HomeMy WebLinkAbout0090 FOX HOLLOW LANE - Health 90 FbX HOLLOW LANE, 6S7ERVILLE
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PREPARED FOR DAVID & IRENE RENT
90 FOX HOLLOW LANE
OSTERVILLE, MASS.
GB FND
ASSESSORS MAP 145 PCL. 6-1
SCALE 1" = 30' `DATE JANUARY 14, 200
ARNE y�N
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JOB #05-307 DATE REG. LAND SURVEY R
DATE: 8/23 99
PROPERTY ADDRESS:_SLFo—B-Q lg-v--,au.__--
Osterville ,Mass .
------------------------
02655
------------------------
145-006001
On the above date, I Inspected the septic system at the above address.
This system consists of the following:
1 . 1-1000 gallon septic tank.
2 . 1—Distribution box .
3 . 1-1000 gallon precast leaching pit packed in stone .
Based on my Inspection, I certify the following conditions:
4 . This is a title five septic system. ( 78 Code )
5 . The septic system is in proper working order'
at the present time .
6 . The waste water is 33" below the invert of the pipe
entering the leaching pit .
SIGNATURE:1+ J.
Name:_,I, P _ Macomber ,_,Jr ______
Cl
Company.: Jose.2h_P. Macomber_& Son , Inc .
Address: Box 66 4(/0i•~(j
0
Centerville , Ma ._02632-0066 r° °F� 19YY
Phone: 508_775_3338_____
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
JOSEPH P. MACOMBER & SON, INC.
Tan ks-Cesspools-Leachflelds
Pumped & Installed
Town Sewer Connectlons
P.O. Box 66 Centerville, MA 02632-0066
775.3338 775-6412
COMMONWEALTH OF MASSACHUSETTS
-� EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET, BOSTON RA 02108 (617) 292.5500
TRUDY CC
Sec re
ARGEO PAUL CELLUCCI DAVID B. STRL
Governor Co:r:ssu
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
ProportyAddre�s: 90 Fox Hollow Lane Narr,. ofo,,,. William Stephens
Osterville .Mas��902655 Address of owner:
Data of u p crb,,:
Nam. of Inspector:(Pt""Print) Joseph P.M a C o m b e r Jr .
1 am a DEPapproved system inspector waist to Section 16.340 of Tide 5(310 CMR 16.000)
man
copy Name: J.P.Macomber & Son Inc .
)A*MNAddress: Box 66 C:PntPrv; 11 P ,Mass _ 02632
TalepAorse Number: n Q �r3 �_S g 3
Tvv— — Ta8
CERTIFICATION STATEMENT
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 Vspsctlon. The Inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
zasses
Conditionally Passes
Needs Further Evaluation By the Local Appro Ing Authority
Fails
JA inspector's Signature: 7 Date:
The System Inspecto all submit a copy of this Inspection report to the Approving Authority (Board of Health or DEP)within thirty (30) days c
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 own
Mail submit the report to the appropriate regional office of the Department ohEnv{ronmental Protection. The original should be sent to VR
system owner and copies sent to the buyer, If applicable, and the approving authority.
NOTES AND COMMENTS
revised 9/2/98 Page Iof11
er.? Prmled on Regcled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (cofdnued)
Property Address: 90 Fox Hollow Lane Osterville ,Mass .
Owner: Bill Stephens
Data of kupoction:8/2 3/9 9
INSPECTION SUMMARY: Chad: A, A C, o/ D:
A. SYSTEM PASSES:
1 have not found any information which Indicates that any of the failure conditions described In 310 CMR 1.6.303 exist. Any failure
.criteria not evaluated are Indicated below.
COMMENTS:
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.
Indicate yes,_no, or not determined(Y, N, or NO). Describe basis of datermination In all Instances. If "not determined-, explain why not.
