HomeMy WebLinkAbout0329 COTUIT BAY DRIVE - Health 3 ?'q Cotult Bay Drive
Cotult
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-\ COMMONWEALTH OF MASSACHUSETTS
z EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS.
~� DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY'ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEMFORM
PART A
CERTIFICATION
Property Address: Q...%..
` l
Owner's Name:
Owner's Address: .
Date of Inspection: ., ) DOC) a
Name of Inspect2 lease print)
Company Name:
Mailing Address: j,
s
Telephone Number: )^��. ,
tr C C�
P
CERTIFICATION STATEMENT
CD,:
1 certify that I have personally inspected the sewage disposal system-at this address and that the information rep rted'
below is true,accurate and complete as of.the time of the inspection. The inspection was performed based on mar
training and experience in the proper function and maintenance of on site sewage.disposal systems. I am bEPl
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The sy tem:
Passes
Conditionally Passes
Needs Further Evaluation by the.Local Approving Authority
Fails
T
Inspector's.Signature:. _ Date:
The system inspector shall submit a 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 flow of 10,000
gpd orgreater,the inspector and the system owner shall submit the report to the appropriate 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.
Notes and Comments
This report only describes conditions at the time of inspection.and under the conditions of use.at that
` time.:This inspection does not address how the system,will perform in the future under the same or different
conditions of use.
Title•5 Inspection Form 6/15/2000 page I
Page 2 of l 1 i
I
OFFICIAL INSPECTION FORM T NOT FOR VOLUNTARY ASSESSMENTS!
SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFP,CATION (continued)
Property Address: -C °zow
.'-f- I
Owner: I_ .rD r
Date of Inspection:. r
Inspection Summary- Check A,B,C,D or E./AI:.WAYS 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:
I
i
I
B. System Conditionally Passes:
I
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired.The system,upon completion of the replac ment or repairs as approved by the Board of Health;will pass.
I
Answer yes,no or not determined(Y,N;ND)in the ! for the following statements. If"not determined"please
explain.
I
The septic tank is metal and over 20 years old i* 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
obstruction is removed
distribution boxi is.leveled or replaced
ND explain:
i
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 pipes)are.replaced
obstruction is removed
i
ND explain:
Page 3, of.11
OFFICIAL INSPECTION FORM-.NOTE FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL;SYSTEM INSPECTION'FORM
PART A
CERTIFICATION(continued)
-3-
Property Address: _7 6!�A_
Owner: ,1 r �'
Date of Ins ection a �
C. Further.Evaluation is Required by the Board.of Health: °t
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.
I. System will pass unless Board of Health determines in accordance with310 CMR 15.303(l)(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 Health (and Public Water Supplier, if 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
surface water supply or tributary to a surface water.supply;
The system has aseptic tank and SAS and the SAS is within a Zone 1 of a public water supply.
t _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet•or more from a,
private water supply well".Method used to determine distance
"This system,passes if the well'water analysis,performed at a DEP certified laboratory, forcoliforn'
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.
3. Other:
, 3
Page 4 of I 1
OFFICIAL INSPECTION FORM.—.NOT FOR.VOLUNTARY:ASSESSMENTS
SUBSURFACE SEWAGE=DISPOSAL.SYSTEM INSPECTION`FORM
PART A.
CERTIFICATION(continued)
Property Address:
Owner: ,77 11
Date of In pection Y 01
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
I/ Backup of sewage into facility or system component due to overloaded or clogged SAS or.cesspool
Discharge or ponding of.effluenf to the surface.of the ground.or surface waters due to an overloaded or
clogged SAS or cessp
ool
P
t! ool
_ — Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
�0 cesspool.
Liquid depth in cesspool is'less than 6"below invert or available volume is less than %day flow
Required pumping more than 4 times in.the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped �
/ 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.
IT Any portion.of a cesspool orprivyis: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,.pr,ovided that no other failure criteria
are triggered..A copy of the analysis.must be attached to this form.]
A/0 jj��
. (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
E. Large.Systems:
To be considered a large system the system must serve a.facility with a design flow of 10;000 gpd to 15,000
gpd•
You must indicate either"yes"or"no"to,each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
the system is within 400 feet of a.surface drinking water supply
— _ the system is within 200 feet.of a tributary-to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—I WPA)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 1
Paae 5 of 1 1
OFFICIAL INSPECTION.FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address.
Owner:
Date of-Ins ection:
Check if the following have been done.You must indicate"yes'.' or"no"as to each of the following:•
'E
Yes No
Pumping,information was.provided by the owner,occupant, or Board of Health
_ % Were anv of the system^components pumped out in the previous two weeks
ZHas 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?
L� Were as built plans of the system obtained and examined? (If they were not available note as N/A)
f Was the facility or dwelling inspected for signs of sewage back up
Was the site inspected for signs of break out?
t� 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?.
Z . Was the facility owner(and occupants if different from owner)provided with information on the proper
me—nance of subsurface sewage disposal systems
The size and location,of the Soil Absorption System (SAS)on the site has been determined 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 1'5.302(3)(b)]
Page 6 of 11.
