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HomeMy WebLinkAbout0090 ARBOR WAY - Health � �+ 90 Arbor Vila _` 165 j J 4 . ,I I o I I i ` l e q -- Commonwealth of Massachusetts Title 5 Official Inspection Form 19 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments go -6 O✓ C,✓G! Roperty Address /31 QNW 6-1 Infon natbn is Owner's Name / ,�,a �d 6©/ �o required for every A`� �� JJ pegs. (2yfTown State Zip Code Date of spectbn Inspection results must be submitted on this form. Inspection forms may not be altered in any way. please see completeness checklist at the end of the form. Inportant:When A. General Information filing out forms on the computer, use only thetab 1. Inspector. key to move your cursor-do not Q use the return key Name of InsInspectorspect ///Q 7 —ZF C .: Company Name Company Address41 G 0.1 Ill • �1 _ �y � �_� ��P�y e— pty/rown scale('D•� U�o� � e Telephone Nift6ar License Number B. Certification i� 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 , d system inspector pursuant to Section 15.340 of sewage disposal systems.i am a DEP approve Title 5�1016.000). The system: Passes ❑ Conditionally Passes ❑ Fails ❑ Nee Further Evaluation by the Local Approving Authority to hspect s Signature Date The system inspector shall submit 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 DER The original should be sent to the system owner, and copies sent to the buyer, if applicable, and the approving authority. **"This report only ciescribes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will pertortn In the future under- f 3 the same,or different conditions of use. TItl080(flpallropec1onFomcSubsWmeSOV"s61VO SYMM fteIof17 . .181ro•3H3 .� ,. TY^� e x, r' _ } 5 r r ❑ .. � : a .. � Y Y r Commonwealth of Massachusetts Title 5 Official Inspection Form $ms Subsurface Sewage Dispbsat System Folug rth Not for Voluntary Asses 90 . 14>,60r wG Roperty Address /Om V'���1 lnf her Q,,r rrers Name Al Od �0/ brfornration IS required for every CtylTawn State Zip Code Date of I rape tion page. B. Certification (cunt.) Inspection Summary: Check A,B,C,D or E/alwayscomplete all of Section D A) System Passes: ;�,�Ve not found any information which indicates that any of the failure criteria described In 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are Indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass'section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for lyes 'no'or"not determined"(Y,N, ND) for the following statements. If'not determined,'please ex$ain. I.The septic tank is metal and over 20 years old"or the septic tank(whether metal or not)is structurally unsound, exhibits su ial Infiltration or exflftration or tank failure is Imminent. System will pass inspection if the existinj tank is replaced with a complying septic tank as approved by the Board of Health. A metal septic tank v4 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. ❑ Y p N .❑ ND(Explain below): Tlbe sOeldA Impxbon P orm Subsvl=Sewage Disposal Symm•Page tot 17 dns•W3 Commonwealth of Massachusetts Tifile 5 Official Inspection Form YJ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 90 ✓b0Y (•✓� Property Address ON nor ON reps� e ��6�l "an inforrnatbn b Gr yr✓l/Sm ulredforevery e. ( y~n state Zip kme Ga B. Certification (corn:) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) system Conditionally Passes(coat.):. ❑ Observation of sewage backup or break out or high static water neven distribution box System will to broken or obstructed pipe(s)or due to a broken, s pass Inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe($). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y C] N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N El ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR : 16.303(1)(b)that the system Is not functioning in a mariner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 7nw 5 0rna81 wepmun F am 9uesLeaca Sewage 018p0g1 81o^'Peas 30{17 Ons•3M 3 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -//Not for Voluntary Assessments 90 14✓lion (.✓0 Roperty Addressall Om Her ON Hers Name �j9 0d 6 01 inform atbn Is rl q✓rvI requiredforevery �y/Town State Zip Code Date of In peotbn page. B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier,If any) determines that the system Is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 fleet 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 fecal coliform bacteria indicates absent 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:' D) System Failure Criteria Applicable to All Systems: You MUM Indicate "Yes" or"No"to each of the following for gjl_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' flow T15o60Md9mepeoaonFam sub,08COSewape01epo g SIB^'Pap 40117 tsina•ans Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 90 A140y, Property Address owner ow Hers Name /hfto / d d 6 O/ nnatbn is ���S requiredforevery CRy/rawn State Zip Code Date of H pectlon B. Cerdf e ' n (conL) Yes No ❑ y� 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. ❑ lid Any portion of a cesspool or privy Is less than 100 feet but greater than50 feed from a private water supply well with no acceptable water quality analys [This system passes If the well water analysis, performed at a DEP certified laboratory, for fecal coliforrn bacteria indicates absent 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 and chain of custody must be attached to this form.] The system is a cesspool