HomeMy WebLinkAbout0341 MAIN STREET (COTUIT) - Health 341 MAIN ST., COTUIT
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
g DEPARTMENT OF ENVIRONMENTAL PROTECTION
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TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM <•
PART A
CERTIFICATION
Property Address: 341 MAIN ST COTUIT,MA 02635 0 3 0 �jUl ' C 6-
Owner's Name: JOHN MALOY
Owner's Address: BOX 153 COTUIT MA.02635
Date of Inspection: 11/16/00
Name of Inspector: (please print) JOHN GRACI
Company Name: SEPTIC INSPECTIONS
Mailing Address: `:{ P.O:BOX 2119 TEATICKET,MA.02536 t /V Cry
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Telephone Number: 508-564-6813 FAX 508-564-7270 �s o fto
CERTIFICATION STATEMENT 4; s,
I certify that I have personally inspected the sewage disposal system at this address and that the inforl ation reported below s;
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 app ov4system
inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
X Passes
_ Conditionally Passes
_ Needs Furthe Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: 11/16/00
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within
30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the
inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be
sent to the system owner and copies sent to the buyer,if applicable,and the approving authority.
Notes and Comments
THE SYSTEM PASSES TITLE V INPECTION.RECOMMEND PUMPING THE SYSTEM EVERY TWO YEARS TO
PROLONG THE SYSTEM'S USEFULL LIFE.
****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 thpe system will perform in the future under the same or different conditions of use.
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Title S 1ncnFrtinn rnrm(,/i s/,)non 1
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 341 MAIN ST COTUIT,MA 02635
Owner: JOHN MALOY
Date of Inspection: 11/16/00
Inspection Summary: Check A,B,C,D,or E/ALWAYS complete all of Section D
A. System Passes:
X 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.Any failure criteria not evaluated are indicated below.
Comments:
THE SYSTEM PASSES TITLE V INPECTION.RECOMMEND PUMPING THE SYSTEM EVERY TWO YEARS
TO PROLONG THE SYSTEM'S USEFULL LIFE.
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,ND)in the for the following statements. If"not determined"please explain.
n/a 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 indicating
that the tank is less than 20 years old is available.
'A
ND explain: n/a
n/a 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: n/a
n/a The system required pumping more than 4 times a year due to broken or obstructed i e s .The system will ass
Y 9 P p g Ott Y pp ( ) Y P
inspection if(with approval of the B"oard of Health):
_broken-pipe(s)are replaced
_obstruction is removed
ND explain:n/a
Page 3 of 11
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OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 341 MAIN ST COTUIT,MA 02635
Owner: JOHN MALOY
Date of Inspection: 11/16/00
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(I)(b)that the systemtis
not functioning in a manner which will protect public health,safety and the environment:
_ Cesspool or privy is within 56 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 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 I of a public water supply.
_ The system has a septicliank and SAS and the SAS is within 50 feet of a private water supply well.
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_ 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 Ito determine distance n/a
"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.
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3. Other:
n/a
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Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 341 MAIN ST COTUIT,MA 02635
Owner: JOHN MALOY
Date of Inspection: 11/16/00
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all-inspections:
Yes No
_ X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged
SAS or cesspool
_ X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool
X Liquid depth in cesspool is less than 6"below invert or available volume is less than ''/z day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times
pumped nLa.
_ X Any portion of the SAS,cesspool or privy is below high ground water elevation.
X Any portion of cesspool or,privy is within 100 feet of a surface water supply or tributary to a surface water supply.
_ X Any portion of a cesspool�or,privy is within a Zone 1 of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
X 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 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"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
4 4
yes no
X the system is within 400 feet of a surface drinking water supply
X the system is within 2,00 feet"of a tributary to a surface drinking water supply
X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—I WPA)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 systeiii has failed,The owner or operator of any large system considered a significant threat
under Section E or failed under Section I)shall upgrade the system in accordance with 310 CMR 15.304.The system owner
should contact the appropriate regional office of the Department.
A
Page 5 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 341 MAIN ST COTUIT,MA 02635
Owner: JOHN MALOY
Date of Inspection: 11/16/00
Check if the following have been done.You must indicate "yes"or"no"as to each of the following:
Yes No
X _ Pumping information was provided by the owner,occupant,or Board of Health
_ X Were any of the system components pumped out in the previous two weeks?
X _ Has the system received normal flows in the previous two week period?
X Have large volumes of water been introduced to the system recently or as part of this inspection?
X Were as built plans of the system'obtained and examined?(If they were not available note as N/A)
X _ Was the facility or dwelling inspected for signs of sewage back up?
X _ Was the site inspected for signs of break out?
X _ Were all system components,excluding the SAS, located on site?
X _ 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?
X _ 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:
e
Yes no
X _ Existing information. For example,a plan at the Board of Health.
X _ 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(3)(b)]
5
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 341 MAIN ST COTUIT,MA 02635
Owner: JOHN MALOY
Date of Inspection: 11/16/00
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):330
Number of current residents: 1
Does residence have a garbage grinder(yes or no):YES
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or no): NO
Seasonal use: (yes or no):NO
Water meter readings,if available(last 2 years usage(gpd)): n/a
Sump pump(yes or no): NO
Last date of occupancy: n/a
COMMERCIAL/INDUSTRIAL
Type of establishment: n/a . 1
Design flow(based on 310 CMR 1S.203): n/agpd
Basis of design flow(seats/persons/sgft,etc.): n/a
Grease trap present(yes or no): NO
Industrial waste holding tank present(yes or no): NO
Non-sanitary waste discharged to the Title 5 system(yes or no): NO
Water meter readings, if available: n/a
Last date of occupancy/use: n/a
OTHER(describe): n/a
GENERAL INFORMATION
Pumping Records
Source of information: n/a
Was system pumped as part of the inspection(yes or no):NO
If yes,volume pumped: n/agallons--How was quantity pumped determined?n/a
Reason for pumping: n/a
TYPE OF SYSTEM
X 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): n/a
Approximate age of all components,date installed(if known)and source of information:
ORIGINAL 1945/UPGRADE IN 90'
Were sewage odors detected when arriving at the site(yes or no): NO
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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: 341 MAIN ST COTUIT,MA 02635
Owner: JOHN MALOY
Date of Inspection: 11/16/00
BUILDING SEWER(locate on site plan)
Depth below grade: 16"
Materials of construction:_cast iron X40 PVC_other(explain): n/a
Distance from private water supply well or suction line: n/a
Comments(on condition of joints,venting,evidence of leakage,etc.):
TOWN WATER
SEPTIC TANK: X(locate on site plan)
Depth below grade:3"
Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a
If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate)
Dimensions:6'X 6' BLOCK CESSPOOL"
Sludge depth: 1"
Distance from top of sludge to bottom of outlet tee or baffle:33"
Scum thickness: 0" '
Distance from top of scum to top of outlet tee or baffle: 8"
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
How were dimensions determined: MEASURED
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.):
MAIN CESSPOOL AND ALL COMPONENTS ARE STURCTURALLY SOUND.RECOMMEND PUMPING
EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE.
GREASE TRAP:_(locate on site,k plan)
V%ci
Depth below grade: n/a
ii��i
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
Date of last pumping: n/a
1;ei
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc,,,
n/a
(3
. 7
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Page 8 of l I %
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 341 MAIN ST'COTUIT,MA 02635
Owner: JOHN MALOY
Date of Inspection: 11/16/00
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Capacity: n/a gallons
Design Flow: n/a gallons/day
Alarm present(yes or no): N/A
Alarm level: N/A Alarm in working order(yes or no): NO
Date of last pumping: n/a
Comments(condition of alarm and float switches,etc.):
n/a
DISTRIBUTION BOX: _(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: n/a
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.):
n/a
PUMP CHAMBER:_(locate on site plan)
Pumps in working order(yes or no): NO
Alarms in working order(yes or no):NO
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
n/a
t. .
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Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 341 MAIN ST COTUIT,MA 02635
Owner: JOHN MALOY
Date of Inspection: 11/16/00
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
n/a
Type
1000 GAL 6' X 6' leaching pits, number: 1
n/a leaching chambers, number: nla
n/a leaching galleries, number: n/a
n/a leaching trenches, number, length: n/a
n/a leaching fields, number: n/a
n/a overflow cesspool, number: n/a
n/a innovative/alternative system
Type/name of technology: n/a
Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.):
THE LEACH PIT IS STRUCTURALLY SOUND AND APPEARS TO BE FUNCTIONING PROPERLY.THE PIT
WAS EMPTY AT THE TIME OF THE INSPECTION.THE PIT HAS NOT HAD 1' OF WATER IN IT.
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: n/a
Depth of solids layer: n/a _
Depth of scum layer: n/a
Dimensions of cesspool: n/a
Materials of construction: n/a
Indication of groundwater inflow(yes or no): NO
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a
PRIVY: (locate on site plan)
Materials of construction: n/a
Dimensions: n/a
Depth of solids: n/a
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a
n
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 341 MAIN ST,COTUIT,MA 02635
Owner: JOHN MALOY
Date of Inspection: 11/16/00 Of
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.
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fPage 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 341 MAIN ST COTUIT,MA 02635
Owner: JOHN MALOY
Date of Inspection: 11/16/00
SITE EXAM
_Slope
_Surface water
_Check cellar
Shallow wells
Estimated depth to ground water 12 feet
Please indicate(check)all methods used to determine the high ground water elevation:
NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a
NO Observed site(abutting property/observation hole within 150 feet of SAS)
NO Checked with local Board of Health-explain: n/a
NO Checked with local excavators, installers-(attach documentation)
YES Accessed USGS database-explain: n/a
You must describe how you established the high ground water elevation:
USGS MAPS AND CHARTS- 12 FEET
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� TOWN F BARNSTABLE
LOCATIONS 1 ` l In 1 SEWAGE #
VILLAGE CjU\ ASSESSOR'S IT��bO
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
J, EACHING FACILITY: (type) (size)
PTO. OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: 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.
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f::�,-r-IV C-0 e)( ft�"tc t)k�N+f- p" \
LOCATION SEWAGE PERMIT NO.
VILLAGE
C� va-T MA ,
INSTALLER'S NAME L ADDRESS
I! U I L E R OR OWNER
C�EcMv77 -Ff zo 6°l1YCk �2 �`
DATE P E R A I T ISSUED
DATE COMPLIANCE ISSUED
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ASSESSORS MAP NO: 2- _
PARCEL
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF-HEALTH
...................I........................OF..........................................................................................
i
Appliration for Uhipaii al Works Tonotrurtion ramit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
/�
System at:eo
`�� 1 GU Ca `f.�d '1��c�1T.9 —�
D .............. -- .......2� f
............................................... . .......8.!�Y
---..' ....._ ... ...:.......... .....................r..
�s or Lot oC,
.......
ocatio d �`
........
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Owne �` �� 'ess
a , ` .................. ...........••--•--••-••------•------- -- ... ® ....... i:........q 7
Instalier Address
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
a' Other fixtures ......................................................
Design Flow........................:...................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................
xDisposal 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 ( )
Percolation Test Results Performed bY..........................................................................
Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
(i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
............................................-................................................................................................................
0 Description of Soil.........................................................--••-•----........---------------------------------........-----------------------------------•-•--•--•----•--
V ...........•••-•---••-••---------------•---...-••--•••-•-------•--------------------•...........---•-------•-------•-•-•---•••-••.....•••-•--•-•------•••••--•.....-•-----•------••----•-••......-•..----
W .
-----
U Nature of Repairs or Alterations—Answer when applicable_... .............--
.E�_� .... ..........%lc?.!� �. ?c 4
---•---•--------------------------••----•-•------------•--•----------------•----------•-----•--------------------------------------...-----....-•------------------------•••-•................_-••---..
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System.in accordance with
the provisions of iITL% 5 of the State Sanitary C .The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee sue hegorf health.
Signed..............
--•---•-•----------------------•....------•----•-•----.....•••--
_..
Date
ApplicationApproved By.................................................................................................. ........................................
Date
Application Disapproved for the following reasons---------------••-----••--•--•-•---------------------•---------•-------------•--•----------------------........_
--.........-•-•---••--•....------•-----...--•----------------------------•---••••------•.....--•-----•--•......--•--•.................••---•-----•......••-••..............•............................
Date
PermitNo......................................................... Issued........................................................
Date
THE FOLLOWING
IS/ARE THE BEST
IMAGES FROM POOR
QUALITY ORIGINALS)
I M A C(�� 'L
DATA
J�
No......... ..........? j FEB.....�,f
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.............:... ....................O F.........................................................................................
Appliration for Dispnsttl Works Tonstrnrtion Prrntit
Application is hereby made for a Permit to Construct (ti)or Repair ( ) an Individual Sewage Disposal
System at: I I--- , "
.... r.. .... ... Location•---aatess•••••-•-•-••..................•... ........... _. ..---..........-•••--..Lot No..... / ....... •r
or
.... 0�Gy'��„.. {J,t.'_S - v ...... •--.. ....���� „ G(1r�Gi 1.........................fo e�5 C'cwi�
- .....
Owngr _ L / Address
t^ CF C. [..v .. S I ..jam:
w �_........`..
Installer Address
d Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
a' Other fixtures .-•-•-•---...-----•......-----••-•••----------
w Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a •-----•-•--••--------••••••.................•-•-.........--•--------•...-•-.........._.......................................................................
DDescription of Soil........................................................................................•-----•--------------•----••-----..............................................
x
U ....•-•------••------------••••-------------••-----••-•-------------------------•••••----••-------•.._....----•---------•-••----••---•--------•-•-•...---------•-•--••----••-••--•---------•--•--•---•--
w
VNature of Repairs or Alterations—Answer when applicable...�?.` �=..............I.GGl G �i 1_ /C
--•----•••--•-•••-••----•-----•---••-•-•-••-•-•••-•-------------------•-------•••--•--....----------------•----•--•------•--•-•--•••--------•-••-
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE, 5 of the State Sanitary Cold—.The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been-issue`issueV7�W�
the b f health
.
Signed 1-7
...................................................
..........................
Date
ApplicationApproved By.................................................................................................. ........................................
Date
Application Disapproved for the following reasons:..............................................................................................................
..............................•-----------........---•---------------•-----•--------------••--------•---....---•-------•--........---------•-•----------------------------••••.....------•••-----........
Date
PermitNo......................................................... Issued.................. ................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
r
BOARD OF HEALTH
..........................................OF...........:.. .. ...........................................................
Tnrtifiratr of Tompliatta
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
...... - ...... •-
/ - Installer
at...................................................t1....---•--.
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...... �..�_.__ `1._....... dated_...___- ./.._.... ................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTIPM SATISFACTORY.
DATE.. - . ................................ Inspector..........O On.................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
o �1 .OF.. ti--
No. .._..... �. FEE.t.:. a
Disposal Works Trrnntrnrtiun rantit
Permission is hereby granted........... `� - :� d !_`=, ....._.
--•- ---...•••.
to Construct ( ) pr Repairr,(_ )-in Individual Sewage Disposal System
at No..................... ._•--/ . .---••-r 1" ' . . ..�� ....... rh
Street ✓
as shown on the application for Disposal Works Construction Permit No::....-... .?� Dated....... ......._.,I -`...........
DATE........................
�),�),
Board of�)ilealth,- V
•-•-•----••-•---•---• .................................
FORM 1255 A. M. SULKIN, INC., BOSTON