CAPACITY .6a© `LEACHING FACILITY: (type) �4 (/ � (size) 1006 NO.OF BEDROOMS-0�j `� BUILDER R OWNER Qe4 G� Y ��'! r r PERMTTDATE: COMPLIANCE DATE: 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 Facility(If any wetlands exist within 300 feet of ac.� �0 C�cih� !J n Feet Furnished by �1,�i�/ /v �?_M Iyl G F F - No Ca _ v Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOV!"-W-F-BARNSTABLE, MASSACHUSETTS Yes Rpplitation for Misp at 6pstem Construttion permit Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name, and Tel.No. VTO Assessor's Map/Parcel 1� Installer�'ds��V�ne,.�lddr�e s d T �c�_���1� D��e,Address,arld,Te1. o. Type of Building: Dwelling No.of Bedrooms Lot Size / sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.requ' ed) [2 gpd Design flow provided gpd Plan Date Number of sheets , Re ision Date Title Size of Septic Tank� m P �tqC Type of S.A.S. , Description of Soil Nature of Repairs or Alterations(Answer when applicable) p T ` L41 Date last inspected: Agreement: . The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Enviruntaital Code and not to lace th stem in operation until a Certificate of Compliance has been issued by thi o lth. *� d Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No. Date Issued [to PX0 PW- No. 41 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BAxNSTABLE,MASSACHUSETTS Disposal 6pstrm ettBtruction Permit s Permission is hereby granted to Construct( ) Repair( Upgrade( ) Abandon( ) System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. , ^' Provided:Construction must be co mpl eted ,within three years of the date of this pe t. F ' . Date Approved byI No. •� '. lr/ Feel THE COMMONWEALTH`OF MASSACHUSETTS Entered incomPUter: z1/ fYes PUBLIC.HEALTH DIVISION - T.y W '," FI ARNSTABLE, MASSACHUSETTS w , �« applitatlon for Ve"P ' arg�pstrm Construction 3pErmit ;"Application'for a Permit to Construct( ) Repair Upgrade( ) Abandon(, )�, ❑Complete System El Individual Components } S Location Address or Lot No. (�,� Owner's Name,Address,and Tel.No. t� , Assessor's Map/Parcel .No. Designer's Name Address,and Tel.No. Installer's Name Address and T Type of Building: Dwelling No.of Bedrooms ", Lot Size sq.ft. Garbage Grinder( ) 'Other. Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.requ' ed) a gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank i Type of S.A.S. zj Description of Soil �\ Nature of Repairs or Alterations(Answer when applicable) 77, r Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore,described on-site sewage disposal system in ; accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this�ffi alth. AA ,�ed Date to -C1 Application Approved by Date dl.� Application Disapproved by Date for the following reasons Permit No. Date IssuedLana --------------------------------------------------------------------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS (Eertificate of Compliance THIS IS TO CER IFY,that the On-site Sewage Disposal system Constructed( ) Repaired Upgraded( ) Abandoned( )by at 1 has been constructed in accordance with the provisions of Title 5 and th fo Disposal System Construction Permit dated �� !�p I as Installer Designer #bedrooms Approved desi n flow gpd The issuance of this permit hall not be construed as a guarantee that the system ill functiodjn� Date, l� Inspector '`^� ''1 own of Barnstable IWKWE Regulatory Services Thomas F. Geiler, Director B^ MASS. Public Health Division 9�'ArE639. Thomas McKean, Director 200 Main Street, Hyannis,MA 02601 Office: 508- 62-4644 Fax: 50 -790-6304 Date: �C�('� Sewage Permi r Assessor's Map/Parcel � Z� Installer &Designer Certification Form Designer: ` �� � Installer: rArE)14k-L— Address: Address: C � 6::;�44 a L On (0 Ito 2�v (f )"kI4t (iNE was issued a permit to install a (d-,Ite) (installer) septic system at 85' t, f)W{ O based on a design drawn by (address) dated (D Z® (designer) certify that the septic system referenced above was installed.substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Stripout (if required) was inspected and the soils were found satisfactory. I certify that, the. septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system).but in accordance with State & Local u '-Lions. Plan revision or certified as-built by.designer to follow. Stripout (if rp cted and the soils we e found sati tory. OF 444 wnr_ b� DABVID C"' ( nsta I Signature) MASON �i ;; 9 No.1066 o c� /ST P 4 esi er s Signature) PLEASE RETURN TO BARNSTABLE PUBLA. fE OF COMPLIANCE WILL NOT BE ISSUED UIN i iL asu i ri i ni6 r'ORVI AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. gAoffice fonnMesignercertification fonn.doc TOWN OF BARNSTABLE LOCATION t 1'-I6tiO M V di l(C&_SEWAGE# 40 VILLAGEtfyWZMW 1 4-0 ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO.C1 0ik4C 6Na)_, V2,6—/ gS✓ SEPTIC TANK CAPACITY T!