HomeMy WebLinkAbout2780 FALMOUTH ROAD/RTE 28 - Health �-y
2780 Falmouth-Rb,
Osterville
A= 122-018-002
F
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TOWN OF 8RNSTABLE
LOCATION �� SEWAGE #
VILLAGE G ASSESSOR'S MAP& LOT
INSTALLEWS NAYa&PHONE NO.
SEPITC TANK CAPACITY
LiACI UNG FACILITY: (type) �4' (size)
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NO.OF'131w®It0OMS .,_._.
1 13UJLDPR OR OWivER.
PERMIT DATE:_._.... .--..:„._CQ1bZYLL4 NCE DATA:
Separadon Oistmi"Between the:
Maximum Adjusted,Groundwater Table to the Bottom of Leaching Pacility fee'
Private Water Supply Well and Leaching Facility (U any wells exist
on site or within 200 feet of leaching facility) Feel
Edge of Wedand and Leaching Facility(if
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments-
�M 2780 Falmouth Rd
Property Address
Bank Owned (Contact Darryll Perry @ D.B. Enterprises 1-508-776-8916)
Owner Owner's Name
information is Osterville MA 02644 10-1-10
required for 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.
A. General Information .�
1. Inspector:
Shawn Mcelroy
Name of Inspector
Upper Cape Septic Services
Company Name
29 Atwater Dr
Company Address
E. Falmouth MA 02536
City/Town State Zip Code
508-495-0905 S13971
Telephone Number License Number
B. Certification 3 .�
0 0
. aE
I certify that I have personally inspected the sewage disposal system at this address a@ thaTthe
information reported below is true, accurate and complete as of the time of the inspectioA.TQ inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. 1 am a DEP approved system inspector pursuant to Seen 'k340 of
Title 5 (310 CMR 15.000).The system: =a
=13 z
3 cn
® Passes ❑ Conditionally Passes ❑ Fails y:
O W.
❑ Needs Further Eva ton by the Local Approving Authority C=) rn
C '
10-1-10
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 describe8 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.
System is in good working order and operating at about 85% capacity. Recommend pumping tank and pit
every 2 yrs for maintenance and to prolong life.
t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not forVoluntary Assessments
2780 Falmouth Rd
Property Address
Bank Owned (Contact Darryll Perry @ D.B. Enterprises 1-508-776-8916)
Owner Owner's Name
information is required for every Osterville MA 02644 10-1-10
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:
® 1 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 is in good working order with no sign of failure and operating about 85% capacity.
Recommend pumping tank and leach pit now and every 2 yrs for maintenance and to prolong life.
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.
Answer yes, no or not determined (Y, N, ND)in the ❑ for the following statements. If"not
determined,"please explain.
❑ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent.
System will pass inspection if the existing tank is replaced with 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 Jess than 20 years old is available.
ND Explain:
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced
❑ obstruction is removed ;
t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.-.Page 2 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
b 2780 Falmouth Rd
Property Address
Bank Owned (Contact Darryll Perry @ D.B. Enterprises 1-5087776-8916),
Owner Owner's Name
information is required for every Osterville MA, 02644 10-1-10
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.) j
B) System Conditionally Passes (cont.):
❑ ` distribution box is leveled or replaced
ND Explain:
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced
❑ obstruction is removed !
ND Explain:
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 and1he environment:
El Cesspool or privy is within•50 feet of dsurface water .
' El- - Cesspool or privy is within.50 feet of a bordering vegetated wetland or a salt marsh
' 2. System Will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a.public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15
Commonwealth of Massachusetts
H v Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
2780 Falmouth Rd
Property Address
Bank Owned (Contact Darryll Perry @ D.B. Enterprises 1-508-776-8916)
Ow9er Owner's Name
information is required for every Osterville MA 02644 10-1-10
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
C) Further Evaluation is Required by the Board of Health (cont.):
❑ 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
El ® Static liquid level in the distribution bok above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6"below invert or available volume is less
than '/z day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
t5insp official document•03/08 Tltle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15
r
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
2780 Falmouth Rd
Property Address
Bank Owned (Contact Darryll Perry @ D.B. Enterprises 1-508-776-8916)
Owner Owner's Name
information is Osterville MA 02644 10-1-10
required for every ~'
page. City/Town , State Zip Code Date of Inspection
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems (cont.):
Yes No
❑ ® Any portion of a cesspool or.privy ismithin a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory, for 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 CM 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.
