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HomeMy WebLinkAbout0164 EVANS STREET - Health 464-EVANSSTREET Ostervil'le A =`142 140 i �II i i i I 64- - � 1/1, LOCATION SEWAGE PERMIT N0. VILLAGE C It �S P�✓i ��J 1 0�q 5 J 9 I N S T A LLER'S NAME i ADDRESS i Z 14-® Ilse BUILDER ¢OR OWN ER / DATE PERMIT ISSUED DATE COMPLIANCE ISSUED Z,:;2, 7 FZ ��'j�U rJ � ., i(CC � I. i� . I �-, - _ T'� i 1 � \� � '�/ r / 1'/ / y1 b� � j I, �` i t�, d�� r 1 s 02 Commonwealth of Massachusetts , �� Title 5 Official Inspection Form Subsurface Sewage Disposal System Forth-Not for Voluntary Assessments 164 Evans St Ilsterville, MA 02655 ' Property Address Barbara Kent 48 Trowbridge Ln. Owner Owner's Name information�y Shrewsbury MA 01545 41612017�4 page. Chyrrown State Zip Code Date of In"clion 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. I"' Wien A. General Information filling out forms on the computer, use only the tab 1. Inspector key to move your cursor-do not Paul Martin use the return Name of Inspector key- Cape Cod Septic Services I� Company Name t 350 Main St Company Adds W.Yarmouth MA 02673 Cihf/rown State Tip Code 508-775-2825 S15016 Telephone Number r 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 Tittle 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails Needs Further Evaluation by the Local Approving Authority 4/11/2017 Inspector's Signature Date The system inspector.shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a.design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable, and the approving authority: ""This report only describes conditions at the 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. . t5ms•W 3 Title 5 OfriogdftspecbmFom S&Mdfew Sewage Disposal System•Pap 1 of 17 ,Lo�� rs Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 164 Evans St Osterville, MA 02655 Property Address Barbara Kent 48 Trowbridge Ln Owner Owner's Name information is Shrewsbury MA 61545 4WO17 red for every page- Cityrrown State Zip Code Date of Inspection Page- .;B. Certification (coat.) , Inspection Summary.Check A,B,C,D or E!always complete all of Section D A) System Passes: ® l:have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR'15.304 exist.Any failure criteria not evaluated are indicated below. Comments: System in working condition — 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. El Y ❑ N 0 ND(Explain below): f5irts•3H 3 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form Not for Voluntary dents 164 Evans St. Osterville, MA 02655 Property Address Barbara Kent 48 Trowbridge Ln Owner Owner's Name informations" Shrew MA 01545 4/6/2017 Shrewsbury required for every Shrew m Sj to Zip Code Date of Inspection page• B. Certification (cunt.)- ❑ Pump Chamber pumpstalarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(coat.): ❑ 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): El obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑= distribution box is leveled or replaced ❑ Y. ❑ N ❑ ND(Explain below). El 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 Healthy ❑, broken.pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) FurtheraEvaluation 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 CHAR 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 salt marsh t5iru•3113 Title 5 ORdel Nspemon Forth:Sum Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 164 Evans St Osterville,.MA 02655 Property Address Barbara Kent 48 Trowbridge Ln. Owner owner's Name information is _ MA 01545 4/6/2017 required for every Shreown Shrewsbury State Zi p Code Date of Inspection Me- B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier,if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal col'rform 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 El ® Backup of sewage into facility or system component due to overloaded or dogged 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 El 0 or clogged SAS or cesspool ® Liquid depth in cesspool is less than 6"below invert or available volume is less than %day flow t5ins•3113 Title 5 OffiCk lrispeetion Form S itaoe sewage Dispose)SYgtem'Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection For Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 164 Evans St Osterville, MA 02655 Property Address Barbara Kent 48 Trowbridge Ln Owner Owners Name information is Shrewsbury MA 01545 41WO17 required for every 1-111 rows St2ft Zip Code Date of loon . per- B. Certification (cont.) Yes No Q ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: 0 ® 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. E] ® Any portion of a cesspool or privy is within a Zone 1 of a public well. -n ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. El ® 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 fees 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 El 0 the system is within 400 feet of a surface drinking water supply El 0 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 fl of a public water supply well If you have answered"yes'to any question in Section E the system is considered a,signficant 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 t5ui •3/13 Title 5 Offices won Form:Sta sw1ace Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official inspection Forrn Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 164 Evans St Osterville,MA 02655 Properly Address Barbara Kent 48 Trowbridge Ln Owner Owner's Name information is Shrewsbury MA 01545 4/6/2017 requires fior every Page- Cilyrram State Zip Code Date of Inspection C. Checklist Check if the following have been done.You must indicate"yes"or"nom 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? El ® 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? ® El available as built plans of the system obtained and examined?(if.they were not , available note as WA) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ 'Was the site inspected for signs of break out? Z ❑ 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 cupants if different from owner)provided with ® information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example,a plan at the Board of Health. a „ ® 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)] M,System Information Residential Flow conditions: : . 3 Number of bedrooms(design): 3 Number of bedrooms(actual): 110x3= DESIGN flow based on 310 CMR 15.203(for example: 110 gpd z#of bedrooms): 330gpd l5ins•3/13 " Tills 5 Official Inspection form:Submsfxe Sewage Disposal System•Page 6 of 17 commonwealth of Massachusetts Title 5 Official inspection Form ism Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 164 Evans St Osterville, MA 02655 Properly Address Barbara Kent 48 Trowbridge Ln Owner Owner's Name information is Shrewsbury MA 01545 41WO17 required for every CitylTown State Zip Code Date of Ins page D. System Information Description: 0 Number of current residents Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No n in this report) infonnatio rs po ) Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage 2015�Ogpd g Y� 9 (gPd)) 2016=16gpd Detail- „ Sump pump? ❑ Yes ® No Unknown Last date of occupancy: Date Commerciallindustrial Flow Conditions: Type of Establishment Design flow(based on 310 CMR`15.203): Gallons perday(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-3113 Title 5 Official kWeowform Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts . Title 5fFicial Ins'pection 0.Form. * F Subsurface Sewage Disposal System Form-Not for Voluntary Assessments -164 Evans St Osterville MA 02655," Property Address Barbara Kent 48 Trowbridge Ln Owner Owner's Name information is MA 545 tii2017 required for every Shrewsbury 01 4/ Citylrown State Zip Code Date.of Inspection per- . . D. System lnfonmtion (co st.) Last date of occupancy/use: Date other(describe below): General Intormation Pum pi ng Records:' - x •No Records ' Source of information: Was system pumped as part of the inspection. ': ' ❑ Yes :� . No if yes,volume pumped. gm .. How was quantity purnped.determined? <r Reason for pumping Type`of System: ®- Septic tank,distribution box,soil absorption system [] Single cesspool []`` Overflow cesspool [] Privy Q Shared system(yes or no (if yes,_attach previous inspection reoords, if any)', [] Innovative/Altemative technology.Attach a copy of the cuerent operation and maintenance contract(to be obtained from system owner)and acopy of latest inspection of the UA system by system operator under contract Tight tanic Attach a copy of the DEP.approval [] Other(describe): z , Page 8 of 17 t •3113 y ` TNe s Official Inspection Forte SdMgfew Sewage Disposal System• WM _ r Commonwealth of Massachusetts IJ Title 5 Official Inspection Forme Subsurface P� SysForm-Sewage Disposal m -Not for Voluntary Assessments 164 Evans St.Osterville, MA 02655 Property Address Barbara Kent 48 Trowbridge Ln. Owner owner's Name information is Shrewsbury MA 01545 4/612017 required for every page. CityrTown State Zip Code Date of impaction D. System Information (corn.) Approximate age of all components,date installed(if known)and source of.inforrnation: 1981 Per BOH records Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 27 Depth below grade: fees Material of construction: cast iron ®40 PVC ❑other(explain): +10' Distance from private water supply well or suction line: feet Comments(on condition of joints,venting,evidence of leakage,etc.): Line checked with sewer camera and was found to be clean, properly pitched with no sign of root intrusion: Septic Tank(locate on site plan): 1W, Depth below grade: Luet , 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 1500Gal