The septic tank Is metal, unless the owner or operator has provided the system Inspector with a copy of a Certificate of
Compliance (attached)indicating that the tank was Installed within twenty(20)years prior to the date of the Inspection; or
the septic tank, whether or not metal,Is cracked,structurally unsound, shows substantial Infiltration or exfilvation, or tank
failure Is Imminent. The system will pass inspection If the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health. •
Sewage backup or breakout or high static water level observed In the distribution box Is due to broken or obstructed pipe(s)
or due to a broken, settled or uneven distribution box. The system will pass Inspection if(with approval of the Board of
Health).
broken pips(s)are replaced
obstruction is removed
distribution box Is levelled or replaced
AM - The system required pumphig-mmv than'fourtmes a•yeardus w broken or obstructed pipe(31. The vynmt wilt-pe"—
Inspection If(with approval of the Board of Heaith):
broken pipes) ars'replaced
obstruction is removed
revised 9/2/98 Page 2orii
J
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
1 PART A
CERTIFICATION (continued)
PropertyAddre": 90 Fox Hollow Lane' 'Osterville ,Mass .
owner: Bill Stephens
Data of Inspection: 8/2 3/9 9
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
AIL0 Conditions exist which require further evaluation by the Board of Health in order to determine If the system is failing to protect the
public health, safety and 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.YALL.PROJfCT THE PUBLIC HEALTH.AND SAFETY AND THE ENMONMENT:
Cesspool or privy is within 60 feet of surface water
Cesspool or privy Is within 60 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 AND SAFETY AND THE ENVIRONMENT:
APO 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 soil absorption system and the SAS Is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS Is less than 100 feet but 60 feet or more from a
private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the
well is free from pollution from that facility and the presence f emmonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm. Method used to determine distance i/ (approximation not valid).
3) OTHER
revised 9/2/98 Page 3of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Prop"Address:90 Fox Hollow Lane Osterville ,Mass .
Owrwr: Bill Stephens
Date of Inspac°o"8/2 3/99
D. SYSTEM FAILS:
You must indicate either "Yes" or "No" to each of the following:
_ 1 have determined that one or more of the following failure conditions exist as described In 310 CMR 15.303. The basis for this
determination is Identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No ,r
1/ Backup of•sewage irrtofecility"er-sYetem component-due tto an overloaded orcfoggsdSi4S•orceaspod.
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 thq distribu on box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in " below invert or available volume is less than 1/2 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is-within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_ - V 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for
+coliform bacteria, volatile organic compounds, ammonia nitrogen-and nitrate nitrogen. -
E. LARGE SYSTEM FAILS:
You must indicate either "Yes" or "No" to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public
health and safety and the environment because one or more of the following conditions exist:
Yes No
Y the system is within 400 feet of a surface drinking water supply
the system-is-witWn 200 feetof-*44butef-t4oasurf000 4r4ciwg•waWoupply ••• - _ -- •• .- _ ._
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)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Department for further inforInation.
revised 9/2/98 Page 4orii
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Addres3: 90 Fox Hollow Lane' Osterville ,Mass.
Owner: Bill Stephens
Date of Inspection: 8/2 3/9 9
Check if the following have been done:You must indicate either "Yes" or "No" as to each of the following:
Yes No /
Pumping information waa provided by the owner, occupant, or Board of Health.
ZNone of the system components.ha�a man pua►pad4oFaeJsast tvvo aiveaks ar the system hasbaeaasicainiwg+ws�a!flow
rates during that period. Large volumes of water have not been Introduced Into the system recently or as part of this
Inspection.
jell As built plans have been obtained and examined. Note If they are not available with N/A.
_ The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or Industrial waste flow.
_ The site was Inspected for signs of breakout.
All system components,excluding the Soil Absorption System, have been located on the site.
_ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles
or tees,material of construction, dimensions,depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on•the site has been determined based on:
Existing Information. For example, Plan at B.O.H.
_ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)
/ (15.302(3)(b))
Y _ _ The facility owner.(and.n^_. upants A diffaraut froze o nef),LYw"raulded.with infor natiom,on tha proper wintaAaac of
SubSurface Disposal Systems.
i
I
revised 9/2/98 Page 5of11
t
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 90 Fox. Hollow Lane Osterville ,Mass .
