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HomeMy WebLinkAbout0097 VALLEY BROOK ROAD - Health 97 Valley Brook F�oa-d Centerville . P A = 189 157 SAW te. ' UPC 10259 e o.H163ORa� e��*iMas. re x COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAI DEPARTMENT OF ENVIRONMENTAL PROTECTION _ F D W V � , d F. TITLE 5 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORMBP PART A CERTIFICATION Property Address: 97 VALLEY BROOK RD CENTERVILLE 02632 Owner's Name: BETSY NELSON Ooi ner's Address: 97 VALLEY BROOK RD CENTERVILLE 02632 Date of Inspection: 1110103 �� Name of Inspector: (please print) JOHN GRACI MAP Company Name: SEPTIC INSPECTIONS. Mailing Address: P.O. BOX 2119 TEATICKET, MA. 02536 PARCEL ` 1 Telephone Number: 508-564-6813 FAX 568-564-7270 LOT it - - _-- CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system ai 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 iraining and experience in the proper function and maintenance of on site sewage disposal systems. I :un a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: X Passes _ Conditiona4y,Passes _ Needs Further Evaluation by the Local Approving Authority _ Fails /?` Inspector's Signature: Date: 1/10/03 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board oftealth 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 senl to the system owner and copies sent to the buyer, if applicable, and the approving authority. Nuws and Comments THE SYSTEM PASSES TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. RECOMMEND MOVING TREE NEAR LEACH PIT TO PREVENT ROOT DAMAGE. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.7 Ilis inspection does not address how the system will perform in the future under the same or different conditions of use. Page I of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 97 VALLEY BROOK RD CENTERVILLE 02632 Owner: BETSY NELSON Date of Inspection: 1/10/03 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X 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: THE SYSTEM PASSES TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. RECOMMEND MOVING TREE NEAR LEACH PIT TO PREVENT ROOT DAMAGE. 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. n/a 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: n/a n/a 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: n/a n/a 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 ND explain: n/a Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 97 VALLEY BROOK RD CENTERVILLE 02632 Owner: BETSY NELSON Date of Inspection: 1110103 C. Further Evaluation is Required by the Board of Health: _ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 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 n/a "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: n/a Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 97 VALLEY BROOK RD CENTERVILLE 02632 Owner: BETSY NELSON Date of Inspection: 1/10/03 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for alLinspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow _ X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped Wa. X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _ X Any portion of a cesspool or privy is within a Zone 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] _ (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 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 X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. a Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 97 VALLEY BROOK RD CENTERVILLE 02632 Owner: BETSY NELSON Date of Inspection: 1110103 Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant, or Board of Health _ X Were any of the system components pumped out in the previous two weeks? X _ Has the system received normal flows in the previous two week period? _ X Have large volumes of water been introduced to the system recently or as part of this inspection ? _ X Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out X _ Were all system components,excluding the SAS, located on site? X _ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction,dimensions, depth of liquid, depth of sludge and depth of scum? X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes no _ X Existing information.For example, a plan at the Board of Health. X _ 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;of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 97 VALLEY BROOK RD CENTERVILLE 02632 Owner: BETSY NELSON Date of Inspection: 1/10/03 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): NO Seasonal use: (yes or no): NO Water meter readings, if available(last 2 years usage(gpd)): coA _ 116()(D Sump pump(yes or no): NO t Last date of occupancy: n/a CP COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: n/a Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: n/agallons--How was quantity pumped determined?n/a Reason for pumping: n/a TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank Attach a copy of the DEP approval Other(describe): n/a Approximate age of all components,date installed(if known)and source of information: 1983 Were sewage odors detected when arriving at the site(yes or no): NO 6 Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 97 VALLEY BROOK RD CENTERVILLE 02632 Owner: BETSY NELSON Date of Inspection: 1110103 BUILDING SEWER(locate on site plan) Depth below grade: 18" Materials of construction:_cast iron =40 