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HomeMy WebLinkAbout0086 VALLEY BROOK ROAD - Health 86 Valley Brook Road Centerville P r A = 188 165 i s '• MAP PARCEL �0r DATE_ 7116104 -- PROPERTY ADDRESS._86_Vaeeey l32ook�2c1. Centeicv.i.e.ee, (�¢. 02632 ------------------- On the above date, the septic system at the above address was Inspected. This system consists of the following: 1. 1- 1000 gaiion 6ept.ic tank.' 2.' 1-Diat2-igut.ion Sox, 3. 1- 1000 ga e eon -eeaching 12.i 1_,. Based on Inspection, I certify the following conditions: 4. 7h.i�3 .iz a t-it.ee dive use/2-tic zy.etem. (78code) 5. The 3epi_ic zyztem -i.6 .in paope2 wo2king o/Ide2 at the paezen.t time. 6. The wa.6t2 waten wa. 50" ge-eow the .invent Pit in .eeach.ing /2.it at time o)e .ins/zeet.ion. SIGNATURE: Name: Sauce Naca.@.e.iztea Company: Joseph 2— —.&—S.0n, Inc. Address: ___-_------ _` N) cs�{ "o ro --- N � CA rr*7 THIS CERTIFICATION DOES NOT CONSTITUTE A GUAR NTY OR WARRANTY JOSEPH P. MACOMBER & SON, INC. Tan ks-Cesspools-Leachflel.ds Pumped & Installed Town Sewer Connections P.O. Box 66 Centerville, MA 02632-0066 775.3338 775-6412 • COMMONWEALTH OF MASSACHUSETTS _. EXECUTm OFFICE OF ENVIRONMENTAL AFFAIRS r DEPAR.TMENT OF YMMONMENTAL PROTECTION �.� TITLE 5 , OFFICIAL INSPECTION FORM—.NOT.:FORVOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART-A CERTIFICATION Property Address:'86 Valley Brook Road en ervi a Ma Owner's Name:Pe er Logue Owner's Address: 2 OT Wheeler Farm road Watertwon CT 067 Date of Inspection--V 16 0 4 Name of Inspector: (please print)Bruce Macall.ist.er Company Name; 1 NacomReh, . Son Inc. Mailing Address: 14o.y -66 - C n eay.c e, 4ash.-02632 Telephone Number: 5 0 8—7 7 .:3 338 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(31.6 CMR45:000. Tice system: X Passes Conditionally Passes Needs Further Evaluation,by the Local Approving.Authority Fails Inspector's Signature: 4Dater l —0 y 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 Jis.a.shated 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 regionalroffiee 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 the tlme of inspectinnr 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. -r:«te C TTc"orffie%n Rnrm 6/15/2000 page I . f Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 86 Valley Brook Road Centervii1e Ma OwnerYeter Logue Date of Inspection: 7 16 0 4 Inspection Summary: Check•A,B,C,D or E/ALWAYS complete all of Section:D" A. System Passes: no 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: 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. Answer yes,no or not.determined(Y,N,ND)in the for the following statements.If"not determined"please explain. P . 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 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 obstruction is removed distribution box is leveled or replaced ND explain: J W 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 obstruction is removed r 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: 86 Valley Brook Road Centerville Ma Owner:. Peter Logue Date of Inspection: 7/1 6 0 4 C. Further Evaluation is Required by the Board of Health: Conditions exist which require furthenevaluation.bythe 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.(i)(b)that the system is not functioning in.a manner which.:will.protect public health,safety and the..' nvironment: 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 any)determines4hat the system is.functioning in a manner that protects the:public health,safety and environment: i10 The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet.ofa surface water supply or tributary to a.surface water-supply. f1 V3 The system has a.septic tank and SAS and the=SAS is within a Zone 1 of a public water-supply. The system has aseptic tank and.SAS and the SAS is withini.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 front a private water supply well". Method used to determine distance - "This*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:,L1�LQ Page 4 of 11 . OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART:A CERTIFICATION(continued) Property Address:86 Valley Brook Road Centerville Ma Owner: Peter Lo ue Date of Inspection: 7 1 6 44 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'14..day flow .Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped , r 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 T water supply. Any portion,ofa cesspool-or privy is within a Zone l ofa: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 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 attache&to this fora►.] (Yes/No)The system fails.I have determined thatone ormore 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• 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 206 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. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS. SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM PART B CHECKLIS T Property Address:86 Valley Brook Road Centerville Ma Owner: Peter Logue Date of Inspection: 7 16 0 4 Check if the following have been done.You must indicate"yes"or"no"alto 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? /r 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) 1 _ Was the facility or dwelling inspected for signs of sewage backup 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? f _ 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: 1 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'0f distance .. is unacceptable)[310 CMR 15.302(3)(b)J 5 Page 6 of 11 OFFICIAL W- SPECTIGN:FORM`—NOT FOR VOLUNTARY ASSESSMENTS SLTB:SURFACE SE ?VACE DISFOSAL SYSTEIVIINSPECTION FORM PART.0 SYSTEM INFORMATION Property Address$6 valley Brook Road Centerville Ma Owner:Peter Logue Date of Inspection: 7/16/-0 4 , FLOW CONDITIONS RESIDENTIAL Number of bedrooms(desigt� Number of.bedrooms(actual): DESIGN.flow based on-510 CIS l 5.203(for ekample: I I O gpd x#of bedroorits): X 7/© ' 83 7 g p-0 Number of current residents: _ Does-residence have a garbage grinder(yes or no):PQ Is laundry on a separate sewage.system( es or.no):. [if yes sepg a inspection required] Laundry system inspected(yes or no): Seasonal use: (yes or no): Water meter readings, if Ivailabie(last 2 years usage(gpd)): T f7 fj Sump pum (yes or no):y Last date o occupancy: kilAwn COMMERCIALMObUSTIUAL Typeofestablphzrii nt: T Design flow( d on 310 CMR 15.203)% M d Basis.of d si i'`flow(seats/persons/sgft,etc.): Grease trap`present(yes or no): Industrial waste holding tank present(yes or no): l Non-sanitary waste discharged to ihg,Title 5 system(yes or no): Water..meter readings,if available: I l�t Last date of occupancy/use: .I1a, OTH,,ER(describe):. t�4) GENERAL INFO)WATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no):_ If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping. TYPE OF SYSTEM 1 Septic tank,distribution box,soil absorption system Single cesspool @�L Overflow cesspool 00) Privy b�Shared system(yes or no)(if yes,attach previous inspection records, if any) IL Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) =- J Tight tank. _Attach a.copy of the DEP.approval Other(describe): Approxim te�age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at.the site(yes or no): 6 _ Page 7 of l l O'FFICIAL.INSPECTION FORM. -NOT FOR VOLUNTARY A$SESSM[ENTS S'U'8S> iRF' CE "E 'w'AG"E �XSPOS`A SY'3TEM T>`IS.I'LG'T"ION FARM SYSTEM INFORMATION"(conttnucd) t'ras+:cr�yA•ddressP6 Valley B:r oQk, Road COnterville Ma, own-er: Peter Lo u'e Dat,c of Gipattlor}: 6 04 BUILDING SEWER(locate on site plain) Npth bdow grade. Materials:a construct of Iron X 40 PVC,_„.other(eatplaGt); Di.st.we&Om.privats watwr supply well of su.ctlon lfna: Comments On conTI.94 909414,.vc .ttng,a;"vidcIwo of leakage, SEPTIC TANK, �(locate on site plan) DV..th b.clow.1 ratic: M aritl.of constrvctlon.: • ,concrcie mctal^,ftbcrglass„polyethylene. If uu c i:s mewl if(agj is age cont'vmc.. by i CcrxFi ofCompl anec(yes or no): (attach a copy of Oimeni""Io.ns:`b 4� (orure Sludge depth: -1-v',L� D{stltncc.from top of sJudgc ig bottom o outlet ttc or bafflcfTrrt,,cX Scum thi9knes;:�„ r Distance from top of scum t"o."top of outlet tee or baffle: G" Disuytcc f om.bonom of sew to bottom of outlet tee or baffle:, H.ow wsre-di,mernsions determined; -.:c Commc9tz.