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HomeMy WebLinkAbout0028 SOUTH PRECINCT ROAD - Health 28 South Precinct Road Centerville A= 148-139 S M EAD® No.Z•1531AIt UPC 12534 smeadcom • Made In USA Ora) xmft FAKJ- Commonwealth of Massachusetts -Title 5 Official Inspection Form 3., Subsurface Sewage Disposal System Form -Not for Voluntary Assessments /7M 28 South Precinct PN4 Property Address Juan Marichal Owner Owner's Name / 1- information is 02632 5/22/18 -Centerville y Ma ' required for every "� 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: forms When A. General Information fillip out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not Michael DiBuono use the return Name of Inspector key. DiBuono Sewer and Drain Company Name 35 Content Ln Company Address Cotu it MA 02635 City/Town State Zip Code 508-364-9587 S113522 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 ❑ Needs Further Evaluation by t proving Authority 5/24/18 In ector's Signature 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. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal �System•Page 1 of 17 os wvs Commonwealth of Massachusetts , u . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 28 South Precinct Property Address Juan Marichal Owner Owner's Name information is required for every Centerville Ma 02632 5/22/18 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: System contains a 1,000 Gallon septic tank. As well as a concrete distribution box and a 6x6 leach pit. Pit was dry at time of inspection and shows a stain line to within 28 inches of invert pipe. System is functioning as designed. 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 28 South Precinct Property Address Juan Marichal Owner Owner's Name information is required for every Centerville Ma 02632 5/22/18 page. City/Town State Zip Code Date of Inspection 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 ❑ 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 El Cesspool or privy is within 50 feet-of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts 4 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 28 South Precinct Property Address Juan Marichal Owner Owner's Name information is required for every Centerville Ma 02632 5/22/18 page. City/Town 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ° 28 South Precinct M Property Address Juan Marichal Owner Owner's Name information is Centerville Ma 02632 5/22/18 required for every page. Cityrrown 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M ,•'" 28 South Precinct Property Address Juan Marichal Owner Owner's Name information is Centerville required for every Ma 02632 5/22/18 page. Cityfrown 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 CM 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts 4 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 28 South Precinct Property Address Juan Marichal Owner Owner's Name information is required for every Centerville Ma 02632 5/22/18 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: Vacant Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Na Detail: Sump pump? ❑ Yes ❑ No Last date of occupancy: 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 28 South Precinct Property Address Juan Marichal Owner Owner's Name information is required for every Centerville Ma 02632 5/22/18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Not provided 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 28 South Precinct Property Address Juan Marichal Owner Owner's Name information is required for every Centerville Ma 02632 5/22/18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Pit was new in 1996 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 feet 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.): Tank is not leaking Septic Tank(locate on site plan): Depth below grade: 1.5 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1000 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts AsOmW Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 28 South Precinct Property Address Juan Marichal Owner Owner's Name information is required for every Centerville Ma 02632 5/22/18 page. Cityrrown 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 24" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 42" Distance from bottom of scum to bottom of outlet tee or baffle Sludge stick How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is sound. Pumping is recommended 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•3113 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 28 South Precinct M Property Address Juan Marichal Owner Owner's Name information is required for every Centerville Ma 02632 5/22/18 page. City/Town 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.): 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 28 South Precinct Property Address Juan Marichal Owner Owner's Name information is required for every Centerville Ma 02632 5/22/18 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 Level and at normal level 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.): 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: t5ins-3/13 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 28 South Precinct Property Address Juan Marichal Owner Owner's Name information is required for every Centerville Ma 02632 5/22/18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: " 6x6 ❑ 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.): 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•3/13 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 28 South Precinct Property Address Juan Marichal Owner Owner's Name information is required for every Centerville Ma 02632 5/22/18 page. Cityrrown 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.): 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts 4y Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 28 South Precinct Property Address Juan Marichal Owner Owner's Name information is required for every Centerville Ma 02632 5/22/18 page. City/Town 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 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts , v Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °�M a 28 South Precinct Property Address Juan Marichal Owner Owner's Name information is required for every Centerville Ma 02632 5/22/18 page. Citylrown 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: 15+ 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: Test hole data on plan Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 5/24/2018 Assessing As-Built Cards TOWN OF BARNSSTABLE LOCATION ag so 1?Rec 14CF KO( SEWAGE# VILLAGE Oen f6<✓/1 f e ASSESSOR'S MAP&LOT INSTALLER'S NAME 8t PHONE NO. 1771 O 0,9 e Seam- f SEPTIC TANK CAPACITY A700 eV9/ LEACHING FACILrrY:(type) /G00 677tz l (size) NO.OF BEDROOMS 3 BUILDER OR OWNER Afl &;tI00 Hy PERMITDATE:__tv` Sl COMPLIANCE DATE: ir,� Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leachbyg Facility Feet Private Water Supply Well and Leaching Facility (If any wells.exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist; within 300 feet of leaching facility) Feet Fumished by Xlz, '':c:• 3,(4 http://www.townofbarnstable.us/Assessing/HMdisplay.asp?mappar=148139&seq=1 1/2 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 28 South Precinct Property Address Juan Marichal Owner Owner's Name information is required for every Centerville Ma 02632 5/22/18 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARNSTABLE LOCATION OF �®� ► �`eej°J�� ^O� SEWAGE#. VILLAGE 0e4 f m V! ASSESSOR'S MAP&LOT/ INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /mo LEACHING FACILITY: (type) ZD®O l (size) ` NO.OF BEDROOMS 3 BUILDER OR OWNER i &0 PERMITDATE: S� COMPLIANCE DATE: _ Separation Distance Between the: " Maximum Adjusted Groundwater Table and Bott-om of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) ��+ t o ��s Feet Furnished by --� I `t i (IS 04 \ j ,4- TOWN OF BARNSTABLF- LOCATION ' 02� `S®- '?dZeC-1.9GP "qC/` SEWAGE"#" VILLAGE Cen 11f2V111P- ASSESSOR'S MAP& LOT/ -/ INSTALLER'S NAME&PHONE NO. 177 170 SEPTIC TANK CAPACITY 1660 eV91 LEACHING FACILITY: (type) /000 67;9-/' (size) NO.OF BEDROOMS 3 BUILDER OR OWNERS ,C /ZO,///� PERMITDATE: 4o " S� COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells`'exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist ~s within 300 feet of leaching facility) t r+ �.:` Feet Furnished by -�:; _: S� A . * i3 1 No. /1 Fee_THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS ' 01pprication for Migpogar *pgtem Congtruction Permit Application is hereby made for a Permit to Construct( )or Repair( )an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. 'Cr RQ —3 ALzo Z-r P Instal�r'��idd��d Tel Designer's Name,Address and Tel.No. Type of Building: Dwelling No. of Bedrooms Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow '� gallons per day. Calculated daily flow 7Z�3 ir,7 gallons. Plan Date Number of sheets Revision Date Title Description of Soil Jh�aQ S h w� Nature of Repairs or Alterations(Answer when applicable) 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 Co e and not to place the system in operation until a Certifi- cate of Compliance has been iss s oar of H _ Sig ed Date Application Approved by Application Disapproved for the following reasons } Permit No. F � Date Issued �'.n"gL r'F.*'1.. !V'.""-i'-•'•..� - nr , , .. K_ .i- ate+.-' -:y.. �ah :,�.,. -.,, _, .. .. .. -.` . .� . 