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HomeMy WebLinkAbout0104 FIFTH AVENUE (HYANNIS) - Health (2) 104 Fifth Avenue -A=246- 100. r� Hyannis ' i dep 2413 11:29p P.1 ■ i ■ Commonwealth of Massachusetts ■■ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 104 Fifth Ave Property Address Sandra Baker Owner Owner's Name information Is every y p Is required for West H annis ort MA 02672 9-18-13 page. Cityrrown State Zip Code Date of Inspection 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. Important:Whenfill ng out forms A. General Information on l the computer, OF use only the tab 1. Inspector. `moo?yaV•.• •..q�yc key tomovsyaur a� JAMES :m? cursor-do not James D.Sears use the fetum arras— ke Name of Inspector ;*; y CapewideEnterprises, LLC Company Name �YSP�G \VQ �a 153 Commercial St. ����urnmuwWINO Company Address ream Mashpee MA 02649 Cityrrown State Zip Code 508477-8877 S1623 Telephone Number License Number B. Certification 1 certify that l 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. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 16.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority -tam 9-24-13 spectors 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 thattime.This inspection does not address how the system will perform in the future undei the same or different conditions of use.. 15ine•3153, - rdle 5 Ofridal vo -rr" ubsurface Sewage Disposes System•Pags 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 104 Fifth Ave Property Address Sandra Baker Owner Owner's Name information's West Hyannisport MA 02672 9-18-13 required for every page. City/Town State Zip Code Date of Inspedion B. Certification (cont.) Inspection Summary:Check A,B,C,D or E I always complete all of Section D A) System Passes: ® 1 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,descdbed 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. 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 exfgltration 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_ ❑ Y ❑ N ❑ ND(Explain below): t5ins•3113 Title 5 Official Inspection Form:SubsLeece Sewage Disposal System•Page 2 of 17 0% �ZdeP■n , 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 104 Fifth Ave Property Address Sandra Baker Owner Owner's Name information is required for every West Hyannisport MA 02$72� 9-18-13 page_ Cityfrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cunt.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ 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 (I 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 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 t5ins-3n3 Me 5 OlFrial Impaction Form:Subsulaw Sewage Oisposat System•page 3 of 17 z'd d £6t,ZdeS Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 104 Fifth Ave Property Address Sandra Baker Owner Owner's Name require for is West Hyannis port MA 02672 9-18-13 required for every p page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health,- safety and environment: ❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has aseptic 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 he 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 0 ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in 1 limt is less than 6" below invert or available volume is less than Y2 day flow &4c111-v ir -15ins-3113 We 5 Off.del bispectlon Fam Subsurface Sewage Disposal System-Page 4 or 17 ,. E'd dlE ll �l �ZdaS Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 104 Fifth Ave Property Address Sandra Baker Owner Owner's Name information is West H annis required for every ort MA 02672 9-18-13 y p page. Cityyrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ 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 e)dst 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 16,000 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 11 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. t5ins-30`13 Title 5 ORuaal Inspection Form:SubwAaw Sewage Disposal System•Page 5 of 17 d dZ£:L 6 0 6 t�Z deS f Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 104 Fifth Ave Property Address Sandra Baker Owner Owners Name required o is West Hyannisport MA 02672 9-18-13 required for 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 NIA) ® ❑ 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)) 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 gpd x#of bedrooms): 330 t5ine•3/13 rile 5 Official Inspection Form:Subsurface Sewage Disposal System•Pepe 6 of 17 g-d dZ£:6 l• 0 l•bZ de_S Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments. 104 Fifth Ave Property Address Sandra Baker Owner Owner's Name information is West H annis rt MA 02672 9-18-?3 required for every y page. City/Town State Zip Code Date of Inspection D. System Information Description: The system is a 1000 Gal. Tank D. Box and four flows. Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes 21 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? Z Yes ❑ No Water meter readings, if available last 2 ears usage d NA 9 ( Y 9 (gP )k Detail: Sump pump? ❑ Yes ® No Present Last date of occupancy: Date Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seatstpersons/sq.fL,etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes .E] No Water meter readings, if available: t5ins-3It3 Title 5 Otfiaal Inspection Fonn:Suhswfsce Sewage Uisposel System-Page 7 of 17 9'd dZ£:l•l, £l•bZ deS Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 104 Fifth Ave Property Address Sandra Baker Owner Owners Name information is required for every West H Yannis port MA 02672 9-18-13 page_ Citylrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: NA 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) 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(describe): t5ins•3113 - - Tide S Official Inspection