HomeMy WebLinkAbout0072 OXFORD DRIVE - Health 7i oXforanrivt1 7 C9( t
A=021-065
I
I.
w
0ATe :8/13/01-- -- -
P R O P E R T=Y A O OR E SS:Dick-Toboj ka -- w-w---
_ '72 Oxford Drive __r-___ .
Cotuit,Mass. 02635
On tho above date, I Inapooted the 8eptfo UylteM at the aboYe address.
Thli aySlom conslsla of the lollowingc
1 . 1 -1000 gallon septic tank.
2. 1 -1 000 gallon precast leaching pit.
8e3ed on my Inepecllon, I cortlfy the following oondlt onu.
3 . This is a title Five Septic System. ( 78 Code ,)
ABLE
4 . The septic- system is in ro proper working order TowNOFsaREPT.
p p 9 r .HEALTH DEPT.
at the present time.
ti $ICNATVRE!
} Name : ----- /.
Compeny; Jot • 2h-P �_N•c_omb.r-b Son , Inc , ` jr—
A d d r e 5 5 ;_ b o x- 6 6-----w-------
nCrrr111eL Na ,-02632-0066
Phone _ 508 775- )778-
- - - ww wv
THIS CCATIFICATION OOCS NOY CONSTITVTC A OVARANTY OR WARRANTY
JOSEPN P, WOOMSER & SON, INC.
Y+nk� Or��pool'I�lr+chllrld+
Pymprd 1, Initillyd
Town 3rwrr Connrollons
P.O. Box 66 CintrrYlllr, MA 02632-0066
775.JJJ0 775'6(12
1
i
-\ COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 72 Oxford Drive
Cotuit,Mass.
Owner's Name:Dick Tobol ka
Owner's Address: 8/1 3/01
Box 972 Cotuit,Mass_ 02635
Date of Inspection: 8/1 3/01
Name of Inspector: (please print) Joseph P.Macomber Jr,
Company Name:J.P.Macomber & Son Inc.
Mailing Address:Box 66
2632 y
Telephone Number: 8-775-3 38
CERTIFICATION STATEMENT
1 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. 1 am a DEP '
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
_Passes '
Conditionally Passes
Needs Further Evaluation by the Local Approving.Authority
F Xils f
Inspector's Signature: Date: / ✓
The system inspector s ubmit 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 describ s 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.
. F
Title 5 Inspection Form 6/15/2000 page I
r
Page 2 of 1 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 72 Oxford -Drive
o ui ,Mass.
Owner: Dick To of a
Date of Inspection: 8 1 3 01
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes: ,
have not found any information hich indicates that any of the failure criteria described in 310 CMR
15.303 or to 3 C 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
The septic system is in proper working order at the present time.
B. System Conditionally Passes: x
22b_ 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:
NOS Observation of sewage backup or break out or high static water level in the istribution bo due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed -
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken'or obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced .
obstruction is removed
ND explain:
h
2
Page 3 of I I
OFFICIAL INSPECTION FORM - NOT FOR.VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 72 Oxford. Drive
o ui , ass.
Owner:Dick To o a _
Date of lospcctioa: 8 1-3 01
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,,safcry or the environment.
I. System will.pass unless Board of Health determloes in accordance with 310 CMR 15.303(1)(b) that the
system is not functioning in a manger wbich will protect public bealtb, safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is witbin 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 fuoctioning 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 rributary to a surface water supply.
The system has aseptic tank and SAS and the SAS is within a Zone I of a public water supple,
kThe system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has aseptic tank and SAS and the SAS is less than)90 feet b 50 feet or more from a
private water supple well". Method used to determine distance ,
'This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other-
3
Page 4 of I I
a
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 72 Oxford Drive
cotuit,mass.
