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HomeMy WebLinkAbout0021 CRYSTAL RIDGE ROAD - Health 21 Crystal Ridge Road Gc�t'Lct.T .A= 056-002-014UPC 12834 \ No.2-153LW HASTINGS dM. Csiu�rc�� i�i�� ��►�►�aNe� ��►� �02 Nv„S,s G, S�c�N�t� a r►� LAT►� �� ��✓E�G1� Q�l�h^, ®�I 'V cii I s- _ crlI C, Ti 9CA- Z-i 3 sct A �=LGw f>F 54`'I z� I'a�FG� �� �: + aGP-c / `� ;ti�l.•� �I� NGf►{ S tib vv `'AT'kjo 7i C LG �e1'p-ac�vt D -'61 Commonwealth of Massachusetts W Title 5 Official Inspection Form A Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 21 Crystal Ridge Road Property Address James Carvalho Owner Owner's Name information is required for every Cotuit MA 02635 07/27/16 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Mike Hudson use the return Name of Inspector key. Septic-wiz Environmental Services rab Company Name 28 Cape Cod Lane ,Company Address Barnstable MA 02630 City/Town State Zip Code 508-367-5669 DEP SI#4254 Telephone Number License Number B. Certification 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 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 07/28/16 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. ****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. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 ed V� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 21 Crystal Ridge Road Property Address James Carvalho Owner Owner's Name information is required for every Cotuit MA 02635 07/27/16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system.components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 P Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �^M 21 Crystal Ridge Road Property Address James Carvalho Owner Owner's Name information is required for every Cotuit MA 02635 07/27/16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 21 Crystal Ridge Road Property Address James Carvalho Owner Owner's Name information is required for every Cotuit MA 02635 07/27/16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 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 a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 21 Crystal Ridge Road Property Address James Carvalho Owner Owner's Name information is required for every Cotuit MA 02635 07/27/16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® 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 fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. 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—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. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 21 Crystal Ridge Road Property Address James Carvalho Owner Owner's Name information is required for every Cotuit MA 02635 07/27/16. page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ' ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 GPD t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 21 Crystal Ridge Road Property Address James Carvalho Owner Owner's Name information is required for every Cotuit MA 02635 07/27/16 page. City/Town State Zip Code Date of Inspection D. System Information Description: 3 bedroom cape Number of current residents: 0-for sale Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ® Yes ❑ No Water meter readings, if available last 2 ears usage d 2015- 299GPD 9 ( Y 9 (gP ))� 2015- 299 GPD Detail: Sump pump? ❑ Yes ® No Last date of occupancy: unknown Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 21 Crystal Ridge Road Property Address James Carvalho Owner Owner's Name information is required for every Cotuit MA 02635 07/27/16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): J General Information Pumping Records: Source of information: N/A Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: N/A gallons How was quantity pumped determined? N/A Reason for pumping: N/A Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 21 Crystal Ridge Road Property Address James Carvalho Owner Owner's Name information is required for every Cotuit MA 02635 07/27/16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 27years old, installed 1989 via as-built and permit Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 2'2" Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: N/A feet Comments (on condition of joints, venting, evidence of leakage, etc.): vented thru roof, no leaks Septic Tank(locate on site plan): it Depth below grade: 12feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: N/A years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ® No 1000 gallon 4'10"Wx8"6"Lx5'8"H Dimensions: i Sludge depth: 411" (1"thickness) t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 21 Crystal Ridge Road Property Address James Carvalho Owner Owner's Name information is required for every Cotuit MA 02635 07/27/16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 33" Scum thickness 0- no scum present Distance from top of scum to top of outlet tee or baffle 8"to liquid Distance from bottom of scum to bottom of outlet tee or baffle 18 How were dimensions determined?' sludge probe, tape measure, LED snake camera, floodlight Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump take every 3 years, inlet and outlet PVC tees in good.condition, tank appears level and structurally sound, all liquid levels normal in relation to outlet invert, no signs of leaks. . Grease Trap (locate on site plan): Depth below grade: feet 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 I Date of last pumping: Date t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form Not for Voluntary Assessments M 21 Crystal Ridge Road Property Address James Carvalho Owner Owner's Name information is required for every Cotuit MA 02635 07/27/16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(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 per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No r t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 4 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 21 Crystal Ridge Road Property Address James Carvalho Owner Owner's Name information is required for every Cotuit MA 02635 07/27/16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert N/A Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 �L Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 21 Crystal Ridge Road Property Address James Carvalho Owner Owner's Name information is required for every Cotuit MA 02635 07/27/16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: (1)6' radius w/ Stone ❑ 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.): Med sand, no signs of hydraulic failure, no ponding, damp soil or abnormally lush vegetation. Bottom SAS 9'6" below grade. (1) 1000 gallon 6' radius leach pit w/stone around. Empty at time of inspection w/clean sidewall. No liquid. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No 15ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 21 Crystal Ridge Road Property Address James Carvalho Owner Owner's Name information is required for every Cotuit MA 02635 07/27/16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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.): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not.for Voluntary Assessments wM 21 Crystal Ridge Road Property Address James Carvalho Owner Owner's Name information is required for every Cotuit MA 02635 07/27/16 page. City/Town State Zip Code Date of Inspection D. System Information (cont) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form R Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 21 Crystal Ridge Road Property Address James Carvalho Owner Owner's Name information is required for every Cotuit MA 02635 07/27/16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar . ® Shallow wells Estimated depth to high ground water: 17 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from.system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Reviewed as-built ❑ Checked with local excavators, installers -(attach documentation) ® Accessed USGS database -explain: Reviewed USGS water resource and topographic maps You must describe how you established the high ground water elevation: Reviewed USGS topo and water resource maps indicate ground water at 17' below grade. Reviewed as-built card. Bottom SAS 9.5' below grade. . SAS not to be found in high ground water. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection'Form:Subsurface Sewage Disposal System•Page 16 of 17 L Commonwealth of Massachusetts - Title 5 Official Inspection Form A Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 21 Crystal Ridge Road Property Address James Carvalho Owner Owner's Name information is required for every Cotuit MA 02635 07/27/16 page. City/Town State Zip Code Date of Inspection E. Report Completeness. Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Asse t ssor's office Ost floor). Assessor's ma and lot number .> .. /. � T $'�� OFT q�' t P... :;INSTALLED IN C !N P L1� � o Board of Health'(3rd floor):' {{��, (r'E Sewage ,Permit number .;..Sn '.�%�•.•dJ• + C WM TffW 5 Z 39Hd9TODLE, i r M a A Engineering Department (3rd floor) I FJS ENVIRONMENTAL CODE AND °o0 39.6�00 House number MKI Definitive.Plan.Approved b PI'annin Board ��_�f____-_ _ -_ 19 _ __ . APPLICATIONS PROCESSED..8:30-9:30:A.M. and 1:00 2:00 P.M;'only. TOWN_ OF BAR.NSTABLE BUILDING : I. SPECTO APPLICATION /9 ..................... FOR PERMIT TO .. G.7 ....RUG.. '.:..........: ./iV(}� � �✓�-ter/L. TYPEOF CONSTRUCTION ........... L) r i d...................................................................................... ` . TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ......k(1) �.......f.0.....C�.Y.�)r44-..../0/Daif .......!�.D..............007-017�................................................ Proposed Use ... .5 �C.fG Zoning District ........... .. Fire District �l)7L1 .................................... .............................................................................. p 19 �!S /L� ..../ � '.....C�........Address ......? ..v:....a�..DX....yS Name of Owner ...IJ. .............................................. Name of Builder 5 'YI Address .................................. . ............................................ kl CY Name of Architect ...)�,..........�.. ...N.SDc •..••••••:••••.. Address .......CU �T .... .......... Number of Rooms ............... ..................................................Foundation .. ....U�z't�/� ....C•....ii./Gn�T� Exterior 6-11M U0/C17.....` ..S L/.N .L ..............Roofin P PP�f� ........................ Floors .rL�...........Interior ...�% /.1�....�...I.....yl�..5 ................... ,,JJ,, � /� P .....:. UPP� ........-�.��.T .�........ 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A-Q - 1 �� - ,..I��r=.\�"•'��� _—___._'_" � I III DRAWING NUMBER ESAY.5tr F— PSLjIL-nD _C:.�..NTF_f1JJll..1_E /hA'`�s-�.:.::--. ••gydP_C:'r 2 oK'l i � ;a t za'-C.- } I '.f`-n !o`_N, 9•-I•, fo.-4-:1 2%.51 .............__— r0 O.F. 1 Q � I cw.1S:i..._ - -' -o w. SPA tt ,�I :/ -- `. ta1. i, \, l0l 4• j 14�-y O 1 O. 1. y L9-o 1/a' - i f -- - ISE*bft i:�aNN 1� R�.a aoo— 3 Z t - — — - -�./AA5-cE2. iS6D,¢M t, O L� Gwn'r�T � 0 S VNowu� o Q l9Ror., I E i, _ O LI q ` r - ; c 3 s t 3=5:3/g!. - SCALE:I n1 PROVED BY: - DRAVIH BY: J DATE:A IL REVISED .FSu.tt 0 1,1�3(� G:a lute onAw 9 us q Sbl E.er 3oP-I »+roriu?:en .,-;.±c,e•,..xnm^,... ..scx I� — r I I I6tLca.i I� PLy o o�a: I ; I 1 0 I I zEw&POGKET EACH EUO ":PIR �pA,CC I- _ - I._.-tiou Nli ..-... _ I-�- L_ J I (Q ��IL`COIJC 1..ly'L4f7c - O .r J 1 r to LA LA LAX GO LJ/A $ •L41 va.'.'.r OoT.INbS I pl � I Lcl I I I az'a CONe..v/iL LsIn i I . co,C.C7NGR IF co! ''.. '10�-o• $AY91pEFj LIILf71NG� Cm INc. � �_._._ .. -CENT6F UILLE /L1A,34..-.:..._.. .. _. • e, CO;r MO.,-WEALTH OF IVLc SSACHUSETTS EXECUTIVE OFFICE OF E_ NVIRONMENT_ AL AFFA IRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINZTER STREET, BOSTON MA 02108 (617) 292-5500 I� TRUDY CORE ° ll Secretary ARGEO PAUL CELLUCCI Governor DAVID B. STRUHS 6ARIW7�1Jt-� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Conunissioner PART A CERTIFICATION Property Address:).I C RgS±AL (c1D&E Rb, Name of Owner R Kt-IARD Rosa Date of Inspetition:3.-i$' Xo Address of Owner: �yq/Y1 Name of Inspector:(Please Print) CID:4R 0 C. ►•//���"VS"I Y'CLc> I am a DEP owed system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: (I&W/Gp Mailing Address: U--ADO 19LIL 4 M-4 CYZ-63 Telephone Number: 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Sigrurisnrrr/ Date: ID-o?DO0 The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. NOTES AND COMMENTS D� G'RL OPU 5ZFP7/C 7;iek Sao G AU&V C t 46y t l 7- r t, k 000 revised 9/2/98 Page Iof11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: C P V STAG K I 06E RD Owner: rz, 05(X Date of Inspection: INSPECTION SUMMARY: Check W B, C, or D: A. /SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure T criteria not evaluated are indicated below. COMMENTS: e. SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health, will pass. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not. _ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank, whether or not metal, is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. _ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). broken pipe(s) are replaced — obstruction is removed distribution box is levelled or replaced _ The system required pumping more than four 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 revised 9/2/98 Page 2of11 • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address,2l CRV5Ta1- R(DGC- (,0 Owner: Q (&Dc Date of Inspection:3_ o00 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and 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 THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of 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 AND SAFETY AND THE ENVIRONMENT: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis 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. Method used to determine distance (approximation not valid). 3) OTHER revised 9/2/98 P2ge3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(contirwed) Property Address: I �12I�SML R I IX c R D owner: R 00scou Date of Inspection: D. SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: 1 have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 112 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a 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 I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: 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: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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-IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: I LR�5�4L 21066 RD, Owner: (�' pa coo - Date of Inspection: Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No Pumping information was provided by the owner,occupant, or Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with NIA. _ The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. All system components, a have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions,depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: Existing information. For example. Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) (15.302(3)(b)] 7< _ The facility owner (and occupants,if different from owner) were provided with information on the proper maintenance of Subsurface Disposal Systems. revised 9/2/98 Page 5ofIt SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property A ress: Owner: �1205 Date of Inspection:3/9 a2000 FLOW CONDITIONS RESIDENTIAL: Design flow: //0 g.p.d./bedroom. Number of bedrooms (design):--y— Number of bedrooms(actual): Total DESIGN flow qo Number of current residents: Garbage grinder(yes or Laundry Iseparate system) (yes or 10D XV: If yes,separate inspection required Laundry system inspected (yes or no) Seasonal use(yes or&:/V Water meter readings,if available(last two year's usage(gpd): Sump Pump(yes or a: /D Last date of occupancy:3F(4�ra,,aEo COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: qpd l Based on 15.203) Basis of design flow 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: OTHER:(Describe) Las:date of occupancy: GENERAL INFORMATION _ PUMPING RECORDS and source of in rmation: I ' � - �'�-3 f System pumped as part of inspection: (yes or a-A0 If yes, volume pumped: gallons Reason for pumping: TYPE OF SYSTEM Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes, attach previous inspection records,if any) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed(if known)and source of information: Sewage odors detected when arriving at the site: (yes or v revised 9/2/98 1`2ge6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property A^ddress:�( C06MC- 210(" Owner: 1 '.posco Date of Inspection: BUILDING SEWER: (Locate on site plan) Depth below grade:_ Material of construction:_cast iron_40 PVC_other(explain) Distance from private water supply well or suction line Diameter Comments:(condition of joints, venting, evidence of leakage,etc.) SEPTIC TANK: (locate on site plan) Depth below grade:.201, Material of construction: concrete_metal_Fiberglass _Polyethylene_other(explain) If tank is metal,list age _ Is age/confirmed by Certificate of Compliance_(Yes/No) Dimensions: B,bV�X /0 W X! t N Sludge depth:_ D r Distance from top of sludge to bottom of outlet tee or baffler Scum thickness: / � Distance from top of scum to top of outlet tee or baffle: y�r Distance from bottom of scum to bottom of outlet tee or baffle:!_ How dimensions were determined: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level iig_relation to outlet invert, structu�inte , evidence of leakage,etc.! Ct,, %L� ?S r/4uiiV 6"74NIG CC.EA�D� COit�C��IL i6/i+�F:�S � _I avf 0 4T 0 T vvrc' TEF GREASE TRAP: (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: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in.relation to outlet invert, structural integrity, evidence of leakage,etc.) revised 9/2/98 P2ge7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM • PART C SYSTEM INFORMATION(continued) Property A ress: ,?/_C Q wwc 'j�E l�0, Owner: 0,, pos coo Date of Inspection: 00 TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or 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 Alarm level: Alarm in working order:Yes_ No_ Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches,etc.) DISTRIBUTION BOX.)—( (locate on site plan) Depth of liquid level above outlet invert:AT Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) iv E PIPE IA,, — c�tic PIPE ovl' N o 5 o t�o$ PUMP CHAMBER:_ (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.) revised 9/2/98 Page 8ofll SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Addr I CRY RJ 066 Owner: R g�oc Date of Inspection:3 16-0 0 SOIL ABSORPTION SYSTEM(SAS) (locate on site plan, if possible: excavation not required,location may be approximated by non-intrusive methods) If not located, explain: Type` leaching pits, number:Olve S i)e FOOT f- cf1C�l Pit leaching chambers,number:_ leaching galleries,number:_ leaching trenches,number, length: leaching fields, number, dimensions: overflow cesspool,number:_ Alternative system: Name of Technology: Comments: (note condition.of7soil, signs of hydraulic failure, Ieyel of ponding, damp soil, condition of vegetation, etc.) s Dy LrgCN Per rs 6�1.Y F/R�F Fut� 6000 ca 0117-0 �o�� � �' N CESSPOOLS:_ (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, 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.) revised 9/2/98 Page 9of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM • PART C SYSTEM INFORMATION(continued) Property A ess: CKL RIOGE Owner: , ROS�DE Date of Inspection:3 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) G � 3� revised 9/2/98 Page 10of11 �. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C r SYSTEM INFORMATION(contuwed) Property Address: G—YSr r7 C Q117G� ��, Owner: R, (zoscoe Date of Inspection:3 NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater I Feet Please indicate all the methods used to determine High Groundwater Elevation: m Design Obtained from n Plans on record g Observed Site(Abutting property, observation hole, basement sump etc.) Determined from local conditions Checked with Local Board of health Checked FEMA Maps Checked pumping records Checked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) Y14�►'►(� - G s20u�v 0 ti � M 19-P/�PO Al P revised 9/2/98 P2ge11or11 �'© r �/d ar OF B RNSTABLE LOCATION S /GX (4 SEWAGE # C� VILLAGE_f' •7-1I'T ASSESSOR'S MAP & LOT A-s C7 ©INSTALLER'S NAME & PHONE NO. it -a OSEPTIC TANK CAPACITY /{ ���T(size) r G(:I.LEACHING. FACILITY:(type) ��,,,,�, NO. OF BEDROOMS_PRIVATE WELL ORS U LIC W-ATI;R7- BUILDER OR OWNER' V 1,eGt V DATE PERMIT ISSUED: DATE COLIPLIANCE ISSUED: - VARIANCE GRANTED: Yes No �� I 40 �2 �i7z No THE COMMONWEALTH OF MASSACHUSETTS _ BOARD OF HEALTH .............. (DW.t3........OF......(?J....;Aqui &-r+P&LE .. ..................................................... AvAratiun for Dispauai Works Tongtrudinn lirrmi# Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal System at ....[.Y.. .d._ ._...Location_Address ......................... .. Lot No Owner Address .......................................... rY!. .......................................................... Installer Address �/! C Type of Building 3 Size Lot............................ `�`......3........Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) '4 Other—Type T e of Building No. of persons............................ Showers W YP g -------•----------------•--• P ( ) — Cafeteria ( ) QOther fixtures .......................................6.� Design Flow.............(..(.0.............:......gallons per �ay. Totally flow....._._.. 1 . WW t� ZI ........... '.` lor�s. W Septic Tank—Liquid capacity. `I.�XJgallons Length.__....(...... Width:..._r!0..... Diameter................ Depth,.......!4'... x Disposal Trench—No. .................... Width.................... Total Length.......... ........ Total leaching area....................sq. ft. 3 Seepage Pit No.....(............... Diameter....1a........ Depth below inlet........fir..-........ Total leaching area:2�L�sq. ft. Z Other Distribution box C ) Dosing tank ( ) '--' Percolation Test Results Performed by...C__ c��" � o✓ �.-Z a <<.... Y Date._.. . ,-1 Test Pit No. 1...��..minutes per inch De th of Test Pit_-.. _..._.'Depth* to ground water.*. P eP gr fi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ PG ........----•---• _... ....... . O Description of Soil................7�,1 . ------- --- ---•--..._..........-••--•-••-•--•-•--•---•-••....................-•-•-••-•••_..•••-•..........-----........•-•--- U ... .------------------ ---- ------------------•-- ------------- ------------- •------------ ... ------- ------------------- ------------- ---•---....... ....... UW .....-•••--•-•----•---------••--•---------•--••-•-•----•••-•--•-•-•---•••-•--•...............••••-••-----•••---•-•----•----.....-----........•-•••..........••......---•-•....•-•-•...............•..... 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 further agree not to p e the syst operation until a Certificate of Compliance has been issued by the board of health. Signed...........Z6. ?'e-W... - ... !..!..... ..---...... �.... -- ^^ Dall e Application Approved By........... ..--_�1-�. ---------------------------------- -•--•-••. -: -.. ..... 1) Date Application Disapproved for the following reasons:............................................................................................................ ..................•-.........--•--•------••--••-•••-...........-•-•-•----...---••••.._..........---•..................•••--••••-••-•-•••---•--•••..........•-••--•--...................................� �y Date Permit No....... Issued........................................................ J................... Date 'No....