9 �+J'' uS. Z/J 6 / No. „i �� Fee �` �"U - THE COMMONWEALTH OF MASSACHUSETTS PU.,BLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS r 01pplication for Migozal *pgtent Con,5truction Permit Application is hereby made for a Permit to Construct( )or Repair( )an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.,No. Gx F s d JZQ __9 w,LZO T`1 P Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling. No. of Bedrooms Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) t Other Fixtures 1 Design Flow '`i ' gallons per day. Calculated daily flow 33 i gallons. Plan Date Number of sheets Revision Date Title Description of Soil ,An�n.Q Nature of Repairs or Alterations(Answer when applicable) !A S T A �� ..��✓�mot/ � 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 Co e and not to place the system in operation until a Certifi- cate of Compliance has been iss�� s oard of He _ Sig etfd Date Application Approved by Application Disapproved for the following reasons f Permit No._ .�w� Date Issued 445 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Certificate of Compliance - )ego IS TO CERTIFY. hat the.O to Sewage Disposal System installed( )or repaired/replaced( )on S ' . )ego by e I. � 6 r��for� � L�,7 as s k'1', has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. � 0 datedm_4 !Jl - Use of this system is conditioned on compliance with the provisions set fo elow: ....�► No. '� Fee4� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS .°t d Migogal *p.5tem Congtruction Permit Permission is hereby granted to r. to construct( )repair( L-�15'n On-site Sewage System located at 6?7' w^cGi 1+ T LgrPt J and-as described"in lthe above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. All construction must be completed within two years of the date below.' r Date: �..7 �' �► Q Approve 1 Commonwealth of Massachusetts - _ f PARCfLNO:.--�-� - Executive Office of Environmental Affairs Department of �to 7' Environmental Protection William F.Weld CEIVE® Governor Trudy COXe MAY ? 2 1996 Secretory,EOEA David B. HEALTH DEPT Commissionerloner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM TOWS]OF EAA+NSTAGLE PART A CERTIFICATION Property Address: C'--;X F S v,T,� 1�P r*C4"W Address of Owner: - , ��L z Date of Inspection15-aa,Ct� (If different) Name of Inspector: Company Name, Address and —elep 1hone Numb 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: _ Passes _ Conditionally Passes Needs Further Evaluation By the local Approving Authority ails Inspector's Sign Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (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 o{the Department of Environmental Protection. The origina! should be sent u, :.ne 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: . I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] �SYSTEM CONDITIONALLY PASSES: / One or more system components need to be replaced or repaired. The system, upon 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 8/15/95) 1 One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500 ri,•Printed on Recycled Paper + r. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM • PART A CERTIFICATION (continued) Property Address: Owner: ri L zo�-i Date of Inspection: B]SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced _ The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ ThP wstPm has a SeNiC tanK ano 5011 aUSorpUUn system and IS wllhin ioo Ices iu a Sullacc water Supp:) of tributary- t0 a surface water supply. _ The system ha, a septic tank and soil absorption system and is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. _ The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm• D] SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or dogged 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. (revised 8/15/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: -�S P.L Date of Inspection DJ SYSTEM FAILS (continued): e5 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). Number of times pumped Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. 6� Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: The following criteria apply- to large systems in addition to the criteria above: /7 The design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one of 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 suppiy 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 8/15/95) 3 l SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B - CHECKLIST Property Address: Owner: -16a L-zoTT° Date of Inspection: s as-g� Check if the following have been done: mping information was requested of the owner, occupant, and Board of Health. ti14one of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. ,.