HomeMy WebLinkAbout0033 SAMPSON HOUSE NOB - Health 33 SAMSON HOUSE ND6 COTUIT
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COMMONWEALTH OF MMSACHUSETTS
' EXECUTIVE OFFICE OF &mRONMENTAL AFFAIRS
. y DEPARTMENT 01F EN•VIRON.MtNTAL PROTECTION'
TITLE 5
OFFICIAL,INSPECTION-FORM—NOT FOR VOLUNTARY- .
1"AI Y ASSESSMENTS
SUBS IWACE SEWAGE DISPOSAL SYSTEM FO
RM
RM
PAK A
cERT><rICATION -
Property Address:
RECEIVED l
Owner's Name.
Address"
Owner's � 2. �
Date of Inspectimr._. TOWN OF BARNS E ABU-,
• /Q� " HEALTH DEPT. �
Name'a[Ins ector: lease riot � ® T _
p ) r !/.
Comp an Name:
• a.
Y �
Mailing Address;
Telephone Number: -
CERTIFICATION.STATEWN1'
I Certify that I have persgitally inspected the aewage disposal system at this address and that the information reported
below is true,accurate and complet¢as of dw tithe of the inspection-The inspection was performed based on my
trainitt$and experience in the.prgper function and maintenance of on site sewage disposal systems,I_am a DEP
approved system.inspector pursuant to Section 15.�40 of Title 5(310 CMR 15.000): The systetnf
passes
Conditionally Passes
_ . • eeds F er Evaluation by.the Local Approving Authority
ails
Date:
Inapceto�r's.Signature:
The system inspector shall suUntit a copy of this inspection reliort to the Approving Authority(Board of Health or:
MP)within 30 days of co"feting this ut~apectiom If the system is a Aared'system or has a design flow-of 10,000
gpd or greater,die'inspector and the systeni.owner shall submit the report to the appropriate regional office of the
DEP,The original should be sent to the system owner a►id:copies sent to the buyer,if applicable,and the'approving
authority.
Notes and Cotrinienta
****This report only describes.eonditioxis.at the tinte.of inspection and,•under the conditions of use at that
time.This in5pect1QR does not address•lto*the system will parform in the future under the some or different
conditions of use.
Title 5 Insneertinn Rnrrn Ott annnn
Nge of I I
:OFFICIAL INSPECTION' FORM•�-NOT FOR VOLUNTARY ASSESSMEN S T
SUBSURFACE.SEW;AGC'DISOOSAL. ' ` ' ,. . SYS�'�,1VI INSPECTION rQIt1vI
PART'A
(ERTIFICATIONcony i
( ►.n act) '
Property Address:
4WnRN7 � 4, A
aatc of Ybspection:__. c✓�/
Inspection Sutnm1kry: Check A,B,C,l)or E/ W YS,caiiipletrr all of Section D
A,7-.thave
em Passe not found any informaiion,wliich indicates that-any of the failure criteria described in 310 CMR
15.303 or in 310 CMR.15,304 exist_An""failure etiteria not evaluated-are indicated below,
Cotnmfnts:
Sy
stem stem Co t'o n i 11 P '
. Y d t na y asses:
_ One or more system cofnponents as.described in the"Conditional Pass".section need to be replaced or
repaired.The system,upon wrnpletion of the repiacemeut on pair,as approved by the Board of Health,will pass.
Answer,yes,no or not.determined'(Y,N,ND)in.the for the following statements.Ifnbt`deterrnined"please
cxrlaut. •
The septic tauk'.is••rhetal and over•20.years old:"or the'•se tic tank whether"metal ar not is structurally p ( )
. Y
unsound exhibits substa•tial infil ion.• . 'o trot loot• ., tt �..exfi r n oc tanl,failure is inllTiinent:System will pass inspection if the
existing:tatik is replaced:witlt a oomply'txr ;septic tank as approved:by the Board of Health.
"A metal%septie tarlk will pass.insleetion,if.it is structurally sound,hol;Ut ing and if a Certificate of Compliance
indicating that the.tank is.less than 20 years old is avtiii4le,
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 d e to•a•bmken;setded-or une•van.distribution box,System*will pass.inspection if(with•
epprovai of Board-of-Malth)i
broken pipes)are itpl4ced
obotrtyction'is removed
distribution box.is.leveled or.replaced
NU 6xp1alm.
_ 'Fhe system required-pumping more"then 4 tiines a year due to tyroken-or obstructed pipe(s).The system will
pass insppection if(with approval.of the Board of Health):
broken pipe(A)are replacod '
obstrtiction is itmoved ;
ND pl.in:
Page 3 of I i
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY-ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAJ,SYSTEM INSPECTION FORM
PART A.
CERTIFICATION(continued)
Property Address:
Owner
Dote of inspection:
C. .Further Evaluation is Required by toe Board of Health;
Conditions exist which require further evaluation by the Hoard of Health in order to determine if the=system
is failing to protect public health,safety or the envirotunent
1.. System.will pass unless hoard of Health rleteturlues in accordance with'310 CMk 13.303(I)(b)that the
systeut.s not fnuctidniug in a'manner which will protect public health,safety and the environment:
Cesspool or privy is within;50, fect of a surface water
CeSsPo9l or privy i5 wit4m•50 feet of a Wide
ririg vegetated wetland or a salt marsh
2• System will fail unlessthe•Tloard of Health(and Public Water Sutiplier,if any determines that the
system is functioning in a manner that protects the publie health,safetyr and eavirontnentt '
_ The system has a septic tack and soil-absorption system(SAS)and theL SAS is within 100 feet of a
surfacc water supply or tributary'to a surface water supply.
_ The system has$septic tack and SAS and the SAS.is.Wit hin a Zone 1 of a public:water supply.
The system has a septic,tauk and SAS and the SAS.is.withat•SO feet:of a private water supply well.
Tito system has aseptic tank and SAS and•tlie SAS is;less.that)•I:00 feet but SO.ftet or more from a.
private water supply wellk*.Mgfltud usedao detetittme distance.
"'This system pusses if the well water`analysis,performed at a DEP certified laboratory,for colifoan
bActeria and volatile organic compounds indicates that the well i,s free from pollution from that facility and
the preseOe of htumonia nitrogen and nitrate nitrogen is equal to or less than 5 pptn,provided that no other
failuxp criteria are triggered.A cbpy of the analysis must be;attachc.d to.this form:
3. Other:
ti'•
Page A of 1'J
OFF- CIA I1 INSPECTION'FORM—NOT rOR VOLUNT"Y ASSESSMENTS
St1BS.L1RFAt~L' ST+''UVAGE nISPOSAL SYSTEM INSPECTION FORM
PART•A
CERTIFICATION(continued)
Property Address: .
Owiier: `
Date of Inspection:
D. ;System I:ailttre Criteria.applicable to all systems,
You must indicate"yes"or"►io"to each'oFthe followmg 6ry .inspections;;
Yes' Nq/
_ t✓J Backup.of sewage into-facility or system component due to overloaded or clogged SAS or cesspool
ischarge or pondittg of rfflueht to-the•surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool'.
— :Static liquid level in the d(stributian box above outlet invert due to an overloaded or clogged SAS or
cesspool
' Liquid depth in cesspool-is less than 6"below invert or available'voltime is lass than '/Z day flow
YRequired pumping more titan 4•times.in the last.year•IVQT due to clogged or obstructed pipe(s).Number
' l Of times pumped
Any portion of the SA%cesspool or privy is below high ground water elevation.
VimyAdy p0ftipit ofcesspool or ptivyis within 100 feet of it.surface.water supply or tributary to a surface
watersupnly.
p4r#ion ofa cesspool or privy is within a Zone I of a publ.tc well.
Any portion.ota ctssppol or privy is-within 50 feet of a•private water supply well.
Any pprtioh of a cesspool'•or privy is less than 100 feetbut greater than•50 feet from a private water
supply Well with no accOptable water quality analygis. [ThWsystemi passes if the well water analysis;
performed•'ht a DgE certified laboratory,for collform bacteria and volatile organic compounds
indicates that the well.is free.from polltitiott.from that facillty and thepcesence of ammonia
nitrogen and nitrate nitrogen is equui to or less than 5 pnm,provided that no otlierfailure criteria
are trlggere&A ctlpy of the antiysis'must be attsichad•to this.form.]
