HomeMy WebLinkAbout0038 OTIS ROAD - Health 38 Otis 'Road f .
Hyannis CP
A = 311 056 Omni,
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n
COMMONWEALTH OF MASSACHUSETTS
x EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
a c DEPARTMENT OF ENVIRONMENTAL PROT C IONiVED
<C,�N SJse �. ,. •. .� OCT 3 .0..2002
.: TOWN OF BARNSTABLE
HEALTH DEPT.
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS.
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION ��
Property Address: d�(
Owner's Name _
Owner's Address: , 0j�� MAP M
Date of Inspection: . PARCEL
Name of Inspec",pleaserint) �' �J.-s �U°"mot LOTCompanyNamMailing Addres .0 Y. _
Telephone Number: R-7 7J
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:
Passes
(/Conditionally Passes
w Needs Further Evaluation by the Local Approving Authority
ils
Inspector's Signature: / Date:
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health dr
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 --V—Ajc, �
b ..****This report oglescribes condition's at the time,of inspection and under the conditions ofse u :a t t hat :.
time:This inspection does not address how the system will perform in the future under the same or different
r- conditions of use.
Title 5 Inspection Form 6/15/20.00 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: ,(go tco )q0
Owner:
Date of Inspection
Inspection Summary: Check A,B,C;D or E/ALWAYS complete,all of Section D
A. System Passes:
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. S stem Conditionally Passes:
19 One or mores stem components as described in the"Conditional Pass"section need to be re laced or
Y P P
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:
V 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): /
V broken pipe(s)are-replaced
obstruction is removed
distribution box is leveled or replaced
ND explain: Pine 1i-om .Yenk 1p P/ 7" /5 P)12�,�///i'V c✓rd,," 14/)7 ��,� ke//Y
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:
2
' Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION`(continued)
Property Address: .
Owner: Al 05 P ,/
Date of I ftspectio,n,:-
_� tip- ao a
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 3.10 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect-public.hcalth,safety'an.d 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`Su.pplier, if any).�dete. rmines 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 10.0 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 yolatile,organic,co.mpounds indicates that the well-is free from pollution from that facility and
the presence of ammonia nitrogen acid nitrate nttrogen is equal to or less than 5 ppm, pcovid'ed°that no other
failure criteria are triggered.A copy of the analysis must be attached to this form.
r�
3. Other.:
3
Page 4 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECT:ON FORM
PART A
CERTIFICATION(continued)
Property Address: O6t1W_
Owner:
Date of I(spection: j")OCQ
D. System Failure Criteria applicable to all systems:
You must indicate"yes or"no"to each of the,following for all inspections:
Yes No
Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
y' Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
_ Static liquid level in the distribution 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 volume is less than '/2 day flow
�j 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 or privy is below high ground water eleval:ion.
_
Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
Jwater supply.
� Any portion of a cesspool.or privy is within a Zone I of&public well.
_ r1 Any portion of a cesspool or privy is within 50 feet of a private water supply well.
r� 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.]
✓V(/ (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 40,000.gp6 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.
'4
Page 5 of 1.1
OFFICIAL]INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B'
CHECKLIST
Property Address: NL>_0,e�_�Cy- y
Owner:
Date.of Inspection:
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
_ Pumping,information.was provided by.,the owner, occupant, or Board of Health
(�Were any of the system components pumped out in the previous two weeks
Has the system received normal flows in the previous two week period ?
v Have large.volumes of water been introduced to the system recently or as part of this inspection?
/_ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
V — Was the facility or dwelling inspected for signs of sewage back up
-L.Z_ 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 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
-tom 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)]
5
Page 6 of l l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address-
Owner:
Date of.nspection: o
V FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 3 10 CM� 15.203(for example: 110 gpd x#of bedrooms).
Number of current residents:
Does residence,have a garbage grinder(yes or no):
Is laundry on a separate sewage system (yes or no / y[if yes separate inspection required]
Laundry system inspected(yes or no
Seasonal use: (yes or no): L 04/7,G'�l� Ol-110,300V
Water meter readings, a�e(last 2 years usage (gPd)):_ K
Sump pump(yes or no):
.�Q�Last date of occupancy: ✓ /� �i��C
COMMERCIAL/INDUSTRIA`L�
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
Source of information: AjeWas system pumped as part of the inspecti (yes or r.o):
If yes, volume pumped: gallons--How was quantity pumped determined?
Reason Tor pumping
TYPE OF SYSTEM
Septic tank,distribution box, soil absorption system
Single cesspool
_Overflow cesspool
_Privy
_Shared system(yes*or no)(if yes,attach previous inspection records, if any)
_Innovative/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
/ p
V Other(describe): �v b"J
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
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:
,1.,2 o-e
Owner:
Date of I spectwn: 1. a
BUILDING SEWER(locate on site pla�
Depth below grade: ,
Materials of construction:_cast iron _40 PVC other(explain): ,
Distance from private water supply well or suction line: '
Comments(on condition of joints,:venting;evidence of leakage, etc.): . ;
SEPTIC TANK:✓`(locate on site plan).