Owner: Bill Stephens
Date Of on=8/23/99
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 1/D g.p.d./bedro
Number of bedrooms desigp): Number of bedrooms(actuaq�
Total DESIGN flowQ�
Number of current resldents:
Garbage grinder(yes or no): A✓
Laundry(separate system) ( s or®:_ If yes, sepamteJrupectlon,required
Laundry System inspected ( a or no)
Seasonal use(yes or no):
Water meter readings,if available(last two year's usage(gpd): "
Sump Pump(yes or no): f ��0 90id o s_,A.V k e_W,
Last date of occupancy: '':�
COM MERCIALIINDUSTRIAL:
Type of establishment: 4)1¢
Design flow: AM Sad ( Based on 16.203)
Basis of design flow
Grease trap present:(yea or no)
Industrial Waste Holding Tank present:(yes or no)A
Non-sanitary waste discharged to the Title 5 System:(yes or noom
Water meter readings,if available:
Last date of occupancy:AJ4
OTHER:(Describe) W-4
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and our of information:
I'MY 2('4 �.0
System pumped as part of inspection: (yes or no)
If yes, volume pumped: gallons
Reason for pumping:
TYPE OF SYSTEM
Septic tank/distribution box/soil absorption system
Single cesspool
AM Overflow cesspool
Privy
AAID
Shared system(yes or no) (if yes,attach previous inspection records,if any)
I/A Technology etc Attach copy of up to date operation and maintenance contract
Tight Tank �R Copy of DEP Approval
Other
A 0 AG a components,date installed{if known)-and Bourse of,information:
Sewage odors detected when,arriving at the site:(yes or no)
revised 9/2/98 Page 6ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 90 Fox. Hollow Lane Osterville ,Mass .
Ownw: Bill Stephens
Date of Inspection: 8/2 3/ 9 9
BUILDING SEWER:
(Locate on site plan).(
Depth below grade:_
Material of construction:_cast iron Z40 PVC_other(explain)
Distance fro �rivate water supply well or suction line _
Diameter
Comments: (condition of joints,venting,evidence of leakage;-etc.) -Joints appear i ghi Nn Pir; manes of l eakago . -System
SEPTIC TANK:_ 9 A
(locate on site plan)Depth below grade�V�+/
Material of construction: concrete11�metalA Fiberglass Polyethylene4)Aother(explaln)
If tank is metal,list/age" Js.age.confwmed by Certificate of Compliance (Yes/No)
Dimensions: �r7 ?Z
Sludge depth:
Distance from top of sedge to bottom of outlet tee orbaffle
Scum thickness: r
Distance from top of scum to top of outlet tee or baffle: - ,/
tt Distance from boom of scum to bottotl of outlet to or baffle. l�
How dimensions were determined:
Comments:
(recommendation for pumpin condition of inlet and outlet tees or-baffles,depth of liquid level in relation to outlet invert, structuraHntegrity,
evidence of leakage,etc.) ump septic tank every 2-3 years - Tnlet & ontlat
tees are in place The tank ; c etrtirtiiral 1 V zmin.l and shol-,o no
GREASE TRAP:
(locate on site plan)
Depth below grade:A14
Material of construction►v�concreteMAmetaltIFiberglass.,f Polyethylenesother(explain)
AM
Dimensions
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:A! 4
Distance from bottom of scum to bottom of outlet tee or baffle:.(
Date of last pumping:
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage,etc.)
Grease trap is not present
I
revised 9/2/98 Page 7or11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Prop"Address: 90 Fox. Hollow Lane Osterville ,Mass .
Owner: Bill Stephens
Dats of bupecvoo:8/2 3/9 9
TIGHT OR HOLDING TANKQ,(Tank must be pumped prior to, or at time of, inspection)
(locate on site plan)
Depth below grade: of
Material of construction:Alt9 concretedlmetall/jFiberglassllR Polyethylene�i4 other(explain)
AM
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm present
Alarm level: Alarm in working order:YesAlh No
Date of previous pumping: VA
Comments:
(condition of inlet tee, condition of alarm and float switches,etc.)
1Q t Orholding- tanks are not present .
DISTRIBUTION BOX:je"�
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note•if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) -
Distribution box has one lateral . No evidence of soilds carry over .