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY'ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART'C
SYSTEM.INFORMATION
Property Address:
Owner: i",
. Date,of In ection:
! FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms.(design)r3 Number of bedrooms(actual):
DESIGN flow based on 3.1 0 CMR 15.203 (for example: 11.0 gpd x;#of bedrooms).: r
Number of current residents:
Does residence have a garbage grinder(yes or no): /V0
Is laundry on a separate sewage system(yeas or no) ?.[if yes separate inspection required]
Laundry system inspected y s.or no):—C?
Seasonal use: (yes or no):
C,
Water meter readi if a e(last,a}�labl 2 � �years usage(gpd)):0 "�� o "ngs,
Sump pump(yes
Last date of occupancy: -iA&t4J
COMMERCIAL/INDUSTRIAL ��
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd '
Basis of design flow(seats/persons/sq#,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:'
Was system pumped as part if the ftfspection(yes o o): zy
If yes,volume pumped: gallons--How was quantity pumped determined?.
Reason for pumping:
TYP F SYSTEM
eptic Tank, distribution box,soil absorption system
Single cesspool
_Overflow cesspool
_Privy -
_Shared system(yes or no)(if yes, attach previous inspection records,if any)
_Innovative/Alternative technology.Attach a copy of the.current operation and maintenance contract(to be
obtained from 'system owner).
Tight tank _Attach.a copy of the DEP approval
Other(describe):
Approximate age of all components,date ins alled(if known)and source of information:
Were sewage odors.detected when arriving at the site(yes or no)
a
6 ,
Page 7 of l 7
OFFICIAL. INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION`FORM
PART'C
SYSTEM.INF.ORIVIATION(continued)
Property Address:
Owner: '1 .4
Date of Ins ection: '.� ;I�
BUILDING SEWER(locate on site,plan)/k/0
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:
Material of construction: h concrete metal_fiberglass_polyethylene
-other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions. 6� f7 7 k .
Sludse depth:
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: L241
Distance from top of scum to.top of outlet tee or baffle`. l®
Distance from bottom of scum to boup. outlet tee or baffle:. _
How were dimensions determined: l
Comments(on pumping recommen ations, i let and outlet tee or baffle condition,structural integrity, liquid levels
a related to outlet invert, evi epce of leakage, etc.):
GREASE TRAPjt plan
(locate on site �
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.):
7
Page 8 of I
OFFICIAL.INSPECTION FORM=NOT:FOR VOLUNTARY ASSESSMENTS:
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
YSTEM INFORMATION(continued)
Property Address: _
Owner:
Date of Inspection.
t .site plan)caeon
TIGHT or HOLDING TANK: tank must be pumped at time of ins ection to . )
( P P P )( P
Depth below grade.
P
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: /' ofresent must be opened)(locate on site.plan)
r a
Depth of liquid level above outlet invert: 0
Comments(note if box is level.and distribution to outlets equal, any evidence of solids carryover, any evidence of
akage into r out of box,etc
l
PUMP CHAMBER:fD(locate on site plan).
Pumps in working order(yes or no); y
Alarms in working order(yes or no):
Comments(note condition of pump chamber, condition of pumps and appurtenances,:etc.):
Pao,e 9 of 11 -
OFFICIAL,INSPECTION FORM—NOT FOR VOLUNTARY<ASSESSMENTS
SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM
aPART C
SYSTEM INFORMATION(continued)
Property Address:
r
Owner:} �tr ) r
Date of Inspection: V30- �� )
SOIL'ABSORPTION SYSTEM (SAS): (locate on site plan;excavation not required)
If.SAS not located explain why: =
Type /
eaching pits,number:
leaching chambers,number: ..
leaching galleries, number:
leaching trenches, number, length:
leaching fields,number; dimensions:
overflow cesspool,number:
innovative/alternative system` Type/name of technoloy:
Comments(note condition of soil, signs of hydraulic failure,level of ponding, damp soil, condition of vegetation,
et o l
Cp
A44
CESSPOOL (cesspool must be pumped as part of inspection)(locate on site•plari)
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;��(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:
Owner
• `L
Date of Inspection: e (�,
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':wherepublic water supply enters the building,
'
tA4 orb
10
Page 1 I of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property,Address:
r
Owner: "
Date of Inspection: `
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water l feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site (abutting property/observation hole within 150feet of SAS)
Checked with local Board of Health-explain:
Checked with.local excavators, installers-(attach documentation)
J Accessed USGS database-explain:
n r
g elevation:You must describe how,Y g you established the high round water e le tton: r -
.9
>4l s"ems' )�/d'i a�'� a w
bh
11
f
Permit Number: Date:
Completed by: ,.
HIGH GROUND-WATER LEVEL COMPUTATION- -
Site Location: j2 " , � ✓7 ;... c! �' �. ..
� � � ' Lot No.
Owner: •P° ""�' Address:
Contractor: ��r( 9 i' L'tG✓ Address: e1_1 ram' i'��'✓d✓ � �✓�r
Notes: ............
STEP 1 Measure depth to water table
tonearest 1/T0 ft. .................... ......... ......:.. ........................ Date
month/day/Year
STEP 2 Using Water-Level Range Zone
and Index Well Map locate g
site.and determine
OAppprop r.i ate Jndex well ..................
OWater-level-range zone ..::.
STEP 3 re
Using monthly port'';Current
Water
`-:Resources Conditions
determine current depth to
water. evel for index well .............
month/year'
STEP 4 Using Table tof Water-level Adjustments
for index well`(STEP':2A),current depth
to water level for index well (STEP 3),
and water level zone (STEP 2B)
. ..
determine water-level adjustment .......................................................:.................................. !
