HomeMy WebLinkAbout0201 HICKORY HILL CIRCLE - Health 201 Hickory Hill Circle
Osterville P
A = 121 032
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
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TITLE 5
OFFICIAL INSPECTION-FORM-NOT FOR VOLUNTARY AS
SUBSURFACE SEWAGE DISPOSAL SYSTEM F RAFECEIVED,
PART A
CERTIFICATION JUL 0 8:2002
Property.Address ' / A& r a_U40 TOWN OF BARNSTABLE
HEALTH DEPT.
Owner's Name:
Owner's Address: / �A
Date of Inspection: �� f
Name of Inspector: lease print
Company Name.
Mailing Address: MAP � t
L
Telephone Number:SCO .'-7-7 PARCEL. ' - --
CERTIFICATION STATEMENT LOT '
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. L am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
Passes
Conditionally.Passes ..
Needs.Further Evaluation by the Local Approving Authority.
ails
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 I0,000
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.
Notes and Comments '
****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.
G
Title 5 Inspection Form 6/15/2000 page I
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Page 2 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: / n,
Owner•
Date of Inspection: �200D-
Inspection Summary: Check A,B,C,D or E%ALWAYS complete all of Section D
E
A. ystem Passes:"
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I have not found any information which;indicates that any of the failure criteria described in 310 CMR
15:30_5 or in310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
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Comments:
B. System.Conditionally Passes:
One or moretsystem components as described in the"Conditional Pass"section need to be replaced or
...7 re aired"The-s stem�u'on com ]etion of the replacement or repair, as approved b the Board of Health will ass.
P t Y01, > RP, P P P PP Y p
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 Tess 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
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:
2
Page 3 of 1]
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY'ASSESSMENTS
SUBSURFACESEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART'A
CERTIFICATION(continued).
Property Address: a0l
Owner
Date of Inspection: W D-
C. Further Evaluation is Required by the Board of Health:
Conditions.exist which require further,evaluation.b.y 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.Aeter.mines.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,l 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 welt..'
_ 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 and volatile organic compounds indicates that the well is free from pollution from that facility 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:
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Page of 11
OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE`SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
Owner:
Date of Inspection:
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the-following for all inspections:
Yes N
t _ Backup of sewage into facility or system component due to overloaded or'cI"g�ed'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 ''/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 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.
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 ofa'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 coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of,ammonia
nitrogen and nitrate nitrogen.is equal to or less than 5 ppm,provided that no other failure criteria
�Vo are triggered. A copy of the analysis must be attached to this form.]
(Yes/No)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•
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)
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.
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Page 5 of 1.1
OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIONFORM
CHECKLIST
Property Address:
d
Owner•
Date of Inspec v d0, �—
Check if the following have been done. You must indicate"yes"or"no". as to each of the following:
Yes �o ,
Pumping..information was provided by the owner;occupant,or Board of Health: ;
v---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
_ _Z 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? 4 `
_ Were all system components,excluding the SAS,located on site
w
t/ 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
).pro.vided 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:
Yes no
— Existing information. For example,a plan.at the Board of Health:
_V_ 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(3)(b)].
5 .
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Page.6 of 1 l
OFFICIAL-INSPECTION-FORM_NOT FOR VOLUNTARY ASSESSMENTS
. .SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION:FORM
PART C
SYSTEM INFO ATION
Property Address:
Owne
Date of Inspection: C} 0-
FLOW CONDITIONS
RESIDENTIAL G� •�
. .Number of bedrooms(design): : Number 'of bedrooms(actual):. 3.
DESIGN flow based on 310 Clv1)t 15.203 (for example: 11:0 gpd x#of bedrooms): y �
-Number of current residents: /
Does residence.have a garbage grinder.(yes or no 6-
Is laundry on a separate sewage`system (yes or no :[if yes separate inspection required]
Laundry system inspected(yes or no):c,.
Seasonal use:.(yes or no):. .f,{?'.
Water meter readings, if available(last 2 years usage(gpd)):
Sump pump(yes or no) h
Last date of occupancy: �vxo atat
COMMERCIA`L/INDUSTRIAIS--�,
Type of establishment:
Design flow(based on 310 CMR.15.203): gpd
Basis of design flow(seats✓persons/sgft,etc.): : ..
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no):_
Non-ganitary waste discharged to the Title 5 system(yes or no)::_
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records iL
Source of information:. An
Was system pumped as part of the inspection(yes-rno):
If yes,volume pumped: gallons--How was quantity pumped determined?
Reason for pumping: .
TYPE OF SYSTEM
c tank,distribution box,soil absorption system�te 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):
proximate age o all co .pon nts,.date installed(if known)and source of information:
Were:sewage odors.,detected when arriving at the site(yes or no): --
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Page 7 of 11
OFFICIAL INSPECTION FORM.-NOT FOR VOL;UNTARY;ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
'SYSTEM:INFORMATION(continued)
Property Address: .C ✓
Owner Frlolftov
Date of Inspection: ��
BUILDING SEWER=(locate on site plant!'-
Depth below grade:
Materials of construction:_cast iron _40 PVC_other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK (locate on site plan)
Depth below grader_
Material of construction: concrete_metal_fiberglass polyethylene
—other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a.copy of
certificate)
Dimensions:
Sludge depth:
Distance from to of sludge to bottom of outlet tee or baffle: .
P � 3
i
Scum thickness:/
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
How were dimensions determined:
Comments(on pumping recommen attons,if let and outlet tee or baffle condition,structural integrity, liquid levels
s related to outlet invert evidence of leak ge,etc.): )
L� � ✓ ���
of
GREASE TRA` �locate on.site plan)
Depth below grade:
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:
Comments(on pumping recommendations, inlet and outlet,tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage,-etc.):
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Page 8•of l l
OFFICIAL INSPECTION;FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
'SYSTEM INFORMATION(continued)
Property Address: (?
a ,4
Owner:
Date of Ins ectio rJ
P
TIGHT or HOLDING TANK/(tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass_polyethylene other(explain):
Dimensions.
Capacity: gallons
Design Flow: gallons/da
y
Alarm.present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches, etc.):
DISTRIBUTION BOX: y* (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert-42",&'ohz;tj
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of
jzkkage into.or out of box, etc.): _
PUMP CHAMBER(locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(.yes or no):..:_
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
8
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY-ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM-INFORMATION(continued)
Property Address: a C u
Owner tslu
.
Date of Inspectio . 2 �
SOIL ABSORPTION SYSTEM(SAS):. locate on site plan,excavation not required)
1f SAS.not located explain why:
w
Type
aching,pits, number:
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,
et t
P �
4
CESSPOOLS3/J1k-(cesspool must be pumped as part of inspection)(locate on site plan)
Number and�l 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 or no):
Comments(note condition of soil,.signs of hydraulic failure, level;of ponding,.condition-of-vegetation;etc.):
PRI`N;// (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.):,
9
Page 10 of l 1
OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
* 4.
Property.Address: o - C �D
Owner`s 4 o
Date of Inspection.
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.
O I
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Pdge 11 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner:
Date of Inspeetion:
SITE EXAM.
Slope
Surface water
Check cellar.
Shallow wells
Estimated depth to ground water Ud feet
Please indicate(check).all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design.plan'reviewed:
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:
11
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Permit Number: �y Date:
Completed by:.
HIGH GROUND-W.A,T,ER LEVEL COMPUTATION
Site Location: .20
Lot N'o.
Qwner: c5 jr Address:.
Contractor: C Address:__ �-al
STEP. 1 . Measure depth to water table
to nearest.1./10 ft..
... .Dateil- ,, �Z '�1
month/day%year
STEP 2 Using.Water-Level.Range Zone
and In.de.x 1NeII::M:a.prlocate
site and determine:
O APPro.priate.index well-..................... .
ill fV Z
OWater-level range zone......:.......'-. -
STEP,;3:: Using monthly.repo.rt-,.-Current
Water Resources Conditions"
determine current-depth to
water level for•indez well .........................
month/year
STEP. 4.. Using.Table.o.;.Water-Level Adjustments i
for index well (STEP 2A),.•curr.ent depth
to water level fo.r index wel.l (STEP 3):,
and water-level zone (STEP 2B)
determine water-level adjustment ............ �j
STEP .S stimate depth to:high water
by subtracting th.e water-;
level adjustment-(STEP 4)
from measu.red.depth to.water
level-at site.(STEP 1) .__....-.. ................................................... ........... .............. 17.I
Figure 13:-- eProo-�ucible uOl PU'LutIOR iGrm.
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LOCATION SEWAGE PERMIT NO.
vILLACE
a A -= i 2 I 03-L fc�J p
INS A L M,fs
S NsME i ADDRESS
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1 � 11� Q.��nuS � �r1�5
® UILDEIII OR OWNER
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DATE PERMIT ISSUED 23
DATE COMPLIANCE ISSUED / ��
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No. .3._...� Fps...�/2..................
THE COMMONWEALTH OF MASSACHUSETTS
_ BOARD OF HEALTH
..........I ...............OF......
� .1 .�`fQ -
ppliration for Bhopa al Worko Tomitxurtinn Frrutit
Application is hereby made for a Permit to Construct (L/or Repair ( ) an Individual Sewage Disposal
System at:
................ � kJ :y_._._ ,.1.1....c f�d.r.........•........... .......-:-••---------- Pt......9....................................................
Locatio -Ad res or t No.
................ .� .5i.a�_ ..... ,�a �n�...Via.. �. ................................... _�,� ..-
Owne p� Address
a ..% .._�.R 1. G .---•---------•----------•----•-- --------------------ts�----------•-•--••---•---•----•---•---•-•------•--
Installer Address
U Tv pe of Building Size Lot________lS !��---Sq. feet
Dwelling --------
-No. of Bedrooms---.____ ...........BuildingOther—Type
No. of persons._____.3__________________ Showers (�) — Cafeteria (�(
dOther fixtures ................................................. ................... .............................................................
Design Flow.......... .......................gallons per person per day. Total daily flow----------3_3.0...................gallons.
WSeptic Tank—Liquid ca$PaC�ity.y, allons Length__.,/.19..... Width...._4_�_ Diameter-------Cf..... Depth................
x Disposal Trench—No. ..N- _ Width.................... Total Length.................... Total leaching area. .---sq. ft.
Seepage Pit No_____________________ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box (� Dosing tank )6 C
Percolation Test Results Performed by....... � 2Cr�t _e...._ 2 .?P �!1__ _..__
G. � � --•--. Date-------- Ali
,.a Test Pit No. 1_____ _______minutes per inch Depth of 'Test Prt___.__.�_____._..__ B'epth to ground water.___.w.._._._.__.
rX4 Test Pit No. 2....L.!2-minutes per inch Depth of Test Pit....../2...... Depth to ground water........................
l s$
O Description vo�f S,Qil--� � l 1�-ak .L----...�e�.�¢�------------�-- j ------r e.........S I"�
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 TI'i 1E 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issu/'d the
bb'o/ard of health.
Si ed..�,J_ of �1< �(j � ................... ------ ..��
V U G o
Application Approved BY--- ---' •. ---------•------------•-----•-----------•--••--•--------------------•------•-
Dat......-••••----
Application Disapproved Jo the following reasons:---•---------------------------------------------•-•--••--•---------------•--------------••......--------------
-•......•-•---•-----------------•------•---•---•-•...-•-•---•--.........••-•---•--•.........-•-...-•-••--'-•....••••-•••.....-•------•---•-----•-----••-•------•---•---•--•••......-•-----•••------...__
Date
PermitNo......................................................... Issued.......................................................
Date
ZIA
' No Fzx...7".........................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..�..( 1;<<J ...............OF.....
Appliration for Bi-oposal Works Tomitrurtion Prrutit
App
lication is hereby made for a Permit to Construct (V or Repair an Individual Sewage Disposal
System"a't:
C tij� k Lot
............................................I....................................................
Locall.Ad es r of No.
................ . ..................... ......................................... . ...............................................
)
Own Address
.......... ...... 1.ft
Rt,...................................... .....................................0
Installer Address
Type of Building Size Lot......I...5.7.12'd.. Sq.4ft
.........
U
—No. of Bedrooms.._.._, _Expansion Attic 014'
Dwelling ........................... Garbage Grinder
x
Other—Type of Building ..Ao.P&..A.17.... No. of persons......-5.................. Showers (,7-) — Cafeteria
Other fixtures .
---------------*--------------------------*......*-----------------------*----------------------------------------------*----------------------Design Flow........�5.,5. ..................*-----gallons per person per day. Total -0 daily low..........33.0...................gallons.
9 Septic Tank—Liquid caVaf ity '%--I----- -- allons Length---M..... Width..... Diameter-------I*..... Depth................
Disposal Trench JV. Width.................... Total Length_._................. Total leaching area.__A.4_.6_.__sq. ft.
Seepage Pit No---------------�4'Diameter.._..___.._......... Depth below inlet................._.. Total leaching area..................sq. f t.
Z Other DistributionDosing tank
Performed by. nl�?02(........Percolation Test Results willd e..... Date........
J.1 Test Pit No. I.....4_.�t_minutes per inch Depth of Pit.......t4�....... 110opth to ground wate De t r
0 -----N
f14 Test Pit No. 2....!!_.;;!tminutes per inch Depth of Test Pit....../ ....... Depth to ground water...... _
P4 . .......................................................... .............t.............?..........0 ......
--------------V........**---------------
Description of �pil... ........ .......... ....P.I.&C,7 .............................
................ ...... ...................................................................................
................................................................
........................................................................................................................................................................................................
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 TIT 1Z- 5 of the State Sanitary Code— The undersigned furtner agrees not to place the system in
operation until a Certificate of Compliance has been issued by the boa of health.
--I----------
d...dWC ..................... .......
. .. ... ........
. ........Application Approved By.... .. .................................................................... ... .Y0
Application Disapproved BY
following reasons:............................................................................................Da.te..............
.....................................................................................................................1,1..................................................................................
Date
PermitNo......................................................... IssuedL.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD, OF HEALTH
........... OF....................................... ...............................................
(9rdifiratr of Tai'p-lia,trp
THIS 0 CE4?TIFY I hat the Individual Sewage Disposal System constructed (/Or Repaired
by............... •
..................... ...................
Z i-,,,..... ------*...........*------------------ ........*---------------------------------
ns ali
-,T....................................................................... .................................... /I........
at......... .......... - ------
I f T I T LE 5 of jhe State Sanitary Cp e des in the
has been installed in accordance with �ie provisions o.........
X dated_-_..._ ... .....application for Disposal Works Construction Permit . ............... -------------------------
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THE ISS;U N ?E OF THIS CERTIFICATE SHALL NOT BE CYONSTR 911AS A GUARANTEE THAT THE
SYSTEM W1 NCTION SATISFACTORY.
DATE.... I ..... ........................................................ Inspector....... .. ........I.............................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
fill AJ
...................OF............ ..
.........................................
FEE........................
Rsvos�a Vorkii Tonstr 4 Vamit
Permission is,hereby granted.......... �q.A?_.np.... ..............................................................................................
to Constr=t ((-4. orpepair an Individual Sewage Disposal System
at No. ........
eac...............................................................................................7
---- ------- ...............
Street
as shown on the appli on for Disposal Works Construction Permit No. I. ......4/ ........
..
................................ ... . ........................................................
Bo&rd of Health
DATE. ... .............................................................
OR'A 1255 HOBBS a WARREN. INC_ PUBLISHERS
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i LDREDGE ENGINEERING .CO IN �AyS,r�E
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