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HomeMy WebLinkAbout0234 EISENHOWER DRIVE - Health �34 Eisenhower Drive otuit A= 038 --015 —020 --- -- -- --— - - ---- - __ I I I !f I .\ COMMONWEALTH OF MASSACHUSETTS r EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION 1 M SV�y 0/5� 0� � © d TITLE 5- OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS_ SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION ,� TJ Property Address: Owner's Name 4 f!- = Owner's Address:_ c�„' 2et,00 vet GJ Date of Inspection: p4j j / 0,5- ' CD Name of Inspects lease print) X%'1`d /�W�� Company Name: Mailing Address: � YA 00�A? Telephone Number: (=•` -71-y32 CERTIFICATION STATEMENT I certify that I have personally inspected,the sewage disposal system at this address and.that.the information reported below is true, accurate and complete as`of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system'inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: d Passes Conditionally Passes Need s Further Evaluation by the Local Approving Authority ai s Inspector's Signature: Date: f(k�"'�— The system inspector shall submi a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this:inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the',system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments i ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/20.00 page 1 c Page 2 of l 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A. CERTIFICATION (continu`:d) Property Address: 2 , � Owner: Date of In pection: a 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.Anyfailure 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: Answer yes,no or not determined(Y N.1..D) in the 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 indicative that the tank is less than 20 years.old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or'due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than'4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Paue 3 of 1 I OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: � QPj _yZ.f'/2t'Je�� tg'A 69 AAA Owner: /A�a Date of spection: , 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 pubhv health,safety and the env`irbnmerid Cesspool or.privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier,if any).determines that the system is functioning in a manner that protects the public health, safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is withir a Zone 1 of a public water.supply. The system has a septic tank and SAS and the SAS is withir 50 feet of a private watersupply 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". K--thod used to determine distance "This system passes if the well,water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,.provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of I 1 OFFICIAL; INSPECTION FORM—.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A. CERTIFICATION(continued) Property Address: La 4 Owner:. n Date of I pection• ��-- D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes N9 _ V Backup of sewage into facility or system component due to+o erloaded jor clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or ,L clogged SAS or cesspool Static liquid level in the dist-ibution 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 '/z day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped Any portion of the SAS, cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface,water supply or tributary to a surface water supply. _ Any portion of a cesspool or privy is within a Zone 1 of a.public well.: Any portion of a cesspool or privy is within 50 feet of a.private water supply well. 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 certifted laboratory,for coliform bacteria and volatile organic compounds. indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and,nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis.must be attached to this form.) <" (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design.flow of 10,000 gpd to 15,000 gpd. You must indicate either"ves"or"no"to.each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply' the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—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 or failed under Section D shall upgrade the system in accordance with 310 CMR 15:304.The system owner should contact the appropriate regional office of the Department. 