HomeMy WebLinkAbout0101 CLAMSHELL COVE ROAD - Health 1 -1 C;:lani Shell ti''o`ve
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` COMMONWEALTH OF M ASSACHUSETTS
a = EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
r� DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE. 5
OFFICIAL INSPECTION FORM[-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM[
PART A
CERTIFICATION
Property Address: 101 Clam Shell Cove Road
Cotuit MA 02635 .
Owner's Name: Mai v&Jack Gorman I ✓��U Owner's Address:
Date of Inspection: - July.24. 2009
Name of Inspector: (Please Print).James M. Ford
Company Name: James M. Ford
Mailing Address: P.O.Box 49
Osterville MA 02655-0049
Telephone Number: (508) 862-9400
CERTIFICATION STATEMENT
I certify that I have personally inspected the:sewage disposal
1 system
n at this
addr
ess and that the information reported
below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: "
✓ Passes
C ditionally Passes. a
e ds Further Evaluation by the Local Approving°A�t ority
ai o .I O
h Inspector's Signature: Date: August 4'::�009
The system inspector shall subs 't a copy of th s in
report to the Approving Authority(Boa d of Healor ~
DEP)within 30 days of completing this inspection. If the system is a shared system or has a desigr flow of.1ftDoo
gpd or greater,the inspector,and the system owner shall submit the report to the appropriate region 1 office ort e
DEP. The original should be sent to the system*owner and copies sent to the buyer,if applicable,a d the appgwmg rTt
authority.
Notes.and Comments
****This report only describes conditions afthe time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page
Page 2 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 101 Clam Shell Cove Road
Cotuit MA
Owner: Mary&Jack Gorman
Date of Inspection: July 24.2009
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below,
Comments:
------------
B. System.Conditionally Passes:
One or more.system components as described in the "Conditional Pass"section need to be replaced or
repaired. The system,upon completion of the,replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please
explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with
approval of Board of-Health):
broken pipe(s)are replaced
obstructiori:is removed
distribution box.is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
Page 3 of 1 1
OFFICIAL,INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
-SUBSURFACE SEWAGE DISPOSAL, SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 101 Clam Shell Cove Road
Cotuit M4.
Owner: _Mary&Jack Gorman
Date of Inspection: July 24, 2009
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and.the environment:
_ Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Heal
th
h(an
d Public
c Water Su
i
Supplier, f any)determines that the
system is functioning in a manner that protects the public.health,safety and environment:
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank.and SAS and the SAS is within a Zone 1 of a public water supply.
_ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and:SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supplywell". Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of anunonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
3
Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 101 Clam Shell Cove Road
Cotuit MA
Owner: Mary&Jack Gorman
Date of Inspection: July 24, 2009
D. System Failure Criteria applicable to all systems:
You must indicate either"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 'h day flow
✓ 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.
✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water .
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered. A copy of the.analysis must be attached to this form.]
No (Yes/No)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 System:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either"yes"or"no to each'of the following:
(The following criteria apply to large systems in addition to the criteria above)
Yes No
— the system is.within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(lnterim Wellhead Protection Area-IWPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat or answered
"yes" in Section D above the large system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
4
` Page 5 of 11
OFFICIAL INSPECTION`FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 101 Clani Shell Cove Road
Cotuit MA
Owner: Mary&Jack Gorman
Date of Inspection: July 24, 2009
Check if the following'have been done: You must indicate"yes"or"no"as to each of the following:
Yes No
Pumping information was provided by the owner,.occupant,or Board of Health
✓ Were any of the system components pumped out in the previous two weeks?.
✓ _ Has the system received normal flows in the previous two week period?
✓ Have large volumes of water been introduced to the system recently or as part of this inspection ?
✓ — Were as built plans of the.system obtained and examined?(If they were not.available note as N/A)
Was the facility or dwelling inspected for signs of sewage back up?
Was the site inspected for signs of break out
✓ Were all system components,excluding the SAS,located on site?
✓ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum ?
✓_ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems ?
The size and location of the Soil Absorption System (SAS)on the site has been detennined based on:
Yes No
✓ — Existing information. For example,a plan at the Board of Health.
✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [310 CMR 15.302(3)(b)).
- 5
I
Page 6 of 11
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 101 Clam Shell Cove Road
Cotuit MA
Owner: Mary&Jack Gorman
Date of Inspection: July 24, 2009
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 4 Number of bedrooms(actual):. 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
Number of current residents: 2
Does residence have a garbage grinder(yes or no): ii/a
Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required]
Laundry system inspected(yes or no): ; No
Seasonal use(yes or no): No
Water meter readings, if available(last 2 years usage(gpd)): Unavailable
Sump Pump(yes or no): No
Last date of occupancy: _Currently
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15,203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no)
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: Unavailable
Was system pumped as part of the inspection(yes or no): No
If yes,volume pumped: ----gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
✓ Septic tank,distribution box, soil absorption system
Single cesspool
Overflow cesspool.
Privy
Shared system(yes or no) (if yes,attach previous inspection records, if any)
Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to b
obtained from system owner) e
Tight Tank Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Installed on 318183-per as built card
Were sewage odors detected when arriving at the site(yes or no): No
6
Page 7 of 11
OFFICIAL INSPECTIONFORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 101 Clam Shell Cove Road
Cotuit MA
Owner: Mary&Jack Gorman -
Date of Inspection: July 24. 2009 '
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: _cast iron_40 PVC —other,(explain):
Distance from private water supply well or suction line: -
Comments(on condition of joints,venting, evidence of leakage,etc.):
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: 4''
Material of construction: ✓ concrete _metal _fiberglass polyethylene
_other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no : (attac
h a cop
y of
certificate PY
Dimensions: 1500 gal.
Sludge depth: 2
Distance from top of sludge to bottom of outlet tee or baffle: 30"
Scum thickness: S"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scuin to bottom of outlet tee or baffle: 101,
How were dimensions detennined: Meanwinz stick
Comments(on pumping reconnnendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,'etc.).
Tees were Present. .The 1 uid level was even ivith the outlet invert. There did not gpi7ear.to be any si ns o leaka e.
GREASE TRAP: None (locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _fiberglass _polyethylene _other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert, evidence of leakage,etc.):'
Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL, SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 101 Clan Shell Cove Road
Cotuit MA
Owner: Mary&Jack Gorman
Date of Inspection: - July 24, 2009
TIGHT or HOLDING TAN
K: None (tank must be tune at '
pumped of inspection)
on)(locat
e on sit
e plan)
Depth below grade:
Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain):
Dimensions
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches, etc.);
DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: Even
Commments(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.):
The D-box I was normalno solids were resent. The cover w "as 18 bel
ow
PUM
P CHAM
BER: N n o e (locate on site plan
Pumps in working order es or no
(Y )
Alarms in working order(yes or no)
Comments (note condition of pump chamber,condition of pumps and appurtenances,etc.):
8
Page 9 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM.INFORMATION(continued)
Property Address: 101 Clam Shell Cove Road
Cotuit MA
Owner: _ Mary&Jack Gorman
Date of Inspection: July 24. 2009
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
✓ leaching pits,number: 2-6'x 6'(1000 ate_
leaching chambers,number:
leaching galleries,number:
leaching trenches,number, length:
leaching fields,number,dimensions:
overflow cesspool,number:
Innovative/alternative system Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.).
The vits had 6"o water on the bottom. The scum line was at the same level.There was noi s n offaalure A camera was used fo
the inspection of the pits. r
CESSPOOLS: None (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 or no):
Comments (note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,etc.):
PRIVY: None (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
9
Page 10 of 11 -
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 101 Clam Shell Cove Road
Cotuit MA
Owner: _Mary&Jack Gorman
Date of Inspection: July 24. 2009
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
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Page 11 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY AS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:. 101 Clam Shell Cove Road
Cotuit, 44
Owner: Mary&Jack Gorman
Date of Inspection: July 24. 2009 ,
SITE EXAM .
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 40+/- feet
Please indicate(check)all methods used to;detennine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
✓ Checked with local Board of Health-explain:_ tonQgraphic and water contours mans
Checked with local excavators, installers-(attach,documentation)
Accessed USGS database-explain'
You must
s describe how you established the high ground water elevation:
Using Barnstable topographic and water contours ma s the maps were
et e showing al2groximately 40 +/-to ground water at this
site.
This report has been prepared only for the septic system and components described herein. This septic system has been
inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will
fi action properly in the fixture. There have been no warranties or guarantees,either expressed, written or-implied,
relating to the septic system, the.inspection, this report and/or any components of the septic system which have not
been located and inspected.
11
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TOWN OF BARNSTABLE
LOCATION 10 C I AM S COVt_ SEWAGE#
<� VILLAGE con lT ASSESSOR'S MAP&PARCEL
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY SW
LEACHING FACILITY:(type) _a ' (*X l"�TS (size)
NO.OF BEDROOMS -1
OWNER G o CMA a
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist on
site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching facility) ) Feet
FURNISHED BY S GTl DA 0
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THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
..........................................OF.......................................------.------.------...__........................--
Apphration for UiipnoFai Works Tnntrnrtinn .truat
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: 7
�:.� ....�. -r....5��. o ' .......'c!r` ..,
.... ..............................................................
s..1 r �/aton`-Add s or Lot No.
...... --� gy_ ; -------------------•---•---------- .........................................................
.........................................
Or Address
. Q ........................•---...
Installer Address �
UType of Building Size Lot.XOPO-----------Sq. feet
Dwelling—No. of Bedrooms...._ .................................... Attic ( ) Garbage Grinder ,m
'4 Other—T e of Building No. of persons............................ Showers — Cafeteria
Q' Ot e ixtures -------------------------------• .
d v
W
Design Flow...- 7--------------------------_-----gallons per person per day. Total daily flow..- .......d....._.......__......._...gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No-----------------_-- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed bY.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water_-_._-_______-_____
Lz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
--------------•------------•-----••----•------------------.......--------------•---•---•----.;.............................................................
ODescription of Soil.........................................................................................................................................................................
x
V ::.-------•...................•-----•-----------•---------...............-•----•-•-------------.....-•---•-•---•----••---------•----...--------------------•--•.....--•••--•--
..------•-•-•....................................._............----------•-------._....--------....----------...------------------...--•-----------------•-•----........................................
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
X:1
-----------------------------------------••--`-----------------------------------------•---------••--•----....--------------------------------------------------------------------------------•-•-----
Agreement:
The undersigned agrees to install the aforedescribed Individual 1.Sewage Disposal System in accordance with
the provisions of TITx , 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 the board of health.
g - -------------------•----..._.
D to
Application Approved By. ..... ...� S.. ......•...---•---------�----•-------------- /0 ................
I -•--•............... Date
Application Disapprov d f r the following reasons------------------------•---•---------------------------------------------------•----------------------......:.._
....................•----------------•--•-•--•--...----------------------•------....----•--•------....--------------•---•--•-••-•---------.........:...................................................
Date
PermitNo......................................................... Issued.......................................................
Date
No....... ._.............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF........................................
Appliration for Bi"oiial Works Tonitrortion Prrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( } an Individual Sewage Disposal
7Sstem at
(/! ation-Address or Lot No.
Ir .o -•e ................................... ............•-•-------...............------...........--------•--.................................
Uw r ► Address
a .................. __F:..t....y ��E°!---------------------•-••----•- --•-••--•-••---...------------•-•--•------.----•------•-••-------••-•---
Installer Address �s f
UType of Building Size Lo ...... C. .....Sq. feet
... Dwelling—No. of Bedrooms-----_�_.__-------------------------........Expansion Attic ( ) Garbage Grinder
a'L Other—T e of Building No. of persons............................ Showers
YP g ---------•----------•------- P ( ) — Cafeteria ( )
dOther,fixtures --------•---------------------------------------------.-------------------------------............._ ----•----•
W Desg �`' .......................... per person per day. Total daily flow__._.... .....................gallons.
ign Flow.._ ...:_. _.
Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
W Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by........................................................................... .Date........................................
a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water------_______-__•-_____.
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a •---••--•--------------•----•-••••----•--••-••••-••-•--•••-•••-•..........•••-•....._•-----.._.............•-•--•--••--------......•-••••......--------•----
0 Description of Soil........................................................................................................................................................................
x
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 TITIE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been i ed by the board of health.
Signe-
•- 11 tea..
IleApplication Approved BY -•-� - ................. ------•------
Date
Application Disapprovod f efr the following reasons---------------------•-•-------------•------------------•-------------------------------------•------...------.
----------------------------------------•-----------------------------•••-------•••---•--------••--•••---••••••••--•••••-••--•••••-••-••--••-----••••-••-•-----•.......................................
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................OF.....................................................................................
Trrtifiratr of Totnpliatta
b TO CERTIFY That the Individual Sewage Disposal System const cted ( or Repaired ( )
THI
y � 1...... ............... - _ 7.....-----------...............--•-----------------
--------- -
��rr Installer
------------- --/e/es'." -•-
------------------
has been installed in accordance with the provisions of TIC: ,jot The State Sanitary Cod cri7bed in the
application for Disposal Works Construction Permit No._ ...........•.,...`........................ dated_-_- - _�__..._..1...................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRU D AS A GUARANTEE THAT THE
SYSTEM W L UNCTION SATISFACTORY.
DATE.L� ... .......................................•..----.. Inspector-- . .........•-•-••----•--••••-•-•••-•••••••-•••._...•-•.....•--..............•-
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
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No. ...................... FEE :-...................
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Permission ereby granted----.--�
to Constr ) 'I epaix (,) an,Indivi u Sewage is
System
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at N... �............� e _ . ..t' il"'c----
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Street -� -
as shown on the application for Disposal Works Construction Permit No...... at .a .............- .............
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DATE. ! �1................
.. Board of xealth
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS ✓✓✓""���
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LOCATION SEWAGE PERMIT NO. �
1, VILLAGE
INSTALLER'S NAME b ADDRE'SS
BUILDER OR 0Wp ED �� �vp
o�A / 65 �?AR
DATE PERMIT ISSUED
' DATE .COMPLIANCE ISSUED ��
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