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Home My WebLink About0298 NYE ROAD - Health 298 Nye Centerville. A= 148 037 i t � 1` i I 'I Commonwealth of Massachusetts Title 5 Official Inspection Form V Subsurface Sewage Disposal System Form -Not for Voluntary Assessments C2 9-F /lam 2 1�2j Property Address GiV 7 00%vq tw ner Cw ner's Name Information isVV�/ required for every page. CityfTown Slate Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered In any way. Please see completeness checklist at the end of the form. Mportutf rms When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your LC5 cursor-do not use the return ��of Inspector / ' _ key. Z 4 y�0 Company Name Company Address / L�G 5 �-�l��► ' 0c� City/Town State Zip Code LI 40 �d� Telephone Nu er License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the Information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CM R 16.000). The system: r-1) __4 Passes ❑ Conditionally Passes ❑ Fa is ❑ Need Further Evaluation by the Local Approving Authority PMI 10 5 l3 d� Inspect o's Signature Date a--- v M The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. This report only describes conditions at the time of Inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. 5 � Ons-3/13 Title501Acis1nspeotionFarmSubsurfaceSe eDlspZLiPage-1of17 Commonwealth of Massachusetts Title 5 Official Inspection Form V Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,:; g�, - Rj Property Address Tool, ') Ow ner ON ner's Name // re requirerrriationd is Ceh vVr �/e �� OD 3a —r—_ required for every page. 5 flown State Zip Code Date of lKspectlah B. Certification (cont.) Inspection Summary: Check A,B,C,D or E I always complete all of Section D A) 71e assss: have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CM 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 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): Wins-3113 Title 5 0f liciel inspection Form Subsu lace Sewage Disposal System-Pape 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form V Subsurface Sewage Disposal System Form •Not for Voluntary Assessments'0? �R �L62 e— /��J Property Address Toolil Cw ner Cw ner's Name ,r information Is CP'1 4 v r -1 �l2 �j�+ O a 6.?0) / required for every page. C yfTown State Zip Code Date of Inspi6ction B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. 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. 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 0 Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): i III C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a mannerwhich will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh tens•3/13 Title B 011f tied Ins pec tion F orm Subsu f ace Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments C� I� e �� Property Address � l ool/V7 ON ner ON ner's Name Information is a // u required for every ry l //� 0) 3� / �3 page. CByrrown State Zip Code Date df Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply, ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the 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 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 must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must Indicate "Yes" or"No" to each of the following for I&inspections: Yes No ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ Static liquid le%el in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less than Yz day flow t51ns•3/13 Title 5 Official Ins pectlon F omr Subsvlace Sewage olsposal System•Page 4 of 17 Commonwealth of Massachusetts ugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Roperty Address ON ner ON ner's Name V! information Is Ce V) lie �- �oZ s �� required for every State Zip Code Date of I specti page. Ci Row n B. Certification (cont.) Yes No ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped; . ❑ Any portion of the SAS, cesspool or privy Is below high ground water elevation. ❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply, ❑ Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ M' 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 6 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ [a/ The system klh1 I have determined that one or more of the above failure criteria exist as described in 310 CM 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems. To be considered a large system'the system must serve a facility with a design flow of 10,000 gpd to 16,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. tSre 3/13 TiVeS01ficial ins pectionForm:Subsulaoe Sewage Disposal System-Page 5 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form 90"M t Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Ow ner Ow ner's Name Information Is `/ required for every e'er f/Vt -� / / � 6 °� 01.E11,;- page. Cily/rown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no" as to each of the following: Yes No �13 Pumping information was provided by the owner, occupant, or Board of Health ❑ LJ Were any of the system components pumped out in the previous two weeks? ❑ [5"" Has the system received normal flows in the previous two week period? ❑ Have large volumes of water been introduced to the system recently or as part of / this inspection? ,u,/ ❑ Were as built plans of the system obtained and examined?