4 I Paoe 5 of 1 I OFFICIAL INSPECTION FORM—NOT•FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: �1J Owner J ! Date of I spection: Ag Q 6YJS— 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, of Board of Health _ZWere any of the system components pumped out in the previous two weeks'? (XHas the system received normal flows in the previous two;week period ? i,, 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 dwell ing,inspected for signs of sewage back up Was the site inspected for signs of breakout? Were all system component;, excluding the SAS, located on Site Were the septic tank manholes uncovered,opened, and the inferior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid,depth.o.f.sludge and:depth of scum V _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes no AZj Existing information. For example, a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part,Cis at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] i 5 Page 6 of I 1 OFFICIAL INSPECTION FORM.-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner: Date of�Ynspection: sJC" FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): , Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 11.0 gpd x#of bedrooms): Number of current residents:&, ,Ytj / Does residence have a garbage grinder(yes or no): JL O _ ry P y (y ) O ye .. .p l pe .,. =: „ Is laundry on a separate sewage system es or no f� .[if es se crate ins ection required] Laundry system inspected yes.or no): � Seasonal use: (yes or no): Water meter readings, if av ilable(last 2 years usage(gpd)): ,00a 0q'��l eop Sump pump(yes or no): Last date of occupancy: &40&x�� COMMERCIAL/INDUSTRIAL/\/() Type of establishment: Design.flow(based on 310 CMR 15.203 t: gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records. Source of information: 0,3 Was system pumped as part of the inspection(yes or no):&0 If yes, volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYP�F 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) -Tight tank _Attach a copy of the DEP approval —Other(describe): - wroximate age of all compone ts,date installed'(if known)and source of information: Were sewage,odors detected when arrivirg at the site(yes or no 6 I Page 7 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM:INFORMATION(continued) Property Address: i4 __ Owner: ¢ GeZe Date of I spection:Skk&eS BUILDING SEWER(locate on site plane Depth below grade: Materials of construction:_cast iron 40 PVC other(explain): Distance from private water supply well or suction line: Comments (on condition of;oints,venthi evidence of leakage, etc.): r SEPTIC TANK: (s/locate on site plan) ° Depth below grade: 1 n � Material of construction: concrete_metal_fiberglass____polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) _ , Dimensions: , br" I X& �K?57- Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: L 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: _ . How were dimensions determined: z't6/ (y .PA Comments (on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels s related to outlet invert,evidence of leakage, etc.): v GREASE TRAPJ/2,�(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 outl,6ttee or baffle: Distance from bottom of scum to bottomi of outlet tee or baffle: Date of last pumping: Comments (on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): 7 4 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: ' Owner: Date of I spection:(Qg 4 TIGHT or HOLDING TAN tank must be pumped at time of inspection)(]ocate on.site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene other(explain):. Dimensions.' Capacity: gallons Design Flow: gallor_s/day Alarm present.