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HomeMy WebLinkAbout0024 MELISSA LANE - Health 24 MELISSA LANE, COTUIT 9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments i 24 Melissa Lane I Property Address Karl Svensson Owner Owner's Name information is Cotuit MA 02635 May 29, 2014 required for Y every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out A. General Information I forms on the .computer,use 1. Inspector: only the tab key to move your Patrick M. O'Connell cursor-do not Name of Inspector use the return key. Company Name r� PO Box 1487 Company Address Marstons Mills MA 02648 feN City/Town State Zip Code 508-776-4186 S1 12855 Telephone Number License Number B. Certification 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 approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority _ May 29, 2014 Job# 14-38 Inspector's Signature Date 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. ****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. D^ r t5ins•3/13 Title 5 Official Inspection o ubsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 24 Melissa Lane Property Address Karl Svensson Owner Owner's Name information is required for Cotuit MA 02635 May 29, 2014 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 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: Tank was not in need of pumping at time of inspection. Infiltrators were found empty. 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. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of 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. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 24 Melissa Lane Property Address Karl Svensson Owner Owner's Name information is required for Cotuit MA 02635 May 29, 2014 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection For Subsurface Sewage Disposal System Form Not for Voluntary Assessments 24 Melissa Lane Property Address Karl Svensson Owner Owner's Name information is Y required for Cotuit MA 02635 May 29, 2014 every page. CityfT'own State Zip Code Date of Inspection B. Certification (Cont.) 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 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: . Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than day flow t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments I 24 Melissa Lane Property Address Karl Svensson Owner Owner's Name information is Y required for Cotuit MA 02635 May 29, 2014 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CM 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. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. 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 Secti,:m D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 24 Melissa Lane Property Address Karl Svensson Owner Owner's Name information is Y required for Cotuit MA 02635 May 29, 2014 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: 1 ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: 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 15ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of (Massachusetts Title 5 Official Inspection For Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 24 Melissa Lane Property Address Karl Svensson Owner Owner's Name information is 'Cotuit MA 02635 May 29, 2014 required for Y every page. City/Town State Zip Code Date of Inspection D. System Information Description: I - Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d N/A Irrigation g ( y g (gp )) system. Detail: Sump pump? ❑ Yes ® No Last date of occupancy: CurrentlyOccupied. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 J Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 24 Melissa Lane Property Address Karl Svensson Owner Owner's Name information is y required for Cotuit MA 02635 May 29, 2014 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Tank pumped every two years. Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or.no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection For Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 24 Melissa Lane Property Address Karl Svensson Owner Owner's Name information is Y required for Cotuit MA 02635 May 29, 2014 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1999 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 1' Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other (explain).- Distance from private water supply well or suction line: feet Comments (on condition of joints; venting, evidence of leakage, etc.): Septic Tank (locate on site plan): 1' Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 10.5' long x 5.8'wide- 1500 gal. Sludge depth: 2 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fr Subsurface Sewage Disposal System Form - Not for Voluntary Assessments i °�.. 24 Melissa Lane Property Address Karl Svensson Owner Owner's Name information is Y required for Cotuit MA 02635 May 29, 2014 every page. CitylTown State Zip Code Date of Inspection D. System Information' (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 30" Scum thickness 2 Distance from top of scum to top of outlet tee or baffle 6 Distance from bottom of scum to bottom of outlet tee or baffle 12 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.): Liquid level was at bottom of outlet invert and tees were intact and clear. Grease Trap (locate on site plan): Depth below grade: feet 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: Date 15ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 24 Melissa Lane Property Address Karl Svensson Owner Owner's Name information is Cotuit MA 02635 May 29, 2014 required for y every page. City/Town State Zip Code Data of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 OfficialInspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 24 Melissa Lane Property Address Karl Svensson Owner Owner's Name information is y required for Cotuit MA 02635 May 29, 2014 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (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. Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No` Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 24 Melissa Lane Property Address Karl Svensson Owner Owner's Name information is Cotuit MA 02635 May 29, 2014 required for y every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: Four Hi-CapInfiltrators. ❑ 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.): Interior of infiltrators were video inspected with no standing water found. Cesspools (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 ❑ No l5ins.3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page la of 17_ Commonwealth of Massachusetts W Title 5 Official Inspection For Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 24 Melissa Lane Property Address Karl Svensson Owner Owner's Name information is Cotuit MA 02635 May 29, 2014 required for Y every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (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.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspecti®n Form Gi Subsurface Sewage Disposal System Form Not for Voluntary Assessments "a J 24 Melissa Lane Property Address Karl Svensson ------- Owner Owner's Name information is Cotuit MA 02635 May 29, 2014 -------- —.. required for --- - City/Town Stale Zip Code Date of Inspection every page —..------ ---- --- D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately Back Yard II� 19 1 7 25 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments I 24 Melissa Lane Property Address Karl Svensson Owner Owner's Name information is Cotuit MA 02635 May 29, 2014 required for Y every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells More than 10 feet Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Low area of adjacent property with no surface water is considerably lower than SAS. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 ICI Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 24 Melissa Lane Property Address Karl Svensson Owner Owner's Name information is Cotuit MA 02635 May 29, 2014 required for _ y every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 i • TOWN OF BARNSTABLE . LOCATION a LA V\kA%SSpt I_ty SEWAGE # (11;�7�3� { VILLAGE C—OTv T— ASSESSOR'S MAP &LOT- 1 •ryN INSTALLER'S NAME&PHONE NO. `olt,3 iAtu�-s X f N SEPTIC TANK1CAPACITY ,Co q�L t� LEACHING FACILITY: (type)_.t�i!-t'\``\e�Z"G�4.S $ (She) i b 2- NO.OF BEDROOMS BUILDER-OR OWNER A �J2i�Ut= W PERMITDATE: 3 —`l — 9 COMPLIANCE.,DATE;` 9 — Z Z — Separation Distance Between the: J . Maximum Adjusted Groundwater.Table and Bottom of Leaching.Facility i 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 _qany wetlands exist+ `'- 'within 300 f t of leac acility) '' Na Feet Furnished b . A a 0 �5 y 3�°6 �� 32"° TOWN OF B.4.P.NSTAF3LE LOCATION �� ,�,o�s SEWAGE # C VILI.AGE_ Ty�—V-7 ASSESSOR'S MAP & LOT 1 N INSTALLER'S NAME&PeiONE NO. UP&NUei D r s�'Zc �? SEPTIC TANK CAPACITY V�QQ CN�l> t - LEACHING FACILITY: (type)—rWV- %\TQ.,UN�p� (size) !A b' 2 t 10 NO.OF BEDROOMS.__ BUFi.DER OR OWNER�� \WWXCO�7 �CQ PERMTTDATE:-3 ! ~ 9 q COMPLIANCE DATE: Z Z,.29 Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility 1® 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 f et of leachi acility) iya Feet Furnished b W Fr" G t c� d fF • 1 r l J No.- - �=® f FEE COMMONWEALTH Of MASSACHUSETTS Board of Health, � f. ��D , MA. APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct(,/Repair( ) Upgrade( ) Abandon( ) - ❑Complete System ❑Individual Components Location f Owner's Name Map/Parcel# ID - "1 - Address Lot# Telephone# Installer's Name Designer's Name Address Address 131 Telephone# Telephone# 2 Type of Building YJQJ 0 AA1 AA I h A Lot Size 3 sq.ft. Dwelling-No.of Bedrooms 3 Garbage grinder ( Other-Type of Building No.of persons Showers ( ),Cafeteria( ) Other Fixtures Design Flow (min.required) %34,3D gpd Calculated design flow Design flow provided U ,2— gpd Plan: Date Number of sheets Revisio Date Title 21 1 )Q Q 0 ��� 1 O E✓Y� �p � Old Description of Soil(s) Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further a to not to ce tjLopptem in operation until a Certificate of Compliance has been issued by the Board of Health. Signed t h7 Date Zillsve MOM— ` 3 o �;r No._-C�L J _ FEE I��/�I'F� I�\UT�t\\�/T ,. p\^\, ��(u�F��IIt TI .1�IIr 4 TICO JLl O V V V MI TII ®JL 1 llASSACJLJL'V SET,,; S Board of Health, &�P— 1-5A-(A-�b�0 MA. APPLICATION FOP DISPOSAL SYSTEM. CONSTRUCTION PERMIT Application for a Per it to Construct( J/epair O Upgrade( Abandon( - ❑Complete System ❑Individual Components Location Q! Owner's Name Map/Parcel# �' .f u,,j �; Address Lot# = I Telephone# Installer's Name / Designer's Name Address Address 131 ppqoG . Telephone# Telephone# (0 Type of Building Lot Size ��-/. / sq.ft. Dwelling-No.of Bedrooms Garbage grinder ( ) Other-Type of Building No.of persons Showers ( ),Cafeteria ( ) Other Fixtures Design Flow(min.required) 4 V gpd Calculated design flow Design flow provided �, gpd Plan: Date I rt/ Number of sheets Revisio Date Title Q Q.�'1 11 S i. u)u Description of Soil(s) arM1 r Soil Evaluator Form No " Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agree to not to ce tem in operation,until a Certificate of Compliance has been issued by the Board of Health. Signed 4/1!' €.+iit Date Tff c ons 3 /3' 130 No.-- COMMONWEALTH OF MASSACHUSETTS A , i y FEE 1411(1 `'C, Board of Health, MA. CERTIFICATE OF COMPLIANCE r r Description of Work: ❑Individual Component(s) Komplete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ),Repaired ( ),Upgraded ( ),Abandoned ( ) by. :� 0.ve I 8"-s at ZZ d � G I[f A A t.R i 40 i has been installed''n accordance with the ro ' ion of 310 CMR 15.00 (Title 5) and thg�a proved design plans/as-built plans relating to application No. / —�3O dated �j Approved Design Flow ,3 g (gpd) Installer Designer: Inspector: A?jA o 1 te. The issuance of this permit shall not be construed as a guarantee that the systeill.func `on as designed. No. /3 Q FEE /��• . COMMONWEALTH Of MASSA 14USETTS Board of Health, 6 C"' S If,W/ 1-e MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system at [n t �I�l�f�� �p � z -" as described in the application for Disposal System Construction Permit No. /9-I�o , dated Provided: Construction shall be completed within three years of the date of th' ermit. All local, ondiftionsXnust be met. 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