t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15
Commonwealth of Massachusetts
la Title 5 official Inspection Form
a a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 2780 Falmouth Rd
Property Address
Bank Owned (Contact Darryll Perry @ D.B. Enterprises 1-508-776-8916)
Owner Owner's Name
information is required for every Osterville MA 02644 10-1-10
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?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
❑ ® Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for or signs of break out.
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
❑ ® 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)]
t5insp official document•03/08 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 2780 Falmouth Rd
Property Address
Bank Owned (Contact Darryll Perry @ D.B. Enterprises 1-508-776-8916)
Owner Owner's Name
information is required for every Osterville MA 02644 10-1-10
page. City/Town State Zip Code Date of Inspection
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
Number of current residents: 0
Does residence have a grinder?
garbage g El Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use? r. ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Sump pump? ❑ Yes ® No
Last date of occupancy: 8-2010
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CM 15.203): gallons per 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:
Last date of occupancy/use: Date
Other(describe):
t5insp official document-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15
Commonwealth of Massachusetts
W Title 5 Official . Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 2780 Falmouth Rd
Property Address
Bank Owned (Contact Darryll Perry @ D.B. Enterprises 1-508-776=8916)F
Owrer Owner's Name
information is required for every Osterville MA 02644 10-1-10
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
General Information
Pumping Records:
Source of information:
N/A
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):
Approximate age of all components, date installed (if known) and source of information:
1980's
Were sewage odors detected when arriving at the site? ❑ Yes ® No
t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 2780 Falmouth Rd
Property Address
Bank Owned (Contact Darryll Perry @ D.B. Enterprises 1-508-776-8916) .
Owner Owner's Name
information is required for every Osterville MA 02644 10-1-10
page. City./Town state Zip Code Date of Inspection
D. System Information (cont.) _
Building Sewer(locate on site plan):
Depth below grade: ° 42"
feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints,venting, evidence of leakage, etc.):
Good condition.
Septic Tank(locate on site plan):
36"
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 gal
Sludge depth:
12"
Distance from top of sludge to bottom of outlet tee or baffle 20"
Scum thickness r f 0
Distance-from top,of scum to top of outlet tee or baffle 6
Distance from bottom of scum to bottom of outlet tee or baffle
16"
How were dimensions determined? Tape
t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
'wM 2780 Falmouth Rd
Property Address
Bank Owned (Contact Darryll Perry @ D.B. Enterprises 1-508-776-8916)
Owner Owner's Name
information is required for every Osterville MA 02644 10-1-10
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.):
Tank is in good condition with baffles installed and no sign of leakage. Recommend pumping for
solids.
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 baffle
Date of last pumping: Date
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):
t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
2780 Falmouth Rd
Property Address
Bank Owned (Contact Darryll Perry @ D.B. Enterprises 1-508-176-8916)
Owner Owner's Name
information is Osteryille MA 02644 10-1-10
required for every '
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Tight or Holding Tank (cont.)
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
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
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.):
Good condition with water at working level and no sign of back-up from leach pit.
Pump'Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
t5insp official document-03/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 11.of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
2780 Falmouth Rd
Property Address
Bank Owned (Contact Darryll Perry @ D.B. Enterprises 1-508-776-8916)
Owner Owner's Name
information is required for every Osterville MA 02644 10-1-10
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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:
Type:
® leaching pits number: 1-1000 gal
❑ 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.):
Leach pit in good condition with water level at 18"below inlet invert and historical stain line at 12"
below invert.
t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 -
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System form -Not for Voluntary Assessments
,M 2780 Falmouth Rd
Property Address
Bank Owned (Contact Darryll Perry @ D.B. Enterprises 1-508-776-8916)
Owner Owner's Name
requiratifo is Osterville MA 02644 10-1-10
required for every
pace. City/Town State Zip Code pate of Inspection
D. System Information (cont.)
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
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.):
t5insp official document-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15
i
Commonwealth of Massachusetts
a W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
ti 2780 Falmouth Rd
Property Address
Bank Owned (Contact Darryll Perry @ D.B. Enterprises 1-508-776-8916)
Owner Owner's Name
information is required for every Osterville MA 02644 10-1-10
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties
to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.
