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Home My WebLink About0300 COMPASS CIRCLE - Health 300 Compass Circle- Hyaiuiis A= 310397 s i e I v Commonwealth of Massachusetts ugitle 5 Official Inspection Form Subsurface Sewage Disposal,System Form - Not for Voluntary Assessments 300 Compass Circle Property Address James Mosher Owner Owner's Name information is required for Hyannis Ma 02601 02/07/07 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. i Ali 61-5 Important: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your Robert Paolini cursor-do not Name of Inspector use the return key. Capewide Enterprises,LLC Company Name reb P.O.Box 763 Company Address Centerville- Ma 02632 rem City/Town State Zip Code (508)428-4028 Telephone Number License Number B. Certification 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 L.i sewage disposal systems. I am a DEP approved system inspector pursuant to=Section 1-5-340'of Title 5(310 CMR 15.000). The system: I F—) y w. ® Passes ' ❑ Conditionally Passes ❑ Fails tom '' ❑ Needs Further Evaluation by the Local Approving Authority 02/07/07 Inspector'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 DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****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. 300 compass cir.•08/06� Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 1 of 15 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 300 Compass Circle Property Address James Mosher Owner Owner's Name information is Hyannis Ma 02601 02/07/07 required for y every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,G,D or E/always complete all of Section D A) System Passes: ® 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: 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. ❑ The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will i pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed 300 compass cir.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 300 Compass Circle Property Address James Mosher Owner Owner's Name information is required for Hyannis Ma 02601 02/07/07 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ 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: 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 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. 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. 300 compass cir.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 15 i Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 300 Compass Circle Property Address James Mosher Owner Owner's Name information is Hyannis Ma 02601 02/07/07 required for y every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria 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 must indicate "Yes" or"No" to each of the following for all inspections: Yes, No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow El ® 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 oficesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 300 compass cir.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 300 Compass Circle Property Address James Mosher Owner Owner's Name information is required for Hyannis Ma 02601 02/07/07 every page. City/Town State Zip Code Date of Inspection 1 B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ❑ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for 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 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. ❑ E The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. 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 feet of a tributary to a surface drinking water supply ❑ El Area 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. 300 compass cir.-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 300 Compass Circle Property Address James Mosher Owner Owner's Name information is required for Hyannis Ma 02601 02/07/07 every page. City/Town State Zip Code Date of Inspection 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? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® . ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic.tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® 0 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)] 300 compass cir.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 300 Compass Circle Property Address James Mosher Owner Owner's Name information is required for Hyannis Ma 02601 02/07/07 every page. Cityrrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: _ unknown Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? Cif yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2_ ears usage d 06:05:139,500 g ( y g (gpd)): 06:0000 Sump pump? ❑ Yes ® No Last date of occupancy: 02/07/07 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): 300 compass cir.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments M 300 Compass Circle Property Address James Mosher Owner Owner's Name information is required for Hyannis Ma 02601 02/07/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: . ; Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: li Were sewage odors detected when arriving at the site? ❑ Yes ® No 300 compass cir.