STEP 5 Estimate depth to high water
by subtracting:the water
level adjustment (STEP 4)
.from measured depth to water
level at site(STEP 1) ..............:.............................................
Figure 13.-Reproducible computation form.
15
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\ COMNIONVVEALTH OF 1VLASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
4yoS
e\l x
.K +a
TITLE 5
0 ICL`�n INSPECTION T FORM—NOT.FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address " '29 f'`�'3 .�.[P., � 1,Lt�/ ;1 lj �✓
Owner's Name:
Owner's:Address 1, 4�,• ' <
t . ;
Date of Inspection 6 , . 1 1"
Name'of Inspector (P;ea e print) rof ). . {� 16 s U
Company Name'f$;�3�,VZZ2Y d''h Oz.
iYlailiiis.Address �)rt 611, 1. �J b7'
e ir,,' s
TelepharieNumber ��`7c`° .� ✓.y ;,} t.;a .
CERTIFICATION STATEMENT
1 certify that I have.personally inspected the sewage disposal system at this address 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
apprnved system inspector pursuant to ection 15.340 of'Title 15(3:1'0 CNIR 15:000). The:system;
Passes
Conditionally Passes:
Needs Further Evaluation by the local Approving Authority
Fail'
Inspectors Signature: Date:
The system inspector shall.submit a copy ofthis 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 flow of.10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate 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. 1f
Notes and Con:meats€,, s!
;w ****This report only describes conditionS at:the time of inspection and.ii.nder the conditions:of use at that
time. This inspection does not add ress"how,the.system will perform In the future under the same or different
conditions of use.
Title 5 Inspection horm 6%19,2000 page 1
Page 2 of 11.
OFFICIAL.INSPECTION FOR NOT FOR VOI,Ul�ITARY ASSESSMENTS
SUBSURFACE SEWAGE;DISPOSAI; SYSTEM INSPECTION FORM
PART A.
CERTIFICATION(continued)
Property Addresses 6,112,9--ci"Q ,
q
Owner:.
Date of:Inspecti'on:
Inspection Summary: Check A,B,C,D or EJ ALWAYS complet'e,all of Section D
A.,/System Passes:
!� I have not found any information Which.indicates that.a n i of the-failure criteria described ur 310`CMK
15.303 or in 310 CMR 15.304 exist. Anv failure criteria.notevaluated 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 IIealtla; will pass.
Answer yes,no,or not determined(Y,,N;ND)in the for the followins statements. If"not cietei�-nined'.'please
explain.1 rn.
The septic tank is metal,arid'over 2..0 years old" or the septic tank(whether metal or not)is structurally
unsound, exhibits substantial infi]tratiorf or esf ltratio J.or.iank failure is i runiiient: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
obstrucied'pipe(sj 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
obstruction 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).'I lie system will
pass.inspection if,(w.ith.approval of the.Board of Health):
broken pipe(s),are replaced
obstruction.is removed
ND explain:
Paee.1) of I 1
OFFICIAL.INSPECTION FORI. .1.-.NOT FOR VOLUNTARY ASSESSMENTS
SUBS ACE SEWAGE DTSPOS�SYSTEM INSPECTTQN°FORM
_ PART A
CERTIFICATION (continued)
Property Address 3sa17
ir '�r
Owner: ✓ {., r�.�a g1,! l�:.l.
Tate of'Inspection lm 1p�:P�� �� z c,(.5f .
C. Furth.er.Evaluation is R-equired by the Board.of Health:
Conditions exist which require,further evaluation by the:Board of Health in order to deterrnin.e if the system
is failing to protect public health, safety or the environment:
1. System will pass unless Board of,Healtli determines in accordance with 310 CMR15 303(1)(b) that the
system is noffunctioning in a manner Which will-protect_public health;'safet.y 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°saltmarsh
2. . Systemwill fail unless the hoard of Health`(and Public.,lVater.Supplier,:if any).deten:.mines that the
system isfunctioning in a manner that protects the public health,safety and environment:
i
The system has aseptic tank and.soil absorption system-(SAS)and the SAS is;within' 100 feet of.a.
surface water supply or tributary to a surface wate.r:supply:
The system has a septic rank and SAS and the SAS is within Zone ] of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water.supply well.
The system.has a septic tank and SAS and the SAS.is less than 100 feet but 50.feet or more from a
private water supply.well"*.Method used to determine.distance
**This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is.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 trieSered. A,copy of theanalysis must be attached to this form.
3. Other:
Page 4 of. 11 -
OFFICIA'L.INSPECTION FOR' .NO FOR VO]L.UNT R.Y:r SSESSMI;NTS
St:BSU-R.FACE.SEWAGE'DISPOSAL S:YSTEIMI`INSPECT ION,FOI�AI
PART A.
CERTIFICATION(continued)
Property Address 4
Owne-t: a
Date of Inspection:
D. System Fai
lure
Criteria-
ria,
applicable
ble t a .o ll.s stems:
PP Y
You must indicate."yes" or"no"to each.of the-following for all inspections:
Yes No
Backup of sewage into:facility,or system componenk due.to overloaded or clogoed SAS or cesspool
Discharge or pondin9 of effluent to the surface of the ground.or surface waters due to an overloaded or
/ clogQed SAS or cesspool
Static liquid level in the distribution
-n box above.outlet.tnverrdue to an.overloaded or cloggeo SAS or
cesspool .
Liquid:depth in cesspool is less.than 6".below invert or available volume is less than %day flow
Required pumping:more than.4:times in.the last year NOT due.to clogQed 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 1.00 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 supplywell;
Any-portion.of:a cesspool or privy is:less:than 1.00 feet.but.greater than.50 feet.from a private water
supply well with no accep(able-water_quality.analysis..[This.system passesif:the:well water analysis,
perforated at:.a.DEP certified laboratory,for coliforiwbacteria and.volafile organic'cornpounds
indicates that the.well.is free.from.pollution.from th2t.facilityand the.-presence of.atprnoliia
nitrogen and.nitra.te nitrogen is equal:to or less than 5 ppm, provided-.that no:oth'er failure criteria
are triggered.A.co.pyof the analysis.must.be attached to this form.]
(Yes/No)The system fails. I have determined that.one or more of the above failure criteria:exist as
described in 310 CMR 15.303, therefore;the system fails..The.system.owner should contact the Board of
Hearth to determine what will be necessary to correct'thefailure.
E. Large.Systelms:.
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 4.00 feet-of a.surface drinking water supply
the system is within 200.feet.of a tributary to a surface drinking water sutiply.
— _ the system is located in a.nitrogen.senslbve area(Interim 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 tlu eat under Section E or failed under Section D shall upgrade the system in accordance with 3.10 CIv1R
15.304.The system owner should contact the appropriate'regional office of the Department.
F
i
Pate 5 of I
OFFICIAL ENSPFCTION FORM—NOT FOR 'VOLUNTARY ASSESSMENTS
SU-BS.CJRI'ACE:SE` AGE DISPOSAL SYSTEM INSPECTION FORM
PARTB.
n
CHECKLIST
.� )e.
Property Address ,� 9 .�., ,�, `
Owner:.
Date of inspection, � )66
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 anv of the system components pumped out in the previous two weeks? "
— Has the system received normal flows in the previous two week period?
Have lnr,e volumes of water been introduced to the system recently or as part of this inspection ?
k,✓�r_ Were as built plans of the system obtained and examined?(If th.ey'were not available notie 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,.Iodated on site
1 _ Were the septic tank manholes uncovered, opened; and the interior of the tank inspected for the condition
of the baffles or tees, material of constriction, dimensions,Aepth of liquid,.depth of,sludge and depth of scum
— _ Was the facility owner(and occupants if different1rom owner)`provided with information on the proper
maintenance of subsurface sewage disposal systems
The size and location of the Soil'Absorf tion,System (SAS) on°the site'has be'ewdeie'rmtnj&d based on:
Yes
no
_ Existine 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 CA/IR 15:302(3)(b)]
l
5 ,
Page,6 of I J
OFFICIAL"INSPECTION rOR:M; NOT FOR VOLUiV T:�aRY,ASSESSMENTS
SUBSURFACE.SEWAGE DISPOSAL SYSTEM`INSPECTION I+OR. M
PART.C
SYSTEM ZNFQRMATIO!1
Property Address: 2 9i°
Owner: /'
Date of Inspection: 1�,. t Vie_!' !'' ,- r >(n
FLOW CONDITIONS
. RESIDI;NTI4L
Number of bedrooms.(design)- Number of bedrooms(actual): "r
DESIGN flow based on 310"C R 15.203 for example: 11.0 g"i ( d x rc of bedrooms):
Number.of current residents: A. r1"LO) r,� �r ) —
Does residence have.a garbage grinder(yes or no)-Alv
Is laundry on ai separate sewage system(yes or no):/yo.f if yes separate inspection required]
Laundry system inspected es.orno);A
Seasonal use: (yes orno):
Water meter read' o . o readings, if av�Table(last 1 V, /,�. J(1 s 2 years usage(4pd)): fl �• �.,� ��...�, ,.
Sump pump (yes or no):
Last date of occupancy: 6 ej) e? ef11
6l"
COMIYIERCIAL/INDUSTRIAL. Al
a
Type of.establishment:
Design flow(based on 3 10 CMR 15.203): gpd
Basis ofdesigr flow(seats/personslsgft,ecc..): V
Grease trap present(yes or.no);
Industrial"waste holding tank present(yes or no):`
Non-sanitarytivaste discharged to.the;Title 5:system(yes or no):_
Water meter readings; if available:
Last date of occupancy/use:
OTHER(describe): .
GENERAL INFORMATION
Nniping_Records
Source•ofinformation: , ,(.
Was system pumped:as part of the inspection (yes r no f
If yes, volume pumped: n1lons---!low was quantity pumped determined?
Reason for pumping:.
TYPE OF SYSTEM
Septic tank, distribution box,soil absorption•system
_Surgle cesspool
_Overflow cesspool
Privy _
Shared system (yes or no)(if yes, attach previous inspection records, if any)
Innovative%Alternative technology.Attach a copy of the"current operation'and maintenance contract(to be
obtained from system"owner)
Tight tank; —Attach a copy:of the DEP approval.
-.Other(describe):
A.p roxirpzte age of all components, date installed(if known) and source of information:.
Were sewage odors.-detected when arriving at the site(.yes or no):.
6
.