serving a facility with a design flow of 2000gpd- ❑ 10,000gpd. ❑ The system� I have determined that one or more of the above failure criteria exist as described in 310 CM 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 1s,000 gpd. For large systems, you must indicate either°yes"or'no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 Beet 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. Ti1960MCWusp9edMF0MSubsufeoeSevM61)(SPOWSpmm•Page Sa 17 b]Me•3M 3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments go AY,40" I'la Property Address Ow ner lnformftn Isomg Name ���f �/� Doi re quired y/Town State Zip Code Date of Ins ion C. Checklist Check if the following have been done. You must indicate'yes'or"no°as to each of the following: Yes ❑ umping information was provided by the owner, occupant, or Board of Health ❑ Were any of the system components pumped out in the previous two weeks? ❑ s 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: ❑ Existing information. For example, a plan at the Board of Health. ❑ Determined in the field (f any of the failure criteria related to Part C is at Issue approximation of distance is unacceptable)(310 CMR 15.302(5)) D. System Information Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): �51-5 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): f�1s-SN 8 T10e 50ftd tmpw kn form Subueaoe ftvage Dloald SYMm-Pepe OOI t 7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Forth -Not for Voluntary Assessments 90 �v�v✓ („/a Prop"Address QNroff infonlmtion is o�vtler's Name Qo?�O V & A✓l�1/S reuw for every C�ylTown State Zip Code Date * n D. System Information Description: / l000 c l'^ `✓ �, a Number of current residents: �/ Does residence have a garbage grinder? ❑ Yes t� No Is laundry on a separate sewage system?(Include laundry system Inspection Yes Ly No Information in this report.) Laundry system inspected? ❑ Yes 0--'No Season al use? ❑ Yes LY No Water meter readings, if available past 2 years usage(gpd)): Detail: Sump pump? ❑ Yes No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM R 15.203): gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): ' Grease trap present? No ❑ Yes [I No Industrial waste holding tank present? ❑ Yes ❑ Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, If available: Tile 50Mdd IrepeatlWF a m suEautaoa Sewage owpoW Symm•Page 70117 CinS•3t1S ' Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Forth -Not for Voluntary AseassmQrtts l�'opetty Address � Omnor ONnerg Name 00) G o/ 6 infomlatbn is a 0 tj r 1 required for every — State Zipp Code Date of In tion �e Rown D. System Information (cont.) Last date of occupancy/use: We Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes Ifyes, volume pumped: gallons Now was quantity pumped determined? Reason for pumping: Type of S m: 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/Altemative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the VA system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Yi1W Sorkial impw6w Form Subsurface Seww DiSPM9 SOMM•P809 Sol 17 tons•3M3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 90 ,�rb�✓ �.✓a Property Address G� vye r owner pry noes Nam �� 0 information is requiredforevery page. Qyfrown Zip Code Gate of i spectfon _...._- D. System Information (cost.) Approximate age of all components, date installed of known)and source of information: i ❑ Were sewage odors detected when arriving at the site? Yes L7 No Building Sewer(locate on site plan): �O tl Depth below grade: feet Material of constructi;�40 El cast iron PVC ❑ other(explain): / O Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank,is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No S > � Dimensions: c7l Sludge depth: ttlre 3H3 Tlre50f cisi impmoonForm Sub%osae Se%WeDisposd SyMm•fie 9of 17 • • s Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal system Form -Not for Voluntary Assessments 90 Property Address ow re Cw ner's Nam �� D v1 G o/ infonratim Is G-1✓�vJ/S required for every State Zip� Date of lnspW n pap. CtyfTown D. System Information (cont.) Septic Tank(coat.) Distance from top of sludge to bottom of outlet tee or baffle Qfs— 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 . /1/C- 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.): I / �✓� r h HJ � lees I V7 00 �0✓+�/7'/OVI Grease Trap aocate on site plan): Depth below grade:• feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness •r 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: we TMe50Mdd ImpeOMF arm subS0WeSevRgeDlapwd SyMm•Page 10d 17 t9m•3M3 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal ay4arn Form -Not for Voluntary Assessments 90 Property Address ON{ i00111 aon is a"'Hers Name I �� f�v2 6 0/ 6/('A required for every CltyfTawn state Zip Code Date of hrspec n pa". D. System Information (coat.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural Integrity, liquid levels as related to outlet invert, e%idence of leakage, etc.): a Tight or Holding Tank(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. p1lons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in worldng older: ❑ Yes ❑ No Date of last pumping: DMe Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No SM-3M3 Tile60Mdd trspacbmFam Subn0=e SftMPDiW*W System-Page 11 d 17 t r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for-Voluntary Assessments Groh Addrfas /' ,' We CWW Cwrlers ram ,� aa 601 !