The URL can be used to link to this page

Home My WebLink About0050 FRESH HOLES ROAD - Health 50 - 52 FRESH HOLE RD. HYANNIS A = 292 175 l - TOWN. OF. JAITMrf-eH V zi LOCATION: v�V �` �/,2ce G 6 VILLAGE• LOT # : PERMIT INSTALLER' S NAME: p a ff� INSTALLER' S PHONE # : LEACHING FACILITY: (type) (, b ,4,5 (size)/j S NO. OF BEDROOMS: `t - BUUILDER OR OWNER: J'G ! g-4-L-.,t PERMIT DATE: COMPLIANCE DATE: I' DRAW DIAGRAM ON BACK ro LU N .04 � a ` ' Commonwealth of Massachusetts 002- F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 50/52 Fresh Holes Rd. Hyannis, MA 02601 Property Address Henrique Fernandes 396 Court St. Owner Owner's Name -.y In is requiredaired for every Brockton MA 02302 4/9/2019 t for page. City/Town State Zip Code Date of Inspection r.- 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:When filling out forms A. Inspector Information on the computer, use only the tab Paul C. Martin key to move your Name of Inspector cursor-do not Cape Cod Septic Services Inc. use the return Company Name key. 350 Main St. Company Address West Yarmouth MA 02673 City/Town State Zip Code r8r�� 508-775-2825 815016 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After Conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 4/22/2019 spector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments v 50/52 Fresh Holes Rd. Hyannis, MA 02601 Property Address Henrique Fernandes 396 Court St. Owner Owner's Name information is required for every Brockton MA 02302 4/9/2019 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) 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: System in working condition. 2) 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. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .�,• 50/52 Fresh Holes Rd. Hyannis, MA 02601 Property Address Henrique Fernandes 396 Court St. Owner Owner's Name information is Brockton required for every MA 02302 4/9/2019 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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 pipes) 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): El obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) 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. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.3030)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 50/52 Fresh Holes Rd. Hyannis, MA 02601 Property Address Henrique Fernandes 396 Court St. Owner Owner's Name information is required for every Brockton MA 02302 4/9/2019 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 / b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 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. c. Other: 4) 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 50/52 Fresh Holes Rd. Hyannis, MA 02601 Property Address Henrique Fernandes 396 Court St. Owner Owner's Name information is required for every Brockton MA 02302 4/9/2019 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %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. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply 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 2000 gpd- 10,000 gpd. ❑ ® 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. 5) 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 CA. 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 t5insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 50/52 Fresh Holes Rd. Hyannis, MA 02601 Property Address, Henrique Fernandes 396 Court St. Owner Owner's Name information is required for every Brockton MA 02302 4/9/2019 page. Cityfrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304; The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes"or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was.the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® 0 Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 50/52 Fresh Holes Rd. Hyannis, MA 02601 Property Address Henrique Fernandes 396 Court St. Owner Owner's Name information is required for every Brockton MA 02302 4/9/2019 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 11.0 gpd x#of bedrooms): 110x4= . 440gpd Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: 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 ® No Last date of occupancy: 2016 Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 7 of 18 t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 50/52 Fresh Holes Rd. Hyannis, MA 02601 Property Address Hendque Fernandes 396 Court St. Owner Owner's Name information is required for every Brockton MA 02302 4/9/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: No Records Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts F Title 5 Official Inspection Form f Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 50/52 Fresh Holes Rd. Hyannis, MA 02601 Property Address Henrigue Fernandes 396 Court St. Owner Owner's Name information is required for every Brockton MA 02302 4/9/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4. 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): Approximate age of all components, date installed (if known) and source of information: 2001 Per BOH Records Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 42 11 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: +10' feet Comments (on condition of joints, venting, evidence of leakage, etc.): Line was checked with sewer camera and found to be clean, properly pitched with no sign of root intrusion. t5insp.doc rev.7/26/2018 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 0 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 50/52 Fresh Holes Rd. Hyannis, MA 02601 Property Address Henrique Fernandes 396 Court St. Owner Owner's Name information is required for every Brockton MA 02302 4/9/2019 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 30" feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ® No Dimensions: 1500Ga1 Sludge depth: 2-311 Distance from top of sludge to bottom of outlet tee or baffle Scum thickness 0il Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Estimated Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 1500Gal tank in good condition. PVC tees in place and clean. Tank at normal operating level. Inlet cover at grade. No risor on outlet. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts , Title 5 Official Inspection Form F5 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 50/52 Fresh Holes Rd. Hyannis, MA 02601 Property Address Henrique Fernandes 396 Court St. Owner Owner's Name information is Brockton MA 02302 4/9/2019 required for every ' page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 • ,, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments g 'yty 50/52 Fresh Holes Rd. Hyannis, MA 02601 Property Address Henrique Fernandes 396 Court St. Owner Owner's Name information is required for every Brockton MA 02302 4/9/2019 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) 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 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Oil 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.): H-10 DB-3 with 1 line in and 1 line out in good condition. Box is clean and level with minimal solidsd carryover. No sign of overloading or hydraulic failure. Cover 3' below grade. t5insp.doc•rev.7/26/2018 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 50/52 Fresh Holes Rd. Hyannis, MA 02601 Property Address Henrique Fernandes 396 Court St. Owner Owner's Name information is required for every Brockton MA 02302 4/9/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. 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. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 4 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system I Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts ( Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 50/52 Fresh Holes Rd. Hyannis, MA 02601 V Property Address Henrique Fernandes 396 Court St. Owner Owner's Name information is required for every Brockton MA 02302 4/9/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont:) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 4 Cmabers with stone. 10W.5'. Chambers were dry during inspection with no evident staining. No sign of overloading or hydraulic failure. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 50/52 Fresh Holes Rd. Hyannis, MA 02601 Property Address Henrique Fernandes 396 Court St. Owner Owner's Name information is required for every Brockton MA 02302 4/9/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): t5insp.doc•rev.7/26/20118 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form la Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ��. 50/52 Fresh Holes Rd. Hyannis, MA 02601 Property Address Henrigue Fernandes 396 Court St. Owner Owner's Name information is required for every Brockton MA 02302 4/9/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form � Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 50/52 Fresh Holes Rd. Hyannis, MA 02601 Property Address Henrique Fernandes 396 Court St. Owner Owner's Name information is required for every Brockton MA 02302 4/9/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells +12' 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: You must describe how you established the high ground water elevation: Hand auger did not encounter water at 12'. Max bottom of leaching is 7'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form la Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 50/52 Fresh Holes Rd. Hyannis, MA 02601 Property Address Henrigue Fernandes 396 Court St. Owner Owner's Name information is required for every Brockton MA 02302 4/9/2019 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 c»�w�lll�r»-nuii� Larus Page 1 of 2 LOCATION': v6 a.Jr k VILLAGE: . " LOT #`: PERMIT' INSTALLER''-Q NAME i INS.TALLER''S PHONE '#.., -71 LEACHING FAC.I'LITY:. (tYpe);[h�ir�. 11 NO. OF BEDRO0MS: B R" R OWNER; f [.-.4 IT DATE. L C.OMPLIANCE DATE: _. DRAW DIAGRAM ON BACK f �pti j f .l N,N- n1 eu� L-e. �. . .1Z https://townofbamstable.us/Departments/Assessing/Property_V alues/HMdisplay.asp?mapp... 3/28/2019 oor�i Z N 3 0 a o p p N p m cv m� 3 N 'Op AFC O =Aµ O R m N � X A m• ® O _ � O O AFC� o O Y 111, IIII III g III ° ° '° °, Till IIII ° � IIII I w s3q� o; W-3112- 13nil o�� ull Ff- FIIII KIIII g allll �° °� ° ° ml IIII IIII O O I O 4 I 4 I � 24-e 50 FRESH HOLES RD z o . O BARNSTANBLE, MA Certified Plot Plan in Hyannis (Barnstable), MA Address: 50-52 Fresh Hales Road Pre ared For: Henri ue Fernandes Assessor's Mop: 292 Lot: 175 Baxter Nye Engineering & Surveying Community Pone/ Number 250001 0566 J Registered Professional F.LR.M. Map Zone: X Engineers and Land Surveyors ! 'x Plan Reference: Land Court Plan 17786—C (Sheet 2) LOT 15 78 North Street, 3rd Floor r1 Certificate of title: 213722 Hyannis, MA 02601 .; Phone— (508) 771-7502 Fax— (508)-771-7622 t-4 Owner: Bonney Street Realty Trust Project Number: 2018-034 Scale: 1" = 20' Date: July 10, 2019 N/F PLAZA TWENTY-EIGHT NOM TRUST, - t�;,T'f MARCEL R POYANT, TR. BK 12801, PG 23 N 8725'10" E �. CB/DH MAP 311, LOT 080 K _ 50 OV % FND O N/F ROSEBUD RIICHHARD D UST N/F BONNEY STREET REALTY TRUST. HENRIQUE A FERNANDES, TR. x ARENSTRUP, TR. ryo. 06' CERT. #213722 CERT. #11172 = MAP 292, LOT 175 MAP 310, LOT 314 UP LOT AREA= 13,056E SF /LP 5C/P HW--- Oh*— OHN' OHVJ OH m n `n x � z O < ' J o. N/F ALJ REALTY CORP. EXISTING CERT. Q15311. DWELLINGS NG � MAP 292, LOT 174 #54 / APPROX. LOCATION r I N/F BROOKSHIRE EXISTING SEPTIC I I X REALTY TRUST •O- SYSTEM PER I VICTOR CHAVES, TR. - 4 K HEALTH DEPT. l O CERT. #168253 kO�S� SKETCH I i MAP 310, LOT 313 9.0- a 6 ,56;1 I O N 26.15'00- EDEED 4.81, CALC. 4.22' / CONC. I 0 N 55'45'00' E / \ PAD P1 CONC. O _ Q ��a / EXISTING PAD e0 a� FOUNDATION •vpP J50/52 CONC. PAD O LOT 15A\ - I - PER LAND\ �V- 1 COURT \ r •^11 X PLAN 17786-C SHEET 2 RIGHT OF WAY v CD I - SEE DOC. / 30,8•f #262934 / lV —————— �— APPROX 30' NE TELEPHONE & TELEGRAPH COMPANY EASEMENT / y Q�PtO — N 89'05'30' W — — — — - 90 ' �S wit 9 - 2t N/F PAULO A & N/F MARJORIE BOURGEOIS VANDERLEIA V CROPALATO G CERT. #187638 CERT. , LOT#1593 1 _ MAP 292_LOT 177 J --- MAP 310�L0T 312— Mt"2S"-----------=------ —— x�_ 1. A ftfLe"SEARCH HAS NOT BEEN PERFORMED FOR THIS SITE THERE MAY BE RIGHTS BY OTHERS,EASEMENT,TAKINGS,MORTGAGES, RIGHT OF WAYS ETC. NOT DEPICTED.IF DETERMINED TO BE NECESSARY,A TTTiE SEARCH SHALL BE PERFORMED BY OTHERS AND SUPPLIED TO BAXTER NYE ENGINEERING&SURVEYING. 2: THE PROPERTY LINE INFORMATION SHOWN IS BASED ON CURRENT AVAILABLE RECORD INFORMATION CONSISTING OF PLANS AND DEEDS.THE EXISTING FEATURES i 1 CERTIFY THAT TO THE BEST OF MY KNOWLEDGE THE EXISTING STRUCTURES SHOWN HEREON IS LOCATED IN RELATION TO THE MONUMENTS SHOWN AND IS NOT LOCATED WITHIN A SPECIAL FLOOD HAZARD AREA. _ THIS PLAN IS NOT TO BE RECORDED, NOR IS IT TO BE USED TO ESTABLISH PROPERTY UNES. =` _< -Z REGISTERED PROFESSIONAL LAND SURVEYOR- BAXTER NYE ENGINEERING&SURVEYING DATE No. (J��/I t-` Fee S ( / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Application for �Digaal *p9tem Construction permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. J _ �pa,k Owner's Name,Address and Tel.No. Assessor's Map/Parcel i+y A pi n t,S a el 2.- L Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. C / Description of Soil Nature of Rem or Alterations(Answer when applicable) �`��/` ,e0 Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of ' le 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issu by th Board ealth Signed Date �3 " Z" Application Approved by Date Application Disapproved for the following reason Permit No. Date Issued 1 -..,. No. Fee . ' `„a Fee i • / THE COMMONWEALTH-OF MASSACHUSETTS Entered in computer: V _ Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Z(pprication for Misoont *pztent Construction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components ' Location Address or Lot No. SJ - S 1- q p k � (a9 Owner's Name,Address and Tel.No. Assessor's Map/Parcel H- t,4 iV N t aL cr 2- (. t Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 7 6 j�o Type of Building: - Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building TTTT�� No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank X� aV Type of S.A.S. Y_ /•. ~ �� Description of Soil Nature of Reps or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions obythi of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issueB and/,Vo,� ealth. Signed Date 3 - �6 Application Approved by ✓ Date 3--3 a -Gov Application Disapproved for the following reasons Permit No. ZQ71 - l9 J Date Issued —————————— ————————————————————— ='—— THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY,that the On-site,Sewage Disposal System Constructed( ) Repaired-(,X)Upgraded( ) Abandoned( )by T 17 010 2 VU at 4 has been constructed in accordance with the provisions of Title 5 and theZor Disposal System Construction Pe (t No. ZUv I' t y S_dated 3—3 a "0 i1 Installer : ie a) Designer The issuance of this e" t shall not be construed as a guarantee that the s stem will�,nc'±�o��a,s.�desig�d. Date ` � /b I Inspector .r r __ __ __ No. " l�!/?� �— � .. . � G ��,7� --------Fee I'` THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Miopooar 6potem Conotruction Permit Permission is hereby granted to Construct( )Repair('0 Upgrade( Abandon System located at and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this pgmit. r Date: 3" �'d� Approved by �5 rl. C we�y 1/6/99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) I, igtc-n 1, , hereby certify that the application for disposal works construction permit signed by me dated fl� R C concerning the property located at V — `T meets all of the following criteria: ' • This failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. • The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. • There are no wetlands within 100 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system • There is no increase in flow and/or change in use proposed • There are no variances'requested or needed. • The bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] • If the S.A.S.will be located with 250 feet of any vegetated wetlands,the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: cc A) Top of Ground Surface Elevation(using GIS information) y!- 6 B) G.W.Elevation +the MAX.High G.W.Adjustment. _ DIFFERENCE BETWEEN A and B SIGNED: DATE: 36 [Please Sketch prop plan of sy tem on back]. NOTICE Based upon the above information,a repair permit will be issued for bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system plans. q:health folder:cert c+ Q �( 5 ! t k J � � 1 �l TOWN OF "TNMff-eH LOCATION: S76 VILLAGE• -/-� �� vC LOT # : PERMIT # : Z,01- 19� i INSTALLER' S NAME: INSTALLER' S PHONE # : 3� LEACHING FACILITY: (type) ( a _ ,�g (size)/ej SZYs f NO. OF BEDROOMS : L BUILDER OR OWNER• �✓� v� �-[� PERMIT DATE: I i COMPLIANCE DATE: _— DRAW DIAGRAM ON BACK 190b� C t------------------- t� 1 cslot 1 ! G _. z _ i } - 1 TOWN OF BARNSTABLE LOCATION '50-�4j SEWAGE VILLAGE42.1 ASSESSOR'S M P 6z LOTS-/ J i INSTALLER'S NAME 6PHONE N SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) NO. OF BEDROOMS PRIVATE W�LL OR PUBLIC WATER BUILDER-OR OWNER DATE PERMIT ISSUED: DATE .COLIPLIANCE ISSUED: VARIANCE GRANTED: Yes No 10 • r . ro • _ 1 � . � _ boo �-Gc.�►'� Co TOWN OF BARNSTABLE LOCATION 50-t�1� k 110LO SEWAGE 3 VITA-AGE ASSESSOR'S M P & INSTALLER'S NAME & PHONE N K%• IJ�� 4� � SEPTIC TANK CAPACITY LEACHING FACILITY:(type) ? (size) NO. OF BEDROOMS PRIVATE W LL OR PUBLIC WATER BUILDER OR OWNER � ~ DATE PERMIT ISSUED: DATE .COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No T x � G L v G d �1 aJ No. Fim THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH TOWN OF BARNSTABLE Appliration for Dis'os al Works Tnnstrnr#inn rami# Application is hereby made for a Permit to Construct ( ) or Repair ( L-)-*a—n Individual Sewage Disposal System at: $� C -- a Lqcation-Address or•Lot No. ---------- -- ----•` r s �`- .-_ owner Address Installer Address dType of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms---.ef....................... _Expansion Attic ( ) Garbage Grinder ( ) PL4Other—T e of Building No. of persons............................ Showers — Cafeteria P4 Other fixtures ............................................................ W Design Flow..... .........................gallons per person per day. Total daily flow-------: 4.0.........___..........gallons. 94 Septic Tank-1-Liquid capacity. gallons Length...k.0....... Width.... Diameter................ Depth................ W x Disposal Trench—No.. .t�� 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........................................ 04 Test Pit No. 1________________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........................ ----------•------------------------•-----------------------------•--.............................---......................................................... 0 Description of Soil........................................................................................................................................................................ W U .....-•-----•--------•--------------------•••------------•--•---..._.....-----------•-----.....-------------•-•--•------------••--------•------••••-••-•---•----------...------------•-------••••-------- W ------------------------ ------------------------------------------------------------------------- ------ -------------------------------------------------------- •3--------- U Nature of Repairs or Alterations—`Answer when applicable.__ _✓ _A..... .sl.�...._�_ �a�j---..t'_�� al -�1. �-.5------. -a k'r! ----•- -------•------------------ Agreement: The undersigned agrees to install'the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issuedhealth. Signed --------- ---------------- --- -------------------- ------.'�_ G Dace Application Approved By ---------- 4 ^ ------- -----Dare--- Application Disapproved for the ollowing reasons- ------------------------------------------------------------------------...................................-------------------------- -------------------------------------- -- ---------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------ ------------------- Date PermitNo. ------------------------------------------------------ ------- Issued ------------------------------------------------------------------- ---` - lKuB THE COMMONWEALTH OF.MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Diipugal Works Tnnitrurtinn Frrutit Application is hereby made for a Permit to Construct ( ) or Repair Individual Sewage Disposal System at:'S CO--c `y=12-e c�\ ^n�Ol � Location-Address --- or Lot No. ------ ---- .......... 