PVC Xother(explain): 20 PVC Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting,evidence of leakage,etc.): TOWN SEPTIC TANK: X(locate on site plan) Depth below grade: 12" Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: 1000 GALLONS" Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle: 33" Scum thickness: 1" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: n/a How were dimensions determined: MEASURED Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): SEPTIC TANK AND ALL COMPONENTS ARE STRCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. GREASE TRAP: _(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): n/a Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 97 VALLEY BROOK RD CENTERVILLE 02632 Owner: BETSY NELSON Date of Inspection: 1110103 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX: X(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE 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.): D-BOX IS STRUCTURALLY SOUND. PUMP CHAMBER: _(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a R Page 9 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 97 VALLEY BROOK RD CENTERVILLE 02632 Owner: BETSY NELSON Date of Inspection: 1110103 SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type 1000 GAL 6' X 6' leaching pits, number: 1 n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a innovative/alternative system Type/name of technology: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): THE LEACH PIT APPEARS TO BE STRUCTURALLLY SOUND AND FUNCTIONING PROPERLY. PIT SHOWS NO SIGNS OF FAILURE. THE PIT WAS VIDEO INSPECTED AND WAS 1/2 FULL AT THE TIME OF THE INSPECTION. RECOMMEND MOVING TREE NEAR PIT-BOTTOM OF PIT AT 9' CESSPOOLS: (cesspool must be pumped as part of inspection)(]ocate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): n/a A ,,"e 10 of I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 1'�operty Address: 97 VALLEY BROOK RD CENTERVILLE 02632 {':v ner: BETSY NELSON 1?:±te of Inspection: 1110103 '::ETCH OF SEWAGE DISPOSAL SYSTEM i' rvide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. 1 ..,,,:ate all wells within 100 feet. Locate where public water supply enters the building. �1 is PA i�3 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 97 VALLEY BROOK RD CENTERVILLE 02632 Owner: BETSY NELSON Date of Inspection: 1110103 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 12+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a NO Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) YES Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: HAND AUGER- 12+FT. tt TOWN—CW BARNSTABLE r OCATION SEWAGE # "� VILLAGE �� ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY / LEACHING FACILITY:(type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the 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 leaching facility) Feet Furnished by Q�-� FRan� AA LIP �r S� 0 e C�, 7 10CATION SEWAGE PERMIT NO. Ld1' r I �J L.c,cy 12ti©&R . &d VILLAGE INSTALLER'S NAME & ADDRESS e U I L D E R OR OWNER r DATE PERMIT ISSUED ` z- DAT E COMPLIANCE ISSUED Ai n � � 0 „ n �4 ................ THE COMMONWEALTH OF MASSACHUSETTS JU BOAR® OF HEALTH OF........... ........................................................... ApplirFation for MipaiiFal Works Ton,strurtion ramit Application is hereby made for a Permit to Construct (A-4 or Repair ( ) an Individual Sewage Disposal System at: tU o 1C- c� Loc t' n Add re or Lot N \1 Q Owner1 Addres Installer Address UType of Building Size Lot............................Sq. feet a Dwelling—No. of Bedrooms.._....................................Expansion Attic Garbage Grinder a Other—Type of Building .:.:................... No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures ------------------------------•-----••--•--•---•••••-......--••••-••-••----•••------••......-••-.•••• .•........ W Design Flow............... __._......._.........._..gallons per person per day. Total daily flow...........3.3-9.................gallons. WSeptic Tank—Liquid capacit� ®..gallons Length---------------- Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area•••..-_-•-_____--•sq. ft. Z Other Distribution box ( ) Dosin ank Percolation Test Results Performed b --- .......................... .. 4 a 7��...-----•-- Date........ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water..................... 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 9 ........................ .......................................................................... V i __._..... Description of Soil % ...-------•-•••�-••••-------•• - .. - -�------------•---- v y ' ._._._..__._�_fi?_�A.rM_________________ =`- --------- --`f�• .................... --.... `......&-- ------•-------- 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 iITLL 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. �f Da Application Approved :11olthefollowing /, ed •-•••••-••-•••••••••-•--•-•...•••---•••....•••..............••---- ...��r. ........... Date Application Disapprove reasons:----•••••---••••----•••••--••-••-•••••-••---•-•••-----••••••-•-••-----•....................•••-••.... --•.................................•--------------•••••••-••••.....•..•• . - ------...•••--...: Permit No...................................................... Issued.. ., Date �r t C Fux.