AVesINP)The system tilts;)h8ft detertnihed.that one.oi'more pf tfieabove failure criteria exist as
descriked in 310 CMR 15303j therefdre the system fails.Tle system owner shoutd.contact the Board of
Health to deter nine:what will be necessary to correct-the failure.
. .Large Systems-
To.be eonsiderod'j�large system the systel i must's
gpd. erve a Yarility with a design flow of 10,000 gpd to 15,000
You must indicate vither"yes"or"no"to each of the following:
(The following eritena'Apply to large systems'ia addition to the criteria above)
Yes no
the system is withiJt..qO feet,uf a surface dtinkirtg water supply
the s5rsteitt is within 260 feet•of a t.ibuta y to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim-Wellhead Protection Area--•IWPA)or a mapped
Zone lI of a public water supply-welj%
If you have answered"yes"to atly•question•in•Section E.the-system is considercd a significant threat,cr answered
"des"in Section D.above-th�large.syst&6 has failed.T lie.owner or-op erator.of ariy large system considered a
.significant threat under Section E-or failed tulde'r Section D.shall upgrade the system in accordance with 310 CMR
15:304.T1tc system•owner should oontacrthc appropriate regional office of the Department.
page5or1.1
OI'CICIAL INSFE+ TION r'ORM NOT FOR VOLUNTARY ASSESSMENTS
St1I3SUR.FACE SEWAGE ]DISPOSA)L SYSTEM WSPECTION FORM
I'AItT B : ,
CHECKLIST
property Address:
Owner:
�AtC of ins a iion:
Cheek if dhc fvllawin have been dRde„You must indicate es"or"no"as to each of the.follown
Yes D10
Pumping information was provided by the owner,occupant,or Board of Health
— Were ahy of the system components pumped out in die previous two weeks
A-Zz Has the system reccived normal flows in the previous two week period?
Have large volumes Of Water been introduced to'the system recently or as part of-this in
spectian?
. ef",, Were tig 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?
_,e� Was the site inspected for si: s of break out?
Were all-system components,.excluding the SAS,located`on site?
Were the septic tank manholes uncovered,opened,and the Anterior of the tank inspected for the condition
ofthe;baffles or tees,material of construction,dimedsions,depth of liquid,depth of sludge and depth of scum?
Was the facility owner(and-occupants if different from owner).provided witli.infotmatioer
maintenance of subsurface sewage disposal systems? n on the prop
. ..
Tht size and location pf tho Soil Absorption System(w)on the site has been determined based on:
Yes no
Existing infonration.For example,a plan at die]Board of Health.
l� Determined in the-field(if any..of the failure criteria related to Fart.
is unacceptable)[310 Chit 15,302 3 G is_at issue approximation of distance
)'age 6 of 1 1
OFFICIAL INSPECTION FORM- ,NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE,,DIROSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION:
Property Address.-->
Owner,
Date of Iuspectioh:
/RESIDENTIAL.' .
Number of bedrooms(design):, Number of bedrooms(actual):
DESIGN flow based on 31 Q CMR 15:203(for example:l IO gPd x of Bedrooms):
Numf er'of current residents.,
Does-residence have a garbage grinder(yes or no);1 —
Is laupdry on a.separate sewage system s ar rao) [if yes separate btspection required)
Laundry system inspected(yes or no) .
Seasonal-use:(y4s or no):
Water meter readings,if available(last 2 years usage(gpd))
Sump pump(yes or no):
Last date of occupancy:. .
Comm ERCI,AUINDUS')"MA , ,0,
Type Of establislunent
Design flow(based'-on 310 CMR i S.2Q3): . EPd
Basis of design flow(seats/persots/sgfietc:):
Grease trap present'(yes-or no): .
Industrial waste holdingaank present(yes or no):
Non-sanitary waste dischargedtq the Title S systerri(yes or no): .
Water'meter readings,if-available:
Last date of occupahcyluse:
OTHER(describe):
GEATtAL'INFORMATION
,Pumping Records•
Source of information: ,
.