•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° M 300 Compass Circle Property Address James Mosher Owner Owner's Name information is required for y H annis Ma 02601 02/07/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 12 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): from private water supply well or suction line: 10+ Distance p pP Y feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of Ieakage.System vented through the house vents. Septic Tank (locate on site plan): 6„ 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 -------------------------------------------------------------------------------------------------------------------------- Dimensions: 8'6"X4'10"X57" 2�� Sludgedepth:the Distance from.top of sludge to bottom of outlet tee or baffle 38 Scum thickness 0 Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 16" Measured How were dimensions determined? 300 compass cir.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °wM 300 Compass Circle Property Address James Mosher Owner Owner's Name information is required for Hyannis Ma 02601 02/07/07 every page: City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump tank every 2-3years.lnlet and outlet tees are in place.Tank is structurally sound.No evidence of leakage. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: . Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): r 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): 300 compass cir.•08/06 Title 5 Official Inspection Form:Subsurface Sewage'Disposal System-Page 10 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System,Form - Not for Voluntary Assessments °M 300 Compass Circle Property Address James Mosher Owner Owner's Name information is required for H annis Ma 02601 02/07/07 y every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No . Date of last pumping: Date Comments (condition of alarm and float switches, etc.): r *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert No 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.): Box is Level and has one Iateral.No evidence of solids carryover.No evidence of leakage into or out of box. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No I Alarms in working order: ❑ Yes ❑ No I 300 compass cir.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 300 Compass Circle M I Property Address James Mosher Owner Owner's Name information is Hyannis Ma 02601 02/07/07 required for y every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 01 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Sandy soil.No signs of hydraulic failure.Vegetation appears normal 300 compass cir.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °wM 300 Compass Circle Property Address James Mosher Owner Owner's Name information is required for Hyannis Ma 02601 02/07/07 . every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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 Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 300 compass cir.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 300 Compass Circle Property Address James Mosher Owner Owner's Name information is required for Hyannis Ma 02601 02/07/07 every page. City/Town. State .Zip Code -Date of Inspection D. System Information (cont.) Sketch"Of Sewage Disposal System:, Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. � ,� I I 300 compass cir.-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 300 Compass Circle Property Address James Mosher Owner Owner's Name information is required for Hyannis Ma 02601 02/07/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to groundwater: 40' 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: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: , AS-Bulit card ® Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Used:Garherty&Miller model 12/16/94 ground water elevations above sea Ievel.Used:USGS observation well data June 1992.Used:Technical bulletin 92-000-01 Plate#2 annual ranges of ground water elevations. 300 compass cir.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 LOCATION SEWAGE PEMIT NO. �� S 3 VIrLLAGE vl - INSTA LER'S NAt/Ml-E i ADDRESS B U I L DE R OR OWNER DATE PERMIT ISSUED 10- :Zo79 DATE COMPLIANCE ISSUED 3 , '7 9 —�.� —�� ' ,,� � 1 ,a�� V� �� - � '�% '' `� •�`7'G.�. .Y S :!+ � II �� X. .. THE COMMONWEALTH OF. MASSACHUSETTS BOAR® OF HEALTH ........................................................ Appliration for Uispoii al Vorkg Cnnnitrnrtiun Vier it Application is hereby made for a Permit to Construct (V ) or Repair ( ) an Individual Sewage Disposal ' System at: �� /� �� ....�/....> ............... ........... .------....... ..... .....................--------------.....---------- �.X..KCLR, Loca o Addr i /.. t N ......... � O er ................. Address ® Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms-...... ..............................Expansion Attic ( ) Garbage Grinder ( ) pa, Other—Type of Building .... No. of persons......9................... Showers ( ) — Cafeteria ( ) a' Other fixtures ............................ . Design Flow..... ?.._ss_______________gallons per person�pFr y. Total da'ly f ow.............3..3...0....................__gallons. WSeptic Tank—Liquid capacity.l,capacity /,PAD-.gallons Length.Q_..._ . Width.`'►�;G.... Diameter................ Depth................. x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area.._..y$Z-----sq. ft. 3 Seepage Pit No__ _______________ Diameter.................... Depth below'inlet.................... Total leaching area..................sq. ft. Z Other Distributio___box ( ) Dosing tank ( ) aPercolation Test Results Performed by.... ............... Date.PG- Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Gi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ O Description of Soil--- .. i .... .... �.........� ti � � x U -•-••---•-•..................••••-----•-----••-----•--•-------•........------•---•-----•-......-•--------•-•-•--•••-•-------••••-------•---...-•---•••--•-------...---............---.........---------- W UNature 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 TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been • s edby oard of h -• ......... .....•---•Signed . J -Date - 77� Application Approved BY ..._._. ....-- Date Application Disapproved for the'f ollowing reasons----------------•-•--------------------------------------•-----•-----------------•- ......................... ...............•----........-----------•----•-•------•---••........-•--------•-....------------.....----------••...._...-•••-----•------•-•---------•---••----•--••-•-•---•-•------•......--------•---. 7 Date Permit No............. ................................ Issued.... CJ ---------- .................... Date r 1 PTO................_....... Fizz............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF H /EALTH C�G ,^..........................OF.......................`¢4 Appliratiun for Disposal Works Tonstrurtiun Wrmit Application is hereby made for a Permit to Construct O or Repair ( ) an Individual Sewage`4Dsposal System at: ---•--- •-•-- ............... ...................................... ........ .Locat�ion�Addr /' or".' No. ... .. .---•-- Owner r Address -. a Installer � Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms........._�.............................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building :,! .... No. of persons....-..4�.................. Showers ( ) — Cafeteria ( ) Q, Other fixtures ................................. W Design Flow...... Fv...........................gallons per person per day. Total daily flow................_.. .-.................gallons. WSeptic Tank—Liquid capacity../,n Q.gallons Length................ Width................ Diameter.--............. Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area......y 2.....sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) a Percolation Test Results Performed by.....1 6-r- ...............�:-..�r�'� -.............. Date- L..�.._ .;..L. - '. Test Pit No. I................minutes per inch Depth of Test P..................................... Depth to ground water....................---. fT4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a .............. .......................................................................................................... O Description of Soil.... � je a�....?�&t. `"" 'Ur. !.�/ t x ' --••. w ----------------------------------------------------------------------------------•---------........------------------------------------------------------------.............--•-----••-._........------ V 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 it Tau p 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..................•..------...----..........-•-•--•--•--------...---------•-----.----- .......................... Date ApplicationApproved By.................................................................................................. Date Application Disapproved for the following reasons:-------•-------------------------•-•--------•--•-------------•-•---------------.........------•------------•-- --------•................................................................••---....-----•••...------........-----•---•-•••-•----•-•----•--------------•------•----------•--•----•---.•---•--•----------... Date PermitNo............../7-- 6--3--•------------...-----------.. Issued....................................................... Date =_ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......................OF........ : .. ....................................... CInrtifiratr of Toutplianrr THIS IS TO QE TIFY;'Th t the Individual Sewage Disposal System constructed (A or Repaired ( ) • Installer at........Ll..e Z...... _._-`�c-//f l.�....................... •---•----........................• has been installed in accordance with the provisions of TITLE 5 of TheI;State Sanitary Code as described in the application for Disposal Works Construction Permit No...........7.r<3...................I =-dated.-..----. ............... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF.4HtALTH f 1?.......................OF....... . ...........-......................... No......................... FizE........................ Disposal Works Tunstrttrtiun rrutit Permission is hereby granted------��" -.......� ------------------•-•-----......-------------•--•-•---........---......--------------- to Construct ( or Repair ( ) an Individual Sewage Disposal S tem 7 Street �� as shown on the application for Disposal Works Construction Permit No....... f _.... Dated........ ............................ ........................•------------....----•--------•------•------•---••----••------...•••---••......_ 1,t9 M71 Board of Health DATE ........................................... FORM 1255 HOBBS & WARREN, INC., PUBLISHERS i i i t i /CFdLIl� ' ��' j Fi�v+sH G�P.gDt� 41�i5 r Fln�tsN G1Pftnc F'� ursN G9�,o�E Tar, o Ai i '``� -44 JT A c �. CELLAR FL /000 ::F1 ,4 Ez-ov P IS -r 6 o x 0 1.7 0 SEPT/C TAi1/K -.- - - _To C3E LELfL e • ± o r c i f�; f►r b S7A�Rt,E � / } � c 0 ' LEr9GN/NC f�/T Des/ G�J c,ei r�'R�A /lf0 Ole' .t3 E D,PU 01'?S 3 Iv coo LA4 'O PsCX-� -/ SCpTI G AtiIk-,. ��lb-- LEA Jr�+Jr•+•'" _ , ! 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