HomeMy WebLinkAbout0085 MICHELLE AVENUE - Health . is
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
GM , 85Michelle Ave. - - - •�•a _
Property Address - W
Perrin
Owner's Name
Cotuit 7 MA 02635 10/6/16 =
Cityfrown State Zip Code Date of Inspection fV
• w
Pa
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.
A. General Information Si' 119�'3
1. Inspector:
Frank Nunes III
Name of Inspector
saa
Company Name
Box 841
Company Address
East Falmouth MA 02536
City/Town State Zip Code
508,272.6433
Telephone 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 16.340 of
Title 5(310 CMR 16.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
10/6/16
Insp or'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.
85 Michelle Ave.•03/68 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
85 Michelle Ave.
Property Address
Perrin
Owner's Name
Cotuit MA 02635 10/6/16
City/Town 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:
Pumping suggested every 3 yrs to prolong the life of the system
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:
n/a
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced
❑ obstruction is removed
85 Michelle Ave.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15
Commonwealth of Massachusetts a
Title 5 Official Inspection Form '
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 85 Michelle Ave.
Property Address
Perrin
Owner's Name
Cotuit MA .02635 10/6/16
Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ distribution box is leveled or replaced
ND Explain:
n/a
❑ 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:
n/a
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
El 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:
El 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.
85 Michelle Ave.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
85 Michelle Ave.
Property Address
Perrin
Owner's Name '
Cotuit MA 02635 10/6/16
Cityrrown State Zip Code Date of Inspection
B. Certification cont.
.C) Further Evaluation is Required by the Board of Health (cont.):
❑ 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 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:
n/a
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 '/2 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 water supply.
85 Michelle Ave.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15
t
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
°- 85 Michelle Ave.
Property Address
Perrin
Owner's Name
Cotuit MA 02635 10/6/16
Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems(coat.):
Yes No
❑ ® 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 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.
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 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.
85 Michelle Ave.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 85 Michelle Ave:
Property Address ,
Perrin
i
Owner's Name
Cotuit MA 02635 10/6/16
Cityrrown State Zip Code Date of Inspection
C. Checklist
F
Check if the following have been done. You must indicate"yes" or"no"as to each of the following:
Yes No
l•
E' ❑ 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:
® ❑ 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)]
85 Michelle Ave.•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 85 Michelle Ave.
Property Address
Perrin
Owner's Name
Cotuit MA 02635 10/6/16
City/Town State Zip Code Date of Inspection
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
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)):
Sump pump? ❑ Yes ® No
Last date of occupancy: Vacant 1 yr
Date
Commercial/Industrial Flow Conditions:
Type of Establishment: n/a
Design flow(based on 310 CMR 15.203): Gauons 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:
Last date of occupancy/use*: Date
Other(describe): n/a
85 Michelle Ave.-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
85 Michelle Ave.
M Property Address
Perrin
Owners Name
Cotuit MA 02635 10/6/16
Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
General Information
Pumping Records:
Source of information: Pumped 4 yrs ago per owner
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: i
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
El Tight tank. Attach a copy of the DEP approval.
x Other(describe): '
Approximate age of all components, date installed (if known)and source of information:
1984 per BOH record
Were sewage odors detected when arriving at the site? ❑ Yes ® No
85 Michelle Ave.-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
85 Michelle Ave.
Property Address
Perrin
Owner's Name
Cotuit MA 02635 10/6/16
Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan):
2411
Depth below grade: feet
Material of construction:
❑cast iron ' ® 40 PVC ❑ other(explain):
>10'
Distancefrom private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
d `
Septic Tank(locate on site plan):
'Depth below grade: 18"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: 1000g
Sludge depth: 41'
Distance from top of sludge to bottom of outlet tee or baffle >12
Scum thickness trace
Distance from top of scum to top of outlet tee or baffle >2„
>211
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined? Measured
85 Michelle Ave.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
s 85 Michelle Ave.
