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Home My WebLink About0218 HICKORY HILL CIRCLE - Health 218 Hickory Hills Circle Osterville - A= 121-043 Al Commonwealth of Massachusetts t Title 5 official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 218 Hickory Hills Circle Property Address Mary Ducas Owner Owner's Name information is required for every Osterville MA 02655 07/02/12 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.Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Michael Kellett use the return Name of Inspector .key. ' Aardvark Environmental Inspections Company Name r�S , PO Box 896 Company Address East Dennis MA 02641 Cityrrown State Zip Code 508-385-7608 SI 3742 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this addressind that this information reported below is true,accurate and complete as of the time of the inspection.Thei6spect$n 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 by the Local Approving Authority 07/05/12 Inspector's Signature Date i The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. �\ t5ins-11/10 Title 5Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts _ W Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 218 Hickory Hills Circle Property Address Mary Ducas Owner Owner's Name information is required for every Osterville MA 02655 07/02/12 ' page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary:Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 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: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined"(Y,N, ND)for the following statements. If not determined,"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 218 Hickory Hills Circle Property Address Mary Ducas Owner Owner's Name information is required for every Osterville MA 02655 07/02/12 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y '❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): 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 El Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh wYTB•'i ii i jive 5 011 11061 inspeeticn Ram.Subsufiace Sewage Dtspmai system•Page 3 01117 Commonwealth of Massachusetts L F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments a� 218 Hickory Hills Circle Property Address Mary Ducas Owner Owner's Name information is required for every Ostervil►e MA 02655 07/02/12 it page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier,if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal 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 1/day flow t5ins•11/10 •Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 ' f , _ .r Commonwealth of Massachusetts g W Title 5 Official Inspection Form` Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ' . 218 Hickory Hills Circle r �• Property Address _ Mary Ducas Owner Owner's Name information is required for every Osterville - MA >; 02655 ,07/02/12 t. page. City/Town :r ' State 'Zip Code.. --Date of Inspection B. Certification (cont.). ; Yes No. ,, _. F, s1 yRequired pumping more th64 times in the last year NOT due to clogged or ® - of structedl3ipe(s). Number oftimes pumped " b _., e ; a ❑. Any portion of the SAS,cesspool or privy is below high'ground water elevation. f -:Any portion of cesspool or privy is within 1004eet of�a surface water supply or a `+❑' ® tributaryto a surface water supply. 4: ❑ _ �® ' Any'portion,of'a cesspool or privy is within a Zone 1 of a-public well f ` El ®' Any portion of a cesspool orprivy is within 50,feet"of a private water supply,well. ❑. ®" .,Any portion of'a cesspool or'pnvy Is less than 100 feet but greater than 50 feet ti `• • from a private watersupply well with`no acceptable water quality analysis.-[This system passes if the well'water analysis,performed at a DEP.certified' ,'laboratory,for fecal coliforin bacteria indicates absent and the presence •e f of,ammonia nitrogen and nitrate nitrogen is equal to or less than's ppm, ; provided that'•no other failure criteria are triggered.A copy of the analysis �.' and chain of custody.must be attached to this form•]` 1 The system is a cesspool serving a"facllitywith a;design,flow of 20006pd-El F .a. 10,000gpd. it #Y `. "' a , The system fails I have determined that'one or.moreof the above failure j criteria exist as described in 310 CMR A 5.303,therefore the system fails.The. system owner should contact th`e Board of Health to determine what will be "; ` necessary.to correctthe failure f E) Large Systems To be considered a large system the system must serve a facility with`a, design flow of 10,000 gpd o 1.5,000 gpd.. m For lar e s-stems;,you must=indica16 either"yes"or"no"to"each of the following,in addition to the g y f questions in Section D.- Yes No .. ,r.• gam. " °> .� t nu r..� �,- Y `• ' P. •� • ❑'� ' � ❑ � ,the system is within 400 feet of a surface drinking water supply , ' the s`Jstem is within 200 feet of a tributa toYa surface drinkin water su I� ❑ ❑ Y .. th r . r 'X, ry . 