HomeMy WebLinkAbout0082 WESTBURY WAY - Health 82 Westbury`Way,
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
i d DEPARTMENT OF ENVIRONMENTAL PROTECTION
EDD
'TC
td 0 8 2005
TITLE 5 )"HEALTH DEPT-
LE
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 82 Westbury Way -y
Cotuit MA 02635
Owner's Name: Linda Lubelczyk& Richard Walden
Owner's Address: 56 Tracy Lane I+,.EI
Mashpee MA 02649 -^
Date of Inspection: January 11,2005 Job#05-13
Name of Inspector: PATRI p CK M.O CONNELL
Company Name: SEPTIC INSPECTIO
N SERVICES CO.
Mailing Address: 189 CAMMETT ROAD
MARSTONS MILLS MA 02648
Telephone Number: 508-428-1779
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 Section 15.340 of Title 5(310 CMR 15.000). The system: N%%%J111111111
Passes t1.OF
X •• �4��i
— — .��.�
Conditionally Passes �? %
Needs Further Evaluation by the Local Approving Authority a � ;m's
Fail — —{=
.yam
M Co
i v
Inspector's Signature: Date: 1/11/05 O • �`�`
Sly
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of I1' ttfAtllt�`
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: Liquid level in leaching pit 24-26"below inlet pipe with a high stain line 2-3"above
current level.Recommend pumping tank in next two years.
****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.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 82 Westbury Way,Cotuit
Owner: Linda Lubelczyk& Richard Walden
Date of Inspection: January 11,2005
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
_XX_ I 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.
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:
Observation of sewage backup or breakout 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
ND explain:
Titles G Tnenr+rtinn Rnrm r,ii,;i,)nnn 2
Page 3 of l l
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 82 Westbury Way,Cotuit
Owner: Linda Lubelczyk&Richard Walden
Date of Inspection: January 11,2005
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:
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 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:
Title S Tncnarfinn Rnrm All G/7(1M 3
Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 82 Westbury Way,Cotuit
Owner: Linda Lubelczyk& Richard Walden
Date of Inspection: January 11,2005
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
_X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
_X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
_X_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
— —X_ Liquid depth in cesspool is less than 6"below invert or available volume is less than %day flow
_X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
X_ Any portion of the SAS,cesspool or privy is below high ground water elevation.
_X— Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
X Any portion of a cesspool or privy is within a Zone I of a public well.
—X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_X_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [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.]
No_(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
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.
Title 1; Tnonontinn 17nrm All VInnn 4
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 82 Westbury Way,Cotuit
Owner: Linda Lubelczyk& Richard Walden
Date of Inspection: January 11,2005
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
_X_ _ Pumping information was provided by the owner,occupant,or Board of Health
_X_ Were any of the system components pumped out in the previous two weeks
_X_ _ Has the system received normal flows in the previous two week period ?
_X_ Have large volumes of water been introduced to the system recently or as part of this inspection?
_X_ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
_X_ _ Was the facility or dwelling inspected for signs of sewage back up?
_X_ _ Was the site inspected for signs of break out?
_X_ _ Were all system components,excluding the SAS, located on site?
_X_ _ 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?
_X _ 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
_X_ _ Existing information.For example,a plan at the Board of Health.
_X_ _ 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)]
Tifla G Tncnanfinn P^rm 411;nnnn 5
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 82 Westbury Way,Cotuit
Owner: Linda Lubelczyk& Richard Walden
Date of Inspection: January 11,2005
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Number of current residents: 1
Does residence have a garbage grinder(yes or no): No
Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required]
Laundry system inspected(yes or no):
Seasonal use:(yes or no): No
Water meter readings, if available(last 2 years usage(gpd)): 2003—27,000 gal. 2004—23,000 gal.=68 gpd.
Sump pump(yes or no): No
Last date of occupancy: Currently Occupied
COMMERCIALANDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):_
Industrial waste holding tank present(yes or no):_
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records: Tank Pumped 2-3 years ago.
Source of information: Owner
Was system pumped as part of the inspection(yes or no): No
If yes,volume pumped:_gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
_X_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/Alternative 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(if known)and source of information:
Compliance date:3/14/85
Were sewage odors detected when arriving at the site(yes or no): No
Title Q Tno—t:nn T7nr ll1 gmnno 6
Page 7 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 82 Westbury Way,Cotuit,
Owner: Linda Lubelczyk& Richard Walden
Date of Inspection: January 11,2005
BUILDING SEWER: XX (locate on site plan)
)
Depth below grade: 16"
Materials of construction:_cast iron _X_40 PVC_other(explain):
Distance from private water supply well or suction line: 30"
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: XX (locate on site plan)
Depth below grade: 11
Material of construction:_X_concrete_metal_fiberglass_polyethylene
_other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions: 8.5' long x 5.21 wide—1000 gal.
Sludge depth: 411
Distance from top of sludge to bottom of outlet tee or baffle: 26"
Scum thickness: 3"
Distance from top of scum to top of outlet tee or baffle: 7"
Distance from bottom of scum to bottom of outlet tee or baffle: 10"
How were dimensions determined: STICK WITH HINGE FLAP.
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
Liquid level at bottom of outlet pipe,baffles intact and clear.Recommend pumping tank every 3-5
years to properly maintain system.
GREASE TRAP: No (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.):
Title G TncnPntinn Rnr Ali,;mnnn 7
Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 82 Westbury Way,Cotuit
Owner: Linda Lubelczyk& Richard Walden
Date of Inspection: January 11,2005
TIGHT or HOLDING TANK: No. (tank 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: gallons
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: XX (if present must be opened) (locate on site plan)
Depth of liquid level above outlet invert: 0"
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.):
Liquid level at bottom of single outlet pipe.No solids or high stains.
PUMP CHAMBER: No (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.):
Title G lnen—tin"Anrm 4/1 VIAM 8
r
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 82 Westbury Way,Cotuit
Owner: Linda Lubelczyk& Richard Walden
Date of Inspection: January 11,2005
SOIL ABSORPTION SYSTEM(SAS): XX (locate on site plan,excavation not required)
If SAS not located explain why:
Type
—X_leaching pits,number: One 6x6 pit
leaching chambers,number:
leaching galleries,number:
leaching trenches,number, length:
leaching fields,number,dimensions:
overflow cesspool,number:
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.): Observed liquid level in pit 24-26" below inlet pipe with a high stain line 2-3" above current level
CESSPOOLS: No (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: No (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,etc.):
Title G Tnenu�tinn 97nr ,</I a11)nnn 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: 82 Westbury Way,Cotuit
Owner: Linda Lubelczyk& Richard Walden
Date of Inspection: January 11,2005
SKETCH OF SEWAGE DISPOSAL SYSTEM
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.
Westbury Way
Water service
#82
24 62
32
28
50
78
10
Page 11 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 82 Westbury Way,Cotuit
Owner: Linda Lubelczyk& Richard Walden
Date of Inspection: January 11,2005
SITE EXAM
Slope None
Surface water None
Check cellar Dry
Shallow wells None
Estimated depth to ground water: More than 25 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(abutting property/observation hole within 150 feet of SAS)
Checked.with local Board of Health-explain:
Checked with local excavators, installers-(attach documentation)
_X_Accessed USGS database-explain: USGS topo map and town GIS.
You must describe how you established the high ground water elevation:
Topo map shows property above el.80 and town groundwater contour map shows water below el.45.
4
Titles i Tnertarfinn Anrm All Vlonn 11
TOWN OF BARNSTABLE
LO'~ATION �Z � T e^� SEWAGE #QSfe-Cfc-'^
'�M-LAGE 4 'tQ i ASSESSOR'S MAP & LOT07.1
Diffotttms NAME&PHONE NO �c.� Lan�t� �2.
SEPTIC TANK CAPACITY
LEACHING,FACILTTY: (type) (size) 10cx�
NO.OF BEDROOMS 11
BUILDER O Lo6slo—zyk
PERMITDATE: CQMOb-beiCE`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 and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
- 1
r
A�zy
~ 9
73
L0CAT ON 7z:f SEWAGE PERMIT NO.
-Lof ? Q� u�
VULAGE
k�INSTA CVE4R,'S NAME & ADDRESS
X
t�
�o
� 16 UILDER OR OwNE
Q DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED S
x
2`?-7 'M
No. � Finac 5.0..........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F ��
,.
N,
... -- --.....OF...... ..................................................................................
Appliratiun for Disposal Works Tonstratiun Prratit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at: .. k � ....
o n- e or Lot No.
�: � �� �!�J -------•------------------------
a ......--....A ..�. Y.- O � d-T4.41`'S?. !L.. ess ..
Installer
� Address �1
Type of Building Size Lot...2j-�.S1tt.�-.Sq. feet
Dwelling—No. of Bedrooms............. .1�j,........................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No. of persons............................ Showers
a yP g --------------------------•• P ( .............
-)--- Cafeteria ( )
04 Other fixtures --------------•---------------•----------•------...-----------••---••-•----•-••-•-•---•----•---•-•-•-
W Design Flow..................... 3 ..........gallons per person per day. Total daily flow--------3- .__.......__..._.._.._gallons.
WSeptic Tank—Liquid capacity/4=.gallons Length................ Width................ Diameter---------------- Depth................
x Disposal Trench—No..................... Width_.. .............. Total Length.................... Total leaching area--__g.._._..... sq. ft.
Seepage Pit No____________ _____ Diameter........ Depth below inlet....-........ Total leaching area; �..Lf-__sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I...........:....minutes per inch Depth of Test Pit.................... Depth to ground water........................
(X, Test Pit No. 2................minutes per inch Depth of Test Pit._............__.... Depth to ground water........................
Pi ............................."
ot
Description of Soil = ..•..... .. . ...........+ - -------------------------------------------------------------------------------
1- -
••-•--•----•-----------------------•-•--••--------•--------------------••••-•-••--•-•-------••-•--••------•----•••--------------------•••-••----------••--•-----•-......•---••-••--•.........--•••-•.... `.
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 TITLi: 5 of the State Sanitary Code— The undersigned further agrees not to place the s stem in
�operation until a Certificate of Compliance has bee is e by e board of health.Signed--- -- ----- ---------------------••----• --•- ..................
.--
�� ate
Application Approved By---• ------ - : -_ ... •. = � � ,G_.. �......-----•........-- ......
Date
Application Disapproved for; the following reasons:................................................................................................................
....................•----...........--•-•---.............•--•......•--••-••---•-••-----.......--•---...-••-•-•••-•--•---••--••••-•----•-•---•-•-•-----•- -•--•--•--• ...............................
D
r ate
PermitNo--------- --------...................................... Issued............. -D-l---�- ............
THE COMMONWEALTH OF MASSACHUSETTS
B30ARD H4A
OF......
................................................
ApplirFaftau for Disposal Works Tonstrortiort Prrutit
Application is hereby made for a Permit to Construct (. or Repair ( ) an Individual Sewage Disposal
System at
or
- . .................... ------..................................
Lot
. 1 Xk.0�" A.............................................................
.. ......... -.
Gd l r ..
4,. Installer Address
U Type of Building Size Lot..� ._Sq. feet
Dwelling;-'-7 No. of Bedrooms..............: :..........................Expansion Attic ( ) Garbage Grinder ( )
Other—Type.of Building ............................ No. of persons............................ Showers =
a Other
: •g-•--•-•---•---•-•--•-•----....-•---------•..P ) Cafeteria ( )
Other fixture -------------•-•---•---------------------- .................................
W Design Flow..................... .............gallons per person per day. Total daily flow____..............'.........gallons.
WSeptic Tank—Liquid capacity/M.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 ar
p g e�al?�.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.................,--_-__-
fx; Test Pit No. 2...............minutes per inch Depth of Test Pit.................... Depth to ground water........................
p---- --•••---•---.••.........................................................
O Description of Soil...... "" - �`�..:`"�'.q 04.....................
x ------------------ ------
�V . .. ....-------•---------------•--------•---------................----------•--••-_
x -•••-•----------•-----•--------------•-•---•-----•-••-••-------•------------------•-•-----•----••-•---•--••--•---. •-----------------------------•-----...---------------•-•-•--•----•••-•---••.-•-•-•
UNature of Repairs or Alterations—Answer when applicable.-.;___.........................................................................................
••.. ---•--••-----•---•---••-•-•--•---•....--•-••••-•-...............................................................................................
Agreement: - .,
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code—The ndersigned further agrees not to place the s stem in
operation until a Certificate of Compliance has bee is e by e board of health.
Signed--- •-- .
Application Approved By...._. ~. ....
Date
Application Disapproved for the following reasons:...........................................................................................................
�; Date
PermitNo......... .. ....--C7........------•--•--..... Issued.....-----•---•---------•---•................•......---
Date
THE..COMMONWEALTH OF MASSACHUSETTS
BOARD F HEA
T
.......OF.......4 .......................................................
(9rdifirate of Tome inure .
THIS IS TO CERTIFY, That the Ind vI ual i o 1 System constructed ( ) or Repaired:(, )
y .....
I t�}ller
at----------------, - - ..�provisi
c. -
has been installed in accordance withs of TIT of The State Sanitar Code-as descriy bed in the
application for Disposal Works Construction Permit No....................................... dated-..............................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FU CTIO —SATISFACTORY.
DATE. �... --------------------------- --- Inspector....... jv . . •---- ---------- ------ -------------------
THE
COMMONWEALTH OF MASSACHUSETTS
BOARD Of HEA H
( :..• OF........../....... ....:. ..................
�-o
No.......- FEE........................
Permission is y granted 0
to Construct ( o ep 'r ( Individual Se a e Dispo t «
. � ------------------------
Street
as shown on the application for Disposal Works Construction Permit No �� Dated...��_
--------------------�...........................
Board of Health
DATE---•---••---------•-------------•----- ,.
FORM )255 A. M. SULKIN, INC., BOSTON - -
„pES/G/V OA74- .
S/N6L E 14-414 L Y -- 3 BEGo e'V47M //° `71
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