Locate where public water supply enters the building.
A
C
-D-
A-�=-37
�F
t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 15
Commonwealth of Massachusetts
a Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 2780 Falmouth Rd
Property Address
Bank Owned (Contact Darryl[ Perry @ D.B. Enterprises 1-508-776-8916)
Owner Owner's Name
information is required for every Osterville MA 02644 10-1-10
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: 30'
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: pate
® 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 groundwater elevation:
USGS and town maps show groundwater at greater than 30'
t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15
No. z.- � .. µ Fimic.Jllo...
THE COMMONWEALTH OF MASSACHUSETTS
- BOAR® OF HEALTH
.. ...-._"..-.OF...... ......................
Appliratiou for Uiipnaal Workii Tatuitrurtiou Famit
Application is hereby made for a Permit to Construct (K) or Repair ( ) an Individual Sewage Disposal
System at:
................_.
......._.1:�Y.1.f....... ..--------4ei1Jj'1� �1 -------------•-------------------....--------------------------------•-----------
Lac tion-Address or Lot No.
..... -S u !9:
------- ---- --------1� J��.�`:� ....cll 14-------------•---------------•---------...........................------
own Address
W
a .--- --•----•-- - -------•---••---- ._..... :-
Installer Address
Q Type of Building Size Lot_._� e.(�- .��_._Sq. feet
aDwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
p, Other—Type of Building ............................ No. of persons............................. Showers ( ) — Cafeteria ( )
Q' Other fixture
W
Design Flow................�.:"�A......____._.____.gallons per person per day. Total daily flow....................63.0.........._gallons.
WSeptic Tank—Liquid'capacity _ allons Length................ Width................ Diameter________.____._. Depth................
x Disposal Trench—NP. .................... Width_... f....._... Total Length..............._f._ Total leaching area____.�.u- __.------ ft.
Seepage Pit No.._.....!__.__._....Diameter.._..._.._... Depth below inlet__._..?___.___ Total leaching area_.L ___sq. ft.
Z Other Distribution box (�✓) Dosing tank ( ). Q
Percolation Test Results Performed b _. Axrb�_� ........ _. ./ _.`-. Date___..f�a. .. _�.
Y
Test Pit No. 1......74�minutes per inch Depth of T st Pit-------- ----------• Depth to ground water-------:7.......
.-
fi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
•---------------------------- --------•-------....------............--------._..........------...............................................................
0 Description of Soil............... .. •----........---------------•--
Y1------.......Sr f. ` ------- - ------- --- ----------------------------------------------------------.
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 iITI.L 5 of the State Sanitary Code— The undersigne f 1 agrees not to place the system in
operation until a Certificate of Complia e has be issued he b of a
Signe ------ •---------------- --- • ...... ................................ ......
Application Approved By.... ._..... t
/ ate
Application Disapprove dj'or ie following reasons: • -•--------------------•-------------------•---•------•-•------------------------------•---------....._
---------------------------------•----.....--•---•-••-------•---------------------------------------••---••••••-•.....------••-•----••--•-••-------....................................................
Date
PermitNo......................................................... Issued........................................................
Date
r � F
y
(No.(j....%�.<� ps... ..................
s THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
1 T.
............... A!2
Appliration for Disposal Works Tonstrairtion ramit
Application is hereby made for a Permit to Construct () or Repair ( ) an Individual Sewage Disposal
System at:
.......................... ..._.. ...:e...::T 1
Location-Address or Lot No.
•------•----- - !� }J_�'E........ ::` 1�. I:34 2 G t i
.... .......................•••--........................................................
f.. '! OwneA Address
Installer Address t
U Type of Building Size Lot.....62.1� _.Sq. feet
Dwelling—No. of Bedrooms..............5..........................Expansion Attic ( ) Garbage Grinder ( )
a`4 Other—Type of Building No. of persons............................ Showers
YP g ----•----------------------- P ( ) — Cafeteria ( )
dOther fixturS� ---------------------------------•-•------------------•-----------------------------------------------------------..f-:-°----------...........----
w Design Flow.................�_.�)........//._..__..gallons per person per day. Total daily flow........................" % ...........gallons.
WSeptic Tank—Liquid"capacity...6 allons Length................ Width................ Diameter................ Depth................
Disposal Trench—N ............ ....... Width____. _ _.�._._._.. Total Length................. Total leaching area.....>,.____...__._sq. ft.
Seepage Pit No........ ......... . iameter....._.... _.. Depth below inlet.......���....... Total leaching area...� ..sq. ft.
Z Other Distribution box ( Dosingltank ( )
a
Percolation Test Results Performed by.BAXV I _........17_:`�?�.'�C ' __ Date......ZI � �y�•-�-
Test Pit No. 1......lni n'minutes per inch Depth of Test Pit........` • Depth to ground water........ -------
fT, Test Pit No. 2................minutes per inch Depth of Test Pit......:............. Depth to ground water........................
a' --------------------------•-•--°--•------•----------------...--•---......-•-----••-----.....---........----••-•---....------•-•---....................-••_... ,.-.
ODescription of Soil................, • .......................................... .-........... --------------•---......---------•-•-°---------------------------•------------------.
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 TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed.-•---•---•-----••--•--•-••---•-------•----------•--•----••----••--•-•-•-•••--•--- -- f......
!� /�Date v
Application Approved By_._..,.. .. L____._. f /—_:-l -
-------------------------------•-•--..........._..........._.:----• -
e ,
Application Disapprove fb�the following reasons:--••--......------••--•---••----•---......•---••---•--•---•--••••---•-----•--•�-----•-••Date-----......._
--------------------------------------•-••--------------------------------....--------.......-------•-•--••---•--•--•-•.._..-----••---------•--•----•-•----------••--••••------••-----••--••--••--------
Date
PermitNo......................................................... Issued...........................
Date
C90
THE COMMONWEALTH OF MASSACHUSETTS
BOARD,OF HEAL.•TH
/._ /
("� r , , ,1_ •..%
..:........................................O F.... s ...........................................................................
(Intifiratr of Tumpliattrr
THI 11S TO CERTIFY, That the Individual Sewage Disposal System constructed ( )-or Repaired ( )
f - s ��
at. /= ' J `----- ....... .......Installer------------------•---------•-------......-•--••-------•----•------ �
has been installed in accordance with the provisions of TITLE 5.,of The State Sanitary Code s deso;/R in the
-•------•-••-
y/}- ..y / x'
application for Disposal Works Construction Permit No ..... ..-------•---.. dated_.f.
THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector...................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
tt� s
l ...........................................OF.....................................................................................
NoZ... ....../......
:`. FEE... .................
isposa1,, orks�C9ottstr ilea Permit
it
is,hereby granted...Z------.. �"... -`' "
to Construct(./") or Repair ( )/L Individual Sev,age Disposal System
f r ;
Street
as shown on the application for Disposal Works Construction Permit,,.N'o__________________ Dated..........................................
..............�......•. ........
............................................................
Board of Health
DATE..................... _ '---•--•...........
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS
-Vc51(�N V�-'• A .
4z
1W6LC- F'AMtLY •. B�DRooM - ;�� a ;
o GAR®ACE G
WI•IDER.
sat Y, Flow S. 110 Y. 3 = a3oG•Ro
EP.T1G TAwK = a3oxl5o'/. = �95�.P. Q.
\ Pei1 .
o15Po5AL P1'T v6E ►vo0 GAt_. ��{
5 Dfiv+lAt.h A2C.A• a 150 S.R �oK
50TTOM AREA r ., jr� �F• ,a,.
