HomeMy WebLinkAbout0024 OVERLEA ROAD - Health 24`,OVerlea Road, -
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BORTOLOTTI CONSTRUCTION, INC.
765 WAKEBY ROAD,MARSTONS MILLS,MA 02648
508-771-9399 508428-8926 FAX: 508428-9399'
SUBSURFACE SEWAOtEOISPOSAL SYSTEM INSPECTION FORM
PART A s
CERTIFICATION
Property Property Address:C2 41'a".
Date of Inspection: a?�/ . Inspector's Name:
O)vVer's Name and Actdress:
CERTIFICATION STATE ENT:
_ I certify that I have personally inspected the sewage.disposal system at this address and that the informa-
tion reported below is true,accurate and complete as of the time of inspection.The inspection was per-
formed b on my training and experience in'the proper,function and maintenance of on-site sewage
disposal stems. The System:
y fi`
Passes w
Conditionally.Passes a r
Needs Further E ation B Local Aproving Authority
�. Fails
Inspector's Signature: Date:
The System Inspector shall submit a copy of this inspection report to the Approving authority within thir-
ty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional
office of the Department of Environmental Protection. The original should be sent to the system owner '
and copies sent to the buyer, if applicable and'the approving authority.
�y NSPECTION SIIMM
I ARY•` ,
.
A)SYSTI PASSES• Y
V I have not found any information which indicates that the system violates any of the failure
criteria as defined_in 310 61R]1 ,303. Any failure criteria not evaluated are indicated.
below:
B)SYSTEM CONDITIONALLY'PASSES;
One or more system components need to be replaced or repaired. The system,upon comple-
tion of the replacement or repair, passes inspection. . ,
Indicate yes,nor,or not'determined(Y,W,OR ND). Describe basis of,determiriation in all instances. if
"not determined",explain why,not
The septic tank is metal;cracked,structurally unsound,shows substantial infiltration or
exfiltration,or tank failure is imminent. The system will pass inspection if the existing sep--
f tic tank is replaced with a conforming septic tank as approved by The Board of Health.
Sewage backkup or breakout or high static water.level observed in the distribution box is due'
to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. The
system will pass inspection if(with approval of The Board of Health):
- 1 -
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Broken pipe(s)replaced
,Obstruction is removed
Distribution Box is levelled or replaced
The System required pumping more than four times a year due to broken or obstructed pipe(s).
The system will pass inspection if(with approval of The Board of Health):
Broken pipe(s)are replaced
Obstruction is removed
C)FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by The Board of Health in order to determine if
the system is failing to protect the public health,safety and the environment.
1)SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE
SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE
PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 Feet of a surface water
Cesspool or privy is within 50 Feet of a bordering vegetated wetland or a salt marsh.
2)SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER
SUPPLIER,IF APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTION-
ING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENTi
The system has a septic tank and soil absorption system and is within 100 Feet to a surface
water supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and is with a Zone I of a public
' ; water supply well.
The system has a septic tank and soil absorption system and is within 50 Feet of a private
water supply well.
The system has a septic tank and soil absorption system and is less than 100 Feet but 50
Feet or more from a private water supply well,unless a well water analysis for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from
the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
1 than 5 ppm.
D)SYSTEM FAILS:
I have determined that the system violates one or more of the following failure criteria as defined
in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health
should be contacted to determine what will be necessary to correct the failure.
Backup of sewage into facility or system component due to an overloaded or clogged SAS
or cesspool.
Discharge or ponding of efluent to the surface of the ground or surface waters due to an
overloaded or clogged SAS or cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clog-
ged SAS or cesspool.
Liquid depth in cesspool is less than G"below invert or available volume is less than 1/2
day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed
pipe(s). Number of times pumped
2-
_ _ I
1
SUBSURFACE SEWAGE'DISPOSAL SYSTEM INSPECTION FORM
PART A
r CERTIFICATION-(continucd)
•
Any portion of the Soil Absorption`System,cesspool or privy is below the high groundwater
elevation.
Any portion of a cesspool or privy is within 100 Feet of a surface water supply or tributary to
r a surface water supply
Arty portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 Feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 Feet but greater than 50 Feet from a private.
water supply well with no acceptable water quality analysis. If the well has been analyzed
to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic
compounds;ammonia nitrogen and nitrate nitrogen.
E)LARGE SYSTEM FAILS:''
The following criteria apply to a large system`in addition to'the criteria,above:
.' The design flow of a system is 10,000 gpd or greater(Large System)and the system is a significant
-`"='threat to public health and safety and'the environment because one or more of the following
' conditions exist:
The system is within`400.Feet of asurface drinking water'supply
The system is-within 200 Feet of a tributary"to a surface drinking water supply
The Sy located in a'nitrogen'sensitive area Interim Wellhead Protection Area
(IWPA)or a mapped Zone 11 of a public water supply well.
The owner or operator of any such system shall bring the system and facility into full compliance with the
groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local
regional office of the Department for further information. ,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
Checkif the following have been done:
_Pumping information was requested`of the owner,occupant,and Board of Health.
j None of the system components have been pumped for atleast two weeks and the system has
been receiving normal.flow rates during that period. Large volumes of water have not been
introduced into the system recently or part of this inspection.
✓ As-built plans have been obtained and examined. Note if they are not available with N/A.
r/The facility or dwelling was inspected for signs of sewage back-up.
_ The system does not receive non sanitary'or industrial waste flow:.,
.✓The site was inspected for signs of breakout :° `°
s x: x
_All system components,"excluding the Soil Absorption System, have been located on site.
The septic,tank,manholes,were uncovered,opened,and the'mterior of the septic tank was in-
spected for condition of baffles or tees,material'of construction,:dimensions,depth of itquid,
depth of sludge,depth of scum. .
The size and location of the Soil Absorption System on the site has been determined based on
existing information or.approximated by non-intrusive methods.
-3-
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST(continued)
�he facility owner(and occupants,if different from owner)were provided with information on
the proper maintenance of Subsurface Disposal System
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
FLOW CONDITIONS
t/
RESMU.NTIAL: ,
Design Flow Ions Number of Bedrooms: Nu r of Current Residents:
Garbage Grinder: Laundry Connected To System:� Seasonal Use
Water Meter Readings,if. 'fable:
Last Date of Occupancy:
COMMERCLAIJINDUSTRIAL:
Type of Establishment:
Design Flow: aallons/day Grease Trap Present: (yes or no)
IndusWal Waste Holding Tank Present:
Non-Sanitary Waste Discharged To The Title V System:
Water Meter Readings,If Available: Last Date of Occupancy:
OTHER: Describe)
Last Date of Occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System Pumped as part of inspection:_ If yes,volu a pum Qallons
Reason for pumping:
TY77OF SYSTEM:
✓✓ Septic Tank/Distribution Box/Soil Absorption System
Single Cesspool
Overflow Cesspool
Privy
Shared System(If yes,attach previous inspection records, if any)
Other(explain):
ROXIMATE AGE of all components,date installed(if known)and source of information:
Sewfige odors detect hen arriving at the site:f/�T
-4-
I
' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM .
C
`GENERAL INFORMATION (continued)
SEPTIC TANK: v
Depth below grader"_ Material of Construction: concrete metal FRP—Other
(explain)
t Dimisions: ',Y ' k Sr Sludge Depth: " Scum T11ickness:
Distance from top of sludge to bottom of outlet tee or baffle: 3 y
Distance from bottom of scum to bottom of outlet tee or baffle:
Comments: (recommendation for pumping,-condition of inlet and outlet tees or allies,depth of liquid -
"level in relation outlet invert structural 00 inte 't evidence of le ka e, etc.
Y g
rr
P,
.r. .
GREASE TRAP:4Q
Depth Below Grade: Material of Constriction: ' concrete metal FRP Other
' (explain) — — — --
Dimensions: Scuiii.Thickness:
Distance from top of scum to top of outlet tee of baffle: '
Comments: (recommendation for'puiifping,condition of inletand outlet tees or baffles;depth of liquid:
level-in relation to outlet inverts structural integrity,evidence of leaknge,'etc,)
.Rs
TIGHT OR HOLDING TANK: lid i 3
Depth Below Grade: Material of Construction: concrete metal FRP Other(explain)
Dimensions: `. Capacity =6 gallons Design Flo« >;allons/day, -
Alarm Level;
Comments: (condition of inlet tee, condition of alarm and float switches. etc:)
DISTRIBUTION BOX: _
Depth of liquid level above outlet invert:
Commenti:.(note if I el and distribution is equal,evidence of solids carryover,`gvidence of leakage into
/orr oFu of box,etc.)
_PUMP CHAMBER
TPttmp is in wdrking order: <<,,. , ,:r), �..;a, ,,. ;ya.'a .by
_ ,Comments: (note condition,of pump chamber;condition of pimps and appurtenances,etc.)
t
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
SOIL ABSORPTION SYSTEM(SAS):_
(Locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive
methods) If not determined to be present,explain:
Type:
Leaching pits,number:L_Leaching chambers, number: Leaching galleries,number:
Leaching trenches,number,length:
Leaching fields,number,dimensions:
Overflow cesspool,number:
Comments: (note condition of soil,signs of hydraulic failure level of ponding,condition of vegetati ,.
etc.
LOP
J
CESSPOOLS::
Number and configuration: Depth-top of liquid to inlet invert:
Depth of solids layer: Depth of scum layer: Dimensions of Cesspool:
Materials of construction: Indication of groundwater:
Inflow(cesspool must be pumped as part of inspection)
Comments: (note condition of soilk,signs of hydraulic failure, level of ponding,condition of vegetation,
etc.)
PRIVY:
Materials of construction: Dimensions:
Depth of Solids:
Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,
etc.)
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3 .
SUBSURFACE`SEWAGE�DISPOSAL'SYSTEM INSPECTION FORM
PART C
SYSTEM`INFORMATION (continued)
SKETCH OF SEWAGE uDISPOSAL SYSTEM k
Include ties.to atleast two permanent references, landmarks or benchmarks.
Locate all wells within 100:Feet." All
r = k-t
..
w e "
,
,
r e
e t ,
r r 1
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DEPTH TO GROUNDWATER. .a "
Dotli to groundwater °, Feet
,
Method of Detennunation or Ap roxim Lion.
