HomeMy WebLinkAbout0033 GERARD CIRCLE - Health 33 GERARD CIRCLE, COTUIT
A= 022 025
,
DATE:.'6/.1,9/98
PROPERTY ADDRESS:33 Gerard Circle Cotuit,Mass.
02635
On the above date, I inspected the septic system at the above address.
This system consists of the following:
1 . 1 -1000 gallon septic tank.
2 . 1 -Distribution box.
3 . 1 -1000 gallon precast leaching pit.
Based bn my lnR.nection, I certify the following conditions:
1 . This is a title five septic system"( - 78 Code ' )
2 . The septic system is in proper working order
-at the present time.
. 3.. Pumped septic tank as part of inspection.
4 . The waste water is, 40" below the invert pipe of
the leaching pit.
5IGNATUR!-:
Flame J_P M_acomber Jr_ _
P Macoc�ber & Son' Inc0�
Company.------------------- f
RECEIVED
Address:_-Be-x-bb-----=�---,--
N
"JUN 2 6 1998
Cente�rvill.eLMass__02.632 ' 70WNOF`6ARNSTABLE
HEATLH DEPT
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
JOSEPH P. MACOMBIi-R'& SON, INC.
Tankt-CestpoolrLeaohf leld:
. Pumped 4 Installed
Town Sewer Connection:
P.O. Box 66' Centerville, MA 02632-0066
775-3338 775-6412
COMMONWEALTH OF MASSACHUSETTS
1i jv- 0 EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION �
ONE WINTER STREET, BOSTON, MA 02108 6117.292.5500
R'IL IA,1 F.v<'
i
L WELD TRLDY CO
Govcmor Sccrcr
ARGEO PAUL CELLUCCI DAVID B.STRI;
Lt.Govcmor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissio
PART A
CERTIFICATION
Property Address: 33 Gerard Circle Cotuit,Mass. Address of Owner:3 Gerard Terrace
Date of Inspection:6/19/98 (If different) Lexington,Mass.
Name of Inspector:Jc)gp12 h R_Macomber Jr" 02173
I am a DEP approved system inspector pursuant to Section 15.340 of Title S (310 CMR 15.000)
Company Name: J"P.Macomber & Son Inc.
Mailing Address: BOX 66 Centerville,Mass. 02632
Telephone Number: 508-775-3�338
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, acc�ratc
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
asses
_ Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
_ Fa'ls
Inspector's Signature: Date: ✓ �
The System Inspector shall 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 repon to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owrw
and copies sent to the buyer, if applicable, and the approving authority.
INSPECTION SUMMARY: Check A, B, C, or D:
A) SYSTEM PASSES:
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:
B) SYSTEM CONDITIONALLY PASSES:
A,A 6 One or more system components as described in the 'Conditional Pass" section need to be replaced or repaired. The system, upo
. 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; c
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exhitration, or tanl
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,
(rtvis•d 04/25/97) Pago 1 of 10
DEP on the World Wide Web: http://www.magnet.state.ma.us/oep
Printed on Recycied Paper
U
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 33 Gerard Circle Cotuit,Mass. ,
Owner: Tom Alspaugh
Date of Inspection:6/19/98
e) SYSTEM CONDITIONALLY PASSES (continued)
4ZQ 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:
W 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:
& Cesspool or privy is within 50 feet of a surface water
1,e 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:
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.
42D The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
.0 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 t44 _ (approximation not valid).
3) OTHER
(zovisod 04/25/37) P&y• 2 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:33 Gerard Circle Cotuit,Mass.
Owner: Tom Alspaugh
Date of Inspection:6/19/98
D) SYSTEM FAILS:
You must indicate ei;f-,er "Yes" or "No" as to each of the following:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The bans
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to cornea
the failure.
Yes NO
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
Static liquid level in Ith,;e�,,dis ribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
157—
-Je liquid depth in*eftpvQt is less than 6" below invert or available volume is less than 1/2 day flow.
Required pumping more thj&4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped U.
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feel 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
the system is within 200 feet of a tributary to a surface drinking water supply
4 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.
(revised 04/35/57) Page 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
a
Property Address: 33 Gerard Circle Cotuit,Mass.
Owner:
Tom Alspaugh
Date of Inspection: 6/1 9/9 8
Check if the following have been done: You must indicate either "Yes" or"No"as to each of the following:
Yes N
Pumping information was provided by the owner, occupant, or Board of Health.
None of the system components have been pumped for at least two weeks and the system has been receiving normal
flow rates during that period. Large volumes of water have not been introduced into the system recently or
as part of this inspection.
As built plans have been obtained and examined. Note if they are not available with 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.
_ All system components, cluding 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.
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) Pegs 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:33 Gerard Circle Cotuit,Mass. `
Owner: Tom Alspaugh r
Date of Inspection: 6/1 9/98
FLOW CONDITIONS
RESIDENTIAL:
Design flow.3'" _g.p.d./bedroom for S.A.S.
Number of bedrooms:
Number of current residents:, ,
Carbage grinder ryes or no).
Laundry connected to system les or no).k
Seasonal use (yes or no).Ak Q/
water meter readings, if available (last two (2) year usage 1gpd1:
`3Sump Pump (yes or no): =Z Z e022 C,AV-
'.Jsl dale of occupancy. y"IF
COMMERCIAUINDUSTRIAL•
Tyne of establishment:_
Design flow: Nif allons/day
Crease trap present: (yes or no)6&14
Industrial V%'asle Molding Tank present: (yes or no)A2i+
Non•sanrtar� Nasle discharged to the Title 5 system: (yes or no)A
Water meter readings, if available.f�/Q
( QUA
Las: dale or occupancy:
OTHER: :Desurbei -�1&
Last date or occupancy, /(J
GENERAL INFORMATION
PUMPING ECOROS a d sour i �rnalion:System umped as pan of inspees or not
If yes, volume pumped: / _gal
Reason for pumping r ) �( -
IV
Tl"PYSTEM
Septic lank/disiribution box/soil absorption system
Single cesspool
-00 Overflow cesspool
_d'ho Privy
Shared system (yes or no) (if yes, anach previous inspection records, if any)
I/A Technology etc. Copy of up to date contract(
Other
APPROXIMATE AGE of all components, date installed (i(known) and source of information: /Q
w
Sewage odors detected when arriving at the site: (yes or not
tt.vl..d 0�/JS/97) Page 5 of 10
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:33 Gerard Circle Cotuit,Mass. ,
Owner: Tom Alspaugh
Date of Inspection: 6/1 9/9 8
BUILDING SEWER:
(locate on site plan)
t�
Depth below grade:
Material of construction: _cast iron /40 PVC_other (explain)
Distance from private water supply well or suction line 4 Id r
Diameter
Comments: (condition of joints, venting, evidence of leakage, etc.)
vented through t o house vent in the rnnf
SEPTIC TANK:-zo Q4Av.S
(locate on site plan)
'el
Depth below grade:
Material of construction: concrete _metal _Fiberglass _Polyethylene _other(explain)
If tank is metal, list age A1d Is age confirmed by Certificate of Compliance 44 (Yes/No)
Dimensions: �6U 'V; 6r7�/!/
Sludge depth:
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:_(_
Distance from bottom of scum to boa of outlet t or baffle:
How dimensions were determined:
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.) Pump tank every 2-3 years, Tnlat P, nut 1 Pt
tees arp_ in p 1 anp_ThP septic tank i c si-r111`t1 rally Sol-ipcl ;j-iiCI
h-wc Qn si;xis of leakage.
GREASE TRAP:A&fQ
(locate-on site plan)
Depth below grade:orv(/�Material of constructiconcretadl0 meta 4Fiberglass4lid Polyethylene V,4 other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:4/0
Date of last pumping: AO
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.)
e grease trap is not present.
(r.via*d 04/25/97) ?&go 6 of 10
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:33 Gerard Circle Cotuit,Mass.
Owner: Tom Alspaugh
Date of Inspection: 6/1 9/9 8
TIGHT OR HOLDING TANK:A&�Tank must be pumped prior to, or at time, of inspection)
(locate on site plan)
Depth below grade: VI
Material of construction,flLQ concreteAjAmetal4, Fiberglass /4Polyethylene,V ther(explain)
Dimensions:
Capacity: AM gallons
Design flow: gallons/day
Alarm level: Alarm in working orderAI/6 Yes;4A No
Date of previous pumping: _
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
Ti ht or holding tanks arenot present-
DISTRIBUTION BOX:A/-
(locate on site plan)
Depth of liquid level above outlet invert:_
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or,out of box, etc.)
Distribution box has one lateral. No evidence of solids carry over.
No evidence of leakage in or out of t-he hox_
PUMP CHAMBER:/ ' (—
(locate on site plan)
Pumps in working order: (Yes or No)
Alarms in working order (Yes or No)-d2
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
The pump chamber is not present.
(revised 04/2S/97) P&g• 7 of 10
1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 33 Gerard Circle Cotuit,Mass.
Owner: Tom Alspaugh `
Date of Inspection: 6/1 9/98
� �A��p
SOIL ABSORPTION SYSTEM (SAS):AM_
(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: 1 ,
leaching pits, number:_
leaching chambers, number:
leaching galleries, number:=
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
Alternative system:
Name of Technology: I rz
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
Loamy sand to fine sand. No signs of hydraulic failure or ponding
All vegetation is normal -Waste water is 40" hPlow invert pine _
CESSPOOLS:G4 a_
(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: IVA
Materials of construction:
Indication of groundwater: _ AAL
inflow (cesspool must be pumped as part of inspection)
Cesspools are not present.
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
Cesspools are not present.
PRI VY:'6VC
(locate on site plan)
Materials of construction: Dimensions: Ah
Depth of solids:Azd—
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
Privies are not present.
(revised 04/25/97) Dog• 8 of 10
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Propeny Address: 33 Gerard Circle Cotuit,Mass .
Ohner: Tom Alspaugh
Date of Inspection: 6/19/98
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)
li
(s•v►••C 0�/15/97) Y•y• 9 of 10
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SUBSURFACE SEWAGE DISP•. t. SYSTEM INSPECTION FORM
I C
SYSTEM INFOI. '{ON (continued)
Property Address: 33 Gerard Circle Cotuit,Mass.
r
Owner: Tom Alspaugh
Date of Inspection: 6/1 9/98
Depth to Groundwater Feet
Please indicate all the methods used to determine High GroundwaterEIv.a:ion:
Obtained from Design Plans on record
Observation of Site (Abutting property, observation hole, basenxnt's.)mp etc.)
—ZDetermine it from local conditions
Check with local Board of health
Check FEMA maps
Check pumping records
Check local excavators. installers
Use USGS Data
Describe in your own words how you established the High Ground./a*crElevation. (Must be completed)
Used water contours map.
Gahrety & Miller Model
12/16/94
(r•vl••G 0//2S/97) t'•4' IOut 10
•n.cn�..-n,•.f.�,-•..,..-n„r.'...•,�..,.,.,,.Rr,.•..,a+r.,,.•r..,m•ns•rny r.a-.rn�,mn .,r....rn„�.r,.-r,--r-.�x-:�--:,.t,.r-•�
TOWN OF Barnstable, BOARD OF HEALTH +
I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION I
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-TYPE OR PRINT CI.EARL1•-
PROPERTY INSPECTED
STREET ADDRESS 33 Gerard Circle Cotuit,Mass .
ASSESSORS MAP , BLOCK AND PARCEL #
OWNER' s NAME Tom Alspaugh
PART D - CERTIFICATION
NAME OF INSPECTOR Joseph P.Macomber Jr.
COMPANY NAME J•P.Macomber & Son Inc:"'
COMPANY ADDRESS Box 66 Centerville,Mass. 02632
Street Tovn or City State LIP
COMPANY TELEPHONE (508 ) 775 - 3338 FAX ( 508 ) 790 - 1578
R O
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at
this address and that the information reported is true , accurate , and
complete as of the time of .inspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems .
Check one :
i/ a System PASSED
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
health or the environment as defined in 310 CMR 16 . 303 . Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form.
System FAILED*
The inspection which I have con acted 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 Signatu Date _6/19/98
One copy of this certification must be provided to the OWNER, the BUYER
( where applicable ) and the BOARD OF HEALTH.
* If the inspection FAILED, the owner or operator shall upgrade ' the eyetem
within one year of the date of the inspection, unless allowed or required
otherwise as provided in 3.10 CMR 15 . 305 .
partd .doc
Ld
U) 7'
ti
- S
THE COMMONWEALTH OF MASSACH USETTS
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
CERTIFIED TITLE S SYSTEM INSPECTOR
as provided in 310 CMR 15 .340 and Section 13 of Chapter 21A of the
General Laws. Issued by The Department of Environmental Protection.
Acuity{ Dirmor of the L) ion of Water Pollution Control
TOWNQF BARNSTABLE
LOCATION,05 ��r� SEWAGE #
VII,LAGE ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
j
LEACHING FACILITY: (type)®// /T (size) �
NO.OF BEDROOMS ,f
BUILDER OR OWNER �
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the: ,
Maximum Adjusted Groundwater Table and Bottom.of Leaching Facility �'' / Feet
Priyate Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and'Leac 'nFa dsesti an �
within 300 feet f lea ng Xility) Feet
Furnished A G��
;-
R
�.
,�� ��
o
�� �.
33 (yea-a� G c . . Ce��'ca;�'
II TOWN Or, BARNSTABLE
LOCATION b— a � (-_Crr s SEWAGE #_<�
VILLAGE_C } t _ _ ASSESSOR'S MAY & LOT
INSTALLER'S NAME & PHONE NO. _�rzs_C.j�_ V 3( rl
Sk P11C TANK CAPACITY_jZnO
LEACHING FACILITY:(type)?a ,S��
NO. OF BEDROOMS PRIVATE WELL ORPUBLIC WATER _
G
4
BUILDER OR-l?WN�t;` j►� i C�_�C'_ �:� . _.
DA'I'L^ PERMIT�,ISSI ISSUED:_
DATE COMPLIANCE ISSUED; S 3 =2L-
VARIANCE GRANTED: Yes P?o ✓� _
a'
�,P 39, �(
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No.. .�:.. �.....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
......... ...........W ta.......OF.........���t�--t� -C .............
Appliration for Disposal Varks Tonotrurtion rrrmi#
Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal
System at:
..
................ ............ .....••------------••------•--• _. _ --- �T..M.......
...� /� . ` N
..... ...._.....-•.................
7
ddress
a ...........................................- ••......................................... ....... ...................................................
Installer Address
Type of Building Z Size Lot. z .�-�.--.Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Other fixtures ...................................
WW Design Flow.............. .0....................gallons per pwsea_ger day. To daily�flow................ .........................galloLn
WSeptic Tank—Liquid capacity.�IXQ..gallons Length..?..(,... Width.: ..,10.... Diameter................ De th.5..�{-..
x Disposal Trench—No. .................... Width.................... Total Length Total leaching area....................sq.2. ft.
3 Seepage Pit No......I............. Diameter....1 ....... Depth below inlet_3.,.�...._... Total leaching area.Z.+-5_....sq. ft.
Z Other Distribution box 61 Dosing tank ( ) _
$4 Percolation Test Results Performed by... .:.��12 �� � ............... Date.....1_�..f_�?�4-)- �-i-E
� .._.....
Test Pit No. l.. minutes per inch Depth of Test Pit.....t+R i�•- Depth to ground water..
Lz, Test Pit No. 2................minutes per inch Depth of Test Pit.....1 -.._.. Depth to ground water........................
O Description of Soil...___AMV.
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 LITA LZ 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.... . •. . •.--•........ ... 3v� ....
Efate'
Application Approved By...... .. .................................... ..........�. �.1.. .. .9...
Date
Application Disapproved for the following reasons:.......................................................................................... _..
.................••--•-...-•--•-•.............-•••----•-...............-----•----...•••----•--•-•.........••----•••-•...---•------•--•••-•-•--••---••...--••----••-•-••---••---................:.......:
DatePermitNo..... .. --... ............................. Issued_.......................................................
Date
No...
Fs. 7.3
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�O............. F................................................._.....................................
Appliraition for Uhipasal Workii Tomitrurtion Permit
Application.is hereby made.for a Permit to Construct or Repair an Individual Sewage Disposal
System at:
............... . /. . ......
. _ T....... ......... .................... ................................................................................................_..
lot
No 2!L D;/7
7 ................. ...... 3
ST
......... ... ...D.R.....S..( . . ...........................................
... .Al........................................................
TInstaller Address
Type of Building
75
Size Lot.. .. ......Z...(r................Sq. feet
Dwelling—No. of Bedrooms...........................................Expansion Attic Garbage Grinder
Other—Type of Building ............................ No. of persons............................ Showers Cafeteria
Other fixtures ......................... .........=.='
< . C_11�. ..............................................................
Design Flow.............. _______gallons per
------------.,-""--gallo per-person per day. Total daily flow_.______.___?' ._.__....__....._gallons.
-f I ...................gallons.
04 Septic Tank—Liquid*'*'c*a"p'acity.11�i(%L�..gallons Length.b..(r'_ Width;4_1,1.0.'�.. Diameter................ Depth.1E)..4='.!...
Disposal Trench—No_.................... Width.................... Total Length.................... Total leaching area_-__.__________..--sq. f t.
Seepage Pit No.__.__I............. Diameter....1:2=........ Depth below inleta..,.�........ Total leaching area.?A:S sq. ft.
Z Other Distribution box (V Dosing tank
7-
Percolation Test Results Performed E' .................... Date___.. ..........-
Test Pit'No. L_Z.�2..minutes per inch Depth of Test Pit.__:I R.Y....... Depth to ground water..k,
I Tq C
44 .-Testt Pit No. 2................minutesper inch Depth of Test Pit__._.!. :- I...... Depth to ground water._...__:._____...__.___.
..............................................................
0 D -----------------------------------------------------------7...................
escription of Soil.p ......................................
.... .....................................................................................................
.. .....
.. ........**------------------*-----------------"-----------------*-------- ----------------- -----------*------------------------
- ------- ----- ....
-
..............................................................................................................................4.........................................................................
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 prov'isiotis,of A I T 1,Z 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.... ........................
............ . ............ ---> 11:3o
Oate?�'`
Application Approved By.................. -...... ...........
Q Date
Application Disapproved for the following reasons:..............................................................................................................
.......................................................................................................................................................................................................
Permit No.....Al.:...7A=........................... Date
Issued........................................................
Date
--------------------------------------- ----------------------- -------- ---------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.........:nj(ll.................OF........... .........................................................................
(gertifiratr of Tompliatta
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (X) or Repaired
by_...'7'U'
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
....!��j.....r Installr
at 7 0/e I
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No._____._. ............ dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE-CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE. . . .......I.................................................. Inspector. ....................................................................
-------------- ----------- --------- -------m�-------------------------- -------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
AU1W......OF........
No...... .............. ........................................................................
.... ...... FEE...2. ...........
Dispagal Works Ton trurtion Permit
Permission is hereby granted....... ...........bg Is 6 az/—
. ......................................................................................................................
to Construct or Repair an Individual Sewage Disposal System
at No...r2 ..... (t .......
............................................ ..................................................................................................
Street
as shown on the application for Disposal Works Construction Permit Dated_.___.._.._....___._..._......___.........
.....................................� A-). .. ------------------------ --------"'Board of
of Health
DATE....................../........
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