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0034 COTUIT COVE ROAD - Health
34 Cotuit Cove Road Lotuit" ` � A=005-032 ' z 6 21 /06 PROPERTY ADDR 34 Cotuit Cove Road Cotuit MA 02635 On the above date, the se 'c system at the address =ove was Inspected. This system consists of the following: to 1-1000 gai-eon zept.ic tank.1 2 I-Dizi-4 i a,_' ion Box. 3.; 1- 1000 ga-eion ieach.ing .Rit.1 Based on inspection, I certify the following conditions: 4.; 7h.iz 1.6 ¢ 7.4t.ee five -6pet.ic *Ztem (78C-o?,i 5.) Sept.ic zyztem .iz .in p4ope2 wo zk.ing o zde/z `fit .the p/zeaent time., SIGNATURE Name: Robert A. Paolini Company: Joseph P. Macomber & Son Inc . Address: P. 0. Box 66 Centerville, Mass 02632 Phone: 508-775-3338 or 508-775-6412 JOSEPH P. MACOMBER & SON, INC. Tanks-Cesspools-Leachfields Pumped & Installed Town Sewer Connections P.O. Box 66 Centerville, MA 02632-0066 775-3338 775-6412 4 Q COMMONWEALTH OF MASSACHUSETTS r EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION t TITLE 5 OFFICIAL INSPECTION FORM-,.NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PARTA CERTIFICATION Property Address: .. 34 Cotuit Cove Road Cotuit MA 02635 Owner's Name: Thomas Regan Owner's Address: PO Box 1810 Cotuit MA- 02635 Date of Inspection: 21 .1 n h Name of Inspector:(please print) Robert '.A Rao.lini Company Name: 9_ 1). 0acomfea � S:o.a Inc.. Mailing Address: Pox 66 Cetp_av7 e, a.6.6.-02632 Telephone Number: 5 0 8-7 7 5=3 3 3 8 CERTIFICATION STATEMENT I 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 approved system inspector pursuant to Section.15:340 of Title 5(310 GMR 1&000). The system: XXX passes Conditionally Passes Deeds Further Evaluation by the Local Approving Authority eails 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 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. 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 1 Page 2 of 1 l OFFICIAL INSPECTIONYORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 34 Cotuit Cove Road Cotuit MA 02635 Owner: Thomas Regan Date of Inspection: 6/21 /0 6 Inspection Summary: Check A,B,C,D or E/ALWAY&.complete all of Section:D A. System Passes: y6S NO I have not found any information which indicates that•any of the failure criteria described7.in 310 CMR 15.303.or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: Septic .i,6 .in PAORea wo/tk.ing o/tdea at the /zaezent t-imeo B. System Conditionally Passes: N0 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. No 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: is: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: NO 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 inspectiondf(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled"or'replaced ND explain: NO 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 I OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 34 Cotuit Cove Road Cotuit. MA 02635 Owner: Thomas Regan Date of Inspection: 6/21 /0 6 C. . Further Evaluation is Required by the Board of Health: iV O Conditions exist which xequire 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: 120 Cesspool or privy is within 50 feet of a surface water 120 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: no The system has a septic tank and soil absorption system(SAS).and the SAS is within 100 feet.ofa surface water supply or tributary to a surface water supply. n o The system has a septic tank and SAS and the.SAS is within a Zone 1 of a public water supply. n o The system has a septic tank and.SAS and the SAS is within 50 feet of a private water supply well. 120 The system has a septic tank and SAS and the SAS is less than 100 feet-but 5.Qfeet or more from a private water supply well**.Method used to determine distance v.izuai **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. 