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0012 ROOSEVELT ROAD - Health
f 12 Roosevelt Road— Cotuit P A = 039 130 SEWA INSPECTIONS �•� � DATE .-OCAlnlON, do LOT �_�i�- ASSESSOR'S MAP VILLAGE 59 INSPBCTOB 1 O O fJ SEPTIC TANK CAPACITY 0 G (size) LEAt.KNO FACE-"' (rf Pe) NO.OF BEDROOMS BUILDER OR OWNER OWNER MAILING ADDRESS 1 (N/ \ \� \ �'I / O �\ / �/ �^ \ � �iz I 0 38 - 15 0 TOAD - 3 e. PARCEL 3 d LOT �.� �A� 6/10/04 U✓" DATE------�---- w„ PROPERTY ADDRESS:__ 2 Roosevelt Rd. g� Cotuit, MA fla.3.6. 02635 On the above date, the septic system at the above address was Inspected. This system consists of the following: 7RECEIVED 1. 1- 1000 gaiion zept-.c .tank 2. 1- 1000 ga .Pon .teach 12it. N 1 $ 2004 Based on inspection, I certify the following conditions: ruvvw of BARNSTABLE HEALTH DEPT. 3.. 7h-iz &3 a .titie )give. zeptic zyztem (78 code') '4. 7he .6ept�.c .system iz .in pao/2e2 woaking oadesc at the /22e3ent time. SIGNATURE:. Name: Bruce Macallister Company: .TngP h ,P- --&-Son, Inc. Address:- P -o--3nx-6-6----------- ranterville, -MA 02632-"66 THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR .� WARRANTY RM1060 CPH P. MACO' & SON, INC.Tanks-Cesspools-LeachfieldsPumped & InstalledTown Sewer ConnectionsBox 66 Centerville, MA 02632-0066 775-3338 775.6412 e �\ COMMONWEALTH OF MASSACHUSETTS EXECUTI`JE OFFICE OF ENVIRONM' NTAL AFFAIRS DEPARTMENT OF�+NVI ONN�`AL PR(MCTION Y • . TITLE 5 OFFICIAL INSPECTION FORM-.NO.T-FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PARTA CERTIFICATION Property Address: 12 Roosevel t Ra Owner's Name: marjnr6 Haller Owner's Address: c, Date of Inspection: Name of Inspector:(please print) .n - der Company Name: 2 P Ma coMf;;i T .S>Wnc. Mailing Address: Cen eay.c e, a6 . 02632 Telephone Number: 5 0 8•-7 7 5:3 3 3 8 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system.at this address and that the.information reported complete as of the time of the inspection.The inspection-was performed based on my below is true;accurate and comp P d experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP training an p P P approved system inspector pursuant to-5ection.15:340.of Title 5(31.0 CMR45:000). The system: .Passes -Conditionally Passes Needs Further Evaluation.by the Local Approving.Authority Fails Inspector's Signafore: Dater The system inspector shall submit a copy of this inspection report to the.Approving Authority.(Board of Health or DEP)within 30 days of completing this inspection.If the System is.a.sltared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner.sliall submit the report to the appropriate regional•office of the DEP.The original should be sent to-the system owner and copies sent to the buyer,if applicable,and the approving. authority., Notes and Comments ""This report only describes conditions at the time of inspection-.and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. nnae 1 a Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSWNTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 12 Roosevelt Rd. Cot I i t� MA Owner: M;1r-ier'ie H�1 1 pr- Date of Inspection: I- i, „ ,^A Inspection Summary: Check.A-,B;C;D o.r.E/ALWAYScomplete=all of Section D A. System Passes: r 0 l have not found any information.which indicates that any of the failure criteria described-in 310 CMR 15.303.or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass".section.need to be replaced:or repaired.The system,upon completion of the replacement or repair,as approved,by the Board of Health,will pass. Answer yes,no or not.determined(Y,N,ND)in the for the following statements.If"not determined"please explain. 60 The septic.tank is metal.and over 20 years old*.or the.septic tank(whether metal.or: 9t),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 obstruction is removed distribution box is leveled or replaced 1 ND explain.- The system required pumping.more than.4 times a year due to broken or obstructed pipe(sij.The.,system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION(FORM PART A CERTIFICATION(continued) Property Address: 12 RoQ-,t-yp1 t- Rci_ C•ni- i f A Owner:. MT"Gri a Haller f Ins ection• Dated p 6 /1 n /na ' C. Further Evaluation is Required by the Board of Health: Condi tions.exist whichrequire further:evaluation.by.the Board ofHealthdri order.to:.deterrnine ifthe 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 4 I 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)determinesahat 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. 1 v' 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€eet or more Born a private water supply well",Method used to determine distance V1LA,01 "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organiccompounds 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: Page.4 of 11 OFFICIAL-INSPECTION FORM—NOTTOR:VOLUNTARY.ASSESSMENTS -SUBSURFACE SEWAGEMISPOSA SYSTEM INSPECTION FORM : PART;A , CERTIFICA'FIQN(continued) Property Address: 1 9 RQQaQx7elt Rd - ro+-Uit., Owner: : a,-;0r.ie Maiie Date of Inspection: -6�-1 a 4 0 4 D. System Feilure.Criteria applicable to all systems:. You must indicate"yes".or"no'°to.each:of the:followingrfor all impections: Yes yo _ Backup of sewage..into facility or system.component due to.overloaded.or clogged SAS or.cesspool Discharge.or,ponding.of eifluent.to the siirface,.O f.l e..ground.o.r,surface maters due to an overloaded or clogged SAS or cesspool L Static liquid level in the distribution box above outlet invert due to,annverlaaded or clogged SAS or } cesspool ./ Liquid depth is cesspool is less than 6"below invert or available volume is less than%.day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped Any portion of the SAS,cesspool of 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. .� .Any portion of-a-cesspool or.privyiswithin-a.Zone 1.of:publicwell..: Any portion of a cesspool or privy is within 50 feet of a private water supply well. / Any portion of a cesspool or..privy is loss.-than_1.00 feet but greater..thon..5.0-feet from a private water supply well with no acceptable water quality analysis.f Thls system..passes:if the 3vell water anaiysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates:.that the.well is.free from{pollution,:from:.that>fac'ility:and.thg presenceof.4mmonia nitrogen and nitrate nitrogen is equal to or less.than 5 ppm,provided that no other failure criteria are.triggered:A copy ofthe analysis must be attached:to.this form.] . C (Yes/No)The system fails,l have determined that-one or<more=of the above..failure.;criterio exist as described in 310 CMR-15.303,therefore they 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 i0;Q0.0 gpd to 15;000. gpd• y 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 nq ✓ the-system is within 400 feet a surface drinkingwater supply- - the system is within 200 feet of a utary•to a surface drinking water supply _ . the system is located in a nitrogen sensitive area Qnterim 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 significantthreat,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 Page 5of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY,ASSESSMENTS SUBSURFACE-SEWAGE DISPOSAL.'SYSTEM:'iNgI'ECiTiON FORM PART CHECIQIST Property Address: 1 9 poi, ui-efi rati-A-t, NA Owner: m.T11 ex Date of Inspee io : Check if the following have been dyne You must indicate,"YW or"no"'asAo each..of tlie.:following: . Yes Pumping information was p ovided'by the owner,occupant,or$oaril of Health — +/Were any of the system components pumped out in the previous two weeks?. — Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of thissinspection? r, _ -✓ Were as built plans of the system obtained and examined!