9 pP Y - e system is located in a nitrogen sensitive area,(Interim,Wellhead Protection. ' El ❑ $Area-.IINPA)or a mapped Zone.h of a public water supply well r " If,y6u have answered "yes"pto 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, w t5ins•11/1d t 3Y ". , Title 5Official Inspection Form.Subsurface Sewage Disposal System•Page,5 of 17 y , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 218 Hickory Hills Circle Property Address Mary Ducas Owner Owner's Name information is required for every Cisterville MA 02655 07/02/12 page. Cityrrown 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? El ® Have large volumes of water been introduced to the system recently or as part of this inspection? . ® El available as built plans of the system obtained and examined? (If they were not available note as 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)] 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 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form.-Not for Voluntary Assessments 218 Hickory Hills Circle Property Address Mary Ducas Owner Owner's Name information is required for every Osterville MA 02655 07/02/12 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 4 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)): Detail: Sump pump? ❑ Yes ® No current Last date of occupancy: Date Commercial/Industrial Flow Conditions:, Type of Establishment: r Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t51ns•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form. Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 218 Hickory Hills Circle Property Address Mary Ducas Owner Owner's Name information is requiredequired for every Osterville MA 02655 07/02/12 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes,attach previous inspection records,if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts a W Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 218 Hickory Hills Circle Property Address Mary Ducas Owner Owner's Name information is required for every Osterville MA 02655 07/02/12 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components,date installed (if known)and source of information: 20Years Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.5 feet Material of construction: f ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints,venting,evidence of leakage,etc.): Septic Tank (locate on site plan): Depth below grade: 0.8 p g feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑polyethylene ❑ other(explain) If tank is metal,list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1,000 gal 3" Sludge depth:. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 d ' Commonwealth of Massachusetts + Title 5 Official Inspection Form Subsurface Sewage Disposal'System Form-Not for Voluntary Assessments 218 Hickory Hills Circle Property Address ` Mary Ducas Owner Owner's Name a information is required for every Osterville MA 02655 07/02/12 ` page. Citylrown State`, Zip Code Date of Inspection D. System Information (cont.) • d Septic Tank(cont.) } Distance from top of sludge to bottom of outlet tee or baffle 29' i 2" Scum thickness Distance from top of scum to topofoutlet tee or baffle 6�- Distance from bottom of scum to bottom of outlet tee or baffle 16" • How were dimensions determined?`" Measured Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): ` The tank was sound and tight with tees in place and liquid at outlet invert. Grease.T rap,(locate on site plan): i y Depth below grade: feet Material of construction: ❑ concrete -„ ❑ metal ❑ fiberglass .,❑ polyethylene ❑lother(explain): { f. d 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 s t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 I ' i • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 218 Hickory Hills Circle Property Address Mary Ducas Owner Owner's Name information is required for every Osterville MA 02655 07/02/12 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): 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 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 t5lns•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 218 Hickory Hills Circle Property Address } Mary Ducas Owner Owner's Name information is required for every Osterville MA 02655 07/02/12 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) t. 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.): There was no box present. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 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: t5ins•11/10 Title 5 Official Inspection Foam:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts v Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 218 Hickory Hills Circle Property Address Mary Ducas Owner Owner's Name information is required MA 02655 07/02/12 requiredd for every page. City(fown State Zip Code Date of Inspection D. System Information (cont.) 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.): This system has a 6'W precast pit surrounded by 2'of stone .The pit had 8'of liquid with a stainline 20'above,the liquid. Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): . Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 r Commonwealth of Massachusetts 4 Title 5 official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 218 Hickory Hills Circle Property Address Mary Ducas Owner Owner's Name information is y required for every Osterville MA 02655 07/02/12 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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.): t5ins•11/10 Tile 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form ws Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 218 Hickory Hills Circle Property Address Mary Ducas Owner Owner's Name information is Osterville MA 02655 07/02/12 required for every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system,-including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.Locate where public water supply enters the building.Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 i Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 218 Hickory Hills Circle Property Address Mary Ducas Owner Owner's Name information is required for every Osterville MA 02655 07/02/12 ' page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 20.0 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record L' 1 If checked,date of design plan reviewed: pate ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with.local Board of Health explain- ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database -explain: You must describe how you established the high ground water elevation: USGS maps show an elevation of over 20.0 feet. Before filing this Inspection Report, please see Report Completeness Checklist on. next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 n Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 218 Hickory Hills Circle Property Address Mary Ducas Owner Owner's Name information is required for every Osterville MA 02655 07/02/12 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C,D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file i t5ins•11/10 Tale 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 _ S MAP N0. "2 PARCEL 1, `_ I �A�Q Niol% M b1I. i AGE ��8 A IZI � 4-3 IM. S, 7 . L L E N�.A q, E A D D R E IUILD[ R DR DAT E C0MPLIANCE 1SS.UED C, (2CC,(Z� to No....47--7-• Fizic;L.................. THE COMMONWEALTH OF MASSACHUSETTS jb_1�3 BOAR® OF HEALTH .... .O F....................................................................................... Appliration -fur Uiupuual Works Tuttotrurtiutt Vrrufil Application is hereby made for a Permit to Construct (x ) or Repair ( ) an Individual Sewage Disposal Sys em at: Hickory.3111B...Ctr............................ ..........#39......Q.5te X ae a.9.s.......................... Location-Address or Lot No. ...............Ja.me.s...P....L.Alioe---L-- Baker...--=----- .......24..Aspen..J ay.,....Oa ervillt.---------------------- a Owner (� j 1 Address----------------z5d.L .......�-h-1-�=�............................................... ...........Cg,-.-L--,Er.V,_.J- ............................................................ Installer Address dType of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms________________ -_.----__-Expansion Attic ( ) Garbage Grinder ( ) ...._... P.,., Other—Type of Building ___________________________ No. of persons..........3--------------- Showers ( 2) — Cafeteria ( ) Q' Other fixtures ------ ----------------------- - W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons. x0 Septic Tank—Liquid capacity_/-0.0tallons Length................ Width............---- Diameter---------------- Depth._..............Disposal Trench—No. .................... Width.................... Total Length-------------------- Total leaching area--3-f-Q.---_-sq. ft. Seepage Pit No..................... Diameter------4__.......... Depth below inlet---&i___........ Total leaching area._-_---.--.--_-_sq. ft. z Other Distribution box ( ) Dosing tank ( ) a Percolation Test Results Performed bY-------------------------------°--------------------------------------- Date-------------------------------------- Test Pit No. 1................minutes per inch Depth of "Pest Pit.................... Depth to ground water-...._---.---.------.--- f=, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------ -----------------------------------------------------------------------------------------------------•------------------------------------------------------- 0 Description of Soil---------------------------------------------------------•------------------------------------------------------------------------------------------------------------ x W --------------------------------- -------------------------------------------------------------------- ---------------------------------------------------------------------------------------------- VNature of Repairs or Alterations—Answer when applicable------------------------------------------------------------------------------------------- -----------------------------------------------------:---------------------------------------------------------------- -------------------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article NI of the State Sanitary Code— The undersigned further agrees not to place the system in operation.until a Certificate of Compliance has been issued by the board of health. 