HomeMy WebLinkAbout0033 WEST VIEW LANE - Health 33 WEST VIEW LANE
- CENTERVILLE
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UPC'12534
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT.OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 33 West View Lane
Centerville, MA.02632
Owner's Name: Gerard Mcgann
Owner's Address:
Date of Inspection: September 16 2010
Name of Inspector: (Please Print) James M. Ford
Company Name: James M.Ford
Mailing Address: P.O.Box 49
Ostervidl MA 02655-0049
Telephone Number: (508)862-9400
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported.
below is true,accurate and.complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 C.NM 15.000). The system:
✓ Passes
Conditionally Passes
eeds Further Evaluation by the Local Approving Authority
F ils
Inspector's Signature: Date: Se tem r n be 19. 2010
The system inspector shall su it a copy oft is inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has.a design flow of M000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving
authority.
Notes and Comments
""This report only describes conditions at 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 1
Y
Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 33 West View Lane
Centerville. MA _
Owner: Gerard Mcann
Date of Inspection: September 16. 2010
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
✓ 1 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 detennined(Y,N,ND)in the for the following statements. If"not determined",please
explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
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):
brokenpipe(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 i e s . The p p 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
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 33 West View Lane
Centerville, MA
Owner: Gerard Mcann
Date of Inspection: September 16 2010
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to detenmine if the system
is failing to protect public health,safety or the environment.
I. 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 5.0 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 fun
ctioning ctionin in
y g 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 aseptic tank and SAS and the SAS is within a Zone 1 of a public water supply.
_ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well".. Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
3
Page 4 of 1 I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 33 West view Lane
Centerville. MA
Owner: Gerard Mcann
Date of Inspection: Sevtember 16. 2010
D. System Failure Criteria applicable to all systems:
You must indicate either"yes"or"no"to each of the following for all inspections:
Yes No
✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
✓ ' Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow
_ ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped_.
✓ Any portion of the SAS,cesspool or privy is below high ground water elevation.
✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
✓ Any portion of a cesspool or privy is within a Zone 1 of a public well
_ ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.)
No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large System:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
Yes No
_ the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
_ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped
Zone 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
CHECKLIST
r� Property Address: 33 West view Lane
Centerville, MA
Owner: Gerard Mcann
Date of Inspection: September M_ 2010
Check if the following have been done: You must indicate"yes"or"no"as to each of the following:
Yes No
✓ Pumping information was:provided by the owner,occupant,or Board of Health
✓ Were any of the system components pumped out in the previous two weeks ?
✓ Has the system received normal flows in the previous two week period?
✓ Have large volumes of water been introduced to the system recently or as part of this inspection ?
✓ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
✓ Was the facility or dwelling inspected for signs of sewage back up?
✓ _ Was the site inspected for signs of break out?
✓ _ Were all system components,excluding the SAS, located on site?
✓ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid, depth of sludge and depth of scum?
✓ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems ?
The size and location of the Soil Absorption System (SAS)on the site has been determined based on:
Yes No
✓ — Existing information. For example,a plan at the Board of Health.
✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [310 CMR 15.302(3)(b)].
5
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 33 West View Lane
Centerville,MA
Owner: Gerard Mcann
Date of Inspection: September 16. 2010
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): I Number of bedrooms(actual): I
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): -
Number of current residents: 0
Does residence have a garbage grinder(yes or no): n/a
Is laundry on a separate sewage system(yes or no): n/a [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)): Unavailable
Sump Pump(yes or no): No
Last date of occupancy: Unknown
COMMERCIAUINDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no)
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: Unavailable
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
Septic tank,distribution box,soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) (if yes,attach previous inspection records,if any)
Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight Tank Attach a copy of the DEP approval
Other(describe):
Approximate age of all components, date installed(if known)and source of information:
installed on 9119100-per as-built
Were sewage odors detected when arriving at the site(yes or no): No
6
Page 7 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INS
PECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 33 Kest View Lane
Centerville, MA
Owner: Gerard Mcann .
Date of Inspection: September 16. 2010
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: _cast iron _40 PVC _other(explain):`
Distance from private water supply well or suction line:
Comments (on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: 11"
Material of construction: _concrete _metal _fiberglass ✓ polyethylene
other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1500 gal.
Sludge depth: -
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle: -
Distance from bottom of scum to bottom of outlet tee or baffle: -
How were dimensions determined: Measuring stick
Comments(on pumping recommmendations, inlet and outlet tee or baffle condition;structural integrity, liquid levels
as related to outlet invert, evidence of leakage,etc.):
Tees were present. The liquid level was even with outlet invert
GREASE TRAP: None (locate on site plan)
Depth below grade:
Material of construction: _concrete —metal _fiberglass _polyethylene _other
(explain):.
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle.-
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Commnents(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert, evidence of leakage,etc.):
7
Page 8 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 33 West View Lane
Centerville. MA
Owner: Gerard Mcann
Date of Inspection: September 16 2010
TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain):
Dimensions: .
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alann in working order(yes or no):
Date of last pumping:
Comments (condition of alarm and float switches,etc.):
DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: Even
Comments (note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box, etc.):
The D-box was normal. The cover was 10"below rade.
PUMP CHAMBER: None (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no)
Comments(note condition of pump_chamber,condition of pumps and appurtenances, etc.):
. 8
Page 9 of l i
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 33 West View Lane
Centerville, M.4
Owner: Gerard Mcann
Date of Inspection: September 16, 2010
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:
✓ leaching chambers,number: 2-500 gal. chambers
leaching galleries,number:
leaching trenches,number, length:
leaching fields,number,dimensions:
overflow cesspool,number:
Innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,
etc.):
There was no sign of failure,from. the leach field
CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer;
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes.or no);
Comments. (note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation,etc.):
PRIVY: None (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.).-
9
'± Page 10 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 33 West View Lane
Centerville, MA
Owner: Gerard Mcann
Date of Inspection: Set2tember 16. 2010
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
r�
00
y v 3q
10
" Page 11 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 33 West View Lane
Centerville, MA
Owner: Gerard Mcanri
Date of Inspection:. September 16, 2010
SITE EXAM
Slope
Surface water
Check cellar
-Shallow wells
Estimated depth to ground water 30+/- feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
✓ Checked with local Board of Health-explain: Topographic and water contours maps
Checked with local excavators, installers-(attach documentation)
Accessed.USGS database-explain:
You must describe how you established the high ground water elevation:
Using Barnstable topographic and water contours snaps the inaps were showing approximately 30'+/ to-around water at this
site.
This r• r.h T s e o t a been prepared
s b e a ed onl or the septic stem r r p p p yf p y and cor tp one nts described herein. This septic system has been
inspected as of the date of inspection and passed. This report is not a warranty or guarantee that the system will function properly
in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the septic
System, the inspection, this report andlor any components of the septic system which have not been located and inspected.
11
TOWN OF BARNSTABLE C. ,
LOCATION �� / b /� ���' � SEWAGE # `Jd��s�zJ �►
VILLAGE C01V 'l�'w�!i'/�-� i ASSESSOR'S MAP & LOT `
INSTALLER'S NAME&PHONE NO. bAl 14 )f W r7 vs—
SEPTIC TANK CAPACITY a�
LEACHING FACILITY: (type) �Z"6®6Gg 1 04 '0$i kV✓s (size)
NO. OF BEDROOMS
BUILDER OR OWNER
PERMTTDATE: �` /0® COMPLIANCE DATE: � 7-o
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) FLoA-r 1AP41f Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet o caching f /Y /<t Feet
Furnished by
� p
Ay
aeP
rr TOWN OF BARNSTABLE
LOCATION ' � / .�s U� �c t SEWAGE #Je'6-'-'S
VILLAGE C01V ftP w.1 i'/�-�' ASSESSOR'S MAP & LOT,!�y,
INSTALLER'S NAME&PHONE NO. J�- AV A LAO e
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) ,,Z °C�,, C—' u.,It i y✓' (size)
NO. OF BEDROOMS / y
BUILDER OR OWNER
PERMUDATE: /� rl 0 COMPLIANCE DATE: e`'
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 o -leaching,f /V- Feet
Furnished by4:i
L -
J'
i
x
j' ,
No. v Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
ZippYication for Migool bpztem Construction Verntit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. S 3 Lt�t�d ��> �,f Owner's Name,Add and/'Tel.No.