(.ort.puM.p n j rceorn-mcnda0*ns, .act a.0 Outlaw orba.fflt condition, structural integrity, liquid levels rcluc4:t vt-lc.t invert,e�ridenca o.f.wt.xg e. etc;): Lce T&nL 15 GREASE TRAP: (locate on site plank �� r�� ,�' I~• Depth b:ciow grtdc: Material.of construction: concretc'1�mfcal�fiberglass�olyethylene IlV�other . (explain): . Dirrten;.lops, Scum tlsicktres:s: D"istmee 4 p.m top"of scum to lvp of outlet fee yr baffle � � D{:suncc from bortom of scum to bottom of outlet tee or ban'. ju . Date of last p=. pLag, (VI Commc.nrs(,.,* pwmpir-I rcaotttmendallpns,.lnlet and outlet tee or baffle condition, sncnual Integrity, liquid levels as relate to autkt Gtva rt, evnce o idef"Ieaka:gts,"etc.): ����ge •`�ta� Ytn� ���.��" 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:86 Valley Brook Road Centerville Ma Owner:Peter Logue Date of Inspection: 7/16 0 4 TIGHT or HOLDING TANK:r)(tank must be pumped at time of inspection)(locate on.site plan) Depth below grade: 6 Material of construction: rnconcrete metal-N& fiberglass A. polyethylene 1 other(explain): Dimensions: f�• ' Capacity: iU --gallons Design Flow: i gallons/day Alarm present(yes or no):ke, Alarm level: JAX Alarm in.working order(yes.or no):, Date of last pumping: IV" Comments(condition ofajarm and flo t switches,etc. i i g h-1• �� �c�ILL ��a �n�5 i'�Ct' �eS�.r��'- - DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:, Comments(note if box is level and distribution to outlets equal,any evidence:of solids carryover,any evidence of leakage into or out of bpQx,etc): PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no):yh Comments(note condition of pump camber,condition of pumps and appurtenances,etc.): _�c)YYLf lUl® V�lf�er i�i 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PART C SYSTEM INFORMATION(continued) Property Address: 86 Valley Brook Road Centerville Ma Owner:Peter Logue. Date of Inspection: 7/1 6/0 4 SOIL ABSORPTIQN SYSTEM(SAS): -(locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: 1 leaching chambers,number: VW leachirg galleries,number: IU leaching trenches,number,length: M leaching fields,number,dimensions: IV) overflow cesspool,number: I V4 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.): �. marts Q drk4j" ii.I Loire t'1or"A.1- CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration* ii\ Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: G� Materials of construction: ja 0, _ Indication of groundwater in ow(yes.or no): Comments(note condition of soilQ sips of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: �d, Dimensions: Depth of solids: Comments(note conditiorkof soil,s4ns of hydraulic failure,level of ponding,condition of vegetation,etc): 9 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FORVOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART C SYSTEM INFORMATION(continued) Property Addressi+86 Valley Brook Road Centerville Ma Owner:Peter Logue Date of Inspection: 7/1 6/0 4 -VIVA 0) 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 lqu feet.Locate w re pub c water su 1 enters the building. \1N 10 Page 1.1 of I I OFFICLAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued). Property Address: 86 Valley Brook Road Cen ervi e Ma Owner; Peter Lo ue Dzte of Inspectioa; 7 1 6 04 SITE EXAM Slope . Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate (check)al.l methods used to determine the high ground water elevation: _Obtained from system design plans on record - If checked,date of"desip plan reviewed: Observed site (abutting property/observation hole within 150 feet.of SAS) _Checked with local Board of Health-explain: Checked with local excavators, installers. (anach documentation) sue_. Accessed USGS database-explain: You must describe how you,establ', hed the high round water Glevatl n: 9 ildl 7>> i 11 4 - ti 0 Leaching Pit :cc( Groundwater: Feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimptcr Method Therefore, the vertical,separation distance between the bonom Of the leaching pit and the adjusted goundwater stable i;,,. feet. Il ,. - r,T.,,..