HomeMy WebLinkAbout0006 NATHANS WAY - Health 6 NATHAN'S WAY, OSTERVILLE
A = 122 052
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TOWN OF BARNSTABLE
LOCATION SEWAGE #
VILLAGE �6S ldZ4Ze— ASSESSOR'S MAP 6T LOT
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) (size)
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER� C �pu, �/.aA�tJ
6,14m �
DATE P
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
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L,OCL,TION 5EW4,G,E PERMIT QO.
VILLAGE ��71
- - - - - - - — 02 —OD -
1NSTaLLE.R 5_ DDRESS
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BUILDERS &DORE/SS
DATE PERNAIT ISSUED
DATE COMPLI &&ICE ISSUED : =��
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r,>y COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS John Grad
DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector
ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119
TeaTicket,Ma.
(508)564-6813
TRUDY COXE
Secretary
ARGEO PAULCELLUCCI DAVID B