HomeMy WebLinkAbout0064 MASHPEE ROAD - Health �6-4 MASHPEE ROAD
007-033- COTUIT E
�i
G ewage Permit No.
Location: APOAP
Village:
Installer's Name & Address 1 Zwy 1..4 � .Zme-
Rw I-Ty
Builder's Name & Address J;h wi /SIG S�/�tA,C Lc c
Date Permit Issued /2-74/
Date Compliance Issued
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JPeC TOWN OF BARNSTABLE
L&CATION/�M Qa.sk koee, &06 SEWAGE #
TLLAGE l `�- SSESSOR'S MAP & L 0 T
SPCR, ::-NAME&PHONF NO.
SEPTIC TANK CAPACI'I'1' /
LEACHING FACILITY: (type) Urfi/7_6 (size) n X f n
NO. OF BEDROOMS ���� _C � '^
BUILDER OR OWNER r Q �� �r)
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PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to th0cottom 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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\ COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5 ;
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: (,.,7 6.11
_1A
"Owner's Nanie: k
Owner's Address: a
.4 -
Date.of Inspection: n 0 6—
�n��1p
Name of Inspect please print). ,/��"`/� ( c��� v�j �a
Company Name � p„ (fyj
Mailing Address`:
c� Y
Telephone Number: 97
CERTIFICATION STATEMENT
I.certify that I have personally inspected the sewage disposal system at this address and that the information reported
below,is true, accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
ap-proved system inspector pursumit-to--Section 15.340 of TitleS=(310.--P11' 1S.r0f1;;a.Tiz<system:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
ils
1 Inspector's Signature: Date: . Rrd(kc -'
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
P . .. w.. 'y: .... a .,.�,. .., - � _ �kt.. � •# �•�. r
****This re ort only describes conditions at-the time of ins ection and under the.conditions of ase at that
P Y P
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
I
Title 5 Inspection Form 6/15/200.0 page 1
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Page of I 1 1,
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
. . a CERTIFICATION (continued)
Property Address: ;Q r
—/� Y
Owner:, / c
Date of'Inspection -
Inspection Summary: Check A,B,C,D or E:/ALWAYS complete all of Section D
A. S stem Passes:
I have not found any
y on which indicates that any-of the failure criteria described in CIO CMR
15.303 or in 310.CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass section need to be replaced or
repaired. The system, upon completion of the replacement or,repair;as approved by the Board of Health,will pass.
AnswerT '
es no or not determined Y h ND in the f t Q
yes, ( ) or he followm 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;Syste.m.,YBI,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:
i
2
Paee 3 of I 1
OFFICIAL'INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM=INSPECTION FORM
PART A
CERTIFICATION.(continued)
Property Address• 7 /-/C"-2, r,42ie _
Owner: "' 'l
Date of Inspection: 'J" ��
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.-'Systeni will pass unless`Board of Health determines in a6cordance`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
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 l of a public water supply.
The system has a septic tank and SAS and_the SA5-fs'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:
3
Page 4 of 11
OFFICIAL.INSPECTION FORM—.NOT FOR VOLUNTARY ASSESSMENTS.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A.
CERTIFICATION(continued)
Proper Address: /� &��
Owne4
Date of Inspection: "X- ( 5
D. System Failure Criteria applicable to all systems.-
You must indicate"yes"or"no"to each of the following for all inspections:
Yes N
Backup of.sewage into facility or system component due to overloaded:or clogged SAS or cesspool
V 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.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 ''/z day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
_ Any portion of the SAS,cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
f� water supply.
. Any-portion of a cesspool.cr privy.is.within a Zone 1 of a.public well.
Any portion of a cesspool cr privy is within 50 feet of a.private water supply well.
Any portion of a cesspool cr privy.is less than 100.feet but greater than 5b 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
—_ni.trogen and nitrate nitrogen is equal to,,or less than 5..p-pm, proti�Ptbw,:f:,ilure criteria
are:triggered. A copy of the analysis must be attached to this form.]
PO (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:flowof 101000 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—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 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.
4
Page 5 of l 1
OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
0 w n e
Date of Inspection: a r- tr.
Check if the following have been done. You must indicate"yes".or"no" as to each of the follow'inc:
Y
r �
Yes No }
t� Pumping.information was provided by the owner;occupant, or Board of Health
Were any of the system components pumped out in the previous two weeks?
v Has the system received normal flows in the previous two week period ?
Have large volumes of water been introduced to,the system recently or as part of this inspection ?
r
Were as built plans of the system obtained and examined?(If they were not available note as N/A)
Was the facility or dwelling inspected for signs of sewage back up
Was the site inspected for signs of break out? +
Z Were all system components, excluding the SAS, located on site
T_ 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,,dgpth.;gf liqut.,depth'of sludge and depth of scum
t/ — 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
Existing information. For example, a plan at the Board of Health.
_ul/ 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)]
I
5
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM
PART C
SYSTEM:INFORMATION
Property Address: ✓1
Owner"'Ix"- e,,
Date of Inspection:
U
FLOW I CONDITIONS
RESIDENTIAL L
Number of bedrooms(.design):-__-2- Number of bedrooms(actual):
DESIGN flow based on 310 C,,4 1.5.203 (for example:.110 op x#of bedrooms):
Number of current residents:t/ae��(/J(��
Does residence have a garbage grinder(yes or no): �\� '
Is laundry on a separate sewage system (yes or no):/_C�.[if yes separate inspection required)
Laundry system inspected Pg.or no):/t (j
Seasonal use: (yes or no):
Water meter readings, if a ilable(last 2 years usage(gpd)): �j��(� al,
Sump pump.(yes or no):Last date of occupancy:
��`�( 611
COMMERCIAL/INDUSTRIAL/(/�
Type of establishment:
Design flow(based on 310 CMR 15.2C3): gpd
Basis of design,flow(seats/persons/sgf,etc.):
Grease trap present(yes or no):—
Industrial waste holding tank present(yes or no):_
Non-sanitary waste discharged to the Title 5 system (yes or no):—
Water meter readings,if available:
Last date of occupancy/use:
11 I.PIER(describe): .._.._ _
GENERAL INFORMATION
Pumping Records R. j
Source of information: 6 A& { ,f
Was system pumped as j1art of the inspection(yes o o): �
If yes, volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
�I
TYPE,OF SYSTEM
eptic tank;.distribution box,soil absorption system
_Single cesspool
_Overflow cesspool
_Privy
_Shared system (yes or no)(if yes, attach previous inspection records; if any)
_Inn ovative%A Item ative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight tank Attach a copyapproval'
of the DEP
— —
—Other(describe):
Approxi ate age of all gompone ts,date installed(if known)and source of information:
r .
Were sewage,odors.detected when arriving at the site(yes or no):
6
Page 7 of 1 1
OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM:INFORMATION (continued)
Property Address: wala�16
Owns
Date of Inspection:
s S
BUILDING SEWER(locate on site plan)
• r
Depth below CY
grade:
Materials of construction:_cast iron. 40 PVC other(explain):
Distance:from private water supply-well or suction line: <:
Comments(on condition of joints, venting, evidence of leakage, etc.):
SE
PTIC TANK: (locate on site plan)
Depth below grade:
Material of construction: L-6oncrete_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: S'J k'C,r }�
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle: V
Scum thickness:
Distance from top of scum to top of outlet tee or baffle: ! �i
Distance from bottom of scum to bottom of outlet tee or Ta ffle:
How were d'itriensions determined
n _
Comments.(on.pumping recomme dations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
related to outlet inve=evnce of leakage etc.):
QzP )ex 1116 to C 4
GREASE TRAP (locate on site plan)
Depth below grade:_
Material of construction:_concrete metal_fiberglass _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.):
7
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Page 8 of I 1 .
