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HomeMy WebLinkAbout0131 NICKERSON ROAD - Health 131 Nickerson Road T Cotu'it -- __ A= 018 -093 .3 TOWN OF BARNSTABLE V 1 LOCATION /3/ 14-1ee('Sa r) 'k2CP # S P VILLAGE dole i ASSESSOR'S MAP&PARCEL Rom'S NAME&PHONE NO.('�r"plc (k o✓1 rL (l Claa-1'175 SEPTIC TANK CAPACITY /Uaa LEACHING FACILITY: (type) 17D1 (size) 1006 Y NO.OF BEDROOMS OWNERS�1 q PERMIT DATE: C ATE: 161 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leac ' g ) Feet FURNISHED BY ' r f r r r r f r:r f ♦ f f'r r r r r r r r'r r / I'•r ♦ r f r r„r f r / r r r f r f f J,!-'/�'r . r r r I f r r J r ♦ r r r J ♦ f r r r r f f r ! / ♦ r r f J I ♦ r / f f r " Coveratgr'ade v , Wunder deck. . r f.,.f ♦ f ♦_.r r'f:.f f /. f J f , r I ♦ r f !.♦ f ! f f r I r .. 21 Commonwealth of IVlassachusett:� x ASSESSORS MAP NO: ■ • • d CIS' - W Title 5 Ofificra . Inspection Form' PARCEL NO- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 131,Nickerson Road- ° Property Address Karen,Bailey , Owner Owner's Name information is required for Cotult% . . , MA" 02635 July 8;2009 -- every page.„ Cityfrown State Zip Code Date of Inspection•, Inspection.results must be'submitted on,this form. Inspection•forms may not be altered in-any, way Important: (� When filling out A• Gelneral_Irtforrnation \` . ) ' b9forms on the - V computer,use 1. Inspector: only the tab key to move your Patrick M. O'Connell cursor do not• Name of Inspector r use the return key. :` Septic Inspection Services.Co Company Name Iviaw 189 Cammett Road Company Address Marstons.Mills MA 02648 Eenn Cityfi•own State Zip Code 508-428-1779 ;;.>: ri,S1.12855 Telephone Number License Number. • B. Certification I certify that) have personally inspected-the sewage disposal system at.thi•s 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 Loral Approving Authority 1�c-- July 8, 2009 Inspector's Signature Date =" The system inspector shall submit a_copy of this inspection report toahe 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 tot he 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 repot 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.. N 09,122 Bailey.doc 08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts Title .5 ®f i I Inspection e tio n Form rm ;. Subsurface Sewage Disposal System Form- Not for Voluntary Assessments M 131 Nickerson Road r Property Address Xaren Bailey , Owner Owner's Name information is Cotuit t MA 02635 July 8, 2009, required for . -- every page. Cityfrown State' Zip Code Date of Inspection B. Certification (conQ` Inspection Summary: Check A B;C,D or,E/always complete all of Section D` 4 ' 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 exisCAny failure criteria not evaluated are indicated below. Comments: . Tank is not in need of pumping at this time, leaching pit has 1 foot of standing water with no high stains. 13) System Conditionally Passes: i i e One or more s-'stem components as described in the"Conditional Pass section n e d 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 R for the following statements. If"not. determined,` please explain. ❑ The septic tank is metal'and over 20 years old* or the septic tank (whether metal or not) is structurally.unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. : . System will pass.inspection if the existing tank is replaced with a complying septic tank as approved by the Board.of Health. - *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is:less than 20'years old is available. ND Explain: , '❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass.inspection if(with approval of Board of Health): broken pipe(s) are replaced 0 obstruction is removed.. 09.122 Bailey.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 ` Commonwealth of Massachusetts; 53 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments. -131 Nickerson Road Property Address Karen Bailey Owner Owner's Name information is Cotuit ' MA , 02635. : July 8, 2009 required for every page. ,' City/Town4: State Zip Code Date of Inspection B. Certification'(cone.) B) System Conditionally Passes.(cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ .The system required pumping.more than;4 times a year`due to broken or obstructed pipe(s). The system will pass inspection if.(with approval of the Board of Health). a ❑: broken pipe(§) are replaced ❑ . obstruction is removed ND Explain: 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 iri accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which'will protect public health, t; safety and the environment: ❑ Cesspool or privy;is within 50 feet of a surface water. ❑ Cesspool or privy is'within 50 feet of a'bordering vegetated wetland or a salt marsh 2. System will fail'unless the-Board of Health (and Public Water Supplier, if any) determines that the system is'functioning,in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil.absorption system (SAS)and the SAS is within 100`feet of a surface'water supply or tributary to a surface water supply. ❑ The system has aseptic 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 upply,well: + 09-122 Bailey.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 15 Commonwealth of Massachusetts Title 5 Official Intpection Form' Subsurface Sewage Disposal System Form Not for Voluntary Assessments` ,M 131 Nickerson Road ;:Property Address ` y, `Karen Bailey Owner s. Owner's Name information is. Cotuit MA 02635. July 8, 2009 required for -- ,,, every page. CityMwn'_: State Zip Code Date of-Inspection B. Certification (cont.),, C) 'Further Evaluation'is Required,by the Board of Health (cont:): The systemhas a septic tank and SAS and the SAS is less than 100feet 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: { s D) System Failure Criteria Applicable to All Systems: ' You must indicate r'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 town overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6" below invert or available volume is less than_day.flow ' Required pumping more than 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: 09.122 8ailey.doc 08106 ° Title 5Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 i ., .. i Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for•Voluntary Assessments 131 Nickerson Road Property Address' -- Karen Bailey Owner - Owner's Name s r information is Cotuit MA 02635 July 8, 2009 required for . --., every page.' City/Town State Zip Code Date of In `. . I; B. Certification (cont.). D) System Failure Criteria Applicable to All Systems (cont.):- Yes No [] Any portion of a cesspool or privy.is within a.Zone 1 of a public well. a: Any portion of a cesspool or privy is within 50 feet of.a private water supply .. : well. E 1z 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 ac ceptable table water quality analY- sis. [This t ,Y s sem asses if the well water analysis, :Y. .. p Performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence, F of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, .provided that no otherfailure ceiteria'are triggered. A copy of the analysis fi and chain of custody must be attached to this form.] ' ® The system is a cesspool serving a facility with a design flow of 20O0gpd 10,000gpd.` ® The system fails: I have determined that one or more of the above failure El criteria exist as described in 31O,CMR 15.303, therefore the system fails. The 4 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 ❑ 0 the system'is within40O 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 0 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. . 09.122 Bailey.doc•0.8106 Title 5 Official lnspection Form:Subsurface Sewage Disposal System•Page 5 of 15 ell Commonwealth of Massachusetts ' W Title 5 Official (Inspection Form fd Subsurface Sewage Disposal System Form - Not for Voluntary Assessments '131 Nickerson Road Property Addresa Karen Bailey Owner = 'Owner's Name information is Cotuit required for MA 02635 July 8, 2009 __ 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 n 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) ®'.. ElWas the facility or dwelling'inspected for signs ofsewage back up? ® ❑ Was the site'inspected for,signs of.break.out? _ 1Z ❑ Were all system components, excluding the"SAS, located on site?: { i ® ❑ 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.rhaintenance of subsurface sewage disposal systems? The size and,location of the Soit 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 ® ET approximation of`distance`is unacceptable) [3.10 CMR 15.302(5)1 09-122 Bailey.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 I i Commonwealth of Massachusetts' W Title 5 Official Inspection Form Subsurface.Sewage Disposal System Form - Not for Voluntary Assessments 131'Nickerson Road Property Address ' Karen Bailey W _ Owner Owner's Name information is required for COtult MA 02635 July 8, 2009 . . _-. every page. CityrTown state Zip Code Date`of Inspection D. System Information ; Residential Flow Conditions: Number of bedrooms (design): —3 Number of bedrooms (actual): 3 330 DESIGN flow based on 310 CMR 15.203-(for example:.110 gpd x#of bedrooms): Unknown Number of current residents: Does residence have a garbage grinder?,; ❑ Yes ® No ,Is laundry,on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No } Laundry systerrl inspected?. El Yes ❑ ,No 7. Seasonal use? : ❑ Yes ® No N/A Irrigation Water meter readings, if available.(last 2 years usage(gpd)). system. Sump pump? ❑ Yes ®- No . E . } Currently. Last,date of occupancy: Occupied r 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 systems ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: pate Other(describe): 09-122 Bailey.doc•08106 Title 5 Official Inspection Form:'Subsurface Sewage Disposal System•Page 7 of 15. r. 'Commonwealth of Massachusetts W Title, 5 Official Inspection :Form: Subsurface Sewage Disposal System Form - Not for Voluntary.Assessments 131 Nickerson Road Property Address Karen Bailey Owner Owner's Name t information`i s required for Cotuit MA 02635 July 8, 2009 every page:. City/Town State Zip Code Date of Inspection: y = D:.System Iriformation.(cont.) General Information . Pumping Records: Source of information: Tank pumped 7/30/08- - Was system pumped as part of the inspection? ❑ Yes ® No If yet,volume pumped. gallons How was quantity"pumped determined? Reason for pumping; 5 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) ❑ v ;Tight tank. Attach a`copy of the DEP approval. ❑ . Other(describe): s Approximate age of all components,'date installed'(if known) and source of information: Compliance date: 1/22/86 .Were sewage odors detected when arriving at the site? ❑ Yes ® No i 09-122 Bailey.doc•OW0.6 Title 5 Official Inspection Form:Subsurface Sewage Disposal System=Page 8 of 15 .Commonwealth of Massachusetts Title 5 Official Inspection Pot Subsurfa.ce.Sewage Disposal System Form Not for Voluntary Assessments. _ 131 Nickerson Road Property Address Karen Bailey.` Owner, Owner's Name information is Cotuit MA 02635 July 8 2000, required for — every page. :CityfTown State Zip Code Date of Inspection D. Systein .lnformation�(cont.),. Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron; 940 PVC ❑ other(explain): Distance from private•water supply well or suction line: feet. . ' Comments (on condition of joints, venting; evidence of leakage, etc.)._ 1 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 Conipliance?:(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 8.5'.long x 5.2'wide- 1000 gal. Sludge depth: Distance from top of sludge.to bottom of outlet tee or baffle„ Scum thickness Trace Distance from top of scum to top.of outlet tee or.baffle Distance from bottom of.scum to bottom of outlet tee or baffle_ How were dimensions determined? Measured 09-122 Bailey.doc•08/06 . Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 9 of 15 } j Commonwealth of-Massachusett Title 5 Official Inspection - Form Subsurface Sewage Disposal System.Form - Not for Voluntary Assessments ' 131 Nickerson Road, I Property Address Karen.Bailey. Owner !. Owner's Name, ,.. r. •_ i . information is COtult MA; 02635; Jul 8 2009 r• required for .: --- .. Y i every page., City/Town State Zip,Code Date of Inspection D. System Information (pont.)': Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related tooutlet invert, evidence of leakage, etc.'): Tees are'intact and clear: Liquid level found'at bottom of outlet invert. } Grease Trap (locate on site plan):: Depth below grade: ' feet<. Material of construction: ❑ concrete ❑ metal ❑.fiberglass' polyethylene El other(explain): i 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.): r Tight.or Holding Tank (tank must"be pumped at time of inspection)`(locate on site plan): ,Depth below grade` - Material of construction; - ❑ concrete L. ❑ metal ❑ fiberglass ❑ polyethylene" '❑ other(explain): 09-122 Bailey.doc•08/06 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 . 131 Nickerson Road Property Address_ Karen Bailey Owner .. . Owner's Name— inform ation is ; required for. Cotuit MA 02635 r July 8, 2009 ` every page. Cityrrown Stale Zip Code Date of Inspection D. System Information ,(cont.) Tight or Holding Tank (cont.),, Dimensions: Capacity: gallons` t Design Flow: gallons per day t _ Alarm present: ❑ Yes ❑.No Alarm leve l: Alarm in working`,order.: ' ❑, Yes ❑ No Date of last pumping: Date, Comments (condition of alarm and float switches, etc.); *Attach'copy of!P6rrent;pumping contract (required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be�opened) (locate on'site plan) 0, Depth of liquid level above outlet invert 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.`` I= pump:Chamber(locate.on site plan).- Pumps in working order. ❑'Yes ❑ No. Alarms in working order. ❑ Yes. ❑ No ! 09-122 Bailey.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 11 of 15 s Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 131 Nickerson.Road Property Address Karen Bailey' T Owner Owner's Name --- •information is 'required for - Cotuit , _ MA 02635. July.8; 2009 every page.` CitylTown.' State Zip Cade: Date of Inspection D. System lnformation.(cont.) ' t Comments (note condition!of pump chamber..condition of pumps and appurtenances, etc.): Soil Absorption $ystem.(SAS) (locate on site plan, excavation not required): a If SAS not located,,explan'why' e Type; t leaching pits number._ One 6x6 pit. ❑ .. . leaching chambers number: s El leaching galleriesI number. 'leaching trenches number, length:- . . 0 leaching fields number, dimensions: ❑ overflow_ cesspool number. . ❑ . innovative/alternative system j Type/name of technology:. Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation;etc,): _ Leaching pit had one foot of standing water with no high stains. l l 09.122 Bailey.doc 08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Ins ectioh Form o Subsur face Se wage a Disposal S ste g , p y m.Form Not for Voluntary Assessments 131 Nickerson Road Property Address Karen Bailey Owner Owner's Name ., — y information is required for... Cotuit MA 02635 July,8, 2009 every page. Cityrrown State Zip Code Date of Inspection A 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 R Depth of scum layer Dimensions of cesspool a •. 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.):. i Privy (locate on site.plan): Materials of construction: a Dimensions — Depth,of solids { Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): P I 09-122 Bailey.doc•08/06_ Title 5 official Inspection Form_:Subsurface Sewage Disposal System•Page:131of 15 . '. .,. Commonwealth of Massachusetts Title 5 Official Ins��ection Corr Subsurface,Sewage Disposal System Form - Not for Voluntary Assessments w„ s= 131 Nickerson Road —_ ----— - - - ------------- _..------- — -- -- ---- Property Address Karen Baile Owner Owner's Name information is ' COtult y MA 02635 July-8, 2009 . required for — --- -- --- -- - — every page. Cily/Towri Stale Zip Code Date of Inspection . D: System lnforr�iation (cunt:) Sketch Of Sewage Disposal System- Provide a sketch of the sewage disposal system including ties tout least two permanent reference landmarks or benchmarks. Locate all wells within.100 feet. rthe.-building., Locate where public water supply enters .'. • ater` ervice. E ♦!\, ,\,\!\, Cover at grade , , . \ , \ , under deck 42 . t Commonwealth of.Massachusetts Title :5 ®fficial ln� �ction Form a Subsurface Sewage Disposal System Form - Not.for Voluntary Assessments 131 Nickerson Road Property Address Karen Bailey Owner. Owner's Name information is COtUIt .. MA y 02635 Jul required for 8, 2009 every page. City/Town State Zip Code Date of Inspection D: System nfarmation (cont) Site Ei S am: . ® Check Slope ® ,Surface water Check cellar ® ,Shallow wells 30 Estimated depth to ground water. ` feet Please indicate all methods used to.determine the high ground water elevation F ❑ R Obtained from system design plans on record If checked, date of design plan reviewed: pate ❑ Observed site (abutting property/observation hole within 150 feet of.SAS) ,- ❑ Checked.with local Board'cifHealth =explain: Checked with local excavators, installers'- (attach'documentation) i ® Accessed USGS database explain:. USGS topo map and town`GiS. You must describe how you established the high ground water elevation: i Topo map shows property above el 30 and town groundwater contour map shows water below el. 5 09-122 Bailey.doc"08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 15 of 15 r" , rior �. A T ION JEMW A G E PE RMiT N0. V 1 L L A G E ® h r e4 e— L/ 1�' , 1'N ST'A LAR'S NAME: is . .ADDRESS' M U I-L/D E R OR OWN ER , D&T E` PER-FAIT ISS.0 E D r DATE: COMPCIA,NCE IS,SU..ED , �� r Fint ........... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH **-*"IOWA)..................OF....... ................OF....... r,r.�/ AvOiration for %Vasal Workii Towitrurtion Fernfit Application is hereby made for a Permit to Construct ( &<or Repair an Individual Sewage Disposal System at: .................... ...................................�35 ... ............................................... Location Address or Lot No. COJ/l�C'?. ....... . ................................................................................................ Owner Address ..................... .............................................. . .................................................................................................. Installer Address Type of Building Size Lot_/44_46._P....Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder aOther—Type of Building ............................ No. of persons........6............... Showers Cafeteria Otherfixtures ............................................................................................................... o .......... gallon Design ,Flow..........................,tr.____gallons per person per day. Total daily flow...................%3% S* Liquid capacity f &f... 14 " 9 Septic Tank /0".gallons Length-0-4... Width.4- .'10*... Diameter................ Depth.,57. ..... Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area. sq. ft. > ....... Seepage Pit No..........4........ Diameter.J0... ..... Depth below inlet.......6... Total leaching area..�.... .......sq. ft. Z Other Distribution box (L")l Dosin Percolation Test Results Performed by .................................;or............................ Date_._ --------------------- Test Pit No. I....Z.......minutesperinch Depth of Test Pit____- Depth to ground water.....:_— Test Pit No. 2................minutes per inch Depth of Test Pit..__............__.. Depth to ground water........................ ............................................................................................................................................................. IV X_,Z) 41 0 Description of Soil.... ...... ......... ................................................................................ -------------------*...... ----------------*---------------------------------------*----------------------------------------------"------*--------------------*----------- ------ ........................................................................................................................................................................................................ 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 TITLE 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in C operat un it Cer to of Compliance has been issued by the board of health. 'p is Approved y......... .......... ed-------------------------------------------------------------------------------------- .............. ?!e onApproved By.......... ... ...........A .................................................................... Da,t'e-------------- Application Disapproved for the following reasons:-------------------------------------------------------------------------------------------------------------- ......................................................................................................................................................................................................... Date PermitNo....... ......14C..Q........... Issued....................................................... Date ------------------------------------------------------------------- No...2.^ 1.. (451 Fz$...' ._ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 'J----------------OF Appliratiun for Disposal Works Tonstrttrtiun Permit Application is hereby made for a Permit to Construct ( i-j"or Repair ( ) an Individual Sewage Disposal System at: . .o 1... ...... ......... _'-,ai vq--�.............................. ---------------»----»»..»..»---------- _ Location-Address or Lot No. co A.Ar - Owner Address q - -------------------------- -----•-----------•--••----•----------•---.....---..................................-----.......... Installer Address U Type of Building Size Lot./4'# .U...Sq. feet ., Dwelling—No. of Bedrooms.......................:....................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of ersons........G............... Showers a YP g ----•....................... p ( ) — Cafeteria ( ) Other fixtures .....��.... - •- ........ W Design Flow........................:. �d......_..gallons per person per'day. Total daily flow..._.__.._......... 3. _.. ....._gallon WSeptic Tank—Liquid capacity dgallons Length....__G__.... Width.¢..!q.... Diameter................ Depth.::s.4..... x Disposal Trench—No--------------------- Width..i....N.._...... Total Length.................... Total leaching area......._..... sq. ft. Seepage Pit No........... - "_.. Diameter...l�_.G. Depth below inlet Total leaching area-.Z .sq. ft. ..... ....... Z Other Distribution box (L-� Dosing lc ) ~' Percolation Test Results Performed by - �C �99+��Ns Date 8 . a -----•--•----••...................... ---....�� ...... Test Pit No. 1..... ......minutes per inch Depth of Test Pit..... ' _ .... Depth to ground water,......^:-:-:......... 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ----------------------------------------------------------------------------•-•y ................ ........................•---- ..----- --..............:_........--•...........-•---...........•.........---...... 0 Description of Soil.....MC .fu-/ 5AV G.OW l x ... . ............._...-•---••--•---••..._..........._...._..._--••......._......--•-•• V ------------------------ --....... ---------•--------•--..--------- ------- •.......... •----•-................................................................................. 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 Sanitary Code—.The undersigned further agrees not to place the system in ope - n unt' a rtificate ofkComl.' has been issued by the board of health. ned..-----•--•................•----••--..........--•---•-•---•... . - Date Appl• tion Approved By....-- .-. ° ��'� .. ... » !/ 5��D .............. Application Disapproved for the following reasons-------------------••--•--------•----•-------•---....---•----•-------------------•-••..............---•....»»» .................... .......................•............ -..._....--•---•---•--••-•-.........--•.....................•.........•• •D�•-.......... Permit No...... '=--(4, -�•----------- Issued..................................................... ... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... Tntif iratle of f ompliattre - THIS�D CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by................... !! rrr .....-•-------•...............••--•----••-•-----...........---••--•------•..: ._.......... ...............»......»...._.:.--•--....»..»»..» Installer at._..........- C:- ......z-:5 —a`_4.------....&---------=TE c.�:.��.........12-14------- e K ut-- ------------------------------------— has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Crde�s described in the application'for Disposal Works Construction Permit No...S`- -----•I.CX2(a......... dated.........).TT/(�'��5;t. ................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL F N��TION SATISFACTORY. DATE... - -•--_... .....�Z 1. .......:........... Inspector.....`_ ...........-----•---•----•-•-••---•....................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH S � ................................OF..................................................................................... No.. ...........�...... Fay.... ........... Disposal Works f�nnntrnrtiun f erntit . `'�errnission is hereby granted............... •----------•--•---......--•--- •.• to Construct or Repair ( ) an Individual Sewage Disposal S stem at No..........L.- ......... Street as shown on the.application for Disposal-Works Construction Permit N .�...�� ated ---..�.�._:...: '......•.•..... c .....:..:.................••-- -_. ...... --•---...................» DATE....... -- --..___ _..?.. m.............. ..2. ka card of Health FORM 1255 A M. SULK1'N, IIV BOSTON ` I I --- - I I I . I I 11 I ., , ,—, "I -- I . 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