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HomeMy WebLinkAbout0431 MARINER CIRCLE - Health 4 11 MARINER CIRCLE, COTUIT A= 024 072 TOWN OF BARNSTABLE LOC hTION ` 3 )NvO Ott,( oi rc ,t SEWAGE #� P i^ VILLAGE t/�°- ASSESSOR'S MAP & LOTtea` S NAME&PHONE NO. �t� SEPTIC TANK CAPACITY �-10 LEACHING FACILITY: (type 1 13- (size) NO. OF BEDROOMS BUILDER OR® ���`'^ �W-e PERMITDATE: C6@M9VftNCE DATE: J FI► o� 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 �� r v[ n � i .. '� ��6 ��; TOTIARNSTABLE LOCATION �I ���� SEWAGE # VILLAGE d ASSESSOR'S MAP &c LOT INSTALLER'S NAME&t PHONE NO. �-� f 4HY, SEPTIC TANK CAPACITY /00 LEACHING FACILrTY: (type 0/ T Z()00 (size) NO.OF BEDROOMS BUILDER OR OWNER PERMUDATE: 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) —K Feet Furnished by l Ci C, M ;i IA c C AC aG COMMONWEALTH OF MASSACHUSETTS v EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS r d DEPARTMENT OF ENVIRONMENTAL PROTECTION h yyf V�v TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 431 Mariner Circle t —. Cotuit MA 02635 Owner's Name: John Donahue R Owner's Address: PO Box 1011 Cotuit MA 02635 E Date of Inspection: May 11,2006 Job#06-130 Name of Inspector: PATRICK M.O'CONNELL =3 Company Name: SEPTIC INSPECTION SERVICES CO. ` Mailing Address: 189 CAMMETT ROAD MARSTONS MILLS MA 02648 9 t Telephone Number: 508-428-1779 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the function and maintenance of on site sewage disposal systems.I am a DEP proper g P Y approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: °°"IOFf/tl/ i __X_ Passes Conditionally Passes O • '•yG Needs Further Evaluation b the Local Approving Authority _�; ATM Iv Ms Fails 01 LL 3 Inspector's Signature: Date: 5/11/06 %, ij ��(3T�F��Q'pQ` � The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Heal o4 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: tank is not in need of pumping at this time. Leaching pit has 2' of standing water. ""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. Page 2 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 431 Mariner Circle,Cotuit Owner: John Donahue Date of Inspection: May 11,2006 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _XX 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. I Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 431 Mariner Circle,Cotuit Owner: John Donahue Date of Inspection: May 11,2006 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1) b that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of 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 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 431 Mariner Circle,Cotuit Owner: John Donahue Date of Inspection: May 11,2006 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_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 _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.) _No_(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) yes no the system is within 400 feet of a surface drinking water supply _ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. Page 5 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 431 Mariner Circle,Cotuit Owner: John Donahue Date of Inspection: May 11,2006 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: 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)J Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 431 Mariner Circle,Cotuit Owner: John Donahue - Date of Inspection: May 11,2006 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR d 5.203 (for example: 110 gpd x#of bedrooms):330 Number of current residents:2 Does residence have a garbage grinder(yes or no):No Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use:(yes or no):No Water meter readings, if available(!ast 2 years usage(gpd)): Two years total: 112,000 gal.= 153 gpd. Sump pump(yes or no): No Last date of occupancy: Currently Occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 1 5.203): gpd Basis of design flow seats/ ersons/s ft etc.): g ( P q ) Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records: Tank pumped November 2005 Source of information: Owner Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: 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): Approximate age of all components,date installed(if known)and source of information: 1988 Were sewage odors detected when arriving at the site(yes or no): No Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 431 Mariner Circle,Cotuit Owner: John Donahue Date of Inspection: May 11,2006 BUILDING SEWER:XX (locate on site plan) Depth below grade: 1' Materials of construction:_cast iron _X_40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: XX (locate on site plan) Depth below grade: 1' Material of construction:_X_concrete_metal_fiberglass_polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions:8.5'long x 5.2'wide—1000 gal. Sludge depth: 0" Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: 0" Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: STICK WITH HINGE FLAP. Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tees are intact and clear,liquid level at bottom of outlet invert.Tank has liquid only and is not in need of aumaine at this time. GREASE TRAP: No (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 431 Mariner Circle,Cotuit Owner: John Donahue Date of Inspection: May 11,2006 TIGHT or HOLDING TANK: No (tank must be pumped at time of inspection) (locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: XX (if present must be opened) (locate on site plan) Depth of liquid level above outlet invert: 0" 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.): No solids or high stains present,liquid level at bottom of single outlet pipe PUMP CHAMBER: No (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 of I 1 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 431 Mariner Circle,Cotuit Owner: John Donahue Date of Inspection: May 11,2006 SOIL ABSORPTION SYSTEM(SAS): XX (locate on site plan,excavation not required) If SAS not located explain why: Type _X_leaching pits,number: One 6x6 pit. leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): Observed 2'of standing water with no definite high stains. CESSPOOLS: No (cesspool must be pumped as part of inspection) (locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: No (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): i Page 10 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 431 Mariner Circle,Cotuit Owner: John Donahue Date of Inspection: May 11,2006 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. Mariner Circle Water Service 56 38 27 36 1 0 f Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 431 Mariner Circle,Cotuit Owner: John Donahue Date of Inspection: May 11,2006 SITE EXAM Slope None Surface water None Check cellar Dry Shallow wells None Estimated depth to ground water: More than 25 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) _Checked with local Board of Health-explain: Checked with local excavators, installers-(attach documentation) _X Accessed USGS database-explain: USGS topo map and town GIS You must describe how you established the high ground water elevation: Town groundwater contour map shows water below el.35 and topo map shows property above el.60. Commonwealth of Massachusetts Executive Office of Envirommental Affairs Dept. of Environmental Protection One winter Street, D.L.Y. Titlee V Sui eptic Boston Ma. 02108 .Titlepti c Inspector Y.O. Box 2119 Teaticket, MA 02536 WILLIAM F.WELD (508)564-6813 Governor ARGEO PAUL CELLUCCI Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORMPART A A CERTIFICATION RECEIVED Property Address: 431 MARINER CIRCLE COTUIT 0 O Address of Owns am S EP 2 4 1998 P Y Date of Inspection: 9117198 (If different) TOWNOFBARNSTABLE Name of Inspector: JOHN GRACI DAN KEANE HEALTHDEPT. I am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000) 4 y� Company Name, Address and Telephone Number: CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: x Passes This Inspection Is based on criteria defined In Title V Conditional) Passes code 310 CMR 16.303.My findings are of how the system is y performing at the time of the Inspection.My inspection does _ Needs Fu her Evaluation By the Local Approving Authority not Imply any warranty or guarantee of the longevity of the Falls septic system and any of Its components useful life. Inspector's Signature: Date: 9r1s198 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. INSPECTION SUMMARY: Check A, 8, C,or D: A] SYSTEM PASSES: x I have not found any information which indicates that the system violates any of the failure criteria defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,passes inspection. 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 Co7hpliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection; or the septic tank,whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exhItlation, of lank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04r2l)97) One Winter Street • Boston,Massachusetts 02108 a FAX(617)556-1049 0 Telephone(617)292-5500 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 431 MARINER CIRCLE COTUIT Owner: DAN KEANE Date of Inspection:9117198 _ Sew.acie backup or.hreakoutor high static water level observed.in.the distribution b.ox is due to a broken. or obstructed pipe(s)or due to 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 leveled 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: _ 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 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 PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface of water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presense of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method usedto determine distance (approximation not valid) 3)Other D] SYSTEM FAILS: You must Indicate either"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 basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage in 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 di.w to an nverloaded or clnaged cesspool. SAS is in hydraulic failure. (revised 04127)971 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 431 MARINER CIRCLE COTUIT Owner: DAN KEANE Date of Inspection:9/17198 D] SYSTEM FAILS(continued) 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 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Numbers of times pumped 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 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. 