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0036 FORSYTH COURT - Health
36 Forsyth Court Cotuit - - _ -- - - O60 A= 055 - — -- No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in comp der: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ftPhCation for Misposal 6pstem Construction 3permlt Application for a Permit to Construct( ) Repair(* Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 36.,—� C+. Owner's Name,Address,and Tel.No. C09-996 Assessor's Map/Parcel 0_5 069-e CC VLX. + or A A_ �p - Installer's Name,Address,and Tel.No. 605-- yZ_$�)� Designer's Name,Ad ress,and Tel.No. 'j/ /,L//4 Oax 0/� i Type of Building: Dwelling No.of Bedrooms 7 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: ! Agreement: r i h nn r TheId"ersi ed ees toisuree construction and maintenan the afore described on-site sewage disposal system ingnT l�J accordance with the provisions of Title 5 of the Environmenta a an�nott ce the system in operation until a Certificate of Compliance has been issued b this Board of Health. Si a Date JT Application Approved by Date Application Disapproved by Date for the following reasons Permit No. ' Date Issued a t No. / t s Fee- V THE COMMONWEALTH OF MASSACHUSETTS Entered in compu(er: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 01pplitation for Misposal *pstetn Construction Permit Application for a Permit to Construct( ) Repair(* Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 3� �i-IrS, � Imo'-(.-. Owner's Name,Address,and TeL No. $'oi(--n,-'7 y� J :,.1uu .G',rdvrsi" Assessor's Map/Parcel S�S�GCo G� C i_'i L., ,.,I Installer's Name,Address,and Tel.No. .0s- yz_ � Designer's Name,Address,and Tel.No. " Type of Building: / Dwelling No.of Bedrooms Y Lot Size " sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil s , Nature of Repairs or Alterations(Answer when applicable) „ 1 Al,L , Y / 1: A. Date last inspected: jd � Agreement: t t TheIderjsigned a'tees tdensure tkie d6nsction and mainten-a—nc—e—of—t�he afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code>andnt to ace the system in operation until a Certificate of Compliance has been issued by this Board of Health. Si ed. r �y ,x Date _ X '•Application Approved by // �/ 11491 VM.41,0 Date I`( f ✓ V Date ! Application Disapproved by t for the following reasons r �r v u Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance ,f THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(,1(� Upgraded( ) Abandoned( )by � T at Y' ,C4 IjA_ 0:+t. (� �,a; has been constru ted in acc rdance with the provisions o Title 5 and the for Disposal System Construction Permit No. / dated Installer y�i r>i.'f�" , �F, -�fii t a+✓ Designer ! )I #bedrooms Approved design flow. gpd The issuance of th s permit shall not be construed as a guarantee that the system will fu 1 ti/on/�as designdd. n/ Date' 1 Inspector l J,G/ 1 ,!/{ v -v i ____________________J__________t/--_--__-______-________---_-______-__-_-_-____--__-_-_____-__________-._________---_-_________,__________- No. / //) Fee THE COMMONWEALTH OF MASSACHUSETTS `f t PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS Misposal 6pstem Construction i3ermit Permission is hereby granted to Construct( ) Repair(Al Upgrade( ) Abandon( ) System located at 1 and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. r. Provided:Construction in st b completed within three years of the date of this permit. Date Approved by / t nLl Commonwealth of Massachusetts Title Official Inspection Form 5 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 36 Forsyth Court u Property Address -------Michael G ill-Ti-ustee-- Owner Owner's Name information is required for every Cotuit MA 02655 4/12/2019 page. City/Town State Zip Code Date of Inspection x D. System Information (cont.) . ............ .. ... r7 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ❑ drawing attached separately A t I ' o a T 3 CO / 3L 1 13 `f 0 3 3a 3. l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 i r - COMPLETE • ■ Complete items 1,2,and 3: A. Signature M Print your name and address on the ieverse Agent so that we can return the card to you. ❑ ddressee o Attach this card to the back of the mailpiece, B. Received by(Printed.Name) C: te'of Pelivery or on the front if space permits. - ------ — - ""cress different from iterd 1? QYes Delivery address below: p No GILL, MICHAEL J TRUSTEE 776 MAIN STREET HYANNIS, MA 02601 { II I IIIIII IIII III I II IIII III I I III'III I III)III III 3. Service Type 0 Priority d Express® , ❑Adult Signature ❑Registerered MaiIT"" ❑Adult Signature Restricted Delivery O Registered Mall Restricted 9590 9402 4798 8344 8569 29 rtmed Mail® , �� ,,pp ellvery ❑Certified Mail Restricted Delivery Return Receipt for ❑Collect on Delivery Merchandise 2. A_rt_i_cleNumber hinSf rom_seniirs-tnt�u_ ...a L1c,ll--:"_DeliveryRestr)ctedDelivery SignatureCoMrmation7 7 015 17 3 0 0001 4 9 8 7 9668 1.01 ❑Signature Confirmation p)I Restricted Delivery Restricted Delivery PSFOrm 3811,July 2015 PSN 7530,02y000 9053 Domestic Return Receipt .� • "t, 5 .Xi � s , tl' u "� � a to Certified Mail Fee Er $ �;o Extra Services&Fees(check box,add fee as appropriate) )+ ❑Return Receipt(hardcopy) $ ❑Return Receipt(electronic] $ y 9OStfI18C1(... T� 0 ❑Certified Mail Restricted Delivery $ Mere Adult Signature Recidired O ❑AduftSignatureRestricteddelivery$ C3 Postage — GS,d ti m .$ s r~-R Total Postage ant $ GILL, MICHAEL J TRUSTEE � Sent to 776 MAIN STREET StieetancfAp£Na HYANNIS, MA02601 City State,ZIP+4' t.` :r� r rr rrr•r� - LISPS TRACKWG# First-Class Mail Postage&Fees Paid LISPS Permit No.G-10 9590 9402 4796 8344 8569 29. United States '� •Sender:Please print your name,address,and ZIP+4®in this box* Postal Service t s Town of Barnstable -� Health Division b 200 Main Street Hyannis,MA 02601 I 11=1' 1€ iSit I l�tj11l:;i&1.1ijltl,#ii; Certified Mail service provides the following benefits: _ •A receipt(this portion of the Certified Mail label). . for an electronic return receipt,see a retail •A unique identifier for your mailpiece. associate for assistance.To receive a duplicate ■Electronic verification of delivery or attempted return receipt for no additional fee,present this delivery. USPS®-postmarked Certified Mail receipt to the ■A record of delivery(including the recipient's retail associate. signature)that is retained by the Postal Service- Restricted delivery service,which provides for a specified period. delivery to the addressee specified by name,or to the addressee's authorized agent Important Reminders: Adult signature service,which requires the ■You may purchase Certified Mail service with signee to be at least 21 years of age(not First-Class Mail®,First-Class Package Service®, available at retail). or Priority Mail®service. Adult signature restricted delivery service,which •Certified Mail service is notavaliable for requires the signee to be at least 21 years of age International mail. and provides delivery to the addressee specified ■Insurance coverage is notavallable for purchase by name,or in the addressee's authorized agent with Certified Mail service.However,the purchase (not available at retail). of Certified Mail service does not change the a To ensure that your Certified Mail receipt is insurance coverage automatically included with accepted as legal proof of mailing,R should bear a certain Priority Mail items. USPS postmark.If you would like a postmark on ■For an additional fee,and with a proper this Certified Mail receipt,please present your endorsement on the mailpiece,you may request Certified Mail item at a Post Office-for the following services: postmarking.If you don't need a postmark on this -Return receipt service,which provides a record Certified Mail receipt,detach the barcoded portion of delivery(including the recipient's signature). of this label,affix it to the mailpiece,apply You can request a hardcopy return receipt or an appropriate postage,and deposit the mailpiece. electronic version.For a hardcopy return receipt, complete PS Form 3811,Domestic Return Receipt;attach PS Form 3811 to your mailpiece; IMPORTAMS Save this receipt for your records. Ps Form 3800,April 2015(Reverse)PSN 7530-02.000-9047 �oF� T Town of Barnstable Barnstable P Inspectional Services nAmefica0v sARN6TABLE, 9� 9. ,�� Public Health Division 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas A.McKean,CHO FAX: 508-790-6304 CERTIFIED MAIL#7015 1730 0001 4987 9668 April 23, 2019 GILL, MICHAEL J TRUSTEE 776 MAIN STREET HYANNIS, MA 02601 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 36 Forsyth Court, Cotuit, MA was inspected on 04/12/2019 by James Ford, certified Title.V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system"Conditionally Passes" under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: • The distribution box is broken and needs to be replaced. You are ordered to repair or replace the septic system within two (2) years from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH t T o i - c ean;R.S, �O Agent of the Board of Health Q:\SEPTIC\Title V Inspection Report Letters Mail ing\Conditional ly Passes Letters\36 Forsyth Court Cotuit.doc Town of Barnstable i , IARIV3I'ABI.E. � 9�prfDp,�� Regulatory Services Department Public Health Division 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Richard Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO Feb 6, 