Was sXstem pumped as at ofdaaspeGiton yes or rro
Ifyes,volume pumped: gallons How was quantity pumped determined? _
Reason for pumping
T
OF SYSTEMptic tank,distribution box,•soil.ab5orptiori system.,
_Single cesspool
Overflow cesspool'
—Privy
Shared system(yes or no)(if jycs,attach.previous inspection records,if any)'
_Intiovative/Altet tine tecluro Sy.Attach a copy of the current operation and maintenance eootract(to be
obtained from system'owner)
Ti$ttt tank Attach a copy of the,DEP approval
Other(describe):
Approximate age of-all componchts,date installed(if known).and source of information:
Were sowage odors detected when arriving•at the site.(yes or ryo):•, f�""'
Page 7 of-II
:OFFICIAL•,INS.PECTIONYORM--NOT`.IiQI3 VOLUNTARY ASSESSMENTS
SUBSURri Cr,, SEWAGE DISPOSALS 'STEM IIVS 'ECTIO)v i•;OItN1( "
PART C
SYSTEM INFO��1YfATION(continued)
Property Address: i
Owner; d.
Date of Inspection:::
BUILDING SEWEA flocate.on site Ohm)
Depth below grade
Materials of cottstruetidn:•• °cast iron 4.0,PVC other th �(explain): •
Dlstanci from private water supply well•of suction..lIEW
Commeltts(on condition cif joia%Venting}pvidenee of leakage,etc.):
SEPTIC TANK:• f (locate on site plan)-
N.
Depth below grade;-.�
Material:of construction:_k-Oticrete Tthetal _f berglass polyethylene
other(explain) .
If tank is metal list age,: ls'agd cbnfumed by a Certificate of Compliance(yes or`noy—(attach a copy of
ccrtiftcate) ./•• .
Sludge depth:
Distance•from too-of shidgE tp bottom caf.atitlet tee or-baffle: 3
Scum thiclatess:i/..,. oI, '
Distanee:from top of s'd'W i to-top of outli i tee or baffle; 3.. ._
Distance.from boadin.ofscutn tobditom:o outlet tee or baffle: 'r
Dow.were.dimensions
determined—(on puiuning-mcommon tioli9j; nlet and outlet tee or baffle,condition,structumf integrity,liquid levels
related to outlet invert,•i;v' once of leakage,•etc.): ,
.��
GREASE TItA,IA ate on site plan.)
Depth below grade
Material of construction: concrotc metal_ _fiberglass'_•polyethylene _other
(explain):,
Dimensions
Seam thickness:
DiUanoo front top of seutn to`top of outlet tee or bailie:,
Dijtance".Bonn bottom of scalp to.bottom'of outlet tee or baffle"
Data of last ptunping:
Comments(On pumping-reeptttntend tions,inlet and outlet:teo or•baftta condition,structum t integrity,liquid levels
as rolatod to outlet invert,evidencc.of leakage,etc.),
• f
1'agc 8 of•1 I
OFFICIAL,INSPECTION;FORM—NOT FOIL VOLUNTARY ASSESSMENTS
STJBSUt3FACE`SEWACC DISPOSAL SYSTEM INSPECTION FORM
PART;C::
SYSTEM(INFOTt,MA'I'TUN(continued)
Property Address; 3
owner:
Crate of Inspectiou: ®/
TIGHT oe HOLI)INC TANK -(tank must be-pumped attune of inspection)(locate on site:plan)
Depth below grade: w
Material of construction:_concrete metal fiberglass polyethylene _other(explain):
Dimensions:
Capaoity:._ nallbns .
Design Flow..
' e$llotts/day
Alarm present(yes.or no); -
Alarm level:_�____� Alarm uj working order(yes or no),: .
Date of last pumping:
Cat ments(condition of alaim end#ldat switches,etc.):
D1S"11UftT-j0N.BOX;✓(ifpresent must be'opeiied)(loca.te on site plan)
Depth of liquid level above-outlet invert; ��
Comments(note if box is level and distribution to�outietsual,any evidence of solids carryover,any evidence of
le age into or out of box,'eicy
PUMP CHANBr'-X2'C.Ake oft site plan) 4.