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: 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 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 0427)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: 431 MARINER CIRCLE COTUIT Owner: DANKEANE Date of Inspection:9117199 Check if the following have been done:YOu must indicate either"Yes"or"No"as to each of the following: ,c_ — Pumping information was requested of the owner, occupant,and Board of Health. x None of the system components have been pumped for at least two weeks and the 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. x As built plans have been obtained and examined. Note if they are not available with N/A. x The facility or dwelling was inspected for signs of sewage back-up. x — The system does not receive non-sanitary or industrial waste flow. _c_ _ The site was inspected for signs of breakout. x All system components,excluding the Soil Absorption System, have been located on the site. x 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. x The size and location of the Soil Absorption System on the site has been determined based on The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal Systens. x Existing information. Ex. Plan at B.O.H. x Determined in the field(if any failure criteria related to Part C is at issue, approximation of distance is — — unacceptable)[15.302(3)(b)) (revised 04127S7) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 431 MARINER CIRCLE COTUIT Owner: DANKEANE Date of Inspection:9117198 FLOW CONDITIONS RESIDENTIAL: Design flow: 3d0 g•p•d./bedroom for S.A.S. Number of bedrooms: 3 Number of current residents: 4 Garbage grinder(yes or no): No Laundry connected to system(yes or no): Yes Seasonal use(yes or no): No Water meter readings,if available:(last two(2)year usage(gpd): rda Sump Pump(yes or no): No Last date of occupancy: n1a COMMERCIAL/INDUSTRIAL: Type of establishment: n1a Design flow:8 gallons/day 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: n1a Last date of occupancy: rda OTHER: (Describe) rde Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: SYSTEM WAS PUMPED ON 919198 BY MACCOMBER TANK ONLY System pumped as part of inspection: (yes or no)No If yes,volume pumped:0 gallons Reason for pumping: rda TYPE OF SYSTEM x Septic tank/distribution box/soil absorptions system Single cesspool Overflow cesspool Privy Shared system(yes or no) ( if yes, attach previous inspection records, if any) I/A Technology etc.Copy of up to date contract? Other: APPROXIMATE AGE of all components,date installed(if known)and source Information: SYSTEM IS 1 D YEARS OLD. Sewage odors detected when arriving at the site: (yes or no) No (revised 04127)97) I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPEC TION FORM PART C SYSTEM INFORMATION (continued) Property Address: 431 MARINER CIRCLE COTUIT Owner: DANKEANE Date of Inspection:9117199 SEPTIC TANK: x (locate on site plan) Depth below grade: 6" Material of construction:x concreate metal FRP Polyethylene_other(explain) If tank is metal, list age �1a . Is age confirmed by Certificate of Compliance No (Yes/No) Dimensions: L8'6"H5'7^w4'10" Sludge depth:0 Distance from top of sludge to bottom of outlet tee or baffle: 0 Scum thickness:0 Distance from top of scum to top of outlet tee or baffle:6" Distance form bottom of scum to bottom of outlet tee or baffle:0 How dimensions were determined: MEASURED 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.) SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING EVERYTWO YEARS. GREASE TRAP: (locate on site plan) Depth below grade: rda Material of construction: _concrete_metal_FRP_Polyethylene_other(explaln) Dimensions: rda Scum thickness:n1a Distance from top of scum to top of outlet tee or baffle:rda Distance from bottom of scum to bottom of outlet tee or baffle: Na Date of last pumping,* 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.) rda ' BUILDING SEWER: (Locate on site plan) Depth below grade: TOWN Material of construction:_cast iron x 40 PVC_other(explain) Distance from private water supply well or suction IineNa Diameter: rda_ Qmments: (conditions of joints,venting,evidence of leakage, etc.) (revlaed 04127)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 431 MARINER CIRCLE COTUIT Owner: DAN KEANE Date of Inspection:9117198 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: rda Material of construction:_concrete_metal_FRP_Polyethylene—other(explain) Dimensions: rve Capacity: r0a gallons Design flow: rda gallons/day Alarm level:_n1a Alarm In working order?