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BORTOLOTTI CONSTRUCTION, INC.
765 WAKEBY'ROAD,MARSTONS MILLS, MA 02
508-771-9399 508-428-8926 FAX: 508-428-9399
t
EWAGE DISPOSAL SYSTEM INSPECTION FO
PART A:
CERTIFICATION
Property Address:
Date of Inspection: nspector's Name:
er's Name d Address- p
CERTIFICATION STATEMENT!
I certify that I have personally inspected the sewage disposal system at this address and that the informa-
tion reported below is true,accurate and complete as of the time of inspection. The inspection was per-
formed based on my training and experience in the proper function and maintenance of on-site sewage
disposal tems. The System:
Passes
Conditionally Passes
'Needs Further luatio By he Local Aproving Authority
Fails
Inspector's Signature: - Date:
The System Inspector shall submit a copy of this inspection report to the Approving,a uthority within thir-
ty(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 Department of Environmental Protection. The original should be sent to the system owner
and copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY-
A)SYS PASSES:
I have not found any information which indicates that the system violates any of the failure
criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated
below.
B)SYSTEM CONDITIONALLY PASSES;
One or more system components need to be replaced or repaired. The system,upon comple-
tion of the replacement of repair, passes inspection.
_. Indicate yes;nor,or not determined(Y,N,OR ND).Describe basis of determination in all instances. If
"not determined",explain why not.
The septic tank is metal,cracked, structurally unsound, shows substantial infiltration or
exfrltration,or tank failure is imminent. The system will pass inspection if the existing sep-
tic tank is replaced with a conforming septic tank as approved by The Board of Health.
Sewage backkup or breakout or high static water level observed in the distribution box is due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. The
system will pass inspection if(with approval of The Board of Health):
-1 -
�.PLX M+1C!
wo
SUBSURFACE SEWAGE-DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Broken pipe(s)replaced
Obstruction is removed
Distribution Box is levelled or replaced
The System required pumping more than four times a year due to broken or obstructed pipe(s).
The system will pass inspection if(with approval of The Board of Health):
Broken pipe(s)are replaced
Obstruction is removed
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 the public health, safety and the environment.
1)SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE
SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE
j PUBLIC HEALTH AND 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.
Z)SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER
SUPPLIER,IF APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTION-
ING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE:
'ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 Feet to a surface
water supply or tributary to a surface water supply. ,
The system has a septic tank and soil absorption system and is with a Zone I of a public
water supply well.
The system has a septic tank and soil absorption system and is within 50 Feet of a private .
water supply well.
The system has aseptic tank and soil absorption system and is less than 100 Feet but 50
Feet or more from a private water supply well, unless a well water analysis for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from
the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm.
D)SYSTEM FAILS:
I have determined that the system violates one or more of the following failure criteria as defined
in 310 CMR 15.303. The basis for this determination is identified below.. The Board of Health:,
should be contacted to determine what will be necessary to correct the failure.
Backup of sewage into facility or system component due to an overloaded or clogged SAS
or cesspool.
Discharge or ponding of efluent to the surface of the ground or surface waters due to an
overloaded or clogged SAS or cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clog-
god SAS or cesspool.
Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2
day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed
pipe(s). Number of times pumped
-2-
I
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater
elevation.
Any portion of a cesspool or privy is within 100 Feet of a surface water supply or tributary to
a surface water supply.
r" Any portion of a cesspool or privy is within a Zone I 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
wafer supply well with no acceptable water quality analysis. If the well has been analyzed
to"be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic
compounds,ammonia nitrogen and nitrate nitrogen.
E)LARGE SYSTEM FAILS:
The following criteria apply to a large system in addition to the criteria above:
The design flow of a system is 10,000 gpd or greater(Large System)and the system is a significant'
threat to public health and safety and the environment because one or more of the following
conditions exist:
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
j (IWPA)or a mapped Zone II of a public water supply well. .
The owner or operator of any such system shall bring the system and facility into full compliance with the `
groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local
regional office of the Department for further information.
Y
f '
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Check if the following have been done:
_Pumping information was requested of the owner,occupant,and Board of Health.
✓None of the system components have been pumped for atleast two weeks and the system has
been receiving normal flow rates during that period. Large volumes of water have not been
introduced into the system recently or as part of this inspection.