41_ Signed . ....... " --------------------------- .f - Date Application Approved By. PP PP A rw ate Application.Disapproved for the following reasons----------------------------- ----- -----------•------------------------------------------•--------------------------------------------------•-•--•------•------------------------------•...--•-----•---------------------------••-•--•----- Date PermitNo........................................................ Issued........................................................ Date No......................... Fuses :...................... THE COMMONWEALTH OF MASSACHUSETTS } BOARD OF HEALTH _.... . ._ ... . ................OF...................................................................................---.-- Applirtttiun -fear Riip ial Workii Towitrnrtion Prrutit Application is heresy made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ------- Location-Address or Lot No. ---- ------ -------- ---- --- -----•--••- Owner /� Address -----•--------- •-------- .................................•------•------•------- Installer Address Type of Building Size Lot----------------------------Sq. feet U Dwelling—No. of Bedrooms--------�_______________________________Expansion Attic ( ) Garbage Grinder ( ) PL, Other—Type of Building ............................ No. of persons......3------------------ Showers Cafeteria ( ) Q' Other fixtures ---••---------•-•------------- - W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons. WSeptic Tank—Liquid capacity/_64.6--gallons Length----_--------- Width................ Diameter---------------- Depth---------- x Disposal Trench—No-____________________ Width..........._-------- Total Length-------------------- Total leaching area--_,.3: d-_-_sq. ft. Seepage Pit No--------_------------ Diameter___..._fa1..... Depth below inlet.......(........... Total leaching area.--_--__--_--____sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Resul_s Performed bY---------- ---••--------------•---•--------••••--•-----•-•----------•----- Date--------------------------------------- aTest Pit No. 1..............__minutes per inch Depth of Test Pit.................... Depth to ground water..-.-_--------.--..-..-. (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.-._---.--.---.__--.---. 04 ----------•---•--------------•-------...---•----•-----•••-------•••-----------._...-------....••----......................................................... 0 Description of Soil................................................................................................. ......................----------------------- ------------------_-- V ------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------- W ------------------------- ------------------------------------------------------------------------------------------------------------------------=--------------------------------------------------- VNature of Repairs or Alterations—Answer when applicable-----------------------------------------------------------------------------.-.-.-:-.-_-.---... -----------------------------------------------------------------------------------------------•------------------------------------------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed ........epaA..................................................._�-- ....-••---•----•-•--------_...-- /. �•^ /DateApplication Approved BY l -"'/, Application Disapproved for the following reasons-------------------------------------t ----------------___------------------------------------------------------ ---•---•----------••--...------•-------------•- ----------------------------------------------------•--------------------------------------------------------------------------------------------------- Date PermitNo--------------------------------------------------------- Issued......................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH r ` �� -,�.,, r{ � ....OF.c..... ..... .... .� d....... . .... ................. ............ C�rrtif iratr of Tnmphaurr 7�IS I PTO CE TIFY,&, 4t, e Individual Sewage Disposal System constructed ( ) or Repaired ( ) T • I � L- i by f ��^ -�'� - --- ...............= ----- --•�-� ----------- S';"` C"" �� Insta}eYr fw ' •`, a at ---- has been installed in accordance wi the provisions of Article XI of The State Sanitary Cnde ' • des 'i. d • the application for Disposal Works , nstruction Permit No------------- l._7___-____ dated.._' �_ ��__._____ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL UNCTI N SATISFACTORY. --- -------------------------•-------- Inspector.---------�---------------------- ------- - ---------....--•----'---- THE COMMONWEALTH OF MASSACHUSETTS BOARD O HEALTH TU '� �w=-T��'�..O F....... ... .......'!' :. . - �---- No.----- I� FEE --- �i� � 1 vrk � n ' rtinnrrntit •, Permission is hereby granted...... G ----------- ------------------------------------------------------------------------- tic) Constr ( � or Repair ( fan I dividual Sew ' e is o'sal .�y9 em at No.-- r_ ,J--- --------- -- bezi/PC2 r '� f - _..� - / �r -�-- Street jf / as shown on the ap lication for Disposal VVoronstruction Pe. i No._____ _____i______: ated__. �.,1-. .�� ------ ordo I a DATE. /r/p �/ ---------------------------- FORM 1255 HOa9BS IN WARREN. INC.. PUBLISHERS �� ((�� .._.-- 'S �� T !1� L Est, r � . ,i �-. ¢- 1 . � �� ,