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Proper Address:
Owner C Ott Cv'
Date of Inspection: _ 00 S
-11
TIGHT or HOLDING TANK:1\10€tank must be pumped at time of ins ection locate on.site plan)
P P P )(
Depth below grade:
Material of construction: concrete metal—.fiberglass_polyethyl-ne other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present.(yes or no):
Alarm level: Alarm in working order(Y or no)es :
Date of.last pumping:
Comments(condition of alarm and float switches, etc.):
DISTRIBUTION BOX:1(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert. ' � ,,��
Comments(note if box is level and distributton to outlets'�qual, any evidence of solids carryover;any evidence of
-N akage into or out of box,FtC4. e
_ o -fie ��`7 Z& —...
PUMP CHAMBER(locate on site plan).
Pumps in working order(yes or no):
r
Alarms in working order(.yes or no):
Comments (note condition,of pump chamber, condition of pumps and appurtenances, etc.)-
8
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Page 9 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
f c
Property Address: , et
Owner'
Date of Inspection: / 05
`s�
SOIL ABSORPTION SYSTEM (SAS):—6, locate on site plan,excavation not required)
If SAS not located explain why:
Type leaching pits,number:
leaching chambers, number:,
leaching galleries, number:
leaching trenches; number; length:.
leaching fields, number, dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure,level of ponding damp soil, condition of vegetation,
et
CESSPOOLS(cesspool must be pumped as part of inspection)(locate on site plan)
Number and confi*aui ation:
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): f +_
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.):
PRIVY/4 locate on site la
( plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,`level of ponding, condition of vegetation, etc.):
9
Page 10 of 1 l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
FART C
SYSTEM INFORMATION(continued)
f
Property Address: . �
Owner: ' V
Date of Inspection:
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.
Lp
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10
Page 1 I of 1 l
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: ��aoez.
Owne-
r: L
Date of Inspection: ca
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells ,
b a
Estimated.depth to ground water 7/ feet
Please indicate(check)all methods used to determine the high around 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)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
1l
Permit Number: cc Date:
Completed by: /IC5;diKT
HIGH GROUND-WATER LEVEL COMPUTATION
Site Location: [lt�f e�l GiC L 1r� Lot No.
f�,®
Owner: ✓[��l'd l�( ��v r�' Address: j y'
Contractor: �C// � �L�f��'i'r�� =Address: Cl J+� ✓ l% `�
Notes: '/y� � 5a1���r
STEP 1 Measure depth to water table
to nearest 1/10 ft. ......... .......... . .. ................
Date r/Mor"
month/day/year
STEP 2 Using Water-Level Range Zone
and.lndex Well Map,locate
site and determine:
A' Appropriate index well;.:................................................
B Water-level range zone ....:................................................
STEP 3 Using monthly report "Current` .
Water Resources Conditions"
determine current depth to
water level for.index well ........ d�
month/year
STEP 4 Using Table of Water-level Adjustments
for index well (STEP 2A), current depth to water level for index well(STEP 3),
and water-level zone (STEP 213)
determine water-level adjustment ........................:..........:............................:.........................
STEP 5 Estimate depth to high water
by subtracting the water
level adjustment (STEP 4)
from measured depth to water
level.at site (STEP 1) :.............. ` .........:........... ................:. .........................................
.-Figure.11--Reproducible computation form.
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No.(D. .... Fizz
THE COMMONWE THTOF MASSACHUSETTS
9
BOAR® OF HEALTH
............ ................OF.....................-................---.-----------------...............................
Appliration for Uispnaal Morks Tnnstrite#iun ratnit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
c io -A ress or Lot No,
Own Address
a ............. 1 .......... I mo---------------------------- .............-------_ ------•-------------------------------------------
Installer Address
PQ Q Type of Building Size Lot......
� ...Sq. feet
U
Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder ( )
Other—T e of Building No. of persons............................ Showers — Cafeteria
a i Other fixtures -----•--------- --------------------------------- -
Q --
-----------------
DesignW Flow............3.3.®.............gallons per person per day. Total daily flow..... _��--............
Wi Septic 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 ) / r
'~ Percolation Test Results Performed by ......................................................... Date..... .................
..a;, xf
Test Pit No. 1................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.--------._.---.__------
�+ •------------------------------------....
--------------
-----...
-.---------------...---•-•--................
•.........
•------------------------------------•--
O, Description of Soil........................................................................................................................................................................
x
U
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'�iTll . 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a C ifi to of Compliance has been issued by e 60,ard health.
Signed--_. ... . 7
Date
Application Approved By-------- :. ----- ----. •. .. ....................................
Date
Application Disapproved for the following-reasons-------------•----...-----•-••-•------------------...-----------------------•----...--••-•--•-------...--------
....................................•----------•-----•-•-----.....---.......----••------------------:..-----------------•--.----- ------------- ....................................................
Date
PermitNo..................................................:n.. Issued.......................-•-------•---------- ------------
Yl Date
No ..5.. 3!.-��`. r Flcs
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.........................................OF..............................................
Allp iratiun fur Disposal 10orkii Tonstrur#iun rumit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
/ al
JJ Loca`tio Adress
- =l .. :...r .Nf.1 or LotNo ... ¢ ....
S
a `� Ad ress
r d
Owner �
...............................................
Installer, Address
UType of Building Size Lot...._� ...Sq. feet
Dwelling—No. of Bedrooms......--_a'�..................................Expansion Attic Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures ._.-..--•------•--------•-----------•-••--------•-•-------•---------•-•------•-•---•-- ........... ......
W Design Flow...........-,e,"'�' . ..............gallons per person per day. Total daily flow__-_. ° .____.__...gallons.
WSeptic Tank—Liquid capacitylfI.P.O.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 ( ) tt � p
a Percolation Test Results Performed by._..._..._.. :_ .__ ,:. ............................. Date._ --:
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground Water....................
44 Test Pit No. 2................minutes per inch - Depth of Test Pit.................... Depth to ground water........................
a -•-•-••....-•-••---••-•-••-------••-•--•.................................•......•----•---•..._....•..........................................................
0 Description of Soil........................................................................................................................................................................
W
M •........
.......•-•----
----
•----------
•••------------
•---------------
•-----------------------
---------
---------------------
•----------------------------------------------------------- -----------
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 TT" 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has ben issued by e bard ealth.
Signed••- = y
s. �y Datt
Application Approved By.....-- �... • .: �! = zk/
Date
Application Disapproved for the following reasons-----------------------••---•-----•---------------•----------------------------------------------------...._.....
...........-_............................................................................................................................................................--••-•--•••-•-••••--------••-•--
Date
PermitNo......................................................... Issued.•.............•--•----•---•-•----••---••---•-••-•-•---
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.................................
Trdifiratr of Tomplianrr
THIS IS TO CERTIFY Th t the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by......
�.... ---•--•----------• ----------------•-•. ------. ---- .............................-•-•-------------
Installer�.
at 2"P__.. — r• 24
— -_------•---- �
has been installed in accordance with the provisions of TIT - of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No......� ��.,� ......... dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE....................................... - .............. Inspector.......... ...•
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
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NOS,�,; .._..__. FEE .....................
'Disposa urkii Cn trurti.un Uprrutit
Permission is hereby granted----. x°.r�� *:a........; -�` ...........................................................................
to Construct for Repair ( ) an Indivi�IGal Sewage Disposal System
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as shown on the application for Disposal Works Construction Permit No..................... Dated..........................................
DATE.................... '� �C..................................... Bo of Health
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
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DESIGN BY:
Carter Basement Lagadinos Building and Design Inc.
NAL 6 Mash pee Rd.
4 P 13 Thankful Lane Coturt, MA 02635
09-15-2007 Cotuit, MA 02635 5o8-428-4097 fax 5o8-428-7709
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