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LPS Title 5 Septic Inspections Page 1
LPS
Subsurface Sewage Disposal System Inspection Forma
P.O. BOX 1797
Plymouth, Ma. 02362
(800) 957-5834 �ECE!lIE�
(508) 746-4411
AUG 1 9 1996
PART A
CERTIFICATION e
Z g
Property Address: Z G1J s Wf},
Date of Ins �/G[,Nt° l/, /9 �o
pection:
Name of Inspector: LokN Z)4;e l �R ,
Address of Owner:
Owner's Name: "A-Xjd(,
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 inspection. The inspection was performed based on my training and experience in
the proper function and maintenance of on-site sewage disposal systems.
The system:
I P asses
Conditionally Passes
Needs FuY4016r Evalu tion By the Local Approving Authority
a'
Inspector's Signature: - Date:
The System Ins shall submit opy of this inspection report to the Approving
Authority within thirty (30) days of completing this inspection. If the system is a
shared system or has a design flow of 10,000 pgd or greater, the inspector and the
system owner shall submit the report to the appropriate regional office of the Depart-
ment of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer, if app-
licable and the approving authority.
LPS Title 5 Septic Inspections Page 2
INSPECTION SUMMARY:
Check A, B, C, or D:
A] SYS EM PASSES:
71 have not found any information which indicates that the system violates
any of the failure criteria as defined in 310 CMR 15.303.
B] SYSTEM CONDITIONALLY PASSES
One or more system components need to be replaced or repaired. The
system, upon completion of the replacement or repair, passes inspection.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination
in all instances. If "not determined", explain why not.
The septic tank is metal, cracked structurally unsound, shows substantial
infiltration, or exfiltration, or tank failure is imminent. The system will pass inspection
if the existing septic tank is replaced with a conforming septic tank as approved by
the Board of Health.
Sewage backup or breakout or high static water level observed in the dis-
tribution box is due to broken or obstructed pipe(s) or due to a broken, settled or un-
even distribution-box. The system will pass inspection if (with approval of the Board
of Health):
broken pipe(s) are replaced
obstruction is removed
distribution box is leveled or replaced
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 the public health, safety and the envi-
orment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE
SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT
THE PUBLIC HEALTH 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 APPROPRIATE) DETERMINES THAT THE
SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC
LPS Title 5 Inspectors Page 3
The system has a septic tank and soil absorption system and is
within 100 feet of a surface water supply or tributary to a water surface
supply.
The system has a septic tank and soil absorption system and is within
Zone 1 of a public water supply. well.
The system has a septic tank and soil absorption system and is 50
feet of a private water supply well.
The system has a septic tank and soil absorption system and is less than
100 feet but 50 feet or more from a.private water supply well, unless a
water analysis for coliform bacteria and volatile organic compounds indicates
that the well is free from pollution from that facility and the presence of
amonia nitrogen and nitrate and is equal to or less than 5ppm.
[D] SYSTEM FAILS:
I have determined that the system violates one or more of the following failure
criteria as defined in a 310 CMR 15.303. The basis for this determination is
identified below. The Board of Health should be contacted to determine what will
be necessary to correct the failure.
Backup of sewage into facility or system component due to an overload or
clogged SAS or cesspool.
Discharge or ponding of effluent to the surface to the ground or surface
waters due to an overloaded or clogged SAS or cesspool.
Static liquid level in the distribution box above 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 1/2 day flow.
Required pumping more than four times in the last year NOT due to an
obstructed pipe(s).
Number of times
Any portion of the Soil Absorption System, cesspool or privy is below the
high groundwater elevation.
Any portion of a cesspool or privy is within 10 feet of a surface water supply
or tributary to a surface water supply.
Any portion of a cesspool or a privy Is within Zone 1 of a public well.
Any portion of a cesspool or a privy Is within 50 feet private. water supply
well.
LPS Title 5 Septic Inspectors Page 4
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. If the well has been analyzed to be accept-
able attach copy of well water analysis for coliform bacteria, volatile
organic compounds, ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria
above:
The design flow of system is 10,000 gpd or greater and the system is a signif-
icant threat to public health and safety and the environment because one or
more of the following conditions exist:
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 supply
the system is located in a nitrogen sensitive area ( Interim Wellhead
Protection Area (IWPA) or a mapped Zone 11 of a public water supply
well)
The owner or operator of any such system shall bring the system and facility into
full compliance with the groundwater treatment program requirements of 314 CMR
5.00 and 6.00. Please consult the local regional office of the Department for further
information.
(revised 8/15/95)
LIPS Title 5 Septic Inspectors, Page 5
PART B
CHECKLIST
Check if the fo owing have been done:
Pumping information was requested of the owner, occupant and Board
of Health.
None of the system components have been pumped for at least two
weeks and the system has been receiving normal flow rates during
that period. Large volumes of water have not been introduced into
the system recently or as part of this inspection.
✓/As built plans have been obtained and examined. Note if not available
/with N/A.
The facility or dwelling was inspected for signs of sewage back-up.
_ZThe system does not receive non-sanitary or industrial waste flow.
>Alle.site was inspected for signs of breakout.system components, excluding the Soil Absorption System, have
/bDen located on the site.ti t nk m nholes were uncovered o ened and the interior
e septic a p
of the septic tank was inspected for condition of baffles or tees,
material of construction, dimensions, depth of liquid, depth of sludge,
depth of scum.
_ZThe size and location of the Soil Absorption System on the site has
been determined based on existing information or approximated by
non-intrusive methods.
/Thefacility owner (and occupants, if different from owner) were pro-
vided with information on the proper maintenance of SubSurface
Disposal Systems.
LPS Title 5 Inspections are offered throughout the state of Massachusetts
CALL 508 746-4411 or 800 957-5834
LIPS Title 5 Septic Inspections Page 6
PART C
SYSTEM INFORMATION
FLOW CONDITIONS
RESIDENTIAL:
L/ /D Design flow in gallons
y -Number of bedrooms
a Number of current residence
✓Y N Garbage grinder
✓Y N Laundry connected to system
Y t/N Seasonal use
�3y3�1 sl Water meter reading, if available
a J Last date of occupancy
COMMERCIAUINDUSTRIAL:
Type of Establishment
Design flow: gallons/day
Grease trap present.: Y N
Industrial Waste-Holding Tank present: Y N
Non-sanitary waste discharge to the Title 5 system: Y N
Water meter readings, if available:
Last date of occupancy:
OTHER: (Describe)
Last date of occupancy:
LPS Title 5 Inspectors working towards a safe environment
CALL 506 746-441 or 800 957-5834
f
LIPS Title 5 Septic Inspectors Page 7
GENERAL INFORMATION
PUMPING RECORDS and source of information:
,Vo�2
Y N Was the system pumped as part of inspection?
If yes, volume pumped gallons
Reason for pumping:���CI1
TYPE OF SYSTEM
Septic tank, distribution box, soil absorption system
Single cesspool J
Overflow Cesspool
Privy
Y ✓N Shared system ( if yes, attach previous inspection records, if any)
Other (explain)
APPROXIMATE AGE of all components, rZs
if different explain:
Source of information:
Y ✓N Sewage odors detected when arriving at the site?
SEPTIC TANK:✓
Depth below grade.-
Material of construction --concrete metal FRP other(explain)
Dimensions L10 W- 5 H J
1I
Sludge depth: 1 D
Distance from top of sludge to bottom outlet tee or baffle:
3� II
LPS
LPS Title 5 Septic Inspectors Page 8
�I
Scum thickness:_
Distance from top of scum to top of outlet tee or baffle: I �l
Distance from bottom of scum to bottom of outlet tee or baffle:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of
liquid level in relation to outlet invert, structural integrity, evidence of Leakage, etc.)
GREASE TRAP:
T' -
Depth below grade:
Material of construction: concrete metal FRP other(explain)
Dimensions: L W D
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:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of
liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.)
TIGHT OR HOLDING TANK:
Depth below grade:
Material of construction: concrete metal FRP other(explain)
Dimensions: L W H
Capacity: gallons
Design flow: gallons/day
LPS The Title 5 Inspection Group here to serve you!
LIPS Title 5 Septic Inspections Page 9
Alarm level:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc,)
DISTRIBUTION BOX:
Depth of liquid level above outlet invert:
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of
leakage into or out of box, etc.)
PUMP CHAMBER:
Pumps in working order: Y N
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
SOIL ABSORPTION SYSTEM (SAS):
(locate if possible, excavation not required, but may be approximated by non-
-intrusive methods)
If not determined to be present, explain:
Type: CIO�
leaching pits, number:
leaching chambers, number:
leaching galleries, number:
leaching trenches, number and length: -
leaching fields, number, dimensions:
overflow cesspool,. number:
LPS Title 5 Inspection are offered throughout the state of Massachusetts!
CALL 508 746-4411 or 800 957-5834
LPS Title 5 Septic Inspections Page 10
Comments:
.(note condition of soil, signs of hydraulic failure, level of ponding, condition of vege-
tation, inc.)
CESSPOOLS:�=t�'
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool: L W H
Materials of construction:
Indication of groundwater:
inflow (cesspool must be pumped as part of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vege-
tation etc.)
PRIVY: V��t
Materials of construction: Dimensions L W H
Depth of solids:
Comments:
(note condition of soil, signs of hydraulic failure, condition of vegetation, etc.)
LPS Title 5 Inspectors working towards a safe environment!
Call 506 746-4411 or 80 957-5834
D
LIPS Title 5 Septic Inspections Page 11
SKETCH OF SEWAGE DISPOSAL SYSTEM-
(include ties to at least two permanent references landmarks or benchmarks)
locate all wells within 100'
Yo' D 00 F
-31
DEPTH OF GROUNDWATER
Depth to groundwater: Z feet NOWe - eo n ,
method of determination or approximation: �0msgz.Lt r PeAtn
P- yq�7
LIPS Title 5 Septic Inspections L2—
CALL 506 746-4411 or 800 957-5834
V
LPS Title 5 Septic Inspections Page 1
�b
LPS
Subsurface Sewage Disposal System Inspection Form
P.O. BOX 1797
Plymouth, Ma. 02362
0) 957-5834
(508 46-4411 JtJL
lifrill"C
PART A r
CERTIFICATION � c 9 Cv.
Property Address: Z F
Date of Inspection:
Name of Inspector: J,9 i,o 1;4 ezl ✓/2 ,
Address of Owner: q / 101 ? D le-
Owner's Name: "P�l �
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 inspection. The inspection was performed based on my training and experience in
the proper function and maintenance of on-site sewage disposal systems.
The system:
I/ Passes
Conditionally Passes
Needs F v luation By the Local Approving Authority
a[
Inspector's Signature- Date:_ _ zi
The System Inspector shall SubrWa copy of this inspection report to the Approving
Authority within thirty (30) days of completing this inspection. If the system is a
shared system or has a design flow of 10,000 pgd or greater, the inspector and the
system owner shall submit the report to the appropriate regional office of the Depart-
ment of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer, if app-
licable and the approving authority.
LPS Title 5 Septic Inspections Page 2
INSPECTION SUMMARY:
Check A, B, C, or D:
A] SYS EM PASSES:
71 have not found any information which indicates that the system violates
any of the failure criteria as defined in 310 CMR 15.303.
B] SYSTEM CONDITIONALLY PASSES
One or more system components need to be replaced or repaired. The
system, upon completion of the replacement or repair, passes inspection.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination
in all instances. If "not determined", explain why not.
The septic tank is metal, cracked structurally unsound, shows substantial
infiltration, or exfiltration,. or tank failure is imminent. The system will pass inspection
if the existing septic tank is replaced with a conforming septic tank as approved by
the Board of Health.
Sewage backup,or breakout or high static water level observed in the dis-
tribution box is due to broken or obstructed pipe(s) or due to a broken, settled or un-
even distribution box. The system will pass inspection if (with approval of the Board
of Health):
broken pipe(s) are replaced
obstruction is removed
distribution box is leveled or replaced
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 the public health, safety and the envi-
orment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE
SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT
THE PUBLIC HEALTH 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 APPROPRIATE) DETERMINES THAT THE
SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC
LPS Title 5 Inspectors Page 3
The system has a septic tank and soil absorption system and is
within 100 feet of a surface water supply or tributary to a water surface
supply.
The system has a septic tank and soil absorption system and is within
Zone 1 of a public water supply well.
The system has a septic tank and soil absorption system and is 50
feet of a private water supply well.
The system has a septic tank and soil absorption system and is less than
100 feet but 50 feet or more from a private water supply well, unless a
water analysis for coliform bacteria and volatile organic compounds indicates
that the well is free from pollution from that facility and the presence of
amonia nitrogen and nitrate and is equal to or less than 5ppm.
(D) SYSTEM FAILS:
I have determined that the system violates one or more of the following failure
criteria as defined in a 310 CMR 15.303. The basis for this determination is
identified below. The Board of Health should be contacted to determine what will
be necessary to correct the failure.
Backup of sewage into facility or system component due to an overload or
clogged SAS or cesspool.
Discharge or ponding of effluent to the surface to the ground or surface
waters due to an overloaded or clogged SAS or cesspool.
Static liquid level in the distribution box above 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 t/z day flow.
Required pumping more than four times in the last year NOT due town
obstructed pipe(s).
Number of times
Any portion of the Soil Absorption System, cesspool or privy is below the
high groundwater elevation.
Any portion of a cesspool or privy is within 10 feet of a surface water supply
or tributary to a surface water supply.
Any portion of a cesspool or a privy is within Zone 1 of a public well.
Any portion of a cesspool or a privy is within 50 feet private water supply
well.
LPS Title 5 Septic Inspectors Page 4
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. if the well has been analyzed to be accept-
able attach copy of well water analysis for coliform bacteria, volatile
organic compounds, ammonia nitrogen and nitrate nitrogen.
E) LARGE SYSTEM FAILS:
The following criteria apply to large.systems in addition to the criteria
above:
The design flow of system is 10,000 gpd or greater and the system is a signif-
icant threat to public health and safety and the environment because one or
more of the following conditions exist:
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 supply
the system is located in a nitrogen sensitive area (Interim Wellhead
Protection Area (IWPA) or a mapped Zone 11 of a public water supply
well)
The owner or operator of any such system shall bring the system and facility into
full compliance with the groundwater treatment program requirements of 314 CMR
5.00 and 6.00. Please consult the local regional office of the Department for further
information.
( revised 8/15/95)
LPS Title 5 Septic Inspectors Page 5
PART B
CHECKLIST
Check if the fo owing have been done:
Pumping information was requested of the owner, occupant and Board
of Health.
None of the system components have been pumped for at least two
weeks and the system has been receiving normal flow rates during
that period. Large volumes of water have not been introduced into
/the system recently or as part of this inspection.
✓ As built plans have been obtained and examined. Note if not available
with N/A.
e/"The facility or dwelling was inspected for signs of sewage back-up.
.4ZThe system does not receive non-sanitary or industrial waste flow.
T e site was inspected for signs of breakout.
All system components, excluding the Soil Absorption System, have
b en located on the site.
The septic tank manholes were uncovered, opened, and the interior
of the septic tank was inspected for condition of baffles or tees,
material of construction, dimensions, depth of liquid, depth of sludge,
/depth of scum.
,/ The size and location of the Soil Absorption System on the site has
been determined based on existing information or approximated by
non-intrusive methods.
/Thefacility owner (and occupants, if different from owner) were pro-
vided with information on the proper maintenance of SubSurface
Disposal Systems.
LPS Title 5 Inspections are offered throughout the state of Massachusetts
CALL 508 746-44 1 1 or 800 957-5834
LIPS Title 5 Septic Inspections Page 6
PART C
SYSTEM INFORMATION
FLOW CONDITIONS
RESIDENTIAL:
y4/0 Design flow in gallons
y Number of bedrooms
�� Number of current residence
✓Y N Garbage grinder
✓Y N Laundry connected to system
Y A Seasonal use
J3y3�I s� Water meter reading, if available
�5 Last date of occupancy
COMMERCIAUINDUSTRIAL:
Type of Establishment
Design flow: gallons/day
Grease trap present: Y N
Industrial Waste-Holding Tank present: Y N
Non-sanitary waste discharge to the Title 5 system: Y N
Water meter readings, if available:
Last date of occupancy:
OTHER: (Describe)
Last date of occupancy:
LIPS Title 5 Inspectors working towards a safe environment
CALL 508 746-441 or 800 957-5834
LIPS Title 5 Septic Inspectors Page 7
GENERAL INFORMATION
PUMPING RECORDS and source of information:
Y N Was the system pumped as part of inspection?
If yes, volume pumped 560 gallons
Reason for pumping:6 eck Lk 0170
TYPE OF SYSTEM
Septic tank, distribution box, soil absorption system
Single cesspool
Overflow Cesspool
Privy
Y ✓N Shared system ( if yes, attach previous inspection records, if any)
Other (explain)
APPROXIMATE AGE of all components, 1
if different explain:
L
Source of information: I�ONs�x= �� r°tlf?�� ''J ?
Y ✓ N Sewage odors detected when arriving at the site?
SEPTIC TANK:✓
Depth below grade: 2 Z
Material of construction 41"oncrete metal FRP other(explain)
Dimensions LO W H
I�
Sludge depth:_1�
Distance from top of sludge to bottom outlet tee or baffle:
i
LPS
LIPS Title 5 Septic Inspectors Page 8
Scum thickness:
l l
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle: 2 ��
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of
liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.)
GREASE TRAP:
Depth below grade:
Material of construction: concrete metal FRP other(explain)
Dimensions: L W D
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:
Comments,-
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of
liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.)
TIGHT OR HOLDING TANK:4�
Depth below grade:
Material of construction: concrete metal FRP other(explain)
Dimensions: L W H
Capacity: gallons
Design flow: gallons/day
LPS The Title 5 Inspection Group here to serve you!
LIPS Title 5 Septic Inspections Page 9
Alarm level:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:
Depth of liquid level above outlet invert: /D)") e,
Comments: I�
(note if level and distribution is equal, evidence of solids carryover, evidence of
leakage into or out of box, etc.)
o �V�d�c'� o � sal f`�..s �>��. ✓�z
PUMP CHAMBER:J� '
Pumps in working order: Y N
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
SOIL ABSORPTION SYSTEM (SAS):
(locate if possible, excavation not required, but may be approximated by non-
intrusive methods)
If not determined to be present, explain:
Type: (P t"/0,0 �l-�u5 �/��' 8
leaching pits, number:
leaching chambers, number:
leaching galleries, number:
leaching trenches, number and length:
leaching fields number, dimensions:
overflow cesspool, number:
LIPS Title 5 Inspection are offered throughout the state of Massachusetts!
CALL 508 746-4411 or 800 957-5834
LPS Title 5 Septic Inspections Page 10
Comments:
{note condition of soil, signs of hydraulic failure, level of ponding, condition of vege-
tation, inc.)
CESSPOOLS:
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool: L W H
Materials of construction:
Indication of groundwater:
inflow (cesspool must be pumped as part of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vege-
tation etc.)
PRIVY:VIA
Materials of construction: Dimensions L W H
Depth of solids:
Comments:
(note condition of soil, signs of hydraulic failure, condition of vegetation, etc.)
LPS Title 5 Inspectors working towards a safe environment!
Call 508 746-4411 or 80 957-5834
LPS Title 5 Septic Inspections Page 11
SKETCH OF SEWAGE DISPOSAL SYSTEM:
(include ties to at least two permanent references landmarks or benchmarks)
locate all wells within 100'
AL
yo' o o F
C -
�= -33
_ 311
yZ 1611 ❑
DEPTH OF GROUNDWATER
Depth to groundwater: Iz feet NbWe Pd ° �
method of determination or approximation:_CDNJ&� - C�vx-) PeAM4
LPS Title 5 Septic Inspections OC Z <S
CALL 506 746-4411 or 800 957-5834
�C� 4
Q
D%61�..3Gr`S
37 -�
9aG
Ficis ...............
No:F�� 00
4-907
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF 0 HEALTH
' < - .........
—7—A ........
..u__)j................OF.... ...A. iLA.)
Appliration for llhqpniial Work.5 Tontilrurthin ramit
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
Vystern at: 'a. ................ .................. .........................................
................................
Location-Address r Lot....
No.
..........................................0......................................................
L1>1-TT... Address
.......................................................
............................,..................Installer.. .....K. .................................. ...........................................
Address
Type of Building Size Lot.3-Q.-IP0...7Sq. feet
U DwellingX No. of Bedrooms----------4.............................Expansion Attic 410) Garbage Grinder 00)
Other—Type of Building ............................ No. of persons_._.._..............._..___. Showers Cafeteria
Other fixtures .........................................................................................................
:4-----------------------------------------
Design Flow..........._.5_6.....................gallons per person per day. Total daily flow....4...*...0------*.................gallons.
WSeptic Tank—Liquid*capacitylSO.Ckallons Length................ Width______-__------_ Diameter................ Depth...41 epr
........
Disposal Trench—No.-------------------- Width.................... Total Length.................... Total leaching area....................sq. f t.
Seepage Pit No......10!1�---'q- Diameter-___*.......1 !Depth below Total leaching area-A-Q-L_..,.sq. ft.
Z Other Distribution box Dosing tank
Percolation Test Results Performed by.....................................................I.................... Date----.--.----------.------ -
aTest Pit No. 1----�.......minutesperinch Depth of Test Pit------ ....... Depth to ground water---
Test Pit No. 2----_---------minutes per inch Depth of Test Pit------i.. ..... Depth to ground water_.. .........a)e-
Rai ............................................................................................................................................................
0 Description of Soil_.._.._ Tqj.-_�01A!r!.....................................................................................................................
W Sol e—
U .................................................... . ...............................................................................................
A—)
---------_-------- ........
licable--------
---------------------------------------------- ---
UNature of RepailsWor. Alterations—Answer when app --- ------/-J. ------ ............................................
....................W - _'�. . .................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of'L7-TL, - 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 liesfit
Signed...jZA ......................................... . ................. .............................
Date
Application Approved By ....................................................... .......... -------
Date
Application Disapproved for the,following reasons:..............................................................................................................
.........................................................................................................................................................................................................
Date
PermitNo.----- ....................... Issued.......................................................
Date
..............
r.
M.
No........................ .........
THE COMMONWEALTH OF MASSACHUSETTS 4-907
BOARD OF HEALTH
...OF........ (-,2:r . . . .. .
Appliratiou for M.6pwial Work.5 Tomitrurtiou ramit
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at:
........42...YJ ---------------------------------------------- --------------------------------------------------------------------------------------------------
Location-Address or Lot No.
... .....................................................I............................................
Owner Address
..................................................4f......../................................. ..................................................................................................
Installer Address
Type of B Size feet
Dwelling
U
ul 3&o. of Bedrooms...........4............................Expansion Attic (Klo) Garbage Grinder
Other—Type of Building ............................ No. of persons--_--_------------------- Showers Cafeteria
P4Other fixtures ......................................................................................................................................................
Design Flow...............�5_tr.................-gallons per person per day. Total daily flow..... .....................gallons.
1:14 Septic Tank—Liquid capacity.150.C?allons Length................ Width................ Diameter______.......... Depth....
Disposal Trench—No. .................... Width_....___....___.__.. Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No --_�_ Diameter......X!P--------I 15epth below inlet_..... .=..... Total leaching area.-.-.-.44?,j.._.,sq. ft.
Z Other Distribution box ( � Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date...___.........._.._.........__......__.
,4 Test Pit No. I.....:Z?------minutesperinch Depth of Test Pit------- ...... Depth to ground water....Ak'f E....e()C_
fi ..............
Test Pit No. 2................minutesper inch Depth of Test Pit....... Depth to ground water....Al�w.ea..-EX)c
----------------------------------- ----------------------------------------"-----------------------------*---------------------------*--------------
0 Description of Soil------ . 1_5f'
59,L ...................................................................................................................
U ....................................... .... ... 2............. Soi L..............................................................................................................
0 4 EZI 4- .....................
----------------------- --------------------------------------------------- --- C::.... .................. .
------4J. i
U Nature of Repairs jor Alterations—Answer when applicable._________ -v
..................... k...... .................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of T-1 T__iE 5 of the State Sanitary Code—The undersigned further a reps not to place the system in
operation until a Certificate of Compliance has been�ssued. by the board of li........... 2 / /,�f 5-
Sign ............. ........... ................................
Date
ApplicationApproved By...................................... I.............. ..................................... .............L-----------
Date
Application Disapproved for the following reasons:................................................................................................................
..................................................................................................... ..................................................................................................
Date
PermitNo...... --- ----------------------------------------- Issued.-----....------------------------------------------.._.
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
................OF........ ................... .
Trdifiratr of Tompliana
TQ_CERTIFY, That the Individual Sewage Disposal System constructed or Repaired
by.........
........../---------------------------------------......................................................................................................
Installer
at.......I..... ....................*. . .. W. .......... ...............................................................
has been installed in accordance with the provisions of II-, LE 5 of The State Sanitary Code al described in the
application for Disposal Works Construction Permit No.__0----k------------:� .......... dated--------0C_J..
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FU CTION SATISFACTORY. —77_,i�
DATE..............
........................................ Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTSI
BOARD OF HEALTH
..........................................OF...............................................................................
No. ....t................. FEE.. ............----•-
Disposal orkii TDomitrudion Vamit
Permission is hereby granted....._ ........................................................ ................................
at U
to Construct or Repair an Individual Sex,qge. sposal System�_2...... -K ... rar�t'..
.. ....................... ...... 1.±..........................................................................
0_� --------- 1... -k,!t
as shown on the application for Disposal Works Con Perini Dated-----0-Je---
X',............... ..................................................................
Board of Health
DATE......... 2........... .........5:�.S .......... ..........
... ... ..........
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
%
LOCAT�o7 WAGE PERMIT NO.
j (n! &�'/ <ag- 239
�gVILLAGE j
INSTALLER'S NAME i ADDRESS t
C 1� erg T Ccw.
iV
B U I L D E R OR WNi�FI
-alY
DATE PERMIT ISSUED
DAT E COMPLIANCE ISSUED
�i
I
f
j SOIL LOG
NO. 1 N0. 2
SITE PLAN
0 T _
f
3
4
5
, TOP OF FOUNDATION El.: ' '?? �=;;i_�av,:-;,,. __- �, 6
----
IZ
8 �
1 ,, 0 9
Y) 10
O O
- f
IN El
IN.E l
• D/B W/ 6 SUMP °� "` ; 13
0 4 LIQUID LEVEL • �' ;�� P%L _ 14El
1
A. ,W. 'r z, ° 0, 1i..;,. 5- <ati .� ERC TEST RESULTS
I , PRECAST SEPTIC TANK WITH a PERC RATE :
� CAST IN PLACE INLET AND �� � �.}d WHITNESSED BY: �_
---- --
OUTLET T "S PER TITLE Y ' ' r..-_.__ �' ' � err
-- '�=- _ ,� - BOARD OF HEALTH
SIZE : �— ; ---,� __ _ DATE: A.)I-7_
.
PROFILE OF PROPOSED SEWAGE SYSTEM t 301
x SYSTEM DESIGNED BY THE TOWN OF ..; REGULATIONS AND
STATE TITLE Y FOR SUBSURFACE DISPOSAL OF SEWAGE . SCALE 1/4"= 1 " 0
4
N . B . Z4-
1. ALL PIPES SHALL BE SCHEDULE 40 P.V.C. SEWER PIPE r , 10
2. ALL PIPES SHALL BE SLOPED 1/4 PER FOOT EXCEPT FOR
THE FIRST 2 FEET OUT OF THE D B WHICH SHALL BE LEVEL
3. DESIGN FLOW __ - _ BEDROOMS AT 110 GALDAY PER BR .� '-- _-` GAL/DAY
SEPTIC TANK SIZE X :. -- - . f GAL . z
� � 1=� � GARBAGE DISPOSAL �
n
! USE i�UU GAL. W. _ 6 0 A
a �
I LEACHING SYSTEM . USE ,- � ',p ,. � ' ET F J - ,- �� / � � F_ -T 01_1e
u 5 E �_5' r o a -D 64 0
3 .IQox
EFFECTIVE AREA : SIDE ? !- S.A ,SR ?
BOTTOM _-'' _`; 4 be z oo �' t� 761 -
TOTAL FLOW __ __ :. -79 0 �����_��
TOTAL REQ 'O FLOW 44o Wlo,);- GARBAGE DISPOSAL
RESERVE FLOW__;.-. 4-4 GAL / DAY
7L
g9xo '
REFERENCE PLANS -
_ 3G
= _
r -- ---'�yl -i/JIJ.� i
APPROVED BY :
_ BOARD OF HEALTH
DATE : _.
PROPERTY OWNER SITE /ANO SEVvAGE f .-AN
J ,
N ?f '4
- • ' �,P = \'f - BEDROOM Sl�fGLE Ff-\Mi _�! DhICL. ►1�IG
G� LOT
` 23 5 1 1tw0r- L 1AM C o2 o re R (�IT 28 2592
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