Owner: Toboj ka Dick
Date of Inspection: 8/13/01
D, System Failure Criteria applicable to all systems: `
You must indicate 'yes"or"no" to each of the following for all inspections:
Yes No
�ackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
ischarge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cessp
Staiic liquid level in the distribPan6"'
bove outlet invert due to an overloaded or clogged SAS or
cesspool 1 .�t
4Liquid depth in4ciip W: is lessow invert or available volume is less than 'h day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped
!�
y portion of the SAS, cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy is within )00 feet of a surface water supply or tributary to a surface
water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
_ /vny 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. (Tbis system passes If the well water analysis,
performed at a DEP certified laboratory, for collform 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 S ppm, provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.)
(Yes(No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303. therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. ~ Large Systems:
To be considered a large system the system must serve a facility with a design flow of I o,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 /�
ldthe 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
i" 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.
4
r
Page 5 of 1 1
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 72 Oxford Drive
o ui ass.
Owner•Dick To of a
Date of Inspection: 8 1 3 01
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
JzWere any of the system components pumped out in the previous two weeks ?
s 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
-lam — 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 ?
y _ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the.site has been determined based on:
Yes no
Existing information. For example,a plan at the Board of Health. +
_ _ 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)]
r
5
Page 6 of 1 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 72- Oxford Drive
P Y -
o ui t,M ass.
Owner: Dick Toboj ka
Date of Inspection:8 f 1 3101
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual): ,p
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 1 JP
Number of current residents: I
Does residence have a garbage grinder(yes or no): �
Is laundry on a separate sewage system fyes or no): Vj) (if yes separate inspection required.]
Laundry system inspected(yes or no):
Seasonal use: (yes or no):. `'s f�, 4A
Water meter readings, if available(last 2 years usage(gpd)): 1 0 'f/�g'y �"•cl
Sump pump(yes or no): ,� 'ma v�"
Last date of occupancy:
COMM ERCIAL(INDUSTRIAL
Type of establishment:
Design flow(based 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)/A
Non-sanitary waste discharged to the Title 5 system (yes or no):2V
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: Vol
Was system pumped as part of the inspection(yes or no):_
If yes, volume pumped: rO gallons-- How was quantity pumped determined? m
Reason for pumping: 422 ,{,gyp ,�yryl�lf
TY E OF SYSTEM
Septic tank, di=ib-tine-box,soil absorption system
Single cesspool
4A Overflow cesspool
Privy
Shared system(yes or no)(if yes,attach previous inspection records, if any)
Innovative/Altemative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight tank Ne Attach a copy of the DEP approval
ND Other(describe): /4 .
Appro��te�e of�1�otte�tt��ate In (if known)and source of information:'
Were sewage odors detected when arriving at the site(yes or no):
r
6
Page 7 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 72 Oxford Drive.
o ui , ass.
Owner:Dick Tu o] a `
Date of Inspection:
BUILDING SEWER(locate on site plan)
1
Depth below grade:
` Materials of construction: cast iron 41040 PVC li/othe r(explain):st/�
Distance from private water supply well-or-suction line:
Comments(on condition of joints, venting,evidence of leakage, etc.):
Joints appear tight.No evidence of. leaka e.SYSTEM IS VENTEd
through the house vents.
SEPTIC TANK: Zlocate on site plan)/
Depth below grade:
Material of construction: concrete�metal<Y_fiberglass polyethylene
0-other(explain)
If tank is metal list age:4,?4 Is age confirmed by a Certificate of Compliance(yes or no)W.* (attach a copy of.
certificate)
Dimensions: Py/1pt,e ✓!��,
Sludge depth:
Distance from top of;judge to bottom of outlet tee or baffle: 41'�
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom 4outlet tee or baffle:
How were dimensions determined:
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 the septic tank annually.Garbage disposal is present
Inlet & outlet tees are -in place The tank is structurally sound
and shows no evidence of leakage.
GREASE TRAP. L(locate on site plan) v
Depth below grade:4/1
Material of construction:0 concrete tO metaWlf fiberglass4 4fpolyethyleneA# other
(explain): A
Dimensions: .110
Scum thickness: 1444 `
Distance from top of scum to top of outlet tee or baffle: V10
Distance from bottom of scum to bottom of outlet tee or baffle: 414
Date of last pumping: .41,V'"
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
Grease trap is not present.
7
Page 8 of 1 1 ,.
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 72 Oxford Drive
o ui ,Mass.
Owner: Dick Tuboj ka ,
Date of Inspection: 8/13/01
TIGHT or HOLDING TANK(tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: AIX `
Material of construction: jj&concrete�gametal A[gfiberglass�9 polyethylene W/,d_other(explain):
A14
Dimensions: _ iQ
Capacity: AV allons
Design Flow: AIA gallons/day
Alarm present(yes or no): '
Alarm level: _QAL Alarm in working order(yes or no):
Date of last pumping: AIV
Comments(condition of alarm and float switches,etc.):
Tanks or holding tanks are not.. present.
DISTRIBUTION BO ,t" (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:�.A
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.):
Distribution box is not present
PUMP CHAMBER)Z&y(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 chamber is not present.
8
Page 9 of 1 1
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 72 Oxford Drive
Co uit,Mass.
Owner:Dick Tubo'ka
e
Date of Inspection: 8 13 01
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Type
Al leaching pits, number: 1
4)0 leaching chambers,number: r�
leaching galleries,number:
110 leaching trenches,number, length:
leaching fields,number, dimensions:
710—overflow cesspool, number: 0
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.):
Loamy sand to. fine sand.No signs of hydraulic failure or
ponding.Soils are dry.Vegetation is normal.
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 or no):
Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
Cesspools are not present_
PRIVY4�(locate on site plan)
Materials of construction: �� a
Dimensions: yA
Depth of solids: . dl
Comments(note condition of soil, signs of hydraulic failure, level.of ponding,condition of vegetation, etc.):
Privy is not present
9
f
Page 10 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address• 72 Oxford Road 7
Owner: Dick Tuboj ka
Date of Inspection: 1
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch or 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.
i
p
-----------------
10
Page I I of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address!72 Oxford Drive
Cotuit,Mass.
Owner: Dick Tuboj ka
Date of Inspection: 8/13/01
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water /(9 feet
Please indicate(check)all methods used to determine the high ground water elevation:
r
Obtained fro ern desi s on record-If checked, date of design plan reviewed:
bserved site abuttin to bservation hole within 150 feet of SAS)
ecked 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:
Water Contours Man_
12/16/94
11
la
•TT{T r'n•r�r•-rr-trn:mr•ntPrrr•+ert re'rrr..R rt7e-�tr�nr+rr*t.mn rRntlY rA•7n�t1.T t'TTT-T.-Zr-..- r
t' '1'UWN OF Barnstable BOARD OF HEALTH
SUI;SURFACF SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION I+
«•rn-r••.•:'t—T.III.�.T.TT{ltr.+n-rt.•rrl TRlrl�e9lnTT'r:r-.t9 nvrR`t wRwr'T�►�wf wl�rR7A7 t.w1 .++rrr•r-•1, •�..A ',
-TYPE OR PRINT CLEARLY-
P/IOPERTY INSPECTED
STREET ADDRESS 72 Oxford Drive Cotuit,Mass.
ASSESSORS MAP , BLOCK AND PARCEL #
OWNER' s NAME Dick Tubolka
PART D - CERTIFICATION
NAME OF INSPECTOR Joseph P. Macomber Jr.,
COMPANY NAME Joseph P.. Macomber V ion Inc
COMPANY ADDRESS Box 66 Centerville Ma 02632
Street Town or City - State LIP
COMPANY TELEPHONE (508 ) 775_ - 3338 FAX ( 508 .) 790 - 1578
-
w
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage diaposa7 system at
this address and that the information reported is true , accurate , and
omplete as of the time ofbinspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience • in the proper function and maintenance of on-
site sewage disposal systems ,
Check one :
System PASSED
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
health or tlie .env ironment as defined in 310 CMR 160303 , Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form , µ
System FAILEll*
The inspection which I have con tcted has found that the system fails to
Protect the j*)ublic health and the environment in accordance with Title
51 3.10 CMR 15 , 303, •and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form .
Inspector Signature Bats
ne copy of this ce ification must be provided to the OWNER, the BUYER
( where applicable ) and the BOARD OF HEALTII,
* If the inspection FAILED, the owner or.,M operator shall upgrade ' the eyetem
within one year of the date of the inspection , unless allowed or required
otherwise as provided in 3.10 CHR 16 . 306 .
partd .doc
C&TION / 5EW&C4E PERMIT UO.
7 6 o
IMS-T&LLER5 ► && AE ADDRESS
BU1L ER 5 Q &MF b DRE S
r3Gr f o �/ S
DN-TE PERWT ISSUED —
C
DATE COMPLI &I ACE ISSUED ;
��
�; � � F
�r. f /�'/���g �
'�
Y
��c
��
' �
® � r ��
i
i.2
/s.
r
�J� r
�......................
THE COMMONWEALTH OF MASSACHUSETTS
E®ARD 9F HEALTH
_ .._....OF....... . ....c��' .......................................—........—
Appliration for :41-4p Qoat Workii Towitrurtion Vrrnfit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
-----------------A42-I------- ?s '' Civr 1..................................................................................
�y cation-Address or Lot No.
Ix.1�,�..A- L._7FA'4ll F--------------------•----. -•--••----•-----...............................................................•------•--••----
Owner Address
Installer Address
UType of Building Size Lot_.__---_�311.006_.Sq. feet
Dwelling—No. of Bedrooms._.-_---�-------------------------------Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
a
Other fi. tures ---------------------
----------------
Design Flow............ .. _--_gallons per person per day. Total daily flow....._._.... ��'
W g< P P P Y Y gallons.
P4 Septic Tank—Liquid capacity_/._.gallons Length---------------- Width---_--..------._ Diameter-----.---------- Depth_..............
W Disposal Trench—No. .................... Width-------------------- Total Length.................... Total leaching area--------------------sq. ft.
x
Seepage Pit No...... _____ Diameter____________________ Depth below inlet. .............. Total leaching area-__-_.___.______-sq. It.
Z Other Distribution box ( ) Dosing t
'~ Percolation Test Results Performed by._. _-_. _______________________ Date----------------------------------------
Test Pit No. 1----------------minutes per inch Depth o "Pest pit
.....
--------------- Depth to ground water.._._..____.__..___.___.
GT, Test Pit No. 2----------------minutes per inch Depth of Test Pit..................... Dee to ground water--_------__._-.._---___.
- �__-
Description of Soil. - , - -------- .
x ti -'
U ....--•-----•-...-•-----•---- Y- ------ -- ---- .
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 Article LI of the State Sanitary C de—Tht;undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bj n ssued'b the b aid' e
Sig .
Date
Application Approved BY------- •.-••-•--- - / .._._ ._.... 7-" �.." �----
Application Disapproved for the following reasons:......... ! ............ ... ....
-- Dats-- j
.,.fie. ---
---••-•-•--------•---•------•-....-•- ..............................................................--------------------------•-• -------------•-•.- - • -•-------------
Date....:.: - .... e
�+
Permit No. Issued `- 'T-a�----•-------------------
Date .
....___�_•__�____-------------------- ------------------ --
7
No...... ..•-•- .... --- Fu$.............................
THE COMMONWEALTH OF MASSACHUSETTS
EOARD 9F HEALTH
..... --------.OF.--.... . .........................
.. % -.............. - ...
Avv tratiou -for Di,ivo.itt1 orko Touotrurtiou Vrruttt
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: r--
.................Aa•1---------7 . A ----------------------------------------------------------------------------------
cation-Address or Lot No.
----•----•- `lf� •--_-f-7_El_�l_)ei--------------------------
Owner Address
Installer Address
Q Type of Building Size Lot......... .4.U A.Sq. feet
U Dwelling—No. of Bedrooms......... ...............................Expansion Attic ( ) Garbage Grinder ( )
p`�-, Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
Pa Other Mures -------------------------------- -
Desi n Flow............. ......................... Mons per person per day. Total daily flow----------__
W g / g P P P Y Y .----- --gallons.
WSeptic Tank—Liquid capacity-/-_gallons Length................ Width-------------.._ Diameter................ Depth._-.____._....-
x Disposal Trench—No- ____________________ Width.................... Total Length------------_------ Total leaching area_____._..__..---____sq. ft.
-Seepage Pit No....../.!�7----- Diameter.................... Depth below inlet_ .............. Total leaching area------ ...........sq. ft.
z Other Distribution box ( ) Dosingrt�
Percolation Test Results Performed by.-lam- ------------------------------ Date-----_---------------------- .........
Test Pit No. I _______________minutes per inch Depth o Pest Pit.................... Depth to ground water....____-_--_---______-
1 (� Test Pit No. 2................minutes per inch Depth of Test Pit.................... De h to ground water........................
0 ---------------------------------------------------- c%�1
Description of Soil �� ..... --• --0---------- --- ------------ ,
U -----------------------------------------------Y. ..... =---- a.- uP--------- --_' � --
U -
W
x ------------------- ---------------...------------------------------------------------------------------------------------------------------------------------------------------------------------
U Nature of Repairs or Alterations—Answer when applicable-------------------------------------------------------------------------______________________-
----------- ----------------------------------- -------------------•---•-------•-------------•-••---••---...-------•---------•---------...--•-•--••-----------------..........------------------..-_--
Agreement: :4
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has ben issued by the bboard, ealth.
Sig d =� �- ---..-.. ................................
Date
Application Approved BY ...: ._.. `- -"�L 7-J------.---
Date
Application Disapproved for the following reasons--------------------------------w------------------------------------------------------.....-----•---------•_...
-------------------------------------•---------•---------------------------------------------------------•••--•----•-----•----------•--•---•-•••-•-•-------------...-••-----•---------.....------------.
Date
PermitNo......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Trrtifiratr of Clutplianre
T IS I TO C IFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
bY--- -��`/-------r�. --c)•.I -e )
/� /� Installer
atl7/-S- rlIy11FF�----.-�•. � •------- �s _ ......................................................has been installed in accordance with the provisions"of e XI of JThe State Sanitary Cod as described in the
application for Disposal Works Construction Permit N ._...a....:...................... dated..
. ...........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE-------------------------------------------------------------------------------- Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
-r BOARD F HEAL
v ---------------
No.......... •--•--•--•---- FEE t U..............
�i��o� . rk� ou�trurti�at �rrutit
Permission is reb ranted -•..
Yg
to Cons uc ( or Repair/ an I ivi 11 ewage posal S m:
at No.- l� --- �----------. —
•.
stre
as shown on the application for Disposal Works Construction P it N ____. Dated___-:/_6
—� _--- •---- ----- ----
Board of Health
ah 7
--
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
- \) I � i I I �• I I i
i � I
i��" �S_^�_� '� � I/fig: ��• i � I- i ;
I ;
-v•-.�C7 -:_ _�- I---�l�S-�-G�j2 �-;-;- C�,�//iT' - l,''�.SS� �-�
-
l�DlNc�_s�l�N_oN_�i�l�sN
qj
':C,4F//TT ViGG,E.
Sµ OF le I I
77) .'I/C2�//�G- /Yb-ZOiSI/�lcrs--_L_. �� 9��, ---. --� '1'S�._ �i✓�5 Ssr_�/,4 7
?�6ZCl/2�1s�1.Lit-NTs q�'.7ff _TIP ALA -
D_ y� iSLr4Z3GE..__ I- W.
NE -
---1
SI,
- 9r9
6