No evidence of leakage into or out of the box_
PUMP CHAMBFR:_,J)f(/
(locate on site plan)
Pumps in working order:(Yes or No) N/9
Alarms in working order(Yes or No)_w
Comments:
(note condition of pump chamber,condition of pumps and appurtenances,etc.)
Primp. rhamher ; s_not p result
revised 9/2/98 Page 8of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
r
Property Address: 90 Fox Hollow Lane Ostervi.11e ,Mass .
Owrw` Bill ►. Stephens
Dau of ki"Ktion,$ 2 3 9 9
SOIL ABSORPTION SYSTEM(SAS)
(locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods)
If not located, explain:
Type:
leaching pits, number:
leaching chambers,number:
leaching galleries,number:,
leeching trenches,number,length:
leaching fields, number, dimensions:
overflow cesspool,number:0
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure,level of ponding, damp soil, condition of vegetation, etc.)
Loamy Gana to mAdi „m fine 8,,a .No signs of hvdraulir failure
o r B o n d i n g_ C n i l .'tea r a d 4 —y 6s9-t•a t-i-9 n _J _A ReFfital .
CESSPOOLS:
(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 (cesspool must be pumped as part of Inspection)
q
Cesspools are not present
Comments:
(note condition of soil, signs of hydraulic failure,.level of.ponding,condition of.vagetation, etc.)
Cesspools are not prPGPnr
PRIVY:AAa-
(locate on site plan)
Materjals of construction: Dimensions:
Depth of solids: /V/7
Comments:
(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation;etc.)
rivy is not present ,
w
revised 9/2/98 Page 9ofII
I
SUBSURFACE SEWAGE DISPOSAL SYSTE INSPECTION FORM
PART C
SYSTEM INFORMATION(c"rdnuad)
Propw Ad&"4: 90 Fox Hollow Lane Osterville ,Mass .
Own*(: Bill Stephens
De,..or I1uP*cvon:
SKETCH OF SEWAGE DISPOSAL SYSTF A:
Include das to at least two psrmanent reference landmarks or benchmark&
locate all wells wlWn 100'(Locate where public water&upplY comes Into house)
1 \
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h, O Fox o k w -
revised 9/2/98 Pp;e)oorn
Ll
y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
i
P,.op"Adr.s,:90 Fox Hollow Lane Osterville ,Mass .
own«: Bill Stephens
Data of kupection: 8/2 3/9 9
NRCS Report name
Soll Type_
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderato Deep _
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells
Jam,i
Estimated Depth to Groundwater Feet ,
Please Indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observed.Site (AbuttJng propert bservation hole,basement sump etc.)
Determined from local conditions
Checked with local Board of health
_Checked FEMA Maps
Checked pumping records
Y Checked local excavators,Installers
Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
Used water .contours Map .
Gahrety & Miller Model
12/16/94
revised 9/2/98 Page II of II
[ ]•wRfSrw•—n.T7,'—TT1T.►�Jt'RI.f.Rff'TrtiSRJT+Rr7rS71►ITIRRnfT T.sTRZI1�-q�pflR•{� .. � .
TOWN OF Barnstable IlOARD OF HEALTH l
SOBSURFACF SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION
-•rn�••. et—r.,n••.rrntnr+n•rr.•rrrww•as+ran•nnr.�n•t rnme•�w.Fn rrvrrw�rw n 9V 9nr.••-•r.-ter—..�
-TYPO OR PRINT CLEARLY-
PROPERTY INSPECTED
STREET ADDRESS 90 Fox Hollow : LaneOsterville ,Mass. '
ASSESSORS MAP, BLOCK AND PARCEL #
OWNER' s NAME Bill Stephens
PART D - CERTIFICATION
NAME OF INSPECTOR Joseph P.Macomber Jr .
COMPANY NAME J.P.Macomber & Scif 'Inc .
COMPANY ADDRESS ' Box .66 Centerville ,Mass . 02632.
Street Town or CSty State LIP
COMPANY TELEPI4ONE ( 508 ) 775 - 3338 FAX (508 1 790-1578
R
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at
D
his address and that the information reported is true , accurate , and
omplete as of the time of -inspection . The inspection Was performed and any
ecommendations regarding upgrade , maintenance , and repair are consistent
with my, training and experience in the proper function and maintenance of on-
site sewage disposal systems .