1Al2�(...... ----------------------------------------------- -------------5 !�—"�s..... ---......_.... -----_: Owner Address a w�Q �skn� s�_ a �- 1P.ob `1. ....._._•--_..... ................•_-_....•_.—_ ........._______.............. ._.......___'_•4-___ -____._ ........... ..................................... Installer Address Q Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms.............................. .Expansion Attic ( ) Garbage Grinder ( ) P4 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) 04 Other fixtures ------------------------•------- . w Design Flow....j. •..............•-•.......gallons per person per day. Total daily flow--.....V.V.-......................gallons. WSeptic Tank 1 Liquid capacity �4)gallons Length._1•d....... Width....6 ....... Diameter................ Depth................ x Disposal Trench—No.�..�A[JJ d Width_............. Total Length...--VY........ 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------------------------ 4q Test Pit No. 2:...............minutes per inch Depth of Test Pit.................... Depth to ground water........................ 9 ----------••-•--------•---•------••--•------•..........•--------------------------------......................................................... 0 Description of.,Soil........................ x w V Nature of Repairs or fAlterations-Answer when applicable.- tti �A.�._\_ �---- s-La.....�.k4t1�uJ_Ste: ...._...._.��2-...............5!4t F --•.--•--4.f..�......e(�(/�..��__._a��.C1�'" ...........................................-....................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued b the board of health. Signedl---- -------- --_ -------------------- ...-------.. - . ----------------------------- ......... -`'/. ... - - Date Application Approved By --------- ---- yr �...... Dne Application Disapproved for the ollowing reasons- ------------------------------------- ---------------------------------------------------- ---------------...------ ------------------------------------------------ ------- ------ ---------------------------------------........................................... ---------------------------------------------- ........................................ Date Permit No. ................................................................. .., ,., Issued . :....... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Cer#ifirate of VI-Iontylianre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( by.. ..rW.; ..��Aw JA....-5-- -Q.. .Z .----------------------------------------------------------------------------------------------------------------------------------- � Ins[aller i . •D 1. at ........ ......................................�.'.�J c��-.... t�5. .} ..(. . ......... ----------------- -----------..........---.......-- ---- has been installed in accordance with the provisions of TITLE 5 of&he State Environmental Code as described in the application for Disposal Works Construction Permit No. ......... .....)-I. /............. dated ................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE..... ........... ...........................�----...... ....................-................. Inspector ....----....-------- .... ........................... j THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE r� Disposal Worko CWunu#rudinn trrntit Permission is hereby granted....... .....�Er-p�... .................................................................... to Construct ( ) or Repair ( )--X_n Individual Sewage Disposal System" atNo............... ------- .Sf .._}(GL ........ --------------- • ............................................. Street as shown on the application for Disposal Works Construction Permit No.._11��/... Dated.......................................... ..............................� .......................................................... Board of Health DATE.......-•............................•-----•----..................•....._...... FORM 36508 H0138S h WARREN,INC.,PUBLISHERS r _ r ^L 0,C AT ION S E E PE RMIT NO. ILLACE Z(161/Y I N S T A LLER'S NAME A ADDRESS 0 U I L D E R OR OWN EN wf-""o,e , DA T E P ERMIT ISSU E D DATE COMPLIANCE ISSUED � /� 4 l LT�� ,, „' y i� ��,! f � ` ` No..Y1..._:...........� F�s..�.4.:.................. THE COMMONWEALTH OF MASSACHUSETTS ..r BOAR® qF HEAL.-Wr�-a�y �... "....... OF.................................................. ................................. Appliration for Disposal Works Tonstrnrtiun rumit Application is hereby made for a Permit to Construct ( ) or Repair ( n Individual Sewage Disposal System at• r- £. ...r. ..fit. ---------------------------------------- ..........----- .--........... . .. .... _ .. .. ............ vim, ` ocation-Addr s r r �No ....... _._ %,1�= l�z... _ -�.�..:..L-f- __ wn . .A dress - ------ --------- (.-. .... ..------. ---.... ... r. Instal er Addres d Type of Building Size Lot............................Sq. feet V Dwelling—No. of Bedrooms................................ .....Expansion Attic ( ) Garbage Grinder ( ) ~ Other—Type T e of Building ________________________•--- No. of ersons..........__..._.._..__.____ Showers — pa., yp g p ( ) 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............�.ss........ Total leaching area---- sq. ft. Seepage Pit No-----------I........ Diameter....1.7 _.__..._. Depth below inlet........tp_....... Total leaching area.J.�_ -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........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-__-_______•___•.--___-_ •---•...................•-••--•-----••--•---•-•----.......... ------------------------ ------------ •------- •....... •-------- •••----------------------------- 0 Description of Soil........................................................................................................................................................................ x U ------------------------------------------------•---------------------------------------••----------••------ U f Nature of Re aI s or Alt ation — nswer when a. licable....__.___ _ _`� _ ._.._____ .. ---- --- -- --.---------. -•--•-------------- -------------------------------- r,eement: The undersigned agrees to install the afored s ribed Individual Sewage Disposal System in accordance with the provisions of iITi LE 5 of the State Sanitary C de—The and si ned furtl r agrees not to place the syst in operation until a Certificate of Compliance has bee sued b the of heal . Sig ed..... •....... ApplicationApproved By..................... ---- ....... --- .................... ................... .......... ..... .................... Date Application Disapproved for the followin easo --- ---------------••---•-----•-----•-•------•-•---•-------------•--•----•-----•------•-._...--•-----......... ......-•-•--•-•.......................•--......_..---•--------...............------.....-•--•------•...---•------------ ---•--•--•-•-••-----•-•--------•-•-••--•---------•-------•-----•-•......-- Date PermitNo......................................................... Issued....................................................... Date No. ..._....... FEsl ....... ............... THE COMMONWEALTH OF MASSACHUSETTS BOARD QF HEAL \11 jj -•--------- . ....-- ----------------OF.......t Applira#iun for Disvuual Vorkii Tongtrurtiun rumit Application is hereby made for a Permit to Construct ( ) or Repair ( Klti Individual Sewage Disposal System at• ..�Z. ... e- z � tt'' � 0, . .- . ...... ..lit ------•----'-•...----•---------------- ----....... ocation-Add s� ) t Own '................ a �.. ress f'/ ........................... ..................................................... Installer Address UType of Building Size Lot----------------------------Sq. feet 1—� Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building .............. No. of ersons........................____ Showers a YP g -------------- p ( ) — Cafeteria ( ) A4 Other fixtures W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons. W Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x :_.Disposal Trench—No..................... Width_..._.,r........... Total Length.................... Total.leaching area _ sq. ft. > Seepage Pit No-----------I--------- Diameter...1 ...... Depth below inlet........ Total leaching area.�.�:._z'_sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by-•-•••-•-•------•--••••••-•-•'-•...'-•---•-'-••......--'•--•-•------•-.-• D ate........................................ 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........................ a .••-•••••-•--•••••••-•----••--•••••-•--•-'•'••••-'------•'-•-•-'.......................•-•----'-•'---•...... .....:..... -------------------------- ••-- 0 Description of Soil.....................................................................................................................•---------•----------......---•••..._.....----•-••. x U ----------------------- ---------•---------------.-----------------•-•----•--••-------------------.----------•---•-------...-•------------'------•-----------------.--•---------------•--------- ..................................... --------------------................................................. ... -------- _ t. =------ - �r U Nature of Repai orrations Answer when llicable_..__:..:' ...__.._______________________________I_--. :.......__ ... ................ ---•-. - tW1 --'•-'•-------------�.----•--------•----•--------•---•----------------....•.......------•-- kgreement: i" The undersigned agrees to install the aforede ribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary C de— The and s• ned further agrees not to place the sys in in operation until a Certificate of Compliance has bee 1issued the of h Signed • . �f �Application Approved By..................... r ? Date Application Disapproved for the followin reaso s:.............-................-...........................................................-.................... ........... ....................................-................................................................----...................-.......-.............. ...................-........... Date PermitNo.......................................................... Issued---------............................................. Date THE COMMONWEALTH OF MASSACHUSETTS - H BOAR ALTH ..........�... ..... .OF....C F" ..................................... Tntifirtttr of (South iatta f THIS IS T!�CERTIFK T the Individ 1 e. age Disposal System constructed ( ) or Repaired ( ) by---------------------_: ......1.......----- U.. � jW) ....!..... .................A_............._._.____............_..........._......_......__.......... Insta le atC' Z -------------•--•-------....------•-•------••---"-•--•••----- has been installed in accordance with the provisions of TI F 5�'o7`he State Sanitary Code as described in the application for Disposal Works Construction Permit No...._...._.. ...._._.l.............. dated............. THE ISSUANCf OF THIS CERTIFICATE SHALL N T BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM VII F CTION SATISFACTORY. DATE.......��°... ...........................-.......................... Inspec . .......... --------------------------------------------------- tor_.. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALT- riP;n/ ..0 ..............OF................ .:.... ....................... No.........: ••--' FEE........................ Eliuvusa Dut Permission is hereby granted- �unriun �eruti - ------------`---- ------....._.....-----•---------------------........-------------••-------•-••-•----..._..-•---.....-••----....... to Construct ( ) x Repair ivi age�Di�posal Sy4tfm at No.- �� Z -................................................an I . al S�jw --•--•.--- Street y as shown/the/ain for Disposal Works Construction Permit No�......_ y---`Dated...................................._:,� � -'-•...............•----...---•-------'---•'--•--•---..../ dBoard of Health DATE.._ //f S- FORM 1255 A. M. SULKIN, INC., BOSTON C Ll)�C AT ION S E E PERMIT NO. . -so . - L .VILLAGE INSTA LLER'S NAME i ADDRESS e U I L D E R OR OWNER - 1l1• act. e� . DATE PERMIT ISSUED DATE COMPLIANCE ISSUED �X11Z y, t r a No. (._ ... Fits.... .::................ H COMMONWEALTH Ts BOARD HEALTH ur . ......OF................................................................ ' ................. Appliration for Uhipoii al Workii Tonutrurtion ramit Application is hereby made for a Permit to Construct ( ) or Repair (X) an Individual Sewage Disposal System at: , .................. a-_A . - •-•'--•'--•--•-----'--•- -•----...---•-----.-�-..... ....---•-----... ation-Addr ...._.1. .._. L c `s or :^ Le— ............. — v .... ............. Installer Address 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 ( ) A'' Other fixtures ...................................................... W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 04 Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................ W 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------------------------ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ w - __ . ice- ,. ,/ ,g,� 4 I:),- .".�`-��-fac. ��++S9 .�.........................•--. ._. .___•.__._- .__._._...._.._._. Descr ption of Sotl....._:.. �.-rtc.-� �..�-rvc.. --- -------------------------------------------------- W -------------------------- ------------------------------------------------------------------------------------------------------------' --------------- ----- U Nature of Repairs oAlterati ons—Answen applicable :_.._ _ ._ - '�. _�.r Agreement: The undersigned agrees to install the aforede ibed Individual Sew ge Disp�4 System in accordance with p '�'T'� E 5 of the State Sanitary C de— The undersign fu ther agree not to place the system in the provisions of �:.::..=. operation until a Certificate of Compliance has bee issued by the boar f a alth: ate �.) Application Approved By-••---•j •----• . • • . ,y-----------------•- -•----- ------ Date e__. Application Disapproved for the f ollo in easons:........... ...................................................................................................................... Date PermitNo......................................................... Issued•---- 'Z = ................... Date UIP� N6.......:L...�� ... Fmc.....`��.....�.�.......... THE COMMONWEALTH OF�-IEAL MASSACHUSETTS H BOARD O Appliration for BiopnaFal Works Tomitrurtinn Vrrmit Application is hereby made for a Permit to Construct ( ) or Repair A) an Individual Sewage Disposal System at: ................... ...+t F�iz<�.t,�r. v- ---.........-------------- ----••---- ....-----.----.... L anon Add rJ ,y Drys +wor t o A✓2�... _ / r/ / e ............... '` �.y.� •- -------- ---._..._ Ow er ��..^....�_#. Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures -----------------------------------------------------............................................................................................... 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 ( ) aPercolation Test Results Performed by-------- ---------•-----............--------•---------------•------------- Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit-------------------- Depth to ground water-._____---_____------.-. rX, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ -___.. ......... ............ 1 - -._. Descr' ion of Soil - - r "e"a�.L-� ------ ----- -------------- ---"� --------- x �./ ...................................................................................................... .......................