Page7 of.i-1
OFFICIAL INSI'E ION FORM.=NOT`F072 VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE-DISPOSAL 1SYSTEM.INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address e,
gA_//I
Owner: ' �r�r.:'. ry �; s 'ZrlZ
Date of Inspection: a a /` 71 r. t�I' trr
BUILDING SEWER(locate on site plan) Al
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: V(locate on site plan)
Depth below wade:,r
Material of construction: v,"concrete_metal fiberglass._polyethylene
_oth: r(explain)_
If tank is metal list acre: Is age:confirmed by a Certificate of Compliance(yes or no): (attach.a copy of
certificate '
Dimensions:
f
Sludge:depth: )Q .
Distance from top of sludge to bottom of outlet tee:or baffle:
, o
Scum thickness: (av
Distance.from top scum of to to of outlet.tee or baffler �a
P.
— r
J
Distance fi-om bottom of scum to bottom f outlet tee or baffle: a
How were dimensions.determined: t` , c:'a'�m. ,; ' ; .t
Comments (on:pumping recommendations, nlet and outlet tee or baffle condition, structural integrity, liquid levels;
a .rela�tped to outlet invert
vert, evidence of lea'k}acr�pe, etc.): y�i. f
.rY"..�'� ���✓ l,Y.f_ J)k .� d'k�s.�'"✓ .e 45.br[._t ', .e; 'a 6',{:� (, _ .��<,-"!%C". ,d .s� e Srd^.. ��`,
1iL 1 j'.�n �r fay _i' P, .6 7p X bl,t ,", /IX, '- 4 , ✓ P.r �`✓,;L [.' -;�.IC ffi�` .:
; 'si'✓ �� : ' i f°° �?. .o .'� '/49 11, C ' . LW'
GREASE TRAP: k locate on site ]an ��'i✓.�r .fit ' ' � 1 � t' l�r ,11�( , :ill,.
( p ) . '', evleinlll
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 of baffle:
Date oflast.purrmping-
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to otitlet'invert, evidence of leakage, etc.):
Page S of 1.1
OFFICIAL-INSPECTION.FORM—NO F.OR.'VOLUNT Y.'ASSESSMEI NTS
SUBSURFACE SEW-AGE DISPOSAL SYSTEN1 INSPECTION FORM
PART C..
SYSTEM INFORMATION(continued).
Property Address t
Owner: A J ,k /: A
Date of Inspection i a1L ti .
Q � ,
TIGHT or HOLDING TANK:` (taiA must be pumped at.time of inspection)(locate ou.site plan)
Depth,below grad.e:.__
Material of construction: concrete metal fiberglass of etfiylene. other ex lain ::
—p y ( P )
Dimensions:
Capacity: gallons
Design Flow:. gallons/day
Alarm present.(yes or no):.
Alarm level: Alarm in working order(yes or no):
Date of last puinpina:
Comments (condition of alarm and float switches, etc.):
DISTRIBUTION BOX: 4.r (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 outleWequal,.any evidence of solids carryover, any evidence of
Leakage into or out of box, etc p
PUMP CHAMBI R:: (.(locate on site plan):
Pumps in working order(yes of no):
Alarms in working.order(yes or no):
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Pace 9 of I l
....OFFICIAL INSPECTION FORM.-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE°DZSPOSAUSYSTEM INSPECTION FORM
PAIR C"
SYSTEM CNFORNIATION(continued).
Property Address � 'y� ' Ji�,�t_ ci'
Owner: `.-r??�`.� "� '�Y�;/✓
Date o.f"inspection;
SOIL A>3SORPTJON SYSTEM (SAS). fd' (locate on site plan, excavation not required)
If SAS not located explain why:
Type '
leaching;pits,number: .
leachin-chambers,number:
:leachulg.galleries, number:
leachina trenches, number, length:.
leaching fields,number, dimensions:
overflow cesspool;number:
-:innovative/alternati.ve system. Type/name of technology:. "
Comments (note condition of soil, signs of hydraulic failure, Level of ponding, damp soil, condition of vegetation,
l,,t, �/J'.y1
. � ✓/:f' ,� .rl... K"ti4 '1...;Y.`f•. .%✓'f J':�;'� ..f� .ls{cp _.G�.., d't_�.s".rf
y
N
lkf.�r�1�..:. a�� �(r�p g.® �; rr /" fr.�..° t / �.: 9
fi'•,��.,;✓ { "Lb+ ����� ✓f,��e'S1 ��'fy.✓„T�'�.,�"a sppyW-�I M .L'•."r.1 '�'r.✓ .e �,d'? ®�Eci'' 1. �.,J d�'Y `." }�"✓/�'P
11111
NF„ �+
CESSPOOLS: )(cesspool must be pumped as part of inspect ion)(Iocate on site plan)
Number and con iauration:
Depth'—top of liquid, to inlet invert:
Depth of solids laver:
Depth of scum.layer:
Dimensions of cesspool:
Materials of construction:
Indication of.groundviater inflow(yes or no):
Comments(note condition of soil, signs of hydraulic failure, level ofponding, condition of vegetarion,.etc_):�
PRIVY: ''&l(locate on site plan)
Materials of construction.
Dimensions:
Depth of solids:
Comments Incite gondition of soil,'signs of hydraulic failure, level of ponding;condition of vegetation, etc.):.
