HomeMy WebLinkAbout0076 CINNAMON LANE - Health 76 Cinnamon Lane
Osterville
A= 165 —082
z
r TOWN OF BARNSTABLF
LOCATION s��v C IA AAMgn 1,4,A& SEWAGE#
VILLAGE 0 krr rv,16, ASSESSOR'S MAP&PARCEL
INSTALLERS NAME&PHONE NO.
SEPTIC TANK CAPACITY OVO
LEACHING FACILITY.(type) PST (OW yX�O (size) 3 -9 JbAk
NO.OF BEDROOMS 3
OWNER mA r#—^IV.[. C
PERMIT DATE: 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 and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
FURNISHED BY A/ C 17o, T e0o-
]
G,O��
e a � � �
��onT
3 � 3
1 ai i�
a a� a,� .
3 �� 30�
TOWN OF BAR STABLE
� LAGE
nnL, t;_�T10N ���� 161y - # ` Q, I V
VILLAGE[ ASSESSOR'S MAP & LOT
INSTALLER'S NAME PHONE NO. akk<�,pmw
SEPTIC TANK CAPACITY 0q
LEACHING FACILITYAtype)�l (size) `3
NO. OF BEDROOMS PRIVATE WELL O UB.LIC WATE
BUILDER OR OWNER �C -
DATE PERMIT ISSUED: 4) QpL
DATE COMPLIANCE ISSUED: 674
VARIANCE GRANTED: Yes No
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COMMONWEALTH.OF.MASSACHUSETTS .
EXECUTIVE OFFICE.OF ENVIRONMENTAL AFFAIRS
k DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 76 Cinnamon Lane
,. Osterville.MA 0.2655
Owner's Name: •Marion Mareneck&`Trust .
Owner's Address: . nn
Date of Inspection: August 15, 2007
Name of Inspector: (Please Print) James M. Ford
Company Name: James M. Ford
Mailing Address: P:O.Box 49' '
Osterville.MA 02655-0049
Telephone Numbers (508) 862-9400
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 tng,
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- I y Fri
✓ Passes. w
Conditionally Passes
eeds Further Evaluation by the Local Approving Authority
F ils to
�-
Inspector's Signature: Date: Au ust 20 2007 C
The system inspector shall sub t a copy of this'inspection report to the Approving Authority(Board:of Health or
DEP)within 30 days of completing this jnspection."If the system is a shared system or has a design flow:of 101000
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 .
UV
time: This inspection does'not address how the system"will.perform in the future under the same or different "
conditions,of use: .
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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: 76 Cinnamon Lane
Osterville. MA
Owner: Marion Mareneck& Trust
Date of Inspection: August 15, 2007
Inspection Summary:. Check A,B,C,D or E./ALWAYS complete.all of Section D
A. System Passes:
✓ I have not found any infonnation which indicates that any of the failure criteria described in 310 CMR
15.303 or in310 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 I 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 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 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
ND explain:
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Page 3 of 11
OFFICIAL INSPECTION.FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION. (continued)
Property Address: 76 Cinnamon Lane
Osterville MA
Owner: Marion Mareneck& Trust
Date of Inspection: A gust I5 2007
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(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within SO 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 private water supply well.
The system has a septic tank acid SAS and the SAS is less than 100 feet but 50 feet.or-more from a.
private water supply well**. Method used to detennine distance .
**This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria and volatile.orgamcc 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:
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Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY"ASSESSMENTS
SUBSURFACE SEWAGE.DISPOSAL.SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued) -
Property Address: 76 Cinnamon Lane
.Osterville "MA
Owner:' Marion Mareneck& Trust
Date of Inspection: August 15; 2007
D. System Failure Criteria applicable to all systems:
You must indicate either"yes", "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 dr
cesspool
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✓ 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_.
✓ 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.
✓ 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 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 determ'ined: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 System
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-I.WPA)or a mapped
Zone 11 of a public.water supply well
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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.
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Page 5 of 11
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 76 Cinnamon Lane
Osterville, MA
Owner: Marion Mareneck'& Trust
Date of Inspection: August 15, 2067
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
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✓ Were any of the system components pumped out in the previous two weeks?
✓ Has the system received norinal flows in theprevious tw week er'H s s so period y p
✓ 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 backup?
✓ 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 in_forination on the proper
maintenance of subsurface sewage disposal systems? . s
The size and location of the Soil Absorption System.(SAS)on the site has been detennined 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 of issue approximation of distance
is unacceptable) [310 CMR 15.302(3)(b)].
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Page 6 of I l
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 76 Cinnamon Lane
Osterville, MA
Owner: Marion'Mareneck& Trust
Date of Inspection: August 15, 2007
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):' 3 Number of bedrooms(actual): 3
DESIGN-flow based on 310 CMR 15.203 (for example: 110 gpdx#.of bedrooms): 330
Number of current residents: .1
Does residence have a garbage,grinder(yes or no): n1a
Is laundry on a separate sewage system(yes or no): n1a [if yes separate inspection required]
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings,if available(last2 years usage(gpd)): Unavailable
Sump Pump(yes or no): No
Last date of occupancy: Currently occupied
q
COMMERCIAL/INDUSTRIA'L -
Type of.establishment:
Design flow(based on 31.0 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 theTitle 5 system(yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of.information:,. Pumped after the inspection for maintenance
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:
y
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
Other.(describe)
Approximate age of all components,`date installed(if known)and source of information:
Installed on 5119192 per as built card
Were sewage odors detected when arriving at the site(yes or no): No
Page 7 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address; 76 Cinnamon Lane
Osterville MA
Owner: Marion Mareneck& Trust
Date of Inspection: August 1 S, 2007
BUILDING SEWER(locate on site plan)
Depth below grade:.
Materials of construction: cast iron _40 PVC other(explain):
Distance from private water supply well or suction line:
Cornments(on condition of joints,venting, evidence of leakage,etc.):
SEPTIC TANK: ✓ (locate on site.plan)
Depth below grade: 20"
Material of construction: ✓ 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: 1000 gal.
Sludge depth: 2
Distance from top of sludge to.bottom_of outlet tee or baffle: 30"
Scum thickness: g„
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: 10
How were dimensions determined: Measuring stick
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,' etc.). TM
Tees were present. The liquid level was even with the outlet invert. There did not a -ear to be any signs o leakage. A riser
was installed on the outletcover. The cover is 2"below jzrade. .The tank was 4zuinpeda ter the inspection or maintenance.
GREASE TRAP: None (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:
Coirunents(on pumping reconunendations,:irilet and outlet tee or baffle condition;structural integrity,,liquid levels
as relate.d'to outlet invert,evidence of leakage;etc.):
7
t, Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
'SYSTEM INFORMATION(continued) ,
Property Address: 76 Cinnamon Lane
Osterville, MA
Owner: Marion Marmeck& Trust
Date of Inspection: Au�sst 15, 2007
TIGHT or HOLDING TANK: None (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 a. &float switches,etc.): .
DISTRIBUTION BOX: ✓ (if presentmust be opened)(locate on site plan
Depth of liquid level.above outlet invert: Even .
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.):
The D-box was level. No"solids were present.
PUMP CHAMBER: None (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.):
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: 76 Cinnainon Lane
Osterville, MA
Owner: Marion Mareneck& Ti ust
Date of Inspection: August 15, 2007
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) -
If SAS not located explain why:
Type
✓ leaching pits,number: 1 -4.'x C 600 gaQ w/3'stoneper as built card
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.):
The pit had I of liquid on the bottom The scum line was at the same level There did not an ear to be any s� n failure.
The bottom to i ade was 8. The cover was 4'below rade. P s of u
CESSPOOLS: None (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: None (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.):
9
Page 10 of I
OFFICIAL INSPECTION FORM.-NOT FOR VOLUNTARY ASSESSMENTS
t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued).
Property Address: 76 Cinnamon Lane
Osterville, MA
Owner: Marion Mareneck& Trust
Date of Inspection: August 15, 2007
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.
'30.6 a
f .
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Page l 1 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM
PART C
SYSTEM INFORMATION,(continued)
Property Address: 76 Cinnatnon Lane
Osterville, MA
Owner: Marion Mareneck&`Trust
Date of Inspection: August'15: 2007_
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to groundwater ' 30+/ 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: topographic and water contours snaps
Checked-with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high groundwater elevation:
Using Barnstable topographic and water contours neaps, the inaps were showing approximately 30'to ground water at this site
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This report has been prepared only for the septic system and components described Herein. This septic system has been
inspected and passed as of.the date of inspection. This report is not a warranty or guarantee that the system will .
function properly in the future. There have been no warranties or guarantees; either expressed,written or implied,
relating to the septic'system,the inspection, this report andor any components of the.septic system which have'not.
been located and inspected.
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Town of Barnstable
�p THE Tp�
Regulatory Services
,,,SLAB Thomas F. Geiler,Director
�$ b 9. ,0� Public Health Division
ACED MA'S A
Thomas McKean, Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
This septic system inspection report was completed by a private inspector who is certified
by the State of Massachusetts, Department of Environmental Protection.
Although the Town of Barnstable Health Division received the original/copy of this
report; this Division does not warranty the functionality of the septic system in the future
nor does this Division agree with any technical observation s and interpretations
contained within this report.
In addition,by receiving this report the Town of Barnstable Health Division does not
automatically approve the number of bedrooms listed within this report. The actual
number of bedrooms approved at a particular property would-be listed on the "Disposal
Work Construction Permit".
If you should have any questions regarding this report, please contact the certified Septic
System Inspector who conducted the inspection.
No.._.c7-.1:24-da- ryV/ FEs.......�� ........_ V/
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
p ^
....Tow.�-j.................OF.... S ✓ ....................................
Appliration for 11ispagal Works Tono#rudion jrrmi#
f V Application isharebY.made
for a Permit to Construct /or Repair an Individual Sewage Disp
osal
ystem at:
Lo-P.... _.. C1NtiiArt�DN.._.-.LA_.►,!5...........:..... . .A`58sSv�s...MAQ'_.. O�65 ....P..A2cEL..9.2......
p l Ll.l N /y� LocationCy_-
.......... Address or Lot No.
.!....
-- -.---.-------•----•----- ............................... ................•.............. .....
- -- .__
W ----•------•--•---•--.--
Address
a ��JJ ddre.............................................
Address
Type of Building Size Lot..)415 k........Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building ........_. No. of persons............................ Showers
a YP g --------•---...... P ( ) — Cafeteria ( )
dOther fixtures ------------------------•---........-----...........--.-•-----------------------------------•---------•---•-........--•--..........._--•-••--•---.....
W Design Flow..........55...........................gallons per person-per day. Total daily flow.........3�O........................gallons.
WSeptic Tank—Liquid capacity).6.00...gallons Length... .r e._.. Width.9'.,� .. Diameter................ Depth...`-.'..�....F•
x Disposal Trench—No..................... Width....:............... Total Length...... .....__..... Total leaching area....................sq. ft.
3 Seepage Pit No........I............ Diameter.....LZ' ....... Depth below inlet--. .1!5 Total leaching area.. :.;._....sq,/ft.�lD
Z Other Distribution box ( ) Dosing tank ( )0.4 P
Percolation Test Results Performed by...'f}�.Oh' 15.....v:..... G )°�.......... Date...I.I.. .��"�1................
-..
1.4 Test Pit No. I................minutes per inch Depth of Test Pit....11....... Depth to ground water..�Johle......
cz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
x .................................. ..............................................................................
����. ., ,
O Description of Soil.........I......--6-=—�8--....--••-----�-....._.._..1.�..--1�..---------U�......... ...............s�.C�........��'...................._.
M.e.v .-.�(r!t.... A�'p...............................................
--------------------------------- -----------------------------...........................
x ----•------------------------------------------------------------------------------------•---------------------------,-------.........•-----......-------------•-------...........-•--•----•---•-•-.....
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
.........................................•---•••••...........
Agreement:
The undersigned agrees to install the aforedes ed Individual Sewage Disposal System in accordance with
the provisions of.:ITL: 5 of the State Sanitar ode he unders' her agrees not to place the system in
operation until a Certificate of Compliance has e e y the oa health
Signed. .. ._ ......
......
{ Date
Application Approved BY---------�J V -1. �:.-----••-----•----------------------
Application Disapproved for the following reasons-...........................................:.-..............................................................
_..
........-•--•................................................•-•--................................................---......................--•---•----------..._....------•----_...----..................
Date
PermitNo...... c -7.---------------------------- Issued_--•-----...........................................................................
....--
Date
f
FE........
...............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
a lh4.... OF....
BA4"703(x
..................................................
Appliraition for Dhipaaal Workii Tonstrurtion Frrmit
lip Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at:
Lo-t +-
,3 CIWMAMOAJ LANIF A%6�ssoss MAP 1,6s P,4tzcE(--
------------------------------------------------------- ......................................................................
Location-Address or Lot No.
L L 1.0l") MAn1XN1ECy_1
........................................................................ ...............................................................................................
� ?7n..e7..
...------ - Address
4 ......... .) -......... ) '� jA I-------------------------- -------------------------------------- -----------------------------------------------
:� Intal.er. Address
Type of Building Size Lot......1:1 4-� 155,...*,-1-"-*,...-Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic GarbageGrinder
04 Other—Type of Building ............................ No. of persons............................ Showers Cafeteria
04 Other fixtures ......................................................................................................................................................
Design Flow.......... 5?............................gallons per person per day. Total daily flow........336 g a kl o,,n s
Septic Tank—Liquid capacity ...gallons Length_. Zr._.. WidthA:Rlyz�.... Diameter....................D"e"p*"t'h"'t I
.. ...........
Disposal Trench—No.-------------------- Width.................... Total Length.................... Total leaching area.........:..........sq. ft.
Seepage Pit No....._.............. Diameter.....i."z ......... Depth below inlet... Total leaching area..!"3......sq/f t
z Other Distribution.box ( ) Dosing tank ( )
Performed by...; ........................................ .........................I............
Percolation Test,Results ..rHA�!� a' M6LJELL44VV.......... Date...11 - 1q -91
Test Pit .No. I....!t:;n._minutes per inch Depth of Test Pit....11+........ Depth to ground water...�40....a....9..........
fZ4 Test Pit No. 2................minutes per inch Depth of Test Pit................_._. Depth to ground water....................._..
C4 ...........*............. ............... .........i....................
N # -------------- ----- A 5-ug
0 Min-....*.................
Description of Soil.........I........ 1.0 L-� ..................1A.- W(
................. ............................................................... ......................
..........................................................................................................................................
U 7
...................... .............!....................................................................................................................................................................
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
1 4, *
............... ...............................I......... ................................................................... ............................................................................
Agreement:
The undersigned agrees to install the aforedescri,beli Individual Sewage Disposal a'i
-5,ysten accordance with
:IT A.
the provisions of LE 5 of the State Sanitary Code Jhe undersigned-fur.ther agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board:,of health)
Signed ...... ......................
Dale
.Application Approved By.......... ...
Date
Application Disapproved for the following reasons:............................................................................................................
......................................................................................................................................................................................................
Date
PermitNo..... ..............:............ Issued.......................................................
Date
---------- -------------------------- ...... ----------I--------
THE COMMONWEALTH OF MASSACHUSETTS C�
BOARD OF HEALTH OV
.......... ...........OF....... ..........................................
Trrtifiratr of Tautpliatta
THIS IS T09CERTIEF That the Individual Sewage Disposal System constructed (��' or Repaired
y
b AP
...... ----------------- -------------------------------------------------------------------------------------------------------
Installer
at......._.. r . ................ :--------------------------.------•--•-•---
has been installed in accordance with the provisions of TITLS 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.__-_--YR__..7_a........... dated................. ........................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL F CTIbN SATISFACTORY.
DATE................. ...........*...........*..... Inspecto ,... .....'..............7.�..............................................
----------- ---------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...........OF....... ..........................................
..........."'L... V, 11...
N021:..l. .... FIZF---
Disposal Worb Tonstrudivit f rrmit
Permission is hereby granted........................................................................................................................0......................
to Construct or Repair ( ) an Individual Sewage Disposal System
atNo....... ......... ............... ........................................................
Street
as shown on the application for Disposal Works Construction Permit No ..........................................
.................
........................... .......................
Board of Health
DATE_ ........ ..........
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