(yes or no): Alarm level: Alarm in working,order(yes or no): Date of last pumping: Comments(condition of alarm and float switches, etc.): DISTRIBUTION BOX: Zif present must be opened)(locate on site.plan) . Depth of liquid level above outlet invert: Comments(note if box is level and dist-ribution to outlets equal,any evidence of solids carryover, any evidence of eakage into or out of box, et I PUMP CHAMBER (locate on ste plan). t Pumps in working order(yes or no): Alarms in working°order(.yes or no): Comments (note-condition.of pump chamber,condition of pumps and ap.ourtenances, etc.): 8 Paae 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(cc•ntinued) Property Address: �� Owner: Date of Inspection: _ !! SOIL ABSORPTION SYSTEM (SAS): EJ (locate on site plan,excavation not required) If SAS not located explain why: TyV __..._... leaching pits,number: leaching chambers, number: leaching galleries,number: leaching trenches, number; length: leaching fields,number, dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of veg/etation, etc.): DIJ-141A.0-1 Z-4-ae-A 4 ,l 1/ o , CESSPOOL'(cesspool must bc`pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert:_ Depth of solids layer: Depth of scum layer: Dimensions of cesspool;.. Materials of construction: Indication of.groundwater inflow(yes or no): Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc'.):, PRIV� f` (locate on site plan) Materials of construction: Dimensions: Depth of solids: # Comments (note condition of soil, signs of hydraulic failure, level of por_ding, condition of vegetation, etc.): 9 t` Page 10 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection���� � 4� SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent.reference landmarks or benchmarks. Locate all wells within 100 feet.Locate where public water supply enters the building, _ s(Ae; I (2.-C m e4--.4" I z C � J �i S4ri ba�ti CJf) iGe pl� 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 3 / Owner: &-/ Date of I spection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked, date of cesign plan reviewed: . Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with.local excavators, in's'tallers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: it 11 r Permit Number: nn Date: Completed by: HIGH AROUND-WATER LEVEL COMPUTATION Site Location: //��'. er"01/k/1-Lot No. Owner: , , . ddress: Contractor: dr �f� l Cams Address: t Notes: STEP 1 Measure depth to water table to.nearest 1/10 ft. ..._... t 7��<�'s' ................... .Da e month/day/year STEP 2 Using Water-Level Range Zone and Index Well Map I:cate ;x= site and determine: r - A Appropriate index.-ive l . OB Water-level range= -' cue STEP 3 Using monthly report-Current - Water Resources..Cond=ions' determine current:depth to water level for index � If........................... 1�©✓� month/year STEP 4 Using Table of Water- eeel Adjustments '- 4,40' for index well (STEP 2.r6,) current depth to waterlevel for inde:>;:.wel! (STEP 3), •- and.water-level zone (STEP 2B) ""'`- <r:;' V: determine water-level -jw- ;'r' _7'a ustment g gmg 41 STEP 5 Estimate depth to high wader by subtracting the water sub _ level adjustment (STEP 4) from measured depth to water level at site (STEP 1) — ................................. . ......... . 4 - nkF YR- OR >: . —Reproducible computation form. 7 V. 15 i Ifr:r��. ' rich�rriT xv i I _ I COA TOWN OF BARNSTABLE OCATIOMQ N r,)e- SEWAGE # • 11 . `7MMLAGE� '[Al` 1i ASSESSOR'S MAP & LOT o)0 PQO�'NAME&PHONE No 1[7 60e-4 Q 6V n 5 -77/M SEPTIC TANK CAPACITY 10W 00 I/On 'o ` LEACHING FACILITY: (type)__O12FO 24 (size) nQ ' k Ce i NO.OF BEDROOMS 1 BUILDER OR OWNERS'Lter+ IBC r'0r0,U PERMTTDATE: COMPLIANCE DATE: Separation.Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by C eMea►+ �t, • o� �..��ed I_fl o � �t5�f i��ju,�bn Ioi�- LOCATION SEw PERMIT NO. 9 3 Ills VILLAGE- To, Yi4ss INSTA LLER'S NAME '' � . AD L[.0 r- �A�S%.�e �'�/�s <-✓Jib+ B U I L D E R AR 'OWNER` DATE PERMIT' •I'SSUED' DATE COMPLIANCE ISSUED j eSF C�o,v / o� ,ova s .. '30 • o �:, ; . L No..?(.�7 �.,1� Fms.....s .............. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH .............OF.....00o" � -....-.......................... Appliration fur Dwpnstal Morki C omitrurtion runfit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: ____ Location-Address Lot No. 1 T ......: ....._...... /- ��d Z .4 . . q Installer Address .� UType of Building g Size Lot_ - _ _._Sq. feet Dwelling—No. of Bedrooms------- ..............................Expansion Attic ( ) Garbage Grinder ( ) WP Other—Type T e of Building ___.... No. of YP g ------------------•-• persons............................ Showers ( ) — Cafeteria ( ) Other fixtures .•---•--------- •----------------=--••• W Design Flow...........r .....:............gallons per person r-p er)ay. Total daily flow._._._...._..................gallons.- - WSeptic Tank—Liquid capacity/��gallons Length_____._.___ Width...�'.,__4 Diameter................ Depth..!i-...X. x Disposal Trench—No. .................... Width.................... Total Length............ Total leaching area....................sq. ft. Seepage Pit No �_.....�D�iaeter'.../ ------- Depth below inlet.... ........... Total leaching area..,S__C� sq. ft. Z Other Distribution box ( Dosing tank ( ) Percolation Test Results Performed by.1 SC'.ph-21i..._.. ? ._..1GA_.._"�__........ Date../4.­.­/­­­­_L* Test Pit No. 1....4�L_-ninutes per inch Depth of Test Pit_.O_r.. __ Depth to ground water-___-/✓ .__. f=, Test Pit No. 2.__---...L,..minutes per inch Depth of Test Pitr/: _e.r. Depth to ground water____-rc ... 0c to --� - - -• • ----- � ------------------ W Description ool ------�--- � ----- - � -: •-••-----•---------- 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 iITIZ- 5 of the State Sanit - The undersigned further agrees not to place the system in operation until a Certificate of Compliance as een issu by etheb of health. I.Or APPlication Approve •----------------------------------_---- 1� 4�... Date Application Disapproved the following reasons:-------•--•-------------------------------------•-----------•----------------------------------------.........- .................••--------------------•......-••••---•-----•----------••-•------•••-------•-•------•-••-............----•-----•----------•----------._...•----•------••-------••------••-----••••-•----- Date PermitNo......................................................... Issued_....................................................... Date THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINAL (S) M P�� C DATA J THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ....................... .1...------...OF..../3'....?........ Appliration for Application is hereby�tf "Permio,C�r ct ( Repair ( ) an Individual Sewage Disposal System at: �. ; x ... - -- _...•••................... ......................................... .................................................................................................. / Location-Address ,' or Lot No. .............................•--•---...........------....---•-••-•---............................. ..................:..-=-------_—.........•--------•------------.............................. Owner Address . •-• .-----. � ----•----•....................................Install ller•-........-----�...................... --•-•........................................Address...................._..................---- d Type of Building Size Lot.:............... ot.:..............:..........Sq. feet V Dwelling—No. of Bedrooms........7- ..............................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons-•__________________________ Showers — Cafeteria p`I Other fixtures --------------- --------------- --...... --------- W Design Flow...................5.............-i....._gallons per person perday. Total daily flow.............................................gallons. . WSeptic Tank—Liquid capacity `:. gallons Length__r_........:_.. Width..`<'....... . Diameter_____.__-_,`_.. Depth.............. x Disposal Trench—No..................... Width._................. Total Length.....................Total leaching,area....................sq. ft. Seepage Pit No...... .......... Diameter...Z.0........ Depth below inlet....5!............ Total leaching area.................'sq. ft. Z Other Distribution box ( e ) Dosing tank Percolation Test Results Performed by..!.)-4_.S�__r J E= 'J ' .J __ Date.�Z_'_._ � --------•-------------------- ------- ......-----••-----••.... Test Pit No. I.... r-minutes per inch Depth of Test Pit_%._=_.__: Depth to ground water..................... (i, Test Pit No. _._._minutes per inch Depth of Test Pit .?:_..._:__._.. Depth to ground water----- ............... ---------�----•--••-•--z-��-----------' S � 'r - mil/ r r,r......Z�— -%`7` - .