�� blformation is a-4 4/f �uirwforevery C�yRown State Zip Code Deteof pw n D. System Information (coat.) Distribution Box of present must be opened)(locate on site plan): ,fA--Ile 1.17 Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D /eve/ /lio Pump Chamber(locate on site plan): Pumps in working order. ❑ Yes ❑ No• Alarms in working orderYes No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): •tf pumps or alarms are not in mrKing order, system is a conditional pass. Soil Absorption Syiftm (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: Ti5e50ficid Impmom Form Subswme SewW9DispoSd Syom-Page 12 d 17 We•W3 r �. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage.Disposal System Form-Not for Voluntary Assessments 90 Averty Address ON ner ow►nerg Nam information Is 47 a 04/s required for every -----"- P�, Ciy/Town State Tip Date of peCtlon s D. System Information (cunt~) type: leaching pits © number: ❑ leaching chambers number. ❑ leaching galleries number ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number ❑ innovative/altematl%e system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Ov' r 0 a / S�H L�j vLe.__ cesspools(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 t Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t9m,3n3 TNIe6OPftW 1mpw0onFam Subsurface Sewpeoispaed System-Papa 13 d V Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form•Not for Voluntary Assessments 90 ✓✓o� �g Property Address Owner ow hfor raon Is rws Name a rJ /7 Da 6 0/ G 6 required for every Cityrrown State Zip— Code Date of Impectlon page. D. System Information (cunt.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy Qocate 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.): tom.3h3 T11e50MddhispeeftParm SubeufewSewagem%wed System-Pigs 14d17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface sewage Disposal System Form -Not for Voluntary Assessments 90 14✓60✓ , Property Address oN►nQ Ow Hers Nine , D'l-C o irlforlr,®tion is Q��/.S requiredforevoy state Zip Code Date of Inspection page. Cly/rown D. System Information (cont.) Sketch Of Sewage Disposal System: Pro%ide a view of the sewage disposal system, including ties to at I t two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate whe public water supply enters the building. Check one of the boxes below. hand-sketch In the area below ❑ drawing attached separately 141 i oz ' 3 ' 3— Co VIV, 3�`lov✓ t5ra,3h3 TiVe5ONdal InapecilonFam:Subsrface S9*%sDfspad Splem•Peps I$d 17 I • Commonwealth of Massachusetts Title 5 Official Inspection Form BubsurFace 8awage Disposal System Form -Not for Voluntary Assessments Property Address ON nor ON Infor rew b G✓)✓I/ required for every State zip cow — Date a peCtion p"e, Ctyfr'own D. System Information (cont.) Site Exam ❑ Check Slope ❑ Surface water D Check cellar ❑ Shallow wells Estimated depth to high ground water. feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record i Kchecked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) Checked with I oard of Health-explain: �G✓iS ❑ Checked with local excavators, Installers -(attach documentation) ❑ Accessed USGS database-explain: , you esta ished the high ground water elevation: You must dosed how y ) /� � �v N a H d Gi Lt 40 0 ki ')C.,, /0 C. ��S S ��✓ ����s A � S !S 7eo I/Iee7 h15 , �o ✓i '%j Before filing this inspection Report please see Report Completeness Checidist on next page. T11e B 0HWd Unpectm Farm SuOavreae Sewage DWpOW Sle*m•Page 16 d 17 Sm•3H 3 •� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9O Pop"Andras ' irdarrymlion Is ONwmre / G�l�r s o regrdredforem /Town / State Zp code Date ofpeoWn f E. Report Completeness Checklist Q"tr;pecdon Summary: A, B, C, D, or E checked t�' ;i 60'aw Summary D(System Failure Criteria Applicable to All Systems)completed CYSy yhtffnation—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate tale OM•*13 TIOe3OMM Ibpeaft Form bVOa =9$WMPOWP-f SYMn•Wp 1741,17 r - Commonwealth of Massachusetts Title 5 official Inspection For Not for Voluntary Sessments � Subsurface Sewage Disposal System Form - _ 90 A✓ L9 Property Address / �0,/ _--- -- �= (� aOwner Owner's Name Qa(p0/ 3:1�� // information is 6i Nh,f State Zip Code Date of Inspection required for every CityTown page. / ubmitted on this form. Inspection forms may not be altered in any inspection reseultsmust eness check)checklist at the end of the form way, Please s Important:When A. General Information filling out forms �J on the computer. use only the tab 1. Inspector: I/ o �S�key to move your V a✓�( cursor-do not use the return Name of Inspector _ /l key. Company Name h Company Address Address � ��Gs State � ZipO Code CitylTown License Number Telephone Nmber B. Certification ress and hat the i I certify that I have personally inspected the sewage disposal system at urate and complete as of the time olf theanspect inspection. The inspection information reported below is true, g experience in the proper function and maintenance of on site was performed based on my training and oved system inspector pursuant to Section 15.340 of sewage disposal systems. T e yDem approved Title 5(310 CMR 15.000). � asses ❑ Conditionally Passes ❑ Fails ❑. Needs Further Evaluation by the Local Approving Authority Date Inspect s Signature (Board The system inspector shall submit a copy of,this inspection report to the Approving ty Authority he system is of Health or DEP)within 30 days of completing the inspector and the ction. If tsystem owned hall submit the has a design flow of 10,000 gp 9 ffice of the DEP. The original should be sent to the system owner report to the appropriate regional o . and copies sent to the buyer, if app licable, and the approving authority. ****This report only describes conditions at the address e of howthe inspection ystem will perform n the future under at that time. This inspection does not /� the same or different conditions of use. C/ L ter, I Tdie 5 OfficW Inmp dion Form:Subsurface Disposal Sy slam• 9a vsim•„l,o Commonwealth of Massachusetts 5 official Inspection Form Title p � Assessments Subsurface Sewage Disposal System Form -- Not for Voluntary Property Address /� ---- owner Owner's Name 7 io - information is a H �s State Zip Code Date f Ins ion required for every City/Town page. B. Certification (cont.) Inspection Summary: Check A,B,C,D or E I always complete all of Section D A) System pa sses I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 13) System Conditionally Passes: One or more system components as described in n of the replacement or repair, as ppro ed by' PaW section need to be ❑ O ion P . replaced or repaired. The system, upon complet the Board of Health, will pass. etermined" (Y, N, ND)for the following statements. If"not Check the box for"yes", "no" or"not d determined," please explain. e septic tank is metal and over 20 years old* or the septic tankfailure W s imminent hether (System or not) (will pass The p unsound, exhibits substantial Infiltration or exfiltration or tank tic tank as approved by the Board of inspection if the existing tank is replaced with a complying P 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. ❑ Y ❑ N ❑ ND (Explain below): . Idle 5 Ofrioial Inspedan Form:Subsurface Sewege D�Po�t System page 2 of 17 t5ins•IWo I .� Commonwealth of Massachusetts Inspection Form Title 5 Official Inspe f Subsurface Sewage Disposal System Form - Not for voluntary Assessments p 1.4 �✓� Property Address Owner owners Name —' /��'/� Qa�'p COIL � / information is A o h if Oate of nspection State Zip Code required for every Cityfrown page. B. Certification (cont.) B) System Conditionally Passes (cont.): of sewage backup or break out or high static water level in the distribution box uneven distribution box System Will❑ Observation or due to a broken, settled o to broken or obstructed pipe(s) pass inspection if(with approval of Board of Health): laced ❑ Y ❑ N ❑ ND (Explain below):. ❑ broken pipe(s) are rep . ❑ Y ❑ N [-IND (Explain below): ❑ obstruction is removed distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): m more than 4 times a year due to broken or obstructed pipe(s). The i The system required pumping system will pass inspection if (with approval of the Board of Health): ❑ Y ❑ N ❑ ND (Explain below) ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further e alluasaon fetyyohthe environment. onment of h in order to determine if the system is failing to protect p in accordance with 310 CMR 1. system well pass unless Board mines functioning inof Health ra manner which will p o ect public health, %303(1)(b)that the system Is no safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh Tdie 5 ofrtcial Inspedion Form:Subsurface Sewage Disposal System•page 3 of 17 t5ins•11110 Commonwealth of Massachusetts TitlT 5 official Inspection Form e sal System Form - Not for Voluntary Assessments ug I Subsurface Sewage Dispo Y / 9p �vr l-✓�t Property Address Owner Owner's Name 0.2j D information is Zip Code Date of Inspection for every State Page. CitylTown B. Certification (cont.) 2. System-will fail unless the Board of Health (and Public Water Supplier,if any) Ines that the system is functioning in a manner that protects the public health, deterrn safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within i 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. + ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. El The system has a septic tank and SAS and the SAS is less than 100 feet but 50 fee or. more from a private water supply well'*. Method used to determine distance: — the well water analysis, performed at a DEP certified lab nitrogen foes fecal *• This system passes If presence of ammonia nitrogen and nitrateo9 coliform bacteria indicates absent and the p of the analysis must to or less than 5 ppm, provided that no other failure criteria are triggered. A copy i be attached to this form. 3. Other: i D) System Failure'Criteria Applicable to All Systems: You must Indicate "Yes" or"No"to each of the following for all inspections: Yes .or. Backup of sewage into facility or system component due to overloaded ❑ clogged SAS or cesspool r ace of the ground or surface waters Discharge or ponding of effluent to the surf ❑ 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 . r� Liquid depth in cesspool is less than 6" below invert or available volume is less ❑ U than Yz day flow Tale s official inspection Form:Subsurface$evall Disposal�'AA11.paw 101.17 Isms•1Vio commonwealth of Massachusetts Title 5 official Inspection FormSments bsurtace Sewage Disposal System Form -Not for voluntary S /] ` / r O ��CJO✓ W Y Property Address Clj�� / Owner Owners Name . & 7 / information is Gi✓)i'1 Zip Code Date Inspection State required for every city,Town page B. Certification (cont.) Yes No 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 9r ace water Supply ilon r/ Any portion of cesspool or privy is within 100 feet