�{� �V yL- /��s4tr�aa �r Y Y w>rrJ f° 4 s. �e•;lC Kl t �'e �a7i t�i�C. JC.� °Y1O l
Pace 10 of 1.1.
i .
OFFICIAL INSPECTION FORM-.NOT F VOLUIN7'A y ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYS TENI.ZNSPEC`I`ION FORM
PART C.
SYSTEM I:NFOI MATION(continued) .
Property Address: kz
. , Vie.
_ ��_
Owner:.
Date of inspection:.
_ SA
SKETCH Of SEWAGE DISPOSAL SYSTEM
Provide a sketch of&.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.
' -0►�1 <�
Vr 19
` f
t o''
a � i
lke Q
f
Page. I of 1 1,
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM "
PART C
SYQ)TrA�M INFOR1MATION.(continued)
Property Address (e)--'l".a
Owner: 1' �^!
Date of s10 tion.
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
t
Estimated.depth to-round water r feet . r
Please indicate (check) all rnethods used to determine the high around 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:
Checked with.local excavators, installers-(.attach,docuinentation)
'r,r''Accessed USGS`database-explain:
Y u must describe how you established the high groundr wa.tgr elevation:
- �.,�1'�°<.�- e�:L�l �����4'r;".�i�..��,✓ /� r �- v i.. .�l.. �. �-1 drFi"' r.1'. ,,� ,1`... y I�
u
ll
Permit Number: Date:
Completed by .
HIGH GROUND WATER LEVEL COMPUTATION.
d i
Site Location L —f d� ✓ . �', iz�. ,:. .. Lot No.
Owner: Address:
Contrabtor N, l/3� I_ '� -e r „ Address: 4/l �..` 1 ✓/Y.✓���tl,�'� 11'N
Notes:
STEP.1 Measure depth to water table
to nearest 1/10 ft. .....: ......... . ........ . .... .... ... ....:. ....:.... .......::. .Date
rrionth/day/Year
STEP .2, Using Water-Level Range Zone
and Index Well Ma.p,Locate
site.and detecmme � ,
0.Ap.propriafe mdex:well ......
OB Water level"range zone :. :.. . ........ .. �
.
STEP '3 Using monthly re ort Current
p
Wa le'rRe"sources Conditions
determine current depth toT
"water aevel for index
month/year
STEP '4 Using'Table of=Water:level-Adjustments
:for index well;=(STEF`_2A) :cu.r-rent-depth
.to waterlevel.!for index--well•(STEP 3),
and water level. zone (STEP 213)
determine water level.adjusiment :............:. �w?
STEP 5 Estimate depth to high water
by subtracting the water-
level adjustment (STEP 4)
from measured depth to water
level at site (STEP 1) ............................................................ )7,
71
Figure 13.--Reproducible computation form:
15
fi
TOWN OF BARNSTABLE
LOCATION SEWAGE
VILLAGE ASSESSOR'S MAP & LOT 009
INSTALLER'S NAME & PHONE NO.6DG� �rl1-sue y� �
SEPTIC TANK CAPACITY /eDO wz
LEACHING FACILITY:(type) /��� ���(size)
NO. OF BEDROOMS 1, PRIVATE WELL OR BLIC WATE
BUILDER OR OWNER �GayD
DATE PERMIT ISSUED: Q D
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes o r
e
.� ' r
��Sr✓
7�r
r
7 k; \
kF5
No...... ...._......... Fss -��...............
THE COMMONWEALTH OF MASSACHUSETTS � .A
BOARD OF HEALTH A p-p !� C p E D J� I
TOWN OF BARNSTABftastabla Conservation Cor z,,ion
. pplirFation for Bi-qV,o s al Workfi T S�� d rnti � _��� z
Application is hereby made for a Permit to Construct ( ) or Repair 0,<' an Individual SewaAabisposal
System at:
/ r,� Location-Addrgss� �Qy� J� J����/ �l�� or Lot o. t
----------------------..e_......7. •-• ....... ............................................... -----h./. 7.. T ................................� - •---.......- ....
....................!J Owner (.�V/d� �� l/LJ �y Ad
/�� +
Installer Address
j
U Type of Building Size Lot _W_.t..Sq. feet
Dwelling—No. of Bedrooms___________________r -----------
-----Expansion Attic ( ) Garbage Grinder ( )
'4 Other—Type e of Building No. of persons............................ Showers
W YP g -------------•-•--•--------- P ( ) — Cafeteria ( )
a' Other fixtures_.__:.
W Design Flow........................ ..............gallons per person per day. Total daily flow--------- l,......................gallons.
WSeptic Tank—Liquid*capacity/4 _gallons Length................ Width................ Diameter-_._-__-____---- Depth................
x Disposal Trench—No..................... Vidth.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No----------Q�-. Diameter....... Depth below inlet.....& .._... Total leaching area..................sq. ft.
Z Other Distribution box ( )' Dosing tank ( )
0-4 Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................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........................
Description of Soil--••--------•-•--& .........
x
W
U Nature of Re ai s or Alterations—Answer when ap livable.__. --_____---21 ?,j
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance s b en issu db,e board of health.
Signed ......:. ... _ ....��...
Application Approved By ------ -------- -- --...... `
Date
Application Disapproved for the following reasons: ............ .......................................... --------------- .........._.....---....------......-------------- .
