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HomeMy WebLinkAbout0004 WATERSIDE DRIVE - Health 4 Waterside Drive Centerville P A = 207 153 I DATE : 10/31 /02 PROPERTY ADDRESS4 Waterside Drive ----------------------- _ CentervillejMass_--_---- 02632 ------------------------- On the above date, I inspected the septic system at the ab ve R01(tF-WE® This system consists of the following: it 1 -1 000 gallon septic tank. NOV 12 2002 2. 1 -Distribution box. ARNSTABLE 3. 1 -1 000 gallon precast leaching pit. ( 6 'X9 ' ) T�WHEALTH DEPT. Based on my inspection, I certify the following conditions: 4 . This is a title five septic system. ( 78 Code) Q g '5. The septic system is in proper working order ] at the present time. 6. Waste water is 54" below the invert pipe of the leaching pit. 7. Pumped 1000 gallon septic tank at time of inspection. SIGNAT / UR Name :- J-._ P . _Macomber Jr . -- --------------- Corripany :josaoh Pam_ Macomber & Son , Inc . Address : aQx _��__--------_- -- Phone: __508- 775_ 3338 THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY son ow", wpm JOSEPH P, MACOMBER & SON, INC. Tanks-Cesspools-Leachflelds Pumped & Installed Town Sewer Connections P.O. Box 66 Centerville, MA 02632-0066 775.3338 775.6412 ,p -\ COMMONWEALTH OF SACHUSETTS EXECUTFVE 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-4 Waterside Drive CPntPrvil P_Masq_ Owner's Name:B__ pUi t-t- Owner's Address- Box 192 Blackstone 4 Date of Inspection: 10 31 02 !came of Inspector: (please print) Joseph P. Macomber Jr. Company Name: J.P. Macomber & Sons Inc Mailing address: Box 66 rpntprvi11p Ma 02632 Telephone Number: 508-775-3338 CERTIFICATION STATEMENT I cemh that I have personally inspected the sewage disposal system at this address and that the information reported below is rrue. accurate and complete as of the tirne of the inspection. The inspection was performed based on my ,rainoe and experience in the proper funcuon and maintenance of on site sewage disposal systems. I am a DEP appr;o�ed system inspector pursuant to SS ction 15.340 of Title 5 (310 CMR 15.000). The system: passes Conditionally Passes ?Feeds Funher Evaluation by the Local Approving Authoriry Fai s 21 Inspector's Sigoature: l Date: )d The system inspector shall it a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of co leting 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 authorir) Notes and Comments •—This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. 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: 4 Waterside Drive Centerville,Mass. Owner: Rarni P Qtii i-t Date of Inspection: 10/31 /0 2 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A System Passes: I have not found any informalhicti indicates that any of the failure criteria described in 310 CMR 15,303 or in 3 R 15.30E exist. ny failure criteria not evaluated are indicated below. Comments: Thp SPntlr Gy-,tem is in proper working order -at UQQ preSelat- i-1 ma B. System Conditionally Passes: Vc 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. k� 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: 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: 2 Page 3 of I 1 p OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:4 Waterside Drive Qent ervi 1 1 F Mass_ Owoer: Date of Inspection: 1 0 31 02 C. Further Evaluation is Required by the Board of Health: VO Conditions exist which require fw-ther evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. S%,stem 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. S'stem 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: .Ud The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or rributary to a surface water supply. ,112 The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply .�Q 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 190 feet u00 feet or more from a private water supple yell•' 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 anached 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: 4 Waterside Drive Centerville,Mass. Owner:Bernie Quitt Date of Inspection: 10 31 02 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 Y Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or /clogged SAS or cesspool V Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool �_J�, ►j iquid depth in eeaapcol is less than 6"below invert or available volume is less than 'h day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number /of times pumped i. !/Arty 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. AnKny portion of a cesspool or privy is within a Zone 1 of a public well. y 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.] (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 th, system is within 400 feet of a surface drinking water supply t}�e system is within 200 feet of a tributary to a surface drinking water supply `_//the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well •If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of i OFFICIAL INSPECTION FORM NNOT SYSTEM FOR RY ASSION FORM SUBSURFACE SEWAGE DISPOSAL PART B CHECKLIST Property Address: 4 W;4 f-t=rQ doh_-,ee OwnerBernie Quitt ' Date of lospectioo: 1 pL /fly Check if the following have been done. You must indicate ' s" or"no" as to each of the following: Yes Ypumpu)g 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 ? YHaNe large volumes of water been inrroduced to the system recently or as pan of this inspection ' zWere as built plans of the system obtained and examined? (If they were not available note as NIA) was the facility or dwelling inspected for signs of sewage back up? was the site inspected for signs of break out %'ere all system components,'14 luding the SAS, located on site ? Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition Cf!ne baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum Was the facilityy owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sev.age disposal systems ? The size and location of the Soil Absorption System (SAS) on the site has been determined based on Yes no� � l/Existing information. For example, a plan at the Board of Health. _P"'/_ Determined in the field (if any of the failure criteria related to Pan C is at issue approximation of distance ;s unacceptable) 13I0 CMR 15.302(3)(b)) S Page 6 of I I Al, OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:4 Waterside Drive Centerville,Mass. Owner: Bernie Quitt Date of Inspection: 10/31 /02 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):A Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): Y))b� Number of current residents:_a� Does residence have a garbage grinder(yes or no): S Is laundry on a separate sewage system(yes or no):.00 [if yes separate inspection required] Laundry system inspected yes or no): s Seasonal use: (yes or no): Water meter readings, if available(last 2 years usage (gpd)):2000-59, 000 gal lons=1 61 . 65 GPD Sump pump(yes or no): .v 2001 -62, 000 gallons=1 69 . 87 GPD Last date of occupancy: 7— COMMERCLAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): Lrnd Basis of design flow(seats/persons/sgft,etc.): iJ 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:2/22/95 10/12/99 Tank Only Maint. Was system pumped as pan of the inspection (yes or no): If yes, volume pumped: Aer� ) gallons-- How was quantiry pumped determined? Reason for pumping: Heavy Scum & solids layers were present. OF SYSTEM Septic tank, distribution box,soil absorption system 4L 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 syst�owner) ]Tight tank /�, Attach a copy of the DEP approval /L)Other(describe): 'ee Approximate ag a pomp}r�ten s ate installed(if known)and source of information: � � � M Were sewage odors detected when arriving at the site(yes or no): —40 6 Page 7 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 4 Waterside Drive Centerville,MasS. Owner:Bernie Quitt Date of Inspection: 1 0/31 /02 BUILDING SEWER (locate on site plan) Depth below grade:/ Materials of construction:,t�cast iron 20 PVC other(explain): x,4 Distance from private water supply well or suction line:/,6' Comments (on condition of joints, venting, evidence of leakage, etc.): ,T{)in s appear tight.No evidence of leakage.The system is vented through the house vents. SEPTIC TANK: t/ (locate on site plan) /G".'"4 Depth below grade: Material of construction: concrete,&mewl,0 fiberglass polyethylene rt other(explain) 4,0 If tank is metal list age: ) is age confirmed by a Certificate of Compliance (yes or no),f'ie (attach a copy of certificate) , Dimensions: Sludge depth: Distance from top of sludge to bonom of outlet tee or baffle: Scum thickness: _ n Distance from top of scum to top of outlet tee or baffle: l(�) Distance from bonom of scum to bonom of outlet tee or baffle: How,µere dimensions determined: Pumped at time of inspection Comrflents(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump the septic tank annual �-y,__ C;arhaQP r3i Epp-,al i c;raGanfi , T n l P t & outlet t e e arp i n n 1 ar.P.The t.a.nk-1 s_s t-r_u.c t u.r_a•1.1 y sound and shows no evidence of leakage. GREASE TRAP (locate on site plan) Depth below grade:ley Material of construction:,�/—X-concretee4 meta V fiberglass�olyethylenefX other (explain): Dimensions 4 Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bonom of scum to bonom of outlet tee or baffle: y� Date of last pumping: 41 + Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): ('reaca t-ran i c not nrpS t 7 Page 8 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:4 Waterside Drive 11 s. Owner: Bernie Quitt Date of Inspection: TIGHT or HOLDING TANKIa'(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: iX concrete metal 419 fiberglass etL polyethylene 0 other(explain): A)/ Dimensions: A119 Capacity: allons Design Flow: NR gallons/day Alarm present(yes or no): Alarm level: AJ4 Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches, etc.): Tight nr hn1dincl tanks ar _ not present DISTRIBUTION BOX: !/ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: /V 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.): Ili Sf_ri hnt-i nn hnx haG nnP 1 a P al No t-vidence of solids carry over No Pyidenre of 1Pakage into or out of the box, PUMP CHAMBER(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.): piiIppr-hamher i c not i rPcent 8 Page 9 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 4 Waterside Drive Centerville,Mass. Owner:Bernie Ouitt Date of Inspection: 10/31 /02 / SOIL ABSORPTION SYSTEM (SAS): tf (locate on site plan,excavation not required) 1_1 000 rral 1 on =recast 1 Pa _hi rig piitt,_(_6 ' X9 ' ) If SAS not located explain why: Located; See page 10 ZType eaching pits, number: / Ah) leaching chambers, number: leaching galleries,number: leaching trenches,number, length: 6 D leaching fields, number, dimensions: ZIT overflow cesspool, number P-innovative/alternative system Type/name of technology:T�i Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Loamy sand to medium fine sand No signs of hydraulic failure nr prinding-Roils are dry Vegetation is normal Waste wa er is 54" below the invert pipe. CESSPOOLS(cesspool must be pumped as part of inspect ion)(locate on site plan) Number and configuration: Depth'top of liquid to inlet invert: Depth of solids layer: Depth of scum laver: 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.): r'e_ccL r)nl G are not present PRIVY4,j�/e (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,): Privy iG nc)t, present 9 PI;( 10 of I I OFFICL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSME!TS SUBSURF.,CE SEWACE DISPO SA1, SYSTEM INSPECTION FOR,,, PART C SYSTEM INPOR.ML TION (continvco) ➢,op,rr) �001c11 4 Waterside Drive Can ervi e, s. 0"-cc Rarni P OUitt �t c 71 Inip,ci oo: 1 n /'21 /0 5X—rTCH Of SCWACC DISPOSAL SYSTEM Ao..oc 1 ttc,cn o1,nc icwtic o;tPottl tytt<m Inclv4lll� tl<t to tl Ic�tl (Wp➢(RT1(n(nl !((cicn<< I� 0,.A(01/T1 Vt, 100 lc ct. Locttc wnccc pvDI;c will' tvPPly (AIM tAc ovflolnl T • I (rive A 0 �\ 10 Page 1 1 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 4 Waterside Drive Centervi e,Mass. Owner: Bernie Ouitt Date of Inspection:10/31 /0 2 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: UQ_ Obtained from system design plans on record - If checked, date of design plan reviewed: NA =Observed site(abutting property/observation hole within ISO feet of SAS) Nn_ Checked with local Board of Health-explain: NA yFSChecked with local excavators, installers- (attach documentation) y.r�rSAccessed USGS database-explain:httA; //town,barnstable,ma. us. You must describe how you established the higgh gground water elevation: tsed: Gahrety & Miller model. 12/16/94 Ground water elevations above sea lPvP1 _ rsed; USGS-'-nhcPYvatlr)n wP11 data - June 1992 Jsed; USrc•Techniaa. h,a1lPt; n 92-ono-1 Plate #2 Annual ranges of ground water TON o uMuna • elevations. Leaching Pit J�I`;eet v� Groundwater: Fcet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method Therefore, the vertical separation distance between the bottom Of the leaching pit and the adjusted groundwater table is feet. ll r SEWAGE INSPECTIONS LOCATION 4 Waterside Drive DATE 10/31 /02 VILL1,0E Centerville,Mass. 02632 ASSESSOR'S MAP & LOT -INSPECTOR Joseph P.Macomber Jr. SEPTIC TANK CAPACITY 1 000 gallons + Box LEACHING FACILITY: (type) 1 -LP-1 000 (size) 1 500gls NO. OF BEDROOMS 3 BUILDER OR OWNER Bernie Quitt OWNER MAILING ADDRESS 'Same f kr si Doiye 6?,,,4-twil La R W 3� /S3 J , LO CAT IO "� SEWAGE PERMIT NO. .LQt 26 WATERSID 84-322 VILLAGE CENTERVILLE v INSTALLER'S NAME i ADDRESS � . Dan A. Speakman it R U I L D E R OR OWNER Gable Construction - Victor Kajko DATE PERMIT ISSUED DATE COMPLIANCE ISSUED �_�� _ 1 � t 1 � qo o � t � t i I A '110HN OF Rarnstahl P IlOARD OF HEALTH S(JHSHFACF 9F.WAGF DISPOSAL SYSTI ..M INSPECTION FORM - PART D .- CERTIFICATION •••T•-1-T••.••.'.,—T..1 ^.�.T.T..�.1'ri:*TI T 1T,TTlf TfTT'..—•.'1`^,i.^l"'TT.rr`T9r�+�a�.1'T ITC'fe1RTR'IC!'1 ' AA1 R'�1RTTT1ir17TT.1T.+r.:�.I'1^� r•.,. �. AAA —TYPE OR PRINT CLEARLY— PROPERTY INSPECTED STREET ADDRESS 4 Waterside Drive Centerville,Mass. ASSESSORS MAP , BLOCK AND PARCEL OWNER ' s NAME Bernie Quitt 1 ARV D - CERTIFICATION NAME OF INSPECTOR Joseph P . Macomber Jr COMPANY NAME Joseph P. Macomber &'-t on Inc COMPANY ADDRESS Box 66 Centerville Mass 02632 Street Town or Clty Stat* ZIp COMPANY TELEPHONE ( 508 ) 775-33-38 FAX ( 508 ) 790-1.578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate , and omplete as of the time of . inspection . The inspection was performed and any recommendations regardi,Ig upgrade , Ina intenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one : L;/S stem PASSED y , The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form . System FAILED* The inspection whicl, I have conducted has found that the system fails to Protect the public hea1L1) and the environment in accordance with Title 5 , 310 CMR 15 - 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . Inspector Signature Date,., rnecopy of this c rt.ification must be provided to the ONER, the BUYER re applicable ) and the DOAItD Oir IIZAL'111. * If the inspection FAILED , thi; owner or"'oparator shall upgrade ' the eyetem within one year of the date of the inspection , unless allowed or required otherwise as provided in 3.10 Ct•IR -5 . 305 . partd , doc + THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ...... .. ..... ...................OF............................... ......... Appliration for Bhipos al Workri Tons rurtinn rnmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: , ll ..... �.7�2C 5.1. .... .f l e..................................... ............. ....---............-----...----------------.....---------•...-------------- L cation-Address I _ VQls' -----....... �....._...--•---•------------- ...LIZL 0 .._...... .. Owner Address ............................................... ..... cu1.�G ... & 5:.-----------......------................ Installer Address `/ Type of Building Size Lot_ ,�,T. _...----...Sq. feet Dwelling—No. of Bedrooms........... ..............................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures -----------------------------------------------------------------•-------------------- W Design Flow..(_110. cd..�_5................gallons per person per day. Total daily flow...33.0............................ WSeptic Tank—Ligdid capacity-!_MO.gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.� Seepage Pit No.......1............. Diameter.6_)C_8....... Depth below inlet... ...... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosinn�. ,tank ( ) '-' Percolation Test Results Performed by. Z Gt '�'.. Ye—_-------. __ Date_____.�.�1._�,��- ......_.. Test Pit No. I f.,Et__.�inutes per inch Depth of est it..../a....._.. Depth to ground water.._A� .l.L,4 rs, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 9 .......... / . --•-----------•--••-••--•.....---- x Description of Soil �z -__ f2. _f.. ............. /z9---©�1 llf2 � �_....__....... V ---- ----- ----------------------------- ------------------ --------------------------- .------------------------------------------------ •------------------- -•---------------------------------- .__--------- W U Nature of Repairs or Alterations—Answer when applicable................................................................................................ -----------------------•-----•------•----------------------•-------------------------------------------------•------...---•-- Agreement: The undersigned agrees to install the afo escribe Individ age Disposal System in accordance with the provisions of iITI:, 5 of the State Sanita ode The un rsi furth ce the system in operation until a Certificate of Compliance has bee d by th b_ ed ---••- -- ------- ... -----•• ....................... .. .....(�- Application Approved By--------------- --- ..... ............. .................................................... _.: _.yiC Date Application Disapproved for e f oll ang reasons:............................ --------------------------------------_.................... ......•--- -------------------.---....•------•--•----•---•----.............................................................. Date PermitNo....................................................... Issued....................................................... Date NoQ.j '. 7': Fps.. ..�`................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .................. ........................OF....................... ......... Applirta#ion for Uisv.ao al Workii Tonstrurtioat Daum Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: 1. ....... 1V----...................................... ............ Location-Address r or Lot No .................................................... Owner Address -------------------------•-------------••------- '" J ° .l t`� i' ii+.+.............................................. Installer p� Address U Type of Building Size Lota,23P�/_�� .... ........ feet 1-, Dwelling—No. of Bedrooms--------3...............................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ....:....................... No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures W Design .................gallons per person per day. Total daily flow..334t.............................gallons. WSeptic Tank—Liq id capacityJrW6..gallons Length................ Width................ Diameter..........------ Depth................ x Disposal Trench—No. .................... Width.................... Total Length....... ... Total leaching area....................sq. ft. Seepage Pit No......j------------- Diameter_,_X.5....... Depth below inlet... .... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) '-' Percolation Test Results Performed by` gib„ � " l l .. .... Date.....- ` fj ........ Test Pit No. lf.,t_._ minutes per inch Depth of Test Pit.../A......... Depth to ground waten.,d''SV&tW_._,_'4 44 Test Pit No. 2................minutes per inch Depth of.Test Pit.................... Depth to ground water........................ Description of Soil...4&.7 1d:--?o: .. u. .......... Cxj ------------------------------- --------------------------------------- •--------------- ----------- -.................................................................................................. W UNature of Repairs or Alterations—Answer when applicable................................................................................................ -------------------•----------------------------....------------------------------------•------------------------------------------•••••-••---•••----•-.....---- Agreement: The undersigned agrees to install the afo escrib Individ 1 wage Disposal System in accordance with the provisions of TITLE 5 of the State Sanit y Code The un rsi nod furth r Qgrgrac.uat«tQ place the system in ~ ; operation until a Certificate of Compliance has Be ed by th b 1 i Application Approved BY :_.......... ............. ........................ ' i Dat Application Disapproved for e foll ing reasons:.........................................-............................. ......................................... ......................................................... •--••--•-••••---•---••-•--.....---•-•......---••---•- < Date PermitNo.......................................................... Issued-.......................... ............................. Date `. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF (Intifirtt#r of f�out�rliau �e T S IS V.,21 CERTIFY, That the Individual Sewage Disposal System constructed ( or kepairedby --------------------- - -----------------------------------------............................. ...................... nstaller atA. ----•--•-�'e� ....--.... -----------_--------------------------•------------------------------ has been installed in accordance with the provisions of TIT LE 5 of The State Sanitary Code as described �.n the application for Disposal Works Construction Permit No.._ f`. Z. ............. dated----------------------------- `__._._...__._.. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTR E® AS A GUARANTEE THAT THE SYSTEM WILL N ION SATISFACTORY. DATE -��v..p =/---------------------------•--..----.....---. Inspector THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH N'4/`' ' .....................OF....-•-------.......•••••••••...••---------•-•-••••....-----•......•...-•••......... ''t? ....... ...... FEE.---•-•---....-.......... �i��ro 'r✓Permission is e�y granted..:. 1" ! " -------•----------------------------------------------------------------------------- ---- to Construct ( or a ai ( waW posal System at No..•• ... ----- ----------- --------_------------------------------------•----.------ w street as shown on the application for Disposal Works C ction5 g�xmit zd ._............................. -'---- - ------------•------------ ---........................................................ �� Board of Health DATE. OC ...................................... FOMM 1255 A. M. SULKIN, INC., BOSTON _ St►�Gt.l` FAMII-Y 3 BEDROOM Cab' 75 29 5"7 /'IIeASA�.IT 44 1.J0 'GAt2BAGE �jW`NDE2 � v ,. 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L• ��+�-`L- ( Q BAXTE2e REG I S'T�Q6D't.Aw 0,5 u 7.Y EYoZ`> -Tul5 PL&►J 1 -5 NOrT Bt 5c P o►d AN o:5-rEP-VILLE • Mite's I� lw5TR.JMENT . 1=F:5ET5 Suout,�D NoT D� 'USEDTG DETER!^11•l� LOT LINES APPLICANT' i