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HomeMy WebLinkAbout0029 PEACOCK DRIVE - Health 29 Peacock Drive Hyannis A= 019-163 C Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,M 29 Peacock Dr Property Address Anna Peselman Owner Owner's Name information is required for every Hyannis MA ' 02601 8-13-13 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form: Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information 1. Inspector: � � Y Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 Company Address . E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 Telephone Number License Number s B. Certification 1 .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 ri�i tenance�f on site sewage disposalm.systems. I am a DEP approved system inspector pursuant ection 1�51340 Title 5 (310 CMR 15.000).,The°syste `''^" i ' ® Passes •t � ❑ Conditionally Passes ❑ Fatly ..,,� • ❑ Needs,Further Evaluatio bythe Local Approving Authority 8-13-13 Inspector's Signature" Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board , of Health or DEP)within 30 days of completing this inspection. If the system is a 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. ****This report only describes conditions at the timeof inspection andunder 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. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 29 Peacock Dr Property Address Anna Peselman Owner Owner's Name information is required for every Hyannis MA 02601 8-13-13 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 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: System is in good working order with no sign of failure. 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. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please exp ain. 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. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts r F Title 5 Official Inspection .Form a Subsurface Sewage Disposal System Form -'Not for Voluntary Assessments M 29 Peacock Dr Property Address Anna Peselman Owner Owner's Name information is required for every Hyannis " .. - MA 02601 8-13-13 "• page. City/Town , State, Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not,operational. System will pass with Board of Health approval if pumps/alarms are repaired: B) System Conditionally Passes (cont.): ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y . ❑, N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑t Y ❑ 'N° ❑ ND (Explain below): ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) further-Evaluation islRequired 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(1)(b)that the system isnot'functioning.iWa fanner which will protect public health, safety'and the environment: ❑ Cesspool or privy is within,.50rfeet of a surface water ❑ Cesspool or privy is within.50 feet of a'bordering vegetated wetland or a salt marsh t5ins•3113 1 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 29 Peacock Dr Property Address Anna Peselman Owner Owner's Name information is required for every Hyannis MA 02601 8-13-13 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 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 fecal coliform bacteria indicates absent 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: 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 ❑ ® 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 Y2 day flow t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts. .' W Title 5 Official Inspection Fora t Subsurface Sewage Disposal System.F.orm -Not for Voluntary Assessments M 29 Peacock Dr Property Address Anna Peselman Owner Owner's Name ' information is Hyannis-_' MA 02601 8-13-13 4' , required for every H y page. City/Town :, p.' State. Zip Code Date of Inspection B. Certification (cont.) E yr Yes No E ® Required pumping more than 4 times in the last year NOT due to clogged or Y obstructed pipe(s). Number of times pumped: ❑ ® Any 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' ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.. ❑ M ~Any portion of a cesspool or.privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is 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 fecal coliform bacteria indicates absent 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 +. _,• j ';and chain of.custody must be attached to this form.]. #, ❑ ®, The system is a�cesspool serving a facility with a design;flow of 2000gpd- 10,000gpd.`t The system fails. I have determined that one or more of the above failure El ® criteria exist as described in 310 CMR 15.303,therefore the system fails. The system,owher,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. . For large systems,you`must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No El ❑ 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 ll 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. ' t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 29 Peacock Dr Property Address Anna Peselman Owner Owner's Name information is required for every Hyannis MA 02601 8-13-13 page. CityTTown State Zip Code Date of Inspection C. Checklist 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? ❑ ® 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) ® ❑ 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 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: ❑ ® 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(5)] D. System Information Residential Flow Conditions: 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 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts r Title 5 Official Inspection--.Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 29 Peacock Dr Property Address Anna Peselman Owner Owner's Name information is t required for every Hyannis "" MA• 02601 8-13-13 ' page. City/Town State Zip Code Date of Inspection « , D. System Information Description: Number of current residents: 0 Does residence have a,garbage grinder? ❑ Yes .® No Is laundry on a separate sewage system? (Include'laundry system inspection El Yes ® No information in this report.) . • Laundry system inspected?,' ❑ Yes ® No Seasonal use? r,,y ❑ Yes ® No Water meter readings, if available.(last 2 years'usage.(gpd)): :- Detail: Sump pump? r,. . ❑ Yes ® No Last date of occupancy: 8-2013 Date Commercial/Industrial Flow Conditions: Type of Establishment: 4 r Design flow(based on 310,CMR 15.203): per er day(9pd) Basis of design flow(seats/persons/sq.ft.,etc.): Grease trap present? " ❑ Yes ❑ No Industrial waste holding tank present?,, El Yes ❑M1 No Non-sanitary waste discharged to the Title 5 system? f {" ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form Subsurface Sewage Disposal System-Page 7 of 17 v 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 29 Peacock Dr Property Address Anna Peselman Owner Owner's Name information is required for every Hyannis MA 02601 8-13-13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: N/A Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for 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) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts N Title 5 Official I nspection form Subsurface Sewage Disposal SystemTorm -Not for Voluntary Assessments f M 29 Peacock Dr Property Address Anna Peselman , Owner Owner's Name information is Hyannis '` . ` MA 02601 8-13-13 required for every y . page. City/Town State Zip Code Date of Inspection yf _ D. System Information (cont.) '~ `' Approximate age of all components,',date installed (if known) and source of information: 1985 . Were sewage odors detected when arriving at the site? f ❑ Yes ® No BuildingSewer locate on siteplan):: ( , ` 22" Depth below grade: a. ` feet iWaterial of construction: ❑cast iron• ,.® 40 PVC other(explain): Distance from.private water supply well or suction line: feet Comments (on condition of joints,venting;,evidence of leakage, etc.): Good condition. Septic Tank(locate on site plan): ` 16' Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑-polyethylene ❑ other(explain) If tank is metal, list age: years' Is age confirmed by a Certificate-of Compliance?(attach a copy of certificate) A ❑ Yes ❑ No Dimensions: 1000 gal 12 Sludge depth:':: t5ins-3/13 "' Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 9 of 17 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 29 Peacock Dr Property Address Anna Peselman Owner Owner's Name information is Hyannis MA 02601 8-13-13 required for every page. City(rown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 20" lotScum thickness Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. Grease Trap (locate on site plan): Depth below grade: feet 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: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments wM 29 Peacock Dr Property Address - Anna Peselman Owner Owner's Name information is required for every Hyannis MA;. 02601 8-13-13 page. CityTTown State Zip Code Date of Inspection D. System Information (cont.) ..� Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert�''evidence of leakage, etc.): Tight or Holding Tank (tank must be,pumped at time of inspection) (locate on site plan): Depth below grade: ' Material of construction: ❑ concrete ❑ metal t❑ fiberglass. ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow:-,,ra gallons per day Alarm present: ❑ Yes ❑ No Alarm level' Alarm in working order: ❑ Yes ❑ No Date of last pumping: pate Comments (condition of alarm and float switches, etc.): `Attach copy of current pumping contract (required):Is copy attached? ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 29 Peacock Dr Property Address Anna Peselman Owner Owner's Name information is required for every Hyannis MA 02601 8-13-13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (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.): Good condition with water at working level and no sign of back-up from pit. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewace Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official InspectionTorm Subsurface Sewage Disposal System Form.-Not for Voluntary Assessments °M 29 Peacock Dr Property Address Anna Peselman Owner Owner's Name g information is required for every Hyannis MA 02601. 8-13-13.. page. City/Town State Zip Code Date of Inspection D. System Information (cont.) t w. Type: ® leaching pits number: 1-1000 gal ❑ leaching chambers: number: ❑ leaching galleries A*%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.): Leach pit in good condition and empty at inspection with stain line at 36"below inlet invert. Cesspools (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 g Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 29 Peacock Dr Property Address Anna Peselman Owner Owner's Name information is required for every Hyannis MA 02601 8-13-13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, cordition of vegetation, etc.): Privy (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.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewace Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title. 5 Official Inspection. Form Subsurface Sewage,Disposal System'Form -Not for Voluntary Assessments ,M 29 Peacock Dr Property Address Anna Peselman Owner Owner's Name information is required for every Hyannis MA 02601 8-13-13 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view 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.Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately qe• } ­ - ' _ t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 29 Peacock Dr Property Address Anna Peselman Owner Owner's Name information is required for every Hyannis MA 02601 8-13-13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 20 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® 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) ® Accessed USGS database- explain: You must describe how you established the high ground water elevation: USGS and town maps show groundwater at greater than 20'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3f13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official I nspection' Form R Subsurface Sewage Disposal System,Form -Not for Voluntary Assessments 29 Peacock Dr Property Address Anna Peselman Owner Owner's Name " information is Hyannis MA 02601.. 8-13-13 ` required for every H y ' page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked. ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to High groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13• Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 r- 0?q LOCATION SEWAGE PERMIT NO. PC'9E OC& VILLAGE INSTA LLER'S N A Mj L& ADDRES U 1 L D E R OR OWNER DATE PERMIT ISSUED sy's� DATE COMPLIANCE ISSUED s s_ XS e NoC—IL..1..HD Fxs ...... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...................OF.......�-TAP W. T L O.:-------------------...-_...------ Appliration for Dispaii al Works Tonotrnrtiun Frrmit &,q Application is hereby made for a Permit to Construct (/4,) or Repair ( ) an Individual Sewage Disposal System at: ... - .: -................................................................ f�Q ocati n Address n V or Lot No. r. ��N ---.48...Z4.c --------- .............� ..................------------------------------------ Own Address W ... C. ----------------------------------- ---•------•----Qsf--....----------Installer Addddrr ess Q Type of Building Size Lot...ja(. .......Sq. feet Dwelling—No. of Bedrooms........ ----------------------------Expansion Attic (�D) Garbage Grinder Via Other—T e of Buildin ayp g .D� __�____._.. No. of persons...... ................ Showers (�) — Cafeteria (yam(j dOther fixtures .......P.rRt�----_------_-----_-_------------------------------------------------------------•------------•-----..------------- W Design Flow........... ,5.....................gallons per person per day. Total daily flow-------3-3.Q•......................... lons. WSeptic Tank—Liquid ca,$acity_/l _-gallons Length-__. ....._ Width.___._....... Diameter....IJ........ Depth..1 __..... x Disposal Trench—No. J1,fB.t C...... Width.................... Total Length.................... Total leaching area---1"4----sq. ft. Seepage Pit No.--_____.-_-------• Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box (X) Dosing t n ( ) a Percolation Test Results Performed by_ ;yy�.... /. ............. Date_._.lQ._1 ............ /� l a Test Pit No. 1....L .minutes per inch epth of Test Pi�--____��)...._--- Depth to ground water....W.i --. ;T Test Pit No. 2................minutes per inch Depth of Test Pit____-___-.____----- Depth to ground water--_____--...____- ___-- Ixi -----I------------------------------------------•----------------------------------------------------------------------------------------------------------- 0 Description of Soil o`+ i Lc1a94'�!1........�5.1�_�L?�L - ----------•--------------------- -------------••----..•------------------ v ------------------- Nam... '^�4►�. . -----•--------- 1 a....---!�e-A..------� 4-------------------------------------•--------------------------------------------•---•--••--------•-- U Nature of Repairs or Alterations—Answer when applicable................................................................................................ ••------------------................--................................................................................................................................................................. Agreement The undersigned agrees to instal e aforedescribed Individual Sewage Disposal System in accordance with the provision of i 5 of the t Sanitary Code—The undersigned further agrees not to place the system in Operation un i a e ificate of ance has be n issued by the bo d of health. _ SignedA .f�.'u�/C _ � � ate APPlication Approved y•--- ; �: - --------------• �� ......... Date Application Disapproved for the following reasons-.................................-.............................................................................. Date Permit No. -_m 4 ------------------ Issued l._. .� .._...........------ Dat v_ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH I�? 3. OF...... • rY, A 6 Appliratiun for Disposal Works Tnnitrurtiun ramit Application is hereby made for a Permit to Construct (},,) or Repair ( ) an Individual Sewage Disposal System at: , t 1. Ld, q s-Address or p -,LocationLot No................ ......••_ .... l;tt_ t t 1 f .. .t I N`t Owner Address W4 I `.... . .... (t'�3-a�.................................... .................../5�........--•---------...........------.......------......--------....--- a --- Installer Address U Type of BuildingJ a.. ..Sq. feet - Size Lot.. �..?------- - --.. Dwelling—No. of Bedrooms............................................Expansion Attic ,(�3) Garbage Grinder 0D) 04 Other—Type of Building ......... No. of persons.....4................. Showers (2- — Cafeteria (Yc7) PL4 Other fixtures ------- .'-•-----------------------------.. W Design Flow...............57_'�........................gallons per person per day. Total daily flow........'ai'6----.--•----.-.._.--..gallons. WSeptic Tank—Liquid capacity 1At??-.gallons Length.._.�t---_._-_- Width../�.._.._..... Diameter... —--------- Depth.C............. x " Disposal Trench—No. L:"fit_x ___.__.. Width.................... Total Length.........._...__.... Total,leaching area..._;? 4e-----sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box (_V ) Dosing tank ( ) '-' Percolation Test Results Performed bye"/'A '� a .. Date._._,? _ `!'�.____..__._. mil - f E 1 1 i a Test Pit No. 1...< '.�_..minutes per inch Depth of Test Depth to ground water... Lam; Test Pit No. 2................minutes per inch Depth of Test Pit`................... Depth to ground water........................ P Description of Soil A+ Y 1 -,A.xt I of III '� (1 x ^/ ydA k s 1 { ({ {y ...................................................................................� W . ...................................5�....t'2`...._.'................... `.:�!•Al '".------. -....---.....-----•------•-••-•-•--•••---•-•--------•--•--.---------------------•-•- U Nature of Repairs or Alterations—Answer when applicable ...........................•_- .............................................................. --------------------------•-----•--------------..........----•------------.....------.....---•-•------------.....••-----------------•----------------------------------------------------••-•--•-•-----` Agreement The undersk ed agrees,to ins the aforedescribed Individual.Sewage Disposal System in accordance with the provisi is o 1 TLi: 5 of t to Sanitary Code— The undersigned further agrees not to place the system in, operation til rtificate o pliDance has been issued by the/board ofhealth. igned.t k.�„ r' 1�uf/, c !rs A• � s ." -- --•--•------------ •------ ---•------------- ✓ t1 ✓ / Date Application Approved B�'".....` 1 ... r4 D� ......... - r Application Disapproved for the following reasons. .--•-•••-•--•••••-•----••-•----•-•---••-•-----••-----••......•--•-••-•••-••-•-• ••-- ...............••---------------------------•----...---------......------....---------.......------....----..........---•-•---------------------••--------------------------•--•--•-----•-•••----••----- Date Permit'No.__� ---•--• Issued... T ate -----••-••--....---- THE CO 14 O$r ALT: OF MASSACHUSETTS BOARD OF HEALTH f7-V7/.....................O F ....:.....................f�l #f! -#r....... f.............:................ %urrtifirtt#r of Toutplintt THIS IS TO CERTIFY;.That the Individual.Sewage Disposal System constructed (A) or Repaired ( ) by------.1 r__el=-( ------------------------------------------=.................................................................................................. Installer tt f ___._ �dC' t at_. '! 1 -------�•----- �Y -t-•..-......--- -- `.1y . ......... .......... I' '-=.......-------------•--------------...------------•. has been installed in accordance with the provisions of TIME 5 of. The Statee Sanitary Code as described in the application for Disposal Works Construction Permit No---- -:.`1. � �.! - ----------- dated---------- - -- '--------------•-•-- F� THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE NSTRU AS A GUARANTEE,THAT THE �s EA+1 1All L FUNCTIONTISFACTORY. o► y' E......_....- •.................. .. ....•----...---•---...-- ----•---.. �-Inspector..... - --- -- --- -1---•--•-•--------.......--••------.._..---•-• ---.._., ,. THE COMMONWEALTH OF MASSACHUSETTS `. P - BOARD OF HEALTH s. .. OF....... .... ..... ...... ........................................... No.. . FEE..�....�....... tF Disposal Works Tunntruainn rrutit Permission is hereby granted...J..�� !f.f-5. . '-! ..... to Construct ()�) or�Repair ( ) an Individual Sewage Disposal System at No... `=== ......ci. ' ;.r 1 t• it r_t!Y', Street V as shown on the application for Disposal Works Construction Permit No. : "Dated...................... 1 DATE-------- +K•,l-• -. - --•.................................. Board of Health r FORM 1255 A. M. SULKIN,'INC., BOSTON TQWN lF$Al2 -STAB VILLAGE // h✓�` A SSESSGR'$1U1.9 '&LOT INSTALL,E S N I 1'>E Ot E No- SEP'ITC TANS CA I'ACITY LEAC%LING /�C01r'T'Y: (gy �) r No OFSEDROOMS :l PERTs lsTP1aTE: ' Sop Arntion I�?isttt6CC 8etv/eeta tlae: %ram lvittxiittum Adjusted Grotmdd 6teOable to t{te l3uttorn of i,each�n�k�s1cility Pbivat.watar Supply'V101 awl Leari9hlna Facility M my t"�e!!s exist eoB on she or within"Wo fe et of ppchiug Ncility) Edge.cif W. C.land and l cae$iing Facility(if any %vet18nd5 exist t4�4tt�iia'Am feet qt lc*C nl;fszcilacy • e Fee urebl3bcd by (il c �r M_ `� � �� \�� � �� 6� � LJ Q � � � •.� � D r ` �. . � � � � �J � pJ O � � � `T� ,� ' . s n 1 4 s a { 6 r 6r lv 4 N o �clvB _vjt vi z¢ kv v Z �#b �";t`',•.: —0 T ? ° `t • ��9:��° � 'i.uA-i c rc � ° �.� , tiLz � N. s' a� P ti 9� ` N of M�ss9 ca fAORSE ux r' > w 10951 Q ti. k'1,F. T �E 1x SSI0NA1. t� g�. q �p ®®//g� p��y pp 0 p� p� ;E� Tlld� 9i'4J ',Elm �� ��9C.tl� Op�0 CERTIFIED PLOT t l by1N s x ;� X 'T1 ® C0NT0UR, — - 0 �§ :ED . SPOT E6.EVA '1:0� 'h ;� 1 f. yq 8p� Yip7'C.•�Ac�o �/p�/ f, ',SHE , ONTOU.� ` `1Vf k,1�„y.�,2��t �'1y`!•;/' ! w �I •r//G 'q` / V` / % /-5 /^(��. 7 -. 3 OT :The of an exisLng .und2 sewerage, , • " wells -or :other utilities.: shown. on .this plan-is, approx-. IN r 8 �$ }xmatexonly as'dotermined from records and/or verbS AR xnformtion. The contractor is responsible fox the '® `° ' '� i a verification of the•existing- locations 'in the field. SC�,IrE " '0 ®ATE , /Z�`t 3AY g 11D�: j. REDGE ENGINEERING CO. 8 I CERTIFY' THAT THE PROPOSED k x EI OSTI�RE R GISTERE® .00P NO.,9 BUILDIIV(3 SHOWN ON THIS PLAN s.C,IVII. LAND CONFORMS TO THE ZONING. LAWS DR.ICY 1 A 'A.�, :�.N® td EI?0$ SURVEYOR �/ ----- ----�-- `O F' ®AR N S TA®L E , M A. T! 2 M A 1 N ,`J T f E E"p' C H. ®0 ' 8 , w n. N YlA N IV 15;:'.I0 A`$S. SHEET ... OF AT.E REC. LAND SURVEYOR .. ) 1Y.. r lu 140 IL e °Y eID �} Sim b p�A ,- - Z ns 44 • o e vv A `� TA Aw- � Uy, S� t , � � �l ' . �9 �8...the" ,r � P, d•` ,,• _,. �: � `-, � M M ft1 �� �C � f7 W loci. g :.:.� y+7 { r .y { •,, tbl,r � a -E!d#ex"�a �,.:b{ lV"''# ^ � a t - " ,,:qra.,ss�.�•.'..iw k`(r�e,y�" ��ea-r:', ':�4'�4!i7a1 �4_-n��" t�Ly9`'0.�H! a�/1sy ��� +�'' � ,'z..Q��/�'�. •�'.:'',�M�a 'e�°fi�4ot' tVag^:.Y Q k w ' gi � •+ui 'V4' 'mare/�$ !d 'K �:: ~ '.;dA c"'J';i7 � _{ '-: 1 } .'L k .q ,tea r, A n •T @g� ° ' ,m'7 '.�<t4 -,�` .�' k- �,S/` !y,•?J) "3" Pegs E�' 'im �: oil "'� �tl *� (p ft� _ � •,$ .•d 44 St. .. a .. ..