Porte:Subsurface Sewage Disposed System-Page 8 of 17 L'd d£E:t i, £l bj deS Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 104 Fifth Ave Property Address Sandra Baker Owner Owners Name informrequired is West H anni ort MA 02672 9-18-13 requir>?d for every Y sp page. Cityrrown state Zip Code Date of Inspection D. System Information (cont) Approximate age of all components, date installed (if known)and source of information: 1987 Permit # 87-662 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 feet Material of 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.): Pipeing is 4"pvc sch 40. Septic Tank(locate on site plan): 1' Depth below grade: feet Material of construction: ® concrete [I 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: 1000 Gal. Precast Sludge depth: 3" 15ins•3113 Title 5 Official Wr4mction Form:Subsurface Sewage Disposal Systi n-Page 9 of 17 g-d d££:I,l•7£l, t Z_des Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 104 Fifth Ave Property Address Sandra Baker Owner Owner's Name information is West H annis ort MA 02672 9-18-13 required for every y p page. cityrrown State Zip Code Date of Inspection D. System Information (cons) Septic Tank(cunt.) Distance from top of sludge to bottom of outlet tee or baffle 2T' 2" Scum thickness Distance from top of scum to top of outlet tee or baffle 12" Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Asbuilt-Tape Sludge Judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): Tank at working level. Tank at 1' below grade under wood deck w/opening panels over covers. inlet tee outlet baffle. No sign of leakage or overloading. Note: Maint pump after inspection. 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 15ins•3H3 Tide 5 official Inspection Forth:Subsurface Sewage Disposal Sys -Page 10 of 17 6.d d£�:6 L.El tbZ deS Commonwealth of Massachusetts Title 5 Official Inspection Form ry Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 104 Fifth Ave Property Address Sandra Baker_____ Owner Owner's Name information is required for every West Hyannisport MA 02672 9-18-13 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.): 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 working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t51ns•3113 MUe 5 Ot4del tnspeetton Farm:Subsurface Sewage Disposal System-Page 11 of 17 0 L'd dVC:L L E L -VZ deS . N Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurrace Sewage Disposal System Form-Not for Voluntary Assessments 104 Fifth Ave Property Address Sandra Baker Owner Owner's Name information is required for every West Nyannisport MA 02672 9-18-13 page. cityfrown State Zip Code Date of Inspection D. System Information (cunt_) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): . D Box is 16"x16' 40" below grade. Box is clean and solid w/one line out. No sign of over loading or solid cant'over. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ Now 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: t5ins-3/13 Title 5 Official Inspection Form:Subs rfaoe Sewage Disposal System•Page 12 of 17 I•I,•d £I• tZdeS I Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y y ' 104 Fifth Ave Property Address Sandra Baker Owner Owner's Name information is West Hyannisport MA 02672 9-18-13 required for every _ page. Cityffown Stale Zip'Code Date of Inspection D. System Information (cost.) Type: ❑ leaching pits number: ® leaching chambers number: 4 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovativelaltemative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is four flows. Flow's are 3'below grade. Flows are clean and wet No sign of over loading. 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 t5ins•31113 Title 5 olfdel Inspection Form:Subsurface Sewage Disposal System•Pape 13 of 17 Zt'd dtS:l,L Sl, tZ deS Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 104 Fifth Ave Property Address Sandra Baker Owner Owner's Name information is West Hyannis port MA 02672 9-18-13 required for every p page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) 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.): t5ins•303 Title S Offidal inspeGdon Form:Subs ace Sewage Disposal System.Pape 14 of 17 0( d Commonwealth of Massachusetts in Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ' 104 Fifth Ave Properly Address Sandra Baker Owner Owner's Name information's required for every West Hyannisport MA 02672 9-18-13 page. City/Town State Zip Code Date of Inspection 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 public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately 30 3 = 30 of ❑� (Sins-3113 Title 5 Official Inspecimn Form Subsurface Sewage Disposal System•Page 15 of 17 tt•d d9E:l-1 `✓6 tiZ daS'.. Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 104 Fifth Ave Property Address Sandra Baker Owner Owner's Name information is West Hyannlsport MA 02672 9-18-13 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells T-T 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 ❑ 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: U.S.G.S. well MIW-29 Zone A You must describe how you established the high ground water elevation: Hand auger T_H.9'G.W./USGS well MIW-29 ADJ 1.6'. Bottom of flows at 4'-6" below grade. Bottom of flows at 4'-6'above G.W.. Bottom of flows at 3'above A.D.J. High G.W.. r J 1 Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5ins-3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 16 of 17 9l,'d d5C:6 L C6 tbZ daS s Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 104 Fifth Ave Property Address Sandra Baker Owner Owners Name information is required for every West Hyannisport MA 02672 9-18-13 page. Cityfrown State Zip Code Date of Inspection E. Report Completeness Checklist E Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3r13 Title 5 Official Inspection Fam:Subsuff8oe Sewage Disposal System•Page 17 of 17 96'd d9e:6 6 C6 VZ dag ASSESSORS MAE' PARCEL NO: THE COMMONWEALTH OF MASSACHUSETTS BOAR®gHEALTH ......... .G OF...... �//.._W. .............. ApplirFation for Mipviiat lVorkg Tonotrurtion Famit Application is hereby made for a Permit to Construct ( ) or Repair (A--en Individual Sewage Disposal System at: Y------- .0:.14. o le7 .......................................................................................... Location Address or Lot No. ....... ......................... ••---•••---......_......._...__..........._.._....-- - O ne a Address........................... ............_._..---•-----••--------••----•. ...•--------•--•-----•-•---.._._.._....---- Installer Address Type of Buildini Size Lot............................Sq. feet V Dwelling vNo. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—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—Liquid*capacity............gallons Length................ Width................ Diameter------------_--- Depth................ x Disposal Trench—No..................... Width.............._..... Total Length.................... Total leaching area______-.------------sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................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.....-__-__---_----____. P4 --------• --•-------------------- ..................................................................................................................... Descriptionof Soil.................. .................-----------•--------------------------------- •-------------------------------------- -................ x x ----------------------------------------•--------------------•--. --------------------------------•-------------- V Nature of Repairs or Alterations—Answer when applicable----- _.�,/:__/l� .._� ..............------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'THE:i is p of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been is ed by t e board of IY71th. Signed.._.a,1=l.--_.__.... �c.�...,.� Date Application Approved By...... � ' V -----------•---•--- -----------Ld- `- Date Application Disapproved for the following reasons-----------------------------------------------------------------------------------------------------------•-•--- •-•-•--•..................•...........-•------------•----------•----------....---••-...•---•--•...........---•-•--------------------------•------•----------------------------------------------------•-- Date PermitNo......&.2...M../.0.. .'-------..... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARDVF HEALTH Application is hereby made for a Permit to Construct or Repair (e��an Individual Sewage Disposal .......... ............ .........41004.0............jw:n4..l4e,04t ............................................................................................ Location-Address or Lot No. Address zns*uer Address Type ofB Size Lot--------------Sn feet Dwelling��o. of Bedrooms-----�V�............................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............................ No. ofpecuoon---_-----_-- Showers ( ) -- Cafeteria ( ) {Jtbec fixtures .---_--.-_-_----.-------------_----.-----.--_-------------'---------- Dea6/o Flow............................................gallons per person per day. Total daily flow............................................gallons. 04 Septic Tank—Liquid cuyucity.-_-'.gulnuu Length................ Width................ Diameter_............ Depth................ Disposal Trench--NTo..................... Wil8h--'-.-.-... Total Leugc6.-.-------' Total leaching area....................oq. ft. Seepage Pit No--_---- Diametor--._-_-' Depth below inlet.................... Total area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) ~~ Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. l................minouteapecincb Depth of Test Pit.................... Depth to ground water._--.-__ Teo Pit No per inch Depth of Test Depth to ground wuter---'--_'' -, ........................ Description `" S""- -------'------------=~---------r------------'-------'----'------------------------------'--'--- ..r---------V.............................. ---__-------'_-.-_---.-_'_''._-----___-' -- . U Nature of Repairs orAlterutiooy—Auswer when -------'------'---'---------------'----------'------' -'---- Agreement: The undersigned agrees minstall the aforedescribeA Individual Sewage Disposal System ioaccordance with He provisions of'Z'7I� 5of the State SanituryCode—Theuoderuigoed further agrees not tu place the system in operation until u Certificate of Compliance has t" � S��cd_ _ ______________ �~- «�~~�_ *bby o=* Application Approved By.--_-' ----'���-..''�=.��c�- � DateDATE......................I.. ............................. Inspector...................'\.:�------------------------------------------------ � Date Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........ iwev..............OF... /_-_0.................... At J.a is 0 CERT4' FY, hat the Individual Sewage Disposal System constructed or Repaired (*01 _____4 APAof by V 1. .. - - -�i---- ---t-------*---------------------------------------------- --------------------- has been installed in accordance with the provisions of TITIE 5 of The State Sanitary Code as described in the THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT YHE SYSTEM WILL FUNCTION SATISFACTORY. ON)� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH o......................... Permission is hereby granted IV- 7e,'IN., ' .. _7.......................................................................... Street as shown on the application for Disposal Works Construction Permit Ng,.Zk�.ry.... Dated.......................................... FORM 1255 HOBBS & WARREN. INC., PUBLISHERS � � | - '