�Yr PD .,4
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BORTOLOTTI CONSTRUCTION, INC.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Address Prop QO P G
Date of Inspec} M Ow
ner
wner
S� ✓(l
PART A — CHECKLIST
CHECK IF THE FOLLOWING HAVE BEEN DONE: Ch_
//PUMPING INFORMATION WAS REQUESTED OF THE OWNER,OCCUPANT,AND BOARD OF HEALT
NONE OF THE SYSTEM COMPONENTS HAVE BEEN PUMPED FOR AT LEAST TWO WEEKS AND THE SY
RECEIVING NORMAL FLOW RATES DURING THAT PERIOD. LARGE COLUMES OF WATER HAVE NOT BEEN O
/THE SYSTEM RECENTLY OR AS PART OF THIS INSPECTION.
v AS-BUILT PLANS HAVE BEEN OBTAINED AND EXAMINED. NOTE IF THEY ARE NOT AVAILABLE WITH N/A.
THE FACILITY OR DWELLING WAS INSPECTED FOR SIGNS OF SEWAGE BACK-UP.
A-- THE SITE WAS INSPECTED FOR SIGNS OF BREAKOUT.
ALL SYSTEM COMPONENTS,EXCLUDING THE SAS,HAVE BEEN LOCATED ON THE SITE.
HE SEPTIC TANK MANHOLES WERE UNCOVERED,OPENED,AND THE INTERIOR OF THE SEPTIC TANK WAS INSPECTED
FOR CONDITION OF BAFFLES OR TEES,MATERIAL OF CONSTRUCTION,DIMENSIONS,DEPTH OF LIQUID,DEPTH OF SLUDGE,
DEPTH OF SCUM.
SHE SIZE AND LOCATION OF THE SAS ON THE SITE HAS BEEN DETERMINED BASED ON EXISTING INFORMATION OR
APPROXIMATED BY NON- METHODS.
THE FACILITY OWNER(AND OCCUPANTS,IF DIFFERENT FROM OWNER)WERE.PROVIDED WITH INFORMATION ON THE PROPER
MAINTENANCE OF SSDS.
PART B — SYSTEM INFORMATION
FL W CONDITIONS
RESIDENTIAL /1
No of Bedrooms o4-No of Current Residents �f V _Garbage Grinder
Ls Laundry Connected to System Seasonal Use
NONRESIDENTIAL: .
Calculated flow
WATER METER READINGS,IF AVAILABLE:
• _Pumping Records and Source of Information: GALLONS
SYSTEM PUMPED AS PART OF INSPECTION? /0 IF YES;VOLUME PUMPED = GALS
Reason for Pumping:
TYPE OF SYSTEM:
.-"'- Septic tank/distribution box/soil absorption system
Sing
le Cesspool 9 of p Overflow Cesspool Privy.
Shared system (if yes, attach previous inspection records, if any)
Other(explain)
Appro3d ate age of all components. Date installed,if known. Source of information. /
le
SEWAGE ODORS DETECTED WHEN ARRIVING AT THE SITE? CJ
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B — SYSTEM INFORMATION (Continued)
SEPTIC TANK: _
Depth below grade: Dimensions: 5—
Material of constructi ncrete Metal FRP Other}
Sludge Depth i Distance from top of s�udge to bottom of outlet tee or baffle
Scum Thickness �� . Distance from Top of 5yim to top of outlet tee or baffle
Distance from bottom of Scum to bottom of outlet tee or baffle
Comments: �/1�[ i'�
.�s i (,
DISTRIBUTION BO DEPTH OF LIQUID LEVEL ABOVE OUTLET INVERT
Comments:
PUMP CHAMBER: Pum sin workin order?
Comments:
SOIL ABSORPTION SYSTEM (SAS):.
IF NOT PRESENT,D(PLAIN:
TYPE: QCoo
Comments: 41)
( mom 0 /ylsj PCI�iO S lJZc�
s/ -
22.
CESSPOOLS: Q Number and configuration
Depth of solids layer
j Depth of scum layer
Depth—top of liquid to inlet invert p
Dimension of cesspool Materials of construction
Indication of groundwater inflow(cesspool must be pumped) i
Comments: F
PRIVY:
Materials of construction
".
i Dimensions
Depth of solids I.
Comments:
Y:. ,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B — SYSTEM INFORMATION (Continued)
SKETCH OF SEWAGE DISPOSAL SYSTEM:
INCLUDE TIES TO AT LEAST TWO PERMANENT REFERENCES,LANDMARKS OR BENCHMARKS.
LOCATE ALL WELLS WITHIN 100'
2
O
DEPTH TO GROUNDWATER: DEPTH TO GROUNDWATER
METHOD OF DETERMINATION OR APPROXIMATION:
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C FAILURE CRITERIA
(Indicate Y—yes N—no ND—not determined.Describe basis of determination.If"not determined",explain why not)
Backup of Sewage into Facility?
Discharge or ponding of effluent to the surface of the ground or surface waters?
I
Y Static liquid level in the districution box above outlet invert?
411
Liquid depth in cesspool, 6"below invert or available volume, 1[2 day flow?
l Required pumping 4 times or more.in the last year?
4 Numb
er ter of t'
p� p 9 y Imes pumped
- P p
Septic tank is metal?cracked?structurally unsound?substantial infiltration?substantial exfiltration?
�— tank failure imminent?
Is an portion of the SA
S,cesspool �
y p s ool or r' below the high groundwat
er er elevation?
privy, 9 9
'T Within 50 feet of a surface water? - -
I
_ Within 100.feet of a surface water supply or tributary to a surface water supply?
Within a Zone I of a public well?
Within 50 feet of a private water supply well'? =
_ Within 50 feet of a bordering vegetated wetland or,salt marsh (cesspools &privies only, not the SAS)?
Less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water
quality analysis? If the well has been analyzed to be acceptable, attach copy of well water analysis for 3
coliform bacteria,volatile organic compounds,amonia nitrogen and nitrate nitrogen.
b
�, PART D - CERTIFICATION
�;INSPECTOR ROBERT J. BORTOLOTTI ADDRESS:„ 765 WAKEBY ROAD, MARSTONS-MILLS
COMPANY:' BORTOLOTTI CONSTRUCTION INC. MA 02648 (508) 771-9399
�i CERTIFICATION STATEMENT
I CERTIFY THAT I HAVE PERSONALLY INSPECTED THE SEWAGE DISPOSAL SYSTEM AT THIS ADDRESS AND THAT THE INFORMATION '
IREPORTED IS TRUE,ACCURATE AND COMPLETE AS OF THE TIME OF INSPECTION. THE INSPECTION WAS PERFORMED AND ANY
I RECOMMENDATION REGARDING UPGRADE,MAINTENANCE AND REPAIR ARE CONSISTENT WITH MY TRAINING AND EXPERIENCE
I IN THE PROPER FUNCTION AND MAINTENANCE OF ON-SITE SEWAGE DISPOSAL SYSTEMS.
CHECK ONE:
I I'HAVE NOT FOUND ANY INFORMATION WHICH INDICATES THAT THE SYSTEM FAILS TO ADEQUATELY PROTECT PUBLIC
�! HEALTH OR THE ENVIRONMENT AS DEFINED IN 310 CMF 15.303. ANY FAILURE CRITERIA NOT EVALUATED ARE AS
STATED IN THE"FAILURE CRITERIA"SECTION OF THIS FORM.
I HAVE DETERMINED THAT T-HE-SYSTEM FAILS TO PROTECT PUBLIC HEALTH AND THE ENVIRONMENT AS DEFINED IN
310 CMR 15.303. THE BASIS FOR THIS DETERMINATION IS PROVIDED IN THE"FAILURE CRITERIA"SECTION OF THIS
II " FORM..
INSPECTOR'S SIGNATURE:
�I DATE:
I. 7
-
I ORIGINAL TO SYSTEM OWNER,COPIES:BUYER Cd applicable),APPROVING AUTHORITY
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TOWN OF BARNSTABLE
LOCATION 0\4-L fA- 1?"'416 SEWAGE # 9(Z5 G
VELLAGE 1'f`!/t'�-t 1��'� ASSESSOR'S MAP&LOT
INSTALLER'S NAME&PHONE NO. ��"21 C6 IJ-1 `/-J-r_ �� o
SEPTIC TANK CAPACITY f D t1 QP,e�
LEACHING FACILITY: (type) ��%- �� /v E w)(size) ( !0 '
""NO.OF BEDROOMS
BUILDER OR O C �J D�t��. ✓� G�--�'�i��.V
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) �/�"� Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
��
_,�-
�. � .�
., .
C
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�.
�. � -�-
� V s. E �� rc
=� �� ./
y� �
• __ TOWN OF BARNSTABLE
`L&ATION c� SEWAGE #s �i�.VII,LAGE ASSESSO 'S MAP& LOT�O //�
S
ZT1S/��G7ZI�S NAME&PHONE NO.J2YZJ&i
SEPTIC TANK CAPACITY JbA Q1 AA �� T„ V.
LEACHING FAClLrrY: (type) �/ (size) ,�D/�d CnL
10.OF BEDROOMS o�
BUILDER OWNER
PERMTTDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
�At
3
[R;ECEIVE ®
�t 1 `5 200
5
DOWLING & O'NEIL
INS. AGENCY, INC.
New
TO',VN OF BARNSTABLE C>
i Al10NZV [ �0Gl.�,� SEWAGE #
'✓MLAGE ` ASSESS 'S MAP & LOTa - /6-6
` Z�e`S.NAME&PHONE Nd n,4a4 JQ? 771
SEPTIC TANK CAPACITY e
LEACHING FACILITY: (type) Z (size) /
r NO. OF BEDROOMS
BUILDER OR OWNER ---��1
f,ERMTTDATE: !COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
v`-Q6 /
Fas.` ...... � r
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF Y 9H-� �1
Appliratiun for Disposal Works Tonstrnr#inn ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( Ic�.7an Individual Sewage Disposal
System at:
. `z�......_Odr �E..� /20 ------- ....f`! ` "'f'rS.j `. v .........................................
ocation-Address or Lot No.
....VY. r. _\Y .... ..._
WCf► (iC� Own w—O C"�
Installer Address
Type of Building Size Lot............................Sq. feet
V Dwelling—No. of Bedrooms..._.�_........., :...........:.....Expansion Attic ( ) Garbage Grinder ( )
'k Other Type of Building ... No. of persons......---------.-•.---------- Showers — Cafeteria
Q' Other fixtures -----•------------------ --••=--•-••••-••-•••••--••---••••-••••-•-•-•••---•••••••••••...••-••...............-•••-•..... .............................
W Design Flow.............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................Width................ Diameter................ Depth.................
x Disposal Trench—No. .................... Width............._...... Total Length.................... 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........................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
x ----------------------------------------------------------------------------------------------------.........................................................
0 Description of Soil.........................................................................................................................................................................
W
U Nature of Repairs or Alteratio -s—Answer when applicable__: _ ........ ..........C":4:4 !J.......
f
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iI`i LE 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&oe tl. 71
-- -•-••-•---••---••••-•--
Application Approv �}
Application Disapproved for the following reasons:....................................... .........................•.-_------ ...............................
--••-•---•-•-•---------------------•--------•-------------....................._......_..----•--------•--••-•-•-•...•••.............--•-•-._.......-••••- ..............................................
Date
Permit No.._- _:_.J_.1- ....... ............ Issued_.....__ 1... .................
Date
I'�••���X'�.E��'N��...yai�'rrY�.-�"'. �'Y -.•:3�^aY.{e.��l�'..�f.1-A�,{Ty1 Y5sp M�l•�wyyy,,,�����, .+i,• 'Tr 1.{"��L.....�;_:' T...y.�,.�, .... r v- • .`-Z'P�.^;L{.}s.�r'..-wx:� 4./"Z Tw.r..�..-.... fir',.r"-� N_y.;r.....s.F.'i
Ifr[ ' i• =Yet' � "� Ss�T.Y`n! _M"t'�.}..�r" Y.,
No./ -•--... Fxs. _ -J
THE COMMONWEALTH OF M HUSET
- BOARD OF HEALTH
TOWN OF Y**MOUjfft a i
Appliration for Disposal Works Tonstrnrtion t1prutit
Application is hereby made for a Permit.to Construct ( ) or Repair ()4:�;7an Individual Sewage Disposal
System at:
.A.1......_O!/ :-.L .......................................................• ` y4 o.c..............................••-•-------------.......--------
} � ocation-.A ddress , or Lot No.
.... . ...---.....
---
QI.cSgO�S���/S
/ 1
( Own
i " ; � r� Addre55
a ................ ............................................................................. .......................... .._____ •' _____._____..._..1.................. ,
Installer Address
Type;of Buildin Size Lot..................... g # ----._._Sq, feet
Dwelling—No. of Bedrooms_...._ ................................Expansion Attic ( ) Garbage Grinder ( ) r
a'4 Other—T e of Buildin No. of persons....................... Showers
YP ng ---------------------------- P ----- ( ) — Cafeteria ( )
dOther fixtures -------•----•-------------•--•------._....------------....------. ----•---------------- .............................................................
Design Flow............................................gallons per person per day. Total daily flow..._................__...._.................gallons.
'
{ W Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth ...............
x Disposal Trench—No. ..'i.................. Width.................... Total Length.................... Total leaching area...................sq. ft.
3 Seepage Pit No..................... Diameter...___.............. Depth below inlet.................... Total leaching area...._.._._.._.___sq. ft;
z Other Distribution box ( ) Dosing tank ( ) '
Percolation Test Results Performed by••--•--------•---•---••......•-••••--• ...---•-•--•-•••.... Date........... .............................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water---_•--.----____--:--.-.
Gi. Test Pit No. 2................minutes per-inch Depth of Test Pit------.............. Depth to ground water........................
R+ -----------------------------••-•----•-----••-------•••------...................-------••--••.---•--....................................-....................
0 Description of Soil.............................................................................................................................................................
. 1
x
W
U Nature of Repairs or Alteratiops—Answer when applicable.:__ _ n........QW ..�__._/f ---------- LSva .......
..
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 o e
Signed.. •-•-- cry - ................
Application Approve y. ___ ._...___
.Date
Application Disapproved for the following reasons:-----------•----------------------------------------------•--•----.....------...._......_...-•-.............--
.....................•---------------•--................................------. -----------------------------------------------...----••--•------•-••---•-------
Date
1
Permit No..__..�.:7z._::n! } .......... Issued_.....
Date
THE COMMONWEALTH OF MASSACHUSETTS
_ BOARD OF HEALTH
TOWN of-WAR34QUI
(9rdifirtttr of Toutplinurr
THIS IS TO CERTIFY That he Indivi pal,. wa Disposal System constructed ( ) or Repaired .dZ':;p
Installer
has been installed in accordance with the provisions of T IE 5 of//TT S to Sanitary C e as described i the
j application for Disposal Works Construction Per No. .- ----__ _G? .. dated_. ` t�"''
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE............ .. ... Inspector..........
' THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.,-
o.? TOWN of FEE._
H �"`�
N .:.........
Disposal Works Tonutrudion rrutit
Permission is hereby granted .'E cC i�' ........- �'...-------------------------------------------------------------------------------------
to Construct ( ) or Repair an Individual Sewage Disposal. System
at No..... OVA 2( riP .�f%f`M"�� 6S�o r�V
---......_.
Strc y
as shown on the application for Disposal Works Construction Per tw -G — D'ated..�.F .�
/ Board of Health
DATE.....C_..0.................. 1. ......7........................
i
04
COMMONWEALTH OF MASSACHUSETTS ' �+
_ r EXECUTIVE OFFICE OF ENVIEONMENTAL AFFAIRS
DEPARTMENT OF.ENVI,RONMENTAL PROTECTION
"I�
" FEB 2 2 2005
TOWN 01'BARNSTABLE
TITLE 5 HEALTH DEPT.
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
;CERTIFICATION
PropertyAddr`e'ss
Owner's.Name: Alryrilq , d . �.
Owner's Address: -�,RCEI,
Date of Inspection: -a .. i' _ ; , �- _ ..
Name of Inspecto (please print) R01446
{{
Company Nam ' (,Ae-
Mailing Address: p ,
AA A,1A O Xr �d
Telephone Number
CERTIFICATION STATEMENT
Ir certify that I have personally inspected the sewage disposal system at this address and that the information rfported
belowis true,'accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper fllncti6n Shd maintenance of on site sewage disposal systems. I am a,DEP
approved system inspector pursuantto Section 15.340 of Title 5(310 CMR 15.000). The system: 4
Passes
Conditionally Passesi
Needs Further.Evaluation by the Local Approving Authority
F ils }
Inspector's Signature: ,' - Date: ��
The system inspector shall submit a copy of this inspection report to the ripproving 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]0,000
gpd or greater,the inspector and the system owner shall submit the reportto the appropriate regional office of the
DEP.The original`should be sent to the system owner and copies sent to he buyer, if.applicable,and the approving
authority.
Notes and Comments
****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 futur me or different
conditions of use. C E. '
V E D
FEB Y 5 2005
Title 5 Inspection Form 6/15/2000 page 1 �OWLING & O'NEIL
AGENCY, INC.
Page of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE:SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address.%2
Owner:9
V
Date of Inspection:`"" ,
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
1'5:303 or in 310 CMR 1.5.304 exist.Ar_y failure criteria not evaluated are indicated below.
Comments:
R. 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.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please
explain.
The,septic tank is metal and ove_2.0 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_complyin�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 y--ars old is available.
ND explain:
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
obstuction is removed
distribution box is.leveled or replaced
ND explain:
The system required.pumping n_cre 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
obstruction is removed
ND explaim
S t
Page 3 of 1'1 '
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
€ PART A-,,
CERTIFICATION (continud)
Property Address: off.
Owner:
Date of Inspection: T „ �t
C. .Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health, safety or the environment.
1 ,System wrill pass unless Board of.Health determines in accordance wi.th.310 CMR 15.303(1)(b) that the
system is not functioning in a manner Vwhich.will protect public health,safety�and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless.the Board of Health (and,Public Water5upplier, if any)'determines that'the
system is functioning ida 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 suply'or tributary to a surface water supply.al F,.
AP
The system has aseptic tank and SAS and the SAS is within 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 coliform
bacteria and volatile organic compounds indicates that the well is:5-ee from pollution:from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to cr 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:
3
i
.f
Page 4 of l l
OFFICIAL.INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: b�
d4
Owner:
Date of Inspection:"
D. System Failure Criteria applicable to all systems:
You must indicate"yes" or"no"to each of the following for all inspections:
Yes N9
V/ 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 overloaded or clogged SAS or
/ cesspool
V Liquid depth in cesspool is less than 6"below invert or available volume is less than %day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
U Any portion of the SAS, cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy is within IOC feet of a surface water supply or tributary to a surface
water supply.
7/
Any portion of a cesspool or-3rivy is within a Zone 1 of a public well.
Any portion of a cesspool or orivy 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 coliform bacteria and-volatile organic,compounds
indicates that the well is.free from pollution from that facility and the presence of ammonia .
nitrogen and nitrate nitrcgen.is equal to or less than 5 ppm, provided that no other failure criteria.
are triggered.A copy of t_he analysis must be attached.to this form.]
(Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.3CG,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•
You must indicate either"yes" or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
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 ILof a public water supply well
If you have answered"yes"to any question in Section E tl:e 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 faile3 under Section D shall upgrade the system.in accordance-with 310 CMR
15.304.The system owner should contact the appropriate regional office of the Department.
•4
Page.5 of I 1
OFFICIAL INSPECTION FORM—NOT.FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART,B
", CHECKLIST
. fe ..
Property Address: w 4
Owner:
Date of Inspection:�e L ��JOS
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,orBoard.of Health
Were.any of the system components pumped out in the previouw two weeks?
Has the system received normal flows in the previous two week period ?
VHave 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 backup
f_ Was the site inspected for signs of breakout
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:he site has been determined based on:
Yes no
/ Existing information:For example, a plan.at the Board of Heavh.
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(3)(b)]
5
Page 6 of I I
OFFICIAL INSPECTIONTORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM
PART C
SYSTEM INFORMATION
Property Address:
Owner:/ CGt.�I.X,f,A,
Date of Inspection:-" ZIAS'
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): . Number of bedrooms(actual): 71
DESIGN flow based on 310 CMR 151M (for example: I W gpd x#of bedrooms):
Number of current residents:
Does residence.have,a garbage grinder(yes or no): JCS
Is laundry on a separate sewage system(y or no): .[if yes separate inspection required]
Laundry system inspected( e or no),
Seasonal use: (yes or no):
Water meter readings, if av able(last 2 years usage (gpd)):
Sump pump(yes or no): �-
Last date of occupancy:H'
COMMERCIAL/INDUSTRIA1,40
Type of establishment:.
Design flow(based on 310 CMR.15.203): gpd
Basis of design.flow('seats/persons/sgft:etc:):
Grease trap present(yes or no):_
Industrial waste holding tank present c-2s or no):
Non-sanitary waste discharged to the Tale 5 system(yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records "
Source of information:
Was system pumped as part of the i s ecti (yes or no):
If yes, volume..pumped: gallons--How was quantity-pumped determined?
Reason Tor 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/Alternative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
_Tight tank _Attach a copy of the DEP-approva "
—Other'(describe):
A roximate age of all components,dat'installe (if}mown)and source of information:
ere sewage odors:detected when arr ving.at the site(yes or no):
Page 7 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
-PART C
` lC `SYSTEM INFORMATION(coi tmu'ed)
Property Address:
Owner:
Date of Inspection:
BUILDING SEWER.(locate on site plan)
Depth below grade:
Materials of construction:_cast iron 40 PVC other(explain):-
Distance from private water supply well or suction line:
Comments(on condition of joints, venting,evidence of leakage, etc.): t
SEPTIC TANK: !/(locate on site,plan)
Depth below grade:
Material of construction: V concrete—metal_fiberglass—polyeth-,7ene
—other(explain)
If tank is metal list age:— Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy,of
certificate) ;
Dimensions:
Sludge depth:
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: Iq
How were dimensions determined: 1
Comments (on pumping recommen ations, nlet and out et tee or baffle condition, structural integrity, liquid levels
a�related to outlet invert, e idence of leakage, a c.):
ecl
l '!
GREASE TRAP;/M(]ocate on site plan) ;
Depth below grade:_
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:;,.
Comments(on pumping recommendations, inlet and outlet tee or baffle c_ndition,structural integrity, liquid levels
as related to outlet invert, evidence of leakage,etc.): r
7
Page 8 of 11
OFFICIAL INSPECTION.FORM—NOT FOR VOLUNTARY ASSESSMENTS`
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM.INFORMATION(continued)
Property Address: �/
Owner:M
Date of Inspection:.% 4-4
L1QS'
TIGHT or HOLDING TANK(_aik must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass__polyethylene other(expNin):-
Dimensions:
Capacity: gallor_s
Design Flow: gallons'day
Alarm present(yes or no): -
Alarm level: Alarm in working order(yes or no):
Date of last-pumping:
Comments(condition of alarm and float switches,.etc.):
DISTRIBUTION BOX: (if present must be openedl(locate on site plan)
Depth of liquid level above outlet invert::��toout
Comments (note if box is level and distribuequal, any evidence of solids carryover,any evidence of.
1 kage into or out of box, etc.): I
° /1 ?
r
PUMP CHAMBE%k (locate on ste plan)
r
Pumps in working order(yes or no):.
Alarms in working order(yes or no):
Comments (note condition of pump chamber,condition of pumps and appurtenances,.etc.):
Page 9 of 1 1
OFFICIAL INSPECTION FORM.—NOT FOR VOLUNTARY ASSESSMENTS
SURSjYRFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART.,C
SYSTEM INFORMATION(continued)
Property Address:
Owner: aO,�
Date of Inspection: .. :
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
. Y
ching pits,number: C2
leaching chambers,number:
leaching galleries,number:
leaching trenches,number, length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of pon3ing, damp soil; condition of vegetation;
etc.): r .
0 .�o
CESSPOOL%/ (cesspool must be pumped a's part of inspection)(locate on site p,lan).r/
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 or no):
Comments(note-condition of soil.,signs.of hydraulic failure; level ofpwi?dirg, conidition of vegetation,etc.):
PRIVY )(;locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil, signs of hydraulic failure,level of pom Sing, condition of vegetation,etc.):
9 .
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT YOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued) .
Property Address:
Owner:/
r
Date.of Inspection:✓
SKETCH OF SEWAGE DISPOSAL.SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 1,,00 feet. Locate where public water supply enters the building.
o
ki
�\\O
4-0
�j
ec�
10
Pace l 1 of l 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM
APART C r r
SYSTEM INFORMATION(co-itinued)
Property Address '
Owner;
Date of Inspection: zZ
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
k_i.�r yqe ei e,,. �
Estimated depth to around water feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record=If checked, date of_design plan reviewed:
Observed site(abutting property/observation hole;A•ithin 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:
11
Permi- Number: Date:
ComF eted by: ----G �
HIGH-GROUND-WATER LEVEL COMPUTATION
Site Location: �GL- �(�%t. � d�'/✓c /` Lot No.
Owner: /'�Q'/ fptd,� 'Jf�Gli�?G�fl Address:
Contractor: �90/z�l� i` C���r Address:* l��G
Notes:
a
STEP 1 Measure depth to water table
to nearest 1/10 ft. : ......... ...:.::.. 2...:.. ...::....:........................... .Date
- month/day/year
STEP 2 Using Water-Level Range 'one
and Index Well Map locate
site and determine: z
(A) Appropriate index we'l !•.'....... . J
OWater-level range zone ............. .................... .
STEP 3 Using monthly report "Current ,
Wate.r Resources Conditicns"
determine current depth to
water level for index well............... -�
month./year
+ STEP 4 Using Table of Waterdevc� Adjustments
for index well (STEP 2A), current depth
to water level for index well (STEP 3),
and water-level zone (STEP 2B) L �J
determine water-level adjustment . ....... .: . .
STEP 5 Estimate depth to'high water
by subtracting the water }
level adjustment (STEP 4)
Trom measured depth to water' >,
levelat site (STEP .1) ......... ..................... ........._. .......................................:........ �l>
Figure Q.—Reproducible computation Toren.
15
r
S
i
j I
f
,, ff
� S
1
3 I
� NN
3
1
e
No.............. � F�s`...:��.. ....
THE COMMONWEALTH OF MASSACHUSETTS HEALTH
BOARD OF
t--.t9.. .n - .........OF.......:. ST .�c.......................................
Appliratinn for Ui4#rrial Workii Ton rnrtinn ramit
Application is hereby made for a Permit to Construct ( ) or R��14 ?
air ( ) div' ew Disposal
System at: � 1 _ pC°�
----------------_.�y.....---®- e �. . o�.......: *+ �f '---------------------------....----------------.....----------------...--------------------
Loca n Add ess -� � or Lot No.
... ,.�r , ..r. - .,. - .....................................................I............................................
///Ay - O ne Address
�. .......... P_.�1��.... .. ...--...--•-•-----••--•----•-•-•-_-_•--•.... ..........................................
Installer Address
QType of Build' Size Lot............................Sq. feet
DwellingNo. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
P., Other fixtures ..........................................
W Design Flow.........................................•_.gallons per person per day. Total daily flow_-__-__-.._--___----__-.....................gallons.
1:4 Septic Tank—Liquid capacity............gallons Length................. Width................ Diameter---------------- Depth................
W Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
x
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........................
(i Test Pit No. 2................minutes per inch Depth of Test Pit__-_____--_.____---- Depth to ground water.--_--_-___.___-.-_-___-
a --------------------------------------------------•----------------------------------...---.........•---•--•.....•--...-•---.........-•------•-----
ODescription of Soil..........................................................................................................................................................._............
x
V ----------------•--•-----------------------•-• ---------••-•----•---•--------------••..........-•-------------------•----••-•-----•-----•-•-----------•-•-----------------------•----•-------•-----•-
M ---------------------------------------------------------------------------------------•-•----------------------............. -............................I..........................--- ------•-------
wV Nature of Repairs r p Ar----
----•................ Alt`rCa`tio /-n ..w .-a phc C��e l ------------------....._....-------------- ---•--------•------•
Agreement---- y� L
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the' rovisions of'T' ._.:
p 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.
igne .. -----= •-••--•------•-----•---------•---------------•--•------------•---.------ ............D...........--•••-
Date
4� . --
Application Approved BY . - = .:
~ Date
Application Disapproved for the following reasons-----------------------------------------------------------------------------------------------•---._......-•----
----------------------------------------•-•--•--•...----••-•--•--••••-•-----•-••-•---------------••-••---••----•----•--•-------------••---•---•------------•---•---------•----------------•-•------•---
Date
Permit No......................................................... �-
-•------- Issued..... ----------------•------------
Date
y •l+ f ►-
No...............C F> c..... ....................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
- D. n........_._....OF.........& .AC D
........................................
Appliratioaa for Uiopoii ai Workii Tonstrortion ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( )) div' a1Cu Disposal
System at: �,,�
................_' '' ........o v lg!?S ... - ! 1 „ ........---............---- ------------------" ....... .....
Coca' n•Add ess or Lot No.
--------------------------------------•-- ..........................................
w Owner Address
Installer Address
UType of Build Size Lot............................Sq. feet
Dwellinging No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building ............................ No. of ersons.............___.__....._... Showers —
a YP g P � ( ) Cafeteria ( )
Other fixtures .........................
-------------------------------------------------------------------------------•-•------•--------------•-------------------
w Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity------------gallons Length................ Width---------------- Diameter................ Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet..................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit--------------------- Depth to ground water-__-_-._________---____.
4� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------_.................
(� -•-•----•--.......--••-•-•--•-•---•.................••-----.....-----......................................................................................
ODescription of:Soil---••-------------------•---•----•----------------•-••--•-•------------.....---------•---•-------•-------------------•---------•-------------•••----•••--......-•------
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c, •--•---------------•---•-----•--------•---------••-••--•---•-----•-----------••-••-•----._.....•-----•-•--------•---••-------••---•-------•-•--••--•••--•----------••------•-•••---------•-•-•----------
w
x ------
U Nature of Repairs terations—Answer whe ap licable.___-'.R '0► � __.... .X /5
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of'T'i
p 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.
lgrie ---- ..•...
r. D to
Application Approved BY . ------••----....---: :^ s' :...... r�"� = ram '
Date
Application Disapproved for the following reasons:...........................................................................
..................................
•--•--...-•---•--------------•---------•--•--....------•----••--------•--•----•--------•---•-----.....---'-----•-----................................. .................................................
Date
PermitNo......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD HE LT
...�...OF.......
F....... .. . ........`.......-....
C�rr�if irtt#r of �oot��i�aaar�e
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
by........ ...
Installx............................. r e
has been installed in accordance with the provisions of T r of The State Sanitary C de as described:n the
application for Disposal Works Construction Permit No:�__.'/_... w ,•______________ dated.....L.�--4�__..._...cr__.____..__........
THE ISSUANCE OF THIS CERTIFICATE SMALL NOT BE CON'STRUE®,AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector.................................... --------•--....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD HEALTH
N0�)
.....A...... FEE..... .................
uiopooa1 ki o trion "unfit
Permission is hereby granted........ l ---- -- .---- =---------------------••--------•--•-- --------••••---•-...._R........._.__.
to Cons or epalr ( ) an ndividual 1r�rage *ispo Sry'tem
, ��� G�_ a
at No.. _. , --- *k. -------°i.. •. ..!� .tl__... GG2v ttf lf`
Street
as shown on the application for Disposal'WO*rks Construcrion it N__� ------ Dated...1............................._.._....
Board of He.
DATE.....................................................................................
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS