HomeMy WebLinkAbout0019 DANA COURT - Health 19 Dana'Court
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��N- \ MAP NO. PARCEL NO.
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1. DATE
i
2. SEPTAGE HAULER:
3. PROPERTY OWNER'S NAME:
4. ADDRESS (PUMPING LOCATION):
5. VILLAGE:
6. VOLUME (GALLONS PUMPED):
7. TYPE OF FACILITIES PUMPED: (CIRCLE ONE) COMMERCIAL•
A) SEPTIC TANKS (HOW MANY?)
B) CESSPOOLS (HOW MANY?)
C) LEACHING FACILITIES (HOW MANY?)
D) GREASE TRAPS (HOW MANY?)
8. REASON FOR PUMPING: (BY CHECK (✓) MARK)
A) MAINTENANCE ( )
B) SYSTEM FAILURE ( )
C)OTHER ( )
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BOARD OF HEALTH
TOWN OF BARNSTABLE
01ppYication jfor lVerr Congtruction permtt
Application is hereby made for a permit to Construct( Alter( ), or Repair( ) an individual well at:
19 '-Diq tUA L- 61.1 .
5 S 4010 �&
Location,Address 0 Assessap and Parcel
Owner Address
Installer-Driller Address C)72
Type of Building
Dwelling
Other-Type of Building No. of Persons
Type of Well "'f11' P V � Capacity 16 GFIVT
Purpose of Well 16
Agreement:
The undersigned agrees to install the afore described individual well in accordance with the provisions of the
Town of Barnstable Board of Health Private Well Pr ection lation-The undersigned further agrees not to place the
well in operation until a Certificate li ce s bee ued by the Board of Health.
Signed
at
Application Approved By Z�
Date
Application Disapproved for the following reasons:
'd % 'n / Date
Permit No. W 2,/t/( Issued
Date
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certificate of Compliance .
THIS IS TO CERTIFY,that the individual well Constructe Altered( ), or Repaired( )
by Au
/y Italler
at
has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private W 1 Pr tection
Regulation as described in the application for Well Construction Permit No. 102,3 Dated 1,112,1
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCT ON S T SFACTORILY.
Date Inspector
/*
' No. �Z3 M " . Fee
BOARD OF HEALTH
TOWN OF ,,BARNSTABLE
41 pplicatiou if or well,Conotructton Permit
Applickion is hereby made fora permit to Construct Alter or Repair( an individual well at:
_.r,.
U 1, i
1 Location-Address Assessors Map and Parcel
IJLR CC lea
Owner 1 Address
Installer-Driller w#t Address )
Type of Building
Dwelling
Other-Type of Building No. of Persons
Type of Well Capacity
Purpose of Well rV f G G 7 /G
r
Agreement:
The undersigned agrees to install the,afore described individual well in accordance with the provisions of the
Town of Barnstable Board of Health Private Well Protection Regulation-The undersigned further agrees not to place the
well in operation until a Certificate of-Compliance h'a�s be/e�n'i sued by the Board of Health.
Signed
° PP PP Y Application Approved B j / \
4Date ✓
Application Disapproved for the following reasons:
Date
Permit No. U� , ' Issued
Date i
�, _.. .. 4_. e_ao__ ,>_oAe___e.____-_o__ -------- ------------e__vo►_--o__--_'�o
BOARD OF HEALTH
TOWN OF BARNS.TABLE
Certificate of Compliance
THIS IS TO CERTIFY,that the individual well Constructed'(.), Altered( ), or . Repaired O
by
C r l o w UI�Q 1
�4 Innstaller
- at
_:has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection
k Regulation as described in the application for Well Construction Permit No. IAI?,,c'Si?,t -M3 Dated W l/h l
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE•CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORILY.
