HomeMy WebLinkAbout0080 WILD GOOSE WAY - Health 80 WILD GOOSE WAY
CENTERVILLE
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UPC 12534 '
No. 2�153LOR °osr.coa��a��
HASTING$, MN
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DATE:
4/30/02
PROPERTY ADDRESS:80_Wild_Goose _W_ay_____-_
0 ,Mass .
-- '--'-'- -------------- MAP I (t
PARCEL • O50
------------------------ LOT
On the above date, I Inspected the septic system at the ab �®
This system consists of the following:
1 . 1-1500 gallon septic tank . MAY 0 3 2002
2 . 1-Distribution box .
3 . 2-1000 gallon precast leaching pits . TOWN OF BARNSTABLE
Based on my inspection, I certify the following conditions: HEALTH DEPT.
4 . This is a title five septic system. ( 78 Code
5 . The septic system is in proper working order
at the present time .
SIGNATURE:-,'
Na me :_.1 _�,_ Macomber jr�______
Company: Joseph-P _ Macomber-& Son , Inc .
Address ; Box 66
__Centerville , Ma ._02632-0066
Phone: 508-775-3338
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
LJOSEPH P. MACOMBER & SON, INC.
anks-Cesspools-Leachflelds
Pumped & Installed
Town Sewer Connections
66 Centerville, MA 02632-0066
775.3338 775.6412
COMMONWEALTH OF MASSACHUSETTS
r EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
Y
V
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 80 Wild Goose Way
entervi e , ass .
Owner's Name: Beth Blaze
Owner's Address: 4 30 02
ame
Date of Inspection: 4/ 30/02
Name of Inspector: (please print)Joseph P .Macomber Jr .
Company Name:J. P .Macomber & Son Inc .
Mailing Address: Box 66
Centerville .Mass . 02632
Telephone Number: 508-775-3-338
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
e��Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date:
The system inspector shal ubmit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system 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
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 1
Page 2 of 11
J
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 80 Wild Goose Road
Centervi le ,Mass .
Owner: Beth Blaze
Date of Inspection: 4/3 0/0 2
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
WO �Lun �R
�5.304
rmation hich indicates that any of the failure criteria described in 310 CMR
15.303' xist. Any failure criteria not evaluated are indicated below.
Comments:
The septic system is in proper working order '
at the present time .
B, System Conditionally Passes:
One or more system components as described in the "Conditional Pass"section need to be replaced or
repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass.
Answer yes, no or not determined (Y,N,ND) in the for the following statements. If"not determined"please
explain.
_A,�' The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or ekfiltration 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.
?'D explain:
44 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 I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:80 Wild Goose Lane
entervi e , ass . '
Owner: Beth Blaze
Date of Inspection: 4/30/02
C. Further Evaluation is Required by the Board of Health:
AIP Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the
system is not functioning in a manner which will protect public health, safety and the environment:
AX Cesspool or privy is within 50 feet of a surface water
AZ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a
surface water supply or Tributary to a surface water supply.
/1/61 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 100 feet but 0 feet or more from a
private water supply well". Method used to determine distance j /`� �
'-'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 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 80 Wild Goose Way
en ervi e , ass .
Owner: Beth aze
Date of Inspection:
D. System Failure Criteria applicable to all systems:
You must indicate "yes"or"no" to each of the following for all inspections:
Yes No/
_ ,/lBackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
f� 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 9-14a164V y 6l�41
Liquid depth in.cc-pnnl is less than 6"below invert or available volume is less than ''A day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped— �.
:ky portion of the SAS, cesspool or privy is below high ground water elevation.
y portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
ater supply.
�y portion of a cesspool or privy is within a Zone I 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 trom a private water
supply well with no acceptable water quality analysis. )Tbis 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 c"
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 now of 1o,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)
des no
_GJhe system is within 400 feet of a surface drinking water supply
//t the system is within 200 feet of a tributary to a surface drinking water supply
Ithe system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA)or a mapped
Zone 11 of a public water supply well 4.
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
5.304 The system owner should contact the appropriate regional office of the Department.
4
Page 5 of I 1
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 80 Wild Goose Way
Centerville ,Mass .
Owner: Beth Blaxe
Date of Inspection: 4/30/0 2
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
mping information was provided by the owner, occupant, or Board of Health
21were any of the system components pumped out in the previous two weeks
_ Has the system received normal flows in the previous two week period ?
Z/Have large volumes of water been introduced to the system recently or as pan 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 g ,components,dudin 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 ?
y _ 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 Pan C is at issue approximation of distance
is unacceptable) (310 CMR 15.302(3)(b))
5
Page 6 of 1 1
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 8.0 Wild Goose Way
Centerville ,11ass .
Owner: Beth Blaze
Date of Inspection: 4/3 0/0 2
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203 (for example: 1 10 gpd x # of bedrooms):
Number of current residents: J
Does residence have a garbage grinder(yes or no):A10
Is laundry on a separate sewage system (yes or no):� [if yes separate inspection required]
Laundry system inspected(yes or no): 15
Seasonal use: (yes or no): ,410
Water meter readings, if available(last 2 years usage (gpd)): 2 000—13 8 , 000 gallons=378 . 09 GPD
Sump pump(yes or no):1)0 2001-160 , 000 gallons=438 . 36 GPD
Last date of occupancy:7-
COMM ERCIALANDUSTRIAL
Ty
pe of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.)10
Grease trap present(yes or no): Ay
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 s stem (yes or no):�G�7
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: 'M'ye e
Was system pumped as part of the inspection (yes or no): _
If yes, volume pumped: lions- How was quantity pumped determined? 1*
Reason for pumping:
TYP OF SYSTEM
Septic tank, distribution box, soil absorption system
_Single cesspool
tt Overflow cesspool
Privy
Shared system(yes or no)(if yes, attach previous inspection records, if any)
4& Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight tank 4�) Attach a copy of the DEP approval
/1.b Other(describe): I
AN mate aee of all c9n1ponen , date installed (if known)and source of information:
Were sewage odors detected when arriving at the site(yes or no):
6
Page 7 of 1 1
OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 80 Wild Goose Way
Centerville . Mass .
Owner: Beth Blaze
Date of Inspection: 4/30/0 2
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: !pJ cast iron Z0 PVC O other(explain): AO
Distance from private water supply well or suction line: /e
Comments (on condition ofjoints, venting, evidence of leakage, etc.):
oints appear tight . No evidence of leakage . System is vented
Through the house vents .
SEPTIC TANK: Zlocate on site plan)%�A- W2 V-1
Depth below grade:
Material of construction: concrete.f/D metal,l�i�fiberglass polyethylene
Ii other(explain) �`;�
If tank is metal list age: 0 Is age confirmed by a Certificate of Compliance (yes or no)N/C/(attach a copy of
certificate)
Dimensions:
Sludge depth:
Distance from top Mudge to bottom of outlet tee or baffle:17-t' �
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom.of scum to bottom of outlet to or baffle:
How were dimensions determined: �
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage, etc.):
thp septic tank every 9-3 � ears . Inlet & outlet tees
`are in place . he tank is structurally sound and shows no
evidence of leakage .
GREASE TRAPG(locate on site plan)
Depth below grade:d//9
Material of construction:4#concretes metai4?A fiberglassolyethylene4_other
(explain): 40
Dimensions: 100
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: Ji'
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
Gr Pa4P trnp i g not r PS`Pn t r
7
Page 8 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 80 Wild Goose Way
Centervi e , ass .
Owner:Beth Blaze
Date of Inspection:
TIGHT or HOLDING TANK�p4tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete AR metal 41A fiberglass g�/ polyethylene�other(explain):
Dimensions: AI
Capaciry: 1✓ gallons
Design Flow: 16f gallons/day
Alarm present (yes or no):
Alarm level: A14 Alarm in working order(yes or no):104
Date of last pumping: xfA
Comments (condition of alarm and float switches, etc.):
Tight or holding tanks are not present
DISTRIBUTION BOX: Zif present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: �d
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.):
Distribution box has two 1 rals No evidence of leakage .
No evidence of leakage into or out o t .e ox .
PUMP CHAMBER,#)dA±&(locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no): V
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
Pump chamber is not present
8
Paee 9 of 1 I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 80 Wild Goose Way
Centerville ,Mass .
Owner: Beth Blaze
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required)
2—precast leaching pits . ( 6 ' X 10 ' )
If SAS not located explain why:
Located see page 10
T y py
leaching pits, number: 'Q4—L
leaching chambers, number:
i(.,21 leaching galleries,number:
AP leaching trenches,number, length:
leaching fields,number, dimensions:
J0 overflow cesspool, number:
2binnovative/alternative system Type/name of technology:
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
or ponding . Soils are dry . Vegetation is normal .
