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Home My WebLink About0088 ELDRIDGE AVENUE - Health 88 Eldridge Avenue Hyannis A = 292 — 248 t _ f Commonwealth of Massachusetts quoTitle 5 Official Inspection Fora Subsurface Sewage Disposal SyfAam Rnsrm N,,,I# tr VOILintary Assess„vents Property Address -- " W Qjv ner �l GPI ai{i�.�. _ �U ! h ON ner's Name ~- information is / required for every 0 1J ✓ 6 0/ �spectpage• Cyfrown State Zip Code Date 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. I"P°rtard When A. General Information f1lCi the out forms on the computer, use only thetab 1. Inspector key to move your cursor- notuse a✓/ o�,�� //the return Name of Inspector , Conpany Name 120 Company Address .L- 4s A,=wr Od6�� Qty/Town State Zip Code _ o- 80 - Telephone tuber 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 C 'S:000). The system: Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority I / ins s S' nature 5 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 iG,GGG go or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DER The odgi nal should be sent to the system owner - and copies sent tothe 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. t5m•3113 TNIe 5 Official Inspection Fart[SubsWace sere Disposal s)stem•page 1 of 17 /O W �� ti Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Dis"I System Form -Not for Voluntary Assessments Property Address Ow ner LLf /S information is ner's Narrte , required 9e edforevery lTowrn - ✓l NI S State Zip Code Date of Inspection B. Certification (corn.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System saes: 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 of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes',."no°or"not determined"(Y,.N, ND) for the following statements. ff"not determined,"please ex0ain- 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 WU 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): x f5ns•3M 3± Title 50rficial Ins pecdon F omc Subsurtace Sewage Disposal Sysbsm•Page 2 of 17 6 Commonwealth of Massachusefs Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address / CWrrer L Ow ner's Name information is l I required for every 4✓►✓7/f 4 page. Cityfrown State Zip Code Date of Impecton B. Cel fification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipes)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ 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(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ 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 15.303(1)(b)that the system is not functioning in a mannerwhich 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 tans•3M 3 Tiae 5 ofticial Inspection Form Subsurface SevwMe Disposal System•Page 3of 17 O Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Ow ner C4 r information is Owner's Name �iJ required for every �✓141 Jr / � 4 L")oa 6 0� page. CRY/Town State Zip Code Date of Inspection B. Certification (corn.) Z 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 sal 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 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 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. I 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 du to an overloaded or clogged SAS or cesspool ❑ tatic 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 day flow _dsne•3M 3 Tide 5 Official lnS peCdonFam[Su0.w0aceSevr•geDisposal SyStem•Pa9e4of17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address �U 19/f 0inr tees Ow nees Narne information is / J required for every � ?✓r`I l S / ',/r G.,) b 0 j 6 ro// page. Cityfrown State Zip Code Date of lruipec6n B. Certification (corn.) Yes No ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ L� 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. ❑ L� Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ LN' Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ G?"'� 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.] e system is a cesspool serving a facility with a design flow of 2000gpd- ❑ Joe pd. ❑ The system fails. 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 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 ❑ ❑ 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 shalt upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ms•3113 Title 50ffiaal Inspection F omc Subsuface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address / Owner (4,215 information is Ow ne's Name �/J required for every / a Avl t f /" ' 3 D L14 page- Gty/Town State Zip Code Date of WiSpection C. Checklis Check if the following have been done. You must indicate`yes"or"no'as to each of the following: Yes ❑ mping information was provided by the owner, occupant, or Board of Health ❑ ere 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 is inspection? 1411" ❑ Were as built plans of the system obtained and examined?(If they were not A available note as WA) 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 n 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: 2 Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): ISrs•3M3 Title SOffidal IrepecUm f am[Subsuiaoe Sewage Disposal Sim•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments O � � t Property Address � is information is ner Owner's Name Al ,{ �1required for everya A if �/J 0 601 6 30 l,& page. Cityrrown State Zip Code Date of spectton D. System Information Description: / /0D0 6 110 h S C- G h /,2 L 0 _ Number of current residents: a Does residence have a garbage grinder? ❑ Yes No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes No information in this report.) Laundry system inspected? ❑ Yes No Seasonal use? ❑ Yes No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes o 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? ❑ 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: t5ns•3M3 Title5 Official lnspectionForm Subsurface Sewage Disposal System*Page 7of17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 46 Eli„ Property Address tea/5 ON ner information is Q"oar's Name required for every page. Citylrown State Zip Code Date of spection D. System Information (coat.) Last date of occupancy/use: Date Other(describe below): 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 S m: stem Septic tank, 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 UA system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(descri be): t5ns•3H3 Yiue 50lfiaal Impectim Form SubsWaw Sewage DiSPOW Sy mm•Page Sof 17 t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address ON ner �► information is Owner's Name /�f requirW for every c�r✓tiIJ / //f 03L6D/ page. CitylTown State Zip Code Date df Inspectan D. System Information (cont.) Approximate age of all compo e�ts date installed known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes o Building Sewer(locate on site plan): Depth below g feet Mated f construction: cast iron 40 PVC ❑ other(explain): 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): l/ Depth below grade: feet Material onstruction: 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 Dimensio ns: Sludge depth: oC t5w-3M3 Title50fftal IrspectionFam SubsLrfaceSewegeDispwd System*Page 9af17 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System/Form e Not for Voluntary Assessments Property Address O'"nerOw ner's Name information is required for every ✓!yr t I /r //� O� O page. C11yRown State Zip Code Date of Inspection D. System Information (coot.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness e"I Distance from top of scum to top of outlet tee or baffle v Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): tit ✓'+ f i9 40 Cc vt G H 7 S /yI ,?J L" CC7 vti�{�r O✓t /VO 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 tyre'W3 Title 5 Official Inspection Form Subsuface Se"eDisposal System-Page 10 of 17 Commonwealth of Massachusetts'` Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address / L ON t4 r f ow ner's Name / inrormrni ation is required for every ✓r N!j ✓¢ oa �D J �v/3s7 page. WITown 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, eHdence of leakage, etc.): 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. gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in worldng 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 t51ns•3113 Tille 5 Official InspecficnForm Subsurface SeviageDisposal System-Page lid 17 f , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments -90 Property Address Oa ner ON r►er's Name /" ' 6ifome is for Qa 6 O/ 6 required for every Gi✓�N/J page. Cityfrown State Zip Code Date o Inspection D. System Information (cont.) 1410 Distribution Box (if present must be opened) (locate on site plan): ISO q Depth of liquid P d level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any �I/4 evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order. ❑ Yes ❑ No` Alarms in working order. ❑ Yes ❑ No; Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): " If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): if SAS not located, explain why: tare•3r13 Title 5 OfSaat Ins peotion F orm Substrface Sewage Disposal S1Stem•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Ow net / information isOwner's Name required for every --Z0,41 page. cityfrown State Zip Code Date of I mction D. system Information (coat.) Type: leaching pits 0 number. ❑ leaching chambers number. ❑ leaching galleries number. ❑ leaching trenches number, length: ❑ leaching fields number, dimensio ns: Cl overflow cesspool number. ❑ innovativelaftemative system Typetname of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): C/ jflo 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 tyre-313 Title 5 Official Ire peefian F am:subsurface sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Addresslug Cw ner orw nei's Name U t S information is ,{ required for every c,vl n t t page- City/Town State Zip Code Date of In pection D. System Information (cont.) 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.): t5i s-3n 3 Title 5Official Inspection F orrtc Subsurface Sewage Disposal Sim•Page 14 d 17 i Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address z Oav ner � /f Cav ner's Name information is required for every 20 y lj //�/T Od 6 page. City/Town State Zip Code Date of lA spectron D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where publ' ater supply enters the building. Check one of the boxes below: and-sketch in the area below ❑ drawing attached separately J r Q 1 t9^s-3M3 'ritle 5 Official Inspection Form SubsufaceSexageDispwal System-Fags 15af 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -lNot for V luntary Assessments Property Address " Ow ner / information isD"y ner's Name required for every z; 44/ G/—fJ �� page Gltyliown State ZiP Code Date of motion D. System Information (cont.� Site Exam: ❑ Check Slope �(> i ❑ Surface waterLi ❑ Check cellar �V4 L ❑ Shallow wells P �w 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: Date ❑ bserved site(abutting property/observation hole within 150 feet of SAS) Checked local Board of Health-explain: t F Csi ❑ Checked with local excavators, installers -(attach documentation) ❑ Accessed IJSGS database-explain: You must descnbb how you established the high groundwater elevation: J o!/ A S rt , k r / ✓1 J�1�''l P/T 4 , _ 04 rO Uh v (OC,� o,/'� o G' -� O e cv Before filing this inspection Report, please see Report Completeness Checklist on next page. t51ns-3M 3 Title50ffieiallnspactimFarrrc Su66erface Sewage Disposal SysOam•Pie 16 of 17 Commonwealth of Wssachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments IF 8 ;P--w f Address ONrff etfornsfion is /� regtiWforev er G,��r ,/ a page. Cly/Town � State F� Date of pecf n E. ,R.,,ep�ort Completeness Checklist a- [nspection Summary:A, B, C, D, or E checked "pection Summary D(System Failure Criteria Applicable to All Systems)completed &I-s-'Y'stem Information—Estimated depth to high groundwater LT Sketch of Sewage Disposal System either drawn on page 15 or attached in separate 51e Oft`3113 TiOeSOffidd IMPSC MFarM Subsu'tW9& M9eDWPMd SYMM,Pepe 170117 No.- .................... �� Fps... e.. .. THE COMMONWEALTH OF MASSACHUSETTS BOA RDI�-a EA ......... ... .OF........ .?(? ......... .. -----------.................... ��r` V . ppliration -for 1iivnfittl larks Tonstrurtion rrmit 0 Application is he by made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: ...-...•._..