__k-As-built plans have been obtained and examined. Note if they are not available with N/A.
__iGThe facility or dwelling was inspected for signs of sewage back-up.
(,—The system does not receive non-sanitary or industrial waste flow.
; The site•was inspected for signs of breakout. .
All system components,excluding the Soil Absorption System, have been located on site. .
v. The.septic tank manholes were uncovered,opened,and the interior of the septic tank was in-
spected for condition of baffles or tees, material of construction,dimensions,depth of liquid,
depth of sludge,depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on
existing information or approximated by non-intrusive methods.
SUBSURFACE SEWAGE DISPOSAL SYSTEM,INSPECTION FORM
PART B
CHECKLIST(continued)
L! The facility owner(and occupants,if different from owner)were provided with information on
the proper maintenance of Subsurface Disposal System
SUBSURFACE'SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C ..
SYSTEM INFORMATION
FLOW CONDITIONS
c�
RFSIDENTLAI : /1
Design Flow: allons Number of Bedrooms: Number of Current Residents:V
Garbage Grinder:. Laundry Connected To System: Seasonal Use: ii
Water Meter Readings,if available:
Last Date of Occupancy:) aeel O—4f, aH_Z y� a
Comm
Type of Establishment.-
Design Flow: . aallons/day Grease Trap Present: (yes or no)
Industrial Waste Holding Tank Present:
Non-Sanitary Waste Discharged To The Title V System:
Water Meter Readings,If Available: Last Date of Occupancy:
OTHER: Describe)
Last Date of Occupancy,
GENERAL INFORMATION
PUMPING RECORDS and source of inform tion: /lW
)�Z��__
System Pumped as part of inspection:_ If yes,volume pump d: V gallons:.,
Reason for pumping:
TYPE OF SYSTEM:
.Septic Tank/Distribution Box/Soil Absorption System
Single Cesspool
Overflow Cesspool
Privy
Shared System(If ye ,attach previous spection records, if any)
=Other(explain):,' Q (<kA06*Pa - / 172a z .
APPROXIMATE'AGE of all components,date installed(if known)and source of information:
Sewage odors detected when arriving at the site: AJ
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:I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
GENERAL INFORMATION (continued)
SEPTIC TANK:
Depth below grade: Material of Construction: concrete metal FRP Other
(explain) —
Dimisions: Sludge Depth: Scum Thickness:
Distance from top of sludge to bottom of outlet tee or battle:
Distance,from bottom of scum to bottom of outliftee or battle:
Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid
level in relation to outlet invert, structural integrity,evidence of leakage,etc.)
a
GREASE'TRAP
Depth Below Grade: Material of Construction: concrete metal FRP Other
. (explain) — — — —
Dimensions: Scum Thickness:
Distance from top of scum to top of outlet tee or battle:
Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid
level in relation to outlet invert, structural integrity,evidence of leakage,etc.)
TIGHT OR HOLDING TAN ,-
Depth Below Grade: Material of Construction:—concrete—metal—FRP—Other(explain)
Dimensions: Capacity: gallons Design Flow: gallons/day
Alarm Level: t
Comments: (condition of inlet tee,condition of alarm and foat„switches,�ctc)-
' t
DISTRIBUTION BOX
Depth of liquid level above outlet invert:
Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into
or out of box,etc.)
PUMP CHAMBERX)d
Pump is in working order:
Comments: (note condition of pump chimber,condition of pumps and appurtenances,etc.)
-5-
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
SOIL ABSORPTION SYSTEM(SAS): y
(Locate on site plan, if possible;excavation not required,but may be approximated by non-intrusive
methods) If not determined to be present,explain:
Type. . ... _ .. . . . .. . *-
Leaching pits,number: Leaching chambers, number: Leaching galleries,number:
Leaching trenches, number, length:
Leaching fields,number,dimensions: `
Overflow cesspool, number:)
Comments: (note condition of soil, si ns of by raulic failu level of ponding,condition of vege lion,
etc.)
CESSPOOLS: ✓ '
Number`and'configuration:/- Depth-top of liquid to inlet invert:
Depth of solids layer: Depth of scum layer: Dimensions-of Cesspool: 6D0 ,
Materials of constructions Indication of groundwater:
Inflow(cesspool must be pumped as part of inspection)
Comments: (note condition of soilk,signs of draulic failure, level of ponding,condi ' n of vegetation,
etc , 60 .
• �t
PRIVY:__�_Jc)
Materials of construction:- - Dimensions: .