---------------------------------------------------------
Permit N Issued Date
-----------------7---- ....... - -----------
.7
No.---- .......... Fxs ............_
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
TOWN OF BARNSTABLE
Appliration for Dwpn,ial Vorkg
Application is hereby made for a Permit to Construct ( ) or Repair W)/an Individual Sewage Disposal
System at:
�! O 5"U i7 x� 29
Location-AddressLot No.
....._ .....
i-77 Address
Installer +
Address
Q Type of Building Size Lot`- j,.44-4-�:-..Sq. feet
Dwelling—No. of Bedrooms............................._..__.Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Q Other fixtures
W Design Flow...................... ..........gallons per person per day. Total daily flow---------- ....................gallons.
WSeptic Tank—Liquid capacityl4%.,M.gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No. ....................Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No
..........I:7, -._ Diameter.__....�4-_/.. Depth below inlet...... ...... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
(X4 Test Pit No. 2................minutes per inch Depth of.Test Pit.................... Depth to ground water........................
a ------•----------------------------•----••-------------•---------•------•••••---------•••-•-•-------------•---•-------------------------------
.--------
D Description of Soil-------------------41`� ----�_(� �. �.5' � Q/ 1'� �''�
x
,
w
x -------------- -------- -------------------- ---------------------------------------•--------------------------.....---------------•---------------•----•- ----- -- --------..
U Nature of Repairs or Alterations—Answer when applicable.___-4-4.n_-__---__, �/ �
........................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has be issued by e board of health.
t
Signed .....�_ ..�._... /�...�.��_..��--------------- -��
_. � .
Application Approved BY f ...... ........... w ... -. -- --........� (v.- ..................................
...
Lhre
Application Disapproved for the following reasons- -------------- --------------------------------- --------------------------------------- --------------------------------------
.... ....... ...................... ......... ........... ..............
/ ...I. - -----------------------------------
Permit No. .. .I/ '�Y-------------------------------------- Issued -----�l .l-mo t ..4�.--1..... Date
rr
// !!/"` /
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Trr#tfkatc of Tontylianc.e
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )V_ )
by d.'.:. LG. T7 Qa)s?.
Installer
at ...................................................
has been installed in accordance with the provisions of TITLE 5 of The �vironmental Code as described in
the application for Disposal Works Construction Permit No. .........../............ ..... .............. dated .................................... ..----
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.DATE.................................... �� ........ Inspector -�' / L rl tit/ I !� 1
fFr ---------- ---------- ......----....----------.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH ~
G� TOWN OF BARNSTABLE
No._.�.� !..._.. ) FEE. ............
Disposal Work.5 101lanitrudion rrntit
Permission is hereby granted.................. D�Z%�Co�3l C�A.ID-,
------------------ -------------------------•-•-•••---......-•--...............•----
to Construct ( ) or Repair (yC; an. Individual Sewage Disposal System
at No.................................................�_ � �� - . x' �J �/tJ�'
r -------------------------------------r---------•-•-
I Street q � - � /D
as shown on the application for Disposal Works Construction Pe mit No.. __..___..(�_'_�__ Dated._.r_________. 30 q_L-n•• ~
DATE..
........ Board of Health,
--- --------- -----
FORM 36508 HOBBS&WARREN,INC.,PUBLISHERS
...................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.................. ........................0 F...............I.................I.....'-I----._........................................
Appliration for UWVviial Workii Taustrurtion V.unfit
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at: C '� -2. �.N 7Z�2-1771-3
...................... ..... .................................................................................................
or Lot No.
WWI 3 .1• ...................................................................................................
................. .................... .............
---O-wner N Address
.............................. ......... ...................... ..................................................................................................
Installer Address
Type of Building Size Lot_____---------I...&t..Sq. feet
U
Dwelling—No...of Bedrooms................ ------........... ...Expansion-Attic Garbage Grinder -
04 Other—Type of Building .......... ..... No. of persons...........L.f-------------- Showers Cafeteria
PL4Other fixtures ......................................................................................................................................................
Design Flow........ ......�.)........ --gallons per person per day. Total daily flow.......... ...............gallons.
1:4 Septic Tank—Liquid'capacityjA : gallons Length................ Width....___._....... Diameter._._-__-_-_____. Depth..............-.
Disposal Trench— o. ................. Width .......... Total Length.............`_.... Total leaching area....................sq. f t.
Seepage Pit Diameter---- ..... Depth below inlet....._........_ Total leaching area..................sq. f t.
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--______-_.-____---____.
44 Test Pit No. 2.................minutes per inch Depth of Test Pit.................... Depth to ground water........................
01 --- - -- ------------ ................*"------------ ------------------------*......*......*"*-----------------------"------
0 Description of Soil........ ................................................................................................................................
....................................... .......... .........................................................................................................
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'JI11 LE4 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 boar ,,6f health.
ned.. .................................................. . ... ..... ...... ............
ApplicationApproved By.............I... ......... ................................................................. ..... ........... .. ............
Date
Application Disapproved f the 6l1owing easons:...........................I.......... .........................................................................
....................................................... ..................;.............. -------*--------*.............---------------------------------------------------*---------------*--------
Date
PermitNo......................................................... IssuedL.......................................................
Date
to. .......-2E_
.........................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...................... ....................OF
Appliration for Ditipasal Workii Towitrifrtion Prrmit
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at: -74/7 -7716
•
..................................................................... ... ..................................................................................................
. ....................X.-A... ............. ..........................................or Lot No......................................................
_,no Address
. ............................. ................... ..................................................................................................
A, Installer Address
Type of Building Size Lot__...:._........�._Atq. feet
Dwelling—No.�of,Bedrooms._........:.... .........1...............Expansion Attic (�,arbage Grinder
Other—Type of Building' y , '. ... ........................... go. of persons._.___.__.:__.............. Showers (*I� — Cafeteria
PL4Other"fixtures ............................................................................... '.
..........................
....Design Flow____._____...~ .. per person per. day. Total daily flow_______________.X,4.7M*..'- ___
gallons.
..... .
r4 Septic Tank—Liquid capacityf!;'4,.Pgallons Length________________ Width_.__...._._._.._ Diameter_________.______ Depth____.__.____._..
Disposal Trench ..................... .......... Total Length...... ..... Total leaching area______.____ .......sq. ft.
Seepage Pit No..... Diameter...A.-
........ Depth below inlet......!�4......... Total leaching area..................sqj t.
z Other Distribution box �D8Mng tank
Percolation Test Results Performed by......................................................................... ---------------------------------
'Test Pit No. I........i-..-.A.minufes per inch Depth of Test Pit.................... Depth to ground"Water........................
P� Test Pit No. 2................minut8l),per inch Depth of Test Pit__.__...____________ Depth to.ground water........................
.... .... .........................................................................................
------------- .........................
0
Description of Soil__.______
...........Y9
.........................................................................................
------------------------- .........
----------------I------- .....................................................................................................................................
..............................................................
------------------------------------------------------------------------**................................................................
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 TITLE 5 of the State Sanitary Code—The undersigned fur,ther,.agrees not to place the system in
operation until a Certificate of Compliance has been issu y'I b rthe boa W D _,00of health'
Sihe.... .. .................................................................
... . . ...........e
fit
Application-Approved By...... .. ....... .................................................................... .......... .........................
r Date
Application Disapproved flqrth��Ilowing seasons-................................................................................................................
..........................................................................................................................................................................................................
Date
PermitNo..................I....................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF.....................................................................................
(9rdifiratr of Tautphaurr,
constructed Repaired 51
T 7, R That the Individual Sewage Dispo I System c
OT or Repair
...... . ..................71 by... ...... ................ ........... ..........................................................................
Faller at.
. . .............. .. ............ ... ........
..... .................. /--------------------------------------
------ ----
has ------- e---------ed-in.-th-e'
has been installed in accordance with the provisions of T-ZL 5, o The State Sanitary 0
9
application for Disposal Works Construction Per i ------
t I ............. dated_--..__.__._._. _ ......... ..........
THE ISSUANCE OF THIS CERTIFICATE-11 VALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WI NOTION SATISFACTORY.
DATE....... ...................................................................... Inspector..
.........................................
;__�- ---------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
No...Ir ......................................OF.....................................................................................
FEE........................
Disposall%rx .091itnu ton Trutt
Permission is hereby grant ...... . ...................................................................
granted...K4. .......
to Construct'( er-or Repair Vi. ms,I
an di Sewage y
at ------- ...........r,�r%_-- -
-----ta......................... ...........
t�S�t, ei,It
as shown on the application for Disposal Works Construction Pe it No............... ed.... ..................................
I U1
0
.........................................•--:. .....................................................
DATE---...------------------------- .................................................. 7of Healtiff
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS
_...... ►1
S ,.
j 5106L& FAMILY - .''S BCoRQoM
i "fir G�4RBAGE trjWNDER.
II DA%L,,( FLOW x 110 X 3 = 330G.P. D+Solo a
5EPT,%C TAWK = 330x Pa%d i G, 6PC7.P Q
U51=-• 1�0.� GAL. • � ,�
o15poS�L PIT u5E I�oo GAL..
'S►DGYIAIL AQ.CIs = a-2G5•F 1
50TTOM AREA-., 171,S4F._ - St=E QL-�� d K °
'IOTA 4:7�3 G•P D. St1'E.ET
'TOTAL, pA1L.4( FLOW - 3306,Po•
j PE2COLA.TION RATE : V'im 2MIN ol`LI~551
Uf H OF
ALAN
F?fCHAF°IO 3� W. m
A. -+
�'I6t y BAX' w JONES '" I
n' K0.24048 0. 25100
A
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e� �
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q9 No SCALE SCALE
ld�, 14t, t -C IS4,9
I CERTIFY THAT THETROP. F•OU Np 5l10ww
► r,-P-Eo N GOMPL`(5 WlTN"T HE• S 1 o6L1t-1 E Q 0
AWP 51cTe.GK IZ6Qv►R.>cMEN7"� of TNT �Cv y
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o SN aR ids
LOGp.TED WIT61w N6 G o0D, PLN
-65 TUN �.1
DATE i
BAxTEQ.e IJ`{E INC.
' REG I S•T f�Q.6U'�.AW D'S u�.Y��(otCS
Tu15 PLb Kl 115 NOT A.N osTEQ.YILLE- - ems• '
IN5R•TutAeWT 5vevey �-rHE vFF5ET5 Suouo -- --. ` A
NoT DE vSEOTo l7L—TEFt/^I►.lrc l_oT �.II-1E�j APPLICAWT
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