(If they were.not available'oete VS 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? opened,and the interior of the tank inspected for the condition _ —. Were the septic tank manholes uncovered,�p cum? of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and.depth of s nt from awner)provided with information on the proper Was the facility owner(and occupants if fliffere maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site.has been determined based oh: Yes 9 ' _ Existing information.For example,a plan at the Board of Health. _✓Determined in the field.(I if any of the failure criteria related to Part C is at issue approximAtion of distance is unacceptable)[310 CMR 15.302(3)(b)J Page 6 of 11 OFFICIAL I:NSPECTIGN FORM`-NOT FOR VOLUNTARY ASSESSMENTS .SUBSURFACE SEWAGE DISFOSAi •SYSTEM.>INSPECTION FORM PART.0 SYSTEM.INFORMATION Property Address: 12 RtnnGPva l t- Ra, Cntn i t , MA Owner: =} , r �� ?l_er- Date of Inspection:-, �r FLOW CONDITIONS RESIDENTIAL Number of bedrooms desi Number of.bedrooms actual DESIGN flow based on�31a CNAR 15.203(for example: 110 gpd x#ofbedmoms): © Number of current residents: .. 1 Doesresidence have a garbage grinder(yes or no):Ab Is laundry on a separate sewage.system.(yes or.no):... [if yes separate inspection required) Laundry system inspected(yes or no): o o o = $Z, 11 Seasonal use:(yes or no):la4 $? 'Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no): Last date of occupancy: COMMERCIALiM bUSTRIAL Type of establ3nt: NA Design flown on 310 CMR 15.203): gpd Basis.of d0sio'flow(seats/perso /sgft,etc.): Grease trap present(yes or no): Pk Industrial waste holding tank present(yes or no): act Non-sanitary waste discharged to th;,,.Title 5 system-(yes or no): Water meter readings,if available: l Last date of occupancy/use: ,�i OTHER(describe):. GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no):_ If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: TlyPE OF SYSTEM lr1 Septic tank,distribution box,soil absorption system , jlj�-Single cesspool Overflow cesspool -A&Privy Ak Shared system(yes or no)(if yes,attach previous inspection records,if any) 00 Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) W Tight tank M Attach a.copy of the DEP approval �b Other(describe): Approximate age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no): 6 - Pigs 7 of I OFFIO:>I • .NS.I`I 'IONflRM,-NOT FOR VOLUNTARY ASSESSMENTS S U� RFA E E i',AGI:]DISPOSAL$Y$TEM INSPECTION FORM PART OIf 4b SYSTEM. INFOR ATION(continued) froperty Adttresst 1�2RR-n^,ncP14al i- Xd. Dwn'e.r: Mari-r' wialler Dsty of ItrsPcalon;_, BUILDING SEWER(Locate OR Ott Plus) Depth bclgw grade: i Matvf-ials of coASnct on:�,,,,e�st Ervn ✓40 PVC other(catpla~In);. Disusntc tr M pri..vau warFr 7uPpty well of sv.ction line., i o comm- cots(on condltlQn of -9 It.41 vontittg,evldclace of- i4 vented thaough the house vents. SEPTIC TANK. (locate on slte plui) Dgpth below grade: M�.tcriil.of consovctjon.:✓concrete metals,,_frbcrgtau �,,polyethykna. flt+� ochcKczp.laln� i U4 is im4%)1tst ags:Qit1 is ago 4ot Wo by a W-1171cste o 0.70,11 nee(yGs or noj; (a11A A. a tiopy of ccrt•iftc'ate) ��� "� <f. ©irnensions:� � l� fo u.' r_ Sludge dtpth: Qistocc.trorn top of sludge to t;ottom o outle.tcc or baffle: scum thielattes;:� , D41- n-c from top pf scum , top of outlet tee or baffle; Disiancc.from.bonom of scum to bottom of outlet tee or.baffle: � .How w.erc-di:mcrtstotts determined: C.ammc�ts.(on.pttsrt.pin.g r.ee©mmcnd►tions, ::ict and Qut.ci tee or battle cortdlllon, structural integrity,liquid levels as rclita4.4o o0l.t inYcrt,"14cnce Q•f.kca}lagc.,ctc;)c 'V .leakage. CREASE TRAP;, t (Locate on site plank Depth.below grade: . Material of conspvetion:Q,gl„concretes m0AA_fiborgl s�gpalyothylene-other- . (txpJair7}: Dimon;.Ions: Scum 1b.114 tcs:s; ,, Distance from top of scum to top of outlet fee yffle r ba ; Di.