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HomeMy WebLinkAbout0236 POPONESSETT ROAD - Health 2�6 ROPOnessett Road 019-066 Cotuit COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENViRONME T. t z �AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTE� IO�F 1-1 a/ 0 /? 0 6,` l) vIS-1O TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUN Y ASSESS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM ME VTS PART A 3 b CERTIFICATION Property Address. 0 Owner's Name• Owner's Address: r, Date of Inspection: 0*7 O Name of Inspector: lease print) I' " /riti� Company Name• (/I °/G Mailing Address: 0 C _ o'X Telephone Numbed 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 Sect 15.340.of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: C f r' The system inspector shall submit a copy of this inspection report to the Approving Authority(B oard 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 g Notes and Comments ****This report only describes conditions at the time of inspection and under the condition s 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 y,. ,r>„a.#,r a rage 1 of=1 l,'�"`k'.�`,:- --p"' f:s -, i,,. -"•`. :tea-^»r s v_7','^ 'ae- + /'-.- m.-v> -"" 3 6 �E:i a -.s.-x '^-€.y 1V fi •'` '� - -` .fir -v i _, r " ; 1 _ =� rt. =II OFFIC 4 I. .yx r �..1 �,�.., n t _ m,z', u r # IAL INSPECTION FOR1V1 NOT FOR VOLUNTARY'ASSESS " SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPEC VENTS TION PART F'OItN A , CERTIFICATION (continued) Property Address Kj II o f7 h�.SS� II Owner ' i fn {, J -�- 19d a r ;' Date of Inspection ,: M e � ,g�p7 ' '°,, -. � , t ,' y, �'. :' ,� fr Q n' ,r �Y -:* tit & x i xs y, .,.a�' '� g x K y Inspection Surnma 7 ; � ,g�r � g¢ � , � .rY' Check AtB9C,D or E/ r, „ � , , {Y ALWAYS complete all of : Sectioin D �t y — --- SYste asses:- i — — r — — # ,: _ r n 4 t t I have not found an �E, y„ Y information which indicates'that any of the failure criteria descnbed6in 310 M 15 303 or in 310 CMR 15 304 exist Any failure criteria not:evaluated are,indi r cated`below CMR Comments t F„ �, v ., _ t' m r >. } t ., '- 4 S stem Cond f u B itionally ' r x Passes h_ t } 3 r One or`inore system co orients t rc trip as described,_ the"Conditional Pass"section need to be ieplaced.or . Y . > . �,repaired.The system,upon completion of the replacement or epair _ ,> ,as approved b Y the Board of Health,will pass z- _-Answer yes,no.or not determined(Y 1V M � �.. x explani.: ) 'the for the folio g statemen - wm is'If` d,,. r � `not determine please x The septic tank is metal an vet`20 + 3 b r do Years old or the septic tank(whether metal or not)is structurall F :F unsound;exhibits substantial uifiltratioi or exfillration or tank failure is 'I existing tank is replaced:with a co 1 �niiiient System will Y Ii *- metals tic _ Ymg septic tank as approved by tfie Board of Health pass inspection if the= �, ep tank anll pass inspection if itis s indicating that the tank is less than 20 years old savailablle sound,not leaking and if a Certificate of Compliance d 4 " -ND explain xis - I u n i Observation of sews f e bac = i ' obstructed i e s 'or due to a brok or break out or high static water level in the distribution box due t0 broken oz . P P ( ) en,settled or uaeven distribution box.S stem: approval of Board of Health) 3 5 Y will pass inspection if(with ' '� , w F l brok `: en pipes)are replaced a 'r obstruction is reinu'ved ; i M distribution box is leveled or r 1 '' � ep aced I 1I explain.' ,i , x r 'r i �" - z # ,:IA c system iequired g ,*', t,Pm more;than 4 times a year due'to broken or obstructed i e s 5 pass inspection if(with approval of the Board of Health) P P ( ) The system will a 3= w : t . 9 -f k - F P �broken pipes)are replaced x' ` =3 Y obstruction is -, k,`= s removedr w , `} x a , - a a ." "" ` ..... '" S ``a. °� "' x ` '•: .� TM F Z } F 4 Q J _ 1VJIJ\explains ;7 x s` - - ,' # �s ti ^I 't ; Y'� .-w6 ., ti , >zY xk Y- s r +�, "' ;:X 4 4h+.o-4..^,. '° . z*v`a F b.,, .,y :7- q `N` '% i-S 3 tt { a x t py . , C�inc1. nartinn s M ft e _T1tlo N Rnrn1�n ci�nnn 2,- r 1 A, — ;;. . = �..... .. kq awd N.we..•N.«�w..w 4? iE a+K v��11,� aa' ^ % aacyw: ...r._...�._.-..wrrr,.�s. x..>..u. ,vy.m.v�x w.i ...�v... a w��.,.........v...a <, .� .x-.<, .....a .�.+.�.«... ,.-n.w.d.c.....n ..�.bs.. !!.n-ns.>_..a.z tf�„�,> .� ...... .. Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A // CERTIFICATION(continued) Property Address: -121 /] ���'G Owner: O Date of inspection:tt �O 2 �1 kC. Further Evaluation is Required by the Board of Health: / Conditions exist which require further evaluation time by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. I. System will pass unless Board of Health determines in accordance with 310 CMR 15.303 1 b that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply wen**. 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. Othe r: T;H. lncnentinn Rnrm!.