;M �fi/✓�
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No. / Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms J__ Lot Size sq.ft. Garbage Grinder
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow d;9-0 gallons per day. Calculated daily flow .906 gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank >6 `—� Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) '0"4 z--
e
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 ontal Code and not to place the system in operation until a Certifi-
cate of Compliance has been issuedr7rjuRF
y this B1, Signe 6 Date
Application Approved by 19 Date
Application Disapproved iokhe following reasons
Permit No. LP Date Issued
" No. _ Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
• ', Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS
2ppfication for 'liow5af *pgtem Co 5truction 'ermit i
,r Application for a Permit to Construct( )Repair( )Upgrade( ` )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 3.3 �OS I AW , // Owner's Name,Address and Tel.No.
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
.t
Type of Building:
Dwelling No.of Bedr`ooms'—L—_ Lot Size sq.ft. Garbage Grinder( )VO
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Desigri Flow gallons per day. Calculated daily flow 19cp d gallons.
Plan Date Number of sheets Revision Date
Title C `
Size of Septic Tank i �, Type of S.A.S.
Description of Soil
1,
Nature of Repairs or Alterations(Answer when applicable) Pn.���c
b
Date-last inspected:
Agreement: `.
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
i i accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been i sue -by this B H th.
Signe � . (u 414 ,9 Date Z Od
Application Approved by i -U r� ate
Application Disapproved/f6f the following reasons
Permit No. Date Issued
I
THE COMMONWEALTtH.:OrMASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
(Certificate of (Compliance
THIS IS TO CERTIFY, that the On-sitf Sewage Disposal,System Constructed( )Repaired'( )Upgraded
Abandoned( )by 7_)�. � �/�
at >_ J: AL� ' r='-1�T�',�_ has b bn constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit N dated
Installer Designer
The issuance of this permit shallndbe construed as a guarantee that the system will function as designed:°.' i �1
Date '- Inspector s�
x No. ---!—� ------------------------Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
Mi5pozal 6pote , (Construction Permit
Permission is hereby gran ed Cons ct( )Repair Upgrad ( ) bandon 7
System located at
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to
,. comply with Title 5 and the following local provisions or special conditions.
Provided: Cons 4ctio Lst be completed within three years of the date of s p
Date: Approved by L°
I j
d
1/6/99
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS)
I, �7d� c, LAi4du7 , hereby certify that the application for disposal works
construction permit signed by me dated
concerning the
property located at Z3 3 �W meets all of the
following criteria:
• This failed system is connected to a residential dwelling only. There are no commercial or business
uses associated with the dwelling.
• The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch.
• There are no wetlands within 100 feet of the proposed septic system
• There are no private wells within 150 feet of the proposed septic system
• There is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
• The bottom of the proposed leaching facility will not be located less than five feet above the maximum
adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when
applicable]
• If the S.A.S.will be located with 250 feet of any vegetated wetlands,the bottom of the proposed
leaching facility will not be located less than fourteen(14)feet above the maximum adjusted
groundwater table elevation,
Please complete the following:
A) Top of Ground Surface Elevation(using GIS information) 7 lo
B) G.W.Elevation /Act +the MAX. High G.W. Adjustment.
DIFFERENCE BETWEEN and B
SIGNED : DATE: y �a
[Please Sketc proposed plan 6Y system k].
NOTICE
Based upon the above information,a repair permit will be issued for bedrooms maximum. No
additional bedrooms are authorized in the future without engineered septic system plans.
q:health folder:cert
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