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Home My WebLink About0545 LINCOLN ROAD EXTENSION - Health 545 LINCOLN ROAD EXT. Hyannis A= 272 - 184 i � a- ��ti Commonwealth of Massachusetts i Title 5 Official Inspection Form ASubsurface Sewage Disposal System Form -Not for Voluntary Assessments + Property Address LL Owner Owner's Name /T �� / information is /.s /9 0required for every ri V)�. -- page. City/Town State Zip Code Date of spec' n ' 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 A. Inspector Inf r ation 51# 1 3 filling out forms on the computer, A r J / /✓� (mil /� use only the tab i+� key to move your Name of Inspector cursor-do not 'E;f11/ '1 0 "i C Ci use the return Company Name n ) key. !!!!/ol/fa/fg Company Address r',S�G✓�/ /�''/� ig City/Town G� State Zip Code ?790 4�a$� Li Telephone tr cense Number B. Certification 1 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 syst . I. Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ F " l is �9 Inspectoa 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. Title 5 Ot`da Inspection=o=:Subs u,ace sewage Disposal system•?age t of 18 t5insp.doc•rev.7/262018 Commonwealth of Massachusetts Title 5 Official Inspection Form rd Subsurface Sewage Disposal System Form •Not for Voluntary Assessments Zme"ol-4 Property Address / airG Owner Owner's Name / 14 �60/ /S lT Q information is a441S required for every R1 page. Cityfrown State Zip Code Date o nspec n C. Inspection Summary Inspection Summary: Complete 1, 2: 3,or 5 and all of 4 and 6. 1) ;em ses: 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: 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): Title 5,?f5dal irspe=on Form:suosurace Sevr'ge Disposal Sysem•gage 2 of t8 [6insp.doc•rev.712612018 Commonwealth of Massachusetts Title 5 Official Inspection Form C1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ZWO111IL Property Address Gilt Owner Owner's Name m ,� information is A„y,f A required for every 14,11 page. City(rown State Zip Code Date of Ir4pectioil C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumpsialarms 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 pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): 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 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: -itle 5 Qffidzl:rsoecuon ro.•r•:suosur`ace sewage oisposal system•?age 3 0/78 t5insp.doc•rev.7/252018 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System/Form -Not for VoluntaryAssessments Property Address &�itr/ Owner Owner's Name Q information is AN��s /9 od6ol . / /5 required for every page. Cityrrown Cz State Zip Code Date of, sped n 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 ❑ ackup 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 Tine 55da!ns?ecnon Forn:Subsurface Sewage Disposal System•Page 4 of 18 t5insp.doc-rev.7252018 Commonwealth of Massachusetts i,. Title .5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address / Owner Owner's Name information is required for every nhl page. Cityrrown State Zip Code Date of Vspectiofi 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 u /or clogged SAS or cesspool ❑ r,�/ Liquid depth in cesspool is less than 6" below invert or available volume is less u than '/z day flow ❑ 21`10— Required pumping more than 4 times in the last year NOT due to clogged or /obstructed pipe(s). Number of times pumped: ❑ yj�✓/ y 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.] ❑ � T e system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. r, The system fails. I have determined that one or more of the above failure --I criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 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 C.4. 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 Title 5 offoal Inspection Fore:Subsurface Sewage Disposal System•Page 5 of 18 t5insp.doc•rev.7282018 4\, Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ry Property Address Owner Owner's Name - information is IS //� a�6 o I required for every page. City(Town State Zip Code Date of spec on C. Inspection Summary (cost.) 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 ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ere any of the system components pumped out in the previous two weeks? X]] this s the system received normal flows in the previous two week period? ve large volumes of water been introduced to the system recently or as part of inspection? ere as built plans of the system obtained and examined? (if they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? Were all system components, excluding the SAS, located on site? ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Existing information. For example, a plan at the Board of Health. Determined in the field (if any of the failure criteria related to Part C is at issue t approximation:of distance is unacceptable)[310 CMR 15.302(5)] 7;Se 5 Qa�irspa-tior=omn suoscr�ace seKage Disposal system-?age 5 of to t5insp.doo rev.7/262018 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments S`tS Zihtoln Property Address / Owner Owner's Name O R)/ information is Qy4191S required for every page CityfTown State Zip Code Date of specti D. System Information .1. Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): ,330 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Description: / /� /J � 4M O Number of current residents: Yes Does residence have a garbage grinder? ❑ 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.) ❑ Yes No Laundry system inspected? ❑ Yes No Seasonal use? Water meter readings, if available (last 2 years usage (gpd)): Detail: ❑ Yes No Sump pump? Last date of occupancy Dace : inspection=or' Swsc`zce Sewage Disposal System•?age 7 of 18 t5insp.doc•rev.726/2018 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments zhtleO/r7 Property Address Owner Owners Name information is �h iS axr.0/required for every page. CityfTown cz State Zip Code Date lnspe on D. System Information (cont.) 2. Commerciaillndustrial 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: Of Was system pumped as part of the inspection? ❑ Yes o If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Page 8 of t8 t5insp.doc-rev.726/2018 Tine 5 official inspection=orn:Suhsu`ace Sewage Disposal System• Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments SYS �i� w Property Address ire✓ Owner Owners Name A4 information is A�� for eve Date of ns ec" n required o every City/Town State Zip Code P page. D. System Information (cunt.) 4. Type of S m: 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 comp/onenttsQs, date installed (if known) source of information. � � Yes No Were sewage odors detected when arriving at the site. 5. Building Sewer(locate on site plan): 1611 Depth below grade: feet Material of construction: /O ❑ cast iron 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet comments (on condition of joints: venting, evidence of leakage, etc.): -itle Bof`dal inspection Fom.Su$surface Sewage oisposal System•Page 9 of 1a t5insp-doc•rev.7/252018 Commonwealth of Massachusetts Title 5 Official Inspection Form j di< Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,l r �— (� Property Address GJl Owner Owner's Name q information is -14 If Q�60� �s �/ required for every HCj page. City/Town State Zip Code Date of/rispeeton D. System Information (cont.) 6. Septic Tank(locate on site plan): /O Depth below grade: feet ?en construction: crete ❑ 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: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle ZL scu 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 0% n / lZ dwiV/ct How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): lid Co l j h0Y1 . Tile 5 otaai Inspection Form:5uosurface Sewage Disposai System•Page io of 78 t5insp.doc•rev.72612018 Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form Not for Voluntary Assessments o/h 12 Property Address Owner Owner's Name ,( information is W.43441 r 60 required for every page. City/Town State Zip Code Date f Inspe 'on D. System Information (font.) 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 Molding 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 -iU c� e S Cfflaat irspeon Forn:suosusface Sewage Disposal System•?age 1 of 1S t5insp.doc•rev.712612018 I Commonwealth of Massachusetts Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address �+I r Owner Owner's Name - information is y� s /mil/¢ required for every State Zip Code Date of In ectio page. City/Town P 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): _71 Depth of liquid level above outlet invert 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.): So �.ec-4s TWe 5 Ot4aal inspection Form-suosuriace sewage Disposal System•Page 12 of 18 tsinsp.doc-rev.7/252018 Commonwealth of Massachusetts a� Title 5 Official Inspection Form 3 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments E� Property Address lAil�' Owner Owner's Name l information is yot s �/9 Opp 6G IT required for every page. City/Town State Zip Code Date of I 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 /L% number: ❑ leaching chambers number: f❑ leaching galleries number: ❑ leaching trenches number, length: (� leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovativeiaitemative system Type/name of technology: 'kie 5 pf`aai:nspe:ion Fcm_Suos�riace Sewage DisO05al System•Page 13&18 t5insp.doc•rev.7262018 Commonwealth of Massachusetts Title. 5 Official Inspection Form i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address �r Owner Owner's Name information is ciA ri 4 if required for every page. City/Town State Zip Code Date o nspecAn 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.): 01, r,li•n ,J I �� SJ ✓� OT C/�Rw�!t ��N/Y 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.): we 5�`cai inspecnen=o,-m:sccsulace Sewage Disposal system•?age�4 of 18 [5insp-ooc-rev.726/2018 Commonwealth of Massachusetts :. Title- 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owners Name information is Q h�11 S �a 6 oI required for every _ page. City7own State Zip Code Date of In pectin 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.): r Tiue 5 Offiaai lnspecoon=om:.suosurace sewage Disposal system•Page 15 of 18 t5insp.doc•rev.7/26,2018 I Commonwealth of Massachusetts -. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4117 eo 1v7 12 j Property Address G�I"2 Owner Owner's Name information is h //� Vef-�0 / l / required for every ✓1 � page. CitylTown State Zip Code Date of I pectin 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 chmarks. Locate all wells within 100 feet. Locate where public water supply enters the build' . Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately I ( i I I Q,4 c �✓ I i -tmoo G�.►lon � .Sep-�r� T4��✓ I j I o C Sfa>n I �e4- 14,4 10/ 3- I l t5insp.doc.rev.7/26/2018 Title 5.CfflCal lsspe=n=Dm:SUDsLrface sewage Disposal System-Page 16 of 1S Commonwealth of Massachusetts Dogma Title 5 Official inspection Form M Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r vs - ry Property Address G/r Owner Owner's Name AU information is z*04t Od6O/required for every4 page. City/Town - State Zip Code Date off pecti D. System information (cons.) 15. Site Exam: L1 Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells 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: pate ❑ Observed site (abutting propertyiobservation hole within 150 feet of SAS) Checked with ioca Board of Health - explain:Ail:ki s fi- / Sf Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must de ibe how you esYr blished the high ground water elevation: w �r7GG(44P Y 10 eLAI ,�• /(/D 60 u 44�aj4e,- 40 CA--jecl & V*%7 or de o Li of Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-Bv.7262018 -iue 5 Q;Sca! -,sPeczon=on:Suosudace Sewage Disposal system•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address SYS -ZlOr-ol-I dcI Irc Owner Owners Name information is //% required for every Gi d1 h�f a601 page. City/Town State Zip Code Date of/nspectron E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: A. Inspector Information: Complete all fields in this section. 11100B,,Certification.- Signed & Dated and 1, 2, 3, or 4 checked Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 ilure 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.7126/2018 Title 5 OtScal inspe=on=o-n:Sut)surface Sewage Disposal System•Page 18 of 18 LOCATION SELVAGE PERMIT NO. VILLAGE 7a /e1w I N S T A LLER'S NAME i ADDRESS C) L l. , c. a )Ash r o 1gi -I: )d Q r-w rAx p o�`t 11UILDEIt OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED 3 �y�y� i c6 ti �I 0 v� X S No1Q! Fs$.J1 ................. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH W/j..............OF......45,61W�./7�.��._ 4,j6------•-----...--•---... Applira#ion for Disposal Works Tom4rnrtion Prrmi# Application is hereby made for a Permit to Construct () or Repair ( ) an Individual Sewage Disposal System at: ....... 4. ....................... 4 0 E ......_.. __ .......... 4. ---- •- Location-Address or Lot No. .......................... r�'.� .. b l�l4 i N .S-'k" Owner Address w O.1. .0 .h.�.t:inc..-s j N --------.- ------------------------- � t�Rr�ozv sr H�413c� =.ram. _ _ �:.. Installer Address Type of Building Size Lot_2-<! _Z� J..Sq. feet Dwelling—No. of Bedrooms................Building No. of persons............................ Showers — Cafeteria f-4 Other fixtures ......................................................... W Design Flow.............��----'�...........-.........gallons per person per day. Total daily flow............. .Z....�.................gallons. WSeptic Tank—Liquid capacity/of.7Lgallons Length...e....... Width..' _4.._.. Diameter................ Depth...4...�... Disposal Trench—No..................... Width_....____._..__.._.. Total Length.........._......... Total.leaching area........--....._..._sq. ft. x Seepage Pit No....../------------- Diameter-__�F,_.�� Depth below inlet......--�..-_. Total leaching area.5.,ZaStrft.� Z Other Distribution box /�) Dosing tank ( ) '-' Percolation Test Results Performed .......�c... Date.... Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water-___-:_--__-_.-_--_-__-. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-------_--_-_-_----_____ a -----------------------------------•------------............---...........--•--••---- .................................................................. 0 Description of Soil...... -------f !`}��1� p---•-- Lr .........................--------------------- U ----------------------- •------------------------------ ------------------- •---------------------------- ---------------------------- ------------------------------------ -•----------..: W U Nature of Repairs or Alterations—Answer when applicable-,.............................................................................................. Agreement: The undersigned agreed to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITIL4 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate/Complin has b-%n issued by t b d of ealth. ne ._.... ----•----••-•... • ------ ----- ----•--•----. ApplicationApproved BY--- ---------------------•----•----•-•-------------.......0....--•--•-- ----- ....... -------�.......... Date Application Disapproved reasons---------------••----•-•------------------------.._._....----------------------------------------------••----•--- --.......••---•-----•--...-•--------------------------------••----------------------......--•-------...-- Date PermitNo......................................................... Issued....................................................... Date----- — No._ ., :'.. .`...�.................. THE COMMONWEALTH OF MASSACHUSETTS _ BOARD OF HEALTH ...._.........../!(J/ ..--------------OF......A56i� -5.�..�C 5 L Applira Lion for UhiposFal Workii TonIrurtiun Prrutit Application is hereby made for a Permit to Construct (X� or Repair ( ) an Individual Sewage Disposal System at: N G O.. n.. _/��!� . C X�, G d----------- ---•--•---------------------•------•--- Location-Address or Lot No. ......................^.......................................................................... ..........--...................................................................................... Owner Address . a ••-•....................•••.................-••.........._....-•••................................ .............................................................'.................................... Installer Address QType of Building Size Lot..62--.Z�J..Sq. feet Dwelling—No. of Bedrooms...............`3.............__.........Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building No. of persons............................ Showers — Cafeteria P-I Other fixtures •••-••............•-•--•-------- W Design Flow............. �.... -._.............__-•-•-gallons per person per day. Total daily flow____.._........._-3__..d..___.__.________gallons. WSeptic Tank—Liquid capacityOO !gallons Length-__- ....... Width._.1��._........ Diameter________________ Depth__4_...._.. x Disposal Trench—No..................... Width.................... Total Length.....................Total leaching area....................sq. ft. Seepage Pit No...... _____________ Diameter... Depth below inlet.....?......... Total leaching area.�.�:..'?sq"'ft G Z Other Distribution box ( ) Dosing tank ( ) � '-' Percolation Test Results Performed bye .0,��...�......L U..........¢-...C.oe_.. Date.._ -------------- aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Gil Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-_-_--____-••---__--____ a -•••-------•••••-------------•-•••-•.._...••-•-•-•-•-•••---•-•--•---••--•.............••••••••.............................................................. O Description of Soil------`S E , :%T� C 4�/ �L-19 --------•-_.. W -•----•----•--- -•----------••...••--•••••••••-••••------------------------------------------------------------------------------------------------••------•----------------------------------••-•..... VNature of Repairs or Alterations—Answer when applicable.............................•...._....__.____._....___................__...__.............._.. -•--------------------------•-------•--------------------------------------•-•----.........-----•----•-•----••--------------------------------------------------------------------------------......... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of 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 board of health. ine ----•-•-•-•••••-•--••••-•--•-•-•-•...........................................•--•••-• ......-••- -'` g Datr ee ... Application Approved By...- r �`` -•--.. !e,/ i' f ate Application Disapproved t following reasons---------------------------------------------•----------------•-----------------•---------------------......._._ --••---•-••---------------••••-•-••-•••••••-- ............................................................................... ............... --- -- ------ --- ---- Date PermitNo---------------------------------------------------------- Issued•....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... Clrrtifirtt n Toutpliatta T-1111&!�YITQ TIFY,_1 t <the--In4i al' age Disposal System constructed (.�or Repaired ( ) b •r ' = -y- Installer ...............................................................---•-........ f.................... has been installed in ac5prda ce with the provisions of T TIE 5-ofXhe-State Sanitary Co as escribed in the application for Disposal Works Construction Permit No.- __... ✓`................._ da.ted_.f__-_ '_........._._._.._.. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM 1dV LL FUNCTION SATISFACTORY. DATE•� -•`�//rJ......---••---------------------------------------------- Inspector-- . THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..r/cr .................................OF....................• d N�.......:.............. FEE/ ...__............. Rappal- nr Agra trm n antic Permission hereby granted -•�,�...•� =='= � `�"= to Con ( for Rea ) .�ndividTraylev��age. sp System at No .............C ------ --- - Street as shown on the application for Disposal Works Construction Permit No........._._1 ate df__ a /j�� -.'f.- ................. ............................. ... __ice-L•4c�--1 .t..................................... 3_ 1�_7-3 Board of Health DATE. -•--. ----•---...... :.. FORM 1255 A. M, SULKIN, INC., BOSTON TO of P2 o ,c AJ loZ o s ,3�a o G�� LEf�G/� 1='� T C->CG.� ✓fJ /Qo 98 <x L�,9CN Pl. T Tb �--5 96 y8 \ ��e D E> 9,^-I!A-1,9 Ti v�(1 94 9 7,7 3 TO of E EL-E v' 92 g7. 10 - 8� 51, 48 D RL L 44 PPL/Cf9 BLE , _ . . /"?,�^:f y O E- C a V&,2 S -r-O 4,-J/T /,l A..,9 P HO F2/z 5 C _ o -- �� / C� 1�.! - _ v E ,2 T S c Fq L E - : O -` �_� C� � . i2"- of A7 ;,v ; ��. A--,' EI-: � . 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