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HomeMy WebLinkAbout0156 PATRIOT WAY - Health 156 Patriot Way Centerville A= 193 - 081 SIP1 � UPC 12534 W.2-153L I - ff-Plt''� ' I DATE 8/8/06 PROPERTY ADDRESS 156 Patriot way Centerville MA 02632 On the above date, the septic system at the address above was Inspected. This system consists of the.foliowing: '410.2,(5 1., 1-1000 gaUon zept.ic tank.) 20 1-d.izta igut.ion dox.lf 3., 2-1000 ga 22on eeach.ing /z.itz., Based on inspection, I certify the following conditions: 4o 7h.i.,3 .iz a 7.it ee Five zept.ic zystem (78Coe) 5o Septic zyhtem .is .in paopea woak.ing oadea at thi-s time., SIGNATUR > Name: Robert A. Paolini Company: Joseph P. Macomber & Son Inc . ' Address: P. 0. Box 66 1 -P- LO _ Centerville. Mass 02632 - uR ca Phone: 508-775-3338 or 508-775-6412 r- c- rn JOSEPH P. MACOMBER & SON, INC. Tan ks-Cesspools-Leachfields Pumped & Installed Town Sewer Connections P.O. Box 66 Centerville, MA 026.32-0066 775-3338 775.6412 • �.\ COMMONWEALTH.OF MASSACHUSETTS EXECUTIVE OFFICE:OF ENVIRONMENTAL AFFAIRS ,DEPARTMENT OF ENVI]kQNMENTAL PROTECTION d TITLE 5 OFFICIAL INSPECTION FORM—.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART-A CERTIFICATION Property Address: .. 1 56 Patriots Way Centerville MA 02632 Owner's Name: James Sullivan Owner's Address: Same. Date of Inspection: 8/8/0 6 Name of Inspector: (please print) Rab, rt A F o.l"ini Company Name: 7_ P. a.com.9eit I S.o.n Inc. Mailing Address: Any- 66 Cen eavi a, a.6.3..02632 Telephone Number: 5.0 8-7 7 5:3 3 3 8 CERTIFICATION STATEMENT . 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.13:340 of Title 5(310 CMR 15:000). The system: XXXPasses °Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails �.. .. tn Date: Inspector's Signa 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. Notes and Comments ""Thisreport only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of t I OFFICIAL INSPECTION,FORM—NOT FOR;VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL-SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 156 Patriots Way. Center;Mie MA U2632 Owner: James Sullivan . Date of Inspection: 8/8/0 6 Inspection Summary: Check A,B,C,D or.El ALWAY9<eomplete all of Section:D A. System Passes: q E S NO I have not found any information which indicates'that•any of the failure criteria described1h 310 CMR 15. 003.or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. C�e�' �sC system .is in paopea woatk.ing oadea at .the. paezen.t Lime.i B. System Conditionally Passes: NO One or more system components.as described in the"Conditional.Pass":section'need to be.replaced:or repaired.The system,upon completion of the replacement or repair,as approved by the'Board of Health,will pass. Answer yes,no or not.determined(Y,N,ND)in the for the following statements.If"not determined"please explain. NO The septic tank is metal.and,over20 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.&s,.gppr0ved.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. ND explain: Nd Observation of sewage backup*or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or duo to a broken;settled or uneven distribution box.System will pass inspectiondf(with approval of Board of Health): broken pipe(s)are replaced Obstruction is removed T distribution box is leveled"or replaced ND explain: NO The system required pumping.more than 4 times a ear due to broken or obstructedpipe(s),The s stem will Y 9 P P & Y Y pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTI.FICATION(continued) Property Address: 156 Patriots Way ' en ervi a MA _ Owner:. James Sullivan Date of Inspection: 818/0 6 C. Further Evaluation is Required by the Board of Health: No Conditions.exist which.require fiuther 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 manner which will protect public health,safety and the environment: No Cesspool or privy is within.50 feet of a surface water No Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: No The system has aseptic 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. No The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. .No The system has a septic tank and,SAS and the SAS is within 50 feet of a private water supply well. No The system has a septic.tank and SAS and the SAS is less than 100 feet.but 50 feet or more front a private water supply well".Method used to determine distance visual "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are.triggered.A copy of the analysis must be attached to this form. 3. Other: 3 Page.4 of 11 OFFICIAL:INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART.A_.. CERTIFICATION(continued) Property Address: 156 Patriots Way Centerville MA 02632 Owner: James Sullivan Date of Inspection: 8 8 0 6 D. System Failure Criteria applicable to all systems:. You must indicate"yes".or"no".,to each of the following.for all inspections: Yes No X Backup of sewage into facility.or system component due;to overloaded.or clogged SAS.or cesspool X Discharge:or ponding of effluent to the surface of the ground or.surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than'/6-day flow X Required pumping more than 4 times in the last year.NOT due to clogged or obstructed pipe(s).Number of times pumped _X_ Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion.of a cesspool or privy is within a Zone I.of a public well... X Any portion of a cesspool or privy is within.50 feet of a private water supply well. �. X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.[This system,passes if the well water:analysis, performed at a DEP certified laboratory,for coliform bacteria.and volatile organic compounds indicates.that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this forip.) No (yes/No)The system fails.I have determined that one or.moreEnf the above failure.:criteria exist as described in 310 CMR 15.303,therefore the system fails,The system owner.should contact the Board of Health to determine what will.be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve.afacility with a design flow of 1.0100.0 gpd to 15,000. gpd. You must indicate either"yes"or"no"to.each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _ X the system is within 400 feet of a surface drinking water supply _ X the system is within 200 feet of a tributary,to a surface drinking water supply _ X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well 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. 4 f Page 54f I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL:SYSTEM INSPECTION FORM PART B CHECKLIST. Property Address: 1 56 Patriots Way ' Centerville MA 02632 Owner: James Sullivan Date of Inspection: 8/8/0 6 Check if the following have been done.You must indicate"yes"or"no"as to each.of the following: Yes No X Pumping information was provided by the owner,occupant,or Board of Health X _ Were any of the system components pumped out in the previous two weeks? X _. Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? X _ Were as built plans of the system obtained and examined?(If they were not available note m N/A) X _ Was the facility or dwelling inspected for signs of sewage back up II X _ Was the site inspected for signs of break out X _ 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? X _ 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: Yes �o Existing information.For example,a plan at the Board of-Health. �( Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 156 Patriots Way Centerville MA 02632 Owner: James Sullivan Date of Inspection:a/R 10 F FLOW CONDITIONS RESIDENTIAL 4 Number of bedrooms(design): 4 Number of.bedrooms(actual): 4 4 0 DESIGN flow based on 310 CMR 15.203(for example:.110 gpd x#of bedrooms): Number of current residents: 2 _ Does residence have a garbage grinder(yes or no): n o Is laundry on a separate sewage.system(yes or no): a [if..yes separate inspection required] Laundry system inspected(yes or no):n o 20 0 4=3 4, 0 0 0 ga ii o n z Gl D=9 3.,.15 Seasonal use:(yes or no): no, . Water meter readings,if available(last 2 years usage(gpd)): 2 0 0 5 2 8; 0 0 0 ga te o n s G%D 7 6o 71 . Sump pump(yes or no): n o Last date of occupancy: P.2 e 13 e nt COMMERCIAU*bUSTRIAL N IA Type of estabOhxnont: Design flow(based on 310 CMR 15.203): gpd Basis of design'flow(seats/persons/sgft,etc.): Grease trap-.present(yes or no):_ Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system-(yes or no):_ Water meter readings,if available: Last date of occupancy/use: . OTHER(describe): GENERAL INFORMATION Pumping Records 10114104 a.i N Na c o m&e n Source of information: Was system pumped as part of the inspection(yes or no): no If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM X Septic tank,distribution box,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) —Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: 24 yea2z Were sewage odors detected when arriving 8t the site(yes or no):n o 6 f Page 7 pf 1 I OFFICIAL INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYS3`EM INSPECTION FORM PART C SYSTEM'INFOIZNUTION,(continued) Property Address: 156 Patriots Way Centerville MA 02.632 Owner: James. Sullivan Date of Inspection: 8/8/o 6 BUILDING SEWER(locate on site plan) Depth below grade: 3 6" Materials of construction:_cast iron X 40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): loin.ts a,QQP n .tiahf 4n 0))Idpare „4 0_ o,,��e Ve2ited though house vent SEPTIC TANK:Y f Ilocate on site plan) 1000 ga e e o n s Depth below grader 18 Material of constructio—�concrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: 8' 6"X5 ' 8"X4' 10" Sludge depth: t 2 a c e Distance from top of sludge to bottom of outlet tee or baffle: to a c e Scumthickness: t2ace Distance from top of scum to top of outlet tee or baffler .t as ce Distance from bottom of scum to bottom of outlet tee or baffle: t 2 a c e How were dimensions determined: m e a s u a e d Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of.leakage,etc.): _ Pum,� tank evezu 2 Uea i Tale Talef R outl�of foe,e n"Q�n �npae¢ lank iz .sz4uctu2aiiy zound GREASE TRAPYVQ (locate on site plan) Depth below grade:Material of constructi— on:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): G2eaze taaI2 .ins not�ae�sent 7 Page 8 of 1 I OFFICIAL.INSPECTION FORM.—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORMW. �. PART C SYSTEM INFORMATION(continued) Property Address: 156 Patriots Way Centerville MA .02632 Owner: .TamPs; Sul 1 i van Date of Inspection:_ /A 4 n r TIGHT or HOLDING TANK: NO (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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes.or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): 7.Lght o2 ho&iag tankz aae . not Raezent; DISTRIBUTION BOX: (S S (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 0 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.): Box i6 2eveio Kas Z iateaa-ezo No zoeid caaayove2 oa .P a _gp In nn out o-1 &ox.1 PUMP CHAMBER:NO (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): 9/ omments(note gonditign of ptupp chamber,cpndition of pumps and appurtenances,etc.): am12 e am e2 iz not /22e sen 8 Page.9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C .: -SYSTEM INFORMATION(continued) Property Address: 156 Patriots Way en ervi a MA 02632 Owner: James Sullivan. Date of Inspection: 8 8 0 6 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not.required) If SAS not located explain why: " Located .see Rape 10. Type X leaching pits,number: 2 leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): Loamy to med. um zando No z ign s oe �a.i2uze of .12onding Anl DA ate dAyo vegetation .is hoamai., CESSPOOLS:NO (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: Y Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes ar no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Ce.6.612ooiz aae not /2,ce.5ent PRIVY: No (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.): 1)2.ivy .is not /2aesent 9 r Page 10 of 11 ` OMCIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS l SUSURFACE SEWAGE DISPOSALSYSTEM INSPECTION FORM PART C` SYSTEM INFORMATION(continued) Property Address: 156 Patriots Way Centerville MA 02632 Owner: James Sullivan Date of Inspection: 8/8/0 6 4 SKETCH OF SEWAGE DISPOSAL SYSTEM Prdvide a sketch of the sewage disposal system including ties to at least two permanent ra6e-nce_landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters.the building. I \ r� 10 •.M..,..-R BARI�STABLE . �•:•-••� . UOARD QF 11 TOWN OF $AL'I'll -sUASURPACR SKINA08 DISPOSAL, flysT!M INSPECTION FORM - DART D. CERTIFICATION -tYPa 0A PAINT C1,aAnbY- , PRO.PERTY MSPECTIi11 STREET ADDRESS 15.6 Patriots Way Centerville 02532 ASSESSORS MAP, ©LOCK AND 'PARCEL OWNSR's NAME James; .Sul;.ivan . PAJiT'D OSIiT.IFICAT;I;ON ; NAME 'OF INSPECTOR Robert::A::-Pao3i:n NAME ,�.=:�Fh��l- -jar- COMPANY COMPANY ApDE SS fox="66'-G? r�!&Vill.6i•'MA '0_ 5-2-b068 ^ ; " :....,:�, Toim..or �ty.. :stafi- ,,..P COMPANY T969PHONE (508. 07.5 .- 3338 -FAX 1' 508•,,1190 f 578 . CERTTFICATION. STATEMENT I certify that I 'hRve persotial-ly .ins-pected ..the eawage 'digpo�a�1. system at this address and that. -tire' information reported ,is true#. s.acara•te-p and omplete' al Qf the time .of•=inspection.t• The inspepti orn was performed and any* recommendations regard.ing .upgrade•, .maintenance 1'. and irepa.ir .are• con$istent with,, my trainipg and experience in the proper functi-on' and maintenance of on- site sewage disposal systems, Check one: ' .�_ System PAS D ° The inspection which J. have .•conducted has ,,n•vt 'found any infQrmation . which indicate$' that. the system' fails to ' ade juately.. protect .public health or the envi.ropment as defined in- .310 CMR. 16*;30.3•, My fAiiu•re criteria o6t ••evaluafe*4' are as stated in the FAILURE' -CRI.TMUA .seeti*'on o•f this form. System FAILED* The inspection which- I have aoric ted 'has :found that the system fails to protect the public health fnd the en4ronmemt ' in acooxdance with Title 61 310 CMR 15 ,3031 :n s • specifically noted -on -PARTC . FAILURE CRITERIA of this it ect on °.form) Ins.pector 6ignature' 'Date Vwnh4ere'copy of this certi,f i.of;Ui m mast •be rovided :to • the .OHM, tho8 B1jan' apili.oable) and tr1tV BgARD OF HEAKI „ ♦• . , * If the inspection FAIL'L'b,, 'thb .ownelo o�r�"9perator A.hall. upg•x.ade'•the system. within one year or the date of the i`nepeation, unless. aI'lowsd ar- req.14,red - n t.ha"f ie'as provided iT FAO CMR 16 ,306 ,. a - '13 6 L O"Ci TION SEWAGE PERMIT NO. VILLAGE INSTA LLER'S NAME i ADDRESS „��✓���s ����� �"�� .�c Ails 's BUILDER OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED � � �� GJ � kLI LI No.... :.y, ... F:i$ ............................. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH .I .E.; s7b ApplirFation for BiipniFal Works Tomlrurfinn ramit Application is hereby made for a Permit to Construct ( ) or Repair (pe) an Individual Sewage Disposal System at: .............&��t''G --------------------------------------••-•----------.............................................. —�— Location-Address - or Lot No. .......;VIr91xt e_..... ......�.ld./�:t vw.................................... ..........-••--• ---...----------•-------------••-------•--....---... W, - ne „� Address .....tl-4- cp.h...... '?VIR0..s,A!�--------------------•-_----- ....----••-----.......-----••--------••--•--...---..........------..........................-•---- as 9 Installer Address Type of Building Size Lot............................Sq. feet p, 1welling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) 1714her—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures -------------------------------- ...........................,�'Design `Flow .................gallons per person per day. Total daily flow..........................._..__............gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................. isposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. r age Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Dth Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed bY.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water................._...... Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water......................... v. :3 Descriptionof Soil...................................................................................................................................-.................................... V ...........•-•-...••-•--••-••••••••--••••-•-•••--•••••••••-----••••••--•--••--••••••••-•-----•--•-••••-•-•-••••-----•-••••••-••••-•-•-•--•-•--•--•-••-----•-•••-•-••••-•••-•••-•--••----••............••. .�. ----•---------- --------------------------------°--------------------------------------....----------=------------------.... V Nature of Repairs or Alterations—Answer when applicable...a C3 . --.------k"."...... der`-A°1----.- `-/ a ........................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with tk the provisions of L I L U 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has beAn issued by the board of healt +' Signed ..... _ Die Application Approved B Lf/ Date Application Disapproved for the following reasons_______________________________________________________________________ - ........................................................................................................'................................................................................................ . Date Permit No......................................................... t r Date f 1 +�h No..- -�"�� -- FEs.......-'�.................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ._./..'.vv�........ OF....._.°1'i.,,.. ................................................... Appliratiou for Disposal Works Toustrur#iun 1hrmit Application is hereby made for a Permit to Construct ( ) or Repair (/5 an Individual Sewage Disposal System at: • 1 ��- .4/24:41_....'/..Y--.......... -------------------------------------------------------------------------------- ---•Location-Address --•.-•-•-•-----_--••------••••---••-•.-.••or-Lot No. es Sul/..rl -----------------•-----------•--•- ---...--------............----------................ ~� Own_err Address a ------------- .5 e�J�!1....... .(/,q C_6 ............................. .......-•-- ............................--------•--•--- Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Pa Other fixtures .......................................... W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. Ga Septic Tank—Liquid capacity............gallons Length................ Width--------........ Diameter---------------- Depth................ W Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. x Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ aTest Pit No. 1................minutes per inch Depth of Test Pit-------............. Depth to ground water.....................__. (i, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a' -•••-............................................................................................................-••-••----••---•---•--..................---- 0 Description of Soil........................................................................................................................................................................ x U -------•--•--•--••----••-•----•---••.................•-•--••--•••-••-•••••--•---•-•............••---•----•----•--•-•---•••-•----•--•----•-•-----•--•--------••••-•-•-----------•------------•••------••- W •-•--•••••------------------••----•-••-•-------••••-•----•--......-----•--•--••---•----•-•--••-••-••---------•---------- . ---------. -------------------------------------------------- UNature of Repairs or Alterations—Answer when applicable_.. _ .._ 67'S....._.f.,3ek ..... a-g!i.'k�7r...... %.!.. 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 begn issued by the board of health Signed. "°, - •••--- Z ./•3---•-� e Date Application Approved By....—,.r.._�2. .... ........................................ •.. ��� Date Application Disapproved for the following reasons--------------------------------------------------------------••-------------•--•------------••-••--•••.......... ..----------•------•.......--•.........................••-•-••-----•--•-•----•--•-----......--•-•...--••-------•-•------••-•--•-••••------••----•••---•---••----•-•-•-••-•-•......-••-•-••--•••......... Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... (9rdifirFatr of T-autpliFaatrr T IS IS 0 CERTIFY, Th the Individual Sewage Disposal System constructed ( ) or Repaired (, by--.. s -°.....�............................. ........•------ -•--•---.........................•...•....------.-----.----..-•------.--.._._..-•---- Installer has been installed in accordance with the provisions of TITLE jo f The State Sanitary Code as described in the application for Disposal Works Construction Permit No....8..........__ �/............ dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A UARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE ' ..:---..--�--S'o'L----.....--••---•---------------- Inspector =---'!._------ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........................................O F.................................._............................................._.... •/ No. r1.'�l J'.lr..• FEE....y.............. i rya ate irk �uat r Wit ami# Permission is hereby granted.__ r.. ... ..... L................................................................................ to Construct ( ) or Repair ( 4-fla/n Individual Sewage Disposal System atNo....14`5..... ............................................................. Street as shown on the application for Disposal Works Construction Permit No........... Board of Hee..... / alth" DATE..............................k',/.f do 1255 HOBBS & WARREN. 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