The URL can be used to link to this page

Home My WebLink About0140 HICKORY HILL CIRCLE - Health E ickory Hill Circle, Osterville F i I r e P Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 140 HICKORY HILL CIRCLE Property Address STACK Owner Owner's Name information is required for OSTERVILLE MA 10/25/08 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. Important:When filling out A. General Information �..� forms on the r r'a e9 computer,use 1. Inspector: only the tab key ;--' to move your DOUGLAS A. BROWN cursor-do not Name of Inspector use the return = ; key. D.A. BROWN a= :;.a Company Namen � P.O. BOX 145 cam ' Company Address f�W CENTERVILLE MA J632. `-n reamCity/Town State Code 508-420-4534 S14297 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address'and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation b the Local Approving Authority Y pp 9 Y 10/25/08 spector S' ature Date Th stem 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. //.!I Title V Inspection Form.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal Syste of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 140 HICKORY HILL CIRCLE Property Address STACK Owner Owner's Name information is required for OSTERVILLE MA 10/25/08 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cunt.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: LEACH PIT MEETS MINIMUM REQUIREMENTS AT THIS TIME B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. 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 less 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 Title V Inspection Form.doc•08106 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 9 p Y VoluntaryAssessments 140 HICKORY HILL CIRCLE Property Address STACK Owner Owner's Name information is OSTERVILLE MA required for 10/25/08 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 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 and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 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. Title V Inspection Form.doc•0806 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 140 HICKORY HILL CIRCLE Property Address STACK Owner Owner's Name information is OSTERVILLE required for MA 10%25/08 every page. Cityfrown 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 ❑ ® Static liquid level in the distribution box 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 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. Title V Inspection Form.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 140 HICKORY HILL CIRCLE Property Address STACK Owner Owner's Name information is required for OSTERVILLE MA 10/25/08 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 is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a`surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Title V Inspection Fonn.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '( 140 HICKORY HILL CIRCLE Property Address STACK Owner Owner's Name information is OSTERVILLE required for MA 10/25/08 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® 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 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)] Title V Inspection Form.doc•08/06 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 140 HICKORY HILL CIRCLE Property Address STACK Owner Owner's Name information is OSTERVILLE required for MA 10/25/08 every;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: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): 07-284/06-180 Sump pump? ❑ Yes ® No Last date of occupancy: CURRENT Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day Y(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): Tide V Inspection Fonn.doc•0&06 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 140 HICKORY HILL CIRCLE Property Address STACK Owner Owner's Name informationrequired is OSTERVILLE re wired for MA 10/25/08 every page. CityrFown State Zip Code Date of Inspection D. System Information (cunt.) General Information Pumping Records: Source of information: PUMPED BY OWNER 9-08 FOR MAINTENANCE Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: MAINTENANCE 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) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: INSTALLED 1984 Were sewage odors detected when arriving at the site? ❑ Yes ® No Title V Inspection Form.doc•08/06 Tide 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 140 HICKORY HILL CIRCLE Property Address STACK Owner Owner's Name information is OSTERVILLE required for MA 10/25/08 every page. Crty/Town State Zip Code Date of inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: feet II Material of construction: ❑ cast iron ❑40 PVC ❑ other(explain): i Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 1 feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑polyethylene y ❑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: 1000GALLON Sludge depth: 0 RECENTLY PUMPED Distance from top of sludge to bottom of outlet tee or baffle Scum thickness 0 RECENTLY PUMPED 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? Title V Inspection Form.doc•08/06 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 140 HICKORY HILL CIRCLE Property Address STACK Owner Owner's Name information is OSTERVILLE required for MA 10/25/08 every page. Cltyrrown 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.): 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: El concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Title V Inspection Form.doc•08106 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System•Page 10 of 15 44 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r` 140 HICKORY HILL CIRCLE Property Address STACK Owner Owner's Name information is OSTERVILLE required for MA 10/25/08 every page. Clty/Town State Zip Code Date of Inspection D. System Information (cunt.) 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 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.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑'No Title V Inspection Fono.doc•08/06 Title 5 Official Inspection Form: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 140 HICKORY HILL CIRCLE Property Address STACK Owner Owner's Name information is OSTERVILLE required for MA 10/25/08 every page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) 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 ❑ 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.): PIT HAS @1 FT OF USABLE SPACE LEFT STAIN LINE AT WATER LEVEL Title V Inspection Form.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 I . . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 140 HICKORY HILL CIRCLE Property Address STACK Owner Owner's Name information is OSTERVILLE required for MA 10/25/08 every page. Cityfrown State Zip Code Date 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.): Tide V Inspection Forrn.doc•08/06 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 140 HICKORY HILL CIRCLE Property Address STACK Owner Owner's Name information is required for OSTERVILLE MA 10/25/08 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) 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. r 3 Title V Inspection Form.doc•08/06 Title 5 Official Insp ection Form:Subsurface Sewage Disposal System•Page 14 of 15 t , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 140 HICKORY HILL CIRCLE Property Address STACK Owner Owner's Name information is OSTERVILLE required for MA 10/25/08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Title V Inspection Form.doc•08/06 . Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 t COMMONWEALTH OF MASSACHUSETTS ,1 EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF E _NMAE,h L PROTECTION - ems ONE HINTER STREET. B N, h1A 02108 6171 19+2•5500 0 uILLIA.NIF 'AELD OCT TR;_D1 CO Goscrno's Z 6 199:7 Sc:rr ARGEO PAUL CELLLICCI TO HFA�jj ABLE D.svID 5 STRI Lt.Govcmor SUBSURFACE SEWAGE D AL SYSTEUENSPEC 11 FORM Commissic CERTI T 9 Property Address: 140 Hickory Hill Circle Ost. Address of Owner: Date of Inspection: 1 0/9/97 (If different) Name of Inspector. ,TO_-,t-=h p Marnmber Jr. I am a DEP a proved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: Y•P.Macomber & Son Inc. Mailing Address: Box 66 Cen ervl e,Mass . 02632 Telephore Number: 508-775-3338 CERTIFICATION STATEMENT I cenify that I have personally inspected the sewage disposal system at this address and that the information reported below is uue. accura!r and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper iuncl,on ano maintena-)ce of on-site sewage disposal systems. The system: Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: Date: 7 The Syste-n Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspectior If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shalt subm'I the repon to the appropriate regional office of the Department of Environmental Protection. The original should be sent to tie sypem o.,n and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: AJ SYSTE.tit ASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR i i 30' hny failure criteria not evaluated are indicated below. COMMENTS: eJ SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The systern. upc completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes,,no, or not determined (Y, N, or ND). Describe basis of determination in all instances. if "not determined', explain wns not The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Cenificale of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection. the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltranon, or tan failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic anK as approved by the Board of Health. (revis•d D4/25/97) ➢age 1 of 10 DEP on the Wono Mae Web: nrtpJrwww.magnet.state ma usroep Printed on Recycled Paper l� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Properly Address: 140 Hickory Hill Circle Osterville,Mass . 02655 Owner: Rlchard Haskell Date of inspection:1 0/9/97 BI SYSTEM CONDITIONALLY PASSES (continued) ,([(� Sewage backup or breakout or high static water level observed in the distribution box is due to oro%en or 00s:r Xec pipets) or due to a broken, senled or uneven distribution box. The system will pass inspection .f (wi!h approval o, m.? Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced ILO The system required pumping more than four times a year due to broker. or obstructed pipe(s) The system —I, pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed 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 the public health, safety and the environment. t) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A ,M' AN .ER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: 4ff� Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THkT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC (HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supo� 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 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds .na.cates (na: the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is eCua' to o- less than 5 ppm. Method used to determine distance _ (approximation not valid). 3) OTHER (r•vis•d 04/25%)7) page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:1 40 Hickory Hill Circle Osterville Ma Owner: Richard Haskell Date of Inspection: 1 0/9/9 7 D) SYSTEM FAILS: You must indicate ej. et "Yes" or 'No' as to each of the following ,Ot) I have determined that the system violates one or more of the following failure cntena as defined in 310 CmR 15 30 1^e :)a, s for this determination is identified below. The Board of Health should be contaned to determine what will be necessary to cones the failure Yes No, Backup of sewage into fauGry or system component due to an 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 o, cesspool. Static liquid level in,the,oilvibution box above outlet invert due to an overloaded or clogged SAS or cesspool 41! Liquid depth is less than 6" below inven 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 plpe!sl 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 tnbutar� to a surface .water supo', 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. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well ,.-r,n nt acceptable water quality analysis. If the well has been analyzed to be acceptable, anach copy of well v ater anatys,s for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: You must indicate ether "Yes" or "No" as to each of the following: The following criteria apply to large systems to 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 s,gn,fican: tnreat to public health and safety and the environment because one or more of the following conditions exist Yes No athe 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 14 the system is located in a nitrogen sensitive area (Interim Wellhead Protenion Area - IWPA) or a mapped Zone is of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment grog a•^ requirements of 314 CMR 5.00 and 6,00, Please consult the local regional office of the Depanment for further information (t•vi••d 0�/l5/97) P•y• 3 of 10 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 140 Hickory Hill Circle Osterville Ma Owner: Richard haskell Date of Inspection: 1 0/9/9 7 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No , Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as pan of this inspection. 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,:s cluding 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: The faciliry owner (and occupants, if djfferent from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. Existing information. Ex. 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) 115.302(3)(b)) (r.vl..d 04/25/37) Pago 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:1 40 Hickory Hill Circle Osterville Ma Owner: Richard Haskell Dale of Inspection: 1 0/9/97 FLOW CONDITIONS RESIDENTIAL: Design flow.. d./bedroom for S.A.S. Number of bedrooms: Number of current residents:0 Garbage grinder (yes or no):_A�? Laundry connected to system (yes or no):,-Z� Seasonal use (yes or no).Aje water meter readings, if available (last two (2) year usage (gpd): Sump Pump (yes or no): O Last date of occupancy f� COMMERCIAUINDUSTRIAL• Type of esfabl shm n(. Design flow: gallons/day Grease trap present: (yes or no)d22� Industrial Waste Holding Tank present: (yes or no)_A'�# Non-sanitary waste discharged to the Title 5 system: (yes or no)' water meter readings, if available Al/1 Lasi date of occupancy OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information System pumped as pan of inspection: (yes or no) �t/U II yes, volume pumped: gallons Reason for pumping A �Qr Lls�f TYPE OF,SYSTEM /Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool �L Privy _1��— Shared system (yes or no) (if yes, anach previous inspection records, if any) rCG I/A Technology etc. Copy of up to date contract? aher APPROXIMATE AGE of all components, date installed (if known) and source of information; Sewage odors detected when arriving at the site: (yes or no)y� (r.vi..d 04/25/97) ➢.q. 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property address: 140 Hickory Hill Circle Osterville Ma Owner: Richard haskell Date of Inspection: 1 0/9/97 BUILDING SEWER: ilocale on site plan) r/ Depth below grade Material of cons(ruc ton /Cast iron Z40 PVC _ other (explain) Distance from private water supply well or suction line Ael Diameter 1/1 Comments: tcondiuon of)oints, venting, evidence f leakage, etc.) /yl //J SEPTIC TANQV0YW/u114� tioc.ate on site plan) Depth below grade:', material of conslruclion: concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age dZ Its age�confirmed by Cenificcaatte of Compliance .60(Yes✓No) Dimensions:/! Sludge depth..�� Distance from toff sludge to bonom of outlet tee or bafflV�ci Scum thickness / Z Distance irom top of scum to top of outlet tee or baHle:41941 -' D-stance from bosom of scum to bonom of outlet tee or, affle Mow dimensions were determined: Comments (recommendation for pumping, conclitigg of inlet and outlet tees or baffles, depth of liquid level to relation to outlet invert, I uclura• me riry, evidence of leakage, et .) ' l✓�ht y' ./ ) 'je GREASE TRAP:&,-,-ve— (loca(eRon site plan) Depth below grade: material of cons(ruaronAWO concreterto meta lq/�Fibergl ass V,4 Polyethyleno/Oother(explain) D,mensrons: Scum thickness. to Distance from top of scum to top of outlet tee or baffle: Distance from bonom of s m to bonom of outlet tee or baffle: Date of last pumping. Y Comments (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invent struc;ura; ntegnry, evidence of leakage, etc.) (r.vi..d O4/75/97) P.q. 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:1 40 Hickory Hill Circle Osterville Ma Owner: Richard Haskell Date of Inspection: 1 0/9/9 7 TIGHT OR HOLDING TANK-xd,&Ze4Tank must be pumped prior to, or at time, of inspection) (locate on site plan) Depth below grade:IVIT Material of con struct ion AhVi-concrete jgmetaWAFiberglassA/*oIyethyleneAb4)ther(explain) IV Dimensions: .4,2 4 Capaciry:��_ gallons ay Design vet., --J CLL Alagallrm w — Alarm level Alarm in working order &i'¢1'es;�(/�i No Date of previous pumping AW Comments. (condition of inlet tee, condition of alarm and float switches, etc l �• s DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet inven:-Itle Comments: (note if vel a d distribution is equal, evidence of solids..carryover evidence of leaks a into o•• out of box, etc.) >� PUMP CHAMBER:AW,—' (locate on site plan) Pumps in working order: (Yes or Not Alarms in working order (Yes or No) Comments: (note condition of pump chamber, condition of pumps and appunenances, etc.) (r.v1..d 04;15/97) P.ge 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Properly Address:l 40 Hickory Hill Circle Osterville Ma owner: Richard haskell Date of Inspection: 1 0/9/9 7 SOIL ABSORPTION SYSTEM (SAS): ;locate on site plan, if possible, excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type. leaching pits, number: leaching chambers, number: leaching galleries, number: leaching.trenches, number,length: _ leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments (n to con ition of soil, signs of hydraulic failure, level of ponding, ndition C4vegetation, etc.) �. ,1 1?- .6 CESSPOOLS: /V/N,�. (locate on site plan) Number and configuration: Depth-(op of liquid to inlet invert:_ 4 Depth of soh,cls layer: _ 4zlel Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow Ic }spool must b pumped as pan of inspection) �/ie_6 Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: (locate on site plan) Materials of construct: r/�� Dimensions: Depth of solids:_ Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (r•v1••d 04/25/97) ?•9• 8 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C s SYSTEM INFORMATION (continued) Propeny Address: 140 Hickory Hill Circle Osterville Ma Owner: Richard Haskell Date of Inspection: 1 0/9/9 7 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locale all wells within 100' (Locate where public water supply comes into house) r 0 ar'Y (r•v 1..d 01/75/97) P•y• 9 of 10 SUBSURFACE SEWAGE DISP; t SYSTEM INSPECTION FORM I. C SYSTEM INFOI: .:ION (continued) Properly Address: 140 Hickory Hill Circle Osterville Ma owner: Richard Haskell Date of Inspection: 1 0/9/9 7 Depth to Groundwaletx,Feet Please indicate all the methods used to determine High Groundwa:Cr Elc-.ation: Obtained from Design Plans on record Observahon of Site (Abuning property, observation hole, baseme-nit-limp etc.) Determine it from local conditions Check with local Board of health _ Check FEMA wraps Check pumping records Check local excavators, installers Use USGS Data Describe in your own words how you established the High Ground a•erElevation. (Must be completed) Used Cape Cod Commission Map September 1995 Water Table Contours And Public Water Supply Well head Protection Ares (r-i-d 04/25/97) ! 10 1• r.n r+ nrr,�--.r,r.-nr.n.Ara--r.nay-r.rrr.:•.,.••.^+v.r:+rr-e.•rn m-�t.*.r�rv.:m. sr,v.�r�rrT.n,..r.;T. .-�-_' - 'I'OWN OF Barnstable BOARD OF HEALTH I SUDSURFACE SEWAGE DISPOSAL SYSTF,M INSPECTION FORM - PART D mcrI FICATION �, �•.•-.. r .--.ii..---r..�-r..•rt:mr,rr:emra�-rr-r-•.,-,in•..�arn+et-T*+r*.ewY m-mmr:-rnr,¢r� mnn�rnrr+...Tv-trr+..�r:-..•��.r. �. -TYPE OR PRINT CI- EARLY-PROPERTY INSPECTED STREET ADDRESS 140 Hickory Hill Circle Osterville,Mass . ASSESSORS MAP , BLOCK AND PARCEL # OWNER' s NAME Richard' Haskell PART D - CERTIFICATION NAME OF INSPECTOR Joseph P. Macomber Jr . COMPANY NAME Joseph P. Macomber & 'Son , Inc . COMPANY ADDRESS Box 66 Centerville , Ma. 02632-0066 Street Tovn Or City Stat• t I P COMPANY TELEPHONE (508 775 -3338 FAX ( 508 ) 790 -1 578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system nt this address and that the information reported is true , accurate , and complete as of the time of .-inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems , one ; :2-c System PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15 . 303 . Any fail�Ire criteria not evaluated are as stated in the FAILURE CRITERIA section of this form . System FAILED* \ The inspection which I have co Ucted has found that the system fails to Protect the public healLh 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 Signature Date C �0'-,5;'� One copy of this certification must, be provided to the OWNER, the BUYER ( where applicable ) and the BOARD OF IIEALI'JI. • IC the inspection FAILED , the owner or operator shall upgrade the eyatem within one year of the date of the inspection , unless allowed or required oCherwise as provided in 310 CMR 15 , 305 , pactd . doc Id Ln THE C OMMONWEi A LTH OF MA..SSA UMSETTS DEPARTMENT OF ENVERONMIENTA L PROTECTION DE IT KNOWN THAT Joseph P. Macomber, Jr. Has satisfied the Department's qualificatign.s as required and is hereby authorized to use the title CER t i D TITLE S SYSTEM INSPECTOR as provided in 310 CMR 15.340 and Section 13 of Chapter 21A of the General Laws . Issued by Tile Department of Environmental Protection. Jun< 8 lw9 — ----- - ncunX Uircc(or of (tic O1on L)f Watct Pollution Control �ti1 F TOWN OF BARNSTABLE J00° ' LOCATION l� SEWAGE # VILLAGE -S ASSESSOR'S MAP & LOTW 0 rJ . INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPAC _ J`^r✓B� LEACHING FACILITY: (type) r (size) ®� NO.OF BEDROOMS BUILDER OR OWNER PERMIT DATE: COMPLIANCE DATE: lvf 4 Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet 4 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 of leaching facility) Feet Furnished by /qo 1it o(I Q1 ((pt k OsI. l , ! ,x C .................. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ...................TOWN....---.....OF....BARN.S.TABLE.....----.------•-•................................. Allp ira#ion for Bigpog al Works Tnntrnrtiun Errant Application is hereby made for a Permit to Construct (X ) or Repair ( ) an Individual Sewage Disposal System at: Hick . ------•--•-•------•...........................•----•--•-- ....•---••••---•----...---...-----•---•••---------............... .............--- o atio -A ss or Lot No. Mrs. Charles I as e� 28 Bavview Rd., Osterville,t MA --- .. Owner Address a Paul T. Lebel _._32__Wianno Ave., _Ost_ervillez_ M_....._ Installer Address 1 3 5 Type of Building Size Lot____..--5................S . f V g— _..._Expansion�Attic ( ) Garbage Grind r Dwelling No, of Bedrooms___..._...3.......................... b 1 Res. p-, Other—Type of Building ............................ .No. of persons............................ Showers ( ) — Cafete ' ) Pa Other fixtures -------------------------------- W Design Flow....... 5...............................gallons per person per day. Total daily flow...............Y9.5.....................gallons. WSeptic Tank—Liquid capacity...0 0.(.�allons Length................ Width-------_--------- Diameter................ Depth................. x Disposal Trench—No..................... Width..........:......... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter....$...f Depth below inlet...5_t 6........ Total leaching area...200......sq. ft. Z Other Distribution box ( X) Dosing tank ( ) Percolation Test Results Performed by.....Te S t...N O.- P 2 4 Date.l 2 2 9 $ ....... ..... Test Pit No. 1?.Z.___2_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.........C-lean medium - no water encounteG _ ------------•-•---------------• x 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 I'j 1Z 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate o ompliance has been issued by the arofJ ealth. gned_ PPlicationApproved By. ----- ---------------------------------------•---......--••---•---•-------------------- Date Application Disapprove or t e ollowing reasons:-•-----•-----------------•--••----------------------•-••---•------------•-•------------------•-•-----------••--- -----•--------•-----•---••-•-----------------------------------------•-----••----•------------------•-•----------•-----••-------------------------------------------------------------------••......... I Date PermitNo......................................................... Issued-....................................................... Date ........................... _ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ------------ --TOWN............OF....BARNS.TABLE..---'-...................................................... ApplirFa#ion for Bi-spaiital Workii Tomtrurtion Vamit Application is hereby made for a Permit to Construct (X ),or Repair ( ) an Individual Sewage Disposal System at: Hickory Hills Circle - No. 55. - Assessor's No. 121/52 --- _--y - ....... ..................................................................................•... ...-.............-----•-•-----. ...-- ---•--•-...... - - atio •A ss or t N9. Mrs. Charles �as'l�e` 2$ Bayview Rd , LOseryille� .MA __ Owner Ac ess a ....Paul T. Lebel ---......•..:----•--•----------•--•-•-•-- 32-Wianno_ Ave..,._.asterville�...T ... ......... . .. Installer Address Type of Building Size Lot......�5�35- S . f et Dwelling—No. of Bedrooms..........3 Expansion�Attic ( ) Garbage Grind r ` '' pa-, Other—Type of .Building _Reg'................ No. of persons-_.:-____bb_____•___--___--_. Showers ( ) — Cafete ) dOther fixtures ----------------------------•--- --• -- Design Flow.......55...................••100 gallons per person per day. Total daily flow_..__..._._....�9.5__....................gallons. W G WSeptic Tank=Liquid capacity.-_.---.__�allons Length________________ Width................ Diameter---------------- Depth................ x . Disposal Trench—No..................... Width.................... Total Length---- _..__-_ ... Total leaching area---_____.__-__.-----sq. ft. 1 $ ft p g 200 - -sq. ft. t n Seepage Pit No_____________________ Diameter...____._...___ De th below inlet__5 .____.__._-_. Total leachin area__.__.._.___ Z Other Distribution box ( X) Dosing tank ) Test No. P2745 I2/29/$3 Percolation Test Results Performed by -------------------••-•---••••-----••-•••-•-••••--•-------•--•- Date---------------------------------------- aTest Pit No. i' '�.._._2_minutes per inch Depth of Test Pit.................... Depth to ground water--__•----_______--___-_. G Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water..............__•_--_-_- RS -----------•--------••---••-------------=-----••-----------------------.............--•--- .......__..:...... ------- •---------•----------------••-- 0 Description of Soil...._....clean medium sand - no water encounted x ----------------------------•--••------.....--------•-•--•-•--------------------------------------•------............................................... ••------------------------- _----------- ---•-•-- ---------------------------------- -------------------------- ------------------- --- : ---------------------------- U Nature of Repairs or Alterations—Answer when applicable............................................................................................... -•-----------------------------------------••---•--------•--------------------------............--•---•-•--•---•----••------------•----•----•--•--- -------•----•--••--••-•------ .-.....-••-•---' Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITI 1Z 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate o ompliance has been issued by the board of health. ��• igned.................................................--------------.....---•--•-•------•- •- _.... Date Application Approved By �" rr�� - --- •----• •--- - f__-r .9 Date-------------- /� Application Disapprove or� e f ollowing reasons:--------••---------------•---•-•----•-------------------•-----•--•--•----- • --•-----.._..------•----- r -•-•-•••................... f..__._....... Date Permit No... •-.... Issued---------------------------------•------•-............ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .................TOWN............OF..BARNSTABLE................................................. Cardgfartttr of (gampli atto 1 8tt1 TO C R IFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )THIS P Le e Lot No. 55 — 121/52 Installer at ---------------------------- -------•----- -------- has been installed in accordance with the provisions of TITLE j of The State Sanitary Co -mae ribed in the application for Disposal Works Construction Permit No._r_`>__`r,�_------__------------ dated__1-------------------------------------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM-WILL FUNCTION SATISFACTORY. DATE ��a'L '.......--....... Inspector--•-------,`"' J•----•-----------------------•------•-•--•---•-•----........ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF EALTH No. FEE..).................... Permission is hereh}� anted 'r� / ! f--•--•--•-•---•-----•-•............................... ....... to Construct_ �p�rt ) axi�Indiv�rlual S� ag�'D> SA atNo....................yam r. ..........................- -�-...-...... . i-_ .. ��'�'-�-� Street as shown on the application for Disposal Works Co 'ruction Permit No............. ...:............................:......... _,�w e I . ......._... _:_-•---•-•---_--..........................................--•---------------•..--- Board of Health DATE--------- -----------------------------•----•--------------•--••-•-•---....:_ FORM 1255 HOBBS & WARREN. INC., PUBLISHERS 51NGLr-- FAMILY N. ►JD -GAR.BAGE 62jNDE2 pialt_.� FLoW s I10x 3 - Z,306.PG? 5EPTAG TAQW- = z3ox150% =1495G.P. Q. U�6- 1 000 015Po5AL PIT v5E 1 vo0 COAL. sl�C t 5%DG.W/At.t_ A¢.EA = 15o 5.F X •.2.5 s 375 G.PR BOTTOM AREA$ . Ir c 5 F• 9y v , o 5 o G. o P> 5 5.F A I \A ' 'TOTAL.. DES►GN * ,c;-25 G.P�- , -TOTAL_ DA►►-Y FLov! = 33oGRD PErzcot~AT►ON RATEI I''IN 2MtN 09-L65 ,N 1. Q /�/•o i y4o ✓. ,ST, `1` ,.l-►.a.r.,►4� t P��N OF 97• ��EXP NALA , ly MLLIAM n••7., o B 9 S' C. JONES 9Z y r 1. -+1:• r, 25100 -� A f o To P FND= /GC•o4 loon tNv. GAL. .�v�ac.._ 6�X• INS. 95.8 $�PTtG Z r I Ooo t N�( 9f G TAN K LEAGII INV. INV. PIT �LF.rL✓ W I T H , 9s Z 9S IP/q•1 Vi. WA SK 6 D 6To Nfa , CEz-rIFtao pLoT PL.AIJ PRoFILG t,o C 4"t►o NGam- �. Wo' SGALE `jcALE >. . SATE �./ 8 P►-A N R E I=r= t4 GE S C E c�T►F•Y T H A'� T H E 'E-'��T. Fc�l.D. 5No µ(N �. LNER.EoIJ GOMPL`(5 WITN"TNE 'SIoELIWGr ,L.OT A W P S6T5ACK 9.6Q01R.EM6NTt�' C) 1`4 "TvWN O;= 13.&Z,l -MOLE AND 115., 1_oGp.TED 'W ITN►4J TH ; .000 PL.t>.I P4 DA-T 5 � '� BAxTE Q.a W YE INC. RE6 I S�EQ6'� LAu o S u Z.v E�(oeS 'Tull PI.AtJ 15 Norr 4n5r_p old AN o3T{"c2.VIIr.t.F k�A-SS• I>JS-r-R,�MEN-r 5v2VeY �--T AS 01:rSET5 6Uout3> NoT-D E`U 5 E 0 TO 0 e-T e F.A I N<` L o"r -I I-I E.�j A P P L I G A,►-1 /v�,�s, 4 y. 44, i,l�/�,��LGI