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CommonweaM of massachuseils
Title 5 Official Inspection .,
Sabsurfaee Sewage Disposal System Porn-Nbt for Voluntary Assessments
Ore �.
ow ner ow s Name
InfWMton is Q�Te Of lnapeCtion
regWwforevgY -- tj�Y�`�✓ i`� ✓ ZP
Page t�grlTown .
h>Speclion results must be submitted on this form. inspection forms a ai redZ AO
way. Please see completienesscheckiistatSO end of the form.
Ewa&' A.General information S/ f-2a a-a—
{�ng ot�t fonrs .
on the corrpvter.
useonythetab q, Inspector;
bey ip trove you .
gnsor-do No
UW them me o mspeeta
Conpeny N3M.
Code
T Licer>se
B..certification
I certify that I have per Mally inspected the sewage disposal system at this address and that the
information reported below is true,accuraEe'and complete.a s of the time ofthe�nspecfion.The insp�tion
;was performed based.an'my training and experience in the proper.trction and maintenance of on site
sewage disposal systems.i am a DEP approved system inspecthe pursuantto Section 15.340 of
Tile 5(310 CMR'1&006.The system:
Passes ❑ Conditionally Passes ❑ Fails-
❑ Needs Further Eval on by the Local Approving Authority.
ki Date
The system inspector shall submits 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#ow of 10,000*or greater,the inspector end the system*Amer shall submit the
report to the approprrate'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 insperaom and under the conditions of use
atthattime.This inspection does.notaddrew how the sysfiem will perform in the future under
the same or different conditions of use.
Tftle50Mtda1 vnspeetlalFarn�Subzrfaoe SevageDispos2l Sptm•YQe 1 of17
Y
commonwealth of oussachuseft.
Title 5 'Offi�ia lnspecdon Form
Subsurface Sewage Divoul Sysbem Form- for•Volu tary Assess
Omner
rs Name
worMOSM IS.
requimsforeverycode of
Pap. c�yrraA�n
B. Certi6cafion (corn) . •
Inspection Summary:Check A,B,C.D or E!alwayscompleteali of Section D
A) Sys6em Passes: . ,
I have not found any.information which ind�cwtes that any of the failure criteria described
in 310 CMR 15.303 or i n 310 CM R 15.304 exist•Any failure crrtena not ev�uated are
indicated'below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the'Cond'rtionsl Pass'SeOiOn need to be '
replaced or repaired.The system,upon completion Of the:replacement o pair,as approved by
the Board of Healt(1,will pass.
Check the box for yes;'no'•or°not determined'(Y,N,ND)for ollowing statements-fE"not
rcnined`:aease�acpain. t .
septic tank-is metal and over 20 years d& a sdoo tank(whether metal or not)is structurally
unsou sobstar al'in on or or tanK farl�e is imminent.System wr�l pass
inspection if tank-rs dace a cxxc wng septic tank as.approved by the Board of
Health.
A metal septic tank vvip inspection cturalty sound.not leaking and if a Certiloate of
Cornplaim ind the tank is I ess th8n'Z old is available.
13 Y ❑ ND(Explain below):
Commonwealth of Massachusetts
Title 5pff!pial Inspection Form
Subsurface Se ge Disposal System Form-Not for Voluntary Assessments
Property Address
Omner ONner's Name
information is
required for every state Zip Code Date of Vpection
page. City/Town
B. Certificatio (cons)
❑ Pump Chamb r pumps/alarms not operational. System will pass wit oard of Health approval if
pumps/alarms re repaired.
B) System Condi onally Passes(cont.):
❑ Observation of s wage backup or break out or high static ter level in the distribution box due
to broken or obs cted pi.pe(s)or due to a broken, settl or uneven distribution box. System will
pass inspection if with approval of Board of He
❑ broken pip (s)are replaced Y ❑ .N ❑ 'ND(Explain below):
❑ obstruction i removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution bo is leveled or rep ced ❑ Y .❑ N ❑ ND(Explain below):
❑ The system required umpi more than 4 times a year due to broken or obstructed pipe(s). The
system will pass in pection i (with approval of the Board of Health):
❑ broken pe(s)are re laced' ❑ Y ❑ N ❑ ND(Explain below):
❑ lbs ction is remove ❑ Y ❑ N ❑ ND(Explain below):
C) Further Evaluation is Required b the Board of Health:
❑ Conditions exist which require furth evaluation by the Board of Health in order to determine if
the system is failing to protect public ealth,safety or the environment.
1. system will pass unless Board f Health determines in accordance with 110 CMR
15.303(1)(b).that the system is not nctioning in a mannerwhich 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
riitleSomcial InspwbonFomc Suhstrfaee Savage Disposal Slstem•Page 3of17
t5ns•3113
k
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Property Address
Ow ner ON ner's Name
information is
required for every --
page. City5own State Zip Code Date of Inspection
B. Certification (cunt.)
2. System will fail unles the Board of Health (and Public Water Supplier,if any).
determinesthatthe syste is functioning in a manner that protects the public alth,.
safety and environment:
❑ The system has a septic t k and soil absorption system(SAS)and the S is within
100 feet of a surface water sup ly or tributary to a surface water supply.
The system has aseptic tan and SAS and the SAS is within a Zon 1 of a public water
supply
❑ The system has a septic tank d SAS and the SAS is within feet of a private water
supply well.
❑ The system has a septic tank and S and the SAS is les han 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 analysi., performed at a DEP certified laboratory,for fecal
coliform bacteria indicates absent and the e e of ammonia nitrogen and nitrate nitrogen is equal .
to or less than 5 ppm,provided that no o er .failur "criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other.
D) System Failure Criteria Applicable to All Systems:
You must indicate ,Yes" or"No"to each of the following for all inspections:
Yes No
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
❑ Liquid depth in cesspool is less than 6"below invert or available volume is less
than%day flow
19rw.3113 Title 5 official lns pecuon Form SuWrfaoe 5eeege Disposal Sygem•Page a of l7
Commonwealth of Massachusetts
ar U
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Property Address
Om ner Cw ner's game
information is f�f I
required for every Zip Code Date of Inspection
page. CSty/Town state
B. Certification (cunt.)
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 of a cesspool or privy is within a Zone 1 of a public well.
❑ Any portion of a cesspool or.privy is within 50 feet of a private water supply well.
❑ gir 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 wateranalysisi 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 tdogered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow'of 10,000 gpd to 15,000 gpd.
For large systems,you'must indicate`either"yes"or"no"to each of the followin n addition to the
questions in Section D.
Yes No
❑ the system is within 400 feet of a su a.drinking water supply
❑ ❑ the system is wit in of a tributary to a surface drinking water supply
❑ El Area
system is loc in a nitrogen ive area(Interim Wellhead Protection
Area— IWPA a mapped Zone ll of a pu water supply well
If you have answered"yes" any question in Section E the system is con ' ed a significant threat,
or answered yes"iry ion D above the large system has failed.The owner or ator of any large
system consider significant threat under Section E or failed under Section D shall u de the
system in rdance with 310 CMR 15.304. The system owner should contact the appropri
regio office of the Department.
6m—3113 Tioe5officiallnspeetionFcrrtc SubmalacesevmeDisposal System•Page5of17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Property Address
Qw ner CW ner's Mime
inforniatiDn is
required for every
page Cityrrown State Tip Code Date of hspection
C. Checklist
Check if the following have been done.You must indicate.`yfes"or"no"as to each of the following:.
Yes No
r I
}f�'/ ❑ Pumping information was provided by the owner,occupant, or Board of Health
❑ j Were any of the system components pumped out in the previous two weeks?.
❑ Has the system received normal flown 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 NIA)
I ❑ 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.
❑ �7/ Determined in the field (if any of the failure criteria related to Part C is at issue
T- approximation of distance is unacceptable)[310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms (actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): �—
t5ns•3113 TiU50ffirial LnspectionForm Subsurface Sewage Disposal System-Page 6of 17
Commonwealth of Massachusetts
UTitle 5 Official Inspection Form . .
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
. 1 PZ,*i(04L
Property Address c�
lJ c
Qane Owner's Name
ir>formation is
ef
required for every State Zip Code pate of Inspection
page. WTown
D. System Information
Description:
Number of current residents: `
Does residence have a garbage grinder? ❑ Yes, No
Is laundry on.a separate sewage system? (Include laundry system inspection [ Yes, No
information in this report.)
Laundry system inspected? ❑ Yes No
Seasonal use? Yes ❑ No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
(J,3 IF7 j.St V JFV 0AR-41 If 19e 5�
0 A/4,L
Sump pump? ❑ Yes E2r No
Last date of occupancy: Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
' n flow(based on 31.0 CMR 15.203): Gallons per da pd)
Basis of design flow(seats p ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes [I No
Non-sanitary waste dischar o the Title 5 system? ❑ Yes. No
Water meter re gs, if available:
-Page 7 of 17
tyre•3M 3 Tine 5 Official Ins peclim F orm Subsurface seviage Disposal SAtem
i
Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
. Property Address
'Qw na :Ovner's me
information is �j fail 1 J
required for every — State ip Code Date of Inspection
page. fown
i
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
• i
General Information.
Pumping Records:r
Source of information:
Was system pumped as part of the inspection? ❑ Yes [B� 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
i
❑ Privy;
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
t
❑ Innovative/Altemative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the UA system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other,(describe):
LSns•yt 3 Title 5 Official Inspection F am Subs,of ace Seaege Disposal System•Page 8 of 117
s
Commonwealth of Mas achusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
pl&evice 6W--
Property Address
Oaf ner Cw ner's Name
information is _ �
required for every �( r=/ �� !-��a d p �J 7
page, bV/Tdwn I State Zip Code Date of Inspection
e
D. System Information(cont.)
Approximate age of all components, date installed (if known)and source of information:
were sewage odors detected when arriving at the site? T❑ Yes�No
Building Sewer(locate on site,plan): 1
Depth below grade: feet
Material of construction:
❑ cast iron 0 PVC ❑ other(explain): .
Distance from private water supply well or suction line: feet�,� r
Comments (on condition of joints,venting, evidence of leakage, etc.):
00 F ® 0i191W4� 04,1
Septic Tank(locate on site plan):
Depth below grade: feet
Material of construction:
concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: yeas
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
Sludge depth:
t5rs-913 riide5official bspecdonForm:Subsurface sewage Disposal SAWm-Page 9of17
N Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
ttl Pam'arm �/�•
Property Address
E
Ow ner Oa ner s NafA
information i e 1 S C� �E
required for every
page. Ctyrrown State Ip Code Date of Insp don
D. System Information (corn.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness
Distance from top of scum to top of outlet tee'orbaffle
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined? ��
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Grease Trap(locate on site plan):
Dept h bel ow g ra de: feet
al of construction:
❑.concrete ❑ fiberglass ❑ poly ene ❑ other(explain):
Dimensions:
Scum thickness —'
Distance from top of scu top of outlet tee or baffle
Distance f ottom of scum to bottom of outlet tee or baffle
Date of last pumping: , Date
t5ir6.3M 3 Tito 5 Official as paction F onl 805408ce Sexegc Oispceal SYtam•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official nspection Form
Subsurface Sewage;Qisposal System Form -Not,for Voluntary Assessments
� f
h
Property Address
ON ner OYv ner's Name
information is
required for every
page. Qty/Town State Zip Code Date of Inspection
D.System Infor ation (cunt.)
Comments (on purr 'ng recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as relat to outlet invert, evidence of leakage, etc.):
I ,
F
l
Tight or Holding Tank(ta k must be pumped at time of inspection)(locate on site plan):
Depth below grade
Material of construction:
f,
F,-
❑ concrete ❑ metal ❑ fibe-rglass ❑ polyethylene ❑ other(explain):
j
Dimensions: f
J�•
,1
Capacity: i' gallons
Design Flow: r' gallons per day
Alarm present: ❑ Yes Q No
Alarm level: Alarm in worlang order. ❑ Yes ❑ No
l
Date of last pu ping! Date
Commen (condition of alarm and float witches, etc.)
Y
*Attach copy of current pumping contract (required). fs copy attached? ❑ Yes ❑ No
45ns-3113 Tide 5 official lrupectionForm SubsurfaceSevMe Disposal 5)rstem•Page 111 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Farm-Not for Voluntary Assessments
Rrope�ddirenl-p'- '
Owner Owner's N me `
information is �,/ S _ ��
required f or every {, M
/Town state Zip Code Date of Ins lion
page. cRY
D. System Information (cons)
Distribution Box (if present must be opened)(locate on site plan):
,,��
Depth of liquid level above outlet invert
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover,any
evidence of leakage into or out of box, etc.):
Pump Chamber(locate on site plan):
mps in working order. /and
❑ No*
Alarm 'n working order. ❑' No`
Comments (n condition of pump chamber, condices, etc.):
• K pumps or alarms not in working order, system is a conditional`p
Soil Absorpti System (SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
�` ,H Tide 5o(6cialispa6anF aim Subw1aceSeaege Disposal Syr,�m•Page12dt7
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form,
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Property A dress
Ow ner CW ner'sinformation is
requiredfor every L S V44
page. bit-t%wn State Zip(bde Date of hips lion
D. System Information (cunt)
' Type:
leaching pits number.