of a,surf ❑ L`S 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. El 211-� D [� 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 . asses if the well water analysis, performed at a DEP certified system p presence laboratory,for fecal coliform bacteria indicates absent and the p of ammonia nitrogen and nitrate nitrogen is equal A copy the analysis to or less than 6 PPM, provided that no other failure criteria are trigge and chain of custody must be attached to this form.] he system is a cesspool serving a facility with a design flow of 2000gpd- ❑ 10,0oogpd. more of the above failure The system fails. I have determined that one or ❑ criteria exist as described in 310 C Board of Health therefore determine whatem fwilsbeThe system owner should contact the f3 necessary to correct the failure. Large Systems: To be considered a large system the system must serve a facility with a E design flow of 10,000 gp d to 15,000 gpd• For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface dunking water supply ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ the system is located in a niZoge II of a'public c bve r watea t ersupplerim y` head Protections w ❑ El Area — IWPA) or a mapped -ant threat. If yo u have answered"yes" to any question in Section E the system is failed. The considered r or operator(o any large or answered "yes" in Section D above the large system a the system considered a significant threat 16 304. The system n E or(ailed under Secbon D owner should contact the appropriate system in accordance with 310 CM regional office of the Department. Tick+5 officiai inspection Form:Subsurface Sewage Drspasei hem'Page 5 of 17 tsins•11/10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Forth • Not for voluntary Assessments r _ Property Address Owner Owner's Name L'' D� 6 0l Oz� information is a N H�l State Zip Code Date o Inspedion required for every CitylTown page C. Checklist 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? O� Has the system received normal flows in the previous two week period?0 Have large volumes of water been introduced to the system recently or as part of this inspection? obtained and examined? (If they were not —/ Were as built plans of the system El 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? I [] 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: 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(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): -- DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): J TAk+5 Official Inspection Forth:Subsurface Sewepe Disposel System•Page 6 of 17 ISirts•1 Nto Commonwealth of Massachusetts Form T• Official InspeCt�®n itle 5 stem Form - Not for voluntary Assessments Subsurface Sewage Disposal Sy o 9 or Property Address Cl� l Owner Owner's Name / " information is G ✓►y r 1 State Zip Code Date o nspecti required for every Cdy/Town page. D. System Information �/o s� Descriptiot�� D g �=, !� Number of current residents: ❑ Yes ff No Does residence have a garbage grinder? Is laundry on a separate sewage system? (if yes separate inspection required] ❑ Yes No ❑ Yes No. Laundry system inspected? ❑ Yes No Seasonal use? _----- .— Water meter readings, if available (last 2 years usage (gpd)) Detail: ❑ Yes Sump Pump? G k✓/�"► ' Date Last date of occupancy CommercialAndustrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gaiions per day(gPdl Basis of design flow (seats/persons/sq.ft., etc.): Yes ❑ No Grease trap present? ❑ Yes ❑ No industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? — I Water meter readings, if available: Trttr.s Olficiad Inspection Forth:supsuAace Sewage Orsporel s'lem page 7 of 17 (sins•11110 Commonwealth of Massachusetts official Inspection Form Title 5 stem Form -Not for Voluntary Assessments o Subsurface Sewage Disposal Sy . Property Address / ✓ _/ owner Owners Name information is yl✓J r State Zip Code Date o Inspect on required for every City/Town page. D. System Information (cont.) Last date of occupancy /use: Date Other(describe below): General Information ods�.-���ro� pumping Records: Source of information: /►' Yes No Was system pumped as part of the inspection? [] If yes, volume pumped: gauons How was quantity pumped determined? — Reason for pumping: Type of Sy em: 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) of the current operation and ElInnovative/Altemative technology. Attach a copy of latest mainte s �em m owner) and by be btained system roperator om eunder contract a copy inspection of the I/Ays Tight tank. Attach a copy of the DEP approval. Cl Other (describe): rnk s orrcW rasped'ron form:Subsurreoe Sewage Disposal SY51— page S or 1,7 t5ins•11110 Commonwealth of Massachusetts Ord � action F Title 5 Official 'Inspection p Not for Voluntary Assessments Subsurface Sewage Disposal System Form - r 90 Property Address �/ /1✓� owner owners Name - �a 6 G h t Zip Code Date�oof I paiO information is State required for every City(Town 0 page. (cont.) D. System lnformatl'on ( and source of information: onen of all com ts, date installed 'rf known) Approximate age /� 0 hl _ _------ ---- n Yes B No Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): _ feet Depth below grade: Material of construction: 40 PVC ❑ other(explain): /D ❑ cast iron I Distance from private water supply well or suction line: feet venting, evidence of leakage, etc.): Comments (on condition of joints, Septic Tank (locate on site plan): feet Depth below