HomeMy WebLinkAbout0036 STAGE COACH ROAD - Health 36 Stage Coach Rd. (Centerville)
A=173-048
No. 42101/3 ORA
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f TQWN OF BARNSTABLE
LOCATION 3 to 1'a_1AGC- COA&k Pd SEWAGE #
VfLLAGE CaAwk ASSESSOR'S MAP & LOT 73 Oy
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY I nb
LEACHING FACILITY: (type) AA01-, F,e,I (size)
NO.OF BEDROOMS /
BUILDER OR OWNER M)GA ede. GA/leo„d
PERMITDATE: 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
within 300 feet of 1 aching facility ) Feet
Furnished by Sc I�f i r �O/G
P n
AI- 30
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 36 Stage Coach Road RECEIVED
Centerville, MA 02632
Owner's Name: Michele Garland
Owner's Address: Same J UN 21 20 01
Date of Inspection: June 12, 2001 TOWHEALTH DEPT.
Name of Inspector:(Please Print) James M. Ford
Company Name: -James M.-Ford
s
Mailing Address: .',�, •P.O.,Box 49 '' Map: .173-' .-
Osterville,MA 02655-0049'- Parcel.--048
Telephone Number: (508) 862-9400
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
✓ Passes
Conditionally Passes
N Further Evaluation by the Local Approving Authority . .
Fa; s
Inspector's Signature: Date: June 18, 2001
The system inspector shall sub a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving
authority:.
Notes and Comments
****This"report only describes.-conditions at"t6e'time of inspection and under the conditions of use at that
time. This'inspection does not address how the system will perform in the future under the same or different
conditions of use.`
Title 5 Inspection Form 6/15/2000 page I
Page 2 of 11 '
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 36 Stage Coach Road
Centerville, MA
Owner: Michele Garland
Date of Inspection: June 12, 2001
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.J3f 03 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. Sysiem 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.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please
., explain.- ,, r
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.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution x u broken or
g p g box due to b o
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
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping,more than.4 times a year due to broken or obstructed pipe(s). The system will
if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 36 Stage Coach Road—
Centerville, MA Y '.
Owner: Michele Garland
Date of Inspection: June 12, 2001
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 cavironment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of bordering vegetated wetland or a salt marsh
-2.. System will fail unless the Board of Health(and Public=Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
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 coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
3
Page 4 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 36 Stage Coach Road ..
Centerville. AM __ X.
Owner: Michele Garland
Date of Inspection: June 12, 2001
D. System Failure Criteria applicable to all systems:
You must indicate either`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 '/z 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 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. T
✓ 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 coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
No (Yes(No)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 System:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd•
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
Yes No
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 I1 of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
4
a
Page 5 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 36 Stage Coach Road
Centerville, AM
Owner: Michele Garland
Date of Inspection: June 12, 2001
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:
Yes No
✓ Existing information. For example,a plan at the Board of Health.
✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)[310 CMR 15.302(3)(b)].
5
Page 6 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 36 Stage Coach Road
Centerville, AM
Owner: Michele Garland
Date of Inspection: June 12, 2001
FLOW CONDITIONS
RESIDENTIAL
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
Number of current residents: 2
Does residence have a garbage grinder(yes or no): No
Is laundry on a separate sewage system(yes or no):_No [if yes separate inspection required]
Laundry system inspected(yes or no): Yes
Seasonal use(yes or no): No
Water meter readings, if available(last 2 years usage(gpd)): 2000-96,000 gals.; 1999-54,000 gals.
Sump Pump(yes or no): Yes
Last date of occupancy: Currently occupied
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310.CMR.15,203)._.
Basis of design flow(seats/persons/sgft;etc.):"
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no)
Non-sanitary waste discharged to the Title 5 system(yes or no):.
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information:Pumped on Sep. 21100 per treatment plant
Was system pumped as part of the inspection(yes or no): No
If yes,volume.pumped: __gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
✓ Septic tank,distribution box,soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) (if yes,attach previous inspection records, if any)
Innovative/Alternative technology. Attach a copy of the�current operation and maintenance contract(to be
obtained from system owner)
Tight Tank Attach a copy of the DEP approval =
'.Other(describe):
- -- Approximate age of all components,date installed(if known)and source.of.information: ..
Apr. 6, 1978-per as built card
Were sewage odors detected when arriving at the site(yes or no): No
6
I
Page 7 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
'SYSTEM INFORMATION (continued)
Property Address: 36 Stage Coach Road_..__. _ . .. `• i•. i.':'s
Centerville. MA
Owner: Michele Garland
Date of Inspection: June 12, 2001
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: _cast iron _40 PVC _other(explain):
Distance from private water supply well or suction line: _
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: 16"
Material of construction: ✓ concrete _metal _fiberglass _polyethylene
_other(explain)
If tank is metal list age:. _ Is..age_confirmed,by a Certificate of Compliance(yes or no):. (attach a copy of
certificate)
Dimensions: 1000 gal. .;
Sludge depth: 1"
Distance from top of sludge to.bottom of outlet tee or baffle: 30"
Scum thickness: 1"
Distance from top of scum to top of outlet tee or baffle: 10"
Distance from bottom of scum to bottom of outlet tee or baffle: 13"
How were dimensions determined: Measuring stick
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 tees were present. The liquid level was even with the outlet invert. There were no signs of leakage.
GREASE TRAP: None (locate on site plan)
Depth below grade:
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:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity;.,liquid,levels
as related to outlet invert,evidence of leakage,etc.):
7
Page 8 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM'INFORMATION (continued)
Property Address: 36 Stage Coach Road r ,
Centerville. kM
Owner: Michele Garland
Date of Inspection: June 12, 2001
TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain):
Dimensions:_..
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION:BOX::.. ; ✓` (if present must be opened)(locateon•sitephn)
Depth of liquid level above outlet invert: Even
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.):
The D-box was level and there were no suns of leakage or solids. There were no signs of back-up from the leach field. The
outlet inverts were 40"below grade.
PUMP CHAMBER: None (locate on site plan)
Pumps in working order(yes or no): -_ -
Alarms in working order(yes or no)
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
8
Page 9 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM
_ !-. : PART C
SYSTEM'INFORMATI,ON (continued)
Property Address: 36 Stage Coach Road
Centerville, AM
Owner: Michele Garland
Date of Inspection: June 12, 2001
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:
leaching chambers,number:
leaching galleries,number:
leaching trenches,number, length:
✓ leaching fields,number,dimensions: 25'L x 16'W(per design plans)
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.):
The leach field was not dug up. ;The D-box was.inrthe..leach field..,There wereno signs offailure. The bottom to grade was
approximately 4'6':
CESSPOOLS: None (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 or no):
Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
PRIVY: None (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.):
F.
9
Page 10 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
- SYSTEM INFORMATION (continued)
Property Address: 36 Staze Coach Road
Centerville, kM
Owner: Michele Garland
Date of Inspection: June 12, 2001
Map: 173
Parcel: 048
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch 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.
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10
Page 11 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM.INFORMATION(continued)
Property Address: 36 Stage Coach Road
Centerville, AM
Owner: Michele Garland
Date of Inspection: June 12, 2001
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water feet
Please indicate(check)all methods used to determine the high ground water elevation:
✓ Obtained from system design plans on record-If checked, date of design plan reviewed: Jan. 9178
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:
The bottom of the leach field to xrade was approximately 46". A test hole was done when the system was installed and water
was observed at 7. Using the Cape Cod Commission Technical Bulletin,the high groundwater adjustment for this site(SDW 252,
Zone A)was 1 1' The system is higher in elevation than the basement floor. Water has never been up to the floor.
This report has been prepared and the system inspected and passed as of the date of inspection. This report is
not a warranty or guarantee that the system will function properly in the future. There have been no warranties
or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report.
II
► '�
j7�
LOCATION SEWAGE PERMIT NO.
VILLAGE
rll 2.
INSTA LLER'ST / NAME & A' DDRESS
' t/O�h � /✓GY/ i�
i
B U I'L D E R OR OWNER
DA T E , PERMIT ISSUED
DAT- E COMPLIANCE ISSUED
i N e9' a b
� 1
� t�•7
ti-------------
No...F.5.... Fps.... . ...
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
............. . L.......OF.........., �...... .....-f----------•---•
Appliratiun for Disposal Works Tonstrur#ion 11amit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
Sys..... at ..tP� f��......t_�f�Psc,�er�+�------� ---'-•••-•---�-----�---.-�-o--------•......-------
.... � ----
_ .....................................
L a � ss Lot No.
-- ---•'................................................... ...---..........-----..
Owner Address
Installer Address
UType of Building, Size Lot............................Sq. feet
Dwelling s-No. of Bedrooms..........P-.............................Expansion Attic ( ) Garbage Grinder 00)
aOther—Type of Building ............................ No. of persons............................ Showers (1 ) — Cafeteria ( )
a' Other fixtures ................................
W Design Flow____ _ ^Sn^ ... gallons per person per day. Total daily flow_______...�d_______________________gallons.
WSeptic Tank=Liquid capacityljd�.gallons Length................ Width---__.. __ Diameter---------------- Depth................
x Disposal Trench' No. .................... Width...../(0....... Total Length......0.Z- ..... Total leaching area•--Mo.......sq. ft.
Seepage Pit No----------------------Diameter-------------------- Depth below inlet_______._ .._... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( ) U�' �W �
Percolation Test Results Performed by �Q^.,._.Z y............................ Date........................................
a Test Pit No. ...minutes per inch Depth of Test Pit/................•. Depth to ground water........................
1._2�_'�
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
�i - t ....... N-•
Description of Soil.- �.....- -
s= - ._..S.-r__... ----�41---- ---- -------------------------------
W --•------•--------------------------------------•- .................... . ---- ... t. .....................................................................................
U Nature of Repairs or Alterations—Answer when applicable................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLI: 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has be n 'sslzed y the board health.
. -e�c-..... �� �j
Signe �rC
_
Date
Application Approved By....._- .. ..._ ................ .
Date
Application Disapproved for the following reasons:----••---------•------------------------------------------------------------------------------------------------
-•------------------------------------------•------------•-----------------...---'-----.......----------------------•---•------•--•-----•--•---•-••-----••-••-•-•-•----------•-------•-•--••-•---'-•'•--
Date
PermitNo......................................................... Issued..... Z S-..�L•----•-•------•-•'-'-'---
Date
No.......... .... FEs... ........'
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH }r
OF..........4se.
Appliration for Bi ipaoal Iforks Tomitriir#iun ramit
Application is hereby made,for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposals
Sy em at 4.
L cation d ess Lot 10.A__
L�.h� Address ....................
Owner
Installer Address
UType of Building,, Size Lot............................Sq. feet
Dwelling No. of Bedrooms......... ...............................Expansion Attic ( ) Garbage Grinder 00)
aOther—Type of Building ............................ No. of persons..........-----____._------- Showers (I ) — Cafeteria ( )
Q' Other fixtures
Design Flow._..._45 .......................gallons per person per day. Total daily flow.---.--._--A.q.......................
W g � - ga P P P Y Y � -- - gallons.
� Septic Tank L,iguid capacity/,j •-gallons L ngth................ Width----- Diameter.........---.... Depth................
Disposal Trench No..................... Width---:/4?......... Total Length..... _._.._ Total leaching area... O...__._sq. ft.
Seepage Pit No..................... Diameter.................... Depth below[inlet__._._. Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( ) d 2, /'dG Z
aPercolation Test Results Performed by.-•--thn-.--a� y.............I....._......_... Date........................................
Test Pit No. l..e"Z.-.'..._minutes per inch Depth of Test Pi .:.................. Depth to ground water........................
G4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
R+' t
D Description of Sof 1 :. .`_ �✓-z' r,� +- /' X ,w� ca n
.......... ..... ate '.
--------------------------------------------------------------------- - ......................................................................................
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
•••-•---------------------•--•-----------------------------•--------•-----•---------'---•-•--......••--••-----•-•••---------------------------•--•-----------•-•-----------------------.._.........--•-
Agreement
The undersigned agrees to install the aforedescriKi d 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 b n ss>ted y the boardj health:
sign ..---= -----
Application Approved By......;� . ..._ "':.. 1 --•-• -�-
Date
---••-----` ----------------------
Date
Application Disapproved for the following reasons-----------------------------•--•------------•-----•---------------------------------------------------•------'--
-------------•••-•---•----.......-----..............---•---------•-•-
Date
PermitNo......................................................... Issued.......................................................
Date
i
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
' ?...........OF.............:.:.:.... ✓ ' ' .... .......................................
��er#ifirtt#�e laf fl�vrnt�rli�tnrr �,,.
T IS IS TO PERT Y, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
..........
---------------•_..- _____------•------•---_-___-•••--__-_______-__-----•--------____--•--___________•-.._.....-•---•--•--------••--
Installer
� -•-t ----.•...--•-------•---------------------------------------•---------------
has been installed in accordance with the provisions of TIJ,�P, 5 of The State Sanitary Code as described in the
application.for Disposal Works Construction Permit No............./5__-.................. dated--../ -.ls -.7�r----..........__...
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEAL H =
Ste` '►:...........OF..--.... . -. .......:.-.
No......................... a FEE........................
Disposaliork epnpItW �erntiPermission is hereby granted..`. r_. ...... ` -: •.Z....`._....._...:..............
to Construct f or ReRlur,. ) an In bldual ra e D po Sys
f7 o�.
at No..... . .__ J.- �X .F---•- �'---••- ...............
- -
t Street
as shown on the application for Disposal Works Construction P N /- . Dated..... l'��'��............
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