-----•______• • .................. -------AIL •Address AVor Lot No: -=---- ------ -------- ow Address ------------- ------ Installer Address d Type=of Building Size Lot... -... ..__ Sq. feet U Dwelling—No. of Bedrooms--------- ---------------------------Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ___________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fix ures ___________ W Design Flow........... _ . ..__. ___--gallons per person per day. Total daily flow............................................gallons. 04 W SepticP ------gallons Length---------------- Width................ Diameter---------------- De)tli----------_--. x Disposal Trench i tNoca capacity Width--_--------------- Total Length-------------------- Total leaching area_ _.....sq.'ft. Seepage Pit No_____________ ___ iameter.................... Depth below inl otal leaching area-------------------sq. ft. Z Other Distribution box ( ) Dosing tank ( ) 100, aPercolation Test Results Performed by--------------_------------- � � ------_ Date--------------------------------------- ,� Test Pit No. 1----------------minutes per inch Depth of "Pest Pit.................... Depth to ground water........................ Li, Test Pit No. 2----------------minutes per inch Depth of Test Pit___________.._.__... De th to ground water_..__--___________---- Description of Soil --_-•------------ 1*7 _ - V ___--------•---------------------- .._.•� -- - ----• ----------• ---- -- •-------•-----------------------•--•-----•------- Z ----------------------------•---------- -------------------------------------- ------•----•--••----•---------•-•-----------------------•----•--------•--•-----------------------•------•---__----•----- V Nature of Repairs or Alterations—Answer when applicable.-_____________________________________________________________________________________________- ----------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Dis osal System in accordance with the provisions of Article XI of the State Sanitary Code— The " zersigned furtl greesnt to place the s tem in operation until a Certificate of Compliance has bee 'ss ed b t board of he /f JT, igned---• • •- • --•••-•-•••--•-•••--- < --- to j Application Approved By•--•• ^- •••-•---- -.. . =�- �- -- �� Dat Application Disapproved for the following reasons------------------------------------ -.... ....________-____________________________________...._____-_•_- ••••-__._..--•-••_._••---•--•--•-•--•------------------------•-•--...•---••-••---•••--•-•---•-------•--•-•-----•------•---•---------------------•--•----------------------------_..._..__----------•-••- Date PermitNo......................................................... Issued........................................................ Date -•--•---- F�a..� e.. ... THE COMMONWEALTH OF MASSACHUSETTS -�� BOARD H EA.I_,.T�H Applirtt#iuu -fur ]iupufittl Workii Tomi#rur#iuu Permit Application is he eby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: eIe ...........................................°...o = A ------...-- ......................... Locc+attiion-Address �f or Lot No: ` '� 1 ---• .................................................................... W ��...---•- ......•—............. . --...............------........... Installer Address / Type of Building Size Lot../ -- Sq. feet Dwelling—No. of Bedrooms-------- ...........................Expansion Attic ( ) Garbage Grinder ( • ) P-1-, Other—Type of Building .............. ............. No. of persons............................ Showers ( ) — Cafeteria ( )Q' Other fixtures ----_______---_ W Design Flow.......... .__--gallons per person per day. Total daily flow--------------------------------------------gallons, WSeptic Tank iquld capacity------------gallons Length---------------- Width................ Diameter--- D pth-___-____-.--.-. x Disposal Trench— X/_ _ -_ 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 b ..-- --___.._✓`�____/�� _....Aj_...__.._ Date________________________________________ 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-------------- ------------------ ..... (xj -- �' -------------------------- W VNature 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 Article XI of the State Sanitary Code—The ersigned furt /agrees not to place/thestemoperation until a Certificate of Compliance has been,isstfed b t e board of he th.J J.(/,Igned._ _ . -•-••-•-•-.....•--- -•-----•--------.•. jj�� ate Application Approved By------ ---� -- ---------- �rf / �j Application Disapproved for the following reasons: ------------- ------------•••---•-------•••...----•------------------------•---------------------•--••--•••--•--•-•-••--------•---•---•-----------------•-----••------•--•-------------------------------------------- Date PermitNo......................................................... Issued--------- .............................................. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OE HEALTH �� I .........................................OF..... ......................... ... ...................................... ,�� 0.rr#ifirtt#.e of f�om�liaurr THIS IS T CERTIFY, T t the Indi al Sewa Disposal System constructed ( �r Repaired ( ) by = ------------- ' nsta( r at........................... --- ----- / _l/--------. - ------ L-,-(-,-----.--- --------•--------......................... has been installed in accordance with the provisions of Article XI o" The State Sanitary Code described in the application for Disposal Works Construction Permit No----------- _�_ --------------- dated.....7Z. .__ ____ _ THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector------------------------------------------------------------------------------------ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH _ ?- .................OF.....-�. ........ ..... FEE_ lw No._ _ 'ilu.i#ru i I r • i# A Permission is herb ranted________ __` i��u�ttl to Construct ( or Rep it ( ) an Indivi Sew ge Dispos 1 System --------------- reet as shown on the application for Disposal Works Construction Permit o._--_---__ _ _ Da d--------------------------------------••-- Board of ea DATE................................................................................ FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS