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0037 BRAMBLEBUSH DRIVE - Health
37 Bramblebush Drive, Cotuit ` x A— � o i NEW LIFE Septic Service 7 (508) 563-7433 (508) 548-3355 - SUBSURFACE GZWAQE DISPOSAL SYSTEM INSPECTION FORM Address of property 39_ BtOALID C®W+ - Owner.'s name d'Ce Ii QA an Date of Inspection PART A : CHECKLIST Check if the ,following. have been done: Pumping information was requested of. the owner, .- occupant, and Board of Health. None_ of .the system components have Y p been pumped-for-at least -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 as part of this inspection. �.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. VThe site was inspected for signs of breakout. All system components, excluding the SAS, have been located on the ..site:..... .. _ The 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. _4LIThe size and -location of -the SAS on the site has been determin ed based on existing information or approximated by non-intrusive methods. The facility owner and occupants, ( p ts, if different from owner)_ were provided with information on the proper .maintenance of SSDS. s .-.-.a.....,..,..,.,e. ,r n. -msysc.�.�•+*......a..e-�....,..«....sc.. �,.�s-„-.,atc«w:sa::-....r..,....,..e.ar -::....v,.,:.+...v ..<._,.....vaea::.:,-v..4,.K..r_..:.>x.x.. ...�:._..«.w...«:-._..,...- - - � 5Hc''-ty.�ar'` ,`3u`� G'' •: r.,� t q y;;,,rk �a a.•. w �,"�'�`.. :� y * . ,,:.'» ,r^ d r .,� .N.'E-. Yr n ANn �.y.r m...'hnmrf:# r-- ••sY'.• :�;.a: a a ..:W:' .- : +a. - .r in.+ •.+4' Y' 'Ei4' ^f4V9F{+0+'iNX'F+� ��t'F'J3 T J q e.. 4 �•.3rkfi.sfypi .,¢ :k3- :k..d yf3i r: .K�L .J•'°u .:lam r. 'af,sr' .m ni..;. .a,n,rc.m a .:+,wyu, �•}by3,+y"t w _ "^,tk - :,c Til 'I �a Y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION _ FLOW CONDITIONS If residential number of bedrooms number of current residents - garbage grinder, yes_or _no r laundry connected `to system, yes or no seasonal use, yes or no If nonresidential, calculated flow: Water meter readings, if, available: Last date of occupancy GENERAL INFORMATION Pumping records and source of information: e veR Pvl�be� System pumped as part of inspection, yes or no if. yes, volume pumped Reason for pumping: Teof 'system Septic tank distributio/ n box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, . attach previous inspection records, if any) Other (explain) Approximate age of all components. Date installed, if known. Source of information: I Lv 1XeA ooe VA 11 Sewage odors detected when arr iving at the site, yes or no _ 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM-INSPECTION BORM PART B SYSTEM INFORXATION continued - SEPTIC TANK: (locate on site plan) . depth below grade:� � oncrete metal FRP other explain) material . of construction: _c dimensions: J� LL L �Q w 5 yLL sludge depth - distance from top of sludge to bottom of outlet tee or...baffle -scum thickness _. - 6" .distance from top of -scum to top of .outlet tee or baffle - -- `! -distance-from bottom-of---scum to bottom .of outlet tee or baffle ...�- Comments: ... .. • .. . - (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in,xelation to outlet invert, structural integrity, evidence of leakage, reca,manda on fo, repair , etc.) e8" e. , e6 even � ,eve DISTRIBUTION BOX: - (locate on site plan) - eve depth of liquid level above outlet invert Comments: (note if level and distribution is equal, evidence of solids carryover, evid nc� of leakage into pr nit of ,pox ecommendation for repairs, etc. ) = FSG�( fe nj �-1 f 4 vi'� a-t . I�D �°r+ of a�fi ki ► ,'tE (locate on site plan) pumps in working,grder, yes or no Comments°:�, ` .:(note.condition-of _pump::chamber, •,condition .of pumps and~appurtenances, .-re-commendations�for .maintenance,or_.repairs,.etc. ) 3. 1 n 9 .4,.e �,av: ..s,.,�a=�.ad, ✓.r �. xa.i 3- _. `__ - - y, t '�' :� 'a�w��c ',.`:� #`��i�, �z"r�3�&�1.,"r��'�����;:�3 ar';#'.� -�x-�e.�, w.-�aa�' •,�.c�-:..,x v: A ._ . r.w-i' '•r"-a4:` .' ,yp+yyyy4. « ./Wsw� Y" uv +.w.r .N?aw «rt w» •«,.Y. al.t.,:: ✓4 o- ' a�y � tcas + � i` Sri Ei u 1x At �A <` ?'c�k j.. r r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART H SYSTEM I RXATION continued SOIL ABSORPTION SYSTEM- (SAS) : _- (locate on site plan, if possible; excavation not required, but may approximated by non-intrusive methods) If not determined to be present, Type - -leaching pits and number leaching '-chambers and 'number` leaching galleries and number r leaching trenches, 'number, length - Ieaching"fields;' '-number; dimensions overflowcesspool, number Comments: (note`�condition of soil, ' signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs,etc. ) CESSPOOLS (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 (cesspool must be pumped as part of inspection)"- Comments: . � (note condition-of--soil-,signs of hydraulic -failure, level' of ponding, condition of -vegetation, recommendations for maintenance or repairs,etc. ) PRIVY: .. ,, ... (locate onsite-plan) , materials-,of-construction ' dimensions depth of It sdo ds 17, Y--I(note-condition�o€-486il signs-of :hydraulic �fai-lure;—level of pondin ry -���,.condition��-of-vegetation; recommendatfons-'�for maintenance or`repairs, k ., «,aRo- «w;w,w-s..wbfa:��tse:./�;�s+r�'gat.�.sn�a#:...�::xarmx�:�%�"+4+�.wzs.exgr:.�ta;.xawn'r.Pc,.as,.�-,14:,-s�v3+.�.+..m�w i �.-:waP.�n,:4'F*.aa=,two-,,,....o,.,.ar..�,.ru,.a.w..�..,a•...«.,:, . yZy, &t'� �,�•= S. n„ X �.r f t. �'`S.f`('F�'fi` ;Y ".�+gl '+Y ,�„e _ _ ' ".fie. -. � .. - ,o-...�..± .-.,..-,..—_>-:�W'*e ';� # n-,-+i.a�"h�%a�ri� 3•ei�"G 't':.j�...�3-*�'bl�:� - ..* .7a'."' f . w .- - _ 21 BUBSURFACE 'SEWAGE'DISPOSAL SYSTEM INSPECTION FORM - PARt B . SYSTEM INFORMATION continued SKETCH=OF. SEWAGE DISPOSAL` SYSTEM:. r include ties to at least -two permanent -references landmarks or .benchmarks locate all wells within 1001 ° A C:1 `1v' A 41'4� DEPTH TO GROUNDWATER � A•h -.x *t p �rt .;Lea R y t -:.+k i .,. •..y � - ?4% _ US depth to�groundwater ^F d' ..�,.:.yam<,SCV 8( c method t of -determination.orapproximation: `" - c,._'x V•-4, ,tom ;.�+k+;Y*af A:- Mt, t , '�-�`w +.��,a + �'r.#�r� �'�f`�.,�-�x�'�.���.�''� ;�`��'�`¢�.�'�?� ,."".Yo,>��",v��t�M1ve ...�s m«: y.r« .•�,.�n _ ... - gai`-+�p�,$ �X,,`.-9 s'"•.e,- $ .E 7r s ;c i� p '�+r a .Eras, ss.w '.�..:w k� i*�t � �-:r�•,rcd� ��ca4'.* s�. � i��, �*.�H%I� +�� ",�•�,��;�,,,��,t.�•,� 9'!z u,e��".a�Y '�E,::`., t✓f-Qh.dtrFtP, *d .-_ � ?��$.��.£- ,""�«.i:.�'rx''(.�'y�';�t "�nr�'�* i.��'•��� �x+ "`-.��'�` `�'�'�1�n�" s'��'' �.�ie3+ � k �, r !,. . - � - � a�.'.fi� A��� �` �.s 'i�i'1'"-^a'r a �,•.4� "x 1 Sr R�x .=1. w'Pc`p ry, ;h y�'Lk�' �, _ _ �x�u�:'3�:•'1:. + ._g�r8 *r,?s.s .��.�,�'q'F�, �.6.�vlr���....x , ��' as3� x` t:i a� r�� ., ;t -_:���,r,r , z i - i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C FAILURE-'CRITERIA Indicate yes, no,` or -not determined (Y., N, or ND) . Describe basis of determination . in all instances: If "not determined", e; plain why not) =�-Backup-of Sewage-.into. facility -- - - -Dischar a or �onding of effluent to the surface of the ground or- surfa-ce-,waters? . .Static liquid level in the distribution box above outlet invert? "WLiquid depth..in cesspool <6""-below invert or available volum < flow? r e 1/2 day Required pumping 4 times or more in the last ear? number of times pumped y. Septic tank is, metal? cracked? structurally -unsound? substantial infiltration? substantial_ exfiltration? tank failure imminent? .XIs any portion of the SAS, cesspool or privy: ,. below the high groundwater elevation? /. within 50 feet of a surface water? within .100 feet of a surface water supply or tributary to a surface water supply? .� within a Zone I of a p ublic well? 5 _ 0_L within �fe et -of a bordering vegetated wetland or s marsh arsh (cesspools and privies only not the SASS? : p^ r a _..(Vwithin-All 50 feet of Al�� �pri tee watersup va �. plywell? T xmn„a..y �;x- #r+wh„ -'amto.:.v1�e.� 3.x.+:u.:;�J°�+e•�iaabb.*t� �.x+.xsa �e;++•s,:'s�...ww:i:�rn:+a«*.w.:-ccer rc. .. ..r ..,...�� . s�M•..- •n. � 4 YrT�it#E a rre .i i' *rem+a tr^?-s 3w 'M � v -less than- feet--but-greati than 50 "'feet from a r supply ywelwl'°,withzno acce table"F ivate water p water quality analysfs� If the well .� has�been analyzed °to be acceptable, attach copy..x �• py .� � � P� �. � �well=water-anal ; for coliformbacteria : volatile'7organic` compounds; ammoniantro en� aA Lr a r 31,Jf-•c t L .b --idx # Kr r,w=±z;.8 x� r p sand=nitratenftrogen: �� � �k � ,R9 �Y n�,o`C' �"'�� o- �u}�'g�•��o"x�'"drw�.'tl" .r.(ea ..'h.�';F'^`iL''�'' •t' �V�416+^�+.•+e.�a.`?S.t} "N/Yeay.N�'4'vTM«.b'a1Nt.mKtr&�u5#7m'�''2t °KSiw'i7r�.�Ws:i 4.+.r'+�+wfwut:m.<+x,,.i.c�a6�=ssw4.&.:^�'9'�'*t'C9k�'?«H.ev..:..,, r. r7sw'wrv'`a'SEr�� h••�'r�'� fT'•f•'e E T�+�•X.�'.w +w +x�u!3r.,t •+wrs.. #aYe F .kx i+" r 1 S x a�}+ i +z.6 7 .k "u'r�5 k e*q'e ia` r4'c.wcx .t'+. ._.s 'Ys,'er'sw.w ;s. ee w.«.•yrr s+ar., .,>. r > x ���+F rz1 m r i s r r"� 4 .^s 'S'=.'t ..,.:i.r .•r"C.x#•v'f`'.r,..h:x?, �a� k- ''x ',s.�'. '. }k 5.. _ma's-. e 4; L-a ;,'., "` 1. 13 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORK PART D CERTIFICATION Name of . Inspector Company Name NEW LIFE-SEPTIC SERVICE - . P.O. Box 2119 - — - T- company Address- Teaticket,MA 02536 - (508)548-3355 Certification Statement I certify that I have personally .inspected .the sewage disposal system at this address and that the information reported is true, accurate and complete_as of`the' time of inspection. , The inspection was.performed and recommendations re ardin .`u rade 'maintenance and repair .are any r 9. 9 Pq � ; d experience in the proper function and consistent with my training an xp P P s . manitenance of on-site sewage disposal y stems. . . Che one: I have not found any information which indicates .that the system fails to adequately protect public health or the environment as defined in 310 CMR •15:303. Any failure criteria ,not evaluated are as stated in the FAILURE CRITERIA section of this form. I have determined that the 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 form. Inspector's Signature Date Original to system owner Copies to: Buyer (if applicable) Approving authority �I s � `+`�,xx.c•. it$yx, f. s� w`T�"* �a 3.a ra° Zss�a " s�"' s"�+h�.. a+•` �, ,k`rd,rt i�" °� .„,,�, '� 1 tip - - sxTii k}a..f y }. ,r a• '�. pF��,.% \ -:xf `' i� .u'�3`�'�' F* -��a Fy_ r 4✓�a, F 3 3� � r "` a .*F '� �' r € x . Finc.......s.................... THE COMMONWEALTH OF MASSACHUSETTS �/- BOAR® OF HEALTH r0t....X...................OF...... � � ...... �....-.. Appliratinn for Disposal Works Tnnstrurtiun runfit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Dis os PP Y ( ) P ( ) g P System at: v Location-Add s I or Lot No7 r: v( y _.. .__..... Ow *Address •- ...-•-• c [ Installer Address Type of Building Size Lot............................Sq. feet a Dwelling—No. of Bedrooms................................._..........Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) d Other fixtures -------------------------------•••---•-------------•--. W Design Flow..............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacitysdd_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. 1................minutes per inch Depth of Test Pit.................... Depth to ground water----_-----------_------. f14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ - - -- Descri tion of Soil= ` .. -- -----4L--:��<) �C�pQ. �.. U U T_ ........----••--------------•------•-------•----••--------------•-•---•---------•_... --------------------------------------------------------------------------------------------------------------------------------------------------•--------------------------•-••--•--._.............. U Nature of Repairs or Alterations—Answer when applicable----------------------------------------------------------------------------------------------- ............................................................................................................................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with.'.., the provisions of iITIE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. ied..--------------••-••-•••----••-------••--•-•-••---------•--•-•-•-•----•--•-••--_-- �ate •-_ ----___...: ' _Application Approved BY-•- --- •----•----•-•----•-•--•--•........ .1. --_-. Application Disapproved r following reasons-------------------------------------•---------------•--------------------------•---------------••----••••--•-•-- ......................................................................................................................................................................................................... Date PermitNo..................................................._.... Issued....................................................... Date No................_....... F�$.�5....._............_. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...,... . ...................... Appliration for Disposal Yorks Tomlrnrtion .motif Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: f •-•----•-•-----....-•-- 1v n /• � Location Address -•-�•_____________________________________or Lot_No. (...,A! Owner { 7Address ..._. -.......- ),As: �_. .. / I/ :==•-• ..............•••-- Installer / Address.... Type of Building Size Lot.................--.....---.Sq. feet .—I Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage. Grinder ( ) a Other—Type of N a- Buildi>a r: ------------------- o. of ersons....._............_......... Showers a 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........ ..... Di;.meter............... 7 Depthibelow inlet_,a,,-_............. Total leaching area..................sq. ft. Z Other Distribution box osing..-t hk-(' 'y"�' -�",o!� �j'w;'� ..�• �"�Pe c l� pry s e u _ Performed by.. ...................... - Date.rJ_`}c__�=. �! a - = ,---- . Test Pit No. I...lt..........minutes per inch Depth of Test Pit.................... Depth to ground water........................ 4.1 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ OW .-••----•-•--•••----------••-------••-•••••••-----•••••....--••...........•-•••...........................•---•••-•••••...:••-•------•............••._...••-- Description of Soil........................................................................................................................................................................... W U -•••••••••••---•-----••••••••....---•-•...•----••••-•-•-------••••......--•--•......•••••....-•--•-•-••...--••••--•-•---••••-•-•--••••---•••-•••-----•••••---•••••••••••-••-•--•••---•••......---•••--- W ------------------------------------------------ U Nature of Repairs or Alterations—Answer when applicable................................................................................................ --•-••••••--•--•••••-••----•-•-••-••----••-•-....----•-•---•-•-•-••-•--••••-----•-•••................••-••••--•---------•-••--••----•••••--•-••••----•••-•--•-•-•--•••••--•-------•••-......•.....--••• Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITIZj 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. igned................................................... Application Approved ey `�.... ......•••. Application Disapprovefollowing reasons:-------••------•••••-------••--•--••----------••----•-...--•••------••••--------••--•--••-•••......••.....-•-•-- f�.: --•------------------------------•••--•--..... -••-Date Permit No.................................................. _ Is\sued............ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF �rrtifiratle of bout fi�tnr�e THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by--------------------------------------------------------------------------------•-----------------------------------•-------------------------------.-.-----------------•---•--------------- -- Installer at. - -•---------- has been installed in accordance with the provisions of TITIF 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......................................... dated_.............................................. THE ISSUA CE OF THIS .CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WIL FU TION SATISFACTORY. DATE----- ! .................................................. Inspector..... ......... THE COMMONWEALTH OF MASSACHUSETTS p� BOARD OF HEALTH ......O F.................. No......................... FZV...................... Per mis ion is here gran , �' r �Zosal . .........................................•-••----...............---...... to tth ) �e r al Sewage DSystem at Co.��� Street as show op ratio r Disposal Works Construction Permit .o................ Dated...........................i'i....._........ .......... ----•-. ..................................................................... jr Board of Health DA /f FORM 1255 A. M. SULKIN, INC., BOSTON D F5 3-7 LOCATION SEWAGE PERMIT 630. VILLAGE INSTALLER'S NAIDE D ADDRESS j y 1L.W70-t/ 7W 0 U I L D E 0 OR OWNER 1� U .gd G c ` - ,, h DATE PERIDIT ISSUED DATE COMPLIANCE ISSUED /� � 3, gy �0 4 W 0 0 ' _ t N0.1a.' ..�.�.. F�s.�l. ............. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ��u --- --------------------oF.. . Appliration for Disposal Works Tonstrnrtiun Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: 2ti...... 61 .............................................. .Location-A ess Lot o. 42 Owner ,J" Address /.....................••--•-•-•--•------......_ �/ems_.----......_........... .............._._........-•-•--•---------•--...-- Installer � Address U Type of Building Size Lot... .....Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) a �Ps 2�,s a Other—Type of Building .......................�No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures ---------------•--------- + W Design Flow.......5 5............................gallons per person per day. Total daily flow..._......•..3.. ._a._...............gallons. WSeptic Tank—Liquid capacity.10o gallons Lengths o.._5 ...... Width--Z ......... 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....�Or..'1�.✓._...�>t.. ff .._...._.-._ Date.._ j, T...t.Zj } a Test Pit No. 1.....9...____minutes per inch Depth of Test Pit....1 ........ Depth to ground water. __l✓�N.. _. 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Q+' -----------•-•---------•---------------------•--. .. •--------------------•------------•----•--------•-•-----.......... Description of Soil/ lr---•----�v .. ca�_.C,............t.�`'P---... ----•--------------•-------------------------•-•--•---•--•--•---•-•---- x w ----•-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- U Nature of Repairs or Alterations—Answer when applicable............................................................................................... -••------------------------------------•---•----------------------------•-......._...................---.....------•------------•-----------•-••-------•-------.........-----------------------....----- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of ilTi.;,,. 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been ' ued by t�of ign ' ........ ........-- 6 .... •. - APPlicationApproved By......•--•• -•...•. ••---------........................................................... L�' a� Date Application Disapproved f t e following reasons:............................................................................................................. ---------------- ---------------------------------------------------- .--.--------------------------- .------- -------------------------------- ----------------------- •--------------------- ---.-•--- Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ....../r.i..i... . .....................OF...x::: ?lr✓ •_.-✓�� '� Appliration for Disposal Works Tonstrurtion "truth Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: _ ,�,/147... /_= •-•--•_ i,! / ��.f =' ,` �•^•/r - ..._.`...`......J............ff/. S ......................................... _.. , Location-Address or Lot No. Owner Address _.":.::...// i lr. .�A..... ....................' ______________.....................________... = Installer Address Type of Building r Size Lot.... .....Sq. feet Dwelling—No. of Bedrooms........... ......................Expansion Attic ( ) Garbage Grinder ( ) aa Other—T e of Building + _____________ No. of ersons._...__________.____.__._._. Showers YP g -----"--------=- P ( ) — Cafeteria ( ) Otherfixtures -------••--------------------------•------------....--•-------------------------------------------------...._..... W Design Flow.............................................gallons per person per day. Total daily flow...................._.___:__..__._.________gallons. WSeptic Tank—Liquid capacity___!=__Z�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....:''�r'.':_"_`r_________ ____'__'_ •�'-'.__..._.___ Date... ' .. . r 14 0.� Test Pit No. I......___.......minutes per inch Depth of Test Pit......!_=.......... Depth to ground water...Z ____,:... fXq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ---•---.....•---•-•••-••-•----•. •---.....;--•__ __------------- ......._......... . ODescription of Soil----•='�-"-='-`-'-"..............:....::...'_...... - = �= x w -----------------------------------------------------------------------------------------------------•---•--••---------------•----•----•---•---•-•-•----...----------------•---•-••-----------•••-•-•-• U Nature of Repairs or Alterations—Answer when applicable..............................................._................................................. -•-----------------------------------------••-----•-----....---....-------------._..._..---._......-----••----------------------•-----------•-•-------------------._._...--------------------•-••-_••-•• Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of i IT`E 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 . _:�-<_. .... .. to f , Application Approved By------ ---. ...... ---1lJf�=y' - "------------ Date Application Disapproved f t following reasons:. - --•................•------------------•-----•-----••••-•-----........-----•--•-••••------...•-------•••--•-------------------_._....----•----•-•-----•--------•---•-••--•-•-•-----•----•-----•••-------- Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................OF......:'.....:.........r....-•'..........//:........................................ wErr#ifiratr of Tompliaurr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by•-fL�...........` s!" r pia. 1 !F r v;� ., �" / r-, - .:.__....:-:J�.:.:.. ........ �• 1/_ i Installer f at.... f r --•••••=-----•••••--•---------•••-•--•--•--•--•-------------------------•--•-------•---------._...--•-•--••••---•-•---..........-•-----------......-----•--------•-- has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code scribed in the application for Disposal Works Construction Permit No. __'____ '©__________________ dated_ 'v__ Z':_______.._._.__.____ THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. Inspector. ..._... DATE............................................1_ ...----------........---------------••-......•--_-••--- THE COMMONWEALTH OF MASSACHUSETTS / BOARD OF HEALTH C� I �✓'� No ...................... FEE.,..e?................. Roponttl Works T.onstri wit rrntit Permission is hereby granted____.:;*�__ . r ........................•--•---------------------------------•_..__._.....--•••--••._._..----•.....••--....-••••........... to Construct ( �) or Repair ( ) an Individual Sewage Disposal System Street / as shown on the application for Disposal Works Construction Permit No _ '`4__ ____ Dated-�!'V�,__/�.9--� .............. Board of Health DATE................................................................................ FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS I {I C� N CITE S _ -_ALL ELC'%f gNo,A/�j Ak C- SEA L_EVIE� I a.. -o-S(:S v •$. oAT u►� PL�..t E PITc-W ALL I. WE A Mr�lrrnv� of 1/b �F�xT! i M 1 UNL.ES`> OTNEQ'`�JlSE. St�Ga� IED. 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ELc✓ 0 T At, 1- } a , 66 fe ; 60 G6�t9 �X6 GSKy 8�RN1,t3 L 49 b yEs/GN C,e/TE�i�► PROPOSED D\[/ELLi ti,lG LOCAT 1 ON 6�— ,otDR� C�ldvt ��Mq��� PROPOSED SEWAGE DISPOSAL 5Y-5 A/vnl B Eels OF BE0,2 Gb/>h s � _ GS.Y`l E,r/'3T �GIT Env /o� `y, PE,CSO/t/5 10E.0 �IPA"loM �' (.7i�3 f ROSSMA T .G.C�� / pl GiILLO.(/SL' feN 1045PD4Y o. 05``4 J' �L� <co rlr) 1 A SS AX45a efeQ Ule6P Sf2 �AL�•� " ✓d L6,r C N/�l/G AIE.I P,t?O{//DC.I� 5�-�-T� _ \�fSsi;, E��'\% • PPOF'OSEO LEACH INC- PIT 100 q' E x PA KI s 10► i \,�, of M Z4 G;ee-, T f�ND per' 22 6 SE�,uE�2 17E�iGN : ' q�s� NORINAN T /'.� t7 i9�r�i4: 3�y�4 �•U 1�j Gn F? /� GROSSMAN I SCALE DATE SHEET u7 7'p TvTAL 4�7G Rom. ��,`�'ST �� j/ DRAWN BY GMKD BY ADO >w: PLAN NO.