�Iq AI16 t) LEACHING FACILITY:(type),Suo / 4Za e4y& size) 07 5"X �S NO. OF BEDROOMS OWNER 2!'3iV4J4- 7 0,0t.1D AA) PERMIT DATE: COMPLIANCE DATE: t7ft ;e0 _ 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 o 7 1� vb Y TOWN OF BARNSTABLE LOCATION t /�jovb M o Cl i(C&-SEWAGE# VILLAG Vr 1 AS�S"SE''SSOR'S MAP&PARCEL /,3 INSTALLER'S NAME&PHONE SEPTIC TANK CAPACITY R'k!i LEACHING FACILITY:(type)77_�� �� � maize) NO.OF BEDROOMS OWNER PERMIT DATE: 6 /6 COMPLIANCE DATE: ) 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) Edge of Wetland and LeachingFacility Feet ty(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY D/l� �,4c4 A-4- O i y� 3 i of`"E 11 Town of Barnstable Inspectional Services Department B"" M10a `� ` Public Health Division c 39. 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL#7015 1730 0001 4988 0701 March 23, 2020 BUONOPANE, DONNA M & MAIN, BARTL L JR TR 70 CALVIN DRIVE DENNIS, MA 02638 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE,TITLE 5 The septic system located at 81 Monomoy Circle, Centerville, MA was inspected on 03/04/2020 by Mark Polselli, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Fails" under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: • Static liquid level in the septic tank above outlet invert due to an overloaded or clogged SAS or cesspool. You are ordered to repair or replace the septic system within one (1)year from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE OARD OF HEALTH as c e , R.S., CHO Agent of the Board of Health Q:\SEPTIC\Title V Inspection Report Letters Mailing\Failed or Needs Further Evaluation Letters\81 Monomoy Circle Centerville.doc I . Town of Barnstable • IIAMSTABLE, A b 9 A Inspectional Services Department rfD MA'S Public Health Division 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 FAX: 508-790-6304 Thomas A.McKean,CHO Feb 6, 2007 Rev. 4/26/19 DEADLINES TO REPAIR FAILED SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) An 'Y' marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑ Discharge or ponding of effluent to the surface of the ground ❑ Pumping more than 4 times during the last year not due to clogged or obstructed pipe. ❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ❑ Structurally unsound septic tank or SAS O 1 YEAR DEADLINE CRITERIA 410�tatic liquid level in the ' above outlet invert due to an overloaded or clogged SAS or cesspool SePkL- ^" ❑ Any portion of the SAS, cesspool, or privy below high groundwater elevation ❑ Any portion of the cesspool within a Zone 1 to a public well ❑ Any portion of a cesspool within 50 feet of a private water supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO (2) YEAR DEADLINE CRITERIA ❑ Single Cesspool ❑ Any "conditionally passed systems" (broken cover, relocation of a pipe, relocation of a driveway due to H-10 components, etc) ❑ Leaching facility with standing liquid level at or above the invert pipe (per Town Code §360-20 h) OTHER Repair deadline: Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc Commonwealth of Massachusetts :. Title 5 Official Inspection Form r� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments , Property Address 5n /� O N �J N J✓J✓ G vl Owner Owners Name // —_ Al information is / � . erVI required for every page. CitylTovm State Zip Code Date of Inspec on _ 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 A. Inspector Inwt tion �hI I�fN3a filling out forms � on the computer, ✓ o e_ use only the tab key to move your Name of Inspector _�� LL'' cursor-do not / � Q f E C--1 - use the return Company Name key.li1Q Company Address ^ Od 6 %A City/Town State�CoZip Code __ '��) TelephoAe-Kurnber License Number B. Certification 1 certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); I have personally inspected the sewage disposal system at the property address listed above;the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ❑ Passes 2. ❑ Conditionally Passes 3. ❑ Nee . Further Evaluation by the Local Approving authority 4. Fails /% !nspectors ignature Date The system inspector shall submit a copy of his inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system 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 form should be sent to the system owner and copies sent to the buyer; if applicable, and the approving authority. Please note: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. 5insp.Coc•2v.?26ic0?8 ?iae ,^•i`c= 'sce.nor.--'n'.S�Csur"ace Se..2ge socsai System•Page'of?8 Commonwealth of Massachusetts - F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address /J� ov10 Gv1-L Owner Owner's Name information is X� 0�3a d o � � required for every Q N v0 Ile— page. City/Town State Zip Code Date of Inspe bon C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: 2) 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): [5insp.00c•rev.726/2018 Tore 5 O`5aa,inspection Fora:Suosurace Sewage Disposal System•?age 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form lk�" Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address �uoho w� Owner Owner's Name information is � del AW Oar,3d, 2 a, required for every ,� page. City[Town State Zip Code Date of In ectio C. Inspection Summary (cost.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box.System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) 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. a. 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: t5insp.doc•rev.7/26/2018 -ide 5 of oai;nspe=on roan:subsurface sewage oisposai system•?age 3 of 18 Commonwealth of Massachusetts �- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -NNot for Voluntary Assessments Property Address &O N O G Owner Owner's Name 14 information is / eµ � 0-6 z, o?t� required for every �/ page. City/Town State Zip Code Date of Ins ection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well'. Method used to determine distance: **This system passes if the well water analysis; performed at a DCP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes o Backup of sewage into facility or system component due to overloaded or ged 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 -itle 5 O OB;'ns?ec ior.Poi^:subsurface see age Disposal System•?age<of 18 Sinsp.tloc•rev.7262018 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �� O ( ONp�N1v Ct r Property Address, &40&4%0 a Owner Owners Name / information isQ lot required for every page. Cityfi own State Zip Code Date of lnspec6 C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ✓vv.- J L_ 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 5" below invert or available volume is less U than'/2 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. El Any portion'of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 7 y portion of a cesspool or privy is within a Zone 1 of a public water supply well. El Any portion of a cesspool or privy is within 50 feel of a private water supply well. U V' 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 2000 gpd- 10,000 gpd. 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. 5) 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 C.4. Yes No 7 ❑ 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 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 t5insp.Goc•rev.M62018 Tiae 5 t78cai inspection For:Subsurace Se rage tisoosal System-Page 5 of 18 t Commonwealth of Massachusetts Title 5 Official Inspection Form • r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address L4Ovld 4 Owner Owner's Name information is required for every page. CitylTown State Zip Code Date of Inspe 'on C. Inspection Summary (cont.) If you have answered"yes' to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed.The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no" for each of the following for all inspections: Yes o ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ Were any of the system components pumped out in the previous two weeks? ❑ as 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 El this inspection? ❑ Were as built plans of the system obtained and examined? (if they were not available note as N/A) ❑ Was the facility or dwelling inspected for signs of sewage back up? �❑ Was the site inspected for signs of break out? ❑ Were all system components, excluding the SAS, located on site? ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? �❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Existing information. For example: a plan at the Board of Health. ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] Title j af5pai inspe.7jon Forn:subscdace sewage Disposal system•Page 6 of 18 t5insp.doo rev.7/26/2018 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4 Property Address Owner Owner's Name /� information is c I_ _ `� � 3�- 3/?bv required for every �/Ge�V page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Description: t"Ooo G„61o,7 Ild o 9 f- Number of current residents: Does residence have a garbage grinder? ❑ Yes Nc Does residence have a water treatment unit? ❑ Yes No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes No information in this report.) Laundry system inspected? ❑ Yes 2 - ll�o Seasonal use? ❑ Yes E�, Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes No Last date of occupancy: Date Tlue 5 C fdaj:nspecdon Pcrm.sucsudace sewage Disposal system.Page 7 of 16 t6insp.doc-rev.7126i2018 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name /^ �Wv# information isH /� ,�1 1 6�� ?required for every �-+� !