$tin;c from. h6nom 91 strum to bottom of outlet ice yr baffle Date of Iast.puinpiA.g: Comments(on pumping re tttlet and outlet tee or baffle condition;structural bttcgrity;liquid levels U.related to o loci tnvtrt, evidence•Of Joaka:ge,•cc.): gzea.se tnaI2 .ins noYt Rze,sent Page 8 of OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS S SURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 12 Roosevelt Rd. Coisulty MA Owner: �,� Date of Ihspectt. n:LZ- , C�4 TIGHT or HOLDING TANK:(tank must be pumped at time of ins ect'p p ion)(locate on site plan) q Depth below.grade: Material of construction: 1Lconcret&,.—metal k fiberglass A&Polyethylene .,"ther(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present es or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: _ Comments(condition of alarm and float switches, etc,): 7__rrhl. nn hQldinci .tank.6 ate •no.t R/Lezen.t. DISTRIBUTION BOX:16,b(if present must be opened)(locate on site plan) 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.):. PUMP CHAMBER: (�(locate on site plan) Pumps in working order(yes or.no) Alarms in working order(yes or no): �k Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.); Miml1__-hrdm9yn not R2ei3ent. I 8 I , Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAOE DISPOSAL.SYSTEM INSPECTIONYORM PART C SYSTEM INFORMATION(continued). Property Address: 1.9 Roosevelt Rd. Owner:. sear-;ozi o Haller Date of Inspection: c/a n i n n SOIL ABSORPTION SYSTEM(SAS): {locate on site plan,excavation.not required), If SAS not.located explain why: Located zee 12aae 10 Type IQ 6leaching pits,number: leaching chambers,number: YV) leaching galleries,number: V\o leaching trenches,number,length: • 11,0 leaching fields,number,dimensions: r q® overflow cesspool,number:. M- 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.): O</m!sl Aanrl In inn .t an rL ly A 4 6 6lfib 3 fh %A time 1/g9-aiat ion i 6 QQ zWr,�g., Leach pit:Vadte waten iz 62" geiow .inveai 12il2e.-Stain ei!ze. w '1 o 56" gez �n e2t e. CESSPO& (cesspooTmust De pumpeed/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.): e6b�lJAA-�4 rA &! 0;0 7"a.3efti PRIVY: (locate on site plan) Materials of cons ction: t Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): P/LivU 1,6 aal f/2aPA_Pnt 9 Page 10 of 1:1 OFFICLAL INSPECTION FORM. NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE`SEWAGE DISrPOSAL SYSTEM•.INSPECTION;FORM ; PART C- SYSTEM INFORMATION(continifed)" Property Address: 12 Rooseve 1 i- Rd. Owner: Haller Date of Inspect,on. SKETCH OF SEWAGE.DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at Ieast two permanent reference landmarks or benchmarks.Locate all wells within 100 feet. Locate where public water supply enters the building. r 0_ ' 10 Page I I of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued). Property Address: 1 2 Rnncm37e1t Rd. �atl;-i-t y NA— Owoer: r -&Iler Date of lnspec too. ;.. SITE EXAM a Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet 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: — Observed site (abuning property/observation hole within ISO feet.of SAS) Checked with local Board of Health-explain: Checked with local excavators, installers. (anach documentation) _Accessed USGS database-explain: You must describe how you established the high ground water elevatJon: 1&3ed: ahn ll e.t � .i eien NodeX y2ot waters agove .zea ievei II.SG.S 92=000- 9 P 2a.te we-te data Top of Qrouna Leaching Pit :cct Groundwater: Feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimptcr Method ?. ' +, 'Rurcfore,the vertical,separation distance between the bottom o ' of the Icaching pit and the adjusted groundwater table is fcct. 9. II T T,'�n• •t-rr' rnrmr•nm*nr-nna�nrs+RM1•r••.ervlft�R*.+'+rR1 rvPI�11 RiTsrlf•r aTt rr TOWN OF Barnstable 130ARD OF HEALTH ,91H)SORFAU SFNACF 1)1Sf'OSAL SYSTEM INSVECTION FORM - PART D - CERTIFICATION I rrrrr+-+"t•+.-nmrrin+rm�+e^e*rrese�r rn�rtrsn^rrn"�' nn+n•rr►�r,�wtrrnFr+n•.++rrr•r.•,. —•.