CESSPOOLSAb&g4cesspool 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 laver:
Dimensions of cesspool:
Materials of construction: NA
Indication of groundwater inflow(yes or no):
Comments (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.):
Cesspools are not present
PRIVYA60 (locate on site plan)
Materials of construction:
Dimensions: A/P
Depth of solids: AIX
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
Privy is not present .
9
Pagc 10 of I I
OFFICLAL, INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
80 Wild Goose Way
Property Address:
entervi e , ass .
Owocr: Beth Blaze
Date of inspccjjoo:4/30/02
SKETCH OF SEWACE DISPOSAL SYSTEM
PToride a sketch of the sewage disposal system including ties to at )cast two permanent reference landmarks or
oencrvnuks. Locatc all wells within too (eet. Locate where public water supply enters the building.
�v (yc)o!E)C.-
Cyr 'l ll�
)o
f o
Page I 1 of 1 1
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:80 Wild Goose Way
Centerville,Mass ,
Owner: Beth
Date of Inspection: 4 30/5-2
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 3_0I feet
Pl7c)btained
. dicate (check)all methods used to determine the high ground water elevation:
from system design RLIans on record-If checked,date of design plan reviewed: 7— T/
serve site abuttin prope bservation hole wi hin 150 feet f SAS /
ecked with local Boar o Health-explain: �j`��
checked with local excavators, installers ,att h documentation)
_Accessed USGS database-explain:
You must describe how you established the high round water elevation:
Used ; Gahrety & Miller Model . 12/16�94 Grond water elevations above
sea level .
Used ; Observation well data . June 1992 USGS
Usedl Technical Lille,t4n. 92-000-1 Plate #2 Annual ranges of water
uroullu elevations .
Leaching
Pit U 'eet
I
I
Groundwater7l"Feet Below Bottom of Pit i gh 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.
11
i
•,+nrw.—n-r•►*—.-rT- rR.—mr•nmrrs�ert rsn.mn rtr+:err:m-�*rtm rm�•+u.+a'�rrsr.nT,
TOWN OP Barnstable WARD OF IIEALTII
SUBSURFACE SFHAGF DISPOSAL SYSTEM INSPECTION FORM - PART D.- CERTIFICATION I
•••Tf•1•T••.••.•t—�.1,7��TT.TI}'„I.,f,1T,T'1T:0'!'tT1TT11'r!'1 "tRR•\71Nr 9'InRRMA•R�f�1�T7 JET II !.+•tI`TT•T•�• �..A
-TYPE OR PRINT CI.EARLY•-
PROPERTY INSPECTED
STREET ADDRESS 80 Wild Goose Way Centerville , Mass .
ASSESSORS MAP , BLOCK AND PARCEL
OWNER' s NAME Beth Blaze'
PART D - CERTIFICATION
NAME OF INSPECTOR Joseph P . Macomber Jr .
COMPANY NAMEJ . P .Macomber & Son Incew ,
COMPANY ADDRESS Box 66 Centerville , Mass . 02632
Street Town or City St&t• E1P
COMPANY TELEPHONE (508 ) 775 _ 3338 FAX ( 508 ) 790 - 1578
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 regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems ,
Checly one
System PASSED
The inspection trhich I have conducted has not found any information
which indicates that the system fails to adequately protect public
heR1Lh or Lhe 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 wificil I have con Ucted has found that the system fails to
Protect the ptiblic health and the environment in accordance with Title
5 , 3.10 CMR 15 . 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form ,
Inspector Signature Date
- - - —
ecopy of this rt.ification must be provided to the OWNER, the BUYER
Dn
Where applicable ) and the 130ARD OF HSAL1'I(,
* If the inspection FAILED, the owner or"" "Porator ehalI upgrade
he ayate
Within one year of the date of the inspection , unless allowed ortrequiredm
otherwise as provided in 3.10 ChJR 16 , 305 ,
partd . doc
TOWN OF BARNSTABLE
`LOCATION O� f�.G�' �� ��Lli SEWAGE #
II.LAGE ASSESSOR'S MAP & LOT_
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type)���7 (size) c
NO. OF BEDROOMS 4
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 3Wfee. f c acility) Feet
Furnished b
O 41 ce
ee Yl �1
Cam,
i
TOWN OF BARNSTABLE
LOCATION O 02da 4CO&C LU/4`Z= SEWAGE#
Va LAGE C9�7 i/19�/� V r Ilk ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMTTDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
' Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
{i^
9 _
f
Ism Cap Ib 691(C T wc
I�
N ASSESSORS MAP N0: �
o.. ......... .....J `7 FAX
T COMMONWEALAC�—MSSAC� . ..,���....
