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HomeMy WebLinkAbout0139 EAST OSTERVILLE ROAD - Health (2) 139' East Osterville Road Osterville A=122-154 r i = S i 51g9' Commonwealth of Massachusetts W Title 5 Official. Inspection Form Subsurface Sewage Disposal System Form= Not for Voluntary Assessments 139 East Osterville Road 15 4 Property Address Jennette Goodman Owner Owner's Name information is,required for Osterville Ma. 02655 10/06/2008 every 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. ImpoWhen filling A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your Robert Paolini cursor-do not Name of Inspector use the return key. Capewide Enterprises,LLC. Company Name r� P.O.Box 763 Company Address Centerville Ma.` 02362 City/Town State Zip Code (508)428-4028 S14454 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal'system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 10/06/2008 Inspe is igna r Date The system inspector shall submit a copy of this inspection report to the Appr�-VI'l Authority(Board of Health or DEP)within 30 days of completing this inspection. if the system Ida shared systeFh has a design flow of 10,000 gpd or greater, the inspector and the system owrfer,shall submit the report to the appropriate regional office of the DEP. The original should be sew to the system owner and copies sent to the buyer, if applicable, and the approving authority. X 7311Z ****This report only describes conditions at the time of inspection and under a conddions"ef use at that time. This inspection does not address how the system will perfor ;in the`f6turrunder the same or different conditions of use. i� t5ins•09/08 Title 5 Official Inspection Form:S ace Sewage Disposal System•Page 1 of 2 I Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 139 East Osterville Road Property Address Jennette Goodman Owner Owner's Name information is Osterville Ma. 02655 10/06/2008 required for every 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 3.10 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The septic system is in proper working order at the present time. 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 explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 2 Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 139 East Osterville Road Property Address Jennette Goodman Owner Owner's Name information is required for Osterville Ma. 02655 10/06/2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 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 ❑ 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 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 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•09/08 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 3 Commonwealth of Massachusetts W Title 5 Official Inspection form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 139 East Osterville Road Property Address Jennette Goodman Owner Owner's Name information is required for Osterville Ma. 02655 10/06/2008 every 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 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 . ❑ Z Liquid depth in cesspool is less than 6" below invert or available volume is less than'/2 day flow t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 4 Commonwealth of Massachusetts w W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 139 East Osterville Road Property Address Jennette Goodman Owner Owner's Name information is required for Osterville Ma. 02655 10/06/2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes. No 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. El ® 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 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. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. 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 ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection' Area— IWPA)or a mapped Zone II.of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes".in Section D,above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 5 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 139 East Osterville Road Property Address Jennette Goodman Owner Owner's Name information is required for Osterville Ma. 02655 10/06/2008 every page. City/Town 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? El ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ElWere 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 ® El 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•09/08 Title 5'Ofricial Inspection Form:Subsurface Sewage Disposal System•Page 6 of 6 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 139 East Osterville Road Property Address Jennette Goodman Owner Owner's Name information is required for Osteryille Ma: 02655 10/06/2008 every page. City/Town State Zip Code Date of Inspection D. System Information Description: The septic system consists of a 1000 gallon septic tank ,distribution box and leaching pit. 1 Number of current residents: Does residence have a garbage grinder? ❑ Yes E No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 2006:77,000 g ( y g (gpd)): 2007:90,000 Detail: 2006:210 gpd. 2007:246 gpd. Sump pump? ❑ Yes ® No Last date of occupancy: 10/06/2008Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons pee day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 7 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GBH , 130 East Osterville Road - - Property Address Jennette Goodman Owner Owner's Name information is Osterville Ma. 02655 10/06/2008 required for every 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: 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 8 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage DisposaliS.ystem Form - Not for Voluntary Assessments CGM , 139 East Osterville Road Property Address Jennette Goodman Owner Owner's Name information is required for Osterville Ma. 02655 10/06/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 1' Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line. 20'+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of Ieakage.System vented through the house vents. Septic Tank(locate on site plan): 1' 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) ❑ Yes ❑ No Dimensions: 1000 4,. Sludge depth: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments GSM ,a'°v 139 East Osterville Road Property Address Jennette Goodman Owner Owner's Name information is required for Osterville Ma. 02655 10/06/2008 every page. City/Town 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 28" 1" Scum thickness 7" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump septic tank every two years.lnlet and outlet tees are in place.No evidence of leakage.Tank appears to be structurally sound. 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 ibaffle Date of last pumping: Date t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 139 East Osterville Road Property Address Jennette Goodman Owner Owner's Name information is required for Osterville Ma. 02655 10/06/2008 every page. City/Town 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 ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 11 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 139 East Osterville Road Property Address Jennette Goodman Owner Owner's Name information is required for Osterville Ma. 02655 10/06/2008 every 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 No 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.): Box is Ievel.Box has one outlet lateral.No evidence of solids carryover.No evidence of leakage into or out of box. 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 12 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 139 East Osterville Road Property Address Jennette Goodman Owner Owner's Name information is Osterville Ma. 02655 10/06/2008 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1-6'x6' ❑ 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.): Sandy dry soil.No signs of hydraulic failure.Leaching pit had 1'of water in it at time of inspection.Stain line is 24" below invert pipe. 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 Indication of groundwater inflow ❑ Yes ❑ No 6ins•69108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 13 Commonwealth of Massachusetts W Title 5 Official, Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 139 East Osterville Road Property Address Jennette Goodman Owner Owner's Name information is required for Osterville Ma. 02655 10/06/2008 every 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, condition 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 14 1 , Map Page 1 of 2 Town of Barnstable Geographic Information System ' Parcel.Viewer I Custom Map Abutters I Map Size ® zoom Out 'J fl '�In 1 Z M K/ vV 1 11 a 0 f - 5 Set Scale 1" = 20 1 I Aerial Photos I MAP,DISCLAIMER r'—,rinhf 7nl1F_7(V1A T--of R—0.1,ln RAG GII rinhf.rcecni. http://www.town.bamstable.ma.us/arcims/dppgeoapp/map.aspx?propertyID=122154&ma... 10/10/2008 �. Commonwealth of Massachusetts W Title 5 -Official .lnspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 139 East Osterville Road M Property Address Jennette Goodman Owner Owner's Name information is required for Osterville Ma. 02655 , 10/06/2008 every 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: Bottom of LP 40' 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: As-Built Card ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high.ground water elevation: USED:USGS Observation Well Data.USED:Technical Bulletin 92-000-01 plate#2 annual ranges of groundwater elevations. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 16 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 139 East Osterville Road Property Address Jennette Goodman Owner Owner's Name information is required for Osterville Ma. 02655 10/06/2008 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Z 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 f . t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 No.. .. z.............................. 15� THE COMMONWEALTH OF MASSACHUSETTS BOARD 4?F:, HE L H --------- ...Vr- ...........OF......... . .. ... ................................. Appliration for Dispaiial Mirk,6 Tonstrurtion Frrutit Application is hereby made for a Permit to Construct or Repair an Individual. Sewage Disposal slyst t . .. .. ... ...........1.9Y........... ....................... Loc n-Ad No. . .. . ......... AA-A) ......... ......... . ................ ............................ Loc Lot wr In ta wntr A Address .......... .....--------------------------------------------- . ....................... Installer Address Type o Buildin Size Lot..,&_ ,_� -.'.ZSq. feet ' U i Dwelling—No. of Bedrooms-------------j------------------------Expansion Attic Garbage Grinder (AF P `_l P4 Other—Type of Building ............................ No. of persons............................ Showers Cafeteria P4Other fixtures ............. ......................................................................................I........................................ Design Flow ......;X ....................gallons per person per day. Total daily flow......___...0.....................g-allons. WSeptic Tank Zliquid capacity,/M. ..gallons Length................ Width..............._ Diameter.___._...._..._. Depth....._........_. Disposal Trench—No. .................... Width...._............... Total Length....._...................... Total leaching area....................sq. ft. Seepage Pit No......./---------- Diameter.......F......... Depth below inlet.....L.......... Total leaching area..'a?.6-1..sq. f t. 0Z Other Distribution box ( ) Dosing tank ( ) /,_�# -4 Percolation Test ResujK Performed by ..... ..Ai-LOL........ Date... 1.4 ... ..4 .... ............ Test Pit No. L.<e---------minutes per incimi�Aest Pit- .................. Depth to ground water..__..............._.__. 'Test Pit No. 2................minutes per inch Depth of Test Pit._`_.._......_..._... Depth to ground water...................._._. ..............................01.................... ;�Z ...................),----------y...... 0 Description of Soil............. ...... .. ..... .......... ----------------*------*----------- ----------------------------------------*----------------------------------------------------"----------------- ------*-------------------- ...................................................................................................................................................................................................... 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 TLITI.E 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 health. igne ------------------------------------------------------------- ................................ Date Application Approved By............ ;Z�............. ---------------- ... ... .... _......................... Date Application Disapproved for the following reasons: .................................................................................... ......................................................................................................................................................................................................... Date PermitNo......................................................... Issued-....................................................... Date --------------- No.......... FHB.. .. THE COMMONWEALTH OF MASSACHUSETTS BOARD F` H E L Y , �..: - Appliratini fear Disposal Works Tonstrurtion Frrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Sys. .. u > t.. .;�:. ._............ .......................... Loc 'on-Ad ess or Lot No. im caner ddress � W - ddress s a Installer pa A -; Type o Buildip Size Lot-_' __ + Sq fect V Dwelling No. of Bedrooms.___. _._'_Ex..Expansion Attic Garbage Grinder g— P i ( ) g Other.—Type of Building ............................. No. of persons_.:......................... Showers ( — Cafeteria ( ) Q' Other fixtures '............................................. L W Design Flow .. gallons per person per day. Total daily flow........ ' .:�_: :._..___._..gallons. WSeptic Tank Liquid capacit/04W.gallons Length .................. Width................ Diameter__ ._............ Depth___................ x Disposal Trench No ................ Width ........... Total Length Total leaching area................... sq. ft. Seepage,Pit No ._._/:_.._.._._.''Diameter..'__ _.__:__: Depth below inlet___:.i _._...:. Total leaching area__ 1_:_Sq. ft. Z Other Distribution box (;, ) Dosin' tank ( ) Percolation Test Resu ' Performed by- ._ _.___ � �.._ ..4LAV X....... Date.../k............ > ......... e th of Test Pit . o. 1.__ . -_.___ �NZ__.N minutes per.inch p Test Pit ___ '_ Depth to ground,water________________________ �T4 Test Pit No. 2.......::_.___._minutes per.inch Depth of Test Pit____________________ Depth to ground water........................ a .-f O Description of So>I_.....---- ". .�*_. .... � "' ` a '✓ �' l= -- WV - x V ..........................................................:::.•• ---•------ ------- ------------------------- •-•--•------•----------- W •-••••--------------------------------- •••••-----•••----r: -----••• ••-••--• •••••. -------------------------------------------_--•-- •--•••-••----•-------••-• Nature of Repairs or Alterations—Xnswer when applicable_________________________________________________________ _-__--_-_____-.___•••--- Agreement: ' The undersigned agrees to install the aforedescribed Individual SewageDisposal System in accordance with the provisions of iim.,;. 5 of the State Sanitar Code=The undersigned further agrees not to lace the system in Y',` g g P Y operation until a Certificate of Compliance has been issued by the board of`'health. tgne �. Date Application A rovedB _ PP PP Y ••. - t� ............ .••- Date Application Disapproved for the following reasons:. ...........-• ------------•--•- -------------------------------------------••-• --•--•---..._•-•-•- ---•--••---•--••-•--...------•--•----••••••--••-••--•-•-.....-•••- •; ••--•-•------ Date pPermit.No. -- ------•-••-_.... -=---- Issued-....................................................... ✓ ',i Date ,I THE COMMONWEALTH OF^MASSACHUSETTS BOARD O t"HEALTH . ... !J 'w..... OF * ................................ y wrrfifiratr of Tuntpli nrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( or Repaired ( ) by .... 4 ................................................. .......... Y0 � v Install (` _,4 X& 0Z.40 has been installed in accordance with the provisions of T j of The State'Sanitary Code-as,descri ed in the application for Disposal Works Construction Permit No._. , :�.... i_.____ da.ted_.-�r� "�.... ?�-:_: THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE,CONSTRUED AS A GUARANTEE THAT THE c* SYSTEM WILL FUNCTION SATISFACTORY.. DATE......1.��..�7 ... b.............................--.............. Inspector.....I -•-'--6---=..--------------•-----•---•---------------------...--- ` THE COMMONW..,ALTH OF MASSACHUSETTS logBOARD O HEAL «. f ...........O F....... No......... ............ ;. • FEE.... ----• •---•-- Disposal Works Tonstrudion prrmit Permission is hereby granted...............•-----............................................ ' K to Constr t:q(, o ke it ( -.1) an Individu wage Di osal y p Street as shown on the application for Disposal N�Torks Construction Per7nit ....... .. .... Dated.'";/? ..................... oar d of Hea DATE..-` - ----- •.....-•-•......__ .. . FORM 1255 HOBBS & WARR,EN. INC.. PUBLISHERS d:• - e x 131 L O C A T ION genN�s EMG AGE PERMIT NO. -0 I g �i9sT VILLAGE INSTA LLER'S NAME & A'DDRESS i,11i,44s 6-k-(ZJ- 0UILDER OR WNER �.Pik d J*be 2) a tl9voAL e-,�t Z114 z- zZ/ S S DATE PERMIT ISSUED DATE COMPLIANCE ISSUED j, y C c� � N s� ti c,,,,k�try �a.r.�t t�{ '?� 13Eta c�po�✓+ g cir P'D PoSAt- PIT - ust= lc>cao �At_. �fP,rx�tCsa1 3"7S 6-P-V p -gorro�vc ,�� F�;o CE:o9�• t ESIGt,I rAUx L "p -T-o-t-o� �v' a.t��f rc.nW = 330 6�• + � ��x T�`- � o P�I2GDl.QT10t.1 QATE : l'�t� 2MIQ OTL LP ID,- 114D t BAXXTEn Na 7t048 , Tot Fub +1oc+.o Safi. 4 '8ox �. Se ne to 2, INK TabtK , IOOo 95.4 tuV. tuV C�A.i.. `4Yi•o qL•Z •'! PIT 4i �� •wire ;.. 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