_Yes_No Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) Na DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: nla Comments: (note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box etc.) Na PUMP CHAMBER: (locate on site plan) Pumps in working order:(yes or no)No Alarms in working order(yes or no)—Yes Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) nla (revised 04R7)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 431 MARINER CIRCLE COTUIT Owner: DANKEANE Date of Inspection:9117198 SOIL ABSORPTION SYSTEM (SAS):x (locate on site plan, if possible;excavation not required, but may be approximated by non-intrusive methods) If not determined to be present,explain: rda Type: leaching pits,number: 1o00 GALLON LEACH PIT leaching chambers,number:Ne leaching galleries,number: nla leaching trenches, number,length: rda leaching fields,number, dimensions:nia overflow cesspool,number:n/a Alternate system:-rda Name of Technology._nra Comments: (note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation, etc.) THE LEACH PIT IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY,THE Pn'HAD 1'OF WATER IN RAT THE TIME OF THE INSPECTION.Pn'HAS NOT HAD MORE THAN 2'OF WATER IN IT. CESSPOOLS: (locate on site plan) Number and configuration: Na Depth-top of liquid to inlet invert: rda Depth of solids layer: rda Depth of scum layer: Iva Dimensions of cesspool: nla Materials of construction: rda Indication of groundwater: nla inflow(cesspool must be pumped as part of inspection) nla Comments:(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) nfa PRIVY:_ (locate on site plan) Materials of construction: rda Dimensions: rda Depth of solids: rda Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) Ma (revlsed O412INT) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 431 MARINER CIRCLE COTUIT DAN KEANE 9117198 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) CC44 SC i ® I C 0 4D AC 5`I PA t g �L (revised04127197) Page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (contlnued) 431 MARINER CIRCLE COTUIT DAN KEANE 9117199 Depth of groundwater 12 Please indicate all the methods used to determine High Groundwater Elevation: Obtained from design plans on record. Observation of Site(Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of.Health Check FEMA Maps Check pumping records Check local excavators, installers x Use USGS Data Describe in your own words how you established the High Groundwater Elevation.(MUST be completed) USGS MAPS AND CHARTS (revised04)271971 page 10 at 10 TOW24 OR PARNSTABLE I�j CATION elU4 SEWAGE # Q - 1✓ VILLAGE ASSESSOR'S MAP & LOT A4� INSTALLER'S NAME & PHONE NO. .SEPTIC TANK CAPACITY /00n 6" AH LEACHING FACILITY:(type) /iT' (size) J000 4&o(W NO. OF BEDROOMS 3 PRIVATE WELL O PUBLIC wATE BUILDER OR OWNER cuxrQ l/ciYdti o DATE PERMIT ISSUED: DATE .COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No �� ., . ''� 0 ��- �, � � �0� fit, _ � � � �� a� a No..lJ-.........--- ---- Fms.....j551... ...... THE COMMONWEALTH OF MASSACHUSETTS / ' 0A4--DF7,R,-073 BOAR® OF HEALTH ......oF... .N.. .T.. --_.��------------------------------- Appliration for Dhipmal lVarkii Touts rnrttun ramit Application is hereby made for a Permit to Construct (+/-) or Repair ( ) an Individual Sewage Disposal System at:All....... A- W.6k....Cl R a..c. Location-Address or Lot No. ..C ? . ...................��Y! f _m.. T1f.--------------.........._.---- Owner Address Installer Address QType of Building Size Lot__.r FS---- feet V Dwelling—No. of Bedrooms...____ _.__ Expansion Attic ( ) Garbage Grinder ( ) ....p., Other—T — e yp of Building �1.�GP�/_4��p �No. of persons._.____.. _______________ Showers ( ) Cafeteria ( ) Q' Other fixtures ------------------------------------------------•------•---•-•••-•--•-----•••••-•--••----••------•••-•--•-----•-••-••••-••-•----•-•-•..........-•---- d W Design Flow.................... ...............gallons.per person ,t d��. Total da;ly f qw__-____-3,30....._..___......_-.- only WSeptic Tank—Liquid Td capacity .gallons Length__ ....... Width._4../,).. Diameter________________ Depth�;-7 ... x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area----- ........sq. ft. Seepage Pit No.........�---------- Diameter........6-------- Depth below inlet....... Total leaching area..��Ly�.�jZ..sq. ft. Z Other Distribution box (+ Dosing tank ( ) aPercolation Test Resultsq Performed by---.�'�46RAI_...IIY&,6._/�/_�/.JS/�..___. Date..../_�_ ......... Test Pit No. 1........ _____minutes per inch Depth of Test Pit.................... Depth to ground water-___�___/- -_-__-_____ . f=, Test Pit No. 2......A......minutes per inch Depth of Test Pit.................... Depth to ground water__/-1`.f ��1 i4 --------------- ------------------------..... ...