The URL can be used to link to this page

Home My WebLink About0108 NORTH PRECINCT ROAD - Health 108 North Precinct Road -- Centerville A=>148-127 IN 1 5 MEAD® No.2.153LOR UPC 12534 smead.com • Made in USA I i I ' Commonwealth of Massachusetts Titre 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary QAssessments r l O D 11119N V_ �eC' ki C' Y�� Property Address / F�d2d't GV Owner owner's Name information isCe-146 I-t t Me, � D a�a 1 S required for every . page. City/Town State Zip Code Date of I pectin Inspection results must be submitted on this form. Inspection forms may not be altered n any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, I �j use only the tab 1. Inspector: � 111��fffr It, key to move your cursor-do not use the return key. Name of Inspectp� 't-ly/ llo — j EG A/ _ Company Name Company Address M I G1 S 7`1'lq ib r Cityf town State Zip Code ro 7 75-7NI'T-1 o 9.2 j Telephone Nu r License Number B. Certification I I certify-that I have personally inspected the sewage disposal system at this address and that tf1e---� information reported below is true, accurate and complete as of the time of they nspection.-The ins coon was performed based on my training and experience in the proper function anal maintenance of ofsite sewage disposal systems. I am a DO approved system inspector pursuant to Section, 5. f Title 5 (310 CMR 15.000). The system: N 2-'-Passes l ❑ Conditionally Passes ❑ Failsco I ❑ Needs Further Evaluation by the Local Approving Authority o_n I P-- i M S_ -U /l Inspector Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authod (Hoard of Health or DEP)within 30 days of completing this inspection. If the system is a shared sy tem or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall subm t the report to the appropriate regional office of the DEP. The original should be sent to the syst owner and copies sent to the buyer, if applicable, and the approving authority. *"'This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the futjre under the same or different conditions of use. l tsins•11r10 Title s Offer Inspection Form:subsurface Sevsge Dft Q�Syst I •Page 11017 i j I ` Commonwealth of Massachusetts i Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �D q /f/0►' 4 ie6/ &1 c �L Property Address // L Owner Owners Name information is Ceo4e1 ✓!".( Ili O l �pl � / required for every / o� L _ page. City'Town State Zip Code Date ofInspectfon B. Certification (cunt.) Inspection Summary: Check A,B,C,D or E /always!complete all of Section D A) 7SYStePasses:e not found an information which indicates that an of the failure criteria y y descnb in 310 CMR 15.303 or in 310 CMR 15.304 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 o 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) isl 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. i • A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Cert sate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): i I t5ins•11/10 Title 5 OftictW Inspection Form:Subsurface Savage Disposal Stilt Page 2 of 9 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address �— Owner Owners Name information is / '� D� 02 required for every ( h 71^Qr��!/ page. Cityrrown State Zip Code Date of Inspe 'on B. Certification (cunt.) i B) System Conditionally Passes (cont.): ❑ 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.distribution 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): I ❑ The system required pumping more than 4 times a year due to broken or obstructed pi�(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain beiowl ): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): I I _ I 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 MR 15.303(1)(b)that the system is not functioning in a manner which will protect pu lie health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water i ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•11110 Title 5 Official Inspection Forth:Subsurface Selvage Disposal Syst$ •Page 3 of 17 i i t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Owner's Name Ile— _informations o,vl AY /`�) / 3)required for every (/O`t7 pL page. City/Town State Zip Code Date of I nspe&ion B. Certification (cont.) i 2. System will fall unless the Board of Heatth (and Public Water Supplier, If any) determines that the system is functioning in a manner that protects the public h alth, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS i within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS land the SAS is within a Zone 1 of a pul lic water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. i ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet of more from a private water supply well". Method used to determine distance: i This system passes if the well water analysis, performed at a DEP certfed laboratory, f Ir 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. 