^ -TYPE OR PRINT eLE.ARLY- PROPERTY INSPECTED STREET ADDRESS 12 .Rooz.eveit 12c1.- Cotuct Na. ASSESSORS MAP , DOCK AND PARCEL # 039-130 OWNER' s NAME l�aa�o��e• Ka.E ielt PART D - CEI?TIFICATION NAME OF INSPECTOR i3?uce Naeaieiz;telt- COMPANY NAME Joseph P. Macomber & Son Inc COMPANY ADDRESS Box 66 Centerville Mass 02632 Strevt Tovn or ClLy State CIF COMPANY TELEPHONE ( 508 ) 775-33-38 FAX ( 508 ) 790-1.578 q crwri FICATION. STATEMENT I certify that I have personally inspected the sewage disposa-1 system at this nddr.ess and that the information reported is true., accurate , and complete as of the time of � inspection, 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 th.e system fails to adequately protect public health or, the environment as defined to 310 CMR 16 . 303 , Any. failure criteria not evaluated are its stated in the FAILURE CRITERIA section of this form . System FAILED* The inspection which I have condtrcted has found that •the system fails to protect the E-)ub.lic health and the environment in accordance with Title 6 , 110 CMR 15 , 3Q3 , and as specifically noted on PART C FAILURE CRITERIA of this inspection form., for Si nature 4ate Inspec S a ine copy of this cpwrc.tfication must be provided to the OWNER, the BUYER where appl icabl e j and the 130ARD OF HEALTH, * If the inspection FAILED , time owner or,,•op.erator. ehall upgrad0 ' the eyetem wil;hin one year of the elate of the inspection, unless a.1l,owed or required otherwise as provided in 3.10 CMR 15 .106 , partd . doc yid, - .- No... .o7 ® FEBI ..�..�`3. .... THE COMMONWEALTH OF MASSACHUSETTS fy� B®A E HEALTH ...11.WJJ.................OF.......:...,F ! %�d............................... , ppliration for Dispasal 10orks Towitrurtion Pumit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal PP P System ate --6 . CA.-n-x...T....�' A1� .s-------•................... atio Address --� or Lo o. ._..:._. .1.�.�._l.�.N1...../:�. ..........-•--•• �r : 4.(. 1...�' ..44./-11.-t�?' i.....--. _ caner dress ` -------.c�_n....Ta Tan- ---,�a",_..-Ag.-s-x------------------- Installer Address Pq Type of Building Size Lot............................Sq. feet a Dwelling—No. of Bedrooms....._3................................Expansion Attic ( ) Garbage Grinder ( ) a p, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures ----------------•--------------- - W Design Flow............Y .......................gallons per person per day. Total daily flow................ jab............._gallons. WSeptic Tank—Liquid capacity. iii0gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—;To..................... Width.................... Total Length................_--- Total leaching area..3.d -.....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........_............... Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Description of _ ,� " B` l�_�- - 5.: " - [.......... ..4-............ y ---- :,� : w --------------------------------------------------------------------------------------------------------------------------------------------------------------------------•--••---------•-•-•--....... 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 Article XI 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 oealth. igne .... :....-----•---•-------------• ............. .................. Date Application Approved By••---------- ------------............. . -----/�!� - ..... � --...?J-.._.... Date Application Disapproved for the following reasons-------------•----------•--...-----•-----•---•-••-----------......-----------------------•------------.......... ......--•-•--•-•-•--•--•--......--•................•-•----•--------------.........-•----••------.....-------.......-----•---•--•----._.....--------•---••••-••----•----------------------------•--•-•--. / -Date Permit No---------------------------•------•-....--------- ---_.. Issued....... `Z�.-....... Date No.... .............. FEE,./©..