Property Address
Perrin
Owner's Name
Cotuit MA 02635 10/6/16
Cityrrown State Zip Code Date 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.):
Pumping suggested every 3 yrs to prolong the life of the system
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
EJ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
n/a `
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
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
n/a
t
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):
n/a
85 Michelle Ave.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
85 Michelle Ave.
Property Address
Perrin
Owner's Name
Cotuit - MA 02635 10/6/16
Cityfrown State ' Zip Code Date of Inspection
D. System Information (cont.)
Tight or Holding Tank(cont.)
Dimensions:
Capacity: gallons
f
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.):
n/a
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
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.):
D-box 2'6" below grade, average condition for its age
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
85 Michelle Ave.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
85 Michelle Ave.
Property Address
Perrin
Owner's Name
Cotuit MA 02635 10/6/16
Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
n/a
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
® leaching pits number: 1
❑ 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.):
Leach pit was video inspected, it is 3'below grade, damp at this time, no indication of past backup
, R
85 Michelle Ave.-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15
J
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 85 Michelle Ave.
Property Address
Perrin
Owner's Name
Cotuit MA 02635 10/6/16
Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
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
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.):
n/a
85 Michelle Ave.-03/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 13 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M Svey`er 85 Michelle Ave. -
Property Address
Perrin
Owners Name
Cotuit MA 02635 .10/6/16
Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
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.
CZ,
W
D
as
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85 Michelle Ave.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15
' •• I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
85 Michelle Ave.
Property Address
Perrin
Owner's Name
Cotuit MA 02635 10/6/16
Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high groundwater: >12
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:
Per elevation of home
85 Michelle Ave.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15
L AT10. SEWAGE PERMIT MQ.
V I LLACE
+ II4STA LLER'S A 8 ADDRESS
I U I L D E R OR OWN
DA T E P ERMIT ISSU E D
DATE COM.PLIANC-E ISSUED 91 2-
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No....................
FRz.. ... .................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD 5F..............W... ..6..6-.ft_-_.....OF
.....OFA H(.��A
.................... .6.V......(.�7..f�.H...........
Appliration for Disposal ..........................
Workii notrurtion Famit
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Application is hereby made for a Perm' to o struct ( t_1 or Repair an Individual Sewage Disposal
4
System at:
...... .................... ................. .......................
441 ...... ........ ............................................
��oca_;ion_-_A_d_d__r_e_s_s_....... 0.
1267-1 ..................... . ............. ...... ...r...... ......... 7 � ...................................
wner 1k7s
......... . ....... . . ........................... ......... ......................................................
Installer Address
Type of Building Size Lot.; ....Sq. feet
ms.......... Garbage Grinder (
U -.Expansion Attic�
Dwelling—No. of Bedrooms ................................
P�_lL4 Other—Type of Building .---_-------_--------_ No. of persons........................_i
.... Showers Cafeteria (
OtherfWures -----------------------------------------------------------------------------------------------------------------------------------------------------
Design Flow.............S1 ....--.__._._.__.gallons per person per day. Total daily flow-----S54�.......................gallons.
04 Septic Tank—Liquid capaci gallons Length................ Width._._...._._.._.. Diameter__-___...._..... Depth................
W t/6-M--
Disposal Trench—No..................... Width ....... Total Length --- Total,leaching area___..__. ........sq. ft.
......... .....
Seepage Pit No.---./... ........ Diameter-----P---------- Depth below inle't"".L..•......... Total leaching area_' ft.
Z Other Distribution box Dosing tank
Percolation Test Results Performed by.......................................................................... Date........................................
a Test Pit No. I................minutes per inch Depth of Test Pit................._.. Depth to ground water.......___..............
Test Pit No. 2................minutes per inch Depth of Test Pit______-_--- _____-- Depth to ground water----------------------
P4 .......
0 7 -- ------
Description of Soil....4_.z----------- /.. -------------------------------------------------------------------
------------- ------------------------------------*............................ .................................................
-------------------------- -----------------Y --------------------------
-------------------- ...................... > vix_'�Cf, ----- ------------------------------------*-------------------------*---------------
Z I ...... --- ......7 ... . ... ..
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 TIME ME 5 of the State Sanitary Code Thep�dersigned further agrees not to place tye syst in
by
operation until a Certificate of Compliance has bee is e b e board of health.
dned.. ...4..................................... ................................... .... ..... ..
D6at"
.... ..........
Application Approved B ..... ................................................................................ --------- ----
Date
0 Wing reasons..
Application Disapproved fo th following reasons:...............................................................................................................
.......................................................................................................................................................................................................
Date
PermitNo......................................................... IssuedL.......................................................
Date
----------
----------------------
I
J:
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® .C?F• HEA /H
Y r,,,
a!" � r�l
.._... .l ` .'' ..- OF.......1 ..'.. ..:``.....`_...--..`..............................................
Appliration for Disposal Works Towitrnrtiun Prrutit
Application is hereby made for a Permit to Construct (&'�or Repair ( ) an Individual Sewage Disposal
System at:
...._... , ........................................... .._....... ---•-- '-__....._-------------------------
Location-Address Y j j„ t ` g¢ t No. "
...._t�..... ......... "
..............
.................._. .5�:`&.- ............ ............... ... _i__.
•caner
.... .;
,fit 1�
av=t....... 4 .t.E........................... Press... ......
Installer Address r.�
Type of Building Size Lot;1_j.rr-- -____Sq. feet
U Dwelling—No. of Bedrooms........................................................................Expansion Attic ( ) Garbage Grinder ( )
Other—Type T e of Building _____________ No. of ersons__...__._.__________..__.._. Showers
� YP g ------•------- ------•P f ) — Cafeteria ( )
Othertur s •••••••••-••......•-----•----•........... •-•••--•••••••-••-----•--•-----•-•---•-•-••-...-••--••---•-•-•---•-••--•••......••----....•--•----
W Design Flow............ ...................gallons per person per day. Total daily flow:_ t _ ........................gallons.
WSeptic Tank—Liquid capaci�t 'ra �_gallons Length................ Width................ Diameter---------------- Depth................
x Disposal Trench—No_ ____________________ Width-___--______-_____ Total Length......,,............ Total leaching area...... ...........sq. ft.
Seepage Pit No...../_____________ Diameter...... Depth below inlet___it._'.______..__ Total leaching area___fS_____sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
a Test Pit No. 1________________minutes per inch Depth of Test Pit.................... Depth to ground water-----------------------
.
pro Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
........................................ ......... .......... •-- .............................................
O Description of Soil____m .A____ __ ' . '
------- ...............................................................
0 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 TITLE 5 of the State Sanitary Code The dersigned further agrees not to place the syst in
operation until a Certificate of Compliance has beeh 1 su/ by e board of health.
Jam' r
l
..
__�� /
Application Approved ; - =="-=- -.._. .z.... .-•��------
Date
Application Disapproved f9 th following reasons:-----------•---------------------•------ .................................................................
......................•---....._...--•--...--•-------------------•-------------.....----•------•--•------.--..-•--•-----•------------------------------------------------
Date
PermitNo......................................................... Issued-.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEA)LTH•
f.. ". ..........OF......... ..........................................................
�rrtifirak of Tuut liunrr
THIS IS TO CERTI Y, That the Ind�i<v�'dual ,Sewage Disposal System,constructed or Repaired ( )
by -•--- ................. ----- --- -
f InItalre �....
-------------------------------••••-••--------•-
has been installed in accordance with the provisions of TITLE "of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.�Z 11_ _______________ dated----------.--------_............................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE...........................................
.'-Z_`._' Inspector........ ..
THE COMMONWEALTH OF MASSACHUSETTS
BOARD PF HE
T�-1
�.
......../. !;�`.. ......OF.......J.. ...................................` ......•--•--•--•--.....
No......................... FEE
Mops >I urkii �ll� �'Strntuan rrutit
Permission is <ebyranted----- ......... ---------------- -- ..to Construct ( oir ( ) an Individual Setrage Di posal System 'r
,. Street
as shown on the application for Disposal Works Construction Permit N ........... Dated..........................................
_ -----------•-• ---- •-.......................................................................
-
t, Board of Health
DATE............................'...................................................
FORM 1255 A. M. SULKIN, INC., BOSTON
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