3. Other: i I I i I I I i i D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all Inspections: Yes No ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool I ❑ Q/' Discharge or ponding of effluent to the surface of the ground or surf ce waters L�J due to an overioaded or clogged SAS or cesspool ❑ LIB tatic liquid level in the distribution box above outlet invert due to an overloaded or dogged SAS or cesspool ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow t5ins•11110 r&5 Ofri al Inspection Forth:Subsurface Senepe Disposal Syst •Pape!of 17 I i ` Commonwealth of Massachusetts 1 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments I IpR Property Address Owner Owners Name information is required for every r-1-65-10 page. Cityrrown State Zip Code Date 6f insp6ction i B. Certification (cost.) Yes No El �// Required pumping more than 4 times in the last year NOT due to clo6ed or u 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. . ❑ [R""� Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ Any portion of a cesspool or privy is within 50 feet of a private water upply well. ❑ L� Any portion of a cesspool or privy is less than 100 feet but greater th n 50 feet from a private water supply well with no acceptable water quality an lysis. [This system passes if the well water analysis, performed at a DEP ce ified laboratory,for fecal coliform bacteria indicates absent and the resence of ammonia nitrogen and nitrate nitrogen Is equal to or less tha�l 5 ppm, provided,that no other failure criteria are triggered. A copy of th analysis and chain of custody must be attached to this form.] ❑ �/ The system is a cesspool serving a facility with a design flow of 2000gpd- 10,OOOg pd. The system fails. I have determined that one or more of the above f El 'lure criteria exist as described in 310 CM 15.303, therefore the system ails. The system owner should contact the Board of Health to determine what ill be necessary to correct the failure. E) Large Systems: To be considered a Large system the system must serve a facility w�th a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking watei supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead F Irotection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered"yes" to any question in Section E the system is considered a signifidant 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. teuns•„no rma s ors i � Forth:Subsume Sewage Diaposel Systdn•Page 5 of 17 1 i i Commonwealth of Massachusetts Title 5 Officinal Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address / ��/ •� Owner Owners /' /f�A O information is / PN��/�///� �/3 ,51d3 required for every l� t� A/— page CityrrovM State Zip Code Date o Ins 'on C. Checklist i Check if the following have been done. You must indicate"yes" or"no" as to each of the fc Ilowing: Yes No Q/❑ Pumping information was provided by the owner, occupant, or Board qif Health I ' Were any of the system components pumped out in the previous two weeks? ❑ Has the system received normal flows in the previous two week period? ❑ ED,--' 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 woe not available note as N/A) — / I Ld� ❑ Was the facility or dwelling inspected for signs of sewage back up? i ❑ Was the site inspected for signs of break out? ❑ Were all system components, excluding the SAS, located on site? L'7 ❑ Were the septic tank manholes uncovered, opened, and the interior�j 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) providetl 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 isiat issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information i Residential Flow Conditions: 3 Number of bedrooms (design): Number of bedrooms (actual): - J DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): - t5ins•1 ill Idle 5 Official inspection Forth:subsurface Sewage Disposal sys -Page 6 of 1 i i Commonwealth of Massachusetts Titlb 5 Official Inspection., Form a Subsufface Sewage Disposal System Form - Not for Voluntary Assessments Property Address L I _ Owner Owner's Name information is CeN �VI AW O�b ?J- � oZ.7 k I _ required for every page. City/rowr1 State Zip Code Date of I pectin D. System Information Description: DPP 00 wr G�G i� Number urrent residents: _ Does residence have a garbage grinder? ❑ Yes U No I � Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes 2 -_No Laundry system inspected? ❑ Yes Seasonal use? ❑ Yis o Water meter readings, if available(last 2 years usage (gpd)): � -- Detail I Sump pump? ❑ Yes (B Np Last date of occupancy: C_ ✓/6n �— Date Commercial/industrial Flow Conditions: Type of Establishment: _ Design flow (based on 310 CMR 15.203): I _ Gallons per day(gpd) i Basis of design flow (seats/persons/sq.ft., etc.): i Grease trap present? i ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No I Non-sanitary waste discharged,to the Title 5 system? ❑ Yes ❑ No i Water meter readings, if available: i r5ins-11/10 rroe s Official inspection Form:subsurface Sewage i syy�„•Page 7 of 17 i I I II Commonwealth of Massachusetts j Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Owners wner's Nam / information is �e� �� /le- Q�6 required for every ` page. CitylTown State Zip Code Date of l4spectiofi I D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): � I I General Information i Pumping Records: I Source of information: i Was system pumped as part of the inspection? ❑ Yes ❑I No If yes, volume pumped: gallons How was quantity pumped determined? I - Reason for pumping: -- Type of Septic tank, distribution box, soil absorption system Single cesspool i ❑ Overflow cesspool [[] Privy i Shared system (yes or no) (if yes, attach previous inspection records, if any) Innovative/Altemative technology. Attach a copy of the current operation a d maintenance contract (to be obtained from system owner) and a copy of I est inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. j ❑ Other(describe): I f5ins•t i/t0 Tdie 5 Of W nspedion Form:Subsurface SeMepe Disposal Syst�n•page 8 of 17 i I I i Commonwealth of Massachusetts Title 5 Officinal Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments " /00 Property Address �was Owner Owners Name Cey�e� /� D�26�.Z information is � required for every page. Cityrrown State Zip Code Date 6f I nspdcbon D. System Information(cunt.) Approximate age of all components, date installed (if known) and source of information: 02oo6 — /(ia°r,✓ Were sewage odors detected when arriving at the site? ❑ Yes 9-Io — Building Sewer(locate on site plan): Depth below grade. feet Material of construction: ❑icast iron 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet i Comments (on condition of joints, venting, evidence of leakage, etc.): I i Septic Tank (locate on site plan): Depth below grade: feet Mate ' of construction: concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ oth ,r(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Ye$ ❑ No Dimensions: ��X Sludge depth: _ r _ i t5irtc•11/10 Idle 5Ofrrdel I I nspedion Form:Subsurface$snags Systbm•pegs 9 d 17 i Commonwealth of Massachusetts Toth 5 Official Inspection Form ' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address /Q Cromer Owners Name information is P, ,"(-l//It required for every C� /✓r� oa6�� 5 a3 a page. City/Town State Zip Code Date Inspe ion D. System Information (cont.) I Septic Tank (cont.) j Distance from top of sludge to bottom of outlet tee or baffle � Scum thickness i It-// Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle i How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): i / �^ - U!� 1 � e 6 o lM ln'1 t°H NG 01, '7 Q n.► C'/ /moil, S Grease Trap (locate on site plan): I Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness I Distance from top of scum to top of outlet tee or baffle i Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date (Sins•,vio rule 5 offiaal Inspection Form:Subsurface Sewage Disposel System Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments /0? 410rf'L, Pe C 10' Property Address Owner Owners Name information is �N �V!