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HomeMy WebLinkAbout0030 OTIS ROAD - Health 30,Otis Road Hyannis 't9 A' 311 - 057 # Commonwealth of Massachusetts ` 5?- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 30 Otis Road Property Address f-• Alan Morrow -] Owner Owner's Name information is required for every Hyannis Ma. 02601 Oct. 12, 2016 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 A. General Information filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not Thomas Roux use the return Name of Inspector ' key. - my Company Name 89 Mayflower Lane Company Address East Wareham Ma 02538 Cityfrown State Zip Code 774-678-9066 . - S14531 Telephone Number License Number r B. Certification I certify that l have personally inspected'the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection. . was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 16.340 of Title 5(31.0 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system 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. t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17. 4 a vs Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 30 Otis Road Property Address Alan Morrow Owner Owner's Name - information is required for every Hyannis Ma. t 02601 Oct. 12,2016 page. City/Town State Zip Code Date of Inspection B. Certification (cont.')' t , 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. m „ Comments: .B) 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. ' *fA 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): Vt5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts` Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments i 30 Otis Road Property Address Alan Morrow Owner Owner's Name information is required for every Hyannis Ma. 02601 Oct. 12,2016 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) m ' ❑ Pump Chamber pumps/alarms not'operational..System will pass with Board of Health approval if " pumps/alarms are repaired: t B) System Conditionally Passes (cont.): s ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipes) 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): . • - b- ❑ The system required pumping'more than times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): r ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ' ' ❑ obstruction is removed ❑' Y ❑ N ❑ ND (Explain below): > ;C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if x the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR ti 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ R Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 > Title 5 Official Inspeclion Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Fonn -Not for Voluntary Assessments „ 30 Otis Road Property Address Alan Morrow Owner Owner's Name information is required for every Hyannis "' Ma. 02601 Oct. 12,2016 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health; safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply.or tributary to a surface water supply. ❑ The system has aseptic 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:' a- **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. 3. Other: s D) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or"No"to each of the following for all inspections: Yes No . ❑ f ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspoolEl 2 " 'Discharge or ponding of effluent to the surface of the ground or surface waters - due to an overloaded or clogged SAS or cesspool El ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ® , Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins-3/13 r Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 30 Otis Road Property Address Alan Morrow Owner Owner's Name information is required for every HY annis Ma. 02601 Oct. 12, 2016 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary,to a surface water supply. ❑ ® Any portion of4a cesspool or privy is within a Zone 1 of a public well. El ® • Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence' of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ® The system is a cesspool serving a facility with a design flow of 2000gpd 10,000gpd. .1 El ® The system fails:a 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 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 D. Yes No ❑ ❑ the system,is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ the system is located in a nitrogen sensitive area (interim Wellhead Protection Area-.IWPA) or a mapped Zone 11 of a public water supply well " If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate F regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form =Not for Voluntary Assessments 30 Otis Road Property Address Alan Morrow ' Owner Owner's Name information is required for every Hyannis Ma. 02601 Oct. 12,2016 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done.You must indicate "yes"or"no"as to each of the following: Yes No ® , ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system,received normal flows in the previous two week period? ❑ ' ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as 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 approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential_Flow Conditions: Number of bedrooms (design): 3 '{ Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203`(f6r example: 110 gpd x#of bedrooms): +330 gpd t t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official. I nspectioh Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 30 Otis Road Property Address Alan Morrow Owner Owner's Name information is .required for every Hyannis Ma. 02601 Oct. 12,2016 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage,system?(Include laundry system inspection ❑ Yes 0 No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes 0 No Water meter readings, if available (last-2 years usage (gpd)): Detail: Sump pump? ❑ Yes'® No Last date of occupancy: Sept. 2016 Date Commercial/Industrial Flow Conditions: Type of.Establishment: Design flow(based on 31.0.CMR 15.203). ., 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? ❑ Yes ❑ No Water meter readings, if available:' t5ins•3/13 'Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form;-Not for Voluntary Assessments 30 Otis Road k Property Address Alan Morrow Owner Owner's Name information is Hyannis Ma' 02601 Oct. 12, 2016 required for every y , page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: T Date Other(describe below):; General Information Pumping Records: t Source of information: owner- . Was.system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped:, gallons How was quantity pumped determined? Reason for pumping: Type of System: ❑ Septic tank, distribution box, soil absorption system Single cesspool ❑ Overflow cesspool ❑ Privy . ❑ Shared system (yes orr 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):- septic tank and single pit with no d-box. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form,-Not for.Voluntary Assessments 30 Otis Road Property Address Alan Morrow Owner Owner's Name information is .required for every Hyannis Ma. 02601 Oct. 12, 2016 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: 37 years, House was built in 1979,from the as-built drawing. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC- El:other(explain): +10' Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank locate on site plan): p ( p ) Depth below grade: feet y Material of construction: " ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) a If tank is metal, list age:' years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions , 81x5.2'Wx5.3'H Sludge.depth: 211 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 97 z ` Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 30 Otis Road Property Address Alan Morrow Owner Owner's Name information is required for every Hyannis *' Ma. 02601 Oct. 12,2016 page. City(Town State Zip Code Date of Inspection D. System Information (cont.) 'Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 32" Scum thickness 3rr Distance from top of scum to top of outlet tee or baffle 5" . - .14r Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined?, measured Comments(on.pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The septic tank was in need of pumping at the initial inspection. The septic tank was pumped out the, following day. Both the inlet and outlet covers were replaced as well as the inlet tee. A return trip was made to verify the,repairs. e 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 t5ins-3113 M t Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Y j Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 30 Otis Road Property Address Alan Morrow Owner Owner's Name information.is required for every Hyannis Ma. 02601 Oct. 12, 2016 " page. City/Town State Zip Code Date of Inspection D. System Information (cont.), 'Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 'Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): .Depth below grade: Material of construction: ` ❑ concrete ❑metal _ ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: ` Capacity: gallons Design Flow: - gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): } *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No '' t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspectio' Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 30 Otis Road Property Address Alan Morrow Owner Owner's Name information is Hyannis Ma. 02601 Oct. 12, 2016 required for every H y ` page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate'on site plan): Depth of liquid level above outlet invert N/A 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.): There is no D-Box. , Pump Chamber(locate on site plan): T Pumps in working order: ' ❑ Yes ❑ No* Alarms in working order: F ❑ Yes ❑ No* Comments (note condition of pump chamber; condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain.why: The pit structure was inspected.There was 28" of water in the pit. There is still more than enough capacity.There is over 500 gal. of capacity remaining. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 30 Otis Road Property Address Alan Morrow ' Owner Owner's Name ? information is required for every Hyannis Ma. 02601 Oct. 12, 2016 page. CityFrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑_ leaching chambers ..number: ❑ leaching galleries number: ❑ leaching trenches number, length: 4 ❑ leaching fields number, dimensions: ❑ overflow cesspool_' number: ❑ innovative%alternative system 41 e Type/name of technology: Comments (note condition of soil, signs of hydraulic_ failure, level of ponding, damp soil, condition of" vegetation, etc.): _ TM The pit structure was inspected. There was 28" of water in the pit. There is still more than enough capacity. There is over 500 gal. of capacity remaining. r Cesspools (cesspool must be pumpedas-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 II� Dimensions of cesspool Materials of construction - Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 '- Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 30 Otis Road Property Address Alan Morrow Owner Owner's Name information is required for every Hyannis Ma. •02601 Oct. 12, 2016 , page.. City/Town State. Zip Code Date of Inspection D. System,Information,(cont.) Comments (note condition,of soil, signs'of'hydraulic failure, level of ponding, condition of vegetation, etc.): - x • 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.): N w i t5ins•3/13 .- Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 30 Otis Road Property Address Alan Morrow Owner Owner's Name ` information is required for every Hyannis Ma. 02601 Oct. 12, 2016 page. City/Town State 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 ` 1 ys// $6 t5ins•3/13 `. - Title 5 Official Inspection Form;Subsurface Sewage Deposal$y5tem•Page 15 of 17. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments G M 30 Otis Road Property Address t Alan Morrow Owner Owner's Name information is required for every Hyannis Ma. 02601 Oct. 12, 2016 page. City/Town "State Zip Code Date of Inspection D. System Information (cont.), , Site Exam: ' ® Check Slope t Surface water r ® Check.cellar` ; ® Shallow wells Estimated depth to high ground water: :" below 10' feet Please indicate all methods used to determine the high ground water elevation:, ❑ Obtained from system'design plans on record If checked, date.of design plan reviewed: Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: t . ❑ "Checked with local excavators, installers- (attach°documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: The abutting sites are at a lower elevation.' Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System'Form -Not for Voluntary Assessments M 30 Otis Road - Property Address Alan Morrow Owner Owner's Name information is required for every Hyannis a W. M601 Oct. 12, 2016 page. Citylrown State Zip Code Date of Inspection E. Report Completeness Checklist ; ®. Inspection Summary: A, B, C, D, or E checked,`.» ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed r ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 On 10/14/16 Septic Installer Jim Leboeuf spoke with Health Inspector David Stanton regarding 30 Otis Road,Hyannis. Mr.Leboeuf just wanted our office to document that he spoke with us regarding the allegation made against his employee\company. Mr.Leboeuf stated that the owner of said property is trying to blame them for breaking the 'septic covers during a recent septic pumping. Mr.Leboeuf stated that he spoke with his employee about the complaint and that his employee denied doing any damage to the cover. Mr.Leboeuf just wanted us to be aware of the situation and feels that nothing was done wrong on his/company rt incase any complaints come in to us. Vi AsBuilt Page 1 of 2 l A T ION S E W A G E PERMIT NO. ,� Ts VILLAGE tiny, a INSTA LLER'S NAME -i ADDRESS BUILDER OR OWNER DATE PERMIT ISSUED _� �79 D A T E C0MPLIA.NCE ISSUED 86 http://issgl2/intranet/propdata/p-rebuilt.aspx?mappar=311057&seq—1 10/12/201 b � � C D H A r CP FA O �� _ o N C ,•� (,� a 33 o f V -� �� �/ OO o `Z.� � �1 k � � , �, o9- No........................ Fxs. ..lJj ................ THE COMMONWEALTH OF MASSACHUSETTS BOARD F HE T _t Apptiration for Disposal Works Tonstrnrtiun ramit Application is hereby made for a Permit to Construct ( ) or Repair (r an Individual Sewage Disposal System at: .................. ............- a.._._.C .�/..s...... �r�,.-- ,ate-d................................................ -.::::: ; ...... Ztion- dd ess or Lot No. D Owner E Address a .....------•-- '� .. .G.f2.2ti4 '--------------•---............. -•--•-•--•--------............--•------.....-•----------.....------•-----•-•--.................... Installer Address Type of Buildings Size Lot............................Sq. feet V Dwelling—No. of Bedrooms................................ .Expansion Attic ( ) Garbage Grinder. Other—Type of Buildin ... 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........................................ aTest Pit No. 1................minutes per inch Depth of Test Pit--_.-_._............ Depth to ground water........................ fi Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ . 04 Description of Soil --•--------------�......----- •-----...-----------..._..................---•--•----•-•-......................................................... O ty x W --------•----------------------=----------- ------ U Nature 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 iITIE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in I operation until a Certificate of Compliance has been issued by the board of health. ISigne ..................... ...... D.... .-.-........_..... + Date Application Approved B . -_ Date Application Disapproved for the following reasons-------------•---------------------•--------------------------------------------------------------------•-------• -------------------------------------•---•-••--------------------•-----------------------•-•------------------•------......--------------------------------------------------------------------......... Date I Permit No......................................................... Issued'- Date No THE B� ^ �®ALTHC C OF /'9 ff GG.. TT .1_......0F......- '.......................... Appliratiun for Disposal Works Tonstrurtiun Frrmit 77�; Application is hereby made for a Permit to Construct ( ) or Repair (JO") an Individual Sewage Disposal System at: r 11 t L tion. ,,.dJes or Lot No. --�- � U ' /-�.}x-• .. _�t. ... r -----------•..................:................... ....•-------•-----..........----- W1-nor, Address Installer Address dType of Buildings Size Lot............................S feet aDwelling_., No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) p.l Other—'Type of Building ............................ No. of persons......................_:____ Showers ( ) — Cafeteria ( ) p' Other fixtures •-• - '- --•-------------------------------------•--...------•-----------•--•-•---.........._.. W Design Flow:.... ...............................:.....gallons per person per day. Total daily flow............................................gallons. WSeptic 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 ( ) Percolation Test Results Performed by.......................................................................... Date........................................ aTest Pit No. I................minutes per inch Depth of Test Pit...................__ Depth to ground water........................ r= Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ �+ ------------------- - - ----------------------------------- •--------------------- ------- •...... ------------------------- •........ ._. O Description of Soil.........................: 1 x W ........................................................ -----•--••-----•-----------------------•-•--•••--•-••---- U Nature of Repairs or Alterations—Answer when applicable___.�tn.... _ ytuz� Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'TTLE 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'laealth. Signe ...... ... •--••---. ---••-------------•--------••----•----- ----•- ---. .•. Application Approved By_---•-- - ...: .n_ 1 r _._ i f Z.7 ._ . --••• . -- l Date Application Disapproved for the;.following reasons:- .............................:. :: ..-------••------------------•-------......--•----•-••••-----..........._.... •------.._.........----••---- ----- ----.................................-------•--- Date Permit No......................................................... Issued_._��1- X<.. V, Date THE�CQMMONWEALTH OF MASSACHUSETTS ' BOARD OF HEALTH .......:. , !r// t........OF............ . .. . .. .:r.. .. %1,11.1rrufiratr of TuntpliFanre y �a THIS IS �O C•� h IFY, That t Inu v> 1,&ewage Disposal System constructed ( ) or Repaired by-_---- f/_ ..A.. ..... �'1' --•-- •.................................................• ----...._ V{{'� ✓ Install has been installed in accordance with the provisions of T j of The Statknitary Co as.described in the application for Disposal Works Construction Permit No.-.. __._....... dL ated_. .._".& k ..... + THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONS- UED AS A GU• RANTEE THAT THE SYSTEM:1A1 L FUN TION SATISFACTORY- DATE ... f -= Inspector. ......... - . ... �F THE COMMONWEALTH OF MASSACHUSETTSM BOARD OF HEALTH �1 , 1 "L( . ............0F........ Q!�rd..No ....... 1 .. FEE....... ............. aiupuu 1 r un#r wn Permission is hereby granted_........_ _ --yrnfit .I-•---•-••-••.... ............................. to Construct j or Repair, fn nd ual Sewage D al S at No.•-- �,1--- .. GLr!X�-----J.4L Street t as shown on the application for Disposal Works Construction_ Perna- �N0./�//___ ___.. Dated.. ./,.. x �/ DATE----•.... �.. 4__�_•_ f- �_.........----- Boar eaith d of H - FORM 1255 HOBBS & WARR'EN. INC.. PUBLISHERS O S W 0. 4 (A W ac 3 W Q N c _W (A C W � � W W W: Q Z 4n V fA ic ac Q W aC 16 y m O W W del C im y h /r 03 No.................... Fx$........ .... .... THE COMMONWEALTH OF MASSACHUSETTS BOAR® F HEALTH _.. .._.......................0 F..... .......................-.........------------------...............---------------- Applira#ion for Uiipooal Workii Tonitrnrtion Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at ..............__........------...---• ............--- ..._................. . --•-------•------------_-----...... L.............�.._..--•----•--- - or Lot No �/ cation-A e� . `J ....:u'....... `''f'...- .............................................. a �v,�.,,ss Oyner Address............ ....... ..........••............................................... --...•--•---•-••-•--.._................. ....-•-.....•-••----....................... Installer Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers — Cafeteria da Design Flow............................................ allons er erson er da . Total daily flow Other fixtures --------------- ------------------------------------------...... .•--•-- W .g g P P P Y Y ............................................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........................................ 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........................ o - •-------- _ . . :............•.-•-------------------------------------•-------------------------------------------- Descriptionof Soils Q G�•--......-••....... -•••-•-•....---••••-•••--•••----•--------------•--------••----••••......•................................................ W -•--•--•••••---------------------•-•--••••-••-•-••------------------------------------------------•--------------------------------------- .......... Nature of Repairs or Alterations—Answer when applicable x ------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions'of iITL r:" 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has ben issued b the board of health. Signed l.... -7-----------------------------•-------- � �/ / Dat Application Approved By.....-...... .�. ..-- - l1. 7--!/- 704� _.... ---••-•••• Date Application Disapproved for the following reasons---------------------------------------------------------------- --------•-----•--•---•••-•••--......--•-•••.... -••-••••-••••................••••----••-••--•-.......•-•----------------•--•---------•---••-------------•-•-•-•....._..-----------------------•-•- ............................................... Date �.J._-Permit No.--=..........................=-•------•---------•...... Issued-------✓���-.................................. Date THE COMMONWEALTH OF MASSAgCHUSETT,S BOAR®��FIE LT OF...... ......... .......... ...... s„ •'.- Appliration for Dinpusal Workii Toutitrud U Prrmit s Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal SystP�l at* c f r , I c io A e � or Lot No. I' F ............. .............. . .�r..�.............................. . ............... ...__.. ..... .............................. ................... ....... r Address W /................... ........................................... .............••----.....---....•-•••------------•. - Insta er Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms------------------------------ -----------Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers — Cafeteria P I 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. I................minutes per inch Depth of Test Pit.................... Depth to ground water.................. f� Test Pit No. 2...i.....___._..minutes per inch Depth of Test Pit..........::........ Depth to ground water._: -----------.------- .............•---•---•-------......................................................... ODescription of So -� --- ---------... .►.... ---•--------------------------...---------•--------------x V ........................................................................ -•------ - ---------------------------------------- W -------------------------- Iz UNature of Repairs or Alterations—Answer when applicable-------- --•--- ... . ..... .: .....................................--•--•--•----•--------------------------------................-------------------------------------------'... . ---------- ---....... •------------`t,--- Agreement: The. undersigned agrees to install the aforedescribed Individual Sewage Disposal System iri"accordance wit II the provisions'of TIT?.;,,. 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has beqn issued b the board of health. Sign� .. ......................... f �r ,Iate/ �� ... Application Approved By....... �- L � "` t................ .......' Date Application Disapproved for the following reasons:.......................................................... ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------= Date PermitNo......................................................... Issued...................................................... Date THE COMMONWEALTH OF MASSACHUSETTS B0ARD F HEAL. T.'.'�'". '..................OF... � ............................ •`�C�rr�ifirtt�e laf (�n�t�li�a�tr� TIS TOE�T F , That the Inu:vadual Sewage Disposal System constructed s( ) or Repaired r by -•------- ------ ................. y ----- -----;----•------•-- ---- --------- ................ ........----------•--- / I 11 at - .. �i ,....................--•--------------- ---------- .............-•----------------•----------------------•----- •- ----------------- has been installed in accordance with the provi ons of TI •' 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No____ .......... dated da.ted--------- .+........... , 5 THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM Wd L FU TI N SATISFACTORY � „ DATE 'zh 'ar-0 y Inspector THE COMMONWEALTH OF MASSACHUSETTSt „ �.. BOARD . F "HEAL tt. .. ....... ............ .... .. ..OF............................................................... .._..._.........- - " No *` � ., FEE........................ Permission is hereby granted -=----------- ------ - , ---------.............__ to Consttu (. ) or r ( an vual Se�rage Disposal System 4. .......................................... Street 1 ........... as shown on the application for Disposal Works Construction P It No :___.. :..__ ` Dated.__ __. :_.�................ --•- .... .. ..................•--- Board of Health DATE.. . ?�� �' ' ---- -- ' FORM 1255 HOSES & WARREN, INC.. PUBLISHERS -,:....•.� tin... - .:..:, ,....... - :,r ,`.