-----........................----...........------•--•-••-----•-••••---•--......---...-•-- O Description of Soil........................... L IV_ ......JAN L)............................................................................... x ..............................................--------------- 6 Z .------------------------------------•-----------------------......------------------ w UNature of Repairs or Alterations—Answer when applicable............................................................................................... -----------------------------------------------------------•------------------•-----•--............-----...--------------------------•------•-••-•-••-•-•-•------•----•---••--••----••--........--••••-- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of i?TLi� 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 boa"ofhhlth. Signe �� .� ' -- -...----/- --._..._..-•------- Application Approved By... :y� � ..... . ...................... / Date Application Disapproved for the following asons:-----••--•---••------•--••-•--•-••••----••--•-••---••••-•-••-•-•--------------••-•-••-----•---•-••-------....._ ..-------••---------------------------•---•... ._...----- ------• • -••--------------------------------------------------- 1�iy ---------------------------••------- ------ j�, Date Permit No..... !/-7---------------------•----... Issued.--- � Date 4 No. .-•--••--6---•---------- � J Fps........... ..�.._..-.�. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 7"��. fV/V........oF..�.f. .N.. ��?..f ............................... ApplirFatinn fur Ui4pnaal Works Tonstrnrtiun rami# Application is hereby made for a Permit to Construct (.-) or Repair ( ) an Individual Sewage Disposal System at: ..................---1-3.1.....M.A.9j,v:6k... - ..... Location•Address or Lot No. .................. �T,e.1•---.......--....-------•----.... p Owner Address i Installer Address Q Type of Building Size Lotj�3'"a_e� S_. q. feet Dwelling—No. of Bedrooms...... ......................._..........Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building r No. of persons....._.. Showers — Cafeteria QOther fixtures ..........--•------- ---•------••••••••••--•-•-•••••••-----•-•---••---•-•••-•-••-••-•-••••--•--•-•-•••......--•--•••••- W Design Flow..................�... ---------------- per person per day. Total daily flow....._3.,.3.0......... ._..._......Olons. It WSeptic Tank—Liquid*capacity e#J9._gallons Length ._ ...... Width.Zj../,0.... Diameter................ Depth '" „�j..... x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area___.•_--•--___ ----sq. ft. Seepage Pit No......./........... Diameter-------6......... Depth below inlet.......______.___ Total leaching area.,4.�..✓. ....sq. ft. z Other Distribution box (, ..) Dosing tank ( ) '-' Percolation Test Results Performed b ? �,1�'/n. !s%! _.._A! f a Y -�A F t� �. ,.. Date. '.` �� Test Pit No. 1......---____minutes per inch Depth of Test Pit.................... Depth to ground water_____ ________________ Gi, Test Pit No. 2..............minutes per inch Depth of Test Pit.................•.. Depth to ground water-AZ � _.,?-�- •••••...............• :.------••--•-••-•-•---....--•-------...........-----••----.........---••--•--•-----•--•---•-----••--•-••-•--•-••--•......----•-•-- ODescription of Soil------------------------- L .. 1 ......J..A.W J,)------------------.---------------------------------------------------------- w 6•1,�?- 4--) --47,e- - UNature of Repairs or Alterations—Answer when applicable._-------------------------------------•--.--___-_-_-__-________.--_____________--•-•••-•----__. ----------------------------•-------•-----------•----------•----------•-•--••-•••••••--............-•••••-••-•••---••------•-----•-•---•---•-••••••-•-................................................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of i T E j 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 thee board of health. Sign/fl d------ f 7 vd t• of •---_ ---------- Vat Application Approved By.__ _ 1'�,./j�} �/// �. .........../�� � �--�•.___�tf7l].r._._ a--._..._ _ /1� ...................... / Application Disapproved for the following easons:••-••-•-----•••••-•-•-•--•••-•-••••----••••••-••••••--•---•----•••-••-•-•--•-•••--••-•-----•-•-••-••••......---- --•---•-•••-•---•---•-•-••.....----•• •-••--•---•-••----•-•-•••-•-•••••--------•-••••----•-•••••••••-•--..................•-•----•••------•------- - ------------------------------------- //� 1� Permit No...La.....1.P_Z__----........................ Issued-._ .r� I at 7-------------.Date Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH /.. ./ ........oF.. .f�. ?/ f`.7"r '.� ......................... (Irdif irair of TampliFanrr THIS IS TO, CERTIFY, That the Individual Sewage Disposal System constructed. _ or Repaired ( } by............... ------ :. ' lz F `�✓ff =u f;fl ---------•--•--------- Installer at. 1.LY._.e.1. ✓1 ._l. " 1 --..C�ft ?G.G --------- ------------------------------------------- has been installed in accordance with the provisions of Ti i l j of The State Sanitary Coe s d crib d in the application for Disposal Works Construction Permit No.....r�._7.-"4p. �...._.. dated-....__. .����__ _______________•-- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A G ARANTEE IiAT YHE SYSTEM,.W LL FUNCT ON SATISFACTORY. DATE.../0..".15_^Q...........................................•--.. Inspector...................... ..4.0........................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH r- No......................... FEE........................ Dispno al nrk TInsfrnrtivit rrmit Permission is hereby granted..f:Fhl'A. <;(.._: 7 ff .....C.1-1,k.C:.f.7. 4..C:..;r�.,tx'.................. to Construct-4- ) or Repair ( ) an Individual Sewage Disposal System y� at '1�'G. 3..... �!a� .. y ,� �fi•r ,?v •.. ...................•... Street O ,,//� y� as shown on the application for Disposal Works Constructi ermit N _' _fcl' "ateld,- -:7 - --�I------_-•--.-. n oard of Health DATE-� /../1-'y/ - ---- •-- -----...-•-----------•------------------•--_----•----- FORM J255 HOBBS & WARREN. INC., PUBLISHERS _y y- 71 Fss... .—No. •••••... _ ......_ MONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...................OF..h)G,��`�.. r�.fit .................................... ApplirFa#iun for DiupuuFal Worka Tonotruriiun Prrutit Application is hereby made for a Permit to Construct (!/ ) or Repair ( ) an Individual Sewage Disposal System at: s M o.:�.�fin : .C:�. t ..... �:.� .�.--t--...��.c�3..... ••---...-•---------------- .....-•--- -... � c Location-Address or Lot No_...... ..• --•-- .?..2. :h.1.S.....?........ - C �`w�' C� •`.. --C�re� ... � ba S© r� Owner• Addres 5t�•e�__L1 �t6�a� � �54 ..0 e ,�_ �rr� O So �r� yo.c.,��•�� ••----••------ ....._...........• ............ --------------------------•••• A. ... ....... ..................................... Installer Address _ Type of Building Size Lot..` `..---'.�.�......Sq. feet Dwelling—No. of Bedrooms.............. ............................Expansion Attic (N ) Garbage Grinder (No Other—Type T e of Buildin 5 p (" ) ( )QI yp g :._�....1��.11:ty5. No. of ersons....___.�+................ Showers �, — Cafeteria Other fixtures -----------------•......•-•-•••• - W Design Flow..........s s..........................gallons per person per day. Total daily flow.... ..............gallons. WSeptic Tank—Liquid capacityl.0.0n._gallons Length O..��r... Width...a_�?��__ Diameter________________ Depth...�.S. x Disposal Trench—No..................... Width.................... Total Length..........._...._._. Total leaching area....................sq. ft. Seepage Pit No.___---__�-.--____--- Diameter.__...6 Depth below inlet-----h........... Total leaching area_.4�........sq. ft. Z Other Distribution box ( ) Dosing tank ( ) W Percolation Test Results Performed by.....A.S:mta; t �h zc �'............... Date....._.. �....7:"_�`{'..._..... ,..a Test Pit No. 1.....!-------minutes per inch Depth of Test Pit....f.T //-_____ Depth to ground water. b Accc� fi Test Pit No. 2................minutes per inch Depth of Test Pit-_-_____-.--__..._-- Depth to ground water--__--__-__-_-_.-.--___. Q+' --•••--•--••......•:•--•••------•-••••--•••-•••--•...............•--•••----•••--...............••...•••••-•-•--••-•••••......-•-••-•--•-...... .... O Description of Soil----•.p„ -V 0 'r I L'c c�w`•. -t ' �� 5`� S.0,I j� U I.l 1.......�-5--.-�U)e\N....a` =—��\---Ai--F!-� ..-••� .................•--------•-- W x ...........-............................................................................................................................................................................................ V 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 TITI-E 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 he(}alth. I Signed--j `'e- 4S Lc �LI,�.�. .... ........................... Date Application Approved By............ `? -.7 /.. Date Application Disapproved for the following reasons:.......................•----•-------•-------------------------•---------------------------------------....•••••- .........................•-•-•------•----•--------...---------------------•------•-----------------------•••--•-••---••----•-••••-•---------•----•-••-•--••••••--•••••-•------••----••-••-••-••--•...-•- Date Permit No.....7,y // 7 - Issued----- ...`�./-...-� Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH t...o.W. �..................OF........................... �2............................................ (9rdifiratr of Tuntpliaanrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (k ) or Repaired ( ) •-•••••.....•••.........•-- •••••. _ , Installer at_....L v. �.S_... 1 4 5 �.. �Y `` v 5. C."A-C 1 . "•2`.. `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....................................................••••......-•--•---•--.•••••• Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH vcc.k /i7 ..................I................ .... ......---............--•••-•••-••-•........................ No.....�...L............ FEE........................ Difyo.o al Workii T.1untr ion lerani# Permission is hereby granted.......P�'��_._.........jtio"/+.c r1 ------------------•---•........ ...••. to Construct (X ) or Repair ( ) an Individual Sewage Disposal System at No._.......d.4,.,.f.........111....15.......... i.. • ...<v�.� ..i...��1 Street .f/- //Jy as shown on the application for Disposal Works Construction Permit No..................... D'ated....n..--- _._J. _0.y........ ...................................................................................................... / _3 t/ Board of Health DATE ................•---r-------..... ........................ FORM 1255 HOSES & WARREN. INC.. PUBLISHERS No......................f" .t:.f.�....... Fizz THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .................OF.... o".hS'ram _--------............................ Appliration for Biipos al Works Tontrnrtion rami# Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at: -..`0;1;5. ..._+. �1 .....��0.t.1hZ:f•C_ C. ��C\C.._...-•----•------•-- .. �kJ-\�................•------•-•---•-----...........---------------.._............._ ___ Location-Address or Lot o •--...-•--._...---_. �....._2 C'C.C ......................................L3 4 C i�U Owner Address a S t�c� o �`. c��.o.s''fi� S G eS Installer Address _ Type of Building Size Lot._ _ .. .g ......Sq. feet V Dwelling—No. of Bedrooms........... .............................Expansion Attic (,v-.) Garbage Grinder (oi c) p,, Other—Type of Building No. of persons.........�................ Showers ( a — Cafeteria ( ) rl' Other fixtures --------------- d --------------- - --------------- _----- W Design Flow........... .......................gallons per person per day. Total daily flow----. 5_ _ ................gallons. WSeptic Tank—Liquid capacity./ Length.Zo'."... Width... Diameter---------------- Depth..2'-3" x Disposal Trench—No...................... Width.................... Total Length.....................Total leaching area--------------------sq. ft. Seepage Pit No---------- Diameter._----L ......... Depth below inlet......L........... Total leaching area...µ _l_....sq. ft. Z Other Distribution box ( ) Dosing tank ( ) a Percolation Test Results Performed by......! ..h 1.................. Date...D ....... ...� 8-`-�- ___._. ,.a Test Pit No. 1....... ......minutes per inch Depth of Test Pit.....Jy�}_._-----_ Depth to ground water.. ................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ---•-------------------------------•--.--_-•-----___---•-•----••------------ ----•-••--••-••--------------------------------•--- ---------O Description of Soil....--Q I I__Via__..3'I._...._._H O C"� 3 " +O /9 r I S y s S 0.` 1 l e y . .........................••-------•------------------------•------------------•------•------------•------------------- 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 TITLI Z-4 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... y r ��Z� 6 / ,'— ey ______--•------ ------------- -------- Application Approved B ... / Date Application Disapproved for the following reasons________________________________________________________________________________________________________________ --------------------•------•-•----•-•-------•------------•--•--------------------......---...------------...-•------•--••--------•--------•------------------------------------- ....................... Date Permit No......:'_._!____..____ " Issued .............................................. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .. .w..v�...............OF..... 0. Fc �a\. ............................. ..... Trr#ifiratr of TompliFanrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( X) or Repaired ( ) b S�eso �����,c`� ,� S Installer. has been installed in accordance with the provisions of TITLE j 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................................................................................ Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No: ..................t FEE... Disposal Works �on #riat �ermi� Permission is hereby granted..........f.,':................. � . ° ` . . ---•--------•----------------------------------------------------------------•---•-•• to Construct ( ) or Repair ( ) an Individual Sewage Disposal System Street 117, as shown on the application for Disposal Works Construction Permit No..................... Dated......_....-_- .......................... Board of Health DATE............ ............ `'..` . FORM 1255 HOBBS & WARREN. 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