� Vd Ogo page. City/Town State Zip Code Date of InsrActiont D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitarywaste discharged to the Title 5 system? ❑ Yes ❑ No 9 Y Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes o If yes; volume pumped: gallons How was quantity pumped determined? Reason for pumping: • -ite 5 offiaa;inscecnon Form:Suos�rface sewage Disposal system•?age 8 of 18 t5irtsp.tloc rev.7fZ6l20i6 r <;NN Commonwealth of Massachusetts 1F Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name CV14 y /Cinformation is / /r _?Ac/,�o required for every l/ page. CityfTown State Zip Code Date ofTns/ectiorf D. System Information (cont.) 4. Type of System: ❑ Septic tank, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) d so ce of information: Were sewage odors detected when arriving at the site? ❑ Yes o 5. Building Sewer(locate on site plan): Depth below grade: feet Ma:r-as;t ?iron ` ction. ❑ 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): 39e 5 r"aai nspecticn For.subsurface sewage oisposai system•Page 9 or 18 t5insp.doc•rev.712512018 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments / Property Address YW 0 V1 0, Owner Owner's Name information is C-eorequired for every 7�c� 6 KKK page. City/Town State Zip Code Date of Insp coon D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: feet Material of nstruction: ncrete ❑ metal ❑ fiberglass ❑ polyethylene ❑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: Sludge depth: ? Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle � How were dimensions determined? Z49 Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): �1/� �vuo r ��.�e✓ry i✓tt. �� �K !✓ ep,bores �JC2✓' 71ae 5?MCUaj Irspecaon Zorn:SL'CSU-ace Sewage Disposai System.?age 10 of 18 t5insp.cioc•rev.7126/2W8 Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form --Not for Voluntary Assessments JVVW9 C! Property Address `J O✓7c� 4 K-L Owner Owner's Name information is required for every CeK ""• e // 3 a-o page. City/town State Zip Code Date of ins6ectich D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet 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: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage; etc.): 8. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc-my.7126=18 'me 5 OfSaa'inscemon Form:Suoscrface Sewage Disposal system•Page 11 of 1a Commonwealth of Massachusetts _ Title 5 Official Inspection Form ti Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1_ fl r Property Address vi- Owner owner's Name /� e� Ac /information is .Qyy 0,49 required for every State Zip Code Date of inspe on page City/Town D. System Information (cost.) 8. Tight or Holding Tank (cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). is copy attached? ❑ Yes ❑ No 9. Distribution Box (if present must be opened) (locate on site plan): Depth of liquid ievei 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.): ------------------------- +Je S 075cai:nspacuon.`Jrm.Suosurface sewage Disposal system•page 12 of 18 t5insp_doc•rev.7252015 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 01i1t%N�o CI•^ Property Address uyho�G� Owner Owner's Name / /�� 0� information is H v` /i required for every page. City/Town State Zip Code Date of Ins p coon D. System Information (cont.) 10. 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.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located; explain why: Type leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number; length: leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovabveialtemative system Type/name of technology: ---- ----- 'sae 5 ot`ioa::nsPezion Form:Suos,.ace Sewage Disposai system•Page 13 of 18 t5insp.doc-7ev.726/2018 I Commonwealth of Massachusetts :. 9 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address �,S�i o✓�� a� Owner Owners Name v` /e. env vc76 �� di) information is ` required for every page. City/Town State Zip Code Date of In ctiont D. System Information (cost.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 04 ell✓J 7�g 0 7' / 04-a cy Ir c -7<1. 16fe-ve 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): t6insp.doc•rev.7/2612018 me Four.sucsu�ace sewage oisposai system•?age 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r -9l /41oKor410 C� Property Address �7u 000 QN,e- Owner Owner's Name // information is !