Dimensions: Sludge depth: WU Title 5 Oftal tigF-H,n Fcmt SL iurface Sewage Dig System'Page 9 ar 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 164 Evans St Osterville, MA 02655 Property Address Barbara Kent 48 Trowbridge Ln Owner Owner's Narne information is Shrews MA 01545 4/6/2017 bury required for every Shrews Statie ZipCode pate of Inspection page Cityrrown - D. Systenn Information (cunt) Septic Tank(cunt.) Distance from top of sludge to bottom of outlet tee or baffle 0" 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 How were dimensions determined? Estimated Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,,evidence of leakage, etc.): 1500Gal tank in good condition. PVC tee in place on inlet with concrete baffle in place on outlet Tank at normal operating level Covers 14 below grade Grease Trap(locate on site plan): Depth below grade: let Material of construction: ❑concrete ❑ metal p fiberglass El polyethylene ❑other(explain): Dimensions: Scum thickness . Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle # Date of last pumping: Date t5vs-3113 Title 5 O tW Mspecbon Fam SW=aface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts irTitle 5 Official inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary,Assessments 164 Evans St Osterville, MA 02655 Property Address Barbara Kent 48 Trowbridge Ln owner Owner's Name information is Shrewsbury MA 01545 4/6/2017 b required for every g Zip Code Date of Inspection per. CWTown D. System Information (cunt.) 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: saw 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-3/13 Title 5 Official Irmpec bm Form:Subsurface Sewage Disposal System-Page 11 of V Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 164 Evans St.Osterville, MA 02655 Property Address Barbara Kent 48 Trowbridge Ln Owner Owner's Name ' information isShrewsbury MA 01545 4/6/2017 required for every per- City/Town State Zip Code Date of tnspec . D. System Information (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 outlets equal,any evidence of solids carryover`,any evidence of leakage into or out of box,etc.): H-10 DB-3 with 1 line in and 1 line out in good condition. Box is clean and level with minimal solids carryover. No sign of overloading or hydraulic failure. Cover 6"below.grade. Pump Chamber(locate on site plan): y Pumps in working order. [❑ Yes ❑ No" Alarms in working order ❑ Yes ❑ No" Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System(SAS)(locate on site plan,excavation not required): If SAS not located,explain why: t5irs•3/13 _ TOO 5 Official bspedw Form Sutuu f"Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 164 Evans St Ostenrille, MA 02655 Property Address Barbara Kent 48 Trowbridge Ln Owner Owner's Name information is Shrewsbury MA 01545 402017 . required for every Page- City/Town State Zip Code Date of lrgvc Wn D. System Information (cord.) Type: ® ' leaching pits number 1-6x6 ❑ leaching chambers number. ❑ leaching galleries number. ❑ leaching trenches number, length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number. ❑ innovativetaltemative system Type/name~of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): 1-6x6 Leach pit with stone. Pit found dry at time of inspection. No staining or signs of hydraulic failure. Cover 30"below grade 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 t5ins•3/13 Title 5 Official Inspection Form:Subsixfece Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 164 Evans St Osterville, MA 02655 Property Address Barbara Kent 48 Trowbridge Ln Owner Owner's Name information is Shrewsbury MA , 01545 4/6/2017 required for every page- City/Town State Tap Code Date of Inspection D. System Information (cons) Comments(note condition of soil,signs 4hydrau1ic 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.):' t5ko 3M3 Tito 5 t)tfidal hVedim Font&bwface sewage Drsposd System•Page U of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 164 Evans St. Osterville, MA 02655 Property Address Barbara Kent 48 Trowbridge Ln Owner Owner's Name ➢equir fo ati is Shrewsbury MA 01545 4/6/2017 required for every page- Cityrrown State ZipCode 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 bekniv ® drawing attached separately t5ins•Wl3 Title 5 o(fiaw hspecfion Form:subsurface sewage Disposal system•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 164 Evans St Osterville, MA 02655 • Property Address Barbara Kent 48 Trowbridge Ln Owner owner's Name information is Shrewsbury MA 01545 4/6/2017 required for every Pam• Cityrrown State Zip Code Date of Inspection D. System Information (cont.). Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells +15' Estimated depth to high ground water. feet Please indicate all methods used to determine the high groundwater elevation: ❑ Obtained from system design plans on record If checked,date of design plan reviewed: Date 1 ® Observed site(abutting property/observation hole within 150 fleet of SAS) ❑ Checked with local Board of Health• explain: ❑ Checked with local excavators,installers-(attach documentation) ❑ Accessed USGS database explain: You must describe how you established the high ground water elevation: Hand auger 5'below bottom of pit with no water encountered. Pit at 10'. Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5eis•3/13 Title 5 OWOW M�ecbw Fomr Sutxwrface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 164 Evans St Osterville, MA 02655 Property Address Barbara Kent 48 Trowbridge Ln owner owners Name information is Shrewsbury MA 01545 4/6/2017 required for every Citylrown State Zip Code Date of Inspection page- 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. r t5ins•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 17 of 17 t0CAT1ON SE.WACE PERMIT N0. PILLAGE INSTALLER'S NAME IL A DRESS 5 U' Pru< lie ,DdILOER 00 .OWNER ertht . DATE PERMIT ISSYEO /� F� bAT E COM►.LIANCE ISSUED 1/ 1 V a. x r { 1 No-8� L3 9 �.. -- -- Fps. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ................O F...74 -xe-t XT-A:6t- ................................ Appliration for U ipviia1 Workii Tontitrurtion Urrmit Application is hereby made for a Permit to Construct (K) or Repair ( ) an Individual Sewage Disposal Syst : _�. 1�. 1 �� :....... :...flu ----------------------------�:1'-------�[..----....-...................-- Location-Address or Lot No. ......................_..... .� 'Y...... ................. ................. �7 T ........................ �[ A Owner Address Wa/L/•.R`�IL�T&I :.... --3..t.'�.>.�-.G-�.................... .....................• ................ Installer Address AA dType of Building Size Lot.... ----Sq. feet aDwelling—No. of Bedrooms________________ _______________________Expansion Attic ( ) Garbage Grinder (N o) p, Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtu es ____________________________ W Design Flow...............�� ...................gallons per person per day. Total daily flow.......................35 .........gallons. WSeptic Tank—Liquid capacitv_ _gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No_____________________ Width_.:__.__..._._.__._. Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--_______.i--------- Diameter--------- Depth below inlet.................... Total leaching area...Z©p_-sq. ft. z Other Distribution box (¢C) Do tank ( A `" Percolation Test Results Performed b� --f' -yQ-•.-----H'- --.- --- Date. Percolation -_-___---_-. . o ,aa Test Pit No. 1____7n.___minutes per inch Depth of Test Pit_______f.Z_..__. Depth to ground water..... f= Test Pit No. 2................minutes per inch Depth of Test Pit.........Iz___. Depth to ground water........................ ODescription of Soil--------------- -----------------------•---------�-------• -••_-oc------- x W -------- -------_------ ----- •-•••-•-•-•--••-------•---•-------------••-•--••-•-••-• •-•-•••••- VNature 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'T':I.- 5 of the State Sanitary Code— The undersigned further agrees not to place the s stem in operation until a Certificate of Compliance has been issued Py the board of health. Signed_._ i .-!�� . . _..•. ---••-- .......--- Date Application Approved By........ C-/ ___-_ %%`� - .....................��Datet ----- Application Disapproved for the following reasons------------------------•-----------------------'------------•-----------------------------------------..-...-_.- ................•----------...------------•--•-••--•-------•..--..._...._.....-----'•--'-----'--"'-•---•-•-----•--•--------•••---'-•---•-------•--------•----•----------•-----_..------------------'-' Date PermitNo.......................................................... Issued....................................................... Date a FEE.............................. THE COMMONWEALTH OF MASSACHUSETTS �-�---'' BOARD OF HEALTH IOV/W �F?�T"Abc& ------- ........... . ............. ....OF...:.................. ................. Appliration for Biipua�al Works Tomitrur#iaan Vamit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at Y ,/ -••---------------------------................................................................... --•--•--•-••••--•-••--.........---.......-•---------------------..........-R-----.......------•- LL Locaattlr-Address ��� C)I,�t�Na_t�+ �C�L •---....---•--••---•--.......................•------•---•--...................................... •••.......•••••••••-•-..................------•-••......_.....--•••-.........::................... W Owner V( f.f` Addres T C tf Z ( C^a Installer Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder (Mo) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Other fx es . ' '.7.