/� � /�]� required for every page. CitylTown State Zip Code Date of nspecti n D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): I I I Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): i Depth below grade.- Material of construction: s ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: i I Capacity: gallons i Design Flow: gallons per day Alarm present: ❑ Yes ❑ No i Alarm level: Alarm in working order. ❑ Yes No I Date of last pumping: ! _ Date Comments (condition of alarm and float switches, etc.): j i I Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No 15ins•11/10 Title 5 Oflidal Ins pedan Form:subsurface Sevspe Disposal System•Page 11 of 17 i Commonwealth of Massachusetts Title 5 Officinal Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments /0-51 At 0✓ ilP C f h �- I Property Address Owner Owner's Name Zet,11f information is ce",4r�,714_ d� S� U /required for every / I��/ . page. City/Town State Zip Code Date df Inspe6tion D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert ILt-'e Comments note if box is Level and distribution to outlets( equal, any evidence of solids ca4over, any evidence of leakage into or out of box, etc.): J �o Lit✓ s Pump Chamber(locate on site plan): Pumps in working order. >>� Yes ❑ Nol I Alarms in working order: Yes ❑ Nol i Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.); i i I i Soil Absorption System (SAS) (locate on site plan, excavation not required): I If SAS not located, explain why: I i I I ISins•t 1/70 Title 5 Official Inspection Fonn:Subsurface SeNege Disposal System,,•Page 12 or 17 i 4N- Commonwealth of Massachusetts Titre 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner information is owners Name ��7�� equired for every //%,/�T 013 L11 page. City/Towit State Zip Code Date of ftpecbdn D. System Information (cont.) i Type: I ❑ leaching pits number: ! ❑ leaching chambers number: - ❑ leaching galleries number: - ❑ leaching trenches number, length: ! - leaching fields � number, dimensions: i ❑ overflow cesspool number: ❑ innovative/alternative system T /name of technology: -- Type/name 9Y� -- Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): I Number and configuration Depth—top of liquid to inlet invert -- Depth of solids layer Depth of scum layer I Dimensions of cesspool Mdterials of construction Indication of groundwater inflow ❑ Yes ❑ Nb t5ins•11/10 rrtle s Otfiaal .nspedion Form:Subsurface Sewage Disposal System.Page 13 of 17 I i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments t o /v o r C -�— QC) Property Address Owner Owners Name /��,/j,�l�� / information is L'L /1 required for every Ge w��t l� �6 �pLl page. City/Town State Zip Code Date of Inspection I D. System Information (cont.) i Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): i i Privy(locate on site plan): Materials of construction: — i I Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): i i I t5ins•11110 Title 5 cxr"w Inspection Form:subsurface Sewape Disposal systeml•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments /y 0'44 Ae c-t 4 4 c Property Address Owner Owners information Cep +v`/ L i //� Od 6'70� required for every page. city/Town State Zip Code Date 94 insspe6fion D. Sylstem Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where blic water supply enters the building. Check one of the bones below: i hand-sketch in the area below ❑ drawing attached separately • r l `I r { o ��- 13 33 �3 -36 t5ins•„n� Trtle 5 Official inspection Form:Sues„eaca se„aAe Disposal syafem:Pages d,7 Commonwealth of Massachusetts Title; 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments /OF Property Address -ewf f — Owner Owners Name information is Ce �e✓y/6 �� a 6 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cost.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high groundwater: 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 property/observation hole within 150 feet of SAS) L� Checked with local Board of Health -expl ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: V-I & -ems Ply S-, •S i s ��ol�� Before filing this inspection Report, please see Report Completeness Checklist on next page. 15ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal Systein•Pape 16 ct 1 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form.