�/// �/ U required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): Tice 5 Ofnaa,;nsoecoon=onm.suosua`ace sewage Disposai system•Page 15 of 18 t5insp.tl0c•rev. /26201 8 Commonwealth of Massachusetts P Title 5 Official Inspection Form Subsurface Sewage Diissp/osal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name information is required for every page. City/Town State Zip Code Date of Ins ctio D. System Information (cost.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or ben marks. Locate all wells within 100 feet. Locate where public water supply enters the buildin eck one of the boxes below: and-sketch in the area below ❑ drawing attached separately � I i A i I i i j I i I l , t5insp.00c•rev.7126/2018 -ue 5 Offidal Yspe%Oon=om:Sut=.rf ce Sewage Disposal System-Page 18 of 18 Commonwealth of Massachusetts ip Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address A/O 00 01�� 64 0N0 Q$4 L Owner Owner's Name AAA information is / I /!�/ /' ^� required for every CecA Y�(/G � /� V� � � o�C7 page. City/Town State Zip Code Date of In pectin D. System Information (cost.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells /� � � �� Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked; date of design plan reviewed: Date ❑ Observed site(abutting propertyiobservation 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: awc�4N zfina�_'41c:1 Before filing this Inspection Report, please see Report Completeness Checklist on next page. Sinsp.doc• ev.7262018 `e 5 0�5aai irspeaon=or:Subsurface sewage Disposal System•Page 17 of 1S cN Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address d Owner Owners Name / 4 �63aZinformation is required for every ---ftt---G��f"� A/ page. City/Town State Zip Code Date of spe ion E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: A. Inspector Information: Complete all fields in this section. B. Certification: Signed & Dated and 1, 2, 3, or 4 checked inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Fail Criteria)and 6 (Checklist) completed System Information: For 8:Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included -;ue 5�5aa7 Inspection For.:Suosur aae Sewage Disposal System•?age t8 of t8 t5insp.doc.rev.7126/2018 BORTOLOTTI CONSTRUCTION,.INC. 2 765 WAKEBY ROAD,MARSTONS MILLS,MA 02648 "90, ,t 508-771-9399 508-428-8926 FAX: 508-428-9399 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM n� PART A 19 . CERTIFICATION Property Address: Date of Inspection: — In c or's Name: Owner's ame and Addr A'U' d CERTIFICATION STATEMENT* I certify that I have personally inspected the sewage disposal system at this address and that the informa- tion reported below is true,accurate and complete as of the time of inspection. The inspection was per- formed based on my training and experience in the proper function and maintenance of on-site sewage disposal Xsiems. The System: Passes Conditionally Passes Needs Further Ev luation By t Local Aproving Authority Fails Inspector's Signature: Date: 7��/�( The System Inspector shall submit a copy of this inspection report to the Approving authority within thir- ty(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. INSPECTION 1MMARY• A)SYS AS I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B)SYSTEM CONDITIONALLY PASSES; One or more system components need to be replaced or repaired. The system,upon comple- tion of the replacement or repair, passes inspection. Indicate yes,nor,or not determined(Y,N,OR ND). Describe basis of determination in all instances. If "not determined",explain why not. The septic tank is metal,cracked,structurally unsound, shows substantial infiltration or exfiltration,or tank failure is imminent. The system will pass inspection if the existing sep- tic tank is replaced with a conforming septic tank as approved by The Board of Health. Sewage backkup 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): - 1 - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Broken pipe(s)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: 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: 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. 2)SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTION- ING 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 with 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 the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal.to or less than 5 ppm. D)SYSTEM FAILS: 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. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of efluent to the surface of the ground or surface waters,due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clog- god SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped -2- L I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a 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 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. 