{ ::_:.1:! �-- -- " FEs.. .5.............._ THE COMMONWEALTH OF MASSACHUSETTS BOARDFOF HEALTH A - ......... Appliratiun for Disposal Works Tonstrurtion trrutit Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal System at: .......... .... -•....... - -Location-Address or Lot No ................Y5�1 ( -L1a• 1:......--•-•--------------- X .. G'. ..... � �c.!T, ✓iC.t��. �— Owner Address a ..........::.:L__:__......_,!-...•ISC JCS...........................•-•----........_ ........N=-- •..G....=.-5----...._._.__.--••------................................ " Installer Address �,r Type of Building Size Lot.�f�+........_YJ_._..Sq. feet .-� Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) `4 Other—Type e of Building No. of persons...................... Showers W YP g -------••................... p . ..-- ( ) — Cafeteria ( ) Other fixtures -------------------------------•-----; �c?,...........................................-......................... . ....__........_............... W� Design Flow............�. . ...:................gallons per person prer day. Total yiailyr flow....._... . �_U.................._g�llons. WSeptic Tank—Liquid capacity./�r gallons Length�.<_...... Width:_...fir?_.... Diameter................ Depth:•-...�..... x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No..................... Diameter.....W......... Depth below inlet......G_......... Total leaching area2�.7_.v.sq. ft. Z Other Distribution box �t ) Dosing tank `'' Percolation Test Results Performed by.... ....... .( ���'' 1 -'�!:v_- :...... Date.... ............. \...... ,.a Test Pit No. I._�::_-.....minutes per inch Depth of Test Pit....l!.. r�....__ Depth to ground water.... Q_11� .-. Test Pit No. 2................minutes per inch Depth of Test Pit..................... Depth to ground water........................ �. -_..... ....-•••-•••-•-•-•••-----•--•..............................•-•-........•-•-•••••-••--•••••--•--..................----•-•-- 0 Description of Soil........... .... .. .v�. ..................................................................................................................................... W ------------------- ••-....... .....------------------------------------ •-------------------------------- •-•-••------------------------ .... ....._... ------------------------•------..........-----------•------------------....-------------•---........----........--------------=---------------------...-----------•-•--•---•--•--------••------••-•••••• V 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 further agrees'not to place the system operation until a Certificate of Compliance has been issued by the board of health. / 7'. Signed...........- -----•-- ......... 1 /l..l... .... ............. 11 Date Application Approved BY �, ._.... - ..............-.�.-.�.,¢/�__.... U ~� Date Application Disapproved for the following reasons---------------•--•--••-•--------.....------------------------........------..........------•-••--....._-•--•- ---•--•-------------•---•--....-•----•--.......-----••-•------------------..........----••-•--------....................._.--------•-----•-•-•---•-•--........---.....--•------------........•---•-_••••- Date PermitNo...... ` -- .................... Issued-....................................................... Date .... ----------- --- --.-- -------------- --- --------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..............TU.Gf/�......OF......��4eAe .ST/�f�Ll�............................. - _" Tntif irate of Toutp atta THIS IS TO CERTIFY That the Individual Sewage Disposal System constructed (,K or Repaired ( ) bY---------- -•--•....................................•---------------................................._....••-•-- —Installer at... ............ .............................................................. has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......K-9`...n7/.--a............. dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.... .... � ' '" ....... ..• Inspector. ............. •..a'Vr..oM.....w♦.w•.4+aw.aareabree•.tr •oe r.•. Tl►0�e4�.•...r.naswvwrew•.e� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH v Q q s q� 1J�" I ............. :........W............OF.......��...1./.��N...T.11....... ........................... FEE.�Zcz.......'^:.. Disposal�Works�Tonutrnrtion 11trutit Permission is hereby granted...... ......: ........-- to Construct (j\) or Repair ( ) an Individual Sewage Disposal System at No....L OT /0 C-X-YST4� � <lJ G.F. -- R � -��`�7 U..��..... --_••-• -••--•--•••••••-....... ..... Street per, _- . as shown on the application for Disposal Works Construction Permit=No- _2f_'� Dated.... - ...-�.-�......... --------------------------------------------------------------------................................. 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