Depth of Solids:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, .«:
etc.)
G„
-6 -
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i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
I SYSTEM INFORMATION (coWinucd)
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include ties to atleast two permanent references, landmarks or benchmarks.
Locate all wells within 100 Feet.
7
y '
DEPTH TO GROUNDWATER:
Depth to groundwater: 2 2 Feet
Method of -termination or Approx)mation:
a r"
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BORTOLOTTI CONSTRUCTION,INC. �fCEO O
765 WAKEBY ROAD,MARSTONS MILLS,MA 02648 MAY 23
508-771-9399 508-428-8926 FAX: 5t18-428-9399 1997
T O HfAOCTeIl STg'It
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FO T N
PART A'
CERTIFICATION Z 1
Property Address: -
Date of Inspection: /d nspe or's ame:
Owner's Name and Address:
CERTIFICATION TAT .MENT•
I certify that I have personally inspected the sewage disposal system at this address and that the informa-
tion reported below is true,accurate and complete as of the time of inspection. The inspection was per-
formed based on my training and experience in the proper function and maintenance of on-site sewage
disposal stems. The System:
Passes
Conditionally Passes
Needs Further Ev ation B the Local Aproving Authority
Fails
Inspector's Signature: Date: 97
The System Inspector shall submit a copy of this inspection report to the Approving authority within thir-
ty(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 Department of Environmental Protection. The original should be sent to the system owner
t and copies sent to the buyer, if applicable and the approving authority.
INSPECTION MMARV•
A)SYSTP4-PASSES:
V/ have not found any information which indicates that the systen3 violates any of the failure
criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated
below.
B)SYSTEM CONDITIONALLY PASSES;
One or more system components need to be replaced or
repaired. The system upon com 1 -
donof the replacement or repair,passes inspection.
Indicate yes,nor,or not determined(Y,N,OR ND). Describe basis of determination in all instances. If
not determined",explain why not.
The septic tank is metal,cracked, structurally unsound,shows substantial infiltration or
exfiltration,or tank failure is imminent. The system will pass inspection if the existing sep-
tic tank is replaced with a conforming septic tank as approved by The Board of Health.
Sewage backkup or breakout or high static water level observed in the distribution box is due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. The
system will pass inspection if(with approvai of The Board of Health):
- 1 -
e—
. I
n i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
e ?, PART
CERTIFICATION (continued)
Broken pipe(s)replaced
Obstruction is removed
Distribution Box is levelled or replaced
The System required pumping more than four times a year due to broken or obstructed pipe(s).
The system will pass inspection if(with approval of The Board of Health):
Broken pipe(s)are replaced
Obstruction is removed
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 9
the system is failing to protect the public health,safety and the environment.
1)SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE
SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE
PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 Feet of a surface water
Cesspool or privy is within 50 Feet of a bordering vegetated wetland or a salt marsh.
2)SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER
SUPPLIER,IF APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTION-
ING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
i.
The system has a septic tank and soil absorption system and is within 100 Feet to a surface
water supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and is with a Zone I of a public
water supply well.
The system has a septic tank and soil absorption system and is within 50 Feet of a private
water supply well
The system has a septic tank and soil absorption system and is less than 100 Feet but 50
Feet or more from a private water supply well, unless a well water analysis for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from..
the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm.
D)SYSTEM FAILS:
I have determined that the system violates one or more of the following failure criteria as defined
in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health
should be contacted to determine what will be necessary to correct the failure.
Backup of sewage into facility or system component due to an overloaded or clogged SAS
or cesspool.
Discharge or ponding of efluent to the surface of the ground or surface waters due to an
overloaded or clogged SAS.or cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clog-
ged SAS or cesspool.
Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2
day flow.
Required pumping more than 4 times in the last year 1YQT due to clogged or obstructed
pipe(s). Number of times pumped
-2-
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIIFICATION(continued)
'Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater
elevation.
Any portion of a 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 I 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. If the well has been analyzed
to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic
compounds,ammonia nitrogen and nitrate nitrogen.
E)LARGE SYSTEM FAILS:
The following criteria apply to a large system in addition to the criteria above:
The design flow of a system is 10,000 gpd or greater(Large System)and the system is a significant
threat to public health and safety and the environment because one or more of the following
conditions exist:
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 I1 of a public water supply well.
The owner or operator of any such system shall bring the system and facility into full compliance with the`
groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local
regional office of the Department for further information.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Check if the following have been done:
V?umping information was requested of the owner,occupant, and Board of Health.
