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Home My WebLink About0291 SOUTH MAIN STREET - Health (2) 291 South-Mad Street', - - Centerville:-�, A= 207 -085 -001 I J oy� to � ' HASTINGO,MR ,4 A �� s 6 No. DM� � Fee I VVr THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Zipplitatlon for Misposal *pstem ConstrUttlon 3dPrmit Application for a Permit to Construct( ) Repair(Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 4. mua� S Owner's Name,Address,and Tel.No. Assessor's Map/Parcel @ KV`k� �.__ (C"C Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date 11 Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil j\ (lip Nature of Repairs or Alterations(Answer when applicable) '^ C��g( �Q of��KQ, — , �5�� 04 Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this of Health. Signed Date f I f T 113 Application Approved by AA Ale- Date 1 Application Disapproved by Date for the following reasons Permit No. C4:�n Date Issued t ` 1 No. Fee MO, iJ THE COMMONWEALTH OF MASSACHUSETTS Entered m computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS, 01ppYication for Bisposal Opstem (Construction permit Application for a Permit to Construct( ) Repair("(Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.c)®)( S. Mcc, S t Owner's Name,Address,and Tel.No. Assessor's Map/Parcel �� 1 `� ((i' Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil R i Nature of Repairs or Alterations(Answer when applicable)�' 30yG .rz,2d a d i i o y. Date last inspected: Agreement: - The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Ao of Health. Signed Date 1S !1 -3 Application Approved by Date 1 Application Disapproved by Date for the following reasons Permit No. C, �� Date Issued—.- i _---------- ' l -- _.. .._...............__..._,...,.._....._._._.._. ------------------------ THE- ---- - - COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( ) Abandoned( )byA A at o�� 1 S • AV CU',A S'—e Cao- .A Q,((e has been constructed in accordance w' he provisions of Title 5 and the for Disposal System Construction Permit No. )v olk dated i Installer Designer 1 n #bedroo Approved design flow and f I; The issuance of this permit shall notbe construed as a guarantee that the systemkillnc'on s signed. I ..Date .—3, Inspector r ---- o --- ----------�---------------- ----- -- ---- ---- ----------------------------- --------- Fee------------------- N �-oc b( a � THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION BARNSTABLE,MASSACHUSETTS Misposal *pstPIJY Construction Permit Permission is hereby granted to Construct( ) Repair((1 Upgrade( ) Abandon( ) System located at 1 NVi lv-\ ,) i and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. 1 1 Provided:Construction must be completed within three years of the date of this permit. ,n Date J �/ 2j Approved by Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 291 South Main st Property Address Giles&Judith Boland 31 Summit Rd Wellesley, Ma 02181 Owner Owner's Name information is required for every Centerville Ma 02632 1-4-13 page. City/Town State 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. Important:When A. General Information filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not David J Burnie use the return Name of Inspector key. David J Burnie Mgmt, Inc � Company Name 307 A Commerce Park North Company Address So Chatham Ma. 02659 City/Town State Zip Code 1-866-980-1440 SI 386 Telephone Number 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 CMR 15.000).The system: ❑ Passes ® Conditionally Passes ❑ Fails r ❑ Needs Further Evaluation by the Local Approving Authority i ,i 1-4-13 Inspector's Signa re Date 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. C.o t5ins•11/10 TitlSea nspect on Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 291 South Main st Property Address Giles &Judith Boland 31 Summit Rd Wellesley, Ma 02181 Owner Owner's Name information is required for every Centerville Ma 02632 1-4-13 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Septic tank is a 1500 gallon H2O tank, the distribution box is rotted and needs to be replace and the leaching area was found dry. 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): t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 L Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 291 South Main st Property Address Giles &Judith Boland 31 Summit Rd Wellesley, Ma 02181 Owner Owner's Name information is required for every Centerville Ma 02632 1-4-13 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 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): Box is rotted, root infested and leaking, needs to be replaced and cover brought to 6 inches below grade. ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): 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 manner which 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 t5ins•11110 \ Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 291 South Main st Property Address Giles &Judith Boland 31 Summit Rd Wellesley, Ma 02181 Owner Owner's Name information is required for every Centerville Ma 02632 1-4-13 page. Cityrrown State Zip Code Date of 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 all 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 level 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 1/z day flow 15ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 291 South Main st Property Address Giles&Judith Boland 31 Summit Rd Wellesley, Ma 02181 Owner Owner's Name information is required for every Centerville Ma 02632 1-4-13 page. CityrFown State Zip Code Date of Inspection 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. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section 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. t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M ,•'r 291 South Main st Property Address Giles&Judith Boland 31 Summit Rd Wellesley; Ma 02181 Owner Owner's Name information is required for every Centerville Ma 02632 1-4-13 page. Cityrrown 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 ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® 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? ❑ ® Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 399gpdPer permit86-357 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 291 South Main st Property Address Giles &Judith Boland 31 Summit Rd Wellesley Ma 02181 Owner Owner's Name information is Ma 02632 1-4-13 required for every Centerville page. City/Town State Zip Code Date of Inspection D. System Information , Description: 1500 gallon H2O tank, distribution box and 3 flow diffussors and 3'of stone Number of current residents: Vacant Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d yes 9 ( Y 9 (gpd)): Detail: 2012=384 gpd .....2011=324gpd Sump pump? ❑ Yes ® No Last date of occupancy: unknown Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 291 South Main st Property Address Giles&Judith Boland 31 Summit Rd Wellesley, Ma 02181 Owner Owner's Name information is required for every Centerville Ma 02632 1-4-13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: unknown Date Other(describe below): General Information Pumping Records: Source of information: BHD 2009, amount of gallons unknown Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® 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) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,M 291 South Main st Property Address Giles &Judith Boland 31 Summit Rd Wellesley, Ma 02181 Owner Owner's Name information is required for every Centerville Ma 02632 1-4-13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: COC dated 6-9-86 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 26"feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: 10+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): None as to what we can see. Septic Tank(locate on site plan): Depth below grade: Inlet cover 18 inches deep outlet cover 6 inches deep Material of construction: ® concrete ❑ metal ❑ fiberglass ® polyethylene ❑ other(explain) Tank at normal working level. If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 X, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 291 South Main st Property Address Giles&Judith Boland 31 Summit Rd Wellesley, Ma 02181 Owner Owner's Name information is required for every Centerville Ma 02632 1-4-13 page. CityrTown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 30" Scum thickness 0 to 2" Distance from top of scum to top of outlet tee or baffle 4" Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? Tape and Estimated. Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tank should be serviced every 2 years if used year round and every 3 if used seasonal. 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 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 4 M , 291 South Main st Property Address Giles&Judith Boland 31 Summit Rd Wellesley, Ma 02181 Owner Owner's Name information is Centerville Ma 02632 1-4-13 required for every page. CityrTown State Zip Code Date of Inspection 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.): Pump every 2 years if used year round every 3 if used seasonal. 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 t5ins r 11110 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y 291 South Main st Property Address Giles&Judith Boland 31 Summit Rd Wellesley, Ma 02181 Owner Owner's Name information is Centerville Ma 02632 1-4-13 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert D box is leaking 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.): Roots have entered the seam of the distribution box , the box is rotted and should be removed and replaced. 