- Not for Voluntary Assessments _ toF _ liY,4G, ��e,I I -]- �,�z Property Address Ze,&V/ Owner Owner's Name information is �� _ a required for every Q / page. Cftyfrown State Zip Code Date of Ins do E. Report Completeness Checklist Inspection Summary: A, B, C, D, or,E checked inspection Summary D (System Failure Criteria Applicable to All Systems) completed . E?_Isystem Information — Estimated depth to high groundwater Sketch of Sewage Disposal System'either drawn on page 15 or attached in separate fife t5ins•1 v1 o Tills s Official i rspecfion Form:Subsurface Sewage Disposal Sysfstn•Page 17 of 17 TOWN OF BARNSTABLE LOCATION I 002 2 SEWAGE# ,200,6-- 5,q VILLAGE �Cr�/7 L1'Z-il6�!C— ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO. g bgtVSnr! Septic 56F-715.10' b SEPTIC TANK CAPACITY 1 , 000 LEACHING FACILITY:(type) I L-P�Z� �i�:�� (size) 2.5,/ 1 NO.OF BEDROOMS 3 OWNER gl t & PERMIT DATE:_ J j � j�, 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) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY F � r 41 t o. 3_ duo No.....4..._ _- 6 g .FI:S..........................._. THE COMMONWEALTH OF MASSACHUSETTS 3 Qb 4 BOARD OF HEALTH . 1..12W OF.... k� ................... Appliratiun for Diupuuttl Workii Tunutrurtiun Permit Application is hereby made for a Permit to Construct (\ot Repair ( ) an Individual Sewage-Disposal System at: t •- -- . 'tl> :'_.. ,1 .._ ---------------------------------------- Location-Address :-:--•-----•----•---------•••-•---•-------or.Lot No. .` -t i ----------------------------- ---------------- Orwner, Address a 1Lon -------------•--...... ...... W --..._..-- == - M - Installer Address Type of Building Size Lot. .. .E.)_��_ .Sq. feet U Dwelling—No. of Bedrooms............ -_---Expansion Attic ( ) Garbage Grinder ( ) `4 Other—Type of Building No. of persons............................ Showers Cafeteria 04 Other fixtures ............................. . Q .. ..........................•------ W Design Flow._._... _.l�Q_________________________gallons per �e�seci per d y. Total til i flow...._.... ..._.___..._..g U10 Septic Tank—Liquid ca acit 1501�_ allons Len th_.O.._k?.... Width: _... Diameter________________ De th 1 W P 9 P Y- g c g ,-t P ��=�' x Disposal Trench—No.5. WiZth___._t-_....... Total Length.. ...._.. Total leaching area..7AG.,LQ:sq. ft. Seepage Pit No:................... lame er_............._..... Depth below inlet..................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) a Percolation Test Result!_„ Performed by...�.. tj4 -3 Pc.�i.----.... Date...�_�.(l?.� _ .�. /. Test Pit No. 1.... ......;..minutes per inch Depth of Test Pit..... ...._. Depth to ground water....AC-5........... f=, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ :..... ------...:- •"'Description of Soil....: ' � .`e L ._..... P�_ .. � _!!.?. ,:..` 5,._. . ............ Wi --..._. .-----------------------• ----------•-----........---. ............-•------•-•-. •----•-•-•-••................•-•••-----•------••---•--••-•••--•-•...---••-•••....-------•-•-----•••--•-------••....-----------_-•••----=-------•----•---•--•---•--•---••-.............................. U Nature of Repairs or Alterations—Answer when applicable............................................................................................... .........................•............................................................................................................................................................................... Agreement: r The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of LImL,: 5 of the State Sanitary,Code— The undersigned further agrees not to place the system in 1 operation until a Certificate of Compliance has been issued by the board of health. �o•-aq s85 Signed__ AQse1RMC°. .. � .. t ....:......... _ Date Application Approved By......... --._�.....-. !%-•- --••............................•• • .. ............0......'�(�.` '. - Date Application Disapproved for the ollowing reasons------------------------•--------••-•----..._._..._..._... ....................... ..........................................................................................................--•-----------•=----------•------•----•-------------•--=----..........••----...........