None of the system components have been pumped for atleast two wccks and the system has
been receiving normal flow rates during that period. Large volumes of water have not been
introduced into the system recently or as part of this inspection.
t1f As-built plans have been obtained and examined. Note if they are not available with N/A.
_LZThe facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow.
VThe site was inspected for signs of breakout.
All system components,excluding the Soil Absorption System, have been located on site.
Tti'The septic tank manholes were uncovered,opened,and the interior of the septic tank was in-
spected for condition of baffles or tees, material of construction,dimensions,depth of liquid,
/depth of sludge,depth of scum.
t� The size and location of the Soil Absorption System on the site has been determined based on
existing information or approximated by non-intrusive methods.
-3- -
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST(continued)
The facility owner(and occupants,if different from owner)were provided with information on
the proper maintenance of Subsurface Disposal System
SUBSURFACE,SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM'INFORMATION
FLOW CONDITIONS
q 80)nr)s._1va,77
RESIDENTIAL*
Design Flow: y y0 gallons Number of Bedrooms: Number of Current Resident
Garbage Grinder: A,b Laundry Connected To System: Seasonal Use:
WaterMeter Readings, if ava' ble:
Last Date of Occupancy p'lYi GZ1 0
COMMERCIAL/INDUSTRIAL:
Type of Establishment:
Design Flow: gallons/day Grease Trap Present: (yes or no)
Industrial Waste Holding Tank Present:
Non-Sanitary Waste Discharged To The Title V System:
Water Meter Readings,If Available: Last Date of Occupancy:
OTHER: Describe)
Last Date of Occupancy:
GENERAL INFORMATION
PU'WING.RECORDS and source of information-A `
System Pumped as part of inspection:_ If yes,volume pumped.' ons
Reason for:pumping:
TYP&OP SYSTEM:
• Septic Tank/Distribution Box/Soil Absorption System
Single Cesspool
Overflow Cesspool
Privy
Shared System(If yes,attach previous inspection records, if any)
Other(explain):
APP O TE AGE of all.components,date installed(if known)and source of information:
/ Cc�
Sewage odors aetected when arriving at tM site: IJO
-4-
�-1
• SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
GENERAL INFORMATION (continued)
SEPTIC TANK: V" m
Deptli below grade: Material of Construction: �oncrete metal FRP Other
(explain)
Dimisions: Sludge Depth:_nP Scum Thickness:
Distance from top of sludge to bottom of outlet tee or baMe:
Distance from bottom of scum to bottom of outlet tee or baffle: Wlellle
Comments:(recommendation fo�pumping;condition of inlet and outlet tees or baffles,depth of liquid
level in tion too clef invert,structural integpjy.,evidence of leakage,et ;a
ii Jr-
GREASE TRAP:
Depth Below Grade: Material of Construction:_concrete_metal_FRP_Other
(explain)
Dimensions: Scum Thickness:
Distance from top of scum to top of outlet tee or baffle: }
Comments: (recommendation for pumping,condition of inlet and outlet tees or bales,depth of liquid
level in relation to outlet invert,structural integrity,evidence of leakage,etc.)
TIGHT OR HOLDING TANK:-d—(J(-)
Depth Below Grade: Material of Construction:_concrete_metal_FRP_Other(explain)
Dimensions: Capacity: gallons Design Flow: gallons/day
Alarm Level:
Comments: (condition of inlet tee,condition of alarm and float switches, etc.)
DISTRIBUTION BOX: I/
Depth of liquid level above outlet invert:aC�
Comments: (note if le 1.and distributi n is equal,evid ce of solids carryover,evidence=nto
or out of box,etc.)
PUMP CHAMBER:_
Pump is in working order:
Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.)
-5--
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
SOLI,ABSORPTION SYSTEM(SAS):_
(Locate on site plan, if possible;excavation not required,but may be approximated by non-intrusive
methods) If not determined to be present,explain:
i
Type:
Leaching pits, number: Leaching chambers, number` Leaching galleries,number:
Leaching trenches, num r, length:
Leaching fields, number,dimensions:
Overflow cesspool, number:
Comments:(note condition of soil, signs o hydraulic fail a level f ponding onditi n o vp elation,
etc.) - v
CESSPOOLS:1—jo.
