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HomeMy WebLinkAbout0061 PEACOCK DRIVE - Health 61 Yeac�y6� ck,Dhve g} - ���_._. �`•i�`, �s3 , I� �F v 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 04 f{'23 J _ `n�51,0 74 ® u >: o r !,.4Of 6. 0 K .. /fir / .,/`� '.� `T ND cv s 7Tt ll� ! SCR 14 K: 4. ' vr� of / teV� �h of r,+` '7:N Lar roc s .de . RSE OF cz R;'Ac _• j �j -�� � . P 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 4"PYC PJPE J/E.4VY CA S AWN. P/71C YRo/y co�ER 3f/:4LL l3E,uSEo ' RLF 7 R a Y r, 2 C E:R CLEAN SA7VO A , !— BAGxF/LL 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 ' * G W.4SXE0 STL3�E a Y. ,� �.O f: • • . • 1• I f �e oa • PRECAST'SEA A6Z f %1 3 X /gip .. f >s . • • • • • • t a o P/7 OR EVUt V f pI T ���A Gy JT ,3 l/tiji�eltT E`LEYAT/GHS s 6:A 4r.. INVT AT BUILD/NG 4 Z•o.FT ER <3 r g/.O T d f] ,O/.�41M. C,(5EE 7ABUL4TJ0N� ' /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 i o LF z. � :4 v[:L f�iz . .fA F:��i4GOcK 2 ALEERT .r� NIORSE �. 7r A \ r 7aP MAIN` , ftY /9,'MA S' /Ef✓T• c' D.�7�6•:� �/Fss rNDGRDONO YY�TER jr/VCOIJ/VT1�fREO, E l�r4/.l1?�' � bx i3 TER AT �L EY ¢O cr$` i�E7;2�i d u' �� .'t'7 J!u GRD UNO I_V JGB ND.e '