2007 Rev. 5/11/16 DEADLINES TO REPAIR FAILED SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) An"x"marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑ Discharge or ponding of effluent to the surface of the ground ❑ Pumping more than 4 times during the last year not due to clogged or obstructed pipe. ❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ONE (1) YEAR DEADLINE CRITERIA ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Any portion of the SAS, cesspool, or privy below high groundwater elevation ❑ Any portion of the cesspool within a Zone 1 to a public well ❑ Any portion of a cesspool within 50 feet of a private water supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO (2) YEAR DEADLINE CRITERIA ❑ Single Cesspool Any"conditionally passed systems" (broken cover, relocation of a pipe, relocation of a driveway due to H-10 components, etc) ❑ Leaching facility with standing liquid level at or above the invert pipe (per Town Code §360-20 h) 0 T'JUR E box d �-e r-e /1, Ce Repair deadline: 02 C,r Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc { Commonwealth of Massachusetts p Title 5 Official Inspection Form 10 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments _0 �y ,.» 36 Forsyth Court L- Property Address Michael Gill Trustee Owner Owner's Na a -1 information is required for every Cotuit MA 02635 4/12/2019 page. Citylrown State Zip Code Date of Inspection r: Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information 6113�1-5 on the computer, use only the tab James Ford key to move your Name of Inspector cursor-do not Ford Septic Services LLC use the return Company Name key. P.O. Box 49 „y Company Address Osterville MA 02655 City/Town State Zip Code 508-862-9400 S12482 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ❑ Passes 2. ® Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 4/12/2019 Inspect Signature Date The s m 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 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 ' Commonwealth of Massachusetts A = ( Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 36 Forsyth Court Property Address Michael Gill Trustee Owner Owner's Name information is required for every COtUIt MA 02655 4/12/2019 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ❑ 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 2) 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*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): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form S Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 36 Forsyth Court Property Address Michael Gill Trustee Owner Owner's Name information is required for every COtUIt MA 02655 4/12/2019 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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 D-box is broken down, needs to be replaced ❑ 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): 3) 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. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 36 Forsyth Court Property Address Michael Gill Trustee Owner Owner's Name information is required for every Cotuit MA 02655 4/12/2019 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. 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. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form X Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 36 Forsyth Court Property Address Michael Gill Trustee Owner Owner's Name information is required for every Cotult MA 02655 4/12/2019 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %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 water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® 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. 5) 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 CA. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts �. (P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u— 36 Forsyth Court Property Address Michael Gill Trustee Owner Owner's Name information is required for every COtUIt MA 02655 4/12/2019 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes"or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ❑ ® Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments • 36 Forsyth Court Property Address Michael Gill Trustee Owner Owner's Name information is required for every Cotuit MA 02655 4/12/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): Detail: unavailable Sump pump? ❑ Yes ® No Last date of occupancy: currently Date t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts - e Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments V 36 Forsyth Court Property Address Michael Gill Trustee Owner Owner's Name information is required for every COtUIt MA 02655 4/12/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: pumped 3 years ago- per owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 I , Commonwealth of Massachusetts �n p Title 5 Official Inspection Form S Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 36 Forsyth Court Property Address Michael Gill Trustee Owner Owner's Name information is required for every Cotuit MA 02655 4/12/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. 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): Approximate age of all components, date installed (if known) and source of information: installed date 1987- per as-built Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 36 Forsyth Court Property Address Michael Gill Trustee Owner Owner's Name information is required for every Cotuit MA 02655 4/12/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 1211feet Material of 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: 1500 gal. Sludge depth: 3 Distance from top of sludge to bottom of outlet tee or baffle 20 Scum thickness 3 Distance from top of scum to top of outlet tee or baffle 6 Distance from bottom of scum to bottom of outlet tee or baffle 13 How were dimensions determined? measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The cement tees were present. The liquid level was even with the outlet invert. ** Note there are two bushes growing over both inlet and outlet covers and they need to be removed l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts � Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 36 Forsyth Court Property Address Michael Gill Trustee Owner Owner's Name information is required for every COtUIt MA 02655 4/12/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene El other(explain): N/a 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 Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): N/a Dimensions: Capacity: gallons Design Flow: gallons per day l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments o v 36 Forsyth Court Property Address Michael Gill Trustee Owner Owner's Name information is required for every COtUIt MA 02655 4/12/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): N/a *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert even 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.): The D-box was broken down and needs to be replaced t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 36 Forsyth Court Property Address Michael Gill Trustee Owner Owner's Name information is Cotult required for every MA 02655 4/12/2019 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 10. 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.): N/a * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 2- 1000 gal. ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.7/26/2016 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 113 of 18 Commonwealth of Massachusetts �. p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 36 Forsyth Court Property Address Michael Gill Trustee Owner Owner's Name information is required for every Cotuit MA 02655 4/12/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): There are 2 Pits. One was full and liquid was over the inlet pipe. The other had 1' of liquid on the bottom and the scum line was at the same level. A camera was used to inspect 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration N/a 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 Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form S Subsurface Sewage Disposal System Form - Not for Voluntary Assessments v- 36 Forsyth Court Property Address Michael Gill Trustee Owner Owner's Name information is required for every COtUIt MA 02655 4/12/2019 page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: N/a Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 I ' ' Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 36 Forsyth Court Property Address Michael Gill Trustee Owner Owner's Name information is required for every Cotuit MA 02655 4/12/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ❑ drawing attached separately A ,, a��k t I I p I I O a 3 O � Q / a 1 13 a a-7 ao O 3 3a 3le' s y s i S? �E E t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal Syst em•Page 16 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 36 Forsyth Court Property Address Michael Gill Trustee Owner Owner's Name information is required for every Cotuit MA 02655 4/12/2019 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 35' feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: topo and water contours map ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: see above Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 I j, Commonwealth t of Massachusetts �- p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 36 Forsyth Court Property Address Michael Gill Trustee Owner Owner's Name information is required for every Cotuit MA 02655 4/12/2019 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 \TDE DRI�WAY / EASEAMEN7�, 1 , EX/STIN I �LL SEPTIC Nd EXISTING N gr. DWELLING I TOP OF MON EL. 50.7t DECK 1 4 ELECTRIC c� PROPOSED F LINE N ADDITION \ F \ 23.0' \ \\ \ \ FATE SWALE \ \\ [501 END TING CONTOUR \ \ N \ \ 72-01 9 T. SPOT ELEV. \ 83.0 \\ \ POSED CONTOUR Yy TOWN OF BARNSTABLE LOCATION SEWAGE # 7 P Z 3 S VILLAGE ASSESSOR'S MAP & LOT �w �akv- S INSTALLER'S NAME & PHONE NO. 3 -'s SEPTIC TANK CAPACITY gOo 9221 LEACHING FACILITY:(type)�.� j©O© 94Z (sue) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER_ BUILDER OR OWNE (2� I1 DATE PERMIT ISSUED: DATE .COMPLIANCE ISSUED: l qg - s l VARIANCE GRANTED: Yes No �� O J z7 J zb t � THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH Town.......................O F..................Barnstable_......_...------..........--------.......•.... Appliration for UiipusFal Works Tonotrurtinn ramit Application is hereby made for a Permit to Construct ( ) or Repair kX) an Individual Sewage Disposal System at: ---.....36 Forsyth.Court. .................................................. .........House No. 36 I..... 5.�..... ........- Location-Address or Lot No... ......................aes M. & Susan E. Gill 36 Forsyth Court,Cotuit. Ma:02635 _-----------------------••-----•--------------------------------...._._..._ .... .......----..... Owner Address Steve Lebel 34LisLae ashpee, a. 064 -•-•--- M ..----• Installer Address vType of Building Size Lot--.43,.56.0...........Sq. feet Dwelling—No. of Bedrooms..............4----_--_---------------Expansion Attic ( ) Garbage Grinder Vo) Other—Type T e of Building ............... No. of ersons__...__..._.............._.. Showers — Cafeteria a YP g ------------- P ( ) ( ) Q' Other fixtures ............................ W Design Flow............................................gallons per person per day. Total daily flow................?...........................gallons. WSeptic Tank—Liquid capacityl,5D.Q-_gallons Length-------_--_--- Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total,leaching area....................sq. ft. 3 Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... 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_.--__--________---_---. rZ4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------ 04 ------•--••-------------------•---------••-----•--------•••••-•••---•-•-•-••••......------------.................................. 0 Description of Soil ll2eriium._tn.fine.sand............................................................................................ -------------- x W ----••---------------------------------••-•--••---•---••--•------------•--•---•--•-----•---•-••---•------••-•-----------------------•••-•-•--------......•-----....................................... U Nature of Repairs or Alterations—Answer when applicable.--___Moye.tank to Construction-of-one.•-•-_-_ .._room_addition_to.existing dwelling,.-_------- ------------------------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions bf TIli U 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 y e b rd of ealth. � ------±,- --- --- .......4 MIK.......... J Date ApplicationApproved By..............................................................." ................................... ......--- Date Application Disapproved for the following reasons--------------------------------•-----------------------------------------------------------•---••---•-........_ -•-------------------------•-------•-----.............-----------------------•-------------•-----------------•-•-••-•-----.....--•••-----•••----•-••--•----------•••-•------•-------•••----••-•••-•-.--- Date PermitNo.....- --...-••••._...•-�--�.�... Issued--------------------------------------------------•--•- Date No.- � � .--........ F� �....--X7. -. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Town.......................OF.................l'nBxr�ck�t�:P Appliration for Ditivati al Works Tnnitrnrtinn rrntit Application is hereby made for a Permit to Construct ( ) or Repair kX) an Individual Sewage Disposal System at: . ........Iiotls T�,..3tz _(L,nt 45--• ....... ... -•----• ................................................ Location-Address or Lot No. .f AtYi� _. i r,` Ca;can �: c ;�i1 `3 i' FOI'svlh Court' C7Ot'lil'� r1� (1`)fi3, -•-••••••••.... ........•....._..•--••._:-a.....�.......................................... ...........'-.......... -..................:-........:............__.................._..... Owner Address .... 4 l,is<t ane. T.Rashnet-. Ma.-02649 f Sq. feet M Installer Address Q7i Type of Building Size Lot-.A.'!- _n_____....... U DwelIin No. of Bedrooms._ ..........A.................... .....Ex Expansion Attic g— --• p ( ) Garbage Grander (To) A4 Other—Type of Building ............................ No, of persons............................ Showers ( ) — Cafeteria ( ) 114_ Other fixtures -------------------------------•-------------•---- - - W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacityj9;_Q:a..gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a •--••-----•-•-----------•-•-------•-••••-•-•------•---••-----•---•••---------------•---•--•••................................................................ D Description of Soil........."_?p�?i_t1 !.¢�.iin•A..c._un -----------------------•-•--•-•-•---------•-----•••-•-•--••-•-•------•-•-••••••••-•-•---------•--•••--------•-•----- W U ---•------------•------------------------•-----•------------------.......---------•--------------------.....-----------•--•--------------------•-----•---------.....---••--•------•-•-•----.........--• W ------------------------------------------------------------------------•---------- ---•-•----------------------------------------------------------•------------------------------------.....-•-•------ U Nature of Repairs or Alterations—Answer when applicable.___.r=lc�ttetan►>..X��_�ll�»_ �?ns C�!ctynn nf-ran ......... I`iinm_ari�j_riran•tn_PxiStin -r....-----•-----------------•------•-......-----------•......•..... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T ITIE 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. Signed - =='7......•---..... ...t a ! --•--.�/%f,l<7-----•..... —1 �n �Date Application Approved By...................=-= _ ----------Lf}I�Yte Application Disapproved for the following reasons:.............................................................................................................. ...........-•-•--•-•-------------••-•-••-•••-•------•--•----•-•---•---•••-----•.......--•..._...----•---•-•-••---•--••••-•-••••-••-•-•---••••••-•••-•---•-••---•••••-•--•---------•---•-••----••-••-•--- Date PermitNo.................. L� =- � _ Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH I .!.n.....................OF............ ,£rn.s.taffle................................................. Trrtifirttte of TnntliliFatta THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired irK ) by................ teve Lebel.................................................. ---.......-------•-•--•-•-••-----------------•-•-•-•-----•----------•----•--............--•••- Installer at.................36 Forsyth Court_, C�otuit:_Ma. 02635 k__ --------.....---------------------••---------------••------•-------------------••......-•-•-----••-....... 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 N ._r-:__ _ ....... dated----------- "{_�_,_f _r�---...._- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE....................... .-.Z`l-_ E.�............................. Inspector ._.. ------------•----•---•--- THE COMMONWEALTH OF MASSACHUSETTS � ---- BOARD •�O�F� HEALTH No. ..:. , tea ...."......�.' .t!'.N...........OF. t'�' ..NS......---•.................•--•-- ..._.... FEE.�Z,-..-----. Nispo al Works Tnntrnriion famit Permissionis hereby granted...--- t------------------------------------------------------------------------...................................... to Construct ( ) or Repair ) an Individual Sewage Disposal System atNo.-- .... sz- _- ------- ...••... ` --------------------•---------------------------------------••---••••....•••- Street as shown on the application for Disposal Works Construction Permit NZ.......�3_5 Dated..___ •'7--- .- ... ....... ............................ DATE. oard of Health FORM 1255 A. M. SULKIN BOSTON sjt(co h.t L/f% I F-., rat�� •�t..�aw - rlia}� ���' 490 �.Pb.� ., � ., �EPi-iG T�a.tK, � 4'40J}.�>f�13'a/o • G(p06.f?D. ` ' .`� �� ` i USE- t 50d 6A L-. 6KAAt noo�,lwYl�o, +wrzrenwn r•w��worw. - '. Lf,P<N E �' ��` w s it w N Ti•<rC +6.+¢} it _•��X�.}��'t,�i / y �- R i.f`' Q C �.� ice. ~� � �O ,. .' ®may glwc-D"Tloo O&M + q 4 Of At WILUAM 11 y.E .Mo. 18334 ��- -�- • Sul zl- 'TEST 70 Tor Fwv s too.o 4'�a� DtSr. � , iw. IG� -8 - ti.c r.r� oX �G•s7 rjPilC Ip' e:, INy I—A W K Od0 .t�tV t� L&AG N, A• LLEA.g W11T1✓I A Ld _ �iTow�Cz i44.8 ` t= ' IS CA L I H< 1'oo ;�"'t' t a f / 7 N W'f+.T k'_ 1 MRTIF: TWAT' 'r1 � F� OAT1dr,J561atiu►J PL4>`l RsFCIZE w/I'T'F# TWA 51 ar .t►- t t-- o T ' T%-AI� t Pi_A►�! I� LloT LA".C. Ua 1 /a�-J OS?ECu►� Ttac ut=� �T<, St4cww APta� t f_A►-JT C_ E_ G. t3`t r F ' ,.�;;� �',? _ t_;•,C��� lc, ter-:1'Lc_M+�JL 11%.'�' t_tN`.�� _._ • a s T-1 N T , T 4(0 3 �.Z 09' v 1 / 4G _ a-, / / Atia ITIoU ,� Val PIT•. r Two? I Soo &A� SWnC-TaJL COWC, �+ I 35 is , , _ .. ..- ` Lcyr 'P�►J ot= 1ZE.04A'Cr StPTIC TANIL AA A a_.. �aMes � I „ 12Z I STWZ.s LRND SU����o►?1� tj (j ALBANEMt GU)OE L0•C AT ION � f SEWAGE � REMIT - NO:. U 7T=�' LACE • Co l " INSTA LLER'S NAME & ADDRESS e �CL�'d yi �7 BUILDER OR OWNER DATE PERMIT ISSUED am-7 7 DATE COMPLIANCE IS-SUED � � � �� sl }� No..---- C) Flca.... .Or✓... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......... ........ -- .OF...._............................... . --- Appliration -fur UWVnuttl Works Tomstrurtiutt Vrruift Application is hereby made for a Permit to Construct (�r Repair ( } an Individual Sewage Disposal System at: I�L7T* _!- _..t-0i25Tt� ®v12T.....---- ii Location,A ss or Lot No. Cl_ 1+tYts._ .. L�sS�`t N_..._ 1_�L...........-•------•------ W Owner Address TICI.......................... --••-•---------------...-----•-----•----••---•-•-----.....--------------------------------------- Installer Address Type of Building tt11 � Size Lot.....4.4_j�__Sq. feet Dwelling—No. of Bedrooms--------------- __-__•----_----________Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures --------------------------------------------- ---- ------------------------- ---------------------------------------------------------------------- W Design Flow............1.1.0.......................gallons per person per day. Total daily flow--------------4-----�-�______.__.__._-.gallons. WSeptic Tank—Liquid capacity-A560gallons Length---------------- Width_-___..._.._--- Diameter.........-._.._ Depth---------------- x Disposal Trench—No- No. ------0....... Width-------------------- Total Length-------------------- Total leaching area____.___--__-----_-sq. ft. Seepage Pit No.._._;;L----------- Diameter____________________ Depth below inlet-...................Total leaching area------.------------sq. ft. Z Other Distribution box ('A) Dosing tank ( ) aPercolation Test Results Performed by---------------- ......................................................... Date-_--.--.-•------------------------------ Test Pit No. 1------- _:='_minutes per inch Depth of "Pest Pit.................... Depth to ground water........._____.-__.._.. (� Test Pit No. 2................minutes per inch Depth of Test Pit-________._.___---.- Depth to ground water_..__._.____-__._____--- ty+ ------------------- ---------------- ----- ----- - -- --------- G Description of Soil---------C.d_/' 17- -LY /d"! s ue . - - - - - -- --- Urr--------- -1 T-------------------- -------------- ---------------------------------------------- w x ----------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------- ---------• -------------- 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 Article NI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b ed by th d of health. Sig e l�j /tf/77 -------------------------• -- - ate Application Approved By........I_.-A ....... `l- 7 ? Date Application Disapprovedo to for following reasons:.........................................................................................--Date . ...............................................................-......................................................................................................................................... Date PermitNo.-------7 =.............................. Issued....................................................... Date No.--.. f-J----•--- ............................. THE COMMONWEALTH OF MASSACHUSETTS Xr.oe' BOARD OF HEALTH .... ... ..... ............OF...............................I..... ---------------.-•-- .................----- �P -for 11iiV aiial Works Tomil.riartion Prrniit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: ° nt -----L?T' 571-90� `�'�"�}_ Qta_!c�T--------- " ......1T, -- ��1 .------------------•--•---rt.. ,/� �y Location•A rr�sc t or Lot No. .... Amr, - ---M .'�i ..--- -I-~nt.......................... ........................................................ Owner Address J. °°rate-------•-•--------------- ------------------- Installer Address ��ii U Type of Building ► Size Lot_._._` _)®�p-Sq. feet :. r.t; Dwelling—No. 'of Bedrooms----------------_________________________-Expansion Attic ( ) Garbage Grinder ( ) per, Other—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) P I Other fixtures ............................................... d -----------•-- W Design Flow.............�.10_______._______-__ ---_gallons per person per day. Total daily flow-------------I.......................:------gallons. WSeptic Tank—Liquid capacitLAS-Pqallons Length................ Width--_--_-_..._.. Diameter------------:._... Deptli---------------- _-_ x Disposal Trench—No. -____ Width-------------------- Total Length-------------------- Total leaching area-.-----._---...___--sq. ft. Seepage Pit No._#0L.----------- Diameter____________________ Depth below inlet..................... Total leaching area------------------sq. ft. z Other Distribution box Y., ) Dosing tank ( ) '-' Percolation Test Results Performed b ... Date........................................ Test Pit No. 1----�" '----rninutes p'&inch Depth of Test Pit..................... Depth to ground water_..-_-----__--.--.------ f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water...-_.-..-_-.__.--__-_-- W -------------------: ---•---- ------- O Description of Soil----- C 6 'd1T C �4� r ��e -••-...-••---..m..---••--. x ,, rJ ------------------- ---- ------- �"�G • -- ---•---------------.--•-•--•-•--••--•-•------------------------------------------------- Ft W r . U Nature of Rep rs�-'orvAlterations—Answer when applicable--------------------------------------------------------------------.------------------------- ----------------------------- ------------== ----------------------------------------------------:--------------------------------------------------------------------------------------------------- Agreement: The undersigned agrees 'to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI af.the. State Sanitary Code+,.The undersigned further agrees not to place the system in t - nor• S,2 r�+'3P t;4.t u'�0�.'"�� operation until a Certificate of Compl<anceMhas b n-rss d by th b of health. Sl nq/7 7 - -------------------- ......... - Date Application Approved By...... ' ------'------------------------------- •-------- �1F"'--•Da�� Application Disapproved for the following reasons--------------------------------------------------------•-------------------------------------------------------- Date PermitNo.-•....7 -- •------------------------------------- Issued................... ---------= •--••---••--••--•- Date ., � kiECOMMONWEALTH OF MASSACHUSETTS z. BOARD OF HEALTH 4`` .. 17 " < ..........OF.. i�. �.�" .C...,. ............... r`{ ' v (Iertifirate of T , mplianrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ;) or Repaired ( ) by j ' f�"' *��'�/+d✓ � j�t �d� � L7 4a�ler " / /Mv.tir S i at............................................................................ •---•---•-------------- ------------------•-•--------------------....---.._..--•-._......._..............--•.......___.. has been installed in accordance with-the provisions of A lciie 'I of The State Sanitlry dw& d se�bed in the application for Disposal Work,sGanstruction Permitrvo ;� `. _---______: -__. dated-------- --------------------------•--- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT- THE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE:. � � p.2 �� _-- 4e Inspector w c THE COMMONWEALTH OF.,MASSACHU S �Itt BOAJ E/ OFF..:.......................................................::----•--....... ..... ...........:............;........... ... No......................... FEE.....-------•....------ f"'je �i��ro� grk��n #rnrtioBt �rrnttt Permissi.Qi is hereby granted.__.. I ---------------------------------------- to Con krb* (� )��Repair (j"y�qV J& al vr�&04i1po,,al 9Fs'APf /r atNo.------... ------------------------------ ••-- 91�`A,��,yx � ,,��'�,c ,�r �� �eet as shown on the application'for'Disposal Works Construction 1'ie`rrnif'No.. .................. Dated__;;__.. y . ---------------------------------------:................................................................ _ DATE........... :_ .. ------� f `7?a,� ~--"= "y',.a ,o?' and of Health Bo h FORM IZSS H'OBBS & WARR,E. INC PUBLISHERS . +D �IG1.I bA'rA _1 4 (o 4 t3t-btzr�a�t/C 8 Z , 3 Z o I / r>at L-e V=Low = to v- 4 = 410 c. �EPrtc `t'A iK = 44ov 150% u5�- lSOca GAL-. t �tA t1 , ti �sPDSAL t�IT�- i,�sE.�1 ooc� G,�.. �xe���g��t-�� �?� .�•` ? �tJ�u1ALL �A2E.A �, So 5F. ,s ��ac a a ,� $c�T T27Nt I�fZC3A r "50�5� \ _ 3 1.' :! r TOTAL 'DCSIGI.1 = . i2Se'y.P.CD.XZc'$$pG.Q.U. PO T ,TAt_ v,dtL�4 FLo",u 4406.p.m. r t �f1CDl.&,Tl0LJ tZhTE { I" 1-milJ, orz U—sS. rl� ta 4i Al . WILLIAM o t4YE y No. 10334 Q �p7ST£ D SU RV4 i -re!ST 70 99a TOP Fuo =+oc.o �o�E o- 97.6C L AL&.4 >. 4 MEb,U►+t (sap IW-g6.70 JW �tr,�nti "BOX 9t,3-,r SEPT IC I c q' � ItJV. l�la N K 31 :,VG L (DOD CIS.8 lllw %W.• ILI ,. GAL. 46 0 9G 20 LEAcNPit a c`enN w y..ia s•, I • WA"SHffD ' STo►.aE A . PRo�'t L.f✓ toC.A.T►a1,4. G 0-r u i 11 ,4, oo,:r,pA.- t--- } o /-77 NGWhT� i� . 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