grade: Material of construction: other(explain) ❑ concrete [] metal fiberglass polyethylene ❑ years If tank is metal, list age: ❑ No, Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes g SX g Dimensions: �— sludge depth: ,srslem•aage9of,17 rele 5 OtfdW insvecrion Form:Subsurface Savage Dispo� t5ins•11/10 Commonwealth of Massachusetts Form fficial inspection Title 5 ® Assessments Subsurface Sewage Disposal System Form Not for Voluntary property Address Owner Owners Name 4N�/I _ Date of I pedio information is / State Zip Code required for every CitylTown page. D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle `7 — y Scum thickness Distance from top Of scum to top of outlet tee or baffle a / Distance from bottom of scum to bottom of outlet tee or baffle Zo/1Q How were dimensions determined? Comments on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,. Comm ( P outlet invert, evidence of leakage, etc.): liquid levels as related to LA&^1 f h �s �e 0n / Gil vl �►// �i^ Cpv1 C 1?W 117, i Grease Trap (locate on site plan): Depth below grade feet Material of construction: (explain [] ❑ []fiberglass ❑ polyethylene ❑ other ) concrete metal 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 Date of last pumping: ��,,.page loot 17 role 5 otfxiW Inspection Fonn:Subsuftoe Sewage Dispose SY t5ins•11110 i commonwealth of Massachusetts ection Form Title 5 Official Insp Assessments for Voluntary T stem Form - Not Subsurface Sewage Disposal Sy a �go ---------- Property Address Owner owners c2,1 6 0/ information is G t/f vI f T State Zip Code Date o Inspe ion required for every Cityrrown Page Cont. D. System Information on pumping recommendations, inlet and outlet e,tee or baffle condition, structural integrity, comments ( P liquid levels as related to outlet invert, evidence of leakage, — oldin Tank (tank must be pumped at time of inspection) (locate on site plan): Tight or H 9 Depth below grade: Material of construction: ❑fiberglass ❑ polyethylene ❑ other(explain): ❑ concrete ❑ metal Dimensions: gallons Capacity: gallons per day Design Flow: ❑ Yes ❑ No Alarm present: ❑ Yes ❑ No Alarm in working order. Alarm level: Date of last pumping: Date Comments (condition of alarm and float switches, etc.): -------------- Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No rdie 5 official Inspedion Form:Subwrfeoe sewage 0iwosel S08m•Pa""of'17 (sins-Ii/10 Commonwealth of Massachusetts Form Titl• 5 Official Inspect'on e Subsurface Sewage Disposal Not for Voluntary Assessments System Form - 9C?r ���o�� property Address // ./'�'✓ / owner owner's Name �J information is Gi Pi✓I V State Zip Code Date Ins on required for every Cityrrown Page. D. System Information (cont. Distribution Box (if present must be opened) (locate on site plan):Depth of liquid level above outlet invert evidence of solids carryover, any Comments (note if box is level and distribution to outlets equal, any c evidence of leakage into or out of box, etc.): v� Sod f pump Chamber (locate on site plan): ❑ Yes ❑ No pumps in working order. ❑ Yes ❑ No Alarms in working order: pump chamber, condition of pumps and appurtenances, etc.): Comments note condition of Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: i Tdle 5 Orrcial Inspedion Form:Subs ftm Sewage DPI System Page 12 d 17 t5ins•1 U10 Commonwealth of Massachusetts Inspection Form Title 5 Official I nspec of for Voluntary Assessments Subsurface Sewage Disposal System Form N/ r _ 90 Address Property CC'' 0�60 / Owner Owner's Name Date Inspect n information is Lam14 + G,✓t✓� I State Zip Code required for every City(town � page. D. System Information (cont. Type: / number: leaching pits ❑ number: leaching chambers number: ❑ leaching galleries number, length: ❑ leaching trenches — number, dimensions: ❑ leaching fields overflow cesspool number: i ❑ innovative/alternative system Type/name of technology g soil, condition of Comments (note condition of soil, signs of hydraulic failure, level of pondin damp vegetation, etc.)! AI 7< �o S Cesspools (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 ❑ Yes ❑ No Indication of groundwater inflow l stem,Page13of17 TAIe 5 Official Inspedio^Form:Subsurface Sewage �' t5ins•11110 commonwealth of Massachusetts � action Form `Title 5 official Inspection posal System Form - Not for Voluntary Assessments Subsurface Sewage Dis property Address V I ✓(. Owner owner's Name information is Ci 0h f State Zip Code Date f Inspe on required for every City/Town page. D. System Information (cont.) vegetation. Comments (note condition of soil, sign s of hydraulic failure, level of ponding, condition of etc.): privy (locate on site plan): Materials of construction: Dimensions Depth of solids -signs of hydraulic failure, level of ponding, condition of vegetation, Comments (note condition of soil, etc.): — i Title 5 Olfidal Inspedion Forth:Subsurface Sewage l hem'page 14 0117 t5ins•1 WO Commonwealth of Massachusetts iai Inspection �O Tithe 5 ®ffic Assessments Subsurface Sewage Disposal System Form Not for Voluntary Uq_ Property Address 1 4" pL/II61 Owner owner's Name l/ ///,[j b� �c;? information is G 041 r —�� Zip Code Date o nspedio required for every State Page. Cityl7own D. System Information (cont.)I le .ties Sketch of Sewage Disposal System: Pranks or benchmarks Locade a view of the sewac te all wellswithin 100 feet l system, including at least two permanent reference landmarks where pu water supply enters the building. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately i f 3`I ✓ Lu � 3 , Core f 8� 3 3 %+ 1'a Title 5 Official Inspection Form.Subsurface Se„a9e Disposal System•Page 15 of 17 t5ins•11110 Commonwealth of Massachusetts Title 5 official Inspection Form sments Subsurface Sewage Disposal System Form • Not for Voluntary As 9() �1-&a,- G U.'" Property Address Owner Owners Name AV �6 0 �� information is �✓%W1l State Zip Code, Date of lion required for every CitylTown page. D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells 1QC Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record ------------ If checked, date of design plan reviewed: pate ❑ served site (abutting property/observation hole within 150 feet of SAS) i Checked w local Board of Health - explain: I /90 5- ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must desc a how you established e hi round water elevation: s <//ll spection Report, please see Report Completeness Checklist on next page. Before filing this In rule s Offied Inspection Form:subsurface sewage oisposel system-page 1fi of 17 t5ins•11I10 i Commonwealth of Massachusetts Title 5 Official Inspection Form sments Subsurface Sewage Disposal System Form Not for Voluntary Property Address Owner owner's Name / �pZ n`f information is � Date inspect' n required for every City/Town State Zip Code Page E. Report Completeness Checklist Inspection Summary: A,'B, C, D, or E checked Inspection Summary D (System Failure Criteria Applicable to All Systems) completed :�Skset7of information — Estimated depth to high groundwater Sewage Disposal System either drawn on page 15 or attached in separate file i i 1 ' TAte 5 Official inspection Form:Subsurface Sev ge Del System•Page 17 of 17 t5ins•11110 OF BARNSTABLE LOCATION /_;,J7- y7, ,6"vr_ SEWAGE # !�'J VILLAGE��,��/�,' S ASSESSOR'S MAP & LOT INSTALLER'S NAME 6z PRONE NO. , Ili SEPTIC TANK CAPACITY /000 (6 LEACHING FACILITY:(type) (size)_ O'—,NO. OF BEDROOMS 3 PRIVATE WELL OR PUBLIC WATERf,,',o ,C BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: At VARIANCE GRANTED: Yes No ✓ l s -�^�� � :' O j "� � � � � � � � � e 0 �� ' � � ' � � .� � �� � � � i ell- No. , P Fss.... _........ THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH II��,, Q.4,> ... OF .... .la.�ST�-_-------------_----. `ippliratinn 'fur Disposal Works Tonstrnrtiun ibrutit !� Application is hereby made for a Permit to Construct ( ) or Repair (t/"an Individual Sewage Disposal System at: 1 y ------.....�u.5 E - a..�.. _....... . ,1��. .. ?- . --... -_............. .......... Location-Add ess J or Lot No. ................... ,.....` '��.�n.4.. ............. ��_z .`(�(�P� s...' u ./. Cs►N ,.t,Mho Owner Address 11 W Installer Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms._.__._..___.__.__ Expansion Attic ( ) Garbage Grinder ( ) ••. aOther—Type of Building No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures--••-•-•--- -------------............................................................ W Design Flow.......... ._Sa.................gallons per person per day. Total daily flow------'3,-1,-0......................gallons. W Septic Tank—Liquid*capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ a Test Pit No. 1................minutes per inch Depth of Test Pit-----_.............. Depth to ground water......................... Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a .....-••--•------------------•-•••....---.............-•-•--•••••.................---....-----------......................................................... 0 Description of Soil....................................................................................................................................................................... x U W ••••-------------------------•---•-•••••---•-••-----•-••••••--------•--''-•-•---•-....•••-••...-------- -- Q UNature of Repairs or Alterations—Answer when applicable............. ...........e...........::............................................ -•--••-••••---•••••....•-••-•---•••.....•••....-••••--•-•--•-•••-•-------------•'---•-•••-------••---------.....••••----------------'••••-••-•------•••••-••------•------------------•-••-----......---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of I: E 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been i su d the board of health. Signed .... �_... ................................1 .. 1,9r --'•-•-••---•••... '� Date Application Approved By • ,o•--• .. . ...... ................. a Date Application Disapproved for the following reaso .------...••••--•-•------•-•-'--••••-•....................•••..... ............................................ ....--•• ----.-----•-----•--•••--._.,�..-------/--------- - ------------•--- -•-•--'-•----•---'-•---•---•--- ------------ --...Date•-------..... T_ _ _ Permit No.---9 L.? : ._. ::.::...: _ Issued:. Nof?_201 Fizz....................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .............OF....... Appliration for Di-qVuBal Works Toustrurtion Fumit Application-is hereby made for a Permit to 'Construct or Repair V-�<n Individual Sewage Disposal System at: .... ................ ......... � "I'A \ .1� �.......................................... Location-Addr r Lot No ................... to . ......ft.......... --- .. ............ ....i.Z0 .. ........ Owner Address ...... .. ......... Installer Address U Type of Building Size Lot............................Sq. feet 4 Dwelling—No. of Bedrooms.........2-_>..............................Expansion Attic Garbage Grinder C14 Other—,Type of.Buildingc—�.