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Home My WebLink About0089 MITCHELL'S WAY - Health 89 Mitchells Way Hyannis A=290-152 y I { i i i 4 i •' ,�/J Commonwealth of Massachusetts /' P ZED A r /SZ Title 5 Official Inspection Form , .,�7 a Z?a�h(P Subsurface Sewage Disposal System Form -Not for Voluntary Assessments -- a 4 a24o/ Property Address � GPj ttr��✓ E5��-?�" Owner e owners Harr Information Is required for every s/ Y1=1 (-P page, City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form.Inspection forms may not be altered in any way.Please see completeness checklist at the end of the form. Important:When tilling out forms A. General Information on the computer, I use only the tab 1. Inspector: I key to move your /— Q cursor-do not Gip�/�/QO 't T use the return Name of Inspector key. q s C //L✓a y � Company Name P� O X 472 9 Company Address City/Town State Zip Code Cof�F�-ti) �f3—�FIB � 3619 ss 289z Telephone Number S2 `UO License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site 'sewage disposal systems. I am a DEP approved system Inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: Passes ❑- Conditionally Passes ❑ Fails ❑ Needs urther Evaluation by the Local Approving Authority Ins ors Signature Date The system inspector shall submit a co of this inspection report to the Approving AuthorityBoard Y P� PY P Po PP 9 of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of Inspection and under the conditions of use at that time.This inspection does not address how the system will perform In the future under the same or different conditions of use. tsins-I of o Title 5 Official Inspection Form:Subsurface Sewspe Disposal System•paps 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owners Name Information is required for every yam'�1 1 S 1-1924 U rt/..—O/ page. City/Town State Zip Code Date e�of Inspection B. Certification (cont.) Inspection Summary: Check,A,B,C,D or E/always complete all of Section D A) 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: -Poo sT G1`/ /� /J C`Yd✓/ia� dG I/Yar B stem Conditional) Passes: Y Y N/ 9 ❑ e or more system components as described in the'Conditional Pass'section need to be rep d or repaired..The system,upon completion of the replacement or repair,as approved by the Bo of Health,will pass. Check the box fo es',Orion or"not determined'(Y, N, ND)for the following statements. If*not determined,"please lain. The septic tank is metal an ver 20 years old or the septic tank(whether metal or not) is structurally unsound,exhibits substantial in tion or exMtration or tank failure is imminent.System will pass inspection if the existing tank is rep with a complying septic tank as approved by the Board of Health. "A metal septic tank will pass inspection if it is cturally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 rs old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins•i mo Title 5 Offldal Inspxtlon Form:Subst0aae Sewage Disposal System•Pape 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments s e 1 Property Address Owner Owner's Name information Is ma- required for every 3 I page. Cityfrown IF State Zip Code Date of Inspection B. Certification (cont.) N14- B) System Conditionally Passes(cont.): ❑ servation of sewage backup or break out or high static water level in the distribution box due to b en or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass in ion if(with approval of Board of Health): ❑ broke ipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ; ❑ obstruction is. moved ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is I eled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a yea a to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board o alth): ❑ broken pipe(s)are replaced ❑ Y ❑ N ND(Explain below): obstruction is removed ❑ Y ❑ N ❑ ND xplain below): C) Further Evaluation is Required by the Board of Health: NIA ❑ Co exist which require further evaluation by the Board of Health in order to determine if the system is o protect public health,safety or the environment. 1. System will pass unles—sVeato of Health determines in accordance with 310 CMR 16.303(1)(b)that the system Is not oning in a manner which will protect public health - safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface wate ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland o aft marsh t51na•T1n0 Title 5 OMdeI Inspectlon Form:Subvidace Sewage Disposal System•P 17 Commonwealth of'Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address &t.- It t a.-vt Owner Owner's Name , 1 information is required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) N (� 2. System will fall unless the Board of Health(and Public Water Supplier,if any) terrnlnes that the system is functioning in a manner that protects the public health, sa and environment: ❑ he system has aseptic tank and soil absorption system(SAS)and the SAS is within 100 feet o surface water supply or tributary to a surface water supply. ❑ The stem has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The syst has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a se pb nk and SAS and the SAS is less than 100 feet but 50 feet or more from a private water pply well*. Method used to determine di nce: *"This system passes if the well water an sis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the pr nce of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other fal Is criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: r, D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all Inspections: Yes No ❑ My 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 Static liquid level in the distribution box above outlet invert due to an overtoade& or clogged SAS or cesspool I ❑ N ,$ Liquid depth in cesspool is less than 6°below invert or available volume is less than'A day flow t5ins-I M0 Title 5 OfAdel Inspection Form:Subsnufece Sewage Disposal System•Pape 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments o, t �� S ts✓-1 Property Address Owner Owner's Name Information Is 6AAy1S required for every page, City/Town State Zip Code- Date of Inspection B.Certification (cont.) Yes No E] 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. ❑,4/ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ Wk ;n Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ Nla Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ p�IF Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. The system fails:I have determined that one or more of the above failure �. criteria 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. E) Large systems: To be considered a large system the system must serve a facility with a de flow of 10,000 gpd to 15,000 gpd. For large syst you,must indicate either"yes"or"no"to each of the following, in addition to the questions in Sectio Yes No ❑ ❑ the system is wit 0 feet of a surface drinking water supply ❑ ❑ the system is within 200 fee a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen s itive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a p 'c water supply well If you have answered"yes"to any question in Section E the system is 'dered a significant threat, or answered"yes" in Section D above the large system has failed.The owner operator of any large system considered a significant threat under Section E or failed under Section D s upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the ap riate regional office of the Department. t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pape 5 of 17 Commonwealth of Massachusetts Dom Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address LIA Owner Owners Name �^ Information is yX required for every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done.You must indicate"yes'or"no"as to each of the following: Yes No ❑ (� Pumping information was provided by the owner,occupant,or Board of Health ❑ �] Were any of the system components pumped out in the previous two weeks? ❑ Has the system received normal flows in the previous two week period? ❑ a] 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? 1p ❑ Was the site inspected for signs of break out? , • �] ❑ Were all system components, ` 1nt�e SAS, located on site? �tJ ❑ 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: ('g] ❑ 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)1310 CMR 15.302(5)J D. System Information Residential Flow Conditions: Number of bedrooms(design): Number of bedrooms(actual): - DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 3 3 NJ 151ns•11/10 Title 5 Official Inspection Pam:Subsurface SwAV Disposal System-Pepe 0 of 17 T Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Forth -Not for Voluntary Assessments 639 N1c�k Q .J( s Property Address `1 Owner Owner's Name information Is 441evg Vt(5 3- 15'— required for every CitylTown page. State Zip Code Date of Inspection D. System Information Description: L .� d-- {Do, .T ano Z -4-�cPw .1 Sl Lq?��1��t�c.�clQ��xt��tLit2- %'rt'v^Z Yw) = 54.9 q '39yg A94r . ms 4-t l 7&q Number of current residents: Does residence have a garbage grinder? ❑ Yes No 'Is laundry on a separate sewage system?[if yes separate inspection required) ❑ Yes No Laundry system inspected? El Yes No,14 Seasonal use? ❑ Yes No Water meter readings,if available(last 2 years usage(gpd)): Detail: L, A.$ Z ys /d °�_ 7�d�s 14 d Yn Sump pump? ❑ Yes No n' Zoo Last date of occupancy: Clbte �✓��C ,mercI Ilindustrial Flow Conditions: Type of Establishm Design flow(based on 310 CMR Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft.,etc.). Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? es ❑ No Water meter readings,if available: t5ins-11/10 Title 5 Official Inspection Fonrr.Subaxfoce Serape Dispose,System-Pepe 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Fong -Not for Voluntary Assessments Property Address Gar l�ta�i Owner Owner's Name information Is ZGo required for everye �h page. City/town State Zip Code Date of Inspection NjD. Sy Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records:, Source of information: Was system pumped as part of the inspection? ❑ Yes IN No. If yes,volume pumped: ri/A gallons How was quantity.pumped determined? Reason for pumping: Type of System: Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no)(if yes, attach previous inspection records, if any) ❑ Innovative/Altemative 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): t5ins-11110 Title 5 Official Inspectlon Form:Subsurface Sewage Disposal System•Pepe 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 0 �g ►'�,k.kQils �a.., Property Address Owner Owner's Name t�n information is required for every page. Cityrrown State Zip Code Date of Inspection D. System Information.(cont.) Approximate age of all components,date installed(if known)and source of information: o -8-g6 901(e Were sewage odors detected when arriving at the site? ❑ Yes I No Building Sewer(locate on site plan): ' Depth below grade: feet Material of construction: { ❑cast iron %A0 PVC ❑other(explain): / Distance from private water supply well or suction line: 7vr � feet Comments(on condition of joints,venting,evidence of leakage,etc.): Septic Tank(locate on site plan): f2i Depth below grade: feet Material of construction: concrete ❑ metal / ❑fiberglass ❑ polyethylene ❑other(explain) ,of 1144q If tank is metal,list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ® No+4. Dimensions: �V ° Sludge depth: t5ins•11110 Title 5 Official Inspection Form:SubwAece Sewage Disposal System•Pape 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner Owners Name information Is m —J , ,, ,P , 17 1 --ff required for every ) ,�y� �J page. Citylrown State Zip Code Date of Inspection. D. System Information (cunt,) Septic Tank(cont.), Distance from top of sludge to bottom of outlet tee or baffle 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 How were dime ions determined? ""` /-2V Comments(on oTN�ES59R� ations, WAWA let tee or,baffle condition, sv;� ur ntegrity, liquid levels as related.t outlet invert,evidence leakage, etc.): AAX1a4vZ1e--)11'1- --Old N/�G ass Trap(locate on.5 plan): Depth low grade: feet Material of con coon: ❑concrete ❑m 1 , ❑fiberglass ❑polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date 15ins-1 t110 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Pape 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspect on Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address owner Owners Name informatlon Is O/ required for every Cityfrown State Zip Code Date of Inspection page. D. System Information (cont.) , Ce�c�Bt is on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels�Telat o outlet invert,evidence of leakage, etc.): /L/ T ht or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth low grade: Material of co ruction: ❑concrete metal ❑fiberglass ❑polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: allons per day Alarm present: ❑ s ❑ No Alarm level: Alarm in wo ' g 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 t5ins-11110 - Tile 5 Offidal Inspecdon Form:Subsurface Sewage Disposal System•Pape 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments a Property Address Owner Owner's Name information is On,3 •�/� p264, ,�-/S'�/ required for every page. Cttyfrown State Zip Code Date of Inspection D. System Information (cunt:) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level aboveputlet iin ert r�� d ) Comments(note if box iJ44d1rf/dAistri��to o'utTets equal,�ny evI nce�6f solids carryover,any evidAnce of leakage into or out of box,etc.): Pum�16hamber(locate on site plan): Pum wo order. ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump c ber,condition of pumps and appurtenances,etc.): Soil Absorption System (SAS)(locate on site plan,excavation not required): f SAS located, explain why(.hcraV� 0209,W"'-° fF vnaesa✓QC-1) 1!b��.? (y°✓ S I-d cj T cvo✓(�1/9 D�a ,*OrL4 s c der CY.e rP cc� ��`f %P�f�� Z S 7�?drw� w�/U p��d{d �t�✓ SC�� 5�. t5ins•11110 Title 5 OlMdal Inspecdon Faro:Subamfew Sewepe Dlepoaal Symm-Pepe 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal Systeem/ Form-Not for Voluntary Assessments Property Address owner Owner's Name information Is required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: leaching pits number !lx-( ❑ leaching chambers number: ❑ leaching galleries number. ❑ leaching trenches number,length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number. ❑ innovative/aftemative system Type/name of technology: Comments(note con of soil,sigryt of hydraulic failure,le el of ponding,d mp soil,condition of vegetation,etc.): ` ) �� 6A f ylyV7�'klf� ' m4cess Is(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins 11/10 TWO 5 Mdal Inspedw Form:Sub urfaoe Seweps Disposal SysWn•Peps 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �Mc�ck�l� f c-J Property Address Cx� l(c a-►t - Owner Owner's Name r Information is required for every page. City/Town 9State Zip Cade Date of Inspection D. System Information (cunt.) Co�m�tia?nb{ o1 condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): IV14 (locate on site plan): Materials of co ction: Dimensions Depth of solids Comments(note condition of soil,signs,of hydrau 'lure, level of ponding,condition of vegetation, etc.): P t51ns•11110 Title 5 Olfldal Inspection Form:Subsurface Sewage Disposal System•Peps 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System lForm -Not for Voluntary Assessments Property Address Owner Owners Name information isYItS ry�/�1 required for every __l6 page. Cityfrown —IL Sta Zip Code Date of Inspection D. System Information (cunt.) 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 i 1 i Z 3 11 4 3'- 8" A-4 '5 3._orr 13 _4 3 S,��lr t5lns-11/10 Title 5 Most Inspection Form:Subsurface Sawa"Disposal System-Pape 15 of 17 Commonwealth of Massachusetts ' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owners Name Information Is `S y QLGc�( required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Site Exam: 13 Check Slope k."/ [� Surface water riaw- Nk aarca [� Check cellar 1 � ® Shallow wells �v4-% QY �J►1 544-e �a'0vvr�- -AecelL 6uvkoa� Estimated depth to high ground via a :T4_ pt 5Tew k 3-5'(go It vv,,,,a cs"evOWOUft4weA I—OG s- v►�(��>m�ioar.7a Senci t''t A ;Tt'Yt'!.M*e a Please indicate all methods used to determine the high ground water elevation: INN Obtained from system design plans on record + c,), Uewv rb.Nf P Ir, 13"1 If checked,date of design plan reviewed: Dace ❑ 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: >•.,r l.i�wYll'l..�r n w��h*v' h i 1��. tlr� Y Q.�/ � .O � .v.xl��..w/,o-��. t till �;. O 84" 13�z+/.OWL I&2'f � O O . I �(Q (4.5 �a Alm Gvw>7d �� 0rcv�r t✓e� Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•Wit) Title 5 Oftal Inspection Form:SubWace Sewape Disposal System•Pape 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �1y1•��te�l 's Property Address Gam.�I i,eM Owner Owners Name inform o requ Fred forn every page. CityfTown State Zip Code Date of Inspedion E. Report Completeness Checklist Inspection Summary:A, B, C, D,or E checked Inspection Summary D(System Failure Criteria Applicable to All Systems)completed (� System Information—Estimated depth to high groundwater, Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•11110 Tile 5 Of ial Inspection Forth:Subsudam Sewage Disposal System•Pepe 17 of 17 ASSESSOR'S MAP NO. PARCEL LOCATION SEWAGE PERMIT NO. VILLAGE Art INSTAL=LER'S NAME L ADDRESS d UILDER 0R OWNER DATE PERMLT ISSUED ZZ2-34L4 `I DATE COMPLIANCE ISSUED i 1� � '�� . � _ � � r Agreement: NO................... .. FEB.............................. THE COMMONWEALTH OF MASSACHUSETTS BOi�'�RU,OF`aH�ALTH C..............................OF....... .` P .�..... ............. Appliration for Disposal Works Tunstrurtion Vrrmit Application is hereby made for a Permit to Construct W or Repair ( ) an Individual Sewage Disposal System at: .�:.a-xG ------------ . i tl A F...i !aO..1 .-- Location-Address or Lot No. a � 1s v N sa,J...................• .........._.�::�f;.... ,.: „,. ................................................... Owner Address W � T �f ,<- ��n/� FlC ��;��.cJ !f� ,) 1J' rJf�' .j�t•�f .... .: .. z ••............:........f...........•-•--•..... t= = = ---....... ----. .... Installer Address Type of Building Size Lot--- .= = =.; ..Sq. feet U Dwelling ZNo. of Bedrooms..........E.............................Expansion Attic Garbage Grinder(/) g (,44 aOther—Type of Building CreL/`�............... No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures ---•--•-•--•------•----•-••-•-•-----•-------•--•----•-........................•--•-•----•---...---•-•................................................ �W Design Flow.....................;, ............gallons per person per day. Total daily flow............._�..3..0.............gallons. 9 Septic Tank—Liquid capacityi.P.GQ..gallons Length................ Width................ Diameter__--_-__--_-_- Depth_4:.`6 F.F �(� Disposal Trench—No. A�......... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No----------/.____----- Diameter.....6........... Depth below inlet...Z............. Total leaching area..?h_ ....sq. ft. Z Other Distribution box ( ) Dosing tank,( ) u'11 'OF t¢9 CIAs,.f 0„l/ W Percolation Test Results Performed by............ M.__ .F-_, . ry✓.•................. Date.._,;;. ?!` ......... a Test Pit No. I......?......minutes per inch Depth of Test Depth to ground water.,A?5.rec,.__.-e.,j (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water_..................... P4 ...................................................... .......•••--•-•-------••---•••---•--••---......................................................... D Description of Soil.............. ........s,-nl.: ...•-fie..e= 5-- (xj Z r-Ly(J r---•- ....5 A W UNature 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 be issued ky the board of health. /- Signed........ Date Application Approved BY '•_-. --•••--�••..... Date - Application Disapproved for the following reasons___ ______________________________________________..----------•.........................•_. ---•-•- ........................................•---------•--•-------...-•------......-----------...-----------....------------------•-------------•--=--••------------------------------------------------------ Date PermitNo......................................................... Issued-....................................................... Date ' THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 1....�?..v .. ..............OF.. (5rrtif iratr of f1 outpliFanrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by........... e,7:.----------. ..e.e.AJ.......I..................................................................... Installer • p y has been installed in accordance with the.provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......................................... dated_............................................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCT/I.O_N_ SATISFACTORY. -- DATE f /. .._1C... I^ Inspector--••--.......... THE COMMONWEALTH OF MASSACHUSETTS _ BOARD OF HEALTH } 2 (?... ............OF.. `� / .�.................... ® --� Z �- No....................... FEE.. .-..-.--.:. Disposal Works T-Lnnotrudion rranit Permission is hereby granted........5' "t C .......... .................................. Y to Construct (A) or Repair ( ) an Individual Sewage Disposal System at No 1. a t -1 .-t _ .5: _F�..,.t... S_ 4.�.� �i �" m --------------•--- street A as shown on the application for Disposal Works Construction Permit No: __{:._C Dated..........-t.. i�. ':�' sa'okeaAc� 1 DATE........................ ................................................... FORM 1255 HOBBS & WARREN. INC., PUBLISHERS - f -' �'•-� ,.' SOIL LOG N0, 1 r N0. 2 I T E LAN Z �s 0 v w L ✓ r _ j J 4 5 TOP Ui QUN D d I W N 11 1717-77E' �,/� � __ f ' S✓ �E 6 G�Y.ltS f rf`) r �MY�i�L 'T 10 _s s x.,. iN.EI: __----_..- �=�____ �L. �, Lin ,• r` � _ ��:...�- . . .. {Y'v 4 •nr �M � � �`':' _ 1 1-4-�q-._. / --._ _� C.'0 137! vr"i �n 12 , y 1 N,E lW tvIuG� � L n . `' 14 D/B W/ fit` SUMP ,N� �, '' �n �t � 14,E LIQUID LEVELC �t" Q / J LJ _ f OP 15 L .. PERC TEST RESU PRECASTSEPTIC TANK K WITH . � ,h� a r p �,,��",a�� PERC RATE : --.-.-.-. CAST IN PLACE INLET AND o _ __ ,� E� �� . 2g WHITNESSED BY: - ' A-- < F a t QUTET T "S PER TITLE r _ ` r �, a .__ BOARD OF HEALTH ! � SIZE : �:. �_ �, �: ; � _ , �_ � !� � � � `� . DATE: i I j PROFILE CIF PROPOSED SEWAGE SYSTEM SYSTEM DESIGNED BY THE TOWN OF :-_. `�'.; - REGULATIONS AND ,, STATE TITLE Tt FOR SUBSURFACE DISPOSAL OF SEWAGE . SCALE 114 = 1 0 N . B . 1. ALL PIPES SHALL BE SCHEDULE 40 P.N.C. SEWER PIPE 2. All PIPES SHALL BE - SLOPED 1,`4�� PER FOOT EXCEPT FOR ,�'� •, �, / THE FIRST 2 FEET OUT OF THE O / B WHICH SHALL BE LEVEL 3. DESIGN FLOW ___�_ ._ BEDROOMS AT 110 GALDAY ' PER BR. _ T . GAL/DAY p SEPTIC TANK SIZE X . .__' GAL . 2 1 C) Ov In �T 1 / USE �___ GAL. W __._ . _ GARBAGE DISPOSAL LEACHING SYSTEM : USE 1LE �Pts r EFFECTIVE AREA : SIDE f f BOTTOM Iv ►�L E� a zr , f TOTAL FLOW " ; r i' 4 TOTAL R.EQ D FLOW _� X r_ �_�-__ __ Wl GARBAGE DISPOSAL RESERVE F L D W _ Y_ ..._ ` ___ __ ._ �. _, G A L/DAY � ! G REFERENCE PLANS „ ._.__ APPROVED BY a # l i F 'w `IL ARN 4STk L BOARDRE HEALTH -� DATE V' G PROPERTY WNER _ SEE , BEDROOM 'sIwtGLt F AM1l`t 1 WCH LLiNG AI~w3TC. .a LET �' r-� �; � 'J �`- � �x � "i�` Z� !5 z 23 5 l 1 nn 3 E'�. LAM C- n-..._. ....,_,_._........ ...,:. .... ..._.._..., _......._...._..w..._.._.__.._.,.. ...._ ._.J.,._w...,_....._.. ...__ .__. .,.. ..._.. ..w,_.�..._... . r_a 5� i