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Located and viewed using a sewer camera, found dry t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 291 South Main st Property Address Giles&Judith Boland 31 Summit Rd Wellesley, Ma 02181 Owner Owner's Name information is required for every Centerville Ma 02632 1-4-13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ® leaching galleries number: 3 flow diffusorswith 3' of stone ❑ 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.): None all dry 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 t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M , 291 South Main st Property Address Giles&Judith Boland 31 Summit Rd Wellesley, Ma 02181 Owner Owner's Name information is required for every Centerville Ma 02632 1-4-13 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): None 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.): t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 i I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 5 291 South Main st Property Address Giles &Judith Boland 31 Summit Rd Wellesley, Ma 02181 Owner Owner's Name information is Centerville Ma 02632 1-4-13 required for every page. Cityrrown State Zip Code Date of Inspection 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 public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ine•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 201 So.Main St.Centerville Owner: Donaldson:327 Regency Dr.Marstons Mills Date of Inspection:11/18/96 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' kc I o ,s� � g jAA 31 I R c s2 c o ! ! 1 I fi i i i r ! DEPTH TO GROUNDWATER ! Depth to groundwater:12 feet method of determination or approximation: I USGS Maps and Charts i I i (revised 11115195) i 9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 291 South Main st Property Address Giles &Judith Boland 31 Summit Rd Wellesley, Ma 02181 Owner Owner's Name information is required for every Centerville Ma 02632 1-4-13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 8'6"from grade 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) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Hand auger done at time of inspection found ground water at 8'6", the bottom of the leaching is 56" allowing for a seperation of 48"to ground water Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 291 South Main st Property Address Giles &Judith Boland 31 Summit Rd Wellesley, Ma 02181 Owner Owner's Name information is Centerville Ma 02632 1-4-13 required for every page. Cityrrown State Zip Code Date of Inspection 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 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 THE COMMONWEALTH OF MASSACHUSETTS - - BOARD OF HEALTH fur Roposal "hs Annsultrum f rrnm 001 Application is hereby made for a Permit to Construct ) or nnRepair (W an Individual Sewage Disposal Systema�^�... .:,w s ue,• -I S_ -S AA- � 1 i. Ada:— Q-3_ 92L1L- — A 1A Address a Type of Building Size Lot<— Sq.feet—— - Garbage Grinder ( ) Dwelling—No. of Bedrooms— -- -Expansion Attic ( ) Other—Type of Building --—-- -- � _ No. of persons----------- __. Showers ( ) — Cafeteria i. Other fixtures ---—-------------------------— —- — - — ons per person per day. Total daily flow._____—_—_.---------gallons. Design Flow_ -----__---- >'� P P P Y• Y x Septic Tank—Liquid-rapacity_—_—gallons Length---__Width_----.____Diameter..__—_—Depth--_--- Zl Disposal Trench—No.—__- ---Width—-.__.--_Total Length-__ —Total leaching arm sq,ft. � Seepage Pit No.._____-_.-__ Diameter.__.___.__.—_ Depth below inlet—.—.—.--Total leaching area.—. sq.ft. z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by_—---.---•------_ _ —._---. Date ____. _ Test 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-_—.__--..—_. - O Description of — U -------------------------------------_____..___—_-- ----------------__—._—__-_-----L � )� _ Otte of Repairs or Alterations—Answer when applicable._ 600 Agreement: U The undersigned agrees to install the aforedesrnbed Individual Sewage Disposal System in accordance with the prrnisions 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 bopxd of health Sign r I±52 .. ___ --__ —Z.=24-8(�___ A Date 4 — Application Approved By--.____-._--_— __ --- — —--- — n= � Application Disapproved for the following real _- - — - ----_--_—__-- Due Permit No.....__._- — - Issued-----"'—Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .. ?:t..........__...OF.I.~. L._�...............