M
i
BOARD OF HEALTH
w ........._....0F.�a�r��dd....- �'
Appliration for 39iipuuttl Worke Tonutnution Vern it
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
stem at•
� ✓/! . : .
. .........•.............-....:...:... ? ------------•----••---••..................
Locat
ion ton-Actress
Jn. . �......['�{r p� • nor o. lst
u N
�3T�J e Ow er Add n3
M dress
er nst I •,
a"V f//..7- �!-
q.
Type o Building � Size LotZT - _, .S feet
....
.. Dwelling—No. of Bedrooms.•.......q.............................Expansion Attic ( ) Garbage Grinder ( )
aa e of Building ........_ No. of
Other—T yp g _-•-_•---------•_-• persons---------------------------- Showers ( ) — Cafeteria ( )
dOther fixtures ....-......................................•------------------•---•----------•---------------•--------•-• ...........................................
WW Design Flow..........._�1 .....................gallons per person per day. Total daily flow......� ��.•....................�allonsu
WSeptic Tank—Liquid ca.pacity4.549gallons Length/401...... Width_:)� . Diameter................ Depth. ....-.6_.
x Disposal Trench—No. --_-..---------•--- Width.................... Total Length.................... Total leaching area....................sq. ft.
3 Seepage Pit No.._...�.......... Diameter.... ... Depth below inlet........ .... Total leaching area... _?V_....sq. ft.
Z Other Distribution box (vim' Dosing n )
Percolation Test Results Performed by...(,..�.dLl!!/g. ..� �w�1..�-a..e ate....3.-1/�....�o.......
.-.e
a Test Pit No. 1.L_Z.....minutes per inch Depth o Test Pit-./.<f..�f_.�... Depth o ground water.:�lt.!2.�...�.K C.
G4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
..........................................................--••............................••-----------...-•••--.......................••---•.......•-•-.....
O Description of Soil....Qd��..-..'. •��..lQl--- ��_•b_�L.12 ----�11�1,i'o-tl f... a.��."1.�} /i
U ....., .----sa .
U Nature of Repairs or Alterations—Answer when applicable......................................................................:........................
'. •---•-•--•-----•.................•........---........-----............--•--...........--------•--•----•--••--•-------------•--------------------------•----------•-----•------............•••••........
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLZ 5 of the State Sanitary Code — The undersigned further agrees not to place the system i
operation until a Certificate of Compliance has been issued by the board of h
Signed.. . .. ._..�...�L��.•..f...
to
Application Approved By... . ....... ...........•-•-- -• ........ .......
ate
Application Disapproved for the following reasons:................... --....-•--•------...------••----•---------...--------------......._-•--••••..........._...
-----•-------•------------------------------------------------------------•--....---•--........._.:........ ...........
Date
Permit No.... ... ............... Issued.........._...`•
------ - ----- -
THE COMMONWEALTH OF MASSACHUSETTS
OARD F H/�j^A TH
vV .OF......... ......... . . lJ....Y .. ......
Trrtif irate of (aomplinna
T S T,� ^CERT FY, That the It*vidual e a e Disp sal System constructed ( ) or Repaired ( )
by... ..1 .. . .. ............................................................_..........
at....... . ......../a........W.l el ... �x -`��V.�._� � .......................•-.
has been installed in accordance with the provisions of TIT' . `5of The State Sanitary Code s descr' in the
If
application for Disposal Works Construction Permit No. .......:.... ... dated:... -.. ....__._. .. .. ::�.........
THE ISSUANCE OF THIS CERTIFICATE SHALL N�,T BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. �- 700
DATE.................................:............................................... Inspector....................................................................................
No 1s............. ... Fps.............../•C/ y
THE COMMONWEALTH OF MASSACHUSETTS� .t
y BOARD OF HEALTH
.........:....oF.. G'rS' �J /
,��r�lirtt�iott�f ox��i,��o�ttlr ork�;C��n��r�trtuan'�rrtni#
• r
Application is hereby made for a Permit to Construct (P ) orR pair ( ) an Individual Sewage Disposal
1pys
o16,76re k�
` -- L
Location-AdIress .....................................`�� ---1---'-�--
r, trNo ( I. .....7..I.�..:. .1T' 7. ............................. .. o. ss'aAddre
Owner ?..�.S.{.-/:-�;•
r•i-
'"!