Pumps in working prder(yes or(io):
Alarms ill working order(yes or tto): 4
Comments(note conditioq of Outnp chamber,condition of puitips and appurtenances,etc.):
I
NO 9 of I 1
OFFICIAL INSPECTION FORM NOT,FOR VOLUNTARY ASSESSMENTS
SMSURFA;CE SE WAGETD SPOSAL SYSTEM INSPECTION.FORM
PART C
'SYSTEM INFORM:A•TION'(continued)
Property Address; ;3
Owner: , r
Date of Inspection
SOIL ABSORPTION SYSTEM(SAS): (locate on.site plan,excavation clot required)
' If SAS not located explain why: ,
Tye
P
r�,�l aching pits;number;
leaching chambers,number:
leaching galleries,number:
leaching trenblaes;number,length:
leaching•fields,number;dimensions:
overflow cesspool,,number. •. __
innovativelalternative system• ,Type uonid of technology:
Comments(note condition of soil,Aligns df hydraulic f$ilurc,level of ponding,damp soil;condition of vegetation,
etc /
r C/Caor
`C.2J�O
tESSP00L$r (cesspool must be pumped as-part of inspect.10010cate on site PI 1)
Number.and-configtotion:
Depth—top of iigwid:to.inlot,invert+ '
Depth of solids.layer.
-
Depth of scum layer:.'
Dimensions of cesspool;
Materials of construction;
f lidication of groundwater i lfldw(yes or no):
Conuiteuts•(note Condition of'oil.signs-of hydraulic failure,level of ponding,•cqudicion of vegetation,etc.): '
PWWjQ 0ocate on.site plan)
•Materials of construction:
• Depth of solids: .� ' •
Comments(noto condition of soil,sips of.hydraulic failure,lever of po'nding,condition of vegetation,etc.):
Page 10 of 1.1.
OFI<IOAE INSPECTION FORM—NOT FOR VOLY1N.TARY ASSESSMENTS
SUBSURFACE SEWAGE WSPOSAY;SYSTEM INSPE CTIQN FORM
PART C
SYSTEM INFORMATION(continued)
Property Adiiress: ( CA0i21�e. 1216 1
Owner:
Date of Inspectiont
SKETCH OF SEWAGE DISPOSAL•SYSTEM'
Provide a sketch of the sewage disposal system including ties to at feast two.pennanent reference landmarks or
benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building.
. c
• Pa��r. I I of 11 . '
OFFICIAL INSPECTION FORM—SNOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
y
PART•C
SYSTEM INFORMATION(continued)
Property Address:
Owner'
Date of Inspection: fX�
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to.ground water feet
Please indicate(cheek)'all•methods used to detennine the high ground water elevation:
Obtained from system design plans On record-If checked',date bf design plan reviewed:
Observed site(abutting prppettylobservation hole within ISO feet of SAS)
Checked with local Board o,f Health-explain:_
Checked with local excavators,installers-(attach docmiientation)
Accessed USOS daiabase-explailt:
You must describe how-ypu.established the high ground water,elevatiou: �
LOCATION SWAGE PERMIT NO.
a
VILLAGE
I N S T A LLER'S NAME i ADDRESS
Al
R U I L D E R OR OWN ER
ro DATE PERMIT ISSUED _
oDATE COMPLIANCE ISSUED <g )13 )?5
m
i s3
3i{ j
i
4$
r
i
G�/Y�
rf�
No / Finc
THE COMMONWEALTH"'OF MASSACHUSETTS
f BOAR® OF HEALTH
bu )aZ �
Applir�a#ion for Uispvii al larks Tonstrurtiuxt antif
S Application is hereby madefor a Pe�jrrm� o Construct ( ) or Repair ( ) an Individual Sewage Disposal
y s �; -� �Alcoi�
. ®�r.. ..... � � . ....�e �..'�fV;�----------------------------•------------------.....--------.......---------
/'��f�Loc ti n-A�dd1ess /� / p� `tor Lot No. �7 �j�y�
......�r1.. _.JG!^:..._.L:::...._ f.LA(.. .................................. ..A.-: .?SK�../..�_. 7C�_Q._ ..��+Lc�1..[�Q'k.Ct.......................
Owner Address
. Q .: r .... s�2� . ....Gll .......
Installer
Address
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms...... 3................................Expansion Attic ( ) Garbage Grinder ( )
; ,- Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
PA Other fixtures ................................................. -
- Design Flow..•...._._4iw g .... .......................gallons per-person per day. Total daily flow-------2_3_.....................gallons.
Septic Tank—Liquid capacity�ff—gallons Length-------_------- Width................ Diameter---------------- Depth................
.W Disposal Trench—No................ . Width..................._Total Length.................... Total leaching area....................sq. ft.
P ----
Seepage Pit No..................... Diameter...._ Depth below inlet.......6.......... Total leaching area.O.P285 sq. ft.
Other Distribution box ( ) Dosing tank (' )
r 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........................
.. ---------------------------------------•••....------•..AXf
Description of Soil............ �s � t.�_k4o.. S14 -•--------------------------- --------•-.----------------•-•----.---•---
x
w
<•V 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
operation until a Certificate of Compliance has b n issued by the board of health.
l y
Application Approved By............... ......•--.• _. -•-•-• •.....•.-•--•-•.........---------- --- - _-a
..........
Date`
Application Disapproved for the following reasons:._.a �.- .......: ......... ..............
......................................................................... y,.. _ .......--.._..•....•.•...•..........................----___......_.......I..__._........................................
Date
Permit No.---.-----�, Issued...
x "--------------------- --------------------
'€<' y Date
THE COMMONWEALTH, OF MASSACHUSETTS
BOARD OF HEALTH
------------------------------------------O F.-.............-.-.............._.......
Appliration for Disposal Works Tongtrurtion Frrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
....... a a .....�LocaMPA .. ua u"------------------------------------------•--•-----.....-----....----.........
ddress or Lot No.
...- �i4s /U- .5- -1�4»--•-••------------------•-------... ?�tx.�a. C ,S6 .�- -------.------__
Owner Address
W "Q �.... > �,.# ----- ��.y��q
� ----...---- -- •Installer ._..P"�+'-J•�----•�w------ ------
Address
Type of Building Size Lot.................... .....Sq. feet
Dwelling—No. of Bedrooms...... __•_______-____•__••__-____--•___Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building ............... No. of ersons....•__........______-_----- Showers
a YP g P ( ) — Cafeteria ( )
a
d Other fixtures ----------------------------•-----------•---.------•--------------------------..._..
W Design Flow....... (..4 "r____________________gallons per person per day. Total daily flow------,- .................
WSeptic Tank—Liquid capacitlfth?.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? ,5.sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
a, Percolation Test Results Performed by........................................................................... Date........................................
Test Pit No. I...........:....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
a water........................
_
O Description of Soil...........
W -----------------..............................................................................
U -----------------------
•--------------
_---------
_------------
......------------------------------------
•------------------------------------------
•---------
•------------••----------------------------
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 TITIE 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.
Igned "-' l
Cyr
Application Approved By.-----="�" " .--• ---- 2c " = _}�_ tom"' ._..
j Date
Application Disapproved for the following reasons----------------------------------------------------------•-------•-----------------------------------....._._._
-----•-•-•--•-•.............................•---...---------•-------•--...----•------------•---...----------•-•....--------------•----------------•-----------------•-----------•------------------_---
Date
Permit No.-------- �-��=:. .......... Issued----•---------------------------••.........
Date
yp4+:�t/ `` ;• THE COMMONWEALTH OF-MASSACHUSETTS ` ` `� - - -•.� _
BoAR,Er OF HEALTH u -
..........................................OF.. .....................................
``'" r f�rr�ifirtt�e iif �L1m�Ii�nr.�
. k THIS IS TO CERTIFY That"the Irid vldual Sewage Dlsposal System constructed ( ) or Repaired ( )
.......................................
Installer
at.• 04.
.M
,has been installed in accordance with the provisions of TI T I F p 5 of The State Sanitary Cade, a,, es rlbed in the
application for Disposal Works Construction Permit No._ _;_ -•;,, '" ........ dated_ _ } . . .......... .
THE ISSUANCE OF THIS CERTIFICATE SHALL NO �E CO TRUED AS A GUA ANTEE THAT THE
SYSTEM WILL FU CTI N SATISFACTORY.
�..� ... Inspector.............
DATE..................-
THE.COMMONWEALTH OF MASS HUSETTS +�
BOARD. OF HEALTH
.� 1"
No OF. ......................... . ........................................ ..... FE
.... ..
Dispo'o t1 VorMi %Tnnitrnrtinn famit
Permission is hereby granted....... _4!L .,a----.--_-- et 2S d- 1 ...... . .......................
to Construct ( ) or Repair ( ) an Individual Sewage'Disposal System
at No........ t. "
---------------- -------------- --- -
Street
as shown on the application for Disposal Works Construction Permit d -_ 3/ Dated Y._ ':
sy{�
DATE...... Board of Health
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