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HomeMy WebLinkAbout0073 CURLEW WAY - Health 73 Curlew Way Cotuit A = 024 - 047 i { Commonwealth of Massachusetts IVTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 93 C(mot V/2�✓ (�/Gi Property Address ` GtiV' � r h Cw ner Ors ner's Name information is � required for every E7C) v t page. City/Town State Zip Code Date of Inspection I Inspection results must be submitted on thisform. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. "'p°rtaforrns " A. General Information filling out forms on the computer, 7611 G use only the tab 1, Inspector; key to move your cursor-do not �� 0/S use the return Name of Inspector �-- key.�''''� s/fim I i Company Name Company Address Cityffown do-9 ?75 y 7 9!/zt State�o � Zip Code Telephone N er 7 License NurTber 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 16.340 of Title 5 (31 MR 15.000). The system; 2//Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority aolq i S �o i3 Inspector'I 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. t5ns 3113 Title 50fAcial Inspection Form.Subsurface Sewage Disposal System•Page 1of17 Ltclo( VJ.OIo/--0-7 03 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form • Not for Voluntary Assessments .p �C (_4� 1��, w Property Address /� p � s Ow ner Cw ner's Name information Is Co 4c, required for every 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) Syste Passes: I have not found an information which indicates h y cates that any of the failure criteria described in 310 CMR 15,303 or in 310 CM 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 Healt h. *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): l5lns•3113 Tibe50fficial lnspectlonForm:SubsLOSCe Sewage Disposal System-Page 2of17 i Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Ox ner ON ner's Name / information Is / o 0�6 3�� .5 3o required for every y &? page. Oty/Town State Zip Code Date of frispedtion 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 mannerwhich 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 t5 ris•3113 Title 5 Official Impaction F orm 5u bsurf ace Sewage Disposal System-Pape 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address C 64 Y'/&L,/ I ON ner Cw ner's Name information is �n r4 required for every � i T page. Oty/Town State Zip Code Date of In ecti 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 ❑ Ud" 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 day flow than '/: t5ins-313 Tile 5Officiel inspection Form:Subsurface Sewage Disposal System Page 4of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments C(4✓1 . (i✓ �i✓Gt Property Address / l Ow ner ON ner's Name Information is required for every page. City rrown State Zip Code Date of I spec ion 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: ❑ 2 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. ❑ 2 Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ LJ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ I� 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.) ❑ Fpr,'� The system is a cesspool serving a facility with a design flow of 2000gpd- 10,00 0g pd. ❑ The system f l 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. t5ns-3113 Tille 5 official Inspection F am Subsurface Sewage Disposal System-Page 5 of 17 I_ Commonwealth of Massachusetts Title 5 Official Inspection Fo m a Subsurface Sewage Disposal System Form - Not for Voluntary ssessments a Property Address Ow ner Cw ner's Name information is ,r req u ired for every � J Qd- 6 "' /j page. Ci/ ow n State Zip Cod Date of InP ectioh C. Checklist i Check if the following have been done. You must indicate "yest or"no" as to each of the following: i Yes L(, ❑ umping information was provided by the Owner, occupant, or Board of Health ❑ Were any of the system components pumped out in the previous two weeks? ❑ as the system received normal flows in the previous two week period? Have large volumes of water been introducied to the system recently or as part of this inspection? Were as built plans of the system obtainedand 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)J D. System Information Residential Flow Conditions: Number of bedrooms n desi ; ( 9 ) Number of bedrooms (actual): DESIGN flow based on 310 CMR 15,203 (for example: 110 gpd x # of bedrooms); --�-- ides &l3 Tite5 Official Ins pectionFamsubsLeaceSewage Disposal System-Page(3017 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address f c� Ow ner ON ner's Name Information Is C04C414 /�� required for every J page. City/Town State Zip Code Date of InspR tion D. System Information Description: / /OGo Number of current residents; / Does residence have a garbage grinder? ❑ Yes 3 No Is laundry on a separate sewage system? (Include laundry system inspection 0 Yes 2- No information in this report.) Laundry system inspected? ❑ Yes No Seasonal use? ❑ Yes No Water meter readings, if available (last 2 years usage (gpd)); Detail; Sump pump? ❑ Yes No Last date of occupancy; bit✓(�" Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM 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: 15lns-3113 Title 5 Official impaction F orm Subsurface Sewage Disposal System page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form • Not for Voluntary Assessments r? Property Address / DNS Cw ner Cw ner's Name information is o U �� required for every page. c /Town State Zip Code bate of Tnspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: /'1/0 7- �y✓�/1F C/ Source of information: Was system pumped as part of the inspection? ❑ Yes If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to 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): tens,31113 Me5Official Iris pecUonForm Subsurlece Sewage Disposel SyMM-Page8017 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 27 Property Address / ON ner ON ner's Name /'� information is Co 4", �- / //7 lJa 61S �' S�0 / 7 requfredforevery page, City/Town State Zip Code Date of In pection D. System Information (cont,) Approximate age of all compone date installed (if known) nd source of information; Were sewage odors detected when arriving at the site? ❑ Yes Er--No � Building Sewer (locate on site plan): 22 / Dept h bel ow g ra de: feet Material of construction: / J ❑ cast iron ❑ 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition ofjoints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: feet