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Home My WebLink About0034 DOLPHIN LANE - Health 34 Dolphin Lane Hyannis A= 268 —059 i r Commonwealth of Massachusetts Title S Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 34 Dolphin Lane Property Address Edward Tausevich Owner Owner's Name information is West H annis ort MA 02672 January 14 2009 required for Y P fY ' 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. Important:When filling out A. General Information forms to the computer,use 1. Inspector: J only the tab key to move your Patrick T. Sullivan cursor-do not Name of Inspector use the return key. Ready Rooter, Inc. I, Company Name PO Box 371 -17 Jan Sebastian Dr. Company Address Sandwich MA 02563 CitylTown State Zip Code 508-888-2805 S112843 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 sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: Passes ❑ Conditionally Passes ❑ Fails Needs Further Evaluation by the Local Approving Authority "-� CO) January 16, 2009 r.' Ins e ors Signature Date .r y =® "� The system inspector shall submit a copy of this inspection report to the Approving Authority (Board C:D s of F ealth or DEP)within 30 days of completing this inspection. If the system is a shared system or . C-4 ha sa 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. ****Thin report only describes conditions at the time of inspection and under the conditions of use I at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 34 Dolphin Lane Property Address Edward Tausevich Owner Owner's Name information is West H annis ort MA 02672 January required for Y P 14, 2009 every page. City/Town state Zip Code Date of Inspection B. Certification (cunt.) Inspection Summary: Check A,B,C,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: 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 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 of * or the septic tank(whether metal or not) is structurally unsound, exhibits substantial in tration or exfiltration or tank failure is imminent. System will pass inspection if the existing nk is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspecti n if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the to is less than 20 years old is available. ND Explain: ❑ Observation of sewage b up or break out or high static water level in the distribution box due to broken or obstructed pe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with pproval of Board of Health): Elbroken pipe(s are replaced ❑ obstruction is removed Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments I� 34 Dolphin Lane Property Address Edward Tausevich Owner Owner's Name information is West H annis ort MA 02672 January 14 2009 required for Y p rY , 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 tt n 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with a�pprovat of the Board of Health): El broken pipe(s) are replaced I J ❑ obstruction is remove '' ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by a Board of Health in order to determine if the system is failing to protect public health, safet or the environment. 1. System will pass unless Board of Health etermines in accordance with 310 CMR 15.303(1)(b)that the system is not function' g in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 fee of a surface water ❑ Cesspool or privy is within 50 f et of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Bo d of Health (and Public Water Supplier, if any) determines that the system is f ctioning in a manner that protects the public health, safety and environment: ❑ The system has a sep tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface ater supply or tributary to a surface water supply. ❑ The system has a ptic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has septic tank and SAS and the SAS is within 50 feet of a private water supply well. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments s 34 Dolphin Lane Property Address Edward Tausevich Owner Owner's Name information is west H annis ort MA 02672 Janus 14 required for Y P January , 2009 every page. Cityrrown state Zip Code Date of Inspection B. Certification (cunt.) 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 wgence sis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the f ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that nore 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 ❑ 0 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 loan overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments N 34 Dolphin Lane Property Address Edward Tausevich Owner Owner's Flame information is West H annis ort MA 02672 January 14 required for Y P ry , 2009 every page. Cityrrown State Zip Code Date of Inspection 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. ❑ ® 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° o"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 40 feet of a surface drinking water supply ❑ ❑ the system is within 00 feet of a tributary to a surface drinking water supply ❑ ❑ the system is to ed in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) a mapped Zone 11 of a public water supply well If you have answered "yes"to any uestion in Section E the system is considered a significant threat, or answered"yes" in Section D ove the large system has failed. The owner or operator of any large system considered a significa threat under Section E or failed under Section D shall upgrade the system in accordance with 3 0 CMR 15.304. The system owner should contact the appropriate regional office of the Dep ment. , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 34 Dolphin Lane Property Address Edward Tausevich Owner Owner's Name information is West H annis ort MA 02672 January required for Y P 14, 2009 every page. Cityrrown 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? ® ❑ 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)] Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 34 Dolphin Lane Property Address Edward Tausevich Owner Owner's Name information is West H annis ort MA 02672 January 14 2009 required for Y P IY every page. Cityrrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 for example: 110 330 GPD ( p gpd x#of bedrooms}: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage 2007= 39 GPD g ( y g (gPd})' 2008= 43 GPD Sump pump? ❑ Yes ® No Last date of occupancy: Nov. 2008 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons Per day(9Pd) 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 ystem? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): Commonwealth of Massachusetts Title 5 Official Inspection Fora, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 34 Dolphin Lane Property Address Edward Tausevich Owner Owner's Name information is West H annis ort MA 02672 January required for Y p 14, 2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Owner, pumped 2006 Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 600 gallons How was quantity pumped determined? Site tube on truck Reason for pumping: Inspection 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) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ® Other(describe): Converted cesspool and leach pit. Approximate age of all components, date installed (if known) and source of information: Cesspool over 30 years old, leach pit installed Nov 1981. Permit and as-built on file at Board of Health. Were sewage odors detected when arriving at the site? ❑ Yes 0 No Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 34 Dolphin Lane Property Address Edward Tausevich Owner Owner's Name information is West H annis ort MA 02672 January required for Y P 14, 2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 2-4'feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: fee Comments(on condition of joints, venting, evidence of leakage, etc.): Clean-outs for each line near foundation Septic Tank (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fibergla ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compli nce? (attach a copy of certificate) ❑ Yes ❑ No ----------------------------------------------------- -------------------------------------------------------------------- Dimensions: Sludge depth: Distance from top of sludge to b, ttom of outlet tee'or baffle Scum thickness i Distance from top of scum o top of outlet tee or baffle Distance from bottom ofcurn to bottom of outlet tee or baffle How were dimensions determined? Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 34 Dolphin Lane Property Address Edward Tausevich Owner Owner's Name information is West H annis ort MA 02672 January 14 required for Y P ry , 2009 every page. Citylrown State Zip Code Date of Inspection D. System Information (cunt.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease Trap (locate on site plan)/El Depth below grade: feet Material of construction: ❑ concrete El metalberglass ❑ 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.): Tight or Holding Tank (tank must be pumpe/te pection) ([ovate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ ❑ polyethylene ❑ other(explain): Icy Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 34 Dolphin Lane Property Address Edward Tausevich Owner Owner's Name information is West H annis ort MA 02672 January required for Y P 14, 2009 every page. Citylrown 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 o alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opene ) (locate on site plan): Depth of liquid level above outlet invert Comments (note if box is level and di ribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of b , etc.): Pump Chamber(locate on site plan): Pumps in working order: /f ❑ Yes ❑ NO- Alarms in working order: ❑ Yes ❑ No Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 34 Dolphin Lane Property Address Edward Tausevich Owner Owner's Name information is West H annis ort MA 02672 January 14 2009 required for Y P ry , every page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) 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: 1-6 X 6 W/ stone ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/altemative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach pit empty at time of inspection. High water staining noted 3.5'below invert. Clean stone visible through side walls. No sign of past hydraulic failure. Riser brings cover within 6" of grade. A - Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 34 Dolphin Lane Property Address Edward Tausevich Owner Owner's Name information is West H annis ort MA 02672 January 14, 2009 required for Y p fY 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 1 Depth—top of liquid to inlet invert 2' Depth of solids layer 1/2 Depth of scum layer 1/2' Dimensions of cesspool 4 X 4 Materials of construction Concrete block Indication of groundwater inflow ❑ Yes ® No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Converted cesspool is structurally sound. PVC outlet tee in place. Liquid level was 10"below outlet at time of inspection. No sign of ground water inflow after pumping. Cover 6 below grade. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of h draulic failure, level of ponding, condition of vegetation, etc.): Commonwealth of Massachusetts G Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 34 Dolphin Lane Property Address Edward Tausevich Owner Owner's Name information is West H annis ort MA 02672 January 14, 2009 required for Y P ry every page. Cityfrown State Zip Code Date of Inspection D. System Information (cunt.) 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 t q u i 2 f O - O j 4(. _ . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 34 Dolphin Lane Property Address Edward Tausevich Owner Owner's Name information is West H annis ort MA 02672 'January required for Y P 14, 2009 every page. Ciityrown State Zip Code Date of Inspection D. System Information (cunt.) Site Exam: ❑ Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: >2'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: 1981 Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers- (attach documentation) ® Accessed USGS database-explain: ma.water.usgs.gov terraserver-usa.com You must describe how you established the high ground water elevation: No ground water intrusion into celler. Hand augered 2' below base of leach pit. No ground water after 2 hours. No ground water noted during leach pit install. Accessed local groundwater contour and topo mapping. ASSESSORS REF.: Map 268, Parcel 059 OVERLAY DISTRICT: GP — Groundwater Protection District s7j, WP — Well Head Protection District c Lot 29 r m Qr� 16,784±SF Q Q� Existing 70.0' Septic System Over/o 12.2' (by Inspection) CIO �. 0 Isty w/f Garage # 34 ° O 4j� 1Sty w/f Dwelling oy 30.4• 11.3' FLOOD ZONE: Zone C S Community Panel No. ` #250001 0008 D 49. ♦ oy July 2, 1992 ZONE: \ CB/DH RB (RPOD) nd Area (min.) 87,120 SF Frontage (min) 20' A11b1% Se Width tba (min) 100' oy oy Front J 'Side 10 Rear 10' ASSESSORS MAP N0: � H'OF PARCEL NO: C��( ° F1 HARQ �{n I certify that the structures A. t13431 2 LDiEl3A �' shown hereon conform to PLOT PLAN the setback requirements ofLA-i.34.Dolph%n..Lane �css�a the Zoning Bylaws of the �� (�T�4�LE' town of Barnstable. v �,VV -019 E(�Hya=nisportJ� NOTES: - - - _ MASS, DATE:291JUN109 SCALE: 1"--30' 1.) The structures shown were located on the ground 0 15 30 ' 45 60 FEET by conventional survey methods on June 25, 2009. 2.) The property line information shown hereon was PREPARED FOR: compiled from available record information. Edward Tausevich67Bramblewood Drive 3.) This plan is not for recording and is not to be Braintree MA 02184 used for construction layout or deed description PREPARED BY: CapeSury purposes. 7 Parker Road Osterville MA 026,55 DWG #: C631_2g1 FIELD BY. RRL/MLL (508) 420-3994 / 420-3995fox �- ` x VII Qu SO rt CR J r � f �; s o � j I i i i j TOWN OF BARNSTABLE I;OC ATICIN � `'1 �4��.:�d-. �-.Aan SEWAGE# 1 Gg 7 VILUAGE C.J, ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO. SEpRT48 '.:dK CA ACITY LEACHING FACILITY:(type)_Lr kr-tI� . (size) NO.OF BEDROOMS OWNERS PERMIT DATE: 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'iZ, ,.Q�4 4 , O L0CAT-ION , SEWA G E PERMIT NO. AZT W — VILLAGE I N S T A LLER'S NAME i ADDRESS ,7--7,aC 0 VV7 6 rjr S UILDEIII OR OWNER e DATE PERMIT ISSUED DATE COMPLIANCE ISSUED /I.//� / / t f ;`\ �� .� � � � � � '� ��rS/ /. i � -... /// �i� V -' {� � 1 No...91=6B Fxs.A�a THE COMMONWEALTH OF MASSACHUSETTS. BOARD 6-I EALT ff99,,y ..........�.�L�. ... .........OF........ ` . � D ...... ApplirFation for Uhipas al Works Tnntitrnrt nn ramit Application is hereby made for a Permit to Construct ( ) or Repair �-- an Individual Sewage Disposal , Sx IV Loc o -Address � r Lot•No. a1.. ��r� 2,10,, J.� ....._. ____ . �.1 ..... .................................. Installer Address Q Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) '4 Other—T e of Building ....... No. of persons............................ Showers — Cafeteria Q Other fixtures = ................................... -----------------•......-------:---------.......................-......................... w Design Flow............................................gallons per.'person per day. Total-daily flow............................................gallons . WSeptic Tank—Liquid capacity............gallons Length_...-. ....., Width................ Diameter................ Depth................. x Disposal Trench—No..................... Width.................... Total Length ............... Toial leaching area.;_.."*..............sq. ft. Seepage Pit No....................'• Diameter.................... Depth below inlet.................... Total leaching area................_.sq. ft. Z Other Distribution box ( ) Dosing.,tank ( ) aPercolation Test Results Performed by ••--•-........--•...................•............ Date ................................. Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth,to ground water.......................... 04 •---------- ------- . ......-- . --------.-•-- ----•---•--•----•------•--------------------------------------O Description of Soil.................. ...7L.... -k&ZZ-7------•-------------............................................................ W U -----•----•---•----••••------•------•••--••--•------------•-•-•------------------------------••-----•---....•-•------•••-----••-•-•-•-•••----••••-••--•--•-----•-•---•---•......---•............-------- w ------------------------------- .........•------•-••••-• . U Nature of Re airs or Alterations—Answer when a licable...____...... - --------- - • _,ems.-- --- - '-------•-------•------- ----------------- U P PP - ----------- �- ----..................................................-............................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TAITYIE 5 of the State Sanitary Code=The undersigned further-Agrees not to place the system in operation until a Certificate of Compliance;has 'en issued by the board of health. Signed:--•-- .�\�r"• C 'L j�<!•ld.�� D Application Approved BY ., ,�: Application Disapproved for the following r'easons:'. .........................r Date ...... ............................................ ------------------•--•-----•-•-----••----.....-----•-••-----...-----•-•-------•--•----•---...--------••--'•-•--......._...•---•--•----•-•---...----------•---•--,•-•••-•---•-•--••--•-•--•---•-•----•--- Date PermitNo......................................................... Issued....................................................... Date AM, Fits. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..._....OF......... q� ........................ Alip irtttilan for UWpoottl Workii Tnnitrnrtilan ratuft Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal Systi�n at: b� .. . _ -- 1. / v6 z'v., ------•---•--------- ----------------------------------- -- ---- --.....------.......--•--••---•...........---- Al Loc o-A ddres i or Lot q., 2 a Installer Address U Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building ............... No. of ersons............................ Showers — Cafeteria Other fixtures ----------------------------•-•• . W Design Flow............................................gallons per person per day. Total daily flow..............:______.._____._____.___......gallons. 9 Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ 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............................ .......: aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water--___-__-__-_-_---_---_- (i, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ -------•--------------------------------------- ------------------- ---------- ODescription of Soil --- ram "_ .............` ` `r ,e` . ---------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------••-.. Nature of Repairs or Alterations—Answer when applicable_._.___.. ! -' � ryX *� E U P /-------- ; Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of J.i:r,;ri. 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 . Application Approved B 1 / D e PP PP y-•••-•••. - � .. Date Application Disapproved for the following reasons________________________________________-•................................................. ........._.._. ---------------------------------:•--------------....------..................---.........._..------------I----•-•••---••-•-•••----•••--•--••-••-••-•••••--••----•••-••••-•-•-••••-...__...-•-••-•--••.... Date PermitNo......................................................... Issued....................................................... Date Y THE COMMONWEALTH OF MASSACHUSETTS BOARD .„OF HEALTH x 3 �.. L°: . ` .��.....OF...N` ':: ................... C�rr�ifirtt#le of �unt�rlittnrr . THIS IS TO CERTIFY, That the Individual,Sewage Disposal System constructed ( ) or Repaired (46.)- r by----........ '....;_.� ..1 .r�r s *' ".!.tV.". � ....................' _ _ ................•---...----••..._............-••.......... �r a !Installer .• has been installed in accordance with the/provisions of T T 7 r f The State Sanitary Code as described in the application for Disposal Works Construction Permit No-------- �-~.... ............. 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 -- i BOARD OF HEALTH 1 • . r y t, A J �If No.. FEE............... ..........OF......fi�,. f °.a.. e.....c�..... �.!. FEE..il.. ..f .. j! , }.ram`.. Permission is hereby granted__.::. ±. ...._._._ , `' � 1 ...... . /._.:: ........... to Construct ( .-or Repair ( ,.�"'an Individual j�e�w:ag Di al, y tem f at No.... 1 1t ;� �'t1 St ee as,shown on the application for Disposal Works Construction Permit No..................... Dated_..__..............................._...... �ar� z B d of Health DATE.................. �•�� - 4 FORM 1255 HOBBS & WARREN. INC., PUBLISHERS