(If they were not ,../ available note as N/A) Ly ❑ Was the facility or dwelling Inspected for signs of sewage back up? L�l ❑ Was the site inspected for signs of break out? Were all system components, excluding the SAS, located on site? ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? �❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Existing information. For example, a plan at the Board of Health. ❑ ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x #of bedrooms): 7 T� Mrs•3113 Title 5 official Ire pectlm Form Subsurface Sewage Olepoad System•page 8 Of 17 5C%\ Commonwealth of Massachusetts Title 5 Official Inspection Form 6 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments P Property Address Ow ner owner's Name Information Is �� l��jI Ile- 0d G 3oZ d r /3 required for every page. City/rown State Zip Code Date of Inspectio D. System Information Description: / / / /000 6:,e, 11oll � 4r c G / x �ell'L 0 Number of current residents: Does residence have a garbage grinder? ❑ Yes Is laundry on a separate sewage system? (Include laundry system Inspection N information in this report.) ❑ Yes 9--" o N Laundry system inspected? ❑ Yes B No Seasonal use? ❑ Yes No Water meter readings, if available (last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM R 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: ins,3113 Ti050f5cief InspeetlonForm Subsurface SewepeoispoW System-Pepe 7of17 Commonwealth of Massachusetts Title 5 Official Inspection Form 6 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .� a2- 9 F � Property Address Do/f -I Cw ner Cw ner's Name I- information is CQ�l 7�i1'VG A required for every State Zip Code Date of Inspect n page. Cityfrown D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Ova Source of information: —�" -- Was system pumped as part of the inspection? El Yes No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of Sy m: Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ 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 and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the VA system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t9ns•W 3 Title 5Offlclal Inspectlon Form Subsurface Sewage Disposal System•Page 8 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form •Not for Voluntary Assessments 90<1 ztl�)e Property Address Ow ner Cw ner's Name / l Information is / P�1��v� / oa 63 d6 �� required for every l� 7t% � page. CrtylTown State Zip Code Date of In pectic D. System Information (cons) Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): Dept h bel ow g ra de: feet s Material of construction: ❑ cast iron ❑ 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Z Depth below grade: feet Matedc%of construction: ff concrete Cl 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: x Sludge depth: Wins 3113 Tide 5Official InspectlmFam Subsurtece S"o13lepoeaV System-Page 9of 17 \ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form •Not for Voluntary Assessments Property Address O+v ner OAv ner's Name information is Ll required for every cal rC✓(/!�� D°� �' �� °`� page. Otyfrown State Zip Code Date of l6spectiori D. System Information (cont.) Septic Tank(cont.) 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? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Vt✓y!� ✓I. ✓�O 4- 4e 4� C00 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 cans•3/13 T1050fecisl inspectlanFam Subsurface Sewage Disposal System-Page to of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form b Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 F Property Address Tool- ,� ON ner AN ner's Name A'4 information is required for every 7L 0 r)63c 02�r l ��✓� w� 'e page. Cityrrown State Zip Code Date of In pection 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.): 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 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 I5rts-3H3 Tide50fAclal Inspectimfarm;Subsurface Sewage Disposal System-Pape 11 d 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form •Not for Voluntary Assessments Property Address rood,� Ow ner 5 ner's Name information is ��//� 1 4 0.) 6 required for every State Zip Code Date of Inspection page. CitylTown D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): /f/0 So/, f 1410 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. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: 15ine 3113 Tile 50fflciallnspecbonForm Subsu1see sewageDlspoW System Pape 12of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form 'W, subsurface sewage Disposal system Form -Not for Volu ntary Assessments C'29 � Property Address Too Cw ner Ow ner's Name information is ✓y QoZ 3.) Id r / required for every page. GtyrTown State Zip Code Date o, Inspects n D. System Information (cont.) Type: leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/aitemative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Q '' �� ' Ste, ��►�� 4z:�7L 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 Wins-3/13 TideBOflicial InspecticnForm:Subsurface SewageDlsposel System-Page 13d 17 Commonwealth of Massachusetts 0 Title 5 Official Inspection Form k1wiSubsurface Sewage Disposal System Form •Not for Voluntary Assessments . :,2 F ltl�)e 9J Property Address TD oll Cw ner ON ner's Name information fsH required for every -�L page. City/Town State Zip Code Date of In pectic D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Wne•3/13 Me50fedal InspectonForm Sumurtwe Sewage DispoeW System•Page 14 d 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments C290<1 Property Address OOIfV7 O+v nor Cw ner's Name /1 information Is '7e V, required for every State Zip Code Date of I spection page. Qyffown D. System 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 p is water supply enters the building. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately 63- 19 One W3 Title 8Offldd Ins peetionForm Subsurface Sewage Disposal System-Page 15 d 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address I oob ` 7 IQfo�rmation is er Ow ner's Name / / required for every ( �e� 1KV/` 1�4 �a �'Z '��/;-//—,r page, City/Town State Zip Code Date of frispecti6n D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells / Estimated depth to high ground water. feet rk Please 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) Checked with local Board of Health -explain: 1110 5 f- I-Ps 4 1q.411 ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: ev- Before filing this Inspection Report, please see Report Completeness Checklist on next page. Mrs•3r13 Title 5 pfAciel Inspection f arm Subsurface Sewage Disposal System•Pape 10 d 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address / OO�iI/I N ner ON ner's Name information is Ile (JoL6 �o� �( 5 / required for every —L1 -- page. City/Town State Zip Code Date of Inspectlo E. Report Completeness Checklist Inspection Summary: A, B, C, D, or E checked. Inspection Summary D(System Failure Criteria Applicable to All Systems)completed [System Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file 15ns 3113 Tito 5offdalInspectionFormSubeurfaceS"e Disposal System•Page 17of17 Nol.�_`---' %.t Fim$....`.5...�'�.............. THE COMMONWEALTH OF MASSACHI�4�ciTS 0. SOAR® , � H A Ti--6 .r J`6 _V.:..IL..................OF......... jP ./7 -e----------------------------------- Appliration for Dispaii al Mirbi Tnnitrnrtinn frrutit Application is hereby made for a Permit to Construct (A) or Repair ( ) an Individual Sewage Disposal System at .. •.. . .e. ................................................... ........................ a •... • --_-••. ...................... ocatipn-Address / 4 �]P aLot��agQ� (to .._� ..... ..................................................... 3_'y_S __ .�... ..........._....... �._................... �.-.�...../._ w Q�ler .... / -9orC /Address D ('.(.-.(..�-------.......................... /(/ ...V ...._/.�.1 ....._.... � Installer Address j/ Q Type of Building Size Lot---l.7i..B .Sq. feet U Dwelling—No. of Bedrooms........3--------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Oth fixtures ...•-••••------•-----•---•------------------------•-------------•--------------------••--•---•--. -------------------------------- Q Design Flow.....- 73.............................gallons per person per day. Total i flow.._.._.._.. . ._. yrs. r--•---------Septic Tank—Liquid'capacity_.�....gallons Length________________ Width__ .._._....__ Diameter..... .______. Depth.. x Disposal Trench—Nq..................... WidtjD...._�...... Total Length--___-- ....... Total leaching area...........7...�..sq. ft. Seepage Pit No---------J---------- Diameter....(l---.l.1._. Depth below inlet.................... Total leaching area.•..a_Y.sj,:ff Z Other Distribution box ( Dosing//d�ank ( ')�`,, �j v P,9- `" Percolation Test Results Performed by....`:OLV_.. .. �//(�................e _______________ Date... ,� Test Pit No. 1•.A.)__-_-minutes per inch Depth of Test Pit.) .......... Depth to ground water �*�_J (s, Test Pit No. 2................minutes per inch Depth of Test Pit-_-___.............. Depth to ground water.�l!C4Ve! �Pd ------------------------- -••--•------ 0 Description of Soil------------------------------------ ! h------ -.................................................. x l -------------------------------------------------------------------------------------------------•------------------------------•------•-------- w VNature 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 iITL%, 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed...................................................................................... ---- ........ ..........--.... te_, ApplicationApproved By.. ...................................................•--------------------...-. - ,� Date Application Disapprove or a following reasons---------------------------------------------------------------------------------------------------------•---.... ---•--------------------------------------------------------------- -------------------------------------------- Date PermitNo....................................................... Issued_....................................................... Date ------ ------------------------------� .............. THE COMMONWEALTH OF MASSACHU-5iETTS BOARD , F H A TI-0 -s/...I! ...................OF......... 1-aP►v Appliration,for Uispao al Workii Tomitrnrtion ranfit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal S..y..s<te.m at ° ......................••.•--..---.--............... _._.-- . ...---- ®DI Address ef...........X....................... a W •�e%1.. r . (e �C Address e w Installer Address Q Type of Building' Size,,Lot...12- -.Sq. feet Dwelling`No. of Bedrooms------- --------------------------------Expansio : ' Garbage Grindernc Othe =TYPe of Building ............... No. of persons..:... .._.__._____----- Showers Cafeteria ( ) QI Oth r.fixtures ---•-•-------•--••......•-----••-•••......•••• F W Design Flow..... .... ..............................gallons per person per day. Total y flow____....... .....'Qr ns. - WSeptic Tank—Liquid capactty.kY gallons Length................ Width-- _........._ Diameter:. ,r�.-------- Depth.. ..__.._. x Disposal Trench—Np. ......:............. Width-..... ,�...._.. Total Length...... ..i;_'...._. Total leaching area_._.._....,-_---.-sq. ft. Seepage Pit No.-______-11---____.. Diameter---.j._-1-._r.... Depth below inlet.................... Total leaching area...")s ,t. Other Distribution box Dosing ank "� a P '-' Percolation Test Ress`ults ) Performed by_.g (.._ ). _. / + ` ................. Dates%' _ a minutes per inch Depth of Test Pit rt 4 '` Test Pit No. 1. ,�.:.___ p p � ' ._ Depth to ground water '�....__�___.. '! 04 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water *�,V1.. _. __________ _ y .... . Ix ........................ t ...........DD pescrpton oo ---••••• --------------------- t . . ---------•------- ep 3 VW -••••-••••••......................•--------•f...••••--............••-•-•---------•••••••-••-----••--.........-----------... - ---------------` 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 TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed................................................................................... ----. -._.-_.._ ate Application Approve rD -------------- Application Disapprov f o the following reasons:............................................................................................................... ....................................... --•-•••••••••••--••••••••...••••-•---.......••---••.......••--••••-••-•-•--------•..................................................................... Date PermitNo......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... (9rdifirtttr of Tontpli anrr T IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( or Repaired by ( ) t` +~, ..l . Installer .. has been installed in accord n with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Wg Construction Permit No._ .' `..2.4................... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE........................................ .: '. . .................. Inspector........ --------------------•------------------•-.----------•-.--•-- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH w No.•••••••••••-•-••.-•---- FE ..--.............. IK"Binfo Fal Workii Tonn#rion motif Permissionis a granted. ........-•.--••---•--•.•••-•--••••-••••••••--•••......•••••-•-•••••••••••••••••..........•••-•.........•.............. to Construct ( IF ep a dividual, e age Disposal System atNo..••••••- •••--•-•••-•.................... 4------r-..---------------------------------------------------------------------------------------------------------------- Street as shown on the ,ppli ion for Dispo Works Construction Permit No...... !'Dated.......................................... ................. ..........••-•••-•••••••--•---••••••••....••-•....--•••-................... Board of Health DATE•••.... -- . ... ..... .....................................:................. FORM 1255 A. M. SULKIN, INC., BOSTON LOCATION SEWAGE PERMIT NO. Lot #2 Nye Rd. 84-211 VILLAGE Y,5-C'37- o� Centerville �INSTA LIER'S NAME i ADDRESS jo _Robert B.Our Co. Inc. Great Western Rd. North Harwich 9 9- R U I L 0 E R OR OWNER I Louis Gordon DA T E PERMIT ISSUED 0 DATE COMPLIANCE ISSUED �._ �y 1 9131 2- 0 . C 1 10 r , OQ ._ ..� - _�....__ to,_ -s}^..•,.- ,:,..,.. .__,..�...._...,.... --___._ ......_._................:_ ,,....- _ .t.._._. �+ .. ,N ..... 7: : _ .. 5 _ ...,- .. -.�.._.....»_,..e..y._._.._,.,_•--_•..J.:_++-_......: ...:.._. .._..,•.,.........-w.e* :,y..tia(:-w ..,,ww...,F"��l 5�:.�'9 ..r...+-•J.. +--F..Y..+..-.—m:.,l_..,--��+"-:w- y.,r f � _ 1 .O # a 1 _ , > " qO X7 c-/uU r x7 1 r~ ,r G" _ t"J} l�,dJ- c U $ To r 1-t'IAJ e X 15 f 1 r) €� c u G7 p !J t 1 E= - r `� ,eta, . c 1v 1 = i ----- --- t 0 1 I .� v r c = ca c r t t 1 f�f Z> G P L.)u . ., G f-! �• / �� .C?l� ram-- ,. o /1 e n 2 -Ye eti►a�h d 5f'ca rF 4 . r 'ca i _-._.._._._�«...-3•+ T,n— ,_.,+__..+uM �F..,�.Rr.. _..__,•'_,^'^•y / ....:,TS,i,]l",:,u�«`Ytka'YG..-_-«........Y _,@.+{, ':, i. Y E` 7 b/ dla. ,... O ✓!. ,.. 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