-.m,.,,..,, �...-.*.ram...,•..."„m,,.n..m..,.�**�..p.r.a [lO AR U OF N EA LT 11 TOWN OF Barn ible SUlf;9UllFACF 9ENn(;E !)I SMSAL SYSTEM INSPECTION FORM - PART D^- CERTIFICATION r 1 i 1.•••ro•t'T""'s—T•'r�'.runs r+n•n:mirwrr,,,s,t„r,rm• .,ivvc OR PqI N'T CLEARLY- PROPERTY INSPECTED Rd. Vaiiey B2ook STREET ADDRESS ASSESSORS MAP , DOCK AND PARCEL # '88- '65 OWNER! s NAME Lo ueol PART D - CERTIFICATI0H B2uce Nacaii.i.-3te2 NAME OF INSPECTOR ,TQseph P. Macomber &—Son Inc COMPANY NAME COMPANY ADDRESS Box_____ _b6. Centerville- Mass 02632?o or �1xY state t�P Street ►m COMPANY TELEPliONE ( 508 ) 775-33-38 FAX ( 508 ) 790-1.578 CrRTI f ICAT-IQN. STATEMENT I certify that I . have personally esorteddisthe tr.ue�,age dispos�'l accurate , and ystem this adcJress and that the informati n reported ..this a of the time of , inspectiOn. The inspection was per and any 'recommendations 1•egarding ui=grade , maintenance , and repair are consistent with my' training and experience in the proper function and maintenance of o site sewage disposa;i systems . Check one : VV System .PASSED The inspection trhich I have conducted has not found any information which indicates that th.e system fails to adequately protect public heaitli or the environment as defined i:n the FAILURE CRITERIA 303 , failtire section c criteria not evaluated are as stated i this form . System FAILED* ' I have cond'ficted h.as found that the system fails The inspection which Protect the j)tib.lic health and the environment in accordance with Titllj 6 , 3.10 CFIR 15 , 3Q3 , and as specifically noted on PART C FAILURE CRITERIA of this inspection. fo>^lnt Date Inspector° Signature . F 0 of this ,OV' ,ification must be provided to the OWNER, the BUYER ,, ne copy n G p .:'( where apPl lcabt.e ) . and . the OhRD QF rt „I .,. yetem * If the inspection FAILED , the- owner or op.©r�tor. ehall �aowed o re uired wit;l)in one year of the date of the inspection, unless. allowed or required 16 otherwise as provided in 3.10 CNR , 3.05 � partd . SEWAGE INSPECTIONS DATE4I .00ATION �C,A V »,3C AdASSESSORS M VILLAGE INs Bc�0 LOT SEPTIC TANK CAPACITY (size) I47",0-� LEACHING FACILM: (p'Pe) Liv NO.OF BEDROOMS t BUILDER OR OWNER �Y OWNER MAILING ADDRESS .. \ \ � � ��� � �� j \�� �� �.� P \ ht' { f �� � I � �� ���i I f - £s� a ey f3�� LOCATION _ SEWAGE PERMIT NO. oT V, c.C_ E Y VILLAGE INSTALLER'S NAME i ADDRESS �^.0 \ BUILDER OR OWNER a Gv% Inn DATE PERMIT ISSUED TL. DATE COMPLIANCE ISSUED 43 _ Q NoA 2'5k& Fss..... ................ b THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH . .�`................OF.............. QCr1 S�c� ............................... Appliration for Bispuiial Works Tonstrurtinn Prrutit Application is hereby made for a Permit to Construct (,,,) or Repair ( ) an Individual Sewage Disposal System at: - ......v \\ -- .........V N....... `V--------------------------------•-.............--------- Lo anAdd t N ------------ .........r&u -n----------------- ------------ .o............................................ Owner _ ddress ..... f?^ ' . ------------------------------------------------------ Installer Address d Type of Building Size Lot._��..000 Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic (130 Garbage Grinder (pJo) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures .................................. W Design Flow__________________�0 .......__.....•._gallons per person per day. Total daily flow-------------33.®..................gallons. WSeptic Tank—Liquid capacity QAO..gallons Length---------------- Width................ Diameter---------------- Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.-__-:/............ Diameter........6....... Depth below inlet.6............... Total leaching area....1-0.......sq. ft. Z Other Distribution box ( ) Dosing tank ( --••-•••... Date......_Percolation Test Results Performed by...... -u .................... '.. `-. �a' � '.. __ '... Test Pit No. 1................minutes per inch Depth of Test Pit-------_............ Depth to ground water........................ 1� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a •----- ....... �Aann ar subso,O Description of Soil.........fl:'--cam_....----•--------- -----------------------------•------••----------------...................................................................... U ................................................X------------Qd �q�-----------....S ca_�.d,!-1---•----------�-oI.U-N�.........--•------------------ x ----------------------------------------- ---------------- -4.............rS_.CA_-,_V_A............................................................................. 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 TITI1Z- 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed--------- M e. O-- f/ Date Application Approved By........ ._. `.�%%r � »�• • -, ------•--•-•- Date Application Disapproved for the following reasons-................................................. -----------------------------•-----•-----....---....------------------.......------------...------------.._...-----•---••-------------------------------------------------------------------------•----- Date PermitNo......................................................... Issued....................................................... Date Fimic ..XX................ THE COMMONWEALTH OF MASSACHUSETTS r BOARD OF HEALTH .................�rJ.r'................OF.............��� ApplirFa#ioat for Dhipavi al Works Tomitrurtion rrotit Application is hereby made for a Permit to Construct (✓) or Repair ( ) an Individual Sewage Disposal System at: ---------- .........'�........... =-- -•-••-•--- L�: •-- --------------------------------------••- �^"' Location-Address or I of No. ................ .t-?�.!�­t........\�_ =`' r��. �..............:. »c��_ t_: c:L,.ice_ Owner ---•--------------------------------------------- dress ........••.... ...................... ......••----•-••--.............-------- Installer Address Type of Building �4 60.,:7 Size Lot.._`....s.----•-•-__..._._Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic (Oq, Garbage Grinder (Po) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures ------------•-•---------------------•--•--------.......-----•---------------------•----- a W Design Flow.................. .___.. 0.................gallons per person per day. Total daily flow............... , ........................gallons. WSeptic Tank—Liquid capacity.K '')_.gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No......./--.--_--_-_- Diameter.............. Depth below inlet.6............... 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........................ fs, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ .....................-------...............--------......--•---....---••---•---.........-•------....-•----------------•--•----•---••-•-•---••-•-...._..._.. D Description of Soil...----- LA 6^ n (� ..................................................._........_ ................. �L...............................................C. ......................................................�......•-----....�.�`�•-�-=-------•-- -`' - - �1 C---- --- 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 T ITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed .St l ------•---------------•---------•-----......--.........---------------•- A Application Approved B .,� I ,c"� .. Dat PP PP Y + /� �� =D Date Application Disapproved for the following reasons:...........................-..................................................................................... ---------------------------••--•••••--••-••---••-•- ------------------------------------------------- Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF` HEALTH :. E 1 ..........................................OF......................... .....'...............:.................................... Corrtifirate of Tauttph attrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( L-j or Repaired ( ) b \�<7\L ,"� ,s AZ) S _ =•------•---•-•-•----••--•---------------------•----------------.....----...----•---•---•--...-----..........._._..------............-- Ins aller 31 c 1 c.<..� , �,. L �a ,,ail �'�at - v = --------•--•_------= = „ • ._ --------------••---•---••••- has been installed in accordance with the provisions of TITIZ ,' of The State Sanitary Code as described in the application for Disposal Works Construction Permit No...0 2............................. dated-............................................... THE ISSUANC OF THIS CERTIFICATE SHALL NOT B>CONSTRUE GU RANTEE THAT THE SYSTEM WI F CTION SATISFACTORY. DATE... «1 '— .:----.............................................................. Inspect ... ............. .................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH -`°"� ^............O F.............:�"(xrN:1�� ...... ............................................ f. No._ ... ---•-• FEE—. ..... ............... io oo�t orko Tott,strudi att Phrmit Permission is hereby granted------... 4 \ _..... h' =�' -----•-- ....................................... to Construct ( or Repair ( ) an Individual Sewage Disposal System at No.------ ±n..----.... �� j•6- \c;,_. !"� .......................................... •••. Street as shown on the application for Disposal Works Construction Permit No----------------- Dated.......................................... Health CS �f DATE--_--------------------- -------------•--------------- FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS 6%w6Lr• FAmto? - 3 BEolzOoA NO GARBAGE GQJwoEP- CIAI---�' DArLs( FLOW a 110 X 3 = 330 G.PR 1 SEPTIC. TAQK = a3ox150% =,4956.Po � va / u5c- I000 GAL. 0%,5Po5AL PIT L,sE 1000 GAL.. / • 5%DG.WALL t 5 o s.r-. x 2.5 = 37 5 G.P o 2Gj � BOTTOM A2E.A= • YO 4F; _. . 4 fb0/p 50 S.F x 1• 0 5p G.PoITAW116 23_ -ToTA L. c�E516N * 4215 6.P 0. TOTAL DA I L-�( F%-OV4 = 330 G.PO, p PST ii11 PaZC01-AT1,09 RATE I I''IN ZfAIM 0VLaS5 n , To ` SH Of,N SM ALANSG RIO ARO W. BAXTER w JONES a Nu.24U49 0. 251 Oi SuR'llE.yO� NA I, T6��T�-►2'L3 - r"L� 4a TOP FklD l -",j �nNwr loon �. INV. - I l Sd6S01�... DIST. INS. $6PTIC. �� 2 IOoo INY, goX 36•G TANK G&L. I COLS® I,.EAG�1 3L Sp�y�� pI•r INV. INV. WITH • 3� 2 „� �� I�13/9•I�i I WASKGD ! � 6TvNfs � G 0 II SCIJ� GEQTIFI cm.D PLOT PI..AW P OPILG L04A'T loN� CeNTIslz4 .t.b �. 1260 WO 5 CA.LE 5_ 1 I!LCj P p.-r E 8 �30/oZ I i o p L,p►t•J REF E 2E N GE CERTIFY N AT THE Foul DA-TIo 14 5No 4WN �' HEREoPi GOMPL�(5 WITH-THE. �,1 Cr�L►t�l E I Al P Sb'TeAGK 6.QV12EMENT'� F-TN� �T I -ro W N O F "BAf2 4%4la L& ANC ►S �� L0Cp.TE0 -WIT IIJ N6 1: 000 PLAIN DAT E��9Z BAXTEQ.e A.I`(E INC. REG I SZ s-QCsV'LAN c>S u MY EYoZ ; t� 'T4115 PL&KI Ili NOT gA56o Gld AN 03Tr=p-vjLLr= - MASS• I� IuSTR.uMaW'I' 15u9-V y NE oF�'SETS 6uou0 NOT I3G- V�C•C�Td pC"TG-c'- l"r-- Lc>T APPLICANT '• �jI►.1Cs�.C- FAMILY - � BEORoo/�1 .. N� GARB<*GE Jjv�NDER. vAl-I.�`�F3�K...- . -•� . DAIL•( FLOW : 110 x 3 = a3oG Po 1 5EPT1G TA►JK = 330XI50% = -4956.P. 0 u51= 1000 GAL. �� i i 0%SP05AL PIT y6E 1 o oo GAL. � • 5%1)r_WALL A2GA 1505.F td FND• 15o 5.f~ x 2.5 . 3?5 G.Po 2S __ / 50TTOM A2EA r �o Sr.F. _. . �Fb0 23 5a S.F.- x 1• o 5 p G.P o -- --T OT A L.. D E 51 GN * ,4 2-5 (�.P p `� ��q° TOTAL TA►I..Y FLOW = 330 G.PO• o bIR p,r PS ZCOLAT►Ou RATE , V IN VAIN o�L�Ss �1 n �` T4 G4 yy,, I �tN OF+1 _ �'A AICNARO AL AN G A. BAXTER v. JONES a .No.24048 0. 251 i ��STE �y0� NA I►'0 SURD 4 o To P FIAD�'4►o•1 a '� NA loco INV. SJ�Sp� B x INS' S6PTIG 3d�8 2 Joao JNY, 36 G TANK Ga'�L5® LEAcu 3G _ 5AIJ4� PIT INV. INV. ; ?� WIITN 3G z. SG I � � f WASKGD Sp�� Gi=QTI>=ICD PI.oT PLAN � �, .. L o C 4Z I o 1J C�IJ'TIsRv .1.b I ?l.. No 5CALE Scp,LE li L.o .. V A,-r� i >. . 4 �a Tom•-' � P L,A N RE F E 2EN GE• G E czT I F Y T N AT 'T N E F.ovhlDpTlO l J SNo vYtJ N6.R6oN GoI�PL`{5 1nl►TN-CHI S i c�LIN E �T Z[`! •. 1 AuD SETc�AGK 6QV12>rM�N'T� F 't`1E- , TC>W N o P - AT244% A WD I LOGp►TED 'WIT lw H6 F OOD PLAIN pAT E 8�3D"S'Z.. ' 13AXTEQ.e IJYE INC• �� R.EG I SZ EQ6V'I.At�I c�5 u K.V E�o� f hTut$ P L& Ili NorT cId AN osTE2vILLE - MAsS• - II IN5T9-UMEW'I* SVeVa-y 4-T kF_ 0F05E7516u0U►,p >` NT i� No-c DC- VJI •DTb �CT�^V,�J�I�� LET I,.•I'-{G f I�PP 1 A J14•t.