/V/Date' l ' Inspector
BOARD OF HEALTH4,
TOWN OF BARNSTABLE
Yell Construction Permit
No.
wlgo `n,3 Fee I-If `
Permission is hereby granted to
�^ I
Installer Y
to Construct( q,.- Alter( ), or Repair O an individual)well at: (g F
I v Street
17
as shown on the application for a Well Construction Permit No. Dated c Z l
Date G / ./% / Approved By
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\ COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE HINTER STREET. BOSTON, MA 02108 617.292.5500
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d� TRL D)'CO\1
WILLIAN1 F 'A ELD
Go,,cmor
ARGEO PAIL CELLUCCI PECFOVEP B STRL FL`
Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECT I N"FORM ommissionc
PART A J U L 15 1997
CERTIFICATION N
TOWN OF BARNSTABLE
HEALTH DEPT.
Property Address: 19 Dana Court,Cotuit, Ma. Address of Owner: NO 4*
Date of Inspection: 9 (If different)
Name of Inspector: JVA h 7P. Macomber Jr. A ti
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.
Company Name: Joseph P. Macomber_ & Son. Inc .
Mailing Address: gOX—b��rV8�� Ma. 02632-0066
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 funaron and
maintenance of on-site sewage disposal systems. The system:
JC Passes
_ Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature- ��'"""III Date:
The System Inspe hall submit a copy of this inspection report to the Approving Authority 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.
INSPECTION SUMMARY: Check A, B, C, or D:
AJ SYSTEM PASSES:
Y I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15 303
Any failure criteria not evaluated are indicated below,
COMMENTS:
BI SYSTEM CONDITIONALLY PASSES:
�y n 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, of
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 conforming septic tank
as approved by the Board of Health.
(revised 04/25/91) Page 1 of 10
DEP on the World Wide Web. httpJ/www.ma9net s<tate.ma us/oep
0 Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 19 Dana Court, Cotuit,Ma. 02635
Owner: Robert Muenzberg
Date of Inspection: 6/2 5/9 7
B] SYSTEM CONDITIONALLY PASSES (continued)
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). Describe observations:
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
C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
NO 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 THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
M Cesspool or privy is within 50 feet of a surface water
_�LQ 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 APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
�L The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or
tributary to a surface water supply.
}U(7 The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
�p 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
nX� 1NC
(revised 04/25/97) Day• 2 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 19 Dana Court, Cotuit, Ma. 02635
Owner: Robert Muenzberg
Date of Inspection: 6/2 5/9 7
D] SYSTEM FAILS:
You must indicate ei;, er "Yes" or "No" as to each of the following:
A)0_ I have determined that the system violates one or more of the following failure criteria as defined 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
v'� 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.
1ec&poo��,7
Liquid depth in c-eccpcel is less than 6�below invert or available volume is less than 1/2 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.
An onion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
y P P Y PP Y rY
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" as 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
V 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 bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(zavimad 04/25/97) Page 3 of 10
4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
19 Dana Court, C otuit, Ma. 02635
Owner:
Date of Inspection: Robert Muenzberg
6/25/97
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.
LZ _ As built plans have been obtained and examined. Note if they are not available with N/A.
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.
I
_ All system components, excluding the Soil Absorption System, 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:
The facility owner (and occupants, if djfferent from owner) were provided with information on the proper maintenance of
Sub-Surface Disposal System.
jC Existing information. Ex. 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))
(revised 04/25/97) P&gs 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 19 Dana Court, Cotuit, Ma. 02635
Owner: Robert Muenzberg
Date of Inspection: 6/2 5/9 7
FLOW CONDITIONS
RESIDENTIAL:
Design flow: g.p.d./bedroom for S.A.S.
Number of bedrooms: 3
Number of current residents:_j�D),
Garbage grinder (yes or no):-4c5
Laundry connected to system (yes or no):_�t S
Seasonal use (yes or no):__�Y D
Water meter readings, if available (last two (2) year usage (gpd): Klc�lJ'�-)O ( r)(5`` -
%
Sump Pump (yes or no):�111i -/ '�( , �G� ��• y j 6
Last date of occupancy: J-�
COMMERCIAUINDUSTRIAL:
Type of establishment: Yy[L
Design flow:_4Z,�,gallons/day
Grease trap present: (yes or no)�( CA—
Industrial Waste Holding Tank present: (yes or no)YJ,C>%—
Non sanitary waste discharged to the Title 5 system: (yes or no) 14/c
Water meter readings, if available: A)G_
Last date of occupancy: YNJCt
OTHER: (Describe) wok
Last date of occupancy: Y�U
GENERAL INFORMATION
PUMPING RECORDS and source of information:
n)r)n)e Cil)n�lra h1 e - SPjt c T7anIC �l�Y?nL�ed y�r(I2 r LE 11�� FC:hc)yt`
System pumped as part of inspection: (yes or no) V �S
If yes, volume pumped: �,� Zgallons
T
Reason for pumping: Y( F-nl)\.1 SI'.1AY`A �C1_TiZ`F -),eu U�
TYPE OF SYSTEM
✓ Septic tank/distribution box/soil absorption system
YV 0 Single cesspool
Y)Q Overflow cesspool
y)11 Privy
-- C Shared system (yes or no) (if yes, attach previous inspection records, if any)
I/A Technology etc. Copy of up to date contract?
Other �)C
APPROXIMATE AGE of all components, date installed (if known) and source of information:
Sewage odors detected when arriving at the site: (yes or no)_
(revised 04/25/97) Page 5 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: it Ma. 02635
p r 19 Dana Court, Cotu ,
Owner:
Robert Muenzberg
Date of Inspection: 6/2 5/9 7
BUILDING SEWER:
(Locate on site plan)
tf
Depth below grader
Material of construction: cast iron 40 PVC other (explain)
Distance from private ater supply well or suction line j)u,
Diameter ;-} tr
Comments: (condition of joints, venting, evidence of leakage tc.)
G C
Yln(ac-�e i1r' '1—�
SEPTIC TANK:J5a) 9C1I1DnS
(locate on site plan)
Depth below grade: /�9
Material of construction: ✓concrete —metal —Fiberglass —Polyethylene —other(explain)
If tank is metal, list age ALk Is age confirmed by Certificate of Compliance (Yes/No)
Dimensions: ) o' � f( )-0Y?Q 51 911 h
Sludge depth: U
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:—C)
Distance from bottom of scum to bottom of outlet tee or aHle: y
How dimensions were determined: rrt
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.) L - 1 ILtQ
(4-�C-d\C 7-n n ih6 '4 ffiboWS YU' PCI P Cl G�
GREASE TRAP:_-anJr7
(locate on site plan)
Depth below grade:lCL
Material of construction:-U_�-gncreilk)�,,metal Agt�ibergl ass J�LPolyethylenelc`other(explain)
Dimensions:
Scum thickness:_1iZGL
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffler_
Date of last pumping: LL1 -
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet inven, structural
integrity, evidence of leakage, etc.)
P 1 ��PVL1T
(ravisad 04/25/97) Paga 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 19 Dana Court, Cotuit, Ma. 02635
Owner: Robert Muenzberg
Date of Inspection: 6/2 5/9 7
TIGHT OR HOLDING TANK:-W(Tank must be pumped prior to, or at time, of inspection)
(locate on site plan)
Depth below grade: r✓�`
Material of construction:J&oncrete �i�rnetal�UFiberglassWolyethylenebother(explain)
VO G-
W
Dimensions: '�)o—
Capacity: YVG�- gallons
Design flow: gallons/day
Alarm level: YU0- Alarm in working order Kjt�Yes; P.CtNo
Date, of previous pumping: �L
Comments:
(condition of inlet tee, condition of alarm a` d float switches, etc.)
)n m U i2 h Ol� lylu n 1)1- )2 t-ct t"
DISTRIBUTION BOX:_✓
(locate on site plan)
Depth of liquid level above outlet invert: NO
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)
�) )S i.rL)e_1 � )4-wz, o 1)c- )n t=-ec0 < YV4 �v id�nG F l err I ►�c; ��P/2
A7r) >> (�.,-o c e C-F- c a V rpge- I ui tn C)Y2 n1,(`t- r )x
PUMP CHAMBER:�()YU�
(locate on site plan)
Pumps in working order: (Yes or No) YWI
Alarms in working order (Yes or No)_�L)Gx
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
p`4 r-Q (-1l rK Y?n Yl (-,.- ►'�l2 r�SP K)7-
(revised 04/25/97) Page 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 19 Dana Court, Cotuit, Ma. 02635
Owner: Robert Muenzber
g
Date of Inspection:p 6/25/97
SOIL ABSORPTION SYSTEM (SAS):,z
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type:
leaching pits, number: I
leaching chambers, number:
leaching galleries, number:_
leaching trenches, number,length: Q
leaching fields, number, dimensions:
overflow cesspool, number: (7
Alternative system: (Z
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition o vegetation, etc.)
Srt�c� �l)f� ��c; �,� o-P Y)wd 11C 'a lu (?� (7�2 ��ucC �. D mr-) r)cs
CESSPOOLS: ,alvyVe
(locate on site plan)
Number and configuration: YUfI�
Depth-top of liquid to inlet invert: YUC`
Depth of solids layer: YU17A,
Depth of scum layer: 0)0,
Dimensions of cesspool: 0)a
Materials of construction: VVC'
Indication of groundwater: )c -
inflow (cesspool must be pumped as pan of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
f�Snnr) 1� n(7� `h�P�PLI)r
PRIVY: Y�E
(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 04/25/97) Page 8 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 19 Dana Court, Cotuit, Ma. 02635
Owner: Robert Muenzberg
Date of Inspection: 6/2 5/9 7
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
0 `
i
N` !1
(revised 04/25/97) Page 9 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 19 Dana Court, Cotuit,Ma. 02635
Owner: Robert Muenzberg
Date of Inspection: 6/2 5/9 7
Depth to Groundwater Feet
Please indicate all the methods used to determine High Groundwater Elevation:
')TO Obtained from Design Plans on record
Observation of Site (Abutting property, observation hole, basement sump etc.)
Determine it from local conditions
Check with local Board of health
Check FEMA Maps
`(VD Check pumping records
/f5 Check local excavators, installers
Use USGS Data
Describe in your own words how you established the High Groundwater Elevation. (Must be completed) I
en cou h7-i�)ems, a- - 0 ' w)> t-
Nay) Cif P5[,f
(revimad 04/25/97) Page 10 of 10
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1'UHN OF st;ab•_e BOARD OF HEALTH
1 SUI)SURFACF 9EHACE DISPOSAL SYSTF;M INSPECTION FORM - PART D - CERTIFICATION
A"•-' T"". •-�.t..��T.T,�I•R:T TTITIT1"T'.r"t1-'IR'n'.y R1R01"� /�TTRTf ISR.n•�+.Tn•'TiT
-TYPE OR PRINT C1.EARL1'-
PROPERTY INSPECTED
STREET ADDRESS 19 Dana Court, Cotuit, Ma. 02635
ASSESSORS MAP , DLOCK AND PARCEL #
OWNER ' S NAME Robert Muenzberg
PART D - CERTIFICATION I
NAME OF INSPECTOR Joseph P. Macomber Jr
COMPANY NAME Joselph P. Macomber & won Inc .
COMPANY ADDRESS Box 66 Centerville , Ma. 02632-0066
Street Town or city
COMPANY TELEPHONE (508 } 775 -3338 st.t. j,P
R FAX ( 508 ) 790 _1578
CERTIFICATION STATEMENT "
I certify that I have personally inspected the sewage disposal system nt
this nddress and that the information reported is true , accurate , and
complete as of the time of .inspection . The inspection was performed and any
recominelldations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of oil-
site sewage disposal systems .
Check one :
Sys te6i PASSED
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
he.alLh or Lhe environment as defined in 310 CMR 15 . 303 , Any fail<lre
criteria not evaluated are as stated in the FAILURE CRITERIA sectio;, of
this form .
System FAILED* \
The inspection whicl) I have con ilcted has found that the system fails to
Protect the 'public health and the environment in accordance with Title
5 , 310 CMR 15 , 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form .
Inspector Signature Date
One copy of this certification must be provided to the OWNER ,
( where applicable ) and the I3onRD OF )IEALI'11, the DUYER
* IC the inspection FAILED , the owner or"•operator shall u
within one Year of the date of the inspection , unless alloweddortrequired
otherwise as provided in 310 CMR 15 . 305 .
partd • doc
A
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W
Ul Z7
7 M
ti
_ sbyv mot
THE COMMONWEALTH OF MASSACHUSETTS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BE IT KNOWN THAT
Joseph P. Macomber, Jr.
Has satisfied the Department's qualifications as required and is hereby
authorized to use the title
CERT FIED TITLE 5 SYSTEM INSPECTOR
as provided in 310 CMR 15.340 and Section 13 of Chapter 21A of the
General Laws. Issued by The Deparnnent of Environmental Protection.
Ju� a. 1995
Acting Dircctor of the ton of Water Pollution Control
LO�CAT ION ( �` SETA C E PEOMIT NO.
vli LAC E�® T� r 7 1-3a� 7 !
IDSTA LLER'S NAME" ADDRESS
Y � L
8UILDEIt OR OW13ER t
DATE PERMIT ISSUED
DAT E COMPLIANCE ISSUED $�.•G- �'Q.
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OTHE COMMONWEALTH OF MASSACHUSETTS
D s BOARD OF HEALTH
. ...............OF..................................... .-----
Appliratinn for Uhipoii aI Workii Tnnitrnrtion JIrrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
..! .......�s�. Al ?....�.:T...........O.Y 1 I..-•----------------•... ..----------------------------•-----------------.................---
7JVLocation-Address or Lot No.
Owner Address
.............. . .}-----------------------------------------------------------------
� � Installer Address
Type of Buildi Size Lot_1'0.1............... "i`•-="'�.��*�
U Dwellin —:No. of Bedrooms............................................Ex Expansion Attic Garbage Grinder
�•+ g � P ( ) g (
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Oth. faxtures .........
J ------------.....................................................
W Design Flow.................................:.........gallons per person per day. Total daily flow.__....._ a _..____..__...........gallons.
WSeptic Tank t Liquid capacity d�e'!.gallons Length---------------- Width---------------- Diameter---------------- Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..........V...... Diameter..).aX(v-___- Depth below inlet...... ........ al 1 ching area.339......sq. ft.
z Other Distribution box ( DosingXtaYk
) "�' Aco�,Percolation Test Result Performed b ..--. . _ !Y -i---- � ,>'---� --° --------- Date------•-----------•--------------------
Test Pit No. L elll .._..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........................
Rie------- . 1....• .... e
Description of Soil.:- ............. - ���-----�- --�-j . .... �� r
V .....-•-•••-••-•--•--------••--••---.....................................................................................................................................................................
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'T`
p 5 of the State San' ar Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance een i sue by 94 board of he lth.
igned...........•• _•-• •....... ... . . ... .... ............. ........... 1nl
Date
Application Approved By.......... «:'eL.0` = �. &:=------............ .......
Date
Application Disapproved for the following reasons----------------------------------------------------------------------------------------------_---------------
-•---•--------------------------------------------------------------------•--------------------.....----•--------------------------------------------------------------------------------•-•--••••---•--
��� A Date
PermitNo......................................................... Issued.... .............................................