-a---------------------- W Design Flow................................1 __gallons per person per day. Total daily flow............................................gallons. LW WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter..._-__-____--_. Depth................ x Disposal Trench—No. .................... Width_.:._........... Total Length.................... Total leaching area..... ,._sq. ft. Other Distribution box Dos tank -l- J Dt t�5 4, g ,� ..................`/ sq. ft. Z See a e Pit No.... .- .._(__ ) Diameter..._._ _____g�.t�( ) � S � � �!Depth below inlet.___._....._____... Total leaching area aPercolation Test Result Performed by. ----- ..................................•-.-•-- ----•••. Date.........................---•-•--•-.... Test Pit No. I................minutes per inch Depth of Test Pit.........?Z Depth to ground water......:-_-_-_--_____-. frq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 9 ----•----•-•-••-•......-----•-•--•-•--••••-••-----••---•-•••--•--•-•••-••-•••---•--•-•---•................................................................... 0 Description of Soil---- J- ... ......_. -- , .. /�.. -_ --------------------------------------------------------••••-••-- U ...............................................-- w UNature 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'T T L: p S of the State Sanitary Code—The undersigned further agrees not to p ice the s stem in operation until a Certificate of Compliance has been issued by the board of health. / .� f Signed j 'f�•f `... Application Approved B µ � �. '. 2Dat Date Application Disapproved for the following redsons:----•••-----••-•-•---------•--•----•••••••--•-••••--•-------•-•-•••---------•-••---••-----......•--••-........:_ ........-•-••-•-•••••-•-••-•-••......••-•••••----•----•-•-••••-•-••---•••••••-•........-•--•----••••-••-----•-••••••--•-•-•-•--•--•...--•--------••--••--•------------••----•••----•-•--•••---••.••... Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOAR-0 OF HEALTH ..........................................O F..................................................................................... �r�i�irtt�r laf f�.a�m�li�a�tre ,. THIS IS\ATO`CERTIFY, Th�ile Individual Sewage Disposal System constructed (�) or Repaired ( ) by -- •••.[ � ----------------------------------------------------------------•••••••....•----•...---•-•-•-- Ll!s7 �VP 1�1J }� Installer at................... •--••-•-••-•---- -------------•--•--••. \ has been installed in accordance with the provisions of T ',� jf�The State Sanitary Code as described in the application for Disposal Works Construction Permit No._e— ..__.___-__I................ da.ted.......__-._._____..._.-________................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATI FACTORY. DATE............................................ f............ Inspector _ 7.................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD"=0F`"H-F,ALTH . � f.�&III-� ,•---'"? ;`j��tJ����•. ,�� ..� ,. 3 / Cj -J No.•`-•-•••••••............. FEE........................ Raposal Works �a� #r irrat r mi Permission is hereby granted.. 6111_. e2 ----------------------- -.......... •---•••-----•-••--•----•------•-•---•-••--•---••....•---•-•......-••--•......................... to Construct ( or Repair ( ) an Individual Se4,age Disposal System atNo....................................:............................................ 7..... Street as shown on the application for Disposal Works Constructign- ermiitt No..................... ated.......................................... �oard of Health DATE............. { = ---------•-• FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS { t s Or—_AslHI.1 T:>�l V7�\M1C_�-� - CON'. --�i- %r o 4 SSD,, 15 C % • 4,ri 5 6.P.z). USA r;r�•.u,/��1.. A.c��A - l�i0 ��.t=. 0�1 9 l 1�J T.la T.u 9 7.0 A- TOTAL '�E�1GrJ .4,ZS — ! 'ToTQt_ r�atl_�( Fld:>w T 33O & D. N -- t 602 cl,O GE eCC)L&TtOL.I 04TE J"tw 2.MiW* oiz lF.v�. Fw�PaSe:� zr lG t D vL", l 6- .N ZI Jry 24 A. v_ IV FlAY r I A x �, I Zd- ' No. ? �x49 1 1 ' �- VA QS ST 0 , I J ?c IT 9 9 LOAN "P.o� ..Y ,uv• 97� S✓�So1�., 4��v� -Z ` fox 9G,G Sew►-�C I C INV. (f TnNK 1�4ZL �o p 9i•o rNv. l�.� � •.,, LFAr_�4 P,T '. T• w�rN �� C_E-QTtF1aD P1-C>T PL />til LOU-T1OtJ OST��vl�-L EL G5 1.z Z J ua Scn�C= SCALt ( �io ]_?ATt� D Olziz. Przopasr r l CGIZTIt=-, Tt4AT T14G Dwr=uaQe_ SUorcJ►..1 Pi—A%_j RI=F-ERc►_4C.a Gi:).4v rL--(S W ITP TNT: �jIDE t_{►-1�: Auc> ;CTL,,ACj/ VCQJJQGAA&"Ty LIT �-L TowU 01 ' Y. i2fJ�7T1��3 r-?a-rr_- 1.n^ .� S� t:r d•.y/� B Q XTG tZ. c� ��(� I�c- Ti-Al-S hr.A►-! ! WOT t32.;cv o� ► A," osTce•�tUt[= �t�CAs;. tl�l'i f��J:✓�C:W iU�:�lt=�' Tta�: �:Ff.:is=r�i il1G1J1� APP, _l GA-1�lT t, �-(:(' C:t'_ U,-.L&7, ro - 0p1��F�T <<,r:iI