YF _.A +`a. �C. ! �f?Sa!�rla ---- ft f_�nr,�X _"7 f✓1. ;�r44i' A/+ % .
6^ Installer r Address
Type of Building // Size Lot.�.--�a-�-�--rZ� Z Sq..feet
Dwelling—No. of Bedrooms.__..._.._`...................... Attic ( ) Garbage Grinder ( )
Gaa4 Other—Type of Building .-__-------_-------------- No. of persons.. .................. Showers ( ) — Cafeteria` ( )
dOther fixtures .----------•----•------••-•-•--•----•-•................-•--••-••-•-------------•-------
W Design Flow..............//0...................... per person per day.' Total daily flow._.....4�l ........................gallons.
WSeptic Tank—Liquid capacity_45 allons Length./n/�..._..�Width:.5__q! Diameter...............
x„/ —Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area........ 'j.._....sq. ft.
3 Seepage Pit No...... .......... Diameter..... ... Depth below inlet.......Via./... Total leaching area.----'`—'_74, ...sq. ft.
Z Other Distribution box Dosing tank ( )
a Percolation 'Test Res �, Performed by.... .r. Y!/!?�.. °u!h. e.. Date...... .`���.-_. ......
1
Test Pit No. L...............Minutes per inch Depth of Test Pit.. . ......... Depth to ground water.,Ot/ e...l-I C.
44 Test Pit No. 2-------_-...minutes per inch Depth of Test Pit.................... Depth to ground water........................
e
--...--•-------------------•-------•----•...--......'....--••-......-•-..................
0 Descri tion of Soil....-OG!r-.... .. .� /...A cr y{-,l-- . r 5/!
W ------------- --------------------------------------------------------------------------------------
--------------------------------------------------------- ........
..................
..
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
' the provisions of:ITILE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health��
�.
Signed ` 2 cl............:. ._.... /i' a rr ? :: /r .c +
9 Date
Application Approved By.._l_... .. 1�,� _. / r
Date
Application Disapproved for the following reasons.,.................................... `{ � �
---- --•---............. •------- --••---- ------.................
.......................................-......--•---------...--...--------••••---•--•-••------•-..................._..-------------•---... _ ..... ............
---- --6a
Permit No.. q" ",_ . ................. Issued...... �`3A? _
Date
....__..__-..r_o-_ae______- M _ _T ___-______-.----,--____. _..
THE COMMONWEALTH OF MASSACHUSETTS
BOARD. OF HEALT/H�f� J.�
..........................................OF...... .AA R„1..,Y�1• _)..(................
Tntif rate of Tomplittnrr
THI-SrIS TO CERTIFY That the Individual Sewage Dispos 1 System constructed ( or Repaired ( )
y........................
------ •...............•----.......------------- .....
r lnst311er
at.....-••_,....:_._..----1�'?�------...R)L-_--. 6o� (.�/�? � • ���'l//�--• �---•--•••--...........................
has been installed in accordance with the provisions of TITLE' 5 of The State Sanitary Code �s described to the
application for Disposal Works Construction Permit No ��"....-.-.- ""� r,. dated-
.. ? . ...........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. ,l'.;�^ :70
DATE................................................................................ Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
` f j�BOARD OF HEALTH jc�l
�- ................///.• /I1...OF..... - �i!,•- / .................. /� r--,
N....... •............. FEE..... ...........
Disposal Yorks Tono#rur#ion permit
Permission is, hereby granted. n.: :: .t,1 ... '�C................... °_* Z C:...............................
to Construct ( ) or Repair, ( ) an Individual Sewageebisposal System
at No....L..T...... ��= W/� t�C�c>`��,� (,ll><!\/ , `e
---------------•----......:••_�-••- ....••.... .........--•---•-- --•----•------•--• --- ------ •-
f street � - f
as shown on the application for Disposal Works Constru is ow Permitl Norr-:__..--- , -(Dated.—. :;— f
..................••-------•---......--- ----_.....
• � \ ` Board of Flealth
/l% // r
DATE...................-=--.-•-••-----•--------------------------------------------� V
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