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH c� ... OF.......................:�-:��... cC,.l� Appliratinn for Uhipoii al Works Corm ruriion thrutit Application is hereby made for a Permit to Construct (%.4 or Repair ( ) an Individual Sewage Disposal System at: .........`}.c�.___""�c 0 r�--.. ...... ............... ------------ ac.........�- ......................................................... ti//on•Address t 6 ............•.._. rN— ......I -- s'!�!1— ---••............. / ^i !J Lot Nq. _. .............................. l«3 rr '' h � • Owner' --� ` Addres a ............... .: r...l�.....------.......................................... -•----....1.0 .l\ .a... C .. ....'......--•---------....... Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic (P(P Garbage Grinder 04D aa Other—T e of Building No. of persons............................ Showers YP g ------------------•--------- --(----)._— Cafeteria (----). Otherfixtures ......-----•......-•--•-.-•--------•--••----------------------------•----•------ --------...-•----------. W Design Flow...............\Q..............__..gallons per person per day. Total daily flow..__...... ..............................gallons. WSeptic Tank—Liquid capacitP92..gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No. .................... V7idth.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing.. ank ~' Percolation Test Results Performed by._....�C .�.....'�.....�..:% {""''.._._..__._. Date........ `_y `._7._ . Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ (a, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water---•--_--_--___-,,..___. ------ ------------------------------ ---•--------------- -----------•----------------- o Description of Soil - �=----------- ='�^ ----------•--•----�"= 'r�- ''�'- ���1 ----- ................4..___ t�- x W . UNature 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 TITiZ 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. r, Signed.•-••-- u. ?`l A :ti r 'S `� Date" Application Approved By.......... ...: ` ........................................ Application Disapprove&f or"the following reasons-----------------------••-------•----•-------•-------•-----•---•--•-------•-•-----------••-----••---------------- ------------------------------------------------------•--•--.......------....•--------•-----•-------.......•-----_....._.....-------------•---------•-------••----------•-•----•----------•--•--------•-- Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .................................................................. Trrtifiratr of Toutpliana THIS IS TO CERTIFY, T, the Individual Sewage Disposal System constructed� or Repaired ( ) by••••---\ -A-.--)�'.�-ems\........--- ...................................................... has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as-/desc6bed in the application for Disposal Works Construction Permit No.._��__..__l_:__�................ dated__..�1.�! ` �� THE ISSUANC OF THIS CERTIFICATE SHALL NOT BE CONSTRUE AS A GUARANTEE THAT THE SYSTEM W F (N CTION SATISFACTORY. DATE.... .. .�P..d..�.--••---•-•-----•.................................................... Inspector...... > .::...---•••----------•-•--••------------------•--•-----..........--- THE COMMONWEALTH OF MASSACHUSETTS BOARD O`FF HEALTH ................... .............O F.................d.. FEE .................. �iu�rrr��al` � n k� �nn,�� ilan �eruti# Permission is herebyranted..............R._ _........................................ -� g '�`�..... .......................................................... to Constr ct ( or Repair ( ) aiQdivi Sewag Disposal Syst c ................................... ... .. --.0.7-._..---._...._------------•....•---- •......----•--..... Street as shown on the application for Disposal Works Construction Permit No........._•_--.______ -- __ :` -- ` -- -------------- ......................................... ... .................................................... DATE..............�--rye--`�---•�'-=��'--'��".......................... ''f/ fBoard. of Health s� FORM 1255 HOBBS & WARREN, INC., PUBLISHERS p�sl�N ,5%W-GLG- ,,FAMILY - BEORQoM BeoOK. ► wo GARBL�GE (�WI.1DE2 D AI Ls( F I-o w z 110 x 3 = 5EPT%G ''1'A►iK 330x15o'/• '�495G.P. R (g0!'► Q US>c• I000 GAL. D15Po5AL PIT ugE tj __ _ N 1000 CAI.. �.' BOTTOM ASZ"lr .. �O 5�F•_ . . - 'Io Q 5.F X 1- o A �j�0 G.P q" lo- - -ToTA I- 17 E516N * .4.2 -To'TAti- 3:>A I►-Y F%-C) ( = 33o C.P. 3 PE2GOLpTION RATE+ J"IN VAIN 09-LI~55 \ 1 r^4k ESN OF bf ST P`tN OF 4 RICHARD t, ALAN A. BAXT�E�Rp H ZONES �� p ,/�`• o.24048� � • 7. L J,V'4� 1I J�I� O Q�STEPy�P G�o•�F SU T65T t? N O LE i 1.I-6Z r G i•� _.... '75 iCTii ram+. F _. •YN' E(* 32 ��y�c; 1000 INS• �IL4— DIST. INS/ GAL. �IB Z BaX SCPTI l�l��+'I 1 000 I NY. �'�• TAN K �I, Sous• GAL, zg l �I PIT INV.. INY. wlTu 201•8 3o 3/4-1V2. '5"A40vr ►Sox Z• 4L1 I al M6�, WASNGD 6TaN6 GIST To EL ?X, ' Sofia �= GE2TIFIGD PLoT PLAID P Ro F i L.G l•o C 4"�I o N (^E,.tTfla�/► AT E I(-2 f3Z gl IQ. NO SGAI.E SCALE I�: !oo .. V �- 1 GEcZT�FY GNAT ?N'E �ovN��1'IorJ SNowN •. 1{ERC-�ol•t GOMPLYS WITH-TH6 S I D�I.IN E oT" AW D S 6-T'eAGK fiL.6QvI R.6MEN'r� o'F_ 't 4�� "ToWN OF -8AZA6r45Le ANv IS I^IoTr LOC, .-TED 'WITNIN T E F 000 LAIN (_paw �UIZ-'r 3SS4g DATE 11 •ram- 1 gA.xTE IJY e E I N C. R.EG 1157 f--Q.6V I-AN O'S u i?-V Tu15 PLAN 1<5 NoT oa AM os'r-E2vILLE • MA55. ! Iu,5TRUMENT SV9-Vr--"( �-'T14S OFr- ,F-r'5 Suoo� I L1--r r-k -. 1J4t'.D TCV L.n-t' 1►INC-lam APPLIeSp w-r