--•---•-----.............................................. s� WI 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 Certificate of Compliance(has been issued by the board of health.,. / Dat ApplicationApproved"B..- -•-----------------'-----•---------•---------------------------•------------------•----•-- c�? Doi r"......••.. Application Disapprove the following reasons:-------•-------------------••----------------------------------------------•--•------------------------------- -••--•••-•••-•--•--••-•--•......•-----------------------•._....---•--....--••-•--•-•-...........•--••---•-----------•---•-------•---••••••--•----••-••--•----------•-----------------------•-•--•-•----- Date PermitNo......................................................... Issued-----------•-•-- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..G�Gv�.........OF'.........�- iZ.-J:tii ................................ Tntifiratr of Tomplittnrr THIS IS TO CERTIFY, That the,Individual Sewage Disposal System constructed ('`) or Repaired ( ) - . ........., � ............. 'j /T✓ r..✓ C ' - Installer at.....-•................................................................•----.........-----•------------• ( 7 U ?""" ----------- •- --------------------------- has been installed in accordance with the provisions of TLE 5 of The State Sanitary Code s des i ed in the application for Disposal Works Construction Permit N ,� '.�/_, ________________ datel_ _ _ ................. f = d':- THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRII ® AS A UAR NTEE THAT THE SYSTEM I �TION SATISFACTORY. DATE....... .. .. Inspector THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .OF....:.�. </V.......... /' ,- r...-................. Dispas l Works Tnntrnrtion Prrutit Permission ids hie,�eby granted.�--=--�--•-=�-------/............ ....--..................................................... to Construct f), or Repair ( ) an Individual Sewage Disposal System at No. t.. . /r--. / -.y.........:... G. Street as shown/on ,epl' tion for Disposal Works Construction t o_____________________ Dated..____......_....._.....__........__......------------------------------------ •.....•-•------••-••--•----••.........- Board of :Health DATE........ FORM 1255 A. M. SULKIN. INC., BOSTON " 1 �� 20 •ff /rein. t�, •foP o f �� O de /O f'f rain. r Gone GovCI'S i= 2" /aysr oyc /�� sch. 40 PVG Pipe /2 rna¢. Cone• Wash aM( � rein. pitch % " h cover per ft. t '¢ ScG Pipe- per zo Pv pitch rI8 psr ff. c/sa f/aw lint sar7d T �F inv. a/. inv. e/;_ �J . .• . . . LOGAT/O/V MAP s` rnv. e/. %" � qoL/. �� bo¢ inv. e/. i Septic fa.rr K nv a/. - s •• . ;1* '• Was/sisal inv. a/. ems`; 61 u 4 .' stored pr-s c dL i t s e e k� ' • . /Caching i000 �1. e basin SEWAGE S`�STEM )=ROF/L41C or o �.; /70 -fo SGa/e eqtL'i✓a/enf o•�• bo O/77 dI• '` ground /,uatGr f-ab/e C/• = _ � y bvY'to.r, -fast hole at {� OCS /Gn.I OAT'A TE ST Hoc. 4E L o G t IIIU/tis& a OF BEO�eOOMS 13 TEST OflTE I-V/T/l/E 55E0 GR)eBAGE O/SPOSt9L. UN/T : ' - I � � � '`• -•, PE,EGOL AT/ON ,2ATE L z M/IV. �/NGH TOTAL_ EST/MATED FLOW GRL.�DRY 1 HOL E _ HOLE s -Z•� " . .� t . p �eEQ. SEP7-/G TF1NK cRPAG/TY . Y 5 Gr9L �L e%= '<' /� �!L e% = e< �v �� �j y `�,'�'? r.�r i` ������ . f�G T U f-i C... S�r P T! T fl N fd. S/Z E . •% ' - G A t. �/y i`-f __._._. _ � ©.ti i- i Vj LEfTGH/NG: f��eEfa �EQU/CEMENTS . S/OEWRI-L �l T/� = Y �� 6AL./S.F. ;r,.. t BOTTOM � TOTAL L E r9 c:H/NG CAPA G /TY 1 ieES�ieVE LEfiGH/tile CAPflC/TY Q y' (7 JO ' - NOTE $ a�U ✓ /) ALL W0A--k1-o7,q/ll5H/P fiNO MflTE,Ie/AL S r 7� SHR L� G oNF 0 TO o. E. CigTcif� �-' / Q• E T/T G.C- $ , - ANO THE TOIAIA/ OF l �e U L E• S 2 E G U L ,oq T/O N S FOIE IUC) �` t SUBSU�E'.FAGE p/SPoSAL OF SAN/ Ty,eY S4eWgGE-. GOMPL/ANC& /w/TH ZON/rVG R& C=Ul I-r/OA/5 p SHR4L4L f3E DETER'/"!/NEC) BY BU/LO//VG �„ /NSPEGTO�e � GOMM155/ONEie. 3) EX/ST/NG flivo F/NAL GRflOES SHALL IeEMA //�/ ES5EN7-/r9LLY' THE SAME. OATS 0VEo : BAD. OF A4&A 4-7 AGENT SIT F-'LAti of P�eoPOS � O CowST� UCT/ON � L O G A T/OIL/ ��S� � ��:� �.- �' l� .���,'C%�� '.-�l��:r S„70 't�.� ra- ` PL. A AJ 1r LEGEtiJC) L . �h � � -fyp. existing Spot a/e✓. o• o— — — �� _E G-Ai sting contour — — OA S G O/V E/VG //V E- E R/NG //V G. fyp• pr-Op- in. Spot G/ev. o•o VIN Prof. n- contour- _ • �' 4 5 -3 /e O U 7 /34 k Ala 1 ` SO. L:>& AJAJ/ S MASS. Otto 6 0 4# ra, 1 7 - 394 - 88 /2AL