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. E)LARGE SYSTEM FAILS: The following criteria apply to a large system in addition to the criteria above: The design flow of a system is 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: The system is within 400 Feet of a surface drinking water supply The system is within 200 Feet of a tributary to a surface drinking water supply The system is located in a nitrogen sensitive area Interim Wellhead Protection Area (IWPA)or a mapped Zone II of a public water supply well. 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. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Check if the following have been done: — 'Pumping information wa's requested of the owner,occupant,and Board of Health. _None of the system components have been pumped for atleast 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. t,"-As-built plans have been obtained and examined. Note if they are not available with N/A. _!!"'The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. , The site was inspected for signs of breakout. All system components,excluding the Soil Absorption System, have been located on site. _ The septic tank manholes were uncovered,opened,and the interior of the septic tank was in- spected for condition of baffles or tees,material of construction,dimensions,depth of liquid, depth of sludge,depth of scum. The siie and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. , -3- SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM PART B CHECKLIST(continued) _ fhe facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Subsurface Disposal System SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION FLOW CONDITIONS RESIDENTIAL: t/ Design Flo*:__2_3 U allons Number of Bedrooms: o.� Number of Current Residents:_ Garbage Grinder: A Laundry Connected To System: VyE5 Seasonal Use:, d Water Meter Readings, if Table: Last Date of Occupancy: CO MERCIAUINDUSTRIAL:/1 V Type of Establishment: Design Flow: ° gallons/day Grease Trap Present: (yes or no) Industrial Waste Holding Tank Present: Non-Sanitary Waste Discharged To The Title V System: Water Meter Readings, If Available: Last Date of Occupancy: OTHER: Describe) Last Date of Occupancy: GENE FORMATIO PUMPING RECORDS and source of information: _Ql � System Pumped as part of inspection: If yes,vol a pumped: gallons Reason for pumping: ' TYPE OF SYSTEM• Septic.Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy Shared System(If s,attach previous inspection records, if any) Other(explain): % ? -ARPROXIMATE AGE of all co m nent ,date installed(if known)and source of;information: dzt 7 Sewage odors detected when arriving at the site: AID -4- I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C GENERAL INFORMATION (continued) SEPTIC TANK:_� Depth below grade: // Material of Construction: ✓concrete metal FRP Other (explain) Dimisions.?,�'',r&'r Sludge Depth: n Scum Thickness: Doe Distance from top of sludge to bottom of outlet tee or baffle: 36 Distance from bottom of scum to bottom of outlet tee or baffle: ,y®r/ Comments:(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation jo outlet invert,structural integrity idence of leakag ,etc.),-1;j�-,S -fir (-IDCW- a Gcl GREASE TRAP: Depth Below Grade: Material of Construction: concrete metal FRP Other (explai n) — — — _ Dimensions: Scum Thickness: Distance from top of scum to top 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.) TIGHT OR HOLDING TANK: Depth Below Grade: Material of Construction:_concrete_metal_FRP Other(explain) Dimensions: Capacity: gallons Design Flow: gallonstday Alarm Level: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: 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:_ Pump is in working order: Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) -5- y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SOIL ABSORPTION SYSTEM(SAS):_L� (Locate on site plan, if possible;excavation not required, but may be approximated by non-intrusive methods) If not determined to be present,explain: Type: Leaching pits, number: / Leaching chambers, number: Leaching galleries,number: Leaching trenches,number, length: Leaching fields, number,dimensions: Overflow cesspool,number: Comments: (note condition of soil, signs of hydraulic failure level of ding,condition ofvegetati , etc.) /i ,} ag oG , CESSPOOLS: 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(cesspool must be pumped as part of inspection) Comments: (note condition of soilk, signs of hydraulic failure, level of ponding,condition of vegetation, etc.) PRIVY: ,d/a Materials of construction: Dimensions: Depth of Solids: Comments: (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.) -6- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) . SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent references, landmarks or benchmarks. Locate all wells within 100 Feet. I 0 ' 0 0 DEPTH TO GROUNDWATER: Depth to groundwater: / Feet �I Meth-1 of Determination or Approximad : 7� i O O O afro d . -7- NSS. Finc/ .................. THE COMMONWEALTH OF MASSACHUSETTS ARD O HEALTH _. . . . . . .. .. ..............OF....... -. .. _.. ............... ............... Appliratiun -fur Uiipuuttt Worko Tunutrurtiun Prrntit Application is hereby-made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: k ------ ............tYC � .. c ion-Ad or a Owner Address ------ ---------- •..... ....................................................... ............................ ..... .......................... Installer Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms-------- --------------------------Expansion Attic ( ) Garbage Grinder Wm/ aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) d Other fixtures ----------------•-----......--•----•------......---------------..........---------------------•---•--- --� __� 5-----•------—------------------------ W Design Flow------- —�'..... v lops per person per day. Total daily flow-------- a....4' ..................gallons. WSeptic Tank L Liquid capacity. ----_---gallons Length---------------- Width.----..-.------- Diameter_.-.--_-.----_ Depth-............... x Disposal Trench—No. .................... Width--------- "et Len�"l�- _;_--_.---------- Total leaching area_..____.._._..._____sq. ft. Seepage Pit No-------I------------ Diameter../_0 .._._. l w inlet.................... otal acliing area------------------sq. ft. Z Other Distribution box ( ) Dosing tank ( )-,I l 7' �� OrAT a Percolation Test Results Performed bY.................P ... _ -___.__--_____--_.-------_____.-__--.-. Date................_------------------ :.-.. Test Pit No. 1________________minutes per inch Depth of "Pest Pit.......__._......._. Depth to ground water...--------------------- rX, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-----------.------------ ---- Dt 9ription of oil . ' -- ----.---- .--- ----- l/00 9 (m •------------------- --- .• x ---------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------- 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 \I of the State Sanitary Code—The undersigl further agrees not to place the system in operation until a Certificate of Compliance has been issued by th anLh.ealthSi ----- - 1,14 " ------•-- .j 2�Date.f Application Approved By.__... J'r1- lam!=------------------------ ...... ---- `� / ••--------------•-------•----.__..Date Application Disapproved for t --............the following re¢sons___________________________________________________________ ------------------------------------------------------------•••---------•--------------------•---------------------••----•---------•-------------- ----------------------------------------------------- Date PermitNo......................................................... Issued........................................................ Date bl No.........................r t', FEE ,/ .................. THE COMMONWEALTH OF MASSACHUSETTS 44��PARD.. QF HEALT�oF....... ► `,--�-t/1-'.................�... ...------------- Apphration -fur Bi,ipunttl Works Cnnnntrnrtimn Vrrntit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at � � ...---�---------•-----•.................. .......................... , 1. �' ? ocakion-Addr ss or - = .... Owner Address ......................................................... Installer Address UType of Building Size Lot------------------------_--Sq. feet Dwelling—No. of Bedrooms-------n—---------------------------------Expansion Attic ( ) Garbage Grinder Wd) aOther—Type of Building ---------------------------- No. of persons_--.-----------.----------- Showers ( ) — Cafeteria ( ) dOther fixtures ------- ---------------------------•------------•- ---------------------------------------------------------------------------••--------------------- W Design Flow............ S:7-d..... .gallons per person per day. Total daily flow.......... '? .................gallons. WSeptic Tank L Liquid capacity/t gallons Length---------------- Width------ ......... Diameter....._._.._..... Depth................ x Disposal Trench—No. .................... Width._..-.---(��,�.��Tot Le,i h�-.----_----- Total leaching area....................sq. ft. Seepage Pit No------1............ Diameter..�t _-_-----llept e ow in e .................... Total leaching area------------------sq. ft. z Other Distribution box ( ) Dosing tank -7 7' Percolation Test Results Performed by y a --�------—---------------------------------- Date------------------------------------._.. Test Pit No. 1----------------minutes per inch Depth of Test Pit.................--. Depth to ground water................._...... fX, Test Pit No. 2----------------minutes per inch Depth of Test Pit.....-..------------ Depth to ground water.........--------------- P4 -------- O D�sg iption of oil Q.'_G f r - - �� �_. P ---------------------- -• w ---- ', - V Nature of Repairs or Alterations—Answer when applicable................................................................................................ ---------•-------------•---•-----•----------------------•--.....---•-----------------...-----------------------------------------------•------..........----------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersign�A�d further agrees not to place the system in operation until a Certificate of Compliance has been issued by toar �df health. Sign --- .. .......... ........ -•-•----••----•--•-•-•--------------- Date / Application Approved BY---- - -- -•--•-•--- -----`---`---74�------- Date Application Disapproved for the following reasons:----------•--------------------------•-•-------•-•----....-•--•-•-•---------------•----------------------------- ..-------•------•--•------------------------------------•---------------...---------•-••-----•--••------ Date PermitNo......................................................... Issued.------................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......OF........... ........................................ ... Orrrtilirate of ITAntpliaurr bTHIdSCERTI That the Individual Sewage Disposal System constructed ) or Repaired ( ) by / ...... -------- - s er rt ee /_ has been installed in accordance with a the rovisions of : fide XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit ------------------- dated... ...7�-.--.-..--------- THE ISSUANCE OF THIS CERTIFICATE SHALL. NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SAT TORY.00 . DATE.........el.... / -------•---•--- Inspector---- -- THE COMMONWEALTH OF MASSACHUSETTS *..'a--- BOARD OF HEALTH .............'........... 1.......OF.......6Gvice.". _.................................................. ///�-)) No......................... FEE.f..(,C.............. Bi>polial k,q Tonstrnrtinn Prrntit Permission, i�.hereby granted / ( / to at N Al ns uct, (l�/) or Re it ( ) an Individu Sewa , Dis osal S�stem /; �2.`/,' ., J_ Street as shown on the application for Disposal Works Construction Pep No C . 7 ated ------- -------- Board of Health DATE--------------•-------.......--------------------------------------------------- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS BY DATE SUBJECT .......... S KI a Z T NC:. OF CHKD. BY OATS' _._. _... ,. _ JOB NO. +1 RICHARD � V C QT-sz% u& A. rR CAXTE RAW._ l'Zgr—s&Go,) .. c�,e rl x y r"l-/.4 r 7-6 X'ov-0,04 77 01 �. �+� Wiz: C'�►: ��, Shown/ E oN Cv t/f`DE'iylS TO 7,-VS 2.G��cJ/ A'�t;�,* O,c T.5✓Gs. J2auV�c? O/_ Q I LE �.. ► AFL 190 L�-; "i-atc-Fpvironmef!tal ( fvi- Town Z_ I (if Health Rep v IQ 0 septic syst!�ir;as `,`iin la n sh a not be instr-, ix-:J -,Sed town _eves approval ink %;rmit fromi.the app•i ol;,,; to j;JS )11,4 j:,11 si 1.1;I; �f!,�rjy th-P !acaticr c- _;,evie-'Z 117L i';] ex!STing S&Pfic rrf)�,`I�,,._ 47 Pit -'cl-jettule 40 F at feet gravlo., c,_-wer pi b�,4 in.— VC ":e firssN .7 z t distribLrbon box �oj�jfl b-�, 1�ve!. AN connections tc; tit J e., �s seo°J a toe any aimer I -design ula! for property lino d. e!- Ti-te v 4 ...... I Z-7 -kin -.'em-p-ments H20'oaded,A L 3 shall be ptahm 1) exi g1, S h t p %h1, . . rifloeTj h j, I"ap pi�jj;gj .dard fill_-j 1i� r �t::`h3nclurlment within the. _!,imposed SAS chal; be with r+ C-f)tiC COMP01EMS MP water sen�ice line. Se,t:- oezl sng at water r hitie -aft _rl' -.vawr serv- �.Jtjle 40 PV' Wjt�! sev". Pr ! 'it) the hc:ng -IC Mle it j�tL a rb a P_g i i n d E- E, re t to -r r- i-rwer(y xid the strucm.:;. civing ti I il p c I) l e�* an be insa l�eevmecmvrepresfif ' c fl 9 of bedroom�.an�' property owner appi-ove !-_r Tile det%ivc e pmp�*� -o- --�vz-.nt of. *-e n ..';iall, � :' At('f ib- bv th --j?i re Vaf':� PIR 1 T L_ thf�PY r , i -'_ - 'r �i ! �0 jily 0j Tjji> 1 1!a _ C) r'tic- val-dil e.xt)!fp C'n i1he Qll�ti Plan On), IJ L �:-_ ZSTCL 1/07 'A. Y z ---------- We -T,C f 4 j7 j, qp- -- (0 �L.q ZIP P9 �WKRD q, 7,� '2 ter l C, v 4 L 6 171 7�",�Lt Y� A9146 1AN ------ cc), fn g kA OF 414, 37 D VID cn I MASON No 1066 lAj Ji 4_1D 7' el