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(cesspool must be pumped as part of inspection)
Comments: (note condition of soilk,signs of hydraulic failure, level of ponding,condition of vegetation,
etc.)
PRIVY:"
Materials of construction: Dimensions:
Depth of Solids:
Comments: (note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,
etc.) _
-6 -
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include ties'to atleast two permanent references, landmarks or benchmarks.
Locate all wells within 100 Feet.
39 ' 6D
t �
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DEPTH TO GROUNDWATER:
Depth to groundwater: 7-1 Feet
Methgd ofDetennination or Approximation: A
/' laid r^ �.�•
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I�
L00 Bra �r? SEWAGE PERMIT NO.
AvPnup 84 • 2 3 /
VILLAG_ E
—0 9
' Hyannis-port. MA 02642
A & B CESSPOOL SERVICE
I
128 BISHOPS TERRACE, HYANNIS, MA 02601
BUILDER OR OWNER
John Orbe
Grafton Avenue, Hyannisport, MA 02647
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED
6/09/84
L
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.71 F 1
. � 1
No...................... Fim.....
THE COMMONWEALTH OF MASSACHUSETTS ,
t
BOAR® OF HEALTH
...........................................O F..........................................................................................
ApplirFatiou for Disposal Works Towitrurtiun Trait
,�j' (•" a Application is hereby made for a Permit to Construct ( ) or Repair n Individual Sewage Disposal
AY System at: 4 it y-r&) k
�_ fS �Oa
. z r...... _......................................... ....••--•--------...--•-•-.........../ ...............................................
Location-Address or Lot No.
1 'r_... .................................................. •----•--•----------------......._....
--
Owner ................................Address
Installer Address
dType of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms................... .....................Expansion Attic &9? Garbage Grinder WZ)
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
04 Other fixtures -------------------------------- .
W Design Flow..............�............_....__..gallons per person per day. Total daily flow.............................................gallons.
1:4 Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
Disposal Trench—No. ...........:........ Width.................... Total Length.................... Total leaching area_...................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date.........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water_____-_____-_-__--__._..
G4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-_-_---___--___..______-
a ---•----•---=•--------------•--••...........----....---......--•••--•-------•--....•••.......................---•-•----•----•-•---•-•--•......._......•----•.
0 Description of Soil---------------------------------------•--------------------------------------------- ------------------------------------------------------------------......--•-..•---
"�
---------------------------------------------------- ---•-•--------------------------••-----•---•---------•------------------....-----•----------------------•-----------------------------•-------••--
U Nature of Repairs or Alterations—Answer when applicable-------144p------ l......'.......7 0..........
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITLij 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the b d of ea
Signed ='-� - -----•• •--_ _ C..._..._
at
Application Approved By--------- /�•----------•--.....---•--•----•-------------•--------•-•-•-••-•---•----•-•••. y •.. `!
Date
Application Disapproved for the following reasons-------------------------------------------------------------------------------------------------------•-•.•.....
....-•---•--...-----•••------•-••--.-•--••••-•-•••-•--•------...••---•--......--•-•-----.......•-•-•-....._.....--••----•..................•-----•••-•------•------••-•-------•-•------••-----...._.-•-•-
Date
Permit No....AV. `3 y............................ Issued....................................................... t
Date
No.... 3g tip. Fxs.:..�s' ..........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...........................................O F........................................
_Appliration for Disposal Works Tontratrtion rrmi ,�*
Application is hereby made for a Permit to Construct ( ) or Repair �an Individual Sewage Disposal
System at:
./ qR...rs ,1_64 i
........0 s r.......�t n Address ..... --- --------------•--------_•--_-----•--•--_---------
Location-Address or Lot No.
.... -. . ....... ......... ..............••-••------ ...... •----------•------------- -----------•-------------.................. .--------
Owner Address
a -•-•-... ...
Installer Address
Type of Building Size Lot...........................Sq. feet
Dwelling—No. of Bedrooms.................. --------------------Expansion Attic 1C4q Garbage Grinder k#0)
aOther—Type of Building ............................ No. of persons........................F;-!.='Showers ( -")'— Cafeteria ( )
Otherfixtures --------------------------------------------------------------------------------------
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 ( )
I~ Percolation Test Results Performed by.......................................................................... Date........................................
a
a 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........................
C�
0 Description of Soil.........................................-.............................................................................................................................
U ------------------------•••-•••--•----•--------...------•-•-•--•--•---•-•---------••-----••---------••----•-------------•-••--------------------•-------------•----------------__----------•------------
W
U Nature of Repairs or Alterations—Answer when a pIicable...... .___.._ � __ l _._..14,�. .......�_____.__...
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the d o lea /f
%° _ 7.
Signed.!' .. ..... .......
Dat r�
Application Approved By-------- 1e............................... = .:: = :. .
..............
Date
Application Disapproved for'the following reasons-----------------------------•......-----------------------...---------------------------------------------••--
.................................•-----------------------------------------•---------...----------------------•---...•••------•----•----••-•••-•------------------------•---•------•--------••---•-_....
Date
Permit No....p ':.. `3 y ..................
...... Issued.....................................................-
x Date
1
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................a.�. V�A' ...
Turrtif iratr of TontpliFanrr
THIS IS TO ERTIFY That the Individual Sewage Disposal System constructed ( ) or Repaired )
., R1/4,e C -JfJwoo t
by.. -•-•----------------.............._..........-•--•--.........------------------------...-----........----........------.._........---•--.....----...................._._.
CJ�i�•r-1CoL �'Uf J/rllg� Insta}� .
'f I ns-6 V
at_..._...... ----------------------------------------•----------------- -
has been installed in accordance with the provisions•.of ,TITLE., 5 of The State Sanitary Code as described in the
application for Dispds�l Works Construction Permit ........ `�:. �
r
dated---.... ......................
.. :=
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATI7SF CT7Yt,. /
DATE. .:...... . G �G/./-u-.l•• Inspector:...._._....2_v..
,.
THE COMMONWEALTH:OF MASSACHUSETTS
4.1.♦
BOARD OF HEALTH'
...................
No......a.:_.��. FEE.....rf =.....
Disposal Works Tontrudion rranit
/y�4/j , rc�JsA,c .
Permission is hereby granted. ------------------------------
to Construct ( ) or;Repair f� ) an Individual Sewage Dis /,,All`
at No... .r Fio,.�----..�Uc...._.... /'_/,�.14...rs d
y.
4 , Street t�
r,n the application for Disposal Works Construction`Permit No.-_'................. Dated:._�'!`.'� �...:_�_._......._..
as shown on they -----�........--•-------•--...--�-�----------------------------•---------.-.-
g/ Board of Health
DATE............................................. J
FORM 1255 A. M. SULKIN'INC., BOSTON, ���
TOWN ^F Fri INSTABLE
LOCAT;ON SEWAGzGL�/ u
IALLAGE .+� ASSESSOR'S MAP & LOT 39 •
CB �S
D4!2 P yCW SNAME&PHONE NO.
SEPTIC TANK CAPACITY /
/n
LEACHING FACII.TTY: (type) (size) Aar
NO.'OF BEDROOMS
BUILDER O OWNER
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the: J
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
.Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
aJ
Q
� I
. t J
J
" TOWNU`'F-I�ARNSTABtE
LOCATION SP U SEWAGE #
VILLAGE Art- ASSESSOR'S MAP LOT klll
INSTALLER'S NAME & PHONE NO. A & B CANCO 775-6264
SEPTIC TANK CAPACITY SOD I
LEACHING FACILITY:(type) 1�^ l�'� (size) /462p
NO. OF BEDROOMS 1_iPRIVATE WELL OR PUBS WATER
BUILDER OR OWNER �Ja N A
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
� W
w
- r
No....t�..L..� �1 Fis.. ._..-....._
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
aw 1.�...............
OF...... GZ.N...S3 L-. .....................
ApplirFafion for Dispaii al Works Cnnntrnrtiun Vernfit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
S p T'o N }iY�a ........................................................
....................... .
........... - ........ .... .._..
Location•Address or Lot No.
01Z_ Q ..-- ...................•---..
W - C N ... ...................................... .........-
lOwner Address
--........c.. •. 3 5`...... tP19........ t.......!'v
Installer Address
dType of Building Size Lot............................Sq. feet
V Dwelling—No. of Bedrooms......4Z................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
a+ 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........................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
----••-•----•••-----••••••---•-----•------••••-••---•--••••--•----•-•--------------•-----•.......---.........................................................
0 Description of Soil-----------------------------------------••-•-------•-•---•------•---•-------•----------------------------------------------••----•--------------------•••...........
