HomeMy WebLinkAbout0015 DEERFIELD ROAD - Health 15 Deerfield Road.._- ;F -tic, .v
Ostervilie P
A = 166 020 '
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS .
DEPARTMENT OF ENVIRONMENTALTROTECTION
R E CS i V E
APR 13 Z004
TITLES TOWN OF BARNSTABLE
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASS ._1 - DEPT.
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION �g
MAP
Property Address: 15 Deerfield Road PARCEL' ;ti' Zo
Osterville-{ MA
Owner's Name: Edward McMahon LOT
Owner's Address:
Date of Inspection:44
Name of Inspector.(please print) W111 i am ' _ • Robinson Sr.
Company Name: William E. Robinson Septic Service
Mailing Address: P O Box 1089
Centerville. .MA
Telephone Number:- (sm 775-8776
CERTIFICATION STATEMENT
i certify that 1 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
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: /, 'j Dates 4/
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of HeaRhvr
DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the.buyer,if applicable,and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time-This inspection does not address how the system will perform in the future under the same or different
conditions of use.
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: 15 Deerfield Road
Osterville, MA
Owner. Edward McMahon
Date of inspection:
Inspection Su `Mary: Cheek A,B,C,D or E/ALWAYS complete all of Section D
A. Sys m.Passes:
1 have not found any information which indicates that any of the failure criteria described in 310 CIvIR:
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
1 II
B. stem Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaire .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.
e septic tank is metal and over.20 years old*or the septic tank(whether metal or not)is structurally
unsoun exhibits substantial infiltration or exfrltration or tank failure is imminenL System will pass inspection if the
existing�anlc is replaced with a complying septic tank as approved by the Board of Health.
•A met�1 septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicatiitg that the tank is less than 20 years old is available:
ND a plain:
Observation of sewage backup or break out or high static water level in the distribution box due to-broken or
obs cted pipes)or due to a broken,settled or uneven distribution box.System will pass inspection if(with
appr,,val of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled orreplaced
ND ex lain:
e system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass in
ection if(with approval of the Board of Health):
broken pipe(s).are replaced
obstruction is raaorod =°
ND explain:
Page 3 of 11
OFFICIAL INSPPECTION FORM.NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 15 Deerfield Road
Osterville, MA
Owner; Edward McMahon
Date of Inspection: .
C Further Evaluation is Required by the Board of Health:
C nditions-exist which require further evaluation by the Board of Health in order to determine if the system
is failing t protect public health,safety or the environment.
1. Syst in will pass unless Board of Health determines in accordance with.310 CMR.15.303(l)(b)that the.
system is not functioning in a manner which will protect public health,safety.and the environincnt:,
esspool or privy is within 50 feet of a surface water
esspool or-privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. Syste will fail unless the Board of Health(and Public Water Supplier,if any)determines that the ,
system is nctioning in a manner that protects the public health,safety and environment:
_ e system has a septic tank and soil absorption system(SAS)and the SAS is within.100 feet of a
surfa a 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 front a
rivate water supply well- Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
ailure criteria are triggered.A copy of the analysis must be attached to this form.
3. Ot er:
3
Page 4 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE"SEWAGE DISPOSAL SYSTEM INSPECTION.FORM
PART A
CERTIFICATION(continued), .,., .
Property Address: 15 Deerfield Road
Osterville, MA
Owner: Edward McMahon
Date of lnspection:. et.—Cr
D. S•slem.Failure Criteria applicable to all systems:
You usot mdicate'Yes"or"no"to each of the following for all inspections:
Yes
Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
1 D ch °SAS o cesspool
ool effluent the surface'of the ground or surface waters due to'an overloaded'or
— g P 8
cloggedP
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'/,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 I00,feet of a surface water supply or tributary to a surface
water supply.
Any portion of a cesspool or:privy is within a Zone I 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 (lie 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.j
(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 a considered a large system the system must serve a facility with a'design now of 10,000 gpd to 15,000
gPd•�ust
You indicate either"yes"or"no"to each of the following:
(The f llowing criteria apply to large systems in addition to the criteria above)
yes o
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)Ora mapped
Zone II of a public water supply well
If you ave answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes" Section D above the large system has fiu'led.The mvner or operator of arty large system considered a
signi cant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.3 4.The system owner should contact the appropriate regional office of the Department.
4
Paje 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART.B
CHECKLIST
Property Address: 15 Deerfield Road
Osterville, MA
Owner: Edward McMahon
Date of Inspection: /,/—:� —c
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-Heahh.: .
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)
jZ- 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:
Yes no
Existing information.For example,a plan at the Board of Health.
_✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance .
is unacceptable)[310 CMR 15.302(3)(b)J
5
Page 6 of 1 I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C .
SYSTEM INFORMATION
Property Address: 15 Deerfield Road
s ervi le, MA
Owner: Edward McMahon
Date of Inspection: 51—in,-—Q
FLOW CONDITIONS
RESIDENTIAL w -`
Number of bedrooms(design):. 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 5.203(for example: 110 gpd x#of bedrooms): . L`�
Number of current residents:
Does residence have a garba grinder(yes or no)�a
Is laundry on a separate sewage system(yes or no); as [if yes separate inspection required)
Laundry system inspected(yes or no) �
Seasonal use:(yes or no):,&,cJ
Water meter readings,if available 2 last ears usage(gP ))d ' 2 0 0 3 9'0,0 0 0
( y
Sump pump(yes or no): A,D 2 0 0 2 1.0 9,0 0 0.
Last date of occupancy:.
COMME IALMIDUSTRIAL
Type of esta lishment:
Design flow aced on 310 CMR 15.203): tad
Basis of desi flow(seats/persons/sgft,etc.):
Grease trap resent(yes or no):_
Industrial w to holding tank present(yes or no):_
Non-sari waste discharged to the Title 5 system(yes or no):
Water mete readings,if available:
Last date o occupancy/use:
OTHER( escribe):
GENERAL INFORMATION
Pumping Records
Source of information: A,a UZ
Was system pumped as part of the inspection(yes or no):!L o
If yes,volume pumped:.A-0 oas-How was quantity pumpeddetermined?
Reason for pumping:
TYP .OF SYSTEM
_ZSeptic 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/Altemative 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 cop onents,date installed(if known),vnd source off formation:
Were sewage odors detected when arriving at the site(yes or no):Z�! n
6
]'age 7 of
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE, SEWAGE DISPOSAL SYSTEM INSPECTION FORM
FART.0
SYSTEM INFORMATION(continued)'
Property Address: 15 Deerfield Road
Ostervi le, MA
Owner: Edward McMahon
Date of Inspection:
BUILD SEWER(locate on site plan)
Depth belo grade:
Materials o construction:_cast iron _40 PVC other(explain):
Distance fr m private water supply well,or suction line:
Comments on condition of joints,vending,evidence of leakage,etc.):
SEPTIC TANK: (locate on site plan)
Depth below grade:/0
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) + )i
Dimensions:_� yr /o v+ L
Sludge depth: G� "
Distance from top of sludge to bottom of outlet tee or batlle:, Q
Scum thickness:
Distance from top of scum to top of outlet tee or.baMe: a'
Distance from bottom of scum to bottom of outlet tee or baffle:
How were dimensions determined:0 Rczvy_ C
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
CREASE P: (locate on site plan)
Depth below ade:_
Material of co struction:_concrete._metal fiberglass__polyethylene._other
(explain): —.
Dimensions:
Scum thicknes
Distance from op of scum to top of outlet tee or baffle:
Distance from ottom of scum to bottom of outlet tee or baffle:
Date of last pu ping:
.Comments(on pumping reconunendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to o lie[invert,evidence of leakage,etc.):
7
Page 8 of l 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 15 Deerfield Road
Ostervi1le, MA
Owner: Edward McMahen
Date of inspection: 6
r
TIGHT or HOL ING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade.
Material of construe ion: concrete metal fiberglass Polyethylene other(explain)::.
Dimensions:
Capacity. gallons
Design Flow: allons/day
Alarm present(yes or o): -
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition f alarm and float switches,etc.):
DISTRIBUTION BOX:Z(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: O
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.):
PUPIP CHA11 DER: (locate on site plan)
Pumps in work' g order(yes or no):
Alarms in work i g 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: .15 Deerfield Road
Osterville, MA
Owner: Edward McMahon
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS): locate on site,plan,excavatiodnot required)
If SAS not located explain why:
T eleaching pits,number.L
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/altemative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.): /
106 c'>
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number nd configuration:
Depth—t,p of liquid to inlet invert:
Depth of olids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials f construction:
Indication f groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: (locate on site plan)
Materialfrl
construction:
Dimens :
Depth olids:
Comore (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
Page 10 of 11 '
II OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
!:PART C
SYSTEM INFORMATION(continued)
Property Address: 15 Deerfield Road
Osterville, MA
Owner: Edward McMahon
Date of Inspection: G
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.
10
Page 11 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:15 Deerfield Road
Osterivlle, MA
Owner. Edward McMahon
Date.of Inspection: %�—
SUE EXAM
Slope
Surface water
Check cellar
Shallow wells .
aC,
Estimated depth to ground water . feet
Please indicate(check)all methods used to determine the high ground water elevation:.
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation)
__;;�ccessed USGS database-explain:
You describe how you established the high ground water elevation:
mus
/�
11
LOCATION
SEWAGE PERMIT NO.
�,� `, � �
VILLAGE
--�-- ab(o 0 � ®
INST.A LLER'S NAME I- ADDRESS
�4h dal
. BUILDER OR OWNER
Pu �� �r .e �ra /9o�
® ATE PERMIT ISSUED 8_ -30 __��,
DATE COMPLIANCE ISSUED
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No.._ 3. ... 0 Fss........P� ,,. 1....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....................O F..........................---................... ......................................
Appliratiun for Biupu, al Works Tontitrurtion Frrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
.......S— ���- - _..2�'.8. ........-•...........................•----_.��"�'.>r��--------�-�-.3,�z,�,4�
�nL G ocation-Address or Lot No.
..--•...........a-[J ............... �--�-T.......---•---•----•.......... .....................•----•-----...---••-• ------•-•-•---•-------•---••---•..............
Owner Address
a .... .......... . ... ......... ........
Installer Address
d Type ortuilding q Size Lot_._1;?... ..Sq. feet
Dwelling—No. of Bedrooms....... / ....................Expansion Attic ( ) Garbage_ Grinder (°
pOther-Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
a Other fixtures ........................... .
-- ---•••.................-•--•-----------•-•---••......-•...•--• •--
............
W Design Flow................j�,�..............gallons per person per day. Total daily flow....................Yfr......................
WSeptic Tarik—Liquid capacitv)J'M.gallons Length................ Width................ Diameter................ Depth.................
x Disposal Trench—No.�4'
.......... Width-................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No._--t Diameter................... Depth below inlet.................... Total leaching area...................sq. ft.
Z Other Distribution box yjµ�./�l Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date..................................•••...
Test Pit No. 1._G:�SJ.._..minutes per inch Depth of Test Pit.................... Depth to ground water.........................
Test Pit No. 2.................minutes per inch Depth of Test Pit.................... Depth to ground water........................
R: ----------
0 Description of Soil_........ _
U .......................................................-- ---r� --��..:�r.-......--•----••--•-• .-------•---•-•-------...................--•---•-••.••-
U
W -------------- -----------•----....----•-•--------._......--------•-•---•--._......-•--•----••-..._..---------....-----•--.......-•---•-----••--•...---•••--•--••--••-•--•-•-•--•-----•---•-----•.....
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 TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of I h.
` r
Signed........ • ............................... ...
Application Approved B �C •
Date
Application Disapproved for the following reasons:.............................................................•------------......------..._.....................-.
.......................................•------•--------------------------••---..........---.........-•---...................---......-•-•-•-•-•---••--•--••----•-•-• •-•--•-•- - -•-•-••-•-••--
Date
Permit No...... ' 67U Issued----------------•--••--•-•--....._...•.
.. 3.................... ..............
Date
r- e
Fss... %�..` '
THE COMMONWEALTH OF MASSACHUSETTS X
BOARD OF HEALTH
....................... ................OF..........................................-....-........
4. Appliration for Uhipa ial Workii Tonotrnrtion ramit
_Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage,Disposal
System at:
t
-- -------------------------------------------------------
--••---•-•-
-cation-Address or Lot No.
......................-----•-•-•-•^---•--••-•----...........=......---..........-•.................................. ............-----...._......-----...........-----.......................•.^-••---..............--
Owner Address
............eV.--
•---•-••-••......--•--•.......................•...... ......................__.......... •••-••-•-•-....._..........................
Installer Address
PQ
Q Type oding Size Lot............................Sq. feet
U Dwelling—,No` of Bedrooms .....................Expansion Attic ( ) Garbage Grinder ( ).�
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
dOther fixtures ---•------------•-•-----..--------------------------------------•----------••--•••-• ......... •.
DesiM,,T ow a •. �11 'gallons per person per day. Total daily flow..................... '.� t, __...._gallons.
WSep c Talk " Liquid cap )..acity. gallons Length................ Width................ Diameter................ Depth................
x Seepage .Pit No._--. Diameter..........:......... Depth below inlet_.._._....--._•_ Total
leaching area....._....._..__....sq"ft.
Disposal Trench—. o. _:_.... .... ....._..._..
� 1- � p leaching area..................sq. ft.
Other Distribution box ( D) a✓Li Dosing tank
Z h g ( )
`~ Percolation Test Results 04 Performed by.......................................................................... Date.........................................
Test Pit No. 1.....___..Ah„;,Irvin Res per inch Depth of Test Pit.................... Depth to groundz"water........................
4q N - Test Pit No. 2................niinut'esper inch Depth of Test Pit..............._.... Depth to ground water........................
P
Description of Soil.............. .........._..____.._
-------•-•••.....••-•_---• •--•••-••-•••--•-••••--••---•-•---••--•-••-••-----..................••-........._...••-••.••...
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-----------------------------•-----------_------.----._------------.----------------•--•-•--•---------------•----------------•--------•----•---------•-•---.---•----•-----------------•---
U• Nature of Repairs o Alterations—Answer when applicable................................................................................._..............
y.. . ........................................................................................................................................................................................................
Agreement: N_•j
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions;of TITLE 5 of the State Sanitary Code— The undersigned further agr es not to place the system in
operation until a Certificate of Compliance has-been issued by the board of h h
- i }� ! ��
Signed -- � • - _. ---- . •... •...--•-•--•---_-•-• ..:.
ApplicationApproved By-•••---••-•%),-------------------------------y ----•••••....................---•--•---••. .
Date '•
Application Disapproved for the following reasons--------------------------------•----•--....---....._......----•----------------•----------=--•-••..............
.........-•----•--•--•...............•••-••--•--...--••-•-••-••-•••••-•-•---•-•----._.....--•-•-••-•-••---•••----.._..••---••-•-•---...------------•--•-••-------------•-•--------•--•••....-•-......••.
67o
-„ t<
Permit No....... 3•-•---......................... '.., '
p ' e�Issued........................... ..... .�`. .....
Date
i
THE COMMONWEALTH OF MASSACHUSETTS "
d r:
BOARD, OF "HEALTH
` ..............7. ......................OF..........................'T�.................................................
Tertif iratr of Tomplittnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
f/J Sri if .' ro6 . i
by-- -..-•---------------•a-•-•'=•-----•-••....... --•--•-----......._....•-••-•......-•••----•--•------ - ------------•--------.........---.....-----------------•---•--......•----.....••....
Installer
..^.............................................................t � ® T
at............ .. ------------•---.....-----...._...........------........................_......_
has been installed in accordance with the provisions of TITLE j of The State Sanitary C de as descr' ed in the
application for Disposal Works,Construction Permit No. __._..��.._��......7 .......... dated__... '-"_-�U...�......................
THE ISSUANC THIS CERTIFICATE SHALL NOT BE CONSTRUE® A GUARANTEE THAT THE
SYSTEM WILL F N �ON SATISFACTORY.
DATE........f� .,.:...._: .......-.:'::==................................ Inspector ••. -•-•------•---•-------- ...... ...................................
���.'�t �� + • rc��a ' `# �- ��, -'fit•.�,. '- - -_ i
c
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF`rHEALTH
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................................... ........................................
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FEE._.:........v.,C.T.�iopoottl Work- Tonstrnrtion rrmit
Permission is hereby granted -....----- --•-............
to Construct ( or Repair ( ) an Individual Sewage Disposal System
at No..... } 1.:�t_. -_ _..r .l s�� uiG e. e. ..--
Street ?`j
as shown on the application for Disposal �1�orks Construettonf Permit No.%�3.. . .....• Dated,,.,•- _ =
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oard of Health
DATE................... -- .............................
FORM 1255 A. M. SULKIN, INC., BOSTON
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li I>JSTRUMENT -rNEnl=t=SETS 5uau4D
►.(o"T P�F uSEDTo C7E-TER+�n1N� l� PPLICP.►-�T
APPLICATION FOR PERCOLATION TEST AND OBSE>RV/ATION PITS
OCATION '"'� / ��� NO.
ILLAGE _ DATE
i
►PPLICANT R , .-� FEE__
iDDRESS TELEPHONE NO. (Non-refundable)
;NGINEER , TELEPHONE NO. _
)ATE SCHEDULED
plicant' s signature)
• • • • • • o m o m o e • m • m • m o e • s • • • • • o 0 0 • o • • • • • • • • o • • • • • • • o • • o • • • • • • • • e • O • • • • • o • • o . . . . • •
SOIL LOG
UB-DIVISION NAME ! DA E ' TIME
XPANSION AREA: YES �60 —A ENGINEER'a�:
OWN WATER ZPjkrjfVATE WELL BOARD OF HEALTH
EXCAVATOR
KETCH: (Street name,etc. ,dimensions of lot, exact location of test holes and
percolation tests, locate wetlands in proximity to test holes)
NOTES
itt
I
1
Lol
Z v►-� i �,
?ERCOLATION RATE: S �'
EST HOLE NO: ELEVATION: TEST HOLE NO: ELEVATION:
4 4 ..
5 5 -W
7 � �� 7
8 8
9 9
10 O 10
11 11
12 12
13 13
14 14
15 15
16 16 / ..
SUITABLE FOR SUB-SURFACE SEWAGE: LEACHING FIELD ACHING PITS_—
LEACHING TRENCHES
JNSUITABLE FOR SUB-SURFACE SEWAGE. REASONS:
NOTE: ENGINEERING PLANS MUST SHOW NUMBER ASSIGNED ON PERC TEST APPLICATION
DRIGINAL: COMPLETED IN ENTIRETY BY P. E. AND RETURNED TO BOARD OF HEALTH
COPY: RETAINED BY APPLICANT
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