Sp S.F x 1 o >a �o G.P P o"o. Ih
,¢ 5 G.P. D- - p Ro P��fl
-rcTA1-
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-ToTAL PA 1 t-Y FLov!. = 33o G,PO•
PE2C0I.ATI0N RATE t I''IN 2MtN oV-Lr= "
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AW1D SE-tge.GK R.6Q 12fcMEN'f� oF 'tNE �� to �63 K-, 5"pt
L
-TOWN OF 1pNkvjS't/\BLCAN> IS pyoT•
II
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o G AczaAGC- 61ZA W D— y ,
110 Y. 3 = 330 G.P. O,
EP.T10 TAwK = z3ox15o'/• = .495G.P. o �
uSE %000 �oa
o1.5Po5AL PIT v4E 1000 GAL..
5 VCLWALL Asz.U► = 1 Jp 5.F �►WoK
DTTOM AREA .. `aF•- . . '�.. "`'' L
8 SR o G.P o' r•H. �
So s.F x I• o �• P oP
•ToTA1- p1F-�jIGN * 1425 G.PR G^e PROP_ p5�'
-TOTAL pA1t.Y FLOW " 330G,Po � '� pw ��
PE2C0t.ATt0N RATE MIN 0Q-1-5ai55 ' P
OF
o� VVILL1AM
IVYE H / �
•i No. 19334�Q y 4 37
r /Ufa'' •• ,^ �`� _� .. r .
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so.L toao INS TANK e
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AuD gG-t5ACX R.GRL)12�M>cN't'� oF 'tN� 41.� N K, 5�t �S.
'(owN OF 1p&kMST^,gL`AND IS KoT�
t"OCp.TED WlTN11J T 6 G ooD PL.AI
D1.'TE� 8Ax->'Eiz.e 1.1`(E INS•
SZEG I S"T EQ6D'1.A 5 0>�
-T111S PI.QN I�i Nor Qn�7>zD old /aN '
� OSTSc�LViLI..E • �SS' �'
No.••••--- ... Fiz$.�t .......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..............OF... .�Q .........................
.
Appliratiuu -fur Ui Voiial Works Cnuuitrurtiou Prruiit
Application is hereby made for a Permit to Construct ( ) or Repair (ter an Individual Sewage Disposal
Sysa . � .... _.U.. --------------------------
atl -Address ;
Ow�neerryyy� /%�� / 7 �j/ Addles t
l�.l�aa rk!d�2-2,1r� .......................
v Installer Address
: Q ype of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
p`44 Other—Type of Building ............................ No. of persons.--------------------------- Showers ( ) — Cafeteria ( )
Q' Other fixtures ----------------------------------
W Design Flow--------------------------------------------gallons per person per day. Total daily flow........................................----gallons.
04 Septic Tank—Liquid capacity------------gallons Length................ Width.................Diameter................ Depth._..___-_-.-----
xDisposal Trench—No...................... Width.................... Total Length.................... Total leaching area......_...__._.____.sq. ft.
Seepage Pit No..................... Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft.
z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by---•----------•. ......................................................... Date------•-------------------------------..
Test Pit No. 1----------------minutes per inch Depth of "Pest Pit.................... Depth to ground water...---..--.---.--.......
�14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water._.--._-.-_.._-.____----
W ----------------------------------------------------------------------------------------------•-•••.........................................................
0 Description of Soil--------- ----------------------------------• •-••---•-•-•••-- ..................... .............--............ --------.....------------------.
V -----------•------------------ --- ••---••-------•-•-----•••--•-••••---••-•--•-•--...------••--•-...._......------. ..
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 Article NI of the State Sanitary de— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has ee issued by th boa�pf h It
%—�
Signed...... : . _. .-•----- �� ....e.7 r- .Uq, _,�e
Date
ApplicationApproved By------------------------------------ ............................................................ ........................................
Date
Application Disapproved for the following reasons:........................•..._....____._.___________.________________.________......_......._.____.._....._.___._
..........................................-•.---.--••-----•-------------•......-------•-
Date
PermitNo......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
_ BOARD OF HEALTH
Apliliratfuu ;fur 4%ipouttl Works Towitrurtion Vleruift
Application is hereby made for a Permit to Construct ( ) or Repair (i.-y an Individual Sewage Disposal
Syste�,m at: h ,p
••--- -• -- ----
Location•Address or Lot No.
,y /�
")J.//_--•ftlr`/.t�i/VZ.1 �-_.�..�1�.��1�-,.G'L=.'-_'_._'_" �+IJ......... ?eYi.�............................................... �
.................../ ,rj?1 f/'- ! F/_...... 'I
� / /'/�1 - 2 r I-1?-�'1.�?�f"/J?, a� `< ...
- ----_._.----
Installer Address
UType of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( )' Garbage Grinder ( )
pa,, Other—Type of Buildings............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
a K
d Other fixtures ------ A---------------------------------------------........................................................... ..............................
Design Flow--------------------------------------------gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity------------gallons Length---------------- Width_.............. Diameter-----........... Depth....-.---.------
x Disposal Trench—No. .................... Width-------------------- Total Length.................... Total leaching area--------------------sq. ft.
Seepage Pit No_________ ___________ Diameter.................... Depth below inlet.................... Total leaching area------------------sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by-------------------------------------------------------------------------- Date........................................
Test Pit No. 1----------------minutes per inch Depth of "Pest Pit.................... Depth to ground water..-.-__.-.-__.__-.-. -.
44 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water-----.--__---_-_-.---_
Q+' ------------------------------------------------------------------------------------------'•'•••-•........_....'•-.............--"--...._.........._.......
ODescription of Soil..... -------------------------------------------------•-----------•-------------------.-.-----------...--_.------------------------------------------------------------
xH......., / >?./"..._..__ IfJ_A'!1I'Y"-------------------•-•----•---•--•----------------------------------------------•-------
W ----------------------------- ---------....... .................................../---------------------------- ------------------------------------ -----------------------------------------
V Nature of Repairs or Alterations—Answer when applicable.._.____ ------.-._f/---- -__-_w---------- p%%" }-----------------
----------------------------------------------------- --------------------------------------------------------------------------------------=-------•------------•----------- ..........................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b ee n/issued by the board,of health! ,
41
Signed. A_ .. .......................................................... c . �-
/ Date f
Application Approved By_...........•-•-------------------.1 --
Date
?application Disapproved for the following reasons---------------------------------------------------------------------------------------------•-------------------
-----------••••'•••-------------•--......•-••---•'--••--------------••--••'•-'---._..._.......-•••-•-•--•-----------------------------------------------------------------------------------------------
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�./.. F'..., fi t'
Trrtifirate of f1.1umpliartre
THIS IS TO CERTIF, Y, That the Individual Sewage Disposal System constructed ( ) or Repaired (tom
by iiT�: n � ��' `-�/>/ ,r�p ;1 / r r t!�f..c-• ........................................................
Installer • tr
has been installed in accordance with the provisions of : tk, XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No._�_..._ ___ ---------------- dated_�_-_.1 ___�_ -�__--_--_-----
THE ISSUANCE OF THIS CERTIFICATE SHALE. NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM ?L IS ACTORY.
DATE---- ---------- --• C - -
Inspectr--------- • - THE COMMONWEALTH OF MASSACHUSETTS
BOARDS OF HEALTH
................OF.a."r'�
No......................... FEE__. ? .
Bi Vagal ark-q TITu�mitrurtfuHtj�_xVrruti y�
Permission is hereby granted._.,..:<_________ ________ --..
o Construct ( or Repair (i---)fan Individual Sewage I?tsposal System
at No,f�c ✓< �� -`, , �, , 7 r-.... �/,..�'.l' f�l._��% f'�!"�.�
street/
as shown on the application for Disposal Works Construction Per ' � ated_._. , ......_..o
------------- - --••• --- ---- -- - -- ! - -
Board o Health
DATE--��/--------------J-------�5�:._._...._-------------------------------
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
T