-'As built plans have been obtained and examined. Note if they are not available with N/A. e facility or dwelling was inspected for signs of sewage back-up. -fi"e system does not receive non-sanitary or industrial waste flow _1-T- a site was inspected for signs of breakout. I system components, excluding the Soil Absorption System, have been located on the site. , Fie 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. vfhe size and location of the Soil'Absorption System on the site has been determined based on existing information or approximated by non-intrusive.methods. _" e facility c•:.,c �� ' occupan1,5, if d ffere from owner! were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 8/15/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property P Y Address: �' -� cSUci (� Owner: U �C1 cuGj— C,v,rt'( a�1 Ti Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: 3� gallons Number of bedrooms: Number of current residents:_a Garbage grinder(yes or no): A-," Laundry connected to system ryes or no):- Seasonal use (yes or no): All _ Water meter readings, if available: 4114- Last date of occupancy: COMMERCIAUINDUSTRIAL• Type of establishment: Design flow:_gallons/day 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: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no)_ If yes, volume primped: gallons Reason for pumping: TYPE O.,ANSTEM (/ 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) Other(explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site: (yes or no) (revised 8/15/95) 5 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: ffa� ;$0v`-k ct- Owner: IZ 4 -ZUZ'T i t Date of Inspection: SEPTIC TANK: t� (locate on site plan) Depth below grade: 6 Material of construction: foncrete _metal _FRP —other(explain) Dimensions: Sludge depth: N(` Distance from top of slydge to bottom of outlet tee or baffle:_ Scum thickness: /?'� - Distance from top of scum to top of outlet tee or baffle: OUf"o-rC-c. Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) — S L GREASE TRAP: (locate on site plan) Depth belo,.%• grade: Material of construction: _concrete metal _FRP_other(explain) Dimensions: 'Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance frorr bottom ry .ro— to hnnnrr ot•owle, tee Q• bdtlie- 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.) (revised 8i!5/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PART C SYSTEM INFORMATION (continued) Property Address:' So✓` 11 Ye C9 , Owner: -B aLZOTT", Date of Inspection: TIGHT OR HOLDING TANK:_ (locate on site plan) Depth below grade: Material of construction: _concrete_metal _FRP—other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:_v . (locate on site plan, Depth of liquid level above outlet invert:�o"�- f�p2z Comments: (note ii ievei and distributicf, > eyua, e�'denee of solid_ ca:ryo�er, evidence of leakage into or out of box, etc.) 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.) (sevised•8/15/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued).- Property Address: yr U��P"►�t'_L;a��l Owner: Z1a1 _z aT1—r Date of Inspection: ab SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number: leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of Wil, sins of hydraulic failure, level) of ponding, condition of vegetation,etc.) CESSPOOLS: (locate on site pla 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 groundwate.-: inflow (cesspool must be pumped as part of inspection) 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.) (revised 8/15/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) . Property Address: 0-7 SO— Owner: I��L Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' DEPTH TO GROUNDWATER No Depth to groundwater: Z� feet method of determination or approximation: U�5'G•S oZ,(e Y�O�St W`c' pt S A bo e� l� �t� (revised 8/15/95) 9 I ,.-.x.•...--:- ,., .....,_::.s..'-....,.c.a^�ar;4:r�.S�"'i�?����`�'!i'ra' rjy - � - -�v__4�-pint-aN.�- s°"'-"' hdy `.was du�mr p�.+�gr tr v BOX ooT s 4 �. v&I .eY10l $ s Hv ti k � c /N✓c.2 T CA pA:C>T Y . /Rt/YE:,eT ! :'� ,! :�T/G •� A i�CkJ/1fi <5 7 5- 1NATGlZT/G7'� /:Nl/E.QT 80! 14,�� �f' f z . UV.V` EST , BAGS:G,et�vb �2-1 -- _ W. r►rv;.��3"�t,_- . •,;6 ,_ 9' w.��_y� s�:�'4 3v�. �'ti�isa. ZZI ����'� -MAP �a OF �� SEAT/G. TAN�� --1-�--�- -�C..�41�L_.-..1fp1?ls � sox . y �S OUTc.ETS� ANDT RO ULD ��� 716P.,44C / ., G(FfORD '� a0a/uG'�2ET� £T2ENGTJy 3600 .�s/ '1/N QK . 20000 r Loia/wG - Cam ... - , VE PAVAY JJOT TO BE L©CArAZD _ � �'L.1,�-M'0�,1.7'��.��T, �/Q.,,1cr'� .-� . .O✓.:.F�2 �5'5 TEM.u�v�E 5 5- f�— ZO. . C �RT I FY THE tiUl LDi"Iv6- SHt1L3i,t /y � �;ti� of S/G�/ -'C0. r-VA.1 TH !5 PLAN IS PROPOSED ' ON TN£ . G RUL'!�1 D AS S N. t3LJrd AN I3: /7 C M PL*Y pow. . . �E7C3fiCK REO►uiR� �n!TS CD F i•- � 'D� o ht - NE orSIT 70L�JN OF OR/ZN 5 TA$ p �A T� •�d 4L7Jy AGc'¢_.t/T r 3 / RvE -A -• �' .l..w r .r � � a. t ', ..e r �� C� 'd v .o. ' q a �r ` .`� !ji:.. -• ,. s .r. .ea-,at:'" c .. ri"..... ':eta-�'+w�.b' y<:3•sc �.i(}�a ,. i � � -. .�-�5�� Y ;t,. .s `.: ¢. �n e-� ' LO We WIC Pi Tj S r- Jf /"I � I ,.C d ♦ .. ' -'.ed S.- '}- F - STA F a vie- o ; {' '- va< _-a �-�� � "Z�\ �`"`lf..i. - _ _ �� ! .I i ♦) d.f i 39..1 - /' 'fit B-'i .}.e-M . � - .. ...<.J'r1 R• K "`! a 'T.\tlT � a f<" .`S-S� ',`• .,3L'.,+5 '� A y a r C: k. y3, i ti45'- nrtaa ,� s , TWX _ 'i 144 s' T 4e'4 NL tti SAIY,Q LEACH ;q. A : 26.Qr o.T -- e.M 1QQS/N.. r- ELCVd 36 tO�MSc) 44 (MS - - Aiinl/rv�v� TER `I1C'bUyV ' TO[v�t emu./L-PlAIG S�TBAC� - L�.�ATCR /S AY 9I4A13LQ' Ur,g SEP 7'I c �wS rye UC , E�tV A1.4 -h/TA4. COS T/.TLE jz aESrGn t.l1 ! F�-D -� .-- -� _ Ti.C��,$. �E.qU<�Ed _.-/fir � � _ •, ',�. -�X�iJv.3 F h :�C 1 _ - I'. nl,�'�/ •__'Y,�r�. •/_�� e'rt ', .,`7 ,`!: .x. �l i�.,;.��..{,-;�y -�]�—� � • -.n '. �` - � j .F.,;�'.L- T •� .-'�.5�� -ram' THE COMMONWEALI;;!H-OF--MASSACHUSETTS BOARD OF HEALTH " - Application is hereby made for a Permit to Construct or Repair an Indi_V—VCdft4j1jj$�*,4&I Disposal System at: 0,,Z Address Installer Address Dwelling—No. of Bedrooms................. GaZge Grinder Z Other Distribution box (X) Dosing tank ( ) Test Pit No. .....minutesperinch Depth of Test Pit.....J.Z. Depth to ground water-/VA77....e.�,/V Test Pit No. 2_:<.��----minutesper inch Depth of Test Pit------/Z....... Depth to ground waterd0.QA/7.9FR_Ct ------` —' --------`------'— Agreoozcoz' � The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'TTLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has beer�jssuje by th r d.o f.1i e.a I.t 1.z. Dat C�P_ Date � Date Date ' ~' 1 FRic w. R ,i, �- r THE COMMONWEAL.Ri-1,OF MASSACHUSETTS BOARD OF HEALTH Appliratilan for Disvva al Works Tomitrnrtion "rani# Application is hereby made for a Permit to Construct ( or Repair ( } an Individual Sewage Disposal syste3v 47 ; r' — ••... — -- -••---•------------------••-• _ a...................... .. ......_.............. r� aj,, a��`y A dre �p� � or Lot No. owner Address Installer Address Type of Building Size Lot___4??.Z.7D-_--Sq. fg�p� Dwelling—No. of Bedrooms................. ......................Expansion Attic ( ) Garage Grinder (/I�+ 7 a Other—Type of Building ............................ No. ofpersons............................ Showers ( ) — Cafeteria ( ) w fixtures - ----------------------------• . ---------- Design Flow.._Other " gallons per person per day. Total daily flow........ _G?.....................gallons. 1:4 x Septic Tank—Liquid ca acit gallons Length___-_�_ ----�-- Width...._.a'... Diameter_______________ Depth------ 57,1... . ispo 'DI,Trench—No. .................. Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit NO......./............ Diameter..... d_�..... Depth below inlet.... Total leaching area_/.6.43...sq. ft. z Other Distribution box (X) Dosing tank ( ) '-' Percolation Test;Results Performed. by.-e—"Rak1C�4-..._. ... 72.4- -.27--------- W ,.a Test Pit NO. 1.�<Z.'..minutes per inch, of,Test,.Pit....../Z...... Depth to ground water.NAT._..(FA - (i Test Pit No. 2__'�'___Z....minutes per inch" Depth of Test`Pit..`::/2_r.... Depth to ground wateit3m-J.70.,X -------------------------------••-••--••--•------• --•----•--•-••-•--•----------•--.._...•--•--------•--------------•-•----•-...--••-••----.......... D Description of Soil 1_ �` 9 1 4J c.J C7�G r---- . ....................................... 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 T:.._ 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been ssue by th rard of healtb. "g . / " d Dated Application Approved:,$Y :__..__ .. . �.:�% �-------------•- ........................................ �' Date APPlication,,D,#t oved for the following reasons:---•-----------------------•-----------------------•------•----•-------...-•-•-•......•...--•--•--............. • �-.----•••..._..-•-•-•-•---•---•-•-•--......•----•--•-------------•--- Date PermitNo..................•_.•.....:.---------...--------------• Issued....................................................... Date 't THE COMMONWEALTH OF MASSACHUSETTS Z BOARD OF EALTH .....OF.......c.;........ .. .e-N Trrtifiratr v Toutplianrr �„ by •-•- ---- � ---;� ..,;- ------------------------------------g•--:-'--•P----•-----� -•---constructed (�r Repaired ( )THIS IS TO CERTIFY, That the Individual Sewage Disposal System 1 _,�..}may..=,, {///{j' /�//� w at32�''" pZ / V�3 ._.w - In ,r..... has be n installed m accordance wrth the provislons o T YrI/� o The State Sanitary Code as described m the application for Disposal Works Construction Permit No.�V>�•-.jv `______________ dated___ ................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT,BE CONSTRUED AS A GUARANTEE THAT THE SYSQTEM,,WILL FUNCTION SATISFACTORY. DATE._-.-•-•---•---••---.•...:--•.................................•---....---•__-•_. Inspector.-.-.-------------------------------------------------------------.._.....---_----- + THE COMMONWEALTH OF MASSACHUSETTS s ,+ y BOARD OF HEA T r ...................... jNo,.• f Zr.... 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