HomeMy WebLinkAbout0054 NARROWS WAY - Health 54 NaiTows Way
Cotuit j
A-= 021 --003 - 004
i
P
- DATE 1 1 /1 5/0$
PROPERTY ADDRESS 54 Narrows way
'Cotu i t
MA 02635
On the above date, the septic system at the address above was
Inspected.
This system consists of the following:
1., 1-1000 gaiion hept.ic tank
2., 1-Dihta.i.&ut.ion 9ox.,
3., 1-1000 gai.Pon ieach.ing p i.t
Based on inspection, I certify the following conditions:
4.t 7h.i-6 i6 a 71t.ee Five zept.ic .sy.3tem.,(78Code)
5.1 The zept.ic bybtem .i.6 .in paopea woak.ing oadea at the paezent time.,
SIGNATUR o `
Name: Robert A. Paolini
Company: Joseph P Macomber & Son Inc .
Address: P. O. Box 66
Centerville, Mass 02632
Phone: 508-775-3338 or 508-775-6412 �
vz
JOSEPH P. MACOMBER & SON,: INC. . CD
Tanks-Cesspools-Leachfields ^�
Pumped & Installed
Town Sewer Connections
P.O. Box 66 Centerville, MA.026.32-0066
775-3338 775-6412
•
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
A�
yt
TITLE 5
OFFICIAL INSPECTION FORM—NOT.FOR.VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: . 54 Narrows. Way
rat,,; t Mn 09635
Owner's Name: Raymnnd McThn+Q Z
Owner's Address: .. Same
Date of Inspection: 1 1 .1.15,f n 5
Name of Inspector: (please print) lRobe t` A 'Pa'otin
Company Name: 2. 2. �lacomge2 & .S.on Inc.
Mailing Address: 6F 66
Ce�xx n tz/t2)i e, ¢zz. 02632
. Telephone Number: 5 0 8-7 7 5-3 3 3 8
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
approved system inspector pursuant to Section.15:340 of Title 5(310 GMR M000). The system:
XXX Passes
Conditionally Passes 040
Needs Further Evaluation by the Local Approving Authority
Fail
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.
Notes and Comments
****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.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of 11
OFFICIAL INSPECTIONYORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 54 . Narrows Way
Cotuit .MA 02635
Owner: Raymond McInnis
Date of Inspection: 11 15 0 5
Inspection ummary:,.Check.A,B,C,D or.E/ALW.AY&complete all of Section:D
A. System Passes: qES „
NO I have not found any information which indicates'thif any of the failure criteria described in,�10 CMR
15.303.or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
septic zmztem .ins .in 22o/2aR wemklnN nnon of tho Limp-
B. System Conditionally Passes:
NO One or more system components as described in the"Conditional Pass"section need tobe 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.
NO The septic tank is metal and.ove..r 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:
NO 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:
NO 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:
2
Page 3 of 11
i OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 54 Narrows Way
Cotuit MA 02635
Owner:. Raymond McTn nis
Date of Inspection: 11 15 0 5
C. Further Evaluation is Required by.the Board of Health:
NO Conditions.exist whichrequire 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:
no Cesspool or privy is within 50 feet of a surface water
no 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:
no The system has aseptic 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.
no The system-has aseptic tank and SAS and the.SAS is within a Zone 1 of a public water supply.
no The system has aseptic tank and.SA&and the SAS is within 50 feet of a private water supply wen.
no The system has aseptic 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 coliforin
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)
Property Address: 54 Narrows Way
Cnfiiit MA 0263S
Owner: Raymond McTnnis _
Date of Inspection: 1111 S j a r;.
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
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
Liquid depth in cesspool is less than.6"below invert or available volume is less than'/2•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.
y .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 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 greaterthan 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 forT..]
NO (Yes/No)The system fails.I have determined that one or.moreof the above failure.:criteria exist as
described in 310 CMR 15.303,therefore the system-fails.The system owner.AWld 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 1.0,000 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 .
X the system is within 400 feet of a surface drinking water supply.
— X the system is within 20.0 feet of a tributary to a surface drinking water supply
_ X 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 a
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
l 5.304.The system owner should contact the appropriate regional office of the Department.
4
Page 5 of 11
' OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL.SYSTEM.INSPEC`FION FORM
PART B
CHECKLIST
Property Address: 54 Narrows Way
Cotuit MA 02635
Owner: Raymond McInnis
Date of Inspection: 1 1 /1 5/0 5
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?
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?
. _ 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))
5
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
.SUBSURFACE SEWAGE DISPOSAL::SYSTEM:INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 54 Narrows Way
Cotuit MA 02635
Owner: Raymond McInnis
Date of Inspection: 1 1 /1 5/05
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): .:3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 3 3 0
Number of current residents: 2
Does residence.have a garbage grinder(yes or no): n_n
Is laundry on a separate sewage system.(yes or no): n n [if yes separate inspection required]
Laundry system inspected(yes or no):
Seasonal use:(yes or no):_ap .
Water meter readings,if available(last 2 years usage(gpd)): NIA *
Sump Pump(yes or no): n o 1
Last date of occupancy: n o
COMMERCIAL/I1bUSTRIAL
Type of estabJ,ishrriont: iV I A
Design flow(biased on 310 CMR 15.203): gpd
Basis of design'flow(seats/persons/sgft,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: .
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part of the inspection(yes or 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:
15 yeasts
Were sewage odors detected when arriving at.the site(yes or no): n o
6
_ l
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 54 Narrows Way
Cotui t- MA 0263S
Owner: Raymond. McInnis
Date of Inspection: 11 /1 (l�
BUILDING SEWER(locate on site plan)
Depth below grade: 30"
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.):
ao.Cntz a/2/2ea2 .t.Lght � No 2n_ rz n Vonfodl f4,,,,,,nl, A vent
SEPTIC TANKy g z (locate on site plan)'l 000 ga e e o n s
Depth below grade: Z 4"
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' 6'X5' 8"X4' 10"
Sludgedepth: taace
Distance from top of sludge to bottom of outlet tee.or baffle: to a c e
Scum thickness: t a a c e
Distance from top of scum to top of outlet tee or baffle: t a a c e
Distance from bottom of scum to bottom of outlet tee or bafflet2 a cQ
How were dimensions determined: m e a 6uaed
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
Pump tank eve&y. 2 eaaz.� In.2et. .& out let tees aae 12Qace.,
7ank iz ztauctuzaity zoun
GREASE TRAP:n o (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
related to optlet invert,evide ce of leakage,etc.):
jaeaze taa/2 iz not /2aezent
7
Page 8 of 11.
OFFICIAL.INSPECTION FORM;—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM �~
PART C
SYSTEM INFORMATION(continued)
Property Address: 54 Narrows Way
Cotuit MA 02635
Owner: Raymond McInnis
Date of Inspection: 1.1:/15/0 5
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(exp)ain):
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.):
Tight o2 Ud.ing tank.6 ate not /zaezent
DISTRIBUTION BOX:9 e s (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.):
Box .i.3 ieve2., /la s 1 eat e2a.2.- No .so-e id cati2U oyez.- o& P kn ga in
out o/ &ox.,
PUMP CHAMBER: n o (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.):
Pump ehamge2 .i s not 22e.6ent
8 ,
Page 9 of 11
OFFICIAL INSPECTION FORM—'NOT FOR VOLUNTARY ASSESSMENTS.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 54 Narrows Way
Cotuit MA 02635
Owner:. Raymond McInnis
Date of Inspection: 11 1 5/0 5
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Located .see /2a.ge �4
Type
X leaching pits,number: 1_
leaching chambers number:
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
inn Y YP technology:
ovative/alternative system T e/name of technolo :
Comments note condition of soil,signs of hydraulic failure,level of ponding,dam soil,condition of vegetation,
( � Y P g P S
etc.):
Loamy to medium. eine .sand, No .s.ignz _ol -Za.i2uae oa /?ond.iag., So.i2.s
aae d)ty.- Vegetation .is noamai.,
CESSPOOLS:a o (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 br no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
ce zpoo.eb a.¢e not p/tesent
PRIVYJVO (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.):
Pa.ivy .is not Rae-sent
9
Page 10.of I 1
FI ' IAL INSPECTION FORM.-NOT FOR VOLUNTARY ASSESSMENTS
S ACE'SEWAG -DISPOSAL SYSTEM INSPECTION FORM
PART C
,SYSTEM INFORMATION(continued)
Property Address: 54 Narrows Way.
Cotuit MA n2ti19;
Owner: Raymond McTnnis
Date of Inspection: 1 1 /1 510r,
.SK,ETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
Locate where public water supply enters the building,
benchmarks.Locate all wells within 100.feet.L p . pp y g
NA
Way
10
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: •54 Narrows way
Cotuit MA 02635
Owner: Raymond MrTnnis
Date of Inspection: 11 1 �—
SITE EXAM .
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to groundwater aL feet
Please indicate(check)all methods used to determine the high ground water elevation:
-NO Obtained from system design plans on record-If checked,date of design plan reviewed:
y e z Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local-Board of Health-explain:a s R a.i.P.t cn lL d -
no Checked:with local excavators,installers-(attach documentation)
�AccessedUSGSdatabase=explainhtt/::town.��a2nhtaQ2e.�ma. u!s
You must describe how you established the high ground water elevation:
Uhed. : Cal2a Cod Commiz•ion Natea 7agia Cohtouaz And l uttic 61ate2 SuPP.By
G1e22 Izead aoteetio-n azeas mql2o Se t 1995
Glaten aehouace s oe,0_i ce cane cod comm•i3410n
op of vround
040
Leaching
Pit eet
Groundwater:' Etta Below Bottom•tif Pit High Groundwater Ad}ustment 1.8 ft per Frimpter Method
Therefore,the vertical.separation distance between the bottom 3_
of the leaching pit and the adjusted groundwater table is
feet. w
11
aLOW
mtnn/rwreer'.n�7nrrwl►ul.w►/�wIRI Win" +1117fer!�irtr.r�••}
TOWN OF BARNSTABLE 130AUD QF HEALTH
SUBSURFACE SEWAUH DISPOSAL SYSTEM INSPECTION FORM - PART D• CERTIFICATION
••'4P1�T•:41f�T1111�CTTVR111U•/ry1�'177RJ/�./M.'71117SrR1 All.
-TYPE 01 PRINT CLEARLY• ~*
PROPERTY INSPEO'TED
STREET ADDRESS 54 Narrows Way Cotuit
ASSESSORS MAP j DLO.GK AND 'PARCE'b -003 -1
OWNER's NAME .Raymond'McInnis
PART' D CERTIFICATION '
NAME 'OF INSPECTOR RogiAvi P.a.o"ni
COMPANY NAME ;obe8h '.P,, (lacom4¢a'''-2' Son Inc "
COMPANY ADDASSS Box . 66 '' Centeaviito l az.a' 02632 '
Str Town-or City LIP
COMPANY TELEPHONE t 508. Y 7.5 - 3338 FAX 508• I190 e f 578
CERTIFICATION STATEMENT '
I certify that. I have persotially .inspected ..the aewage 'dI io,sal, system at
this address and that t4d information reported .is true,. s.ocUra•te-i and
omplete as of the time ..a,f�inspeetion..• The inspection was performed and any
recommendations regard.ing upgrade., .ma-intenance,' abd repair .are. eon$istent
with my training and exP.erience in th8 proper function' and maintenance of on
site sewage disposal systems.
Check one; ,
System PASSU .
The inspection which -I have conducted has .,niat found any information .
which indicates that the system' fails to • adeq.uately. protect .publi•c
health or the. envi,.ropment as defined in .310 CMR. 18;803, Any failure
criteria rlvt evaluated are as stated in the FAI•LURV CRITERIA .section o-f
this for)n.
System FAILED*
The inspection which I have bon ted 'has -'found that the system fails to
protect the public Health and the en`lronmen•t - in aegordanc�e with Title
61 310 CMR 15 . 3031 and as specifically noted on .PART' C —. FAILURE
CRITERIA of this inspection form.
Inspector signature' / Dat
4
Ynb� copy of this eertlfi.oat.foh must •be providedto the .pWNEl7, the BUYER
re appli•.oable) and thin 33QARD OV HEALTH.
* If the inspection FAIL-Eb., thv .owner' .ox'"operator -*.ha' 13, upir-10e..'.tihe system.
within one year of the d.a•t•e of the inspection, unless. al.-jawod or, recui.red .
ASSESSOR'S-RAP �. t PARCEL 3 .e.T
LOCATION " Y SEWAGE PERMIT NO.
L-0 20 I&61 46 �-
VILLAGE
U
INSTA LLER'S NAME A " ADDRESS
R U I L D E R 0 OWNER
Cam-
DATE JPERMIT ISSUED
x
DATE COMPLIANCE ISSUED
I
O -
r -
rs+�f y Fxs� .....
No.. ..
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
............ ....................OF... .► 5.. .1-: _..._................_.........
Appliration for Uiapnaal Works Tnnitrurtiun Prrutit
Application is hereby made for a Permit to Construct ( A4 or Repair ( ) an Individual Sewage Disposal
System at:
�(.�14�_ .T�.t:..........
_.... -•. ................................... ------••---- ..... ...... ..............
�/� Location-A ess or t N�
Z' :�- i4� t �- � .......................
Own Address_
el
a ---...
I taller Address
Q Type of Building Size Lot43a...........L..._..Sq: et
U Dwelling—No. of Bedrooms.........3...............................Expansion Attic WO Garbage Grinder )5
'4 Other—T e of Building No. of persons............................ Showers — Cafeteria
Q' Other fixtures -------------------------------- -
W Design Flow.....J`- ..........gallons per person per day. Total ily,0ow--------- ....................gallons.
WSeptic Tank—Liquid capacity.L allons LengthA0.'(0_. Width_ B.... Diameter................ Depth.,.-.1�5
x Disposal Trench—No. .................... Width.................... Total Length..................... Total leaching area....................sq. ft.
Seepage Pit No........I-----.-_---- Diameter....... Depth below inlet.... .._..... Total leaching area..................sq. ft.
z Other Distribution box ( $ Dosing_ nk ( ) �
0-4 Percolation Test Results Performed b '� _2Z ..!.Y................................
Y _ ��
a Test Pit No. 1--4Z-..__minutes per inch Depth of Test Pit..... ......... Depth to ground wate 1 &N
44 Test Pit No. 2................minutes per inch Depth of Test Pit--- Depth to ground water........................
P4 •-----------------------------•-- ....---..._._...........-----------......_..................................................
0 Description of Soil....Z= 2--•WAVVIL C2_ �-- Z� m �-----.�A?dD.............
x
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 TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has iss ed7th ar health.
� .��Signed ......... ............ ............. .....--- ...
Application Approved By ..... ... 1�--'
U Date
Application Disapproved for the following reasons- ----------------------------------------------------------------------------------------------------------------------------------------
---------------------------------------------------------------------------------------------------------------------------------------------------------------------.......................................... ---------------------------------------
Date
Permit No. .....r.?----�a �y....................... Issued ---...-���'�^
------------- -------
Date
2-
Noll.. ....... F�$. .....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Applirattion for Disposal Works Toustrnrtion Prrmit
Application is hereby made for a Permit to Construct ( or Repair ( } an Individual Sewage Disposal
System at
-• }- ---.. .�:�..�.... .�' .............................................` ....... ���..k..- "a•......°-....•.... .... ..............
...........
Location Address �.� - r
` n Imo: : .. :.�' .. . ..�.. ° :.. ►�!f��.
.�. .._...... l�u-
Owner Address
W - ----------------------------------------- .... .,���. .....
a 4
Installer Address ,P�.
Q Type of Building Size Lot___ ?>.: ........i.......Sq. feet
Dwelling—No. of Bedrooms........ ...............................Expansion Attic (n,e Garbage Grinder` )
aOther—Type of Building ............................ No, of persons............................ Showers ( ) — Cafeteria ( )
Other fixtures`.
W Design Flow...... ::. gallons per person per day. Totahc�atlysf�ow....... ........................gallons.,
...- .
WSeptic Tank—Liquid capacity , *: allons Length.;', ._ r.__ Width_ .:. , ...._ Diameter________________ Depth
x Disposal Trench—No. ..:....
............ Width,...,,,,,........... Total Length.._...__...f..__.._ Total leaching area....................sq. ft.
Seepage Pit No..................: Diameter-______`( °...._. Depth below inlet...�.: _.._.__._. Total leaching area..................sq. ft.
z Other Distribution box ( —1- Dosing tank
Percolation Test Results Performed by......................... ........ ........ Date-_---I—-
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........................
............ --------------•----�..---------------
0 Description of Soil•-•t=1...................................
.F .. ...........; .,. ` .`+ .................................. + 1 s e,
�- s
-•-- . •. •• ••---- ••--•-- ....... .
x
U -----------------------
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....................
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••-•------------
Wt---------------•-----------------•••-•--•--•------------------•--•-••-•--•----••-.......----•-----------------------------------•----------------------•-----------------•••......••-••--•--......
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
•--------•-----------------------••----------------------------------------•-••-••-•---•-----......••---••••-••---•----••-•-----•--••--•---•-••----•••---•••-•--••---•--•-•-•••••-----•................
Agreement:
The undersigned agrees to install the'aforedeseribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of ComplianceWhasbe 's-ssued b t e of health.
Signed . ............................. ...../-.---
Application Approved By ---------------- --- --------------------------------------------------------------------------------------------------------------------
Dace
Application Disapproved for the following reasons: .................... ........................ .... .................................... ......................................
-- -- ------------------------------
Permit No. X-P -79-4�6.......................... Issued
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Cer#ifirate of C90m Cianre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( :K ) or Repaired ( )
by............ .!. .. -.. ,� ----- ..... ---------------- -- _ ------------------..._..---- . . --------------
ZX
Inst_alle
�".:at r+€ + t wyt z '.` T !�4 .. .. . `� -......... ............... - --- --- ........... ..
--- -----
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. y. ,.�............ dated ................... ....... -.......
THE ISSUANCE OF THIS CERTIFICATE SHALL NBf CCSl7ED AS A GU� fi�MTHE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE f f ff/ ��t t .......................................' �.�L�'.-✓(
..........-_.f.....................
Inspector
% ,f
r I
THE COMMONWEALTH OF MASSACHUSETTS
BOARQ 'OF HEALTH
...............OF..... .................................
,�`..... F --
Disposal Works %Tnnstrnrtaon rrmit
Permission is hereby granted � Ow.. r-------------------•--------------------------------••........................
to Cons;uc or Repair ) an I dv'dual Seer e Di osstem
at No..---`�-E- ..- �' !vr,�a�,���5 �. cam.` .............r��-�.' �.
.......
Street
as shown on the application for Disposal Works Construction F;p mit 70r__-___ Dated -.._... _
.
Board of Health
DATE-------- f f ` .................................... `Vl
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