Date
NO FEx.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF -HEALTH
........... .................OF..... ....................................................................................
Apofiratiou for Dh4paiial Workii Towitrurtiou Famit
Application is hereby made for a Permit to Construct or,'�Repair an Individual Sewage Disposal
System at: .
13
...........Z..aa.%..... ...........4MV-11........................ .�="O.T... 6....................................................................
Location A,dd dres or Lot No.
_, ---- ---------------- -----------------------------------------------------I--------------------------------------------
Owner Address
..............
Installer Address
Type of Buildingpe- Size Lot bai_'
U *qm&"
�_4 Dwellingv—o' No. of Bedrooms.........I.............................Expansion Attic Garbage Grinder
Other—Type of Building ............................ No. of persons._.___.__._.______.______._. Showers Cafeteria
Oth /tures ......................................................................................................
< ------------------------- ------------
Design Flow..... 3 S 0
W
D .......................................gallons per person per day. Total daily flow...................... ...................7gallons.
9 Septic Tank-I—Liquid?capacity!5 gallons Length---------------- Width__..____________ Diameter-_________.._.__ Depth_______.._._.__.
Disposal Trench—No_ ______________ _ Width_____...__._._____._ Total Length..__._____.___.._.__ Total leaching area----................sq. ft.t*q* 1�)
Seepage Pit No---------- Diameter.14X�P..... Depth below -/Le.......... Tptal leaching area3i?tel------sq. f t.eow
Z Other Distribution box Dosing to k V.0
........... Date....41,..•
...........................Percolation Test Result Performed by
Test Pit No. 1 `:..._..minutes perinch Depth of �t Pit____________________'.....................Depth to.ground water.___.._......_.........
44 Test Pit No. 2................minutes per inch Depth of Test Pit__.._.._______.____. Depth to ground water_`.__-_______________-
Zy..... • ............. ------------------
............
Description of Soil------... ---------------------------------
0 S.......1,"
.......... ..........................................
U ............................................... ..............................6.........................................................................................................................
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'TT L- 5 of the State Sa ar Code— The undersigned further agrees not to place the system in
operation until a Certificate o f f Compliance en sue by qtt board of hylth,
gne ... ....... .. .............
Date
..-I. . . . ... .................... ........ tn Application Approvej By.
Date
Application Disapproved for the following reasons:...............................................................................................................
.........................................................................................................................................................................................................
Date
PermitNo......................................................... Issued-........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD 0 HEALTH
OF.........!A..,j!jo0
...... . . ......................................
Tatifiratr of Tompffiturr
Individual Sewage Disposal System constructed THIS IS T CER FY, That the Indiv or Repaired
----------------------------
- ---- --------- ------ .......
-------- ------------------------------------------- ------ ih;;al er
at ..".Jv.......................
has been installed in accordan ith tl. provisions of T of The State Sanitary Code as desKiNed in the
application for Disposal Workn Permit No ........ y------------ dated__.'S-_'A'()- 4—
� I TUQtIo --- ---- .............................
THE ISSUANCE OF IS N"IRTIFICATE SHALL,NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUN V
JOTION_SATISAACTORY.
0,140 p
------------------
DAT17.......................Ct.- ......................................... Ins ector...../
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF",'HEALTH
..... . . . .......................................................
No._._.. .............. .............. OF.....
FEE._. ...A..............
'Bilipasal'oork . %unwitruct ion Vanfit
Permission;*shereby granted...... .............................................................................................. .......
to.Const tVir air an I ividual Sle`"Y' 941spo a-D L
4
at No... P .... ...... . .
tem
---rs. L*.... ......
Opp", Street
D s,'sbbwn on the application for Disposal Works Construction Pej4t N . .. ....... --- ....... ..................
ated....
..... ........... ..............
Board of Health
.7 ...............................................................
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