�!S/�nnn 3 • Page 4 of I I v . OFFICIAL INSP ECTION ON FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM A CERTIFICATION(continued) Property Address: ie, Owner: pAV p� 3 j Date of Inspection: to p> D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections; Yes No sCAS or cesspool �ackup of sewage into facility or system component due to Overloaded or clogged Discharge or ponding of effluent to the surface of the ground or surface waters due So an overloaded dogged SAS or cesspool or Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS zesspool c uid depth in cesspool is less than G"below invert or available volume is less than y=day g flo or '! Required pumping more than 4 times in the last times pumped Year NOT due to clogged or obstructed ipe s N �1uy portion of the SAS,cesspool or Privy p p ( ) der — _✓Any portion of cesspool or privy P �'is below high ground water elevation. water supply. P �'Y is within 100 feet of a surface water supply or tributary to a surface Y Portion of a ci�tesspool or privy is within a Zone 1 of a public well. 71 Y 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 eater supply well with no acceptable water quality � than 50 feet from a private water performed at a DEP certified water quty or cOliform bacteria analysis. [This system passes if the well water analysis, indicates that the well is free from pollution from that facility anddthe presence o volatile f ammonia compounds nitrogen and nitrate nitrogen is equal to or less than 5 are triggered.A co PPm,provided that no other failure criteria copy of the analysis must be attached to this form.] (Yes/NO)The system ve fail fails.I have determined that on e or described in 310 CMR 15.303,therefore the system fails.rThe e ofystemoowner shoal ure criteria intact the Health to determine what will be necessary to correct the failure. Board of E. Large Systems: To be considered a large system the system must serve a facility with a design now of 10,000 gpd. You must indicate either"yes"or"no"to each of the following; 0 gpd to 15,000 (The following criteria apply to large systems in addition to the criteria above) Yes no system is within 400 feet of a surface drinking water supply the system is within 200 fe et of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWpA o ne II of a public water supply well Ora mapped 1f you have ans ed"yes"to any question in Section E the system is considered a significant t "yes" in Section D above the large system has failed. The owner or operator of any large system significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR k threat;or answered 15.304. The system owner should contact the appropriate regional office of the Department.y m considered a Tit1- Q Incnnntinn Rn�m�/1 G/7MI1 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: O N C j:) Q� Owner: 3 � Date of Inspection: 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? -i Have large volumes of water been introduced to the system recentlyof or as part this inspection? Were as built plans of the system obtained and examined?(If they were not available note as N/A) _ Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out. Were all system components,excluding the SAS,located on site? _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the b ' es or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? I _ 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 ap roximation is unacceptable)[310 C1V1R 15.302(3)(b)J P of distance Title C fnc^nrfinn �'nrm lil ci�nnn 5 Page 6 of 11 OFFICIAL INSPECTION FORM-N OT FOR SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION A FORM RY ASSESSMENTS PART C SYSTEM INFORMATION Property Address: 0 0 n H eft e� Owner: a `�`. �d� 6.3 j l/ Date of Inspection: �p r RESIDENTIAL LO CONDITIONS Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMS 15.203(for example: 110 gpd x#of be ooms): u�, Number of current residents. f�// Does residence have a garbage grinder(yes or no):, Is laundry on a separate sewage system(yes or no): [if yes separate inspection required] �1 Laundry system inspected yes or o): /J Seasonal use:(yes or no): P� Water meter readings, if a ai able(1 t 2 years usage(gpd)): Sump Pump(yes or no):ZO Last date of occupancy: COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): d Basis of design flow(seats/persons/sgft,etc.): r 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): Pumping Records GENERAL INFORMATION 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: TTYPF SYSTEM Septic tank, distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Altemative 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 Cif known)and source-, f' �� C rmation: Were sewage odors detected when arriving at the site(yes or no):A/� Titles G Incnartinn Fnrm!/1 imtinn 6 A Page 7 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 61 00 0 r14eS� Owner:/ 0 �o t� 14 � Date of Inspection: 0 02 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction:_cast iron _140 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ' _(locate on site plan) Depth below grade: 0 Material of construction: concrete metal fiberglass_—polyethylene _other(explain) If tank is metal list age:_ Ise/` confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) / y /Q Dimensions: (O Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle:C Scum thickness: L eSf / v If Distance from top of scum to top of outlet tee or baffle: 7 Distance from bottom of scum to bottomAAf 9utlet tee or ba,Ifle: How were dimensions determined: 71, /te OF 16 yi C G Comments(on pumping recommendations,inlet and outlet t or baffle condition,structural integrity,liquid levels as ated to outlet invert,evidence of leakage,etq.): vt✓v1 r� ✓I o f- N2eC.VC, -7(-A[r -7L 1 vtit h (H GREASE TRAP:_(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 as related to outlet invert,evidence of leakage,etc.): T;t1. Incnurtinn 4'nrrn 4/1 Vnnnn 7 Page 8 of 1 l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: /"0 m g Owner: Date of Inspection: to 0> TIGHT or HOLDING TANK:zoank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: lallons 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.): DISTRIBUTION BOX: (i— f present must be o ened locate o P )( n site plan) Depth of liquid level above outlet invert: 0(91-''`7 Gi Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage' to or out of box, tc.): /tt !;D/I /S PUMP CHAMBER:&V (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.): Titlo G Incnortinn Rnrm 4/1 cnnnn 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: U6 Oo o m e fs e 4 A o , p oZ G 33 Owner: 14�0 Date of Inspection: 0 aL 0S SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: X leaching chambers,number: ` leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool, number: innovative/alternative system Type/name of technology: Continents(note condition f soil, 'gns of hydraulic failure,level of ponding, soil,condi 'ono vegetation, etc.): �� �v A /`�/ TS ©0 C' 1 ./� 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.): PRIVY:A/0ocate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level ofponding, condition of vegetation, etc.): Titlo G Inen i;— P—m 4/I 4�iinnn 9 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: o?,3, A' 0 O 0 1.5, Owner: 0 .3 Date of Inspection: /o oZ. SKETCH OF SEWAGE DISPOSAL SYSTEM I Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.Locate where public water supply enters the building. LW G 63 - Lf3 J L`` Titio G InenorYinn (.nrm 411 10 A Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: b G 0 NBf SC oot 6 �3 Owner• Date of Inspection: to SITE EXAM Slope Surface water Check cellar J' Shallow wells I i Estimated depth to ground water _ ;v feet C p✓y Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: F ODserved site(abutting property/observation hole willun 150 fieet of SAS) 1.0 (.-Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must descri e how ou established the high groupjt water el e ation: - o C'`�r o h 1 s _73 w) e Ps All /f 6 0 Wej Y 11 �► O l/• A0 vi %0 o Grp c�G c pro �1 �1 dood Li dr � w T:tlo G fnencrtinn Rnrm f./1�/7nnn 11 LOCATIOR SEWAGE PERMIT NO. VILLAGE P INSTALLER'S NAME AND ADDRESS POD U-1 Qt s •e � q,5 t R t 6 A G. S SaL 6az Lai 91 ic, m BUILDER OR OWNER , DATE PERMIT ISSUED DATE COMPLIANCE ISSUED i v n i 4 I } M 1 0 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .57� Appliration for Dispoti al Works Cnnnitrurtinn Permit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ®t ._.__ ,; ,.. `....... .........•-.........---......��:. ..................................................... - Loc do Address or Lot No. f-----------------------------_.----.-------• s O er ddress wF� ------ ••-•....------]f�....t.A..... . ............................. Instal er Address Type of Building Size Lot............................Sq. feet U Dwelling'—No. of Bedrooms.............. -. -•---..__--_-------.--Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building .........................,.. No. of.persons.........._......_.......... Showers ( ) Cafeteria ( ) a Other fixtures ------------------------------I•---------•---•---- W Design Flow............................................gallons per, person per day. Total daily flow:...........................................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-------------------- Diameter-------------------. Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by........................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit-________.-__-----•• Depth to ground water........................ r 4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Chi ODescription of Soil....................................................................................................-----------------------•--•------------------------•••••.......•--- x UW ----•------•-----------------------•----•-•---•-----•----•-•-------•••----------------------•-.._...---•---------•-----------•------•--•--•----••---•••-••..............._...._..-•--• ............... Nature of Repairs or Alterations—Answer when applicable...__ r—....__�..._. 5.......__. ...OP- G:tAI- -----------------------------------------------------------------------------------------------------------------------------------•----------....---- Agreement: The undersigned agrees to install the aforedescri Individual Sewage Disposal System in accordance with the provisions of iIliL.i� 5 of the State Sanitar Code he unders' d further rees no ace the system in operation until a Certificate of Compliance has bee sued by the b ar of health. @_ Signed. C` .._.... ------- - ---------• .. .... �- :. � Date Application Approved By..... -••------------------- Date Appliea 'on Disappr ved for tyh�e-f o�llow'ng re sons-------------------------,......----------------------------------------------•--•------------•-••-•----••...... no .. _ .... .. ..... ... __ ..... ...................................... ............ Date Permit No..... .1__ _ .................... 44"luedL1 --- ----- -- Date w s. ` No..u.. ..:_.. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........ t . ................OF..... ....:..'. Appliration for Disposal Works Tonstrn.rtiun Fund# Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: , 4 11 ....... °............. .... .S.. R ...'.. ...........................3 rJ d f ------.•-.-.-----------------•---.-------- Lccation:Address or Lot No. Owner Address W Installer Address UType of Building Size Lat............................Sq. feet °-, Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) `4 Other—T e of Building ._ No. of persons............................ Showers a04 Other fixtures ................... ( ) — Cafeteria ( ) Desl n Flow •---------•-------------------•----------------------------------------------------••--------------------- W ig gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity_..._.......gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length..................... Total leaching area....................sq. ft. 3 Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by-••--•-----------•--_..•-•-•-----•-•--••-----••-•--••---••----•-•-••-•-•. Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to g-ound water-----------------.___--. (14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-------------------------- a -•••--••----•••••••-•--•-•••--....-••--•--•••...............•--...-..-----•••-•--............_---•-•..................................................... 0 Description of Soil.......................................................................................................................................................................... x U w ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- U Nature of Repairs or Alterations—Answer when applicable...................................................................:............................ ......................................................................................................................................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual S,2wage Disposal System in accordance with the provisions of TITa 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed-------•---------------------•-... :- ------------- ••--•---••••......-:....-------- Date Application Approved By................v-'P J -�-�------•�. Date Application Disapproved for the following reasons ..... ....... ........ ............. .............................................•.---..--.. gp .. ---... ------------------------ .................... v� ft3,r �/ fv' t. 3.a G S 5a7 4rrr SG Date Permit No...... ............ IssuecL Date e THE COMMONWEALTH OF ,MASSACHUSETTS f .-� BOARD OF HEALTH ........./L_. 6kk:a.............OF........� �...I�r.`.d `�=. / (Infifirtt#r of Toutph aurr THIS.�S TO CERTIFY, That the ;Individual Sewz e Disposal System constructed ( ) or Repaired / by..............VaL.lk--•....J ....... zze> ._ j. -A ............. -----------------------------------------------•--------------•-•--------•-------------- (/ Installer at..................r .., z�' /.Ll.i.a>22-�a-7 --- -- ........ --•---•----•----•--•----•---••----------••--•-•-----------------•--------------- has been installed in accordAce with the provisions of T-TU 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No........ .9.... ..J ...... dated_.......................................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. , ./ f g r /'" ,+"°°f,��." .... •fir•.�.rs-�' f " n'.n�; �lr,-4` . DATE .................... ,• Inspector... ... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH r , rZt it � C60_. FEE ..................... Disposal !,arks (guns a iun ami#_Permission is hereby granted.__.,..P« _ -..._..._. tc.__ '"` �= ---------------------------------------------••-•-•-••--.........--- to Construct ( ) or)fZepair (.�c) an Individual Sewage Dis OSal System -} 11 J......... .. Street ri� .3 as shown on the application for Disposal Works Construction Permit No.._.....:..t_..____. ated.......................................... C -----•---- ....... bard of Heath DATE................. l�-a---=-f-�--=•--� FORM 1255 HOBBS & WARREN. INC., PUBLISHERS LOCATION SEWAGE PERMIT NO. gq VILLAGE INSTALLER'S NAME AND ADDRESS Iu Mat BUILDER OR OWNER I DATE PERMIT 'ISSUED 1 '`""' r ..• 2� I DATE COMPLIANCE ISSUED 4 I s