•------------------_----..-. UW ___________________________________________________________r___-______------.--_--__------•---_-------_____---___-__.-______-_.--__. y Nature of Repairs o. Alteratlo s Answ,er_w en applicable..*-�� ..._..._ _..._�..__. Agreement: The undersigned agrees _to..,install_.the.afored ribed Individual Se ge Disp al System in accordance with the provisions of:T T I_.:" p 5 of the State Sanitary""C de—The undersign f tt:er agre not to place the system in operation until a Certificate of Compliance has be` a ued by the6board alth: Signed..... . ....... ...... lel 04 ate Application Approved By........_�_. ll ate Application Disapproved for the f ollo ti easons-------------------- -----•---------•--------•-----------•--------•-------•---•----•------•----•-...--------- ------------•.....-•------------•-----•-------------------•---------•-•----------'----------------------'-----------------•--••-••-•------------------•------------.......``'-------------------------- Permit No.::'= ............. s'` Issued •. ......................................� a Date a. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH . .........7-0-u- 4---`-TntifirFatr of Tontplianrr THIS j CE TIF. Y, Tha he Individual Sep-age Disposal System constructed ( ) or Repaired ( ) by. •r- 1 -- }�' I ' ----- -------- --------------------•----•--•-----...------------.............-•---------•------. f. ---------•----------------------•--•---------------- has been installed in accordance with the provisions of T of The State Sanitary Coe a desc 'be m the x _ application for Disposal Works Construction Permit No. ... ...........•_ ._ .___.__...._. dated_ --__C�' ....____._... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM W!"- FUNCTION SATISFACTORY. DATE......... �..... , Inspector A10' 2-7 THE COMMONWEALTH OF MASSACHUSETTS BOARD F HEALT. ............ ... .. .........OF....... ...........E._.._......_............ No.....;✓.11....... FEE---. ... nr (1-010n nrtinn rmit Permission is hereby granted..... to Construct ( ) or ReeA ( n jn iv1. .al Sew, g asVeet ystem , atNo.. = - � __.. .---•-----------------------------------•----.........-- as shown on the application for Disposal Works Construction Permit✓ o............ .. ated......�:_ .�'__.._. aP p ` J jdL!� R Board of Health DATE........ - FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS x No...................... 9 F.E$............................ THE COMMONWEALTH OF MASSACHUSETTS BOARD/'OF HEALTH JV� ------------------OF.... ---------_..-..------------------ ............... Appltration for Disposal Murky Tonstrurttun 11trutit Application is hereby made for a Permit to Construct ( ) or Repair (L-115, an Individual Sewage Disposal ystem at. - _ A�....... ..... .............. ...�../'cL ��.�: ..••---- ..-----•------....------....... - - -.... - �Loca' ti � — or Lo o. ...... �..•....... ......... .............. .............. 1. .......••--•.................................. Owner Address W �?t .. a •. .... ..............•.......................... -•----••••--•--...-•-------•--•-••••••---•-••••---•-•-........................................... Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) 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.................... Depj�h below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank (// ) Percolation Test Results Performed by......................................................................... Date........................................ � Test Pit No. I................minutes per inch Depth of Test Pit_..........._....... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Ix ...........................................................-.......-----------------------------------------------•---------------•---------------••----•.... 0 Description of Soil........................................................................................................................................................................ x x ------------ �- U Nat e of airs Alterations— saver when a plicable.._ .._..._____ _ orb l�c� ._................... -�j� --------•-•------- ..•..... ----•---•---------. -•---.----� }-----------................................... Agree nt: e undersigned agrees to install the afored ibed Individual wage Disposal System in accordance with t p usi is i TLE of the State Sanitary de—The unders' n further agrees not to place the system in io unti a ti of Compliance has.bee issued b the b r f health. S- ned................. ............................................. ---•-••-------•-- ------ F7� Date AI 'on Approved By............. .•...•-- .-- -- --••--..... ............••-•-----•••......• .......... Date lieation Disapproved for the f 11owing reasons----------------•---------------------------------------------•---------------------........................... .......................................................... •--•-•--••-•..........................................................................................•-••- .............................. Date Permit No--------- ----------•-•----•-•---•• Issued------..... D-- .}------. Date ------