---•• Date Permit No.._.........g.��.._..`.� 7.�............. Issued....... .: ............. Date ,Ik, . aN FEB..................... . THE COMMONWEALTH OF MASSACHUSETTS (j r- 'BOARD OF HEALTH CJV3�................0F.......F t` L � , ......................... AppliratiIIn f IIr Uhipasal Workii Tonstrnrtiun Permit Application is,hereby made for a Permit to Construct (\,_�or Repair ( ) an Individual Sewage Disposal System at�J --�- _ �+ yyp►.y��J�) t`4 �yyq , j �✓ .. I Location•Address Lo r or t No. � .. ..---••--- .......----•--------•-•-------------------•--..........................--•••-..... •Owner---••--•-•-•^--•^;•--�•--•-- ` r_ � Address W ��t� i�OLtlt a ( , - -----------------•-••---•---•----- ----......... ddr ._. ........ Installer Address ` Type of Building Size Lot 71D k .Sq. feet .� Dwelling—No. of Bedrooms............ ........................Expansion Attic ( ) Garbage Grinder ( ) Other=T e of Building No. of persons............................ Showers Gr YP g ---------------------------• P ( ) — Cafeteria ( ) , Q Other fixtures w .r '` WW Design Flow.......1__A.!r a.........................gallons per person per day. Total tit �{flow_...........;:_> ..............glallonst, W Septic Tank—Liquid ca acit �`r_"- allons Length .�..(P... Width. ..._ Diameter �'�"'._.•... De th#�• P 9 P Y-•-- --1 i >� � P x Disposal Trench—No.�: � ?4 :Wid h__...Q ._.._.... Total Length... .__.... Total leaching area.�. ,(zx-Q.sq. ft. 3 Seepage Pit No.................J. Diameter.................... Depth below inlet ....... .....::,Total,leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank Percolation 'Test)Results� Performed 'b ._ .,. 1 ,s1 L - :_ �...... Date...l.bknj�;......... 1.4 1.,..a Test Pit No. 1.....:..........minutes.;per inchDepthFof Test Pit..... � ...... Depth to ground water..... La, Test Pit No. 2................minutes per inch /D''epth of Test Pit.................... Depth to ground water...............:........ ..................... ...... °� ..................'_ t --..:..-^-----....� -.............................. I........ ......... ... p Description of Soil.... ?......` ...... i `�'-a� .4 U --------------•-• ----•---•-------------•---•----------------•--.-- ------..._...__.....-•------------••--------------•-------.._........................ ... ..... ....-•••••••.........---•.... --••-•------------------------•••... -••-•-------•-•---------.....;--- -------------••-------.......-••--•--------•---......----•------•---------...-----.....--•-----------•--•-----•-•---•••.•••--- U Nature of Repairs or Alterations—Answer when-Applicable............................................................................................... �;,� --••----•----•-•---------------••--••--••----.....---•-----••••• ---•-•-•---- -- --------------------------------- ---- -----------------•------..---.- Agreement: The undersigned agrees to install the 'afored'escribed Individual Sewage Disposal System in accordance with e- 'the provisions of A IT1 S of the State_S initary 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. , ��rE? 'X Signed. Date Application Approved BY--------. -.. � �.Q Date Application Disapproved for the ollowing reasons:-----•-•------•--•----.......-•-------------Z......---•-------••---- --------............---------......------ ...................•--..................... ..•-------------------•--................................... ................. Date Permit No.••... �...........7.4..-••-------- Issued. •-----•--•---•----•--.....•....•.................. Date THE COMMONWEALTH OF MASSACHUSETTS � TTS ' OARD O HEALTH , ............... .... .........OF............... ..... .............. Trrtif utttr of ToMplittnrr THIS IS TO CERTIFY, T t e I div' u Sewage isposal System constructed or Repaired ' by........•-••-.........--•••-•............................. . ........-----...--•-------................................................................... ..........._..._-- Lb I N Rt nstaller at.....•-----•---•......... .......•-...... 9 h P�rE. ...................................................................................................... r` has been installed in accordance with the provisions of TITLE j of The State Sanitary Code as described in the 'F application for Disposal Works Construction Permit No----- .`?. ............ dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE r. SYSTEM WILL FUNCTION SATISFACTORY. ' DATE...........IQ........---v---- Inspector..................t _.. �._( ............. ,•...'..: .w,r,,t��,..,.../r..c,..............^,,w.rvS.wwr.s.+ ....r« �..r,MW yn.,.r.ati ,w..t,ar a..:r r.a.r rw •eras..u.. ..MT...a.........K�.. THE COMMONWEALTH OF MASSACHUSETTS fAVST SwP 44ASC :ZAASULL TIZ> FWD G El3'�i�'�/ •f'}�t£ `� st�1 IV 0ARD OF HEALTH pt, wN ................... OF..... No. _« ...................... Permission is hereby granted....... ....::. to Construct ( ) or Repair ( ) an.Individ Sewage Disposal System ual Street as shown on the Application for:Disposal Works Construction Permit No.......... ....:.... Dated.._............. .......:..-------.-.... - ............. f{ lth » lloani of ea DATE............:5..-.P-3 -•F ...---------------.........•---••• - ' T _ . .r.. O — - - nS K ^hl_I.1y Za JIB 13s-q--t =52.5 L=3Z .15' -Ilkr 49•0:!.f b-I3aX . __. .100d._G-�ht- � '',.� 3- 1;Ld W b l�1✓U5oR5 . St�PT IC TAI l K W I'(I-I Z' 6!% 5'(DIJg, uAsf2vfo v%T. 43,Z ,9.0J, cut. �K of of `�Pf Ic A5 — 31J I I,�. `y LO( 9 N. PIS I IVG'( Rb, � ARNE H. �,, � ARkE cam, J cvI �aw o No.30792 vf�Isuao PAS 5-Z9-o(- 5«1L� I`=46' ARN5, N. .DJ ALA. .. . . PS KL-!5 �i .w Permit Number: Date: r Completed by a` HIGH GROUND-WATER LEVEL COMPUTATION Site Location: Lot No. Owner: Address: Contractor: Address: Notes: STEP ''1 Measure depth to water table to nearest 1/10 ft. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . date STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: A) Appropriate index well . . . . . ... . . . . . L--J B) Water-level range zone . . . . . . . . . . . . STEP 3 Using monthly report"Current Water Resources Condit.ions" determine current depth to water level for index well . . . . . . mo yr STEP 4 Using Table of Water-level Adjustments for index well STEP 2A , current Apth to water level for index well (STEP 3) , and water-level zone (STEP 2B) determine 3�s] water-level adjustment . . . . . . . STEP 5 Estinate depth to high water by subtracting the water- level adjustment (STEP 4) from measured depth to water level at site -(STEP 1) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... . . . . . . . 4 - � 4a 1 t �$ - i�- 7 Y` OCA 1ON SEWAGE PERMIT NO. J�cR Z!� vPFG i��c VILLAGE t0 INSTALLER,'�S NAME & ADDRESS /514- B U I L 0 E R OR OWNER a fl DATE PERMIT. ISSWED 0 DATE • COMPLIANCE ISSUED Zq. 6 uS 10 y3 It SECTION - SEWAGE . ` . 26An YA.rzC) s' I 'T�E1�iG�{ � • t i -SEPTIC TANK- 15. -"D"BOX- { -imam TOP OF FDN - - (MSL)N -•.2•'OF 1/eT0 Vi" WASHED STONE , IN• OUT-TdLi4 QQG IN• OUT• INI �,EPTIC qB, TANK �.�o�ELEV. ELEV. ELEV. ELEV.. / \' + ELEV. ELEV. �' / ��(/ �op�GI_ 1 ,01 WASHED STONE VEST.HOLE LOG .�' ,,: � ,K, ,n �. _ . • sn 4:3.Z � TEST BY P- i✓ WITNESS TEST DATE r ro 5 DESIGN. BEDROOM.HOUSE O , T.F . # 1 T.H 2 p p jj 36 c;l ELEV. 50.2 ELEV: 1r NO PERC RATE MIN/IN. DISPOSER11 FLOW RATE (cAL/DAY). - 30 / P -Nc SEPTIC.TANK {t.b'1= � �z 1 5t� ►o REO'D SEPTIC TANK SIZE i,dry �8 3� /l -- 4 XN LEACH FACILITY SIDE WALLC4' J�T_ 7Z.o(z ?2�,.y G/D. M\\ BOTTOM zZ C3.G/D. TOTAL o. la '�' USE: mil Z( ol~ dd — Lo �Zd WATER ENCOUNTERED ` t _ ti I C " Q-- WIC`} -- L-C7Tell NOTES: (UNLESS OTHERWISE NOTED) 1.DATUM(MSL)~TAKEN FROM-Sc5%-�!_T____.._..»_-,-QUADRANGLE MAP 2.MUNICIPAL WATER--__-}5___--________AVAILABLEj. 3:PIPE PITCH:44"PER FOOT vor e Gtc,-,t i 4.DESIGN LOADING FOR ALL PRE-CAST UNITS:AASHO- -44 �OAt -SfSJ•=f`� "�C F t r• (, �'`�' \� / 5.MIN.GROUND COVER OVER ALL SEWAGE FACILITIES:(1) FT. /-,+Mc-- -\'J 6:PIPE JOINTS SHALL BE MADE WATER TIGHT �� r TO BE ACCORDANCE WITH COMM. F r-< <7.CONSTRUCTION DETAILS O MASS. STATE ENVIRONMENTAL CODE TITLE 5 H OF N of q p ✓` SITE PLAN F,.t�c pta7t3STNt�r�r� � �p�� Mgssq� >1ys?_-n -.,- �+P?�I� �1 LOCUS: i�c ,mac tva ?�O CZ�,i a<. t �� ARNE y � ARNE 2 yG� �f{sSvM�b� C DS,15 f M 6nI C 3s A of-4. �v..2. OJA FI C I -f '1` I '`ti!! I.rL.� hiclA� u)nff� R R FaAIAL EER CIVIL Z ' NO-CIVIL o a8 0 ' REF: f'LAn-t (c_ 6,l q. `THIS FLAW NOT -Vv ZE VS4 Q FOQ- 2 t LD LTV down cafe en,fiaeering PREPARED FOR: CIVIL ENGINEERS 4 , LAND SURVEYORS ------------ BOARD OF HEALTH REG.LAND SURVEYOR CONTOURS (EXISTING)----- - �� `• SCALE (PROPOSED)-0-0-0-0- APPROVED DATE �S�A L� MA 'Y .w �jL�-40 DATE � ... I