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: 34 Cotuit Cove Road Cotuit MA. 02635 Owner: Thomas Re an Date of Inspection: 6 21 0 6 D. System Failure Criteria applicable to all systems:. You must indicate"yes"or"no"to each of the.following:for all inspections: Yes No X Backup of sewage into facility or system component due;to overloaded or clogged SAS or cesspool X Discharge.or.ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _ X Liquid depth in-cesspool is less than.6"below invert or available volume is less than '14.day flow X Required pumping more than 4 times in the last year.NOT due to clogged or obstructed pipe(s).Number of times pumped X Any portion of the SAS,cesspool or privy is below high ground water elevation. _ X Any portion of cesspool or privy is within 100 feet of a surface water supply.or tributary to a surface water supply. X Any portion of a cesspool or privy is within.a Zone 1 of a:public well... X Any portion of a cesspool or privy is within.50 feet of a private water supply well. �.. X 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 corrbct thetailure. E. Large Systems: To be considered a large.system the system must serve a facility with a design flow of 1.0,000 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 X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive 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 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: 34 Cotuit Cove Road Cotuit MA 02635 Owner: Thomas Regan Date of Inspection: 6/21 /0 6 Check if the following have been done. You must.indicate"yes"or"no"as to each of the following: Yes No X Pumping information was provided by the owner, occupant, or Board of Health X Were any of the system components pumped out in the previous two weeks? X _ Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this linspection? X _ Were as built plans of the system obtained and examined? (If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out X _ Were all system components,excluding the SAS, located on site? X _ 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? X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no X Existing information.For example,a plan at the Board of Health. X _ 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)] S Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL-SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 34 Cotuit Cove Road Cotuit MA Owner: Thomas Re an Date of Inspection: 6 21 0 6 FLOW CONDITIONS RESIDENTIAL 3 Number of bedrooms(design): 3 Number of.bedrooms(actual): 3 30 DESIGN flow based on 310 CMR 15.203 (for example:110 gpd x#of bedrooms): Number of current residents: Z Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no):_no [if yes separate inspection required] Laundry system inspected(yes or no): n.o Seasonal use:(yes or no):n.o Water.meter readings,if available(last 2 years usage(gpd)):" N� Sump pump(yes or no):_n o Last date of occupancy: 122 e hen t COMMERCIAL)INDUSTRIAL N14 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 I?uml2 tank at. time o� --n,6R•' Source of information: Was system pumped-as part of the inspection(yes or no):LLF 3 If yes,volume pumped: 1 0 0 0 gallons--How was quantity pumped determined? Reason for pumping: ma at TYPE OF SYSTEM X 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 be obtained from system owner) —Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Z3 yea2,6 Were sewage odors detected when arriving at the site(yes or no):n o 6 Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) .Property Address: 34 Cotuit Cove Road Cotuit MA 02635 Owner: Thomas Re ,an Date of Inspection:. 6/21 /0 6 BUILDING SEWER(locate on site plan) Depth below grade: . 