�'�.. .... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH --•--------- - -------------•---..O F........-..-:-.....-..........-.........---------------................................. Applirativn for :41,5pin i lVarbi Tontrnrtinn rumit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at Location-Address, or Lot No. .... ..1 - ..} .:! ...:. .�__._ ?.(,•��•�'.... ................. -'/_?......J ... ,�, . . f - �''` f wner _ A/ddress arfb+i 4.....�y,... ..?.�: � J 1-----•--•--•-••----•- •--••• —Eer! � at A .................'- Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms.......__................................Expansion Attic ( ) Garbage Grinder ( ) '4 Other—Type T e of Building _._____.___ No. of ersons____________________________ Showers p•, yp g _________________ p ( ) — Cafeteria ( ) a' Other fixtures ...................................................... Design Flow............ f:�:_______________________gallons per person per day. Total daily flow................. ed_�,2..............gallons. WSeptic Tank—Liquid capacity_/&?_ ,;gallons Length________________ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area.._: _f_`°?.....sq. ft. Seepage Pit No..... 1 LA... Diameter.................... Depth below inlet..................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit____________________ Depth to ground water_______________________. i, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ / -' �C I= -,'-_-------- �-•-----•-'--'---- - --.. r .-.. _ _�� �..pDescrlptlon of Soil - '-- - ._ W --------------------------------------------------------•------------------•-------••---...___...--•----••-•---....................................................................................... 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 Article XI 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. _Ii'g-ne� t F�. tom' '„ -..(4................................. --'----'---'-------•----......-- /�� `�'' __ r Date Application Approved B `�''✓f G — !� Date Application Disapproved for the following reasons-------------•---------------•--•-------•------'--'-----'-•---....------------•--•••----•------'•-'••••'___...... ..---•---•--.._.....--•-••-•'----...•'-'---'-----'-'---•__.___------"'-'-'-'.............'-•"''--'-------••-'-'-•_._...._..-------•-----------••--------'--"'-•-'______--•--------•---'-'_---•------' Date PermitNo......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH t` ;a.................OF..... : �t • t�tz. °'' ............................ wrtifiratr of (9nntphanre THIS ISO CERTIFY,/That the Indvidual Sewage Disposal System constructed ( ) or Repaired ( ) r" .. -----•--------------•--------•---•----------•-•-----•-•---•---•---•------------------•--•-- by. MR..... V, a .... ' -� s Install r c] _ r 1 has been installed in accordance with the provisions of Agic4e XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit No..-__5_____- _______________ dated....... '_..__.._._______. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD, OF HEALTH 113 d No.. 4.. ............. .X ........oF. ._ ka. asj.. 6__. . ......-------....._.. FEE..... 1 �r�� ��n�trnrt��n rrntit Permission is hereby granted___._ua)- ln......C _.._ to Construct ) or Repair-( ) an Individual Sew age--Dispo System Street as shown on the application for Disposal Works Construction Permit o________ ___________ Dated--- �lo, ,� �H •- DATE..--•-•-•-------'-'..................................'--'-"'-"•....._•-_-•-•. Board o V FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS ..,,.,.. ,r/'///A/ ..« ,..,......rr,,,,,,,,,,,,,,,r,,,.r,_ p»,..m ........... ....................... ,_'!1'• 4;...�A //"'r l,,/'./, ,/ - 9/ •.0,........... a �✓/�rl�lewrr'"i. 'r ,.r rr,°� P� � � '!� t.� ti,,f` ...............r............................. 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