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HomeMy WebLinkAbout0110 WAQUOIT ROAD EAST - Health 110 Waquoit eOltI t) WA=018-003 s ;COT!ITT) i f D`ATI'_ ,_8/30/01 --- - P R O P E R T Y A O O R E S S; E_,.MCElorx_------_---- Box 19.Q2.............. On Iho aboyo dolo, I inapoolod the aeptlo oyitoM at the aboYo address. ThIl ay3iom oonslais of the following; 1 . 1 -1000 gallon septic tank. 2. 1 -Distribution box. 3 . 1 -1000 gallon precast leaching pit. 6 'X10 ' minium Based on my Inspocllon, I oortlfy the following oondlllona, 4 . This is a title five septic system. ( 78 Code ) 5. The septic system is in proper working order at the present time. 6. Waste water is 3 ' 8" below. the invert pipe of the leaching pit. 510NATUREI.� Name ! sQak9-r--)J,,--------0 Company;_Jo, • ph-P . _N•comb@r_b Son , Inc , 00 Addle aa ; Box 66 ----- _-CentervillsL 6_-_02632-0066- Phone 508 775- 73 )8 - TMIS CCRTIFICATION 0OCs NOT CONSTITVTC A OVARANTY OR WARRANTY + J6SEPH P. MACOMBM & SON, INC, Y+nk� 0+i�pool� l.�+chll�ld+ Pvmpfd G, Inilillld Town S+wtr Connf9U9n) P.O. Box 66 C+nlirYlllf, MA 02632-0066 775JJJ8 7756112 AVC3,3 2001 rowel OF BNri'NSTABLE HEALTH DEpT. �I \ COMMONWEALTH OF MASSACAUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION i TITLE 5 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 1 1 0 Waquoit Road Cotuit,Mass, Owner's NameBugene cElroy Owner's Address: Same Date of Inspection: 8 30 01 Name of Inspector: (please print) Joseph P.Maeomber Jr. Company Name: J.P.Macomber & Son Inc. Mailing Address: Box 66 .02632 Telephone Number: 508-775-3 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: Z—/Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails is Signature: Date: R—�I Inspector's g The system inspector shall mit 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 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. r Title 5 Inspection Form 6/15/2000 page I Page 2 of 11 OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A . CERTIFICATION (continued) Property Address: 1 1 0 Waquoit Road Cotuit,Mass, Owner: Eugene McElroy Date of Inspection: 8 3 0 0 Inspection Summary: Check A,B,C,D or /ALWAYS complete all of Section D A. System Passes: /i, I have not found any information hich indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 C R 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: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of thereplacement 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: ItId 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 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 M1 ND explain: 2 Page 3 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1 1 0 Waquoit Road Cotuit,Mass. Owner: Eugene McElroy Date of Inspection: 8 3 0 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, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(l)(b) that the system is not functioning in a manner which will protect public health,safety and the environment: ,fld Cesspool or privy is within 50 feet of a surface water ,40 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: X)O 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 fegt but 0 feet or more front a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria 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 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1 1 0 Waquoit Road Co uit,Mass. Owner: Eugene McElroy Date of Inspection: 8 3 0 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 _ �V ackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool :Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or /clogged SAS or cesspool i� Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or ]cesspool l�fj _ ,/ Liquid depth in 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 Q. arty portion of the SAS, cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface ]water supply. �ny y portion of a cesspool or privy is within a Zone 1 of a public well. y Portion of a cesspool or privy is within 50 feet of a private water supply well. 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. [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.] (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 10,000 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/ _/ the system is within 400 feet of a surface drinking water supply _ Z- the system is within 200 feet of a tributary to a surface drinking water supply /the system is located in a nitrogen sensitive area(Interim Wellhead Protection 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 I Page 5 of l 1 ; OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 1 1 0 Waquoit Road Cotoit,Mass. Owner: Eugene McElroy Date of Inspection: 8 30 01 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes YPumpi=ng information was provided by th- owner, occupant, or Board of 'Heal I th YWere any of the system components pumped out in the previous two weeks ? Has the system received normal flows in the previous two week period? Yliave large volumes of water been introduced to the system recently or as part of this inspection ? /We r re 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 baffles or tees, material of construction,dimensions, depth of liquid, depth of sludge and depth of scum ? Was the facility owner(and occupants if di'-ferent 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)] I 5 THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINAL (S) I A , I- m / IL DATA r Page 6 of 1 1 OFFICIAL INSPECTION FORM ti OT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DI4�;OSAL SYSTEM INSPECTION FORM .-�,i�T C SYSTENI I NFORMATION Property Address: 1 1 0 Waquoit Road Co ui ,Mass. Owner: Eugene McElroy ' Date of Inspection: 8 3 0 01 FLOW COND!rlONS RESIDENTIAL Number of bedrooms(design): Number of'oe,. stuns(actual): DESIGN flow based on 310 CMR 15.203 (for examp. : 1 10 gpd x#of bedrooms);,A�,!�JM+p� Number of current residents: a Does residence have a garbage grinder(yes or no):;, Is laundry on a separate sewage system (yes or no) Z `if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use: (yes or no): 4�) Igo ., Water meter readings, if available(last 2 years usage +)): / =off )E� �/� — �J Sump pump(yes or no): ✓ Last date of occupancy I �rll_ COMM ERCIAL4"USTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): _gpd Basis of design flow(seats/persons/sgft,etc.): =f Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system ( •s it no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): Al/9 GENERAL i.N' ; 'I MATION Pumping Records - Source of information: Was system pumped as part�f the inspection(yes cc !f yes, volume pumped: V gallons--How",as + : cv pumped determined? Reason for pumping: TYPX OF SYSTEM Septic tank,distribution box,soil absorption systc..I Single cesspool Overflow cesspool ` Privy Shared system(yes or no)(if yes,attach previous :asnection records, if any) _Innovative/Alternative technology. Attach a copy .`the current operation and maintenance contract(to be obtained from system owner) Tight tank Attach a copy of the DEP app,c .fll� Other(describe): Appro imate ate of all compon nts, date installed (;t otrn) and source of information: A tires - Were sewage odors detected when arriving at the si. no): Page 7 of 1 1 1, OFFICIAL INSPECTION FORM - r FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE Dl$,' ti,L SYSTEM INSPECTION FORM t 1 TC SYSTEM INF(. IATION (continued) Property Address: 1 1 0 Waquoit Road Cotuit,Mass. Owner:Eugene McElro Date of Inspection: 8 30l1 BUILDING SEWER(locate on site plan) Depth below grade: _ Materials of con struction:,j&�;ast iron Z- 40 PVC ier(explain): Distance from private water supply well or suction I,rr ✓�'' Comments(on condition of joints, venting, evidence t :.;age,etc.): Joints appear ti ht.No evidenc ._f leakaae.The system is vented EH_r_o_ug_Ti the house vents. SEPTIC TANK: (locate on site plan) 15 Depth below grade: Material of construction: k'concrete 4,b metaV. z ass 1!i! polyethylene 4�lother(explain) IUA If tank is metal list age:db Is age confirmed by a :are of Compliance(yes or no):40 (attach a copy of certificate) �� r� ` Dimensions: � )A' Sludge depth: Distance from top of s dge to bottom of outlet tee Scum thickness: Distance from top of scum to top of outlet tee or ba Distance from bottom of scum to bottom pf outlet t .1F11e: ,,(s How were dimensions determined: �zj Comments(on pumping recommendations, inlet an, t tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of.leakage, etc.) Pump t•hP septic tank anniia l X}- go disposal is present. I n l e t 9 rn>t 1 P t tA a c are ink l 'h-e tank—i s sound and shows no evidence c akage. GREASE TRAP4�. e(locate on site plan) Depth below grade: 1 Material of construction;lticoncrete�metal,sir'. :ss/per polyethylene4�tother (explain): Dimensions: Scum thickness: lfl� _ Distance from top of scum to top of outlet tee or ba Distance from bottom of scum to bottom of outlet t. !`ne: _ Date of last pumping: 41 Comments(on pumping recommendations, inlet a.: we or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc. Crease trap is not presence—.- Page 8 of 1 1 OFFICIAL INSPECTION FOI i'I FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE . �,L SYSTEM INSPECTION FORM .' " C SYSTEM x-�TION(continued) Property Address: 1 1 0 Waquoit Roa o ui , ass. Owner: Eugene McElroy Date of Inspection: 8/3 0/01 TIGHT or HOLDING TANKeke,(tank mt at time of inspect ion)(locate on site plan) Depth below grade: Material of construction: eI4 concrete mN _ :r,lass !f4 polyethylenee&_other(explain): 1 Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: 4�,4 Alarm in working order Date of last pumping: Alh Comments(condition of alarm and float switc Tight or holding tan s.ar.- f> en . DISTRIBUTION BOX: (if present must _ 1,,:ate on site plan) Depth of liquid level above outlet invert: + Comments(note if box is level and distribution ,-a;,any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Distribution box has one lE. evidence of solids harry over.No evidence of 1. 4.nto or out of the box. PUMP CHAMBER ,(locate on site plan' Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber, c. and appurtenances,etc.):, Pump chamber is not preset Page 9 of 11 OFFICIAL INSPECTION FOI: R VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE )) 'STEM INSPECTION FORM SYSTEM I. )N(continued) Property Address: 1 1 0 Waquoit Roast o ui ,Mass. Owner: Eugene McE roy Date of Inspection: 8 3 0 01 SOIL ABSORPTION SYSTEM (SAS): t+ n, excavation not required) If SAS not located explain why: Located. Type leaching pits, number:L _,&I leaching chambers, number: leaching galleries,number: leaching trenches,number, length: T _ leaching fields,number, dimensions:_Z,, overflow cesspool,number: innovative/alternative system Type/name. Comments (note condition of soil, signs of hydra:,,; )f ponding, damp soil, condition of vegetation, etc.): Loamy sand to fine sand.No .ydraulic failure or ponding.Soils are dry. Veg` norma . Waste water is 3 ' 8" below pipe. CESSPOOLS(cesspool must be pumped );)(locate on site plan) Number and configuration: �} _ Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Ail? Dimensions of cesspool: AM Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil, signs.of hydr�.-4, f ponding,condition of vegetation, etc.): Cesspools are not present. PRIVY ,* (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil, signs of hydra ponding,condition of vegetation, etc.): Privy ; s no `present` Page 10 of 1 1 OFFICIAL INSPECTION F01 VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE. 'STEM INSPECTION FORM SYSTEM r A ')N(continued) Property Address: 1 1 0 Waquoit Rc t cztuit,mass. Owner:Eugene McElroy Date of Inspection: 8 3 0 01 SKETCH OF SEWAGE DISPOSAL SYS"F, Provide a sketch of the sewage disposal syster: least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. i : water supply enters the building. � 46 , gage 1] of 11 T, OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1 1 0 Waguoit Road Cotuit,Mass. Owner: Eugene McElroy Date of Inspection: 8/3 0/01 SITE EXAM 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: btained es s on record-If checked,date of design plan reviewed: Observed sit�(abuttin g property/ bservation hole within 150 feet of SAS) tec a wrtoar o ealth-explain: Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Used water contours Map. Gahrety & Miller Model 12/16/94 11 a• .•r,rnr+r.—rs,•rs*—.•r�—.nr►rmr•nreais�en senrerrrnr+++vRn+�+�++,m rtorn�u+�•�rr�„nn .. , TOWN OF Barnstable WARD OF HEALTH SUIlSURFACR SEWAGE; DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION -TYPE OR PRINT CLEARLY- PROPERTY INSPECTED STREET ADDRES$ 110 Waquoit Road Cotuit,Mass. ' ASSESSORS MAP, BLOCK AND PARCEL # OWNER' s NAME Eugene McElroy PART D - CERTIFICATION NAME OF INSPECTOR Joseph P.Macomber Jr. COMPANY NAME J.P.Macomber & Son Inge' COMPANY ADDRESS Box 66 Centerville Mass.02632 Street Town or City state =Ip COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX ( 508 ) 790 - 1 578 R CERTIFICATION .STATEMENT I certify •that I have personally inspected the sewage disposaj system at this address and that the information reported is true , accurate, and omplete 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. _�/Syste6 PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 16 . 303 , Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form . System FAILED* The inspection which I have con Meted has found that the system fails to protect the public health and the environment in accordance with Title =5 , 310 CMR 15 , 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form Z/Inspector Signature`'` Date ne copy of this certification must be provided to the OWNER, the BUYER ( where applicable ) and the BOARD OF HEALTri. * If the inspection FAILED, the owner or*"'operator shall upgrade within one year of the date of the inspection, unless allowed ort required he m otherwise as provided in 3.10 CMR 16 . 305 . partd .doc �y`- /7A oaL3s %/.b� -u�✓J.s� lone+-.-� J.P .Macomber & 3ur� in,'c. � i�__..---.,. >, ..._ � ._ -• : - Box 66 Centerville ,Mass . 02632 Grey Grover �- �C��' 1080 02635 I�1!l1111111111fifHli11i!l1111111$111 Ili III IdIthill11111111 i i"" etc JOSEPH P. MACOMBER & SON, INC. . P.O.BOX 66 CENTERVILLE,MA 02632-0066 775-3338 775-6412 Carey Grover ; The septic system at 110 Waquoit Road jlCotuit is, large enough for a bedroom home. Presently this is a three bedroom home. 330 GPD. The present system is designed for 516 GPD. Requirements for a four bedroom home is 440 GPD; We have an accesgof seventy six gallons per day. Side Wall Area 157 SF 157 SFx2. 5 G/SF=393 GPD ! Bottom Area 123 SF 1 . 0 G/SF=123 GPD Leaching provided 516 GPD. 4 . .. Leaching pit is 6 ' 6" with 3 ' of 12" stone all around . V 12 6" X6 1 eaching•`pit : .. Respectfully ; L I TOWN O BARNSTABLE LOCATION jd SEWAGE # ,.VILLAGE ASSESSOR'S MAP & LOT+� r INSTALLER'S NAME&PHONE NO SEPTIC TANK CAPACITY A20 LEACHING FACILrrY: (type) ' '�s (size) NO.OF BEDROOMS _ BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland an ;ac * g Facility(If an wetlands exist within 300 feet o e ) Feet Furnished b t l® uJacLooi NNI ASSER AP N0. l PARCEL SSO L0 C/A T 1`9 N lia SEWAGE PER IT NO. LA z QAli VILLAGE u r LLE 'S NAME i ADD,RESS ` a �e U I DER OR 0wa ER �. ,'DATE PERMIT ISSUED c� DATE COMPLIANCE ISSUED Z-3--& � � � �. .. -� �� � w /y� 7 r �.�' � �P�� � q(� V �� . :-:gym>._. -. 39 THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ............. ..OWI........O F........ ..Rws;xa 6L Appliratiun for Disposal Works Tonstrurtiun Prratit Application is hereby made for a Permit to Construct X or Repair ( ) an Individual Sewage Disposal System at: ...................... ®%. G%2 c6 ---------------- oc i n- d r�jjejj��s or Lot No. ............... a... ..t�r l.._.._... ..... ............................................. Owner Addr sus Installer •J Address U Type of Building l�o�� Size Lot..� - Q .Sq. feet Dwelling—No. of Bedrooms.._..._..... ..........................Expansion Attic ( ) Garbage Grinder ( ) aOther Other—Type of Building ............................ No. of persons._...__..............__.___. Showers ( ) = Cafeteria fixt es ------------------------------------•-----------....--------------------------------------------......---•--. -- W Design Flow..............//0................._...gallons per person per day. Total daily flow.............s �.:...____.__...gallons. WSeptic Tank—Liquid capacity/M gallons Length................ Width................ Diameter..........__..._.."'D-epth.................. x Disposal Trench—No. ......... .......... Width.........r...... Total Length.................. Total leaching area....................sq. ft. Seepage Pit No________________ __ Diameter..1e....6... Depth below inlet........ Total leaching area.....Zea.sq. ft. Z Other Distribution box (+ Dosing tank ( �-g�- '-' Percolation Test Results Performed by..l��rl�/S�...................p 4_c.�,z�r_._ �9__ Date_...___ _�sa.'� ._...... W Test Pit No. L..C.z__.minutes per inch Depth of Test Prt..� _. . Depth to ground 7_61- VC 4� Test Pit No. 2... Z...minutes per inch Depth of Test Pit._��j�z_.._... Depth to ground water..N49__6rNC,1` ---------------_-----------------•----••-•--•---------....-------------------•-.----- O Description of Soil.........�1 0..__�Sljfl� x U •---------------------------•---------......----.....------------......-----•---------•••----•----------••------------•-••-•-......-----•-----......--------_...._ ----- W ----------------------- ------------=-----•-----------------------------•--------------...----•----•-----------------------------------•----------------------- U Nature of Repairs or Alterations—Answer when applicable..................................................... Mc Agreement: 470 , The undersigned agrees to install the aforedescribed Individual Sewage DisposalSys the provisions of TITLL 5 of the State Sanitary Code—The undersigne gre -n h in operation until a Certificate of Compliance has been iss he board heal'h. Signed .. ..... Date Application Approved By........ ............ ...---- ..... ------------------------------------------------ ..............1 Date Application Disapproved.f or the f ollowin reasons:.-----•-------•-------•----•-•---•---------------------•-----....----------------•-------. -••----••---....._ ......................•------•---•-----.....-•-----•-----------•----------••-------......--•-•-----------.........------------------•------------------•-------------------------------------•----•••---- Date PermitNo......................................................... Issued....................................................... Date ............... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..............7.42WI.---...OF....... ............................... Allpfiration for Dhiposal Works Tomitrurtion Frrutit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: ................... ................ ....... ........................................................... Location',§dT. or Lot No. Z7 Owner Address Installer .............................................Addres s Type of Building Size Lot___a feet Dwelling—No. of Bedrooms.............::...___.____________._.__._Expansion Attic Garbage Grinder ( ) 04 Other—Type of Building ........................... No. of persons............................ Showers Cafeteria ( ) 114 Other fixtures ..................................................................................................................................................... Design Flow______________ .....................gallons per person per day. Total daily flow.___._..._..__.:.: ...............gallons. WSeptic Tank—Liquid capacity.A,,.��'.Vgallons Length................ Width____..___.____._ Diameter._._.._.________ Depth_.__.__.____._.. Disposal Trench—No_.................... Width_._.___...__._._.__ Total Length.____.__....____.__. Total leaching area....................sq. f t. Seepage Pit No..................... Diameter...Z­ (--%./?Depth below inlet____._!:......... Total leaching area..... ft. Z Other Distribution box ( 4--f Dosing tank ( ) , Percolation Test Results Performed Dat e........7. ........... Test Pit No. 1...A�".?_...minutes per inch Depth of Test Pit--- Depth to ground Test Pit No. 2.....�Z_....minutes per inch Depth of Test Pit... Depth to ground water.- ................................................................................................................................. 0 Description of Soil._ _./'.2 .................................................................... ....................................................................................................................................................................... ...... U ............... .................................................................................................................................................... f. Nature of Repairs or Alterations—Answer when applicable........................................................... U ... . 706 ..........................................................................................................................................I............................ .. ....... .... Agreement: t ST The undersigned agrees to install the aforedescribed Individual Sewage Disposal Sy�'tem in I the provisions of T IT 11 5 of the State Sanitary Code— The undersigned further agrees not'�b-prj c th in operation until a Certificate of Compliance has been issued by the board of health. Signed..................................................................... ............. ... ................ Date .... ---­--­-­- a Application Approved By--- ...... . .....L.�._ ----------------------------------------- te Application Disapproved for the followin reasons:............................................................................................................. .........................................................................................................I............................................................................................... Date PermitNo......................................................... Issued-....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH P-j 1 ...................OF........... ....... ........................... (9rdifiratr of Tantpliatta THIS IS �O CERTIFY T Individu4,Sewage D�sposaM-stem constructed or Repaired Tat he by...................... .... ........ .....C. ........................................................ Installer at..................................................................................................................................................................................................... has been instilled in accordance with the provisions of TIZIE 5 of The State Sanitary Code as described in the _application for Disposal Works Construction Permit No. :l ..... dated---------- - ..................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. _T w11 DATE..................... ..........S....4....................... Inspector.......................................................... )----.................. 3> THE COMMONWEALTH OF MASSACHUSETTS BOARD OF 0... HEALTH .................OF......... ". 17 -6 7...7................... .....FEE...... 6- Permission is hereby granted............ .... to Construct or Repair.( ) an Individual Sewage Ni'sposal System (�u .J.............................................................. . ..................... as shown on the application for Disposal Works Construction Permit No_:.........a.._ Dated..... Y/ ­* at No.....L,_4D+5.( )J..Z............ Street V-" 3?_7 .............. ....................... DATE....... ..................................... 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