❑ leaching chambers number.
❑ leaching galleries number.
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number.
❑ innovative/altematiw system
Type/name of technology:
Comments (note con_dition.of soil, signs of hydraulic faiture,.level of ponding, damp soil, condition of
vegetation, etc.):
Cesspools(cesspool must be pumped,as part of inspection)(locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Tide5Official frspection Form Subsurface SewegeO40sal Sytem•Page 13 d 17
Commonwealth.of Massachusetts
Title. 5 ffMal Inspection Foirm
Subsurface Sewa a Disposal System Form -Not for Voluntary Assessments
Property Address
Ow ner Cw ner's Name
information is
required for every State Zip Code Date f Inspection
page. CitylTown
D. System Infor ation (cons)
Comments (note con ition of.soil,signs of hydraulic failure, level of nding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condi 'on of soil, 'gns of hydraulic failure, level.of ponding, condition of vegetation,
etc.):
Tide 50ticiad ImpectonFom[SubsurfaeeSera9eOisPMW Sytem•Page 14of 17
Commonwealth of Massachusetts
• Officialion. Form
5 Official Inspection.ect
Title p �
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
Roperty Address
CW ner ON ner's Name �
intonretion's llo
'?4'
required for every _g ate Zip CAde Date of Inspection
Me. (Sty
D. SystemIn (cont.)
cont•)
Sketch of Sewage Disposal System: Provi de 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 L 6"LP_
re
r
92, e??
� r /
Title50ff dal Ir,spectianForm SuWxtace SevageDispcsal System•Page 15 d 17
Commonwealth of Massachusetts
Title 5 Official- Inspection Form .
Subsurface Sewage Disposal System Form-Not for Vol untary.Assessments
'qo
Property Address
Om net Ow ner's me A
information is l
required for every U State Zip Code Dale of lKspecton
page. Cayfrown
D. System Information (cunt.)
Site Exam:
Check Slope
Surface water iv
Check cellar 049
*Shallow wells WL
Estimated depth to high ground water. fee /
Please indicate all methods used to determine the high groundwater elevation:
Obtained;from system design plans on record a ,
K 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:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain: '
1 y
You must describe haw you established the high ground water elevation:
i
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
'nde50t5rialImpedonform SubSeaoe Sewage 0jrposal S-Atem•Page 16d 17
i
' Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
.Om ner ON ner's Name
information is
required for every
page. City/Town Sate Zip Code Date of hspection
E. Report Completeness Checklist
Inspection Summary:A, 8, C, D, or E checked
Inspection Summary D(System Failure Critera Applicable to All Systems)completed
System Information—Estimated depth to high groundwater
Sketch of Sewage Disposal System either drawn on page 15 or attached in Separate file
J
• J
•5m 3/13 Title 501tldal lmrimbonFarm Subsurfaw SevmeDisposal System-Page 17 d 17
1
aye/a,67 Povjq P,,,,,i zoz
LOCATION SEW AG PERMIT NO.
VILLAGE
INSTALLER'S NAME � A ADDRESS
R U I L D E R OR OW ER w
G" [ S e t
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED
� � �
O-
`` � � (o 'i
�.
�^
Ir
No .-�� Fss�
THE COMMONWEALTH OF MASSACHUSETTS
_ BOAR® OF HEALTH
... . ..................OF......
�
Appliration for Biopos al Works Tonitrnriion Frrutit
Application is hereby made for a Permit to Construct (.V—) or Repair ( ) an Individual Sewage Disposal
System at�
.._...P:e a_.....__ --..�.�,...........0.................
Location-Address or t No.
--------------
..................................................... -•--•-•----•........ ...... -------------------..........---------:. -----
Own Address
---•----•---J..... �. i..s--- ---------- -------------------------------------- -------------------------------- -----------------------------------
..
Installer Address ``//
Type of Building Size Lot....-�`r.7._� ......Sq. feet
�. Dwelling—No. of Bedrooms Expansion Attic (NV) (Garbag )
pa., Other—Type of Building ®.............. No. of persons...._ Showers Cafeteria VD)
Otherfixtures .... 8 ..0 ----------------------------------•----•-•-•--••••--••---------------•-------••-••-------•-------.....--------•-••-•-...------
W Design Flow.....13_0.........................gallons per person per day. Total daily flow..._.._....S_$ .......................gallons.
WSeptic Tank—Liquid capacityl gallons Length_:....L11..... Width-_____-&...... Diameter....... Depth.&..._.....
x Disposal Trench—No._A).............. Width.................... Total Length.................... Total leaching area... -Ck.y
---sq. ft.
Seepage Pit No. C.. Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box (DU Dosing tank �) l
Percolation Test Results Performed by ��- L�l `� _>!t.WV;Date---•-- .-
Test Pit No. 1----K. _.minutes per inch Depth of Test Pit..../.iP......... Depth to ground water___A.AIPA __.
fT4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
R'+ F ----------------
---•--------------
--.-------
--------
------------------
-------
O Description of Soil---------------.0. A'!11--$'----5Jr3 SAIL
VI ----------------------•----------------........J- Y �' S'q i?`b.._ ._.f� ?9 VCL•
W . ------------------------------------------------- ------ -----
x
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 iITLi4 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation un ' a Certificate mpliance has been issued/by the board of health. /
Signed.dvzj-S�l �..b•/�--- .------- y-............... ---- ---------` I- • �, -i
Application Approved By............ ......C3 • � to <
Date
Application Disapproved for the following reasons:--------•-------------------------------------------------------------------------------- ----------------------
.............................................................•----------------------------------------------•••-•••---•-•••••-----•-•••-•----------....................................................
Date
Permit No............. �. Issued
Date
J
Mh
� I
1
FEsy ►dJ..............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
. .......................OF.... •r+?.:�?/ .STr1.).J f.f
, ppliration for Disposal Works Tonotrnr#iun ramit
Application is hereby made for a Permit to Construct (>L.) or Repair ( ) an Individual Sewage Disposal
System at: }
..... c
Location-Address Q or Lot No.
Owner -�w Address
E__ `... .... ..._.
Installer Address
Pq
UType of Building -� Size Lot.... ........Sq. feet
Dwelling—No. of Bedrooms......__ram'_'.................................Expansion Attic (t/d) Garbage Grinder (Jo)
r'r No. of persons `�____________________ Showers — Cafeteria Off)
p, Other—Type of Building ........................ p (� )
Other fixtures -----------
xtures ..iJJ- f.:.
Design Flow_____a_ _� .........................gallons per person per day. Total daily flow............ �5..........................gallons.
WSeptic Tank—Liquid capacity�..gallons Length------!!!..... Width.....A....... Diameter___-- ......... Depth_::_..........
x Disposal Trench—No. __�.............. Width.................... Total Length.................... Total,leaching area.......?_�_.t!----sq. ft.
Seepage Pit No �J!��....Diameter.................... Depth below inlet.................... Total leaching area._-_._._.___._....sq. ft.
Z Other Distribution box (X--) Dosing tank
Percolation Test Results Performed by.... ...............................................................?ii! Date_.___: f__:�a =_ =-----_---..
0.4 Test Pit No. 1... _-?...minutes per inch Depth of est Pit.... ........ Depth to ground water___�.'�!L:''.
0-4
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a •••••••••---------------------------------------------
------
[ i
_-------- --------------------------
•-•---------------------•------------
..
rWrl ••--------------•-------•--•--------.------------................lv...'.1 :��!�... f..-•._...-•-----
►4 ...............................
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 TITLi; 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. /J // ( (/(_�/( /jJ/
Signed---•••••-••----•-•••- t
"'_ �- ate
Application Approved BY `"'........ .aV-- . .......................... -----
Date
Application Disapproved for the following reasons--------------------------------------------------------•------•-......----------...-••-••-•••••••..__...._......
--.....--•--....-•--•-----....--•--------•---------------------------------------------------------------'--------------------------------..............................................................
Date
S
PermitNo................ _�>--•--------------•--------•--. Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
I/3...t f .- .r �� Llr
O F......:..............................................................................
�rrtifiratr of Toutplianrr
THIS IS TO CERTIFY, That the,Individual Sewage Disposal System constructed O or Repaired ( )
by•--------•......---••, '? Sri-1 ..t+ ...� ---------------------------------------------------------------------------------------------------------
- -----
�t ems. Installer 1 /
• ------•-----------------------------------------.............................
'!f
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No...... .......... dated.........� ) --__•--___-____
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CO STRIKE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE..............•-•--�_ �-�l - I -------------------------------- Inspector....---- .. 4jhj-----.........................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
d..............................rSZ�yr. ...OF. ..7._... �......................._.................r --
1\ .:..:.:...:� �.`.:F .
FEE.....`.. .....
Disposal Works Tons inn unfit
Permission is hereby granted........ __..-/_____ ?_ i_- /'-(I
• ••-- •••-•••---••-•-••-••-•------••----•-••--•-...•••••••••-•--•-••••......••••••................•••...
to Construct ( )'or;Repair ( ) an Individual Sewage Disposal System
at No.-•+ tl........... •� x!X ! - = ! 1, N, . ..
.. . . • --•---. --••-•• ••-----•••••-•••--_---- ---•-•......••.............
(l ✓ Street .w
as shown on the application for Disposal Works Construction Permit No-Tr -�"� Date ���r�[��..............
Board of Health
DATE................................................................................
FORM 1255 A. M. SULKIN, INC., BOSTON
it
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1.E G E N D
EXISTING SPOT ELEVATION 00, ' " P�� 10307
`' a h'rl�7c�,�° .� 1A CERTIFIED. PLOT . PLAN
EXISTING CONTOUR --- 0 -- �.. i„ Al
< i�118HED "SPOT ELEVATION t��er a p�,F>�,� ,,
RIM1'gHEO CONTOUR 0
�r LOT 9 A PEA�.oCl< J...=-r E/L
NOTE: The location of any existing and giound sewerage,
wells, 'or other util;i.ties shown. on this plan is approx
IN
mate ,only:: as d�termiried from records. and/or .verbal;
=information. The contractor is responsible. for •the SA)Ikl`S Jr ASS
' �verificat:ion of"the. existing locations in the field. SCALE; / `�=.40 DATE .S/�
x; DREDGE ENGINEERING Ca ING b A,Ys+
CLIENT.,, I, CERTIFY THAT THE .PROPOSED
771
EGISTERE REGISTERED JOB NO. 8 :BUILDING' SHOWN ON THIS PLAN
` CIVIL'' `"'`LAND : CONFORMS. TO THE ZONING LAWS
DR.BY'�
E 0 or RV . . OF BARNSTABLE , MASS.
t .. . ,
` T12 MAIN STREET. CH. BYE 'C � _ _�-�"
HYANNI S', MASS.: SHEET..._ OF 'Z, 4TE' RE- G. LAND SURVEYOR
f _
r I1lOTF /F, E/TN�R TSIE SEPTIC TANK
IO l=T M/N
.!rRADE�.4 24'O/AMET.E& CONCH C. fOi/E.Q' h
S/IAL`L F �RDCJGHT -TO G!�'AGE.' �N EXTRA
CpNCR�TE
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AWN. P/71C
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CLEAN SA7VO
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L.94/ID LEXFL
4-: SGHED tILS�O - '. • • z•LAYF R
:pKc PiPF /aka. :GAL ss ;;� • • • • n !�� WASHED STDNE
q. MJN.P/TC/y D/ST
..%�'PCR`J? % SEPTIC TA/YK ' • • • . • • • •
o f '� •L�FFEC777V r ' *
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INVT AT BUILD/NG 4 Z•o.FT
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' /A�ZET 'SsEOTK'.` Ti4NK. F
pt/7LET SEPTIC TANK • 8 iT
GROUNO. TER 7A64E
/INLET D/STR113!/T/ON 80X 40 ;fY SECT'/ON.OF
ouTo�sr�eieirriow .— it SEJs/�GE. O/SOO�SA L .SY.ST�M
/VtFT tt�cNJJv& PST 39 /rr P T T♦gQ1JLATlD/V
orEnrsLON 3 pT
t ,7CALE
r , DJESISM CRITERIA h►l,�113/oJv �-=FT
AlVMSER Of AM PROOMS -3
GtRaAGE.DISPOSAL UNIT �0�✓E. .SOIL LOG S01L TEST
TOTAL.E.ST/JrL�TED `FLOW 33 v G.4L./pqY DSO%L TEST / SOIL 71�ST#2
j /
i NUM&F-e Or LOACRINZ P/TS I J`�F[EY.
4.�S`- ELEY. ` DATE OF Se 0I(. TEST /6S�
31DE Z.4-ACNJN6 RER.P/T .SQ I�7 f` �j_ RESULTS./�/ITNESSED dY G��DR
doTTOMLFrIG'N/NG.PER P/T L i 3 ,$Q. FT. PE/tCOLATIDJy RATEfjOI CE55IM�/yti/JNCH ;`
L o + �?
' TOT�lG LEACHING AREA Z6 4_ SQ, FT. �� ;• i L _ PIFRC04ATJGN RATE AZ A�JyI�V /lVGN
z
..�ESERYE LB4rNml6 AREA W. FT. Z ` 7
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bx i3 TER AT �L EY ¢O cr$` i�E7;2�i d
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