__.. _ (SPl gh—ab of Iffm titam b - THIS IS TO CERTIFY, That the4ndiyiduel,See a e Disposal System constructed ( ) or Repaired y `R._____ at has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as d bed in the application for Disposal Works Construction Permit No.__.__ c_ ._�_— dated... _....... 9� _ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE. a' SYSTEM WILL FUNCTION S TIS ACTORY. DATE ___. ._YY~� �C — Inspector— THE COMMONWEALTH OF MASSACHUSETTS _ _..;s r BOARD OF HEALTH NO._g 3S7. ...-I__?fit-_..........................0F R i �iS}tu8�i �tS 1ffDn11 lrttrti n Print - Permission is hereby granted----- CA I?co _.. to Construct ( ) or Repair (SC ) an Individual S e Disposal System , at No.. ._ ___ _ �ct•L S �n!y�.�_5?� __Sts��_�1 F as shown on the application for Disposal Works Construction Permit No.._...._._..— Dated.-_ DATE-_' FORM 1255 A.M.SULKIN.INC..BOSTON - a - Commonwealth of Massachusetts John Grad ExecuWe Office of Environmental Affairs D.E.P. Title V Septic Inspector Department of P.O. sox 2119 EEnvironmental Protection Te�tt;cl<et,Ma 02536 ' (508) 564-6813 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM V 1 PART A CERTIFICATION ®�(a^ I J ftrej,"Ae -, lib. �� ,�► Property Address: 291 So. Main St.Centerville Address of Owner: Nk S' Date of Inspection:11118f96 (If different) ` �✓��e Name of Inspector John Graci Donaldson:327RegencyDr.MarstonsMills �; Company Name,Address and Telephone Number: 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: X Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: Date: 11118196 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B.C, or D: A] SYSTEM PASSES: X I have not found any information which indicates that the system violates any of the failure criteria defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: _One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes,no,or not determined(Y, N,or ND). Describe basis of determination in all instances. If "not determined",explain why not.) _ The septic tank is metal, cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 11115195) One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500 1 _ I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 291 So.Main St.Centerville Owner: Donaldson:327 Regency Dr.Marstons Mills Date of Inspection:11118196 _ Sewage backup or breakout or high static water level observed in the distribution box is due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced _The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: _ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER, IF APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface of water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone 1 of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. _ The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria volatile organic compounds indicates that the well is free from pollution for that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm. 3) OTHER D] SYSTEM FAILS: _ I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage in facility or system component due to an 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 cesspool. SAS is in hydraulic failure. (revised 11/15195) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 291 So.Main St.Centerville Owner: Donaldson:327 Regency Dr.Marstons Mills Date of Inspection:11/18/96 D] SYSTEM FAILS(continued) Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Numbers of times pumped Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria: _ The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area (IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 11115195) 3 _- I I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: 291 So.Main St.Centerville Owner: Donaldson:327 Regency Dr.Marstons Mills Date of Inspection:11/18/96 Check if the following have been done: X Pumping information was requested of the owner,occupant, and Board of Health. X None of the system components have been pumped for at least two weeks and the and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. n1aAs built plans have been obtained and examined. Note if they are not available with N/A. X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout. X All system components,excluding the Soil Absorption System,have been located on the site. X The septic tank manholes were uncovered,opened, and the Interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions, depth of liquid, depth of sludge, depth of scum. X The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. X The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11115195) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 291 So.Main St.Centerville Owner: Donaldson:327 Regency Dr.Marstons Mills Date of Inspection:11118196 FLOW CONDITIONS RESIDENTIAL: Design flow: 330 gallons Number of bedrooms: 3 Number of current residents: 4 Garbage grinder(yes or no): No Laundry connected to system(yes or no): Yes Seasonal use(yes or no): No Water meter readings,if available: nla Last date of occupancy: nla COMMERCIAL/INDUSTRIAL: Type of establishment: nla Design flow:0 gallons/day Grease trap present:(yes or no) No Industrial Waste Holding Tank present: (yes or no) No Non-sanitary waste discharged to the Title 5 system: (yes or no) No J Water meter readings,if available: nla Last date of occupancy: nla OTHER: (Describe) Na Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System has not been pumped In the last two years. System pumped as part of inspection:(yes or no)No If yes,volume pumped: 9 gallons Reason for pumping: nla TYPE OF SYSTEM x Septic tank/distribution box/soil absorptions system Single cesspool Overflow cesspool Privy Shared system(yes or no) ( if yes, attach previous inspection records,if any) Other(explain) APPROXIMATE AGE of all components,date installed(if known)and source information: 1991 Sewage odors detected when arriving at the site: (yes or no) No (revised 11115195) 5 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 291 So.Main St.Centerville Owner: Donaldson:327 Regency Dr.Marstons Mills Date of Inspection:11118196 SEPTIC TANK: X (locate on site plan) Depth below grade: 1' Material of construction:X concreate_metat_FRP_other(explain) Dimensions: L 8'B'1-15'7-W 4'10-H-20 tank Sludge depth:2' Distance from top of sludge to bottom of outlet tee or baffle: 25" Scum thickness:0 Distance from top of scum to top of outlet tee or baffle:5' Distance form bottom of scum to bottom of outlet tee or baffle: 0 Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) Septic tank and all components are structurally sound.Recommend pumping system every two years for maintenance. GREASE TRAP: (locate on site plan) Depth below grade: nla Material of construction: _concrete_metal_FRP_other(explain) Dimensions: nfa Scum thickness:n1a Distance from top of scum to top of outlet tee or baffle:n1a Distance from bottom of scum to bottom of outlet tee or baffle: n1a Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) Na (revised 11115195) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 291 So.Main St.Centerville Owner: Donaldson:327 Regency Dr.Marston Mills Date of Inspection:11/18/96 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: nla Material of construction:_concrete_metal_FRP_other(explain) Dimensions: n1a Capacity: n1a gallons Design flow: n1a gallons/day Alarm level: n1a Comments: (condition of inlet tee, condition of alarm and float switches,etc.) n1a DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: n1a Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box etc.) n1a PUMP CHAMBER: (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber,condition of pumps and appurtenances, etc.) n1a (revised 11115195) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 291 So.Main St.Centerville Owner: Donaldson:327 Regency Dr.Marstons Mills Date of Inspection:11118196 SOIL ABSORPTION SYSTEM(SAS):x (locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present, explain: nla Type: leaching pits, number: n1a leaching chambers,number:3-flowdiffusers leaching galleries,number: n1a leaching trenches,number, length: n1a leaching fields,number,dimensions:n1a overflow cesspool,number:n1a Comments:(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) The sas is functioning property. CESSPOOLS: (locate on site plan) Number and configuration: n1a Depth-top of liquid to inlet invert: n►a Depth of solids layer: n1a Depth of scum layer: n1a Dimensions of cesspool: n1a Materials of construction: n1a Indication of groundwater: n1a inflow(cesspool must be pumped as part of inspection) Na Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.) n1a PRIVY:_ (locate on site plan) Materials of construction: n1a Dimensions: nla Depth of solids: nla Comments:(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) PrivyComments (revised 11115195) 8 1 ` y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 291 So.Main SL Centerville Owner: Donaldson:327 Regency Dr.Marstons Mills Date of Inspection:11119196 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' 9(kc d � � R Al 3u R c � 14 DEPTH TO GROUNDWATER Depth to groundwater: 12 feet method of determination or approximation: USGS Maps and Charts (revised 11115195) 9 J ASSESSOR'S MAP JNO. 2,0t-7 PARCEL 001 66 -25 7 LOCATION SEWAGE PERMIT NO.% CL-Inal/t,lle M a Qcl 1 S®o°t 11 a i'" VILLAGE 1�y s CA INSTA LLER'S NAME i ADDRESS BE R U I L D E R OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED Cg / 19g,(o ;_ f I � ' Y Y NO.......... ......... y Fps..... ........ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .........TW'+c'1 O ..................OF.E.J 4rnoWe............................................................ / Appliration for Dig as al Works T.omi rur#ilan rruti eor Application is hereby made for a Permit to Construct ) or,Repair (4(.) an Individual Sewage Disposal > System at: a/ /� /ATt',oc�at/fion-Address .Li,.. - (� u 1 -o--L/ott�1 o.-•. - .................. .-.- - Qv1.�l.X.Tray_A-... ........... :i.Gi' ........._._. . ... ...�.X/�::I �[l. T 1. �. ........................... Owner Addres a ............44.E 0�n Q .... ..�k �„.. e �..( �rr�rQrc i. .... Installer Address Type of Building Size Lot.................... .....Sq. feet U Dwelling—No. of Bedrooms........... ..........:....................Expansion Attic ( ) Garbage Grinder ( ) a'14 Other—T e of Building No. of persons............................ Showers YP g ---------------------------- P ( ) — Cafeteria ( ) Otherfixtures --------•----------------•-•-•---------•-------.._.....----•----------------•-•--•-••--•-•---•--•---•-•--------•---------......-•-•-••....._....--•-•- w Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--_----------------- Diameter.................... Depth below inlet.................... Total leaching area....:.............sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water......................... 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 -••---•--•-------------------•-••--•••••--••-••-.........---••-......---•-•-•-••••-----...._.....••......................................................... 0 Description of Soil.........................................................,............................................................................................................... x U --••--•••-••----------•••••--•-••-••--•---......•••...--••••--........••----•------••••-...-•-•-•---.......•-•••-•••••.......•-•-•-•--•-----•---••••--•••••-••-......•••-•-••----••--•--••••....._..-•-- w __ _ x V N tu�e of Repairs or Alterations—Answer when applicable..�600,4i 9. k.t#14) G3,�.. /d- _ G _41.bqf..5---1, is na m6... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System.in accordance with the provisions of TITU 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 bo rd of health. Signed �.JC� --• - ---- - Z-F�o_..._.... Application Approved B Date PP PP Y ------•-------------- •-•--••--....._.._........ Z Date Application Disapproved for the following real s:...---•-------------------------------------•-------------------------------•--•-------•---•••-••-••.........._ --.....--•----------•-•----------------------•----------•--------•---•--......---•-•-•-----••---.........._.........----------------------------...-------------•--------------......................... Date PermitNo.......................................................- Issued-....................................................... Date k ..l...r»4' No......................... Fps... :....... .. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...... W ..................OF.IPM4�A)le........ Applira tiun for Disposal urku 'Tons#.rurtion errant Application is hereby made for a Permit to Construct ( ) or Repair ( >) an Individual Sewage Disposal Systm at: c� 1.... ithih IttC�1Yt .�� a , t e:t2rut��R_ Location-Address t s / / or Lot No. 1��'pfSQ. (, i� Ek•�' J42, n 7a erU[�lP_ .............. — -....-.....................Owner........ C' .........._...__....... ......................................................Address -.........-••-•-•�---._............... a E1f.l�1CCS St9 olntI S "�'Es��i� IIJP!�1 W/®fir/iMttj� ..........--•-------. ............................•-----•-•••.......---••-....... .........._.._.................i............................................................ Installer Address(: VType of Building Size Lot............................Sq. feet �..� Dwelling—No. of Bedrooms.........:...:..............................Expansion Attic ( ) Garbage Grinder ( ) Other—Type e of Building ............... No. of ersons._.........._............... Showers — Cafeteria W YP g ............. P ( ) ( ) C4Other fixtures ---------------------------------------•---•--.--- .._.... Design Flow............................................gallons per person per day. Total daily flow............................................gallons. Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Dept h................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area...................sq. ft. 3 Seepage Pit No............:........ Diameter............. ._..... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ ,aa Test Pit No. I................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........................ a ---------------------------------••••-••••------•.....--•••-•-•-............ ......................•---•-•......--••-•••.....---•-•-••------....._...... 0 Description of Soil........................................................................................................................................................................ W V •--------•---------------------------- ••-•------------------------- •-------- --------•-------------..._.......------------------------------------------- ----------- ........... ......... W ----•-•---------•-----------------•-------••----.....------......--------....._............--------------------------•----•------...-----------•----_--- U Natuje of Repairs Qr Alterations—Answer when applicable.ZS�-r�'Ae`��?�_.��'-��,�._`��'��'�:.�'�. �C�'' c-le u_ser ....,.,s.Gn�.......ray A "9-----------••-•-••--••••••.................. ............... ... ....... 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. Slgne . '+ e v Date Application Approved By..... ••................. ........................... ........... .�.. Date Application Disapproved for the following real :-------•----•------•----•-----•-----------------------•----------------.......--------..._...................._ --•--•-------------•--........--.................................................------...-----..............----------------•-•-----...----.......------......--•--------•--------•-••-•--•-••--••-•--- Date PermitNo...................................................-._. Issued......................................................-- Date -� THE COMMONWEALTH OF MASSACHUSETTS l� s BOARD OF HEALTH Gv.'til OF f.:rnS.lc.)�4.... ..... .................................................. .......................................... Gr#if irate of dw- woutplittnrr THIS IS TO CERTIFY, That theAlndiwidual�Sewage Disposal System constructed ( ) or Repaired •( ) by-•.... . ... ..... .... •- -.. co .........................................................=--..... -- -- --•••.............._••---.................._ Installer .t f v �Vj t-1 %�\>i oA at._....-----•••••••............................................•-•---••-•••......_.... .....-•--------._......--•-..........••-•-.._..-----........................••.•. •-•-•-•--...__..._.. has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as desqribed in the application for Disposal Works Construction Permit No..........f?6a__:_1:E.1............ dated.__.__....._qj-�....]J._g6 THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION S TIS ACTORY. . DATE..................................... - .........•---•-----• - Inspector....... --------------•--.............................................. = � THE COMMONWEALTH OF MASSACHUSETTS BOARD OF OF HEALTH g6- 3�"� 1 '[�"i........................0 F..k3C¢/r/� <� ?,/? ..................................... No......................... Fn. 5......:.......... Disposal rku Tonufrudion rrrntt# Permission is hereby granted....................1.1�... .......C 6.!-A. --- --•---•--•--------.............................................__.... to Construct ( ) or Repair (4 ) an Individual Sewage Disposal System at No................... ............��1.t. -C�o-c�'t1\ N^^t%\ S-r4..._.._...0 Street g6.:S7 4 as shown on the application for Disposal Works Construction Permit No......................,Dated............ _.. ...... ............................................. r C �.. DATE. g / Boar o Health FORM 1255 A. M. SULKIN, INC., BOSTON } S . a ( s i C .B. FND. FND• ��V pPJ li 97520 S.F. ± UPLAND rn '( �� ✓ 4, 253 S.F. 4- WETLAND\ v 32773 S. F. TOTAL \ \ � ;OU S Ilp 3 SHED cl) T> �x m �� 14, 839 S.F. ± UPLAND gE V ( Q? 3, 01 5 S. F, f WETLAND NUJ 5 +\� 17, 854 S.F. TOTAL p�K C.B. \ 67.27 W 2 5 9 '— F N D. \ 8? C.B. FND. N.�01-LY ;.4 IAI C t PARCEL a BS 04 `s_2 T ASSESSORS MAP NO- I L0 CAT 10N SEWAGE PERMIT NO. yILL.A0E . t Cat v�CsJ_ 1NST A LLER'S NAME. i ADDRESS IIot =)q d UILDER OR OWNER DATE PERMIT { SSUED (�rBi2c q to DATE COMPLIANCE ISSUED i F 7- 5( � c� r i i I a: f REVISIONS t ZONE REV DESCRIPTION DATE APPROVED C r� 11 i Existing House Kitchen Gl� S uy� B—B 4'-6• � r 6' Proposed Kitchen Addition W VI 4'-6' 3/ Closet r t 14' f A-A 4 r door plan -- Drawings for permitting only, All construction must Meet Mass, building codes, SIZE FSCM NO. DWG NO. REV Any structural analysis must be performed by an licensed architect, Gary R. Stubbins . SCALE 1/4"=1 SHEET House �x - Eristirg - _ Kitchen ,p D B - B itches PrOP05eci K W 4/_6„ 3 C dose -t 1 4 F 0 ! �a� REV DWG N0. A _ SizE FSCM No. Gary R, $tubbins SHEET Mass, building codes, SCALE tion Must ►'eet chitect. All construc licensed °ar ctural ermitting ° ust be perf orMed by an Drawings for p analysis Any stru w