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HomeMy WebLinkAbout0117 EEL RIVER ROAD - Health low117 Eel River Road Osterville A= 116-097 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner 6 4) information Is Owners Name /`v, /� `/�, required for every /1 /Y�.53— A page. Crty/T State Zip Cie --=�--`�` ZS z� L 76�( Oate of Inspe n 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. Important:When filling out forms A. General Information on the computer, use only the tab 1 Inspector. key to move your . ' cursor-do not e�DGr///p� 9 . "�—6�rG�use the return key. Name of Inspector � S Se/rz✓& y rvZ Company Name Company Address Citylrown 3 State Zip Code Telephone�Nu�rber -5z z�9 �C 5176-SZ 7—3G QO Manse 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 Falls j ❑ Needs Further Evaluation by the Local Approving Authority Insp rs Signature 9 Y--/Z � Date - 1 ,. + The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. *This report only describes conditions at the 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. t5ins•t ino Tide 5 OtHdal inspedlon Fomr.Subsurface Sewage Disposal System•Pape 1 of 17 i I _ 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Fonn-Not for Voluntary Assessments Property Address �oW Owner Owners Name Information is /�)J required for every zgle"p /"/f e page. Cityrrown State Zip Code Date o nspe&o—n B. Certification (cont.) Inspection Summary:Check A,B,C,D or E/always complete all of Section D A) System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.30 3 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: / Gob W B) System Conditionally Passes: ❑ One ore system components as described in the"Conditional Pass"section need to be replaced epaired.The system,upon completion of the replacement or repair,as approved by the Board of Ith,will pass. Check the box for'yes', o"or"not determined"(Y, N, ND)for the following statements: If"not determined,"please explai The septic tank is metal and ove years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltrati r exfiltration or tank failure is imminent.System will"pass inspection if the existing tank is replaced a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is stru ally sound, not leaking and'if a Certificate of Compliance indicating that the tank is less than 20 yea old is available. ❑ Y ❑ N ❑ ND(Explain below): tsina•11/to Title 5 Oflidal Inspection Fomr subsurface sewsoe a apo8al sra>wn•Pap 2 or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Forth-Not for Voluntary Assessments Property Address �GwY-4n/a Owner Owners Name information is �Tryy/� /vll OZG f� 9 required for every page. Cityrrown State Zip Code Date of Inspectiory B. Certification (cont.) 1%14 B) System Conditionally Passes(cont.): ❑ Ob ation of sewage backup or break out or high static water level in the distribution box due to brok or obstructed pipes)or due to a broken,settled or uneven distribution box.System will pass inspe n if(with approval of Board of Health): ❑ broken pipe are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is rem d ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is levele r replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due broken Y q P P 9 y ken or obstructed pipe(s).The system will pass inspection if.(with approval of the Board of He th): ❑ broken pipe(s)are replaced. ❑ Y ❑ N ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N . ❑ N Explain below): C Further Eva luation aluatton is Required by the Board of Health: w/a ❑ Con �existich require further evaluation by the Board of Health in order to determine if the sto protect public health,safety or the environment. - 1. System will pass unle4aQoard of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is in nctioning in a manner which will protect public health,. safety and the environment: ❑ Cesspool or privy is within 50 feet of,a surface wate , ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland o aft marsh t5ins•11/10 Title 5 Offidal Inspedon Form Sdboalaoe Sewage Disposal System•Pape 3 of 17 Commonwealth*of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary:Assessments Ze, Property Address dk Owner Owner's Name information is required for every L• ' "C �ZG SSA aJ 2!� page. own State Zip Code Date o nspection B. Certification (cont.)" AIA 2. ystem will fail unless the Board of Health(and Public Water Supplier,if any) dete !nos that the system Is functioning in a manner that protects the public health, safety nd environment: ❑ Th system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a rface water supply or tributary to a surface water supply. ❑ The sys has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply: ` . . ❑ The system has. septic tank and SAS and the SAS is within'50 feet of a private water supply well. ❑ The system has aseptic tank an S and the SAS is less than 100 feet but 50 feet or more from a private water supply we Method used to determine distance:' r **This system passes if the well water analysis, perform at a DEP'certified laboratory,for fecal coliform bacteria indicates absent and the presence of amm nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are t ered:A copy of the analysis must be attached to this form. 3. Other: w , D). System.Failure Criteria Applicable to All Systems:. You must indicate"Yes"or"No"to eachyof the following for ali inspections: Yes No ❑ Backup of sewage intofacility 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 N� Liquid depth in cesspool is less than 6°below invert or available volume is less ❑ '7� ® than%day flow tsfns•w10 Title 5 Oftat ftpecdon Form:Substdace Sewage Disposal system•Pape 4 of 1-7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments /7 _:5;77e/ let;.ems Property Address po✓ �jtf Owner Owners Name information Is /� h� required for every l/S?P✓t/r/(-o "'/d OLL 3'3, 9 L¢, Z i Zv/Z page. City/Town State Zip Code Date f 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. N/k 1�] Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ K/d. 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. ❑ �a- on. 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.] 0 The system is a cesspool serving a facility with a design flow'of 2000gpd- 10,000gpd. ❑ The system falls.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. KId E) La Systems: To be considered a large system the system must serve a facility with'a design ow of 10,000 gpd to 15,000 gpd. For large syste you must indicate either"yes"or"no"to each of the following, in addition to the questions in Sectio Yes No . ❑ ❑ the system is in 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 fee a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen itive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a p 'c water supply well If you have answered"yes"to any question in Section E the system is sidered a significant threat, or answered"yes"in Section D above the large system has failed.The own or operator of any large system considered a significant threat under Section E or failed under Section all upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the ropriate regional office of the Department. tsins•1 v10 Title 5 Official Inspectlon Fomc Subsurface Sewage Disposal System•Page 5 of 17 r fA t I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner Owner's Name Information is required for 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 thleor,occupant,or Board of Health ❑. E 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) r ❑ Was the facility or dwelling inspected for signs of sewage back tap? © ❑ Was the site inspected for signs of break out? ❑ Were all system components, t vlty y po ,���he 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 Absorpti n System(SAS)on a site has been determined based on: burs IPQ � ❑ 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):. 1 3 Number of bedrooms(actuaq: 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 33y t5ins•11/10 Tide 5 Offidal inspection form subowace sewage Disposal SYstem•Page 6 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments //7 �//1"�tee✓1�� Property Address !!�� Owner Owner's Name - Information is �iy� required for eve ds�v d I1 �d /Z/.ss' every page. Clty/Town State Zip Code Date Inspection D. System Information Description: L fir. Z.r �3?1 0� -: Number of current reside nts: w� d r�yurra�I Does residence have a garbage grinder? ❑ Yes No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ($ No Laundry system inspected? ❑ Yes P5 No Seasonal use? ❑ Yes No Water meter readings,if available(last 2 years usage(gpd)): 1 Detail: /� /Z3 DOD r•93 you o o ��.rnr 11�, ,Yw�r 1/ Zo// z¢j�god /67,ooa //B oov e 9/Z —12c� Sump pump? 2yr`) El Yes No Last date of occupancy: /j �V yy--?M� Date Co ercialAndustrial Flow Conditions: Type of Es ta ' hment: Design flow(based on CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/perso ft,etc.): Grease trap present? ❑ Yes ❑ No . Industrial waste holding tank present? El Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings,if available: lSlns•11/10 Title 5 Olficim Inspection Form Subsurface Sewage Disposal System•Pape 7 of 17 . 1 Commonwealth of Massachusetts lug Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 117 c. /ew /;f Property Address �UGv/o17 ✓ Owner Owners Name information is required for every page. City/Town 9 z¢ ey/L State Zip Code Date o nspection D. System Information (cont.) N/a Last da 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: VDU S•T ( �-ZS—lz gallons / How was quantity pumped determined? -- �p� �`� Al`e41 ►�+�5 Reason for pumping: —G' i�/ Acre�ertd�i� Type of System: Septic tank, distribution box,soil absorption system ❑ Single cesspool ❑ Overflow.cesspool ❑ . Privy El 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): t9ins•11/to Title 5 Official Inspection Fom Supsurtece Sewage Disposal system•Pape 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner Owner's Name information is required for every Ds��`"I� page. Cltylrown State TIP Code Date 6f inspection D. System Information (cont:) Approximate age of all components, date installed(if known)and source of information: ��'ss Exsaas /.e��✓L Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑cast iron t PVC ❑other(explain): _T G Distance from priv to water supply well or suction line: � •Pt/ feet Comments(on condifon A joints,venting.evid ce of leakage,etc.): Septic Tank(locate on site plan): Depth below grade: / feet Material of construction: concrete ❑metal ❑fiberglass ❑polyethylene ' ❑other(explain) If tank is metal, list age: A/ years s ageconfirmed by aACertificate of Compliance?(attach a copy of certificate) El Yes El No lDimeflSlons• X x X 5� /� x7Al c� Sludge depth: i tsins•11110 Title 5 Offidal hspscoon Form:Sub"fam Sewape.Dlsposal system•Pop 9 of 17 I` i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address A&W A , a Owner Owners Name information is w ` required for every f // /l U&S� �flnspecfion � 0/Zpage. CdylTown State ZIP Code Da D. System Information (cont.) Septic Tank(cont.) 3O n Distance from top of sludge to bottom of outlet tee or baffle 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 �� y How were dimensions determined? ,� 7� Comments(on pumping recommendatio s,inlet and outlet tee or b2if ie condition struco al iegrity, J iquid levels r relate to ou et inve ,e ' ence of leakage, etc.): i Q � c ✓ �' a� � G ase Trap(locate on site plan): Depth b w grade: feet Material of constru n: ❑concrete ❑me ❑fiberglass polyethylene El other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•11f10 Tice 5 omaai Inspection Form:suoawface sewage Disposal system•Page 10 of 17 commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments v-ev Property Address Owner owner's Name information Is /' required for every � � I "!'d A&SSA page. Cltyfrown 24 ZT 2u/2 State Zip Code Datejspection D. System Information (cont.) Comments(on pumping recommendations,inlet and outlet tee or baffle"condition,structural integrity, id levels as related to outlet invert,evidence of leakage,etc.): ►u/d Tight or Holding Tank(tank must be pumped at time of inspection)(Io toon site plan): Depth be rade: Material of cons tru 'on: ❑concrete ❑m 1 ❑fiberglass, ❑polyethylene y ❑other(explain): Dimensions: Capacity: lions Design Flow: gallons p ay Alarm present: ❑ Yes o Alarm level: Alarm in working orde . ❑ 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 t51ns•11/10 Title 5 Ofidal Inspection Forth:Subsuface Sewag e Oi aposal System•Pepe 11 of 17 Commonwealth of Massachusetts Title 5 Official -Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner Owner's Name information is �a-- D2G5� required for every �/!r y' page. City/Town � zf, Z: " toiz i State Zip Code Date f Inspection D. System Informa tion Y (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert Comments(note if box is level and distribution to �s qual,any evict once of solids carryover,any evidence of ak a into or out of box,etc.): X 2d�y /2 � �� oa. ` ovev i.Suo& Pum Chamber(locate on site plan): Pumps in working r. ❑ Yes ❑ No Alarms in working order. El ❑ No Comments(note condition of pump chamber,con f pumps and appurtenances,etc.): ° Soil Absorption System (SAS) (locate on site pia ,eation not required): 4SAS located e�c� �d tT e4mete� e � t5ins•11,10 . Title 5 Offidal Inspection FonTr SubsuAam Sewage Disposal System-Page 12 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments //7 �;e l / r vev Property Address Owner owners Name information is required for every page. City/Town State Zip Code Date OT Inspection D. System Information (cont.) Type: leaching pits number d ❑ leaching chambers number. ❑ leaching galleries number. ❑ leaching - tr enches trench number, length: ❑ leaching fields number,dim ensions: ❑ overflow cesspool number. ❑ innovative/alternative system pe/namg off tec o ogy: �x Comments( ote condition pf soil igns of hydraulic failure ���ondftn Y vel of ondin am v eta ion, tc.) p p /i •moo � � %//� � -/p �� 2i �j— / � VC741),d 41 1,4 r CIJ 4' esspo (cesspool must be pumped as part of inspection)(locate on site plan): Number and con i ton Depth—top of liquid to inlet inve Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Ye s-s No t5ins•11110 Title 5 OHidal h0ecgon Fomc Subwrface Sewage Disposal System•Peps 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection. Form Subsurface Sewage Disposal System Foam-Not for Voluntary Assessments i/7 �/�tee►. ,�<.l Property Address Owner Owners Name Information is �� required for every r`/ l ��/ 61G 9 ra z�r page. Ctyfrown Lam/ 2. State Zip Code Oat f Inspection D. System Information (cont.) 7. Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, 'V14- etc. 11161- Privy(locate on site plan): Materials of cons Dimensions Depth of solids Comments(note condition of soil,signs of hydraulic failure leve ndi n etc.): g,condition of vegetation,. ------------------------- t5ins•11/f0 Title 5 OHfdal Inspection Form Subsurface Sewage oisposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address OW/�j �✓ Owner Owner's Name information is /� required for every 14V,''Ile" �'/�j /d D26 Sf 2 T Z�/Z page. CltylTown State Zip Code Date of Inspection D. System Information (cunt.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.Check one of the boxes below: hand-sketch in the area below drawing attached separately 1 117 `.. _ q7 i z \ tsooS.T. �� ^� 3dg - Z _' 13 *,Or Mina 11/10 Title 5 Official kispection Fonm Suba dace Sewage Disposal System•Page 15 of 17 Ice. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address �7 Owner Owners Name /1 information Is ale � �s� 2d ZS Z�lz required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: Check Slope /!v'z o [ ] Surface water 7 �l/� ��d �•"� aYAkw Check cellar 4/1 Shallow wells 4 Estimated depth to high ground water: To LZ•�if Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked,date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators,installers-(attach /documentation) Accessed USGS database-explain: You must describe how you established the high group water elevation: f �♦ 6J ca 3 afore fil ng thi Ins tio eporplease see sport Completeness Checklist on next page. - t51rro•1//10 Title 5 OfBdal Inspecdw Fome Subsurface Sewage Disposal system•Pape 16 of.17 f Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments -�117, Ilydw �� Property Address Owner Owners Name Information is required for every �55 `!/j / U1G S� 4e zj- Z page. City/Town State Zip Code Date7lof Inspection E. Report Completeness Checklist (� Inspection Summary:A,B, C, D,or^E checked Inspection Summary D(System Failure Criteria Applicable to All Systems)completed System Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file, t5ins•t 1l10 Tide 5 Official Inspection Form Subsurface Sewage Olsposaf System•Page 17 of 17 r, 1x NoC) �a............ THE..COMMONWEALTH OF MASSACHUSETTS _ BOAR® O HEALTH ""- R=�1 t® F" ���..�:i,•,� ~� —' LARNSTABLE CONSERVATION Orsll.E� F. - i, .....................o :.-.. ..................................... COMMISSION App iration for Disposal Works Tnnstrn.rtirn Pumit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: J ..� C ........:.i✓-( .....-- '�............. - .......-..... ----........------. ... Locationoddress or Lot No. • _ .......•. ............................... Owner Address a ............................... ''/ t ..... c .�..--•-••----•- -----------------------------------------------------------------------------•--•-•-----•....•--•- . Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms............!3...........................Expansion Attic ( ) Garbage Grinder (V,) 4 Other—T e of Building No. of persons............................ Showers — Cafeteria dOther fixt res -•---•-••--•-•••--•----•-•---•----•-•-•••-----•-----••.----------------•-------•-------•-•-•---------................. *30 W Design Flow.................... ...................gallons per person per day. Total daily flow___.......•........._3 .........._.gallons. WSeptic Tank—Liquid capacityl,*W..gal-Ions Length................ Width................ Diameter................ Depth................ Disposal Trench—No. .................... Width.................... Total Length.............�......Total leaching area....................sq. ft. 3 Seepage Pit No.........�.._...... Diameter.........f2_-.... Depth below inlet............... Total leaching area.....3 .7..sq. ft. Z Other Distribution box (f.,) Dosing tank ( ) e (� / 0-4 Percolation Test Results Performed by� __-+ .s ..._-_,t `v __.I. Date......... � � L_.....__.. 4 Test Pit No. I......7L....minutes per inch Depth of Test Pit.......IV..... Depth to ground water......''............. 44 Test Pit No. 2.........._.....minutes per inch Depth of Test Pit........IV..... Depth to ground water......_............ a' ................. ------•---•------------------------•-•--------....--•------........_....---•---•-•-•--•••-•----••••-•-•••••------••----••-•--•••-•--.••••-- ODescription of Soil................................... •---•- •----------------•------------------------•-••-•.........-•----•- x .............................. j �a� l S'.� �--' � _ :. mS----------...------------.--•------.......---•------------------- 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 TITS 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be iss d the and o he lth. SignedF ....j........................................................... -•-•-•-------•-----.....__..-- Application Approved By_._. fie_„ Date Application Disapproved for the.following reasons--------------------------------------------------------•------------•----------...............•-•-••-----...---- ---------•.........................••---••....••--•-------....--•-------.....••-------•-•••----....•----------•-•-----•-••----•-----------•-•--•--•---•---••••---------••--•••---•--••••-•--•--••-•-•--- Date PermitNo...................................................... . Issued....................................................... Date j p 2'2. Fnim 7 d 1 THE COMMONWEALTH OF MASSACHUSETTS 0 BOARD OF HEALTH ...Ow-- ..............---...OF...... �Z.� �"1( -- .(,&............__..._..........._...._. Appliratiaan for .Disposal Works Tonotrnrtiun ramit ' Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: Location ddress or-Lot No. ......................- .. .!�(�J_.......-l4nwc.,�,l•l� ------..... ................................••------•---.... Owner Address a z...... w LS-----....... Installer Address d Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms............ ............... .Expansion Attic ( ) Garbage Grinder (V, ) QI Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) <11 Other fix r s ..•-•-••-•-••---•-••---••-•-••................. W Design Flow.................AA........_.........gallons per person per day. Total daily flow____................ ���.__.___._....gallons. WSeptic Tank—Liquid capacityl3�._gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................SQ. ft. Seepage Pit No........./--------- Diameter........ z._.... Depth below inlet...... ?.......•. Total leaching area......53 9..sq. ft. Z Other Distribution box (,A,) Dosing tank�'.arK.T�7�.. '"' Percolation Test Results Performed b _.. .N l.Q._ _:� C Date....- � l/•7/ �/ Test Pit No. 1................minutes per inch Depth of Test Pit.......-•••._+..... Depth to ground water......__--.............. (Z4 Test Pit No. 2................minutes per inch Depth of Test Pit........ Depth to ground water-------- C4 -•••-•---•••-•••.....••••••-••••-•••-•••--••••••-••••••••.....-•-•------•..........................•......................................................... ODescription of Soil.............................. ....----------- _ ................................................................ V -•-••-•--••--•----••-•---- `► D!f/�'!'1.-.- •- IJU l??C✓►�� lD W UNature of Repairs or Alterations—Answer when applicable............................................................................................... i Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITTLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance.,has bee iss ed b the oard o li lth. Signed--- .��. Date Application Approved By •.. � � Date Application Disapproved for the following reasons---------------- -----------_------_-------------------------------------•---------------------•--•------ ..........................••---------••-•-•---------••--•---------••--•---••----••-•••--•----•-----••-•-.••---••----•-•--•--•--•---•••••••--••-•-••----------••--•--•-••••••••-••--•------•-•-•--------- Date PermitN6 ....................................................... Issued_...............----•--•--------••-••--...... .-•--- Date 1 THE COMMONWEALTH OF MASSACHUSETTS l BOARD OF HEALTH ............awtJ..............OF.......... fi. z .Y?.T. .. . .�..............---................ Trr#ifiratr of Taantplianrr THIS IS 70 CERTIFY, That the Individual Sewage Disposal System constructed O>) or Repaired ... ( ) by.......... ...•-� ..•... .�.�..L�.A'---...-----........------------------------------------------...........------..........................--................-----......------ ,, Installer has been installed in accordance with the provisions of T Z r 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No. 9/..z. .............. dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM V611LL FUNCTION SATI FACT RY. DATE. --••---•------------ --l_�_. 1_._.�... Inspector.......................... f ............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH i ......:'�1..!J.................OF.--E . I}rJ....Tl...13 L.....--•--•----.....---••---•--- N .. FEE.. --3,1........ Disposal Workii Tnndrndiaan rptit Permission is hereby granted...... „1 ....... 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'� M i _ � Zack �•; /ko { jt 1 f4-7 R Iq ,i. 50aeT 2 or S"L- 11, i cap f[ 7 r f — , QU LOCATION SEWAGE PERp1T NO. V I ': L A G E �' ZZZ S ` INST �LER'S NA III E i ADDRESS R OR OWN ER ��.DE I GATE PERMIT ISSUED f DAT E CO1APLIANCE ISSUED 150 �, 4 �` � �� yd3, :ra++r•.•.r�-- �[l/ r+.�+/Jy��,s.:.y.wv`"� *.y4+.gear--�".,•,; LSO.X A.T 16N _ . S E M A 6°E =67✓E Rf.71T q®.. V 4 igSTA I ER'S' - gA:ffi E`., ADDRES,S I U" DER 'OR 0W E13 ; DA T, E. PARClI.T 1SSM 1 D OAT `E C0 PAP L LA 'RCIE ISS,4ED77 ; LLLJ r Ad r 4o s _