Check one:
System PASSED 'f ,
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
le-alth or the environment as defined in 310 CMR 16 - 303 , Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form.
System FAILED*
The inspection which I have con icted has found that the system fails to
Protect the public health and the environment in accordance with Title
5 , 310 CMR 15 . 303, and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form .
Inspector SignatureZAd
Date
r
ecopy of this rtification must be provided to the OWNER, the BUYER
Dn
where applicable ) and the I30ARD OF ?HALT!!.
* If the inspection FAILED, the owner or"„operator shall u d
within one year of the date of the inspection, unless allowed ortrequiredm
otherwise as provided in 3.10 Ch1R 16 , 305 ,
partd .doc
TOWN OF BARNSTABLE
,ATION 7� iYG �� � � SEWAGE #
VILLAGE ASSESSOR'S MAP & LOT _
INSTALLER'S NAME& PHONE NO. n I s 6
SEPTIC TANK CAPACITY
1E.r1CHING FACII.ITY: (type) < (size) J
OF BEDROOMS J
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or•within 200 feet of leaching facility) ' Feet
Edge of Wetland and Leaching Facility If any wetlands exist
within 300 feet o leachin fa ' ity Feet
Furnished by. zm
Fig
e) � 8 t®v�j
TOWN OF BARNSTABLE
LOCATION� I � Ol��6yV. SEWAGE #
VILLAGE e f>D/
ASSESSOR'S MAP & LOT ` (D
:INSTALLER'S NAME & PHONE NO. �
SF^PTIC TANK CAPACITY DO
LEACHING FACILITY:(type) (size)
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER��� �
BUILDER OR OWNER -sdP4`-�-5 % y!/�•
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
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No .__.1- 3 F .......
THE COMMONWEALTH OF MASSACHUSETTS
F HE�k�_TH
..........
LO.W+ ............OF..............A2 - ��.------......
App iratiutt for Uiupuuaf Works Tutc uurtiurt Vrrutit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at I I
T2`�........s�.._l0�?.... ... .......................... �.._ � .. ......................................
dress� tt
Lot
.__l_: ................... ........ �... ..... �- — v --�U4-_
... J
Own r � Address
w _ vw .. ..._-
a ....
� stal er 10t�#--M0 Address
Type of Building Size Lot_3-1_,-L Z..2--_•--•Sq. feet
U Dwelling—No. of B ----------
Other Expansion Attic ( ) Garbage Grinder (nlfl)
! ts ..... No. of persons............................ Showers — Cafeteria Other—Type of Building p ( ) ( )
Q' Other fixtures -•----------------------------- - -
w Design Flow.................. .................gallons per person per day. Total daily flow........ ......................gallons.
9 Septic Tank—Liquid capacity.100Dgallons Length................ Width................ Diameter________________ Depth................
Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area--------------------sq. ft.
Seepage Pit No________________ _- Dia .............. Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date.......................................
Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water-.--_-_____-_-_-__---__.
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P+ •-•••---•-----••------------••-------•-------•...•--•••....................•---••-----------•-•••---.........................................................
0 Description of Soil.....................................................................!t------------_----------------------------------------------------------------•--------------•-
x
w .
UNature of Repairs or Alterations—Answer when applicable...............................................................................................
--------•-----------------------------------------------------------------------------------------------••--•-------------------------------•--•-------------------------------------------.........•••.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System i ccor ance with
the provisions of iiTl 5 of the State Sanitary Code—The undersigned further rees t t�pi t ystem in
operation until a Certificate of Complian s u of health.
11................ Us ..... . -•----................ ZC e
Application Approved By--•-----•-•- •� ._ .: ------ -- ----------•-. -----1--
II Date-
Application Disapproved for the following reasons:------••-----------------------•----•------------------•------ ......--••••--•-•-------._.........------------.
-•------------------••-------------•--....-----...-------------••---------......----------•-•----------..__.....---......---------------------------------------------------------- ------------------
Date
PermitNo. �Q................�`�............. Issued.......................................................