\6 r ....... No. of persons............................ Showers Cafeteria -. - Otherfixtures ...... ........... ---------------------------------------------------------------------------------------------------------------------------- Design Flow.......... C.�.................gallons per person per day. Total daily flow-_-___- .....................gallons. ,:4 Septic Tank—Liquid'capacity............gallons. Length................ Width............__.. Diameter________........ Depth........_....__. Disposal Trench—No. .................... Width..................... Total Length.................... Total leaching area....................sq. f t. Seepage Pit No..................... Diameter................ Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box Dosing tank Percolation Test Results Performed by-......... ............................................................. Date........................................ Test Pit No. I................minutes per inch Depth' of Test Pit.................... Depth to ground water......................... PLI Test Pit No. 2................minutes per inch Depth ofTest Pit............._._.... Depth to ground water._...._____.___......... ............................................................................................................................................................. 0 Description of Soil........................................................................................................................................................................ ...................................................................................................... ......................... ...... . ........................................................ U I .................................................................................................... .. Nature of Repairs or Alterations—Answer when applicable............ U . . ...... 1�-----------e---------------------------------------------------------- ....................................................................................................................................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT 1E 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been piu d the board of health. Signed......... ........... . ...... .. --------- I'll/2- 3 1 0 Date Application Approved By_/U= � -A........ . .......... ......... .. ........................................ Date Application Disapproved for the following reaso ................................................................................................................. .................................................................... ... ............................................................................................................................ Date Permit No.... .............. Issued-.._..________... - ------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........ .................... Terfifirab 01 Toutphana THIS IS TO CERTIFY, That the Individual Sewage Disposal System:constructed or Repaired by...................................................................................................................................................................................................... 2.1 at. ..............0...Q .................................................................................. has been instilled in accordance with the provisions of TITIE 101-3A to Sanitary Code s die b in the application for Disposal Works Construction Permit No.,...E..Z..........—A—Z.i . dated..... ------------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUXRANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. ,i7........................ Inspector...................... DATE.............................. ....... ..... ------------------- ........... THE COMMONWEALTH OF MASSACHUSETTS BOARD 0 �CIL ........................ OF... ................ fo W NO.0'.0......�... FEE...- .,� Disposal 11\orkii Tonstrurtiou 'prrmit Permissiony* hereby granted.............................................................................................................................................. to Constr t or e n Se ra . .. ........at No..... . .. 7� Street s-a shown on the application for Disposal Works Construction Permit No ........ ated. .. . ............... ...... .............................. ........ ................................... L oard of Health DATE.......... .................. FORM 1255 HOBBS,84.WARREN. INC.. PUBLISHER _S Alt Cape 95•s aq Ra-rbo�t road ldyanru�,, Ma: :02601 00y ' . 93.E I00 Scalz I"-30 atoms 10066 . i fot �S 11 Ex1STihith a " aCot 23: : : FauND. N M a d'o;t2Ll .; � ... Sep tic %)eaic�n 0.37 Ac. Alt 1.. 11l0. 6 echoo nv,. ? :-1 r Cdtt ul. ?tow 330 qpd ,('eacli i a a,,�-ea 201 v 20/ Capac,Uq 427 ee ; . a J5�461 E 95.E 9s 4 i ttbo t ,.Jay . . . . R7.G Ll0 wide (gown) i /40.6 No Se /000 1p i 4 Z. JE'/J/l. J-.rtYl/�-n36 : 1. ` u JG t 1 i Made 1-6-89 Sketch J-))tan o f xand yin Hgaqn � Juyuzi►zca Clvw�. Kaap � Alo watm. enco boa L ; 1 Pe2c. 2 rtiui pee 1" ig6bsq. tot 24 as � otdn on .C.C.247,40 C sip 1 994 P 2 8�L £teuatiootd. awe on an top -top 97.9 &.7 ---A ---J Sze-goc Z-o OF OF �1u2l� I (4C`nd o ED ARD�I v K CD 6 V' M NE q t 2490 oe pp 10 TER��G�� ISTER�SJQa�`,',.. ; Al LA% ifr.. . . . . . ��.. -Lei