W ---••••--••--••-----•-•••--•-••-•••------•--•---•----•----•--•-----••-•----•--•••••••••-•-----•-•--•-•.....--•••-•---•-••-•••--•-•--•---••--•---••-•••-•--•-----•••----------------•--••--------•-••----
W --------------------------------------------------•---------------------------------------•-------------------------------------•-------------------------------------------------------------------•••.
UNature of Repairs or Alterations—Answer when applicable DNS-1—A"- /SOo__�1�---Tti u�___� '_a0`{
.-----•--•---•...................................................•-----•-•--•-•-•--•-•--•-----••--•-..........
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with,
the provisions of ilTl j 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance ha been ' sued by the board of health.
Signed------ •. ._... •- -------------------•----- ---•••Y
Date
Application Approved By.... -- • ---. •. ......... --- °-----. Da•-- ----•-•••••---••--.. -te..............
Da
Application Disapproved for the following reaso ------------------ ----•••-•------•------•--•-•----•----•---•••••••••••------••-•-•--......---......._...--.-_...
•----------------------•-----•---•-------•--•----------------------------•-•-----•--------------------•--'---------------•---••-•------- -•-•----•------------•--•-•---......-•---•••-••-•--------_....
Q 9 q Date
Permit No.-.(. I-••` �• Issued---------------------------•---•-----�' ------------
Date 4
No..?1::IV _ Fxs............._............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...........................................O F........................................................_...........................-•----
Apphra#inn for Dhipoii al Works Tomitrurtinn ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
••.............._--_------.....--•-----.•......--••---•--..........................••-•••.•_.... _......----•----•--..................---....----•-•----------......_..........................--•-
Location-Address or Lot No.
......................_..........._............................................................. ----....-••--••••---..........................-•----......•--------_....._...•••..................
Owner Address
W .........................................
Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons............................ Showers — Cafeteria
. dOther 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.
3 Seepage. Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
'~ Percolation Test Results Performed by.......................................................................... Date........................................
aTest Pit No. 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........................
OG ••••-•-••---•----------•••••-••-•-•-----...•••••••••------••-----••-----•-•-••...............................................................................
0 Description of Soil........................................................................................................................................................................
U '-----------------------
------------------------
----------------------
-..................................................................................................................................
W •-•••------•----------------•----------------------••-------------•••-•-•--•-----•------•-----•---••----•-••••-•---....--••--•--------------------------------•`--••••-••••-••-----•----•---------_.....
UNature of Repairs or Alterations—Answer when applicable...............................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
TITLithe provisions of of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed.----v .... . ..... 0.....Y. ---------------•••••• ............Date._.................
Application Approved By-- • 1TC"1.in7t, °- /9
Date
Application Disapproved for the following reaso _________________
•.......................................................................... .....-•--•---
--------------------------------------------------------------------------------------------•-----------...------------------------------------------------------------------------------------------•---
067 Date
..
Permit No.. --•---- ------•--------_--•--• Issued---------------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
��) BOARD OF HEALTH /
............I.r, .....OF. �. .. �..� 1..t. 6 -...................
(9pr$ifiratr of TnntpliFatta
THI I, TO CE TI , That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
b, 0- cz t --- .......-•------•--- ---- ------•-- --(3..................... ........................................................
at..__.... _ .... f-".'.•'--y j�--°-----`---' :)'---------' �nst"1. /-K•"�c..:•i••.Y......... ....^_..------------•-------------------------------------
has been installed in accordance with the provisions of TIT F' j of She State Sanitary C d r as�jed�cr ed in the
a lication for Disposal Works Construction Permit No._.,� '"__1 �.._..__..... dated__..�j/.� f J/�
PP P `u.. . ES
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUTARANTE HAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.......................�' 1.--:-!?.-.2...-----•------........... Inspector...................... A) ...........................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
l
l l/ VV _.
99 FEE... ..................
No. .._l........ ...
fglosal rkii nn inn [prntit
CN.. F
Permission is hereby granted..--------- :• .r --------------------------- ----------------------•------............._..........:._....
to Constru ) or R air ( ) a In iv'dual Sew ge i po al yes
f /�/Sa
at No...� 1. TU >`. ..... j� /K Street �O .................
as shown on the application for Disposal Works Construction it N .." .___ __ ed....... J. ... ... ........
SY
W
.--------- - -----DATE...---•--•-•--
-. �- -_. ................ --•--•------ Board of H alth
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
:Y
oHo aHa OHoa®a a®a ooHH®o _ - .. .
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