Mateda construction: concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age; years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions; 5- Sludge depth; '? (5ins'3113 TIOa5Official IrepectionForm Subsurface Sewageoisposal System-Page 9of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments dp / C(,f ✓ 1e�-✓ G✓ Property Address /I i Ory ner OW ner's Name information is C��� required for every page. City1rown State Zip Code Date f Insp ction D. System Information (cont) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle ^� Scum thickness ii Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle / How were dimensions determined? I C/e 4-1/c e— Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): cyV1 kv God 7�s 44 L Co� 140 Grease Trap (locate on.site plan): Dept h bei ow g ra de: 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 Date of last pumping: Date 151ne•3/13 TWeSOfBcid ins pecBonForm Subsurfam Sewage Disposel Syelem•Pape 10of W Commonwealth of Massachusetts Title 5 official Inspection Form ug Subsurface Sewage Disposal System F//orm - Not for Voluntary Assessments Property Address e tv- fi ow ner ON ner's Name Cou inrormatlon is (� 7` t '9;� l- �' /y required for every page. GrylTown 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.): pumped at time of Tight or Holding lank (tank must be p inspection) (locate on site plan):p 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 worWng 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 t5ins 3113 Title50fflcld Ins pectlonFonrt SubsLrtace Sewage Dispoed System Pepe 11 d 17 Commonwealth of Massachusetts - v Title 5 Official Inspection Form b Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ------------------ Property Address �JJ /71 - Ow ner ow ner's Name information Is 0 4� ✓� p, `33 �o / (_ i / / required for every State Zip Code Date of nspe tion page. CIIy/Town D. System Information (cont.) Distribution Box (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 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: Title 5 Official ins pec tlon F orm Subsurf ace Sewage olsposd System-Page 12 of V t,Nns-W3 f Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Ow ner Cw ner's Name information is 0 I tA ���3�� 30 A? required for every / -- page. 0 /Town State Zip Code Date of 16spectlon D. System Information (cont.) Type: 6 YV leaching pits number:0 ❑ 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.): �!/LGIV1 61- ✓ p py L(N'e 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 Mns 3113 Tide50fBcial ins pection Form Suburfece Sewage Disposal System-Peg e 13of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form b Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address 4414,( Ow ner Ow ner's Name I information is ro required for every !L page, City/Town State Zip Code Date of I spectl n 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.): t51ns•3113 Tills 5 Official Ins peo ton Form Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form b Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address / Ow ner Owner's Nance / � / inform o information is V I �S required for every State Zip Code Date of nspe tion �— page. City/Town 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 =in er supply enters the building. Check one of the boxes below: the area below ❑ drawing attached separately �• L ate ' / 14c,r Rvo,,- Co rP,r r a o T05016cial Inspection Form suburtaoe Sew99e01spasal Syatem•Pepe 15of 17 ons•3/13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not Not for Voluntary Assessments Property Address Ow ner Ow ner's Name information -�0, �� Od LU required for every page, CitylTown -- State Zip Code Date of Inspec ion D. System Information (cons) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells r //0vv--- Estimated depth to high ground water: 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: pate ❑ Observed site (abutting property/observation hole within 150 feet of SAS) Checked with loca Board of Health-explain: �l��S1�.s4 /fib4,5 ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: s s��l�P� O�✓ �� Before filing this inspection Report, please see Report Completeness Checklist on next page. t5ins 3/13 Tille 5 Of ficial Ins pec ton Form:SubsLeace SewageDispossl System-Page 16 d V Commonwealth of Massachusetts Title 5 Official Inspection Form b Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °¢ /23 C(/f P, le 1'%/a�Q Property Address /4 i / N Ow ner Cw ner's Name nl information is �0 required for every �LA page. aFrown State Zip Code Date of Inspection E. Report Completeness Checklist Inspection Summary: A, B, C, D, or E checked Eg Inspection Summary D (System Failure Criteria Applicable to All Systems) completed [91 System Information—Estimated depth to high groundwater [�Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file Ona 3/13 TO5olAclel ins pecbcn F orm:Subsurface SewageDlsposel System•Page 17 d 17 7c 7 LO CAT I N � SEWAGE PERMIT NO• d1.LLAG INSTALLER'S NAME i ADDRESS GUILDER OR OWNER DATE PfRINIT ISSUED DAT E COMPLIANCE ISSUED 1 l i o� c 1660V z:..�2,� Fxs.. No... ......3 5.............. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ,nn 4,q, 0 q 7 .........................................OF....................................................-................................... .. 1 Applira#ion for Eliiplaa al Works Toustrnrtinn ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal tem at: /J 4*� -7y'.......................................�_Y' c w.. 4t :t:1V.f........... .................................................................................................. ioR-Add,Fess -----••-- •.-.or.Lot No. ..:..A. .^W�►f[S. . O nor n Address QY�i'I.AA t......At v a� t .�l:: W��!----•--- ---•-•----- -••-------•-•--•--•-....................... � Installer Address Type of Building Size Lot..Z.d_j.0_i�._..Sq. feet Dwelling—No. of Bedrooms...._..�................... .Expansion Attic A4 Garbage Grinder (/t fj(7 ---------- `� Other—Type T e of Building ............. No. of ersons........................__._ Showers — Cafeteria f� YP g --------------- P ( ) ( ) Q' Other fixtures ................................. Design Flow......- .... g P P P Y Y gallons. W ��............................gallons per person per day. Total daily flow..._..._��0....__.._...._..__.. WSeptic Tank—Liquid capacity ZO .gallons Length________________ Width................ Diameter-------------__. Depth................ Disposal Trench—No..................... Width.................... Total Length___................. Total leaching area....................sq. ft. Seepage Pit No----.' ............. Diameter----/Z__........ Depth below inlet....4............ Total leaching area..................sq. ft. Z Other Distribution box ( 3) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test 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........................ R+ ------------------------------------------------------�-------------------------•------•----------•----------------- ... ......... •----••-•-•------. ----- 0 Description of Soil.....'G-- �.......�='�...X.t►krm.t................. ... ... Z.. rx V ----------- ---•-- W -•-••-----------------------------------•-------•-•-----------..._..----••..........•-----•--------------•----••--------------.....--•-•----•-•••---•-•-•-•------•-•-----------•--•-----•-.....--.--•-•- 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 iIHE' 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a ertifi of Compliance has been issued by t e bo health. Signed•-- ............... Dat�ate t Application Approved BY = �i/y r ----..---•--•--------- Z�� Application Disapproved for the following reasons:................................................................................... ............................ ......................................................................................................................................................................................................... Date PermitNo......................................................... Issued....................................................... Date No.. . =.. r Flms........................... �. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........ ................................O F............................................----.......................................... ApplirFatiou for Disposal Works Tonstrnrtion rrntit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System t/at: �0 �u Y' isU �U 4 j L c tioh-Address or Lot No. �. r...................•--•---------- ner ' a Address �Y ' teal_TTA_. t.-V..{?-----_�"`'l t-�•------- ------•-•-••----•------••--•-••---.--.--------.-•-•----•----------------------•-•---------.------. Installer Address Type of Building Size Lot..M O 4 4 7�....Sq. feet U Dwelling—No. of Bedrooms.........:.................... .. (.Expansion Attic 41, Garbage Grinder ( '4�PL4 Other—T e of Building No. of persons............................ Showers — Cafeteria a Other fixtures ..-•-----•----- --------------• . W Design Flow____._. ............................gallons per person per day. Total daily flow.._...... -------._ g a o n lls. WSeptic Tank—Liquid capacity/ gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width...... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..... Diameter----/2-__.__..... Depth below inlet....G............. Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed bY........................................................................... Date........................................ Test Pit No. 1.:::............minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ •-------•-----------------------•------.....----•-........•---------- ------------•--......-•----......................................................... O Description of Soil......' "� .---...:r ,_E >rrt....!'_sa 5 cad ° ........................................... "�i 'iG• .�. lara Y rGt °`l�t/f '*.Allf...__...--�5'_Cr2o. f.T t9 -------------•---•--------------- .......... -••--- V .............................................. f W --•-•-----------------------•-••--•--•--------....------....----------------•-----•-••-•---•----•------•----•••------•----------....----------•....--------------............_-----•-----------•........ 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 TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificite•of Compliance has been issued by t e boXl.iealth......Signed---•- -- ---•----"•' ---- •• ---- --- ---•---•----•--------- f Date Application Approved BY /•. s_.,. �'�' ��......................•. /?......r ''� �,. 1 ---------- ate Application Disapproved for the following reasons---------------•------------.._..------------.......---------------------------------•----------•---•------•-- ......-••••---------------••------•-------------------•------------------•------------------•-----------.-••----------------------•---•-----•----•------------------------•----------•---•----------•--- Date PermitNo......................................................... Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ' ................................I.........OF........................................... ......................................... (Iritifiratr of TunipliFanrr THIS IS TO CERTI� That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by...... .... .`f.t'f?.. !t ` -c�...+ ' '...--•-----•---.----- . --•-•--------------••--•-•-----••--..........-••-•----•--•-•••••......................-•--••.......... Installer at------ - ?- ------ 4J..KJ:!!--W--#--------- t ---•--------------------------------------------•-••-------------------•------..._.....-•-•------------- 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.___.. _z..--.. :Z. __._. dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONST A AS A GUARANTEE THAT THE SYSTEM WILL F NC N SATISFACTORY. DATE.........11-_•1 Y ........................ Inspector---- .._ ... .•-• •-----------------------............._.............-•-...... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF.................................. FEE.,?.. ............... Disposal sal Works Tnntnrtion rrntit Permission is hereby granted......ll..CA.. --- 4 4•ffre--------------------------------------------------------------------------------- to Construct ( or Repair ( ) an Individual ewagge Disposal System at No........j` `�_ fir_v .' ?. a I. .........................Street as shown on the application for Disposal Works Construction Permit No.................... Dated.......................................... ..n............................................... / $o rd of Health DATE................................................................................. FORM 1255 HOSES & WARREN. INC.. 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