18 Materials of construction:_cast iron X 40 PVC_other{explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting, evidence of leakage,etc.): ao.ini-z appeaa t.i ht ,No evidence o� ieakageo Vented .thltough aoo)e . vent., SEPTIC TANKS e,6(locate on site plan) 1000 ga i i o n z Depth below grade:- 1 2" Material of construction:Xconcrete 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: 8' 6"X5' 8"X4 ' 10" Sludge depth:_ taace taace Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: t a a c e Distance from top of scum to top of outlet tee or baffle: t as c e Distance from bottom of scum to bottom of outlet tee or baffle: t a a c e How were dimensions determined: m e a.6 ua e-d Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to.outlet invert,evidence of:leakage,etc.): i ump .tank annuaiiy gaazgage diz/zozae 'iz R?e,6ent.1 Ini-e"t 9 out"2et eez aae in /2 ace., /ank i.6 .6 auc uaa y o.6urz .i GREASE TRAP:NO (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.): Gaeaze- taa i,6 not 2eLent 7 Pagel 8 of l 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 34 Cotuit Cove Road rntnit MA n2615 Owner: Thomas Regan Date of Inspection: 61211 h TIGHT or HOLDING TANK: NO (tank must be pumped at time of inspection)(locate on site 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.): tight o2 hoiding tanks ¢ice .not /22eZen.t DISTRIBUTION BOX:ryez (if present must be opened)(locate on site plan) 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 leakage into or out of box,etc.): i3ox .ins eevei haz I No. eo-e id cap z zyoven o2 ieakage .in oa PUMP CHAMBER: NO (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.): 2um12 chamge2 .ins not 122e3ent 8 Page 9 of 11 OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 3 4 roi-ii i t rpup Road Cotuit MA 02635 Owner: Thomas Regan Date of Inspection: 6/21 /0 6 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: _ Located .see /gage 10. TyXpe leaching 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 technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): Loamy to medium 4ine zando No z-i n.6 of lai-Pulte o o a2e 2y.T eyetat.ion iz no2ma-eo CESSPOOLS: NO (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.): Ces/zoot a2e not /1 2e.6ent., PRIVY:NO (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.): Pzjvy .iz not paezerzto 9 Pdge 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 34 Cotuit Cove Road Cotuit MA 02635 Owner: Thomas Regan Date of Inspection: 6/21 /0 6 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. 17 � /7 �nlv � 1 � 3'2�' r I i r 10 � Page 11 of I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART.0 SYSTEM INFORMATION(continued) Property Address: .34 Cotuit Cove Road Cotuit MA 02635 Owner: Thomas Regan Date of Inspection: r,,/01 Z n SITE EXAM Slope Surface water Check cellar _ Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: -NO Obtained from system design plans on record-If checked,date of design plan reviewed: ues Observed site(abutting property/observation hole within 150 feet of SAS) e,3 Checked with local Board of Health-explain:a.6 P u./ no Checked:with local excavators,installers-(attach documentation) Accessed USGS database-explainA t tR:town.,g a lt n,t¢g Pe.,m a.-u s You must describe how you established the high ground water elevation: /l,6ed Cape Cod Comm.is.ion 1datea Tag.Pe CoAtou2b And %ugtic ldatea Su121?iy Ue�i head paotect.io•a a2eaz mal2o Sept 1995 �ate2 aehou/tce,3 o�-J.ice cape .cod comm.i.6.ion., Top of Ground Leaching Pit feet Groundwater�Feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method 4 Therefore,the vertical separation distance between the bottom of the leaching pit and the adjusted groundwater table is feet. rJ 11 n ,•••�•,,•V-�••••�••-- TOWN0 BARI��LTgBT.F _ WARD OF. HEALTH SUBSURFACE 8F,WA09 DISPOSAL BYSTKM It♦ EC ION FORM - MART D CERTIFICATION ••.TI'1�.'•SL{7�1 T1111'VGTrlMflwl'RIRITRJ + ST�A•1.'� -TYPE OR P11HT CI,I;ARLY— PROPERTY INSPECTCID STREET ADDRESS 34 .Cotuit Cove Road Cotuit . 02635. ASSESSORS MAP BLWK AND 'PARCEL # OWNER's NAME .Thomas• an` PART` D C,ERTIFSCAT30N NAME 'OF INSPECTOR Robert A Paolirii COMPANY NAME COMPANY ADDRESS f' $Ox `66 _ Centerville MA" 0263-2-006� O Stra6�' Town-or City. StaAr LIP COMPANY TELEPHONE S 508• ) 7.5 3338 FAX (' 508' .790 ;. f578 CERTIFICATION. STATEMENT I certify that I -haws personal.-1Y .inspected .the aewage 'digpoga`l. system at this address and ttlat• .tlls' information reported ,is true. gccUra•te•p and omplete as of the time a,f inspection..- The in., Peotio.n was performed and any recommendations regard.itlg• .upgradej .ma•intenance l' and irepaIr •are• eon$is'tent with my trainip,g and exP.erience in the proper funeti•on• arid maintenanoe of on- site sewage d4sposal systems Check one; ' Systed PASS'kD The inspection vhic.h •.I. have .•conducted has .,n•at found any information . which indicates that the system fads to •,adeduately. protect .public health or the env�.ro �ment as defined its. .310 CMR. lg•;30.3-, •Any failure cri-ter.ia Dot evaluated are. as stated in the FAILUIt CRIR�A .section o:f this form. System FAILED* The i nspectioh which I }rave bin ted -has:'•found that the system fails to rrotec.t the public lieal o end tho eny4ronmen•t ' in aevo'rd•ance with Title 6 , 310 CMR 15 . 303 , and as • speci f lcall y noted 'on •Pa'RT. C FAILURE CRITERIA of this ins ' ec'tio fo Ins.pector Signature' Date `r2 j O its 0 .� ne' copy of this ceirt�,f icat•i:ari must .40 1rovi'ded `to , the .oNgH., tho yER- where ayaPli'•a&ble) and tht 139ARD OV HEA Tit. .. , » L * If the inspection FAIL'E.D,, thb .own*V .oxMoperator -0vL1j . up9•r.ade'•the system• within o'ne year of the date of the inspection, unless, al-lowed Qr• requ#.;red - L® C 10rd SEdYA G E . 1'ER:AAITMO• .. d! L GE ! NS LLER'S NAME fir' AD0ItESS ° r. • U 1 E �y OR d�J EQ � , D A T E P E 0 M! T ISSUED ' r OAT E COMPLIANCE ISSUED `� '' o - t Flo 54 a. -f.,9 t - • r �'. � ' r.�.---�--•� 1V`.^`� Tom' O � _ No...�... � t� ...��............ THE COMMONWEALTH OF MASSACHUSETTS BOA R® OF . HEALTH ..............................OF.......................................................................................... firatiun for ,Dispn, til Workg Tnnitrurtuan rrmff pp ication is her b for' a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at • •- ...... (> / •..........C......ids.... ...............•---•--••---•--......._----- -•-•------••......................._---•-- ddress or Lot No. ......... ........................................... ... ..........................•----••----_..... .._.......----•-••-•-•--------................. • b Owner Address Address ................ ... ____.......� . .----•--- .. _........ . -_... .........-----------------......__...------•-•-••_.......-•2....• ............---- Installer Address Type of Building Size Lot._____... Dwelling ( ) Garbage Grin r a g of Bedrooms---•-•-----• ---•------•-------•-•-------- .Expansion Attic a Other—Type of Building ............................ No. of persons............................ Showers W Other fixtures ------ ••--••------------------- WDesign Flow.............................................gallons per person per day. Total daily flow............ _. ................gallons. WSeptic Tank—Liquid capacity./,42*T.gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No...../........... Diameter.....16)....... Depth below inlet.....6.......... Total leaching area..J.f...sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date......................................... Te5e Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ (i T st 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'TTILZ 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operad ii and a rtificate of Compliance has bee ssued b e b d oLLTalth. Sign _ S r Application pproved By----•--- -•----•-------•------------••---••-•-•-------------------•--•----•---•-------•--------- ...................Date--•----•••-•-- Application Disapproved for the following reasons---------------••-------•-----------------------------......--•-------------•--•------------------------------- ...........-............................................................................................................................................................................................. Date PermitNo......................................................... Issued._.....---•-----•--•----------------------•------•-•-- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............. ..--- .--- ..................... OF......................................................................................... Appliration for Biipusal Workii Tomiuurtiun rwrmft Application is hereby made for a Permit to Construct ( . or, Repair ( ) an Individual Sewage Disposal System at ... ... .....:'' .... ..... ..... }r' r ..... ................ ..................................................... � ddress or Lot No. .: •. W —y Owne�.l f `��'� Address tv.. �% .............. ...•--------------- �"� Installer � Address 2-7 Type of Building Size Lot......../J.l'.............S ee U Dwelling—No. of Bedrooms.......... .....Expansion Attic ( ) Garbage Grin r41, A4 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafet is p' Other fixtures ........................................... ----•----•-------------•...... -.-.------------------------------------ W Design Flow............................................gallons per person per day. Total daily flow............ . . ................gallons. WSeptic Tank—Liquid capacity-/)d.?9.gallons Length................ Width................ Diameter:_-_____-__..._- Depth................ x Disposal Trench—No..................... Width................:... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No...../........... Diaineter.....ltjf....... Depth below inlet.....6.......... Total leaching area..J.f..�-.Aq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by-••••••-•-.....--••••••-•........................•••-..•••••......_•---_. Date........................................ aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ (% Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water`........................ LLI' ----------------------------•--•--••--------.........----................................................................................................... 0 Description of Soil.............................................................................................•--------------------------•----------•-•-•---................:•••••...... x c, UNature 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 u 1 a Certificate of Compliance has bee issued be lid o h. -� Date ApplicationApproved By-•---•--••-•-----...-••..........••-•••.........-••••••-••.......-•-••...........•-•----•••--_... ----------------....................... Date Application Disapproved for the following reasons---------------•••--••-•----••-•---•---•-------•••-•••••••••-•-••••••••-••••••••--•••..................---•--•-- ....••-•---•--........•••---••--••••-••-•--•-----...•------••---....--•......•---•--••--••-•--••------••--•••••••------•--•-••-•-......-----•-------------•----•••••---•-•---•••••-----•--•••--••-•-••-- Date PermitNo......................................................... Issued-------•••-.....---••- Date THE COMMONWEALTH OF MASSACHUSETTS _ BOARD 'OF HEA T . .............................OF......✓ 4f&,iZ.. ......e..... f ....................................:... Trdif iratr of Toutpfittnrr T .1 F'Y, That the Indivl S wage IDi.posal System constructed (✓�or Repaired ( ) ....' ..Q..�.._ . by = }ZL .......... all.. at.................----• ---.---_. has been installed in accordance with the provisions of TI&- 7 ` of T State Sanitar Cad as din the. _�� f -------- datedy`� '�-fapplication for Disposal Works Construction Permit No___ ___________________ ____ __ _.__.._:_:._:_... ' THE ISS11A CE THIS CERTIFICATE SHALL NOT BE CONSTRUE® A GUARANTEE THAT THE SYSTEM WIL FU TION SATISFACTORY. DATE... .. -•-••--••••-......•-•-• Inspector........ .... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH r ..................:............._OF...................................................................................... ...... FEE..... ........... �i��ruo� rk� ��an�#rUan rruti� Permission is.,hereby granted---- = - ._.._.... ..... •••••-----------•••----.......•-••-••••••--•••-••.......................:............:.. to Constr�,r or Repa � �/ I �n�ag osal System atNo..f....�.... . ---..------- -----•----------------------•---------- ----------- ' Street _ �r as shown on the application for Disposal Works Construction Permit Dated ..:. %.:_. :'`______________ � ..................... --• ---•--.....-•••••----•----------•---•-•--••......--•-••.....:........... Board of Health DATE............... / /.� -------------•-•••--•-•---•-•----••....-•--•• FORM 1255 HOBB,S & WARREN. INC.. PUBLISHERS - ' I - $ , - r . , ' _-. r r . �. • . - . . ;-. " }. , �, . z - , , *. w b . . 1. o o . a . . EXIST. 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PORCH_. ,,: , _ . .:.: 1. ,,, .,. i... _ OPENING: ..:'I:I- .. r- .: ..s�. , I<L,'�I 4�,1II*1I MUD I'1I I.I.I.. ,I.'1�.I-I"-...�.I:II I..I1�.I I1.�-I 1.,. �,.�I��,�.,,II�.-� -;�I I,I..'I I.-L N L�\.,I, .I..- 4�l ...VI I�1r_1-..I:I_�-..".�-.1:II.�.��l-�I�.,"., �,�L,,.L..;,-' g'.I.� -"1..,.�,,1�: �.I�--�" HALL �, KITCHEN_ _ H TO 4 ,- .. .. - ..:. � a u�: .- . .,:.: .. I .-: .. -- VERI ITCH . _ .. LAY I WIOWNE.: , r , u p r, I 1 1 I . .:' ., , .. -- .. 1ST.::. , L RErk��E F�IscIry Tii.E TP fr '' . ,__= , . - ' - -- . --.. I- .REMOVE CLOSET `.I '- XIS..>. .. - . w T. EXIST. e e " w ORCH: , .1 , . . GARAGE , • r_ __-_----- CLOS': °CLOS.. Exlsr. • . . - --------- , _ p ::EXIST. Ex{{ST. x _, y:. _ _ -.gip .. -_ - I EXIST.W '1 # # - ,. c aez. - - v I . I ,AA DOM-YL( rhl ---�- -- , c., - ---- �- �. I , �t 1 A l r .. / i - - , - / ,Al .. � EXIST, b _ _ ..� I _ i LIVING Q 3 !\ - . _ _ _ -� .. .py : .. 4 ,} „. a Ill 3 _ .. _ ,. _ - . 0. - s - - z %�' UP i L£ EXIST. e' eXt�T 1 O EXIST. . BATH m - DEN - ., - y ., d EXIST. . - . - - S> y �' I Il HALL P . m d . , ro �, _ - - _ w I I - I - . . . - � - - � TOP OF PLATE - ' - '. EXIST,FLOOR dO1STS - - - - : - : - .;. I i.I ;, /// , . - - :. \ ! ::x :„ .:. ,: -_ NEW 2-2 O':, , .. - - ,. e O.. L. i. :.' ., .. .`_ . .HEADER,. _- a O O. :.I : - .u : .- - , - .. O s .. �. is ,.,I.I-1-. lw I. I. ,: L - =.. EX T I ST e, • f :. " - --•4 EXIST. _ ,; - ..-. EN , - v M A ; ' HALL , , , aM1 ' . r . o... ,,„., ' _ x _ - - _- ' ,« a�.. ,�.,., - FLOOR UNDER NEW _. � ; t - f . , 5 Q ,. yn' 3,. ,'. FIR T FLOOR .:POSTS ABOVE'. - - - , _ - ,� • - + ,, SUBFLOOR .. ,t _ - .. .. ,. :; rT, -. -, :, ', ::, x. -" -+„ _ E3(iSL.FLOOR-JOISTS- - - , .-. - - - . k _ ,� �` _ „=# EJCIST GIRT �� '�� �� :,... : _ _ ..,....z. e O O y >= Is PARTIAL FLOOR PLAN x T Z _ . . .: � . „ _ .A _ BASEMENT _ E , , , ;: ,.R , W LEGEND. -- , v, : .,,_ . „ _ - e _ 4 V . . - - - _ - 2 i ' , r EXISTING WALLS lk ' ° TOP of s r ,. r- e - .. I ,.... « - CONSTRUC. TO BE R.EMOVED . F 0 NEW CQNSTRUCT.ION >, , . .,. :: e:,.. ,, - ` .. .s ,... F 4. .. `. s . a A 80 . DING. SECTI�IV NEW;OPENING - NOTES. , w� .. ,:' ' 4i . : . ..-. 1 CONTRACTOR I5 TO VERIFY ALL EXISTING CONDITIONS '- . _ - :. &DIMENSIONS IN THE FIELD d,_„ "SCALE: \ ;,.: � m 1/4 '1 0• ,'� , j _ ;,' ,, , ,.n T . , 2. CONTRACTOR:TO VERIFY ALL .MATERIALS _ „ ±' DA I E:. . . . . . ° � ._ AL'i4o7�a �Y fli3 DETAILS &FINI IN �-'; '• , , SAES THE FIELD WITH 017)MER 4 TH DESIGNEER SHALL BE NOTIFIED IFANv :'. 3 -I- - _ i .' - ;_r I .ERRORS OR OMISSIONSARE FOUND ON , .ALL CONS RUCTION TO CONFORM TO 780 C,MR MASSACFiUSETTS „ ` :,,. 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