Date
No......... Fx$............._............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD -Q F HE LT H
.......... C54J.��:-----.....OF........��~-,.... .1. ......................................................
Appliratiun for Eliupoii al Works Tontrurtion Prrutit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
Syst aa�t•.
- 4 "(.� .........Lc �_�Q.---......�! .......................... .....•- `........ l ----• .............................
.. sq�-Addreu^_ or
Lot
.......................................Address
_ l..A .... ............................
...................� `�X� ZL?_u..........`� .__..................
nstal er �;�a 1�� Address
U Type of Building Size Lot..-1i,_.LIZ- .------Sq. feet
,..., Dwelling—No. of B `__________________________Expansion Attic ( ) Garbage Grinder �)o)
aOther—Type of Building :_� _r�...... No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures -------- --- --------------•-•••-•-......-••--------------•---------------------------------.....:.;-----------------------...................---
W Design Flow..................do.................gallons per person per day. Total daily flow------._:'��j6.......................gallons.
C4 Septic Tank—Liquid capacity_l:Q0D.gallons Length................ Width................ Diameter---------------- Depth.................
Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--_----------------- Dia lrr:------------------- 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 Test Pit.................... Depth to ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
---•----•------------------------------------------------••-•---....----••----------------------.............................................................
0 Description of Soil........................................................................................................................................................................
x
U ---•--•-•---•-------•--•--•-•---•---•----....--•••--•--------------------•-....--••------------•-••.......------•-•-•-•-----•-••--------------------•--•-•---------•---•-------------------------......_
W
------------------------------ ------------------------------------------------------------------------------------------------------•----•---------------.------------------------------------------
U Nature of Repairs or Alterations—Answer when applicable___________________•--_____-•--_-_-•••--________-__-•_•___-___________-__-____--_---_-_--_-___.
•-----------------------------------•-----------------------••-•-•-•••--•--••--••-------------------•-------...-•--•------------•----------•-•---••--•-••-•-..--------------------------------.....-•--
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System i ccof dance with
the provisions of T_Tf..�, j of the State Sanitary Code— The undersigned furthers^green of pi t�th� system i
operation until a Certificate of Compliance--1 -heex�is ued d of health. 1 . ,
��cry; 4 U« �< 11 -Z'
Da e
Application Approved B �,��":
PP PP y----•--------•-•-------•••• �- - :_l............... Z.sJ -
Die
Application Disapproved for the following reasons:-------•--------------------------------------------•-------------------------................--•-•--------•--
----------------•--•-----•---•-••---•----....---•--•----•-•---------•-••--....__.....----------......-------•-•-•------•----------•---------••-•--------------•-----•--------------------------•--------
Date
Permit No.------ C... �' ."••- -..... Issued.......................................................
- -------------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
- OF HEALTH
..............1 ...........OF.......
C1'c ...............................................
V"Ferrtifiratr of Toutphaurr
THI TO CERTIFY, T at- he Individual Sewage Disposal Systeg constructed ( or Repaired
by............... r . ......------....... . �.�........... �G :e�`.-' V_ .!------... v
j 4 Installer
at ----------------------------------------------------------------•••--•--•----
has been installed in accordance with the provisions of TiTIE 7 of The State Sanitary Code as deskr-ihedin the
application for Disposal Works Construction Permit No.� ___. _L� dated...... ............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GU RANTEE THAT YHE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD_ OF nHEALTH
/23 .................. ....---.........._.._.....................- --�
No ........... FEE........................
ot! �on��rttr�i�an lermi�
Permission is hereby gran -1'~ ...•._ ..?.� �'!!......._�'_ _f1i........_..
to Construct ( ) or � epair ( . ),anTndividua Sewage I�spo�stem
atLTo. = �.... -1.. }` x.__.!. �r 1. 2-----......................'`. ...--------...--------------------------•--------.....-•------•-
Street
as shown on the application for Disposal Works Construction `Dated-___---
Board of Health
DATE--;--- --------------------------------••--•--.....-----------•-----... !h
FORM IL�5 HOBBS & WARREN, INC.. PUBLISHERS 'g:
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