Depth.below grade: _
Material of construction:jZncrete_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:
Sludge depth:.,-
Distance from top of sludge to bottom of outlet tee.or baffle: %7
Scum.thckness:,-�)
t
.Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom o outlet tee Qr baffle: /D
How were dimensions determined:
Comments,(on pumping recommend tions, irflet and outlet tee or baffle condition,structural integrity, liquid levels
related to'outlet invert:, v'dence of leaka e, etc.):
U�i
GREASE TAAaL44(locate on site plan) A ''
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.): .
7
Page 8 of I I
OFFICIAL INSPECTION FORM—NOT FOR'VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM,
PART C
SYSTEM INFORMATION(continued)
Property Address: O
Owner:
-01
Date of I spection: c
TIGHT or HOLDING TAN\ (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 alai-in and float switches,etc.):
DISTRIBUTION Bif present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
a
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: ocate 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:):
8
Page 9 of 11
OFFICIAL.]INSPECTION FORM—NOT FOR VOLUNTARY<ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM.INFORMATION(continued)
Property Address:3E'�
Owner:
Date of Anspection: 3
SOIL ABSORPTION SYSTEM (SAS):_�/ (locate on site plan,excavation not required)
If SAS not located explain why:
T)Pe -
.............
leaching pits,number:L
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,
): y
r 6L. w
CESSPOO�(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:4
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.);'
PRIYL�(locate on site plan)
Materials of construction:.
Dimensions: _
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition ofvegetation,etc.):
9
Page 10 of]1
OFFICIAL INSPECTION FORM.—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM`.INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: p
A-WA
Owner:
Date of nspecti.on: a(�Op`Z
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.
lq
10
Page I 1 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM IN,SPECTIO.N FORM
PART C '
SYSTEM INFORMATION(continued)
Property Address:
Owner:
Date of spection: Q�
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated.depth to ground water l 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:
_VChecked with.local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You tnust describe how you established the high ground water elevation: /1�Q
OK
(�
11
ID
C0npleted by:.
�.i CFR 0UMD-Vk!A _R L=VEL --A ION
c.alv�Pu
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Site LOC.c:;On:"� ��G �G•zE ( ���C�C�G����__Lot N`t7•.
J.wne:: lam`/,ct�
Contrac_or: Address:
1 •. IVIeaSU•re CcC?ti7.tC•Watei tcbfe _ .
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_ • ' no;ath/cay/.Year' I
S T.=:° 2 Usine—Water-Level.R-anae Zone
and Ind�e.x WeII M. p:locate
Site•at�.d e ermine:
O. A�-cpriate.indexWei'L......--•..............:.............r..-l__..:._.- i I• : I
vWare:-levei•._n_ce zora _.........:..... ......
S%, cP•;3:. �ISlnc mOi7" ll•V.i l7Qr.:4•`CWi?"P l•i -
i �•
We is r RI escu rces"Cendi Lions" l I
d'cterm I ne Cl.;ri etl i de;D'in'i0
G--
water. 1'eval ror•inc�irx wehl .......................... J• ' ' �'
... monii 1/year
ST�= — Urine _ �. i
abi�.o:,.'.N•s�er-i. rel AGj't!S'im9ni5 . I.
o index vdeil (STEP 2, ),:c�r•�nt de .tn
o waterIevel foi.index Wel.l ('STEP 3•);, i
and•wacer-)e.vel zone (STEP•26)
aet rml•.na.water-level adjus men.t .................................-.:.:..:.......................
:-......._;.:_:..._.. ( '
ST: ,P: 5 s ima:e•deptr,tOalran water
by sabt;-actima .e•water--'
level adjus m.'an.'.(S:T'cP4)
=zor reasL.red:.deptn o:water
level at;ize (STEP*1). _._............ - .........................................._................................
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li°I�iv liJill 10F
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LOCQ,TION p .5EWW:C E PERMIT UO.
IMSTQLL.ER 5 IJ&MF- ADDRF-
bUILDER5 IJ &VAF- ADDRESS
-Cl-'aa !f LMAtj cam,— — — - - - -
DINTE PERNAIT ISSUED =-`�'—do�L� — — — —
D ATE COMPLI WACE ISSUED : — — —
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No.... `L.._ ------ Fsa.. ...................
THE COMMONWEALTH OF MASSACHUSETTS
.B®A R® F H EA T
/.. .........OF.......- �.. . .."...................
� �irtt i -for Dio uitt1 Workii Tiatui#rurtion Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair (�an Individual Sewage Disposal
System at: ��
--------------•-- ----------•--.---------- = -•---------------------
ation-Address or Lot No.
- -- --- - ------------------ ---- =
r Address
W �.. --" -• -- aller-�� ..
Address
Q Type of Building- Size Lot----------------------------Sq. feet
U DwellingNo. of Bedrooms___________________ ____ p ( ) g ( )
__...______.Ex Expansion Attic Garbage Grinder
per, Other—Type of Building _______________________--- No. of persons..____-----____-•_-____-___- Showers ( ) — Cafeteria ( )
a' Other tures ------------- .................!�._
W Design Flow 4...wommv..._.__.gallons per person per day. Total daily flow_________,_ .............
WSeptic Tank—Liquid capacity------------gallons , Length----------------- Width................ Diameter..........------ Depth----------------
x Disposal Trench—No- ____________________ Width.................... Total Length_--_..___________ Total leaching area.......-------------sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area------------------sq. it.
Z Other Distribution box (. ) Dosing tank ( ) &�` '
aPercolation Test Results Performed by-------- - ---------------------------------------•-----------• --------•- Date---•-- --•------------- -------------
W Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water..-------------------
f� Test Pit No. 2----------------minutes per inch Depth of Test t-----------_-------- Depth to ground water-_._-_________--__-_-._.
O
x Description of Soil-----------------_
U ---------------------------------------------------------------------------•- - •----•-•-------•--•-•--------•-------------------------------------------------------
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 Article XI of the State Sanitary Code—The undersi ned f ther agrees not to place the system in
operation until a Certificate of Compliance has bee s by e o e th.
JA
Sign e •••---•........-.J••-• •... -------------
--
------
Date
Application Approved By------ `1 ' 'C .--�'C�.-- ----�
Da e
Application Disapproved for the following reasons:............................... -------------------- I--------------------------------------------------
----•---•-------•-•----------------------•--••---•------------•-•----------------------•-•-•---------•---------------------------------------�--- - -fie------........
Permit No..........................................-------------- Issued...... �------ ---7--
- ------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD !-6EA T
7 OF........ F
Appliratiun -for Bi,ipusttl Works Towitrurtion Prrmit
Application is hereby made for a Permit to Construct ( ) or Repair (40*70'an Individual Sewage Disposal
System at
eG� s... ".....
L anon-Address or Lot No.
er` Address
W ... .A, -------------------
aller Address
d Type of Build* ' Size Lot___________________________Sq. feet
U Dwellin No. of Bedrooms-----------------.. .:..g ...................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of.Building .........7.................. No. of persons..____-_-._--------_.____.__ Showers ( )' — Cafeteria ( )
b�iyer tures _ ------.- •---------------------------•-------------------•--------•-----------------•••-----.------••-- ---•-------------•--------
Des* n Flo ```
W g L�.... ........: ...........gallons per person per day. Total daily flow.....___�_�"""_�_............gallons.
1:4 Septic Tank Liquid capacity........---,gallons Length................ Width---------------- Diameter_---___._..-_-__ Depth----------------
xDisposal Trench—No. .................... Width.................... Total Length.................... Total leaching area--------------------sq. ft.
Seepage Pit No--------------------- Diameter..................... Depth below inlet.................... Total leaching area..____-.._---___sq. ft.
z Other Distribution box ( ) Dosing tank ( ) a:- -
Percolation Test Results Performed bY---------------------------------------------------------------------------- Date----.----------------------------------
a ; s
Test Pit No. 1-----------------minutes per.inch Depth of Test Pit.................... Depth to ground water..._____---__----.--....
fTq Test Pit No. 2................minutes per mch De th of Test 't--__-___-___-_____-- Depth to ground water------:-----------------
------------------•-------•-----------•----- -
Description of Soil____________________ ....... - ------- e,44................
------------------ ..............................------------------------------------
W _
x --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
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 undersi ned f ther agrees not to place the system in
„ operation until a Certificate of Compliance has be s d by e o � th.
Signe ••--•--�•... .- ✓ ..
Application Approved BY /�" ate
� «� Da e T
Application Disapproved for the following reasons:............................... . ......---------------------------------------_-_----------_----_----_-------
•--••---••------------•...--•---••--•---••----------------•---•------------•---•-•••---------•••-•-••...............................•----... ..........................................................
Date
PermitNo......................................................... Issued...................... .................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O HEALTH
' .............OF... ....... '' !�!6e
ow
Trrtifirtttt. of ntphat rr,
HI I CERTIFY t the v' ua Sewage Disposal System��cohstructed ( ) or Repaired
by....
� 'I'r/�--•- ----�---- ta._r-�..174 ...... L-.... ................
has been installed in accordance with the provisions of Artic ,X�jI of The State Sanitary cle s desc d t the
•.!.j--.Y-
application for Disposal Works Construction Permit No........ ------------------ dated..... .....RA/ ..----.-
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONS UED AS A G NTEE THAT THE
SYSTEM WILL PUNCTION SATISFFA�CTORY. '
DATE =.4 -------- < : Inspector --------••------...--
----
THE COMMONWEALTH b.F MASSACHUSETTS-
BOARD HEAL
No. r FEE.
is >or tt� ks (,IT>Q r � t rrutif
Permission is hereby granted ---•. .,.....=--• .r "_=
to Construc ) or ate at an Indiur al Se wa e i os yste .00
--- -- --- ... _.at No.+ `
-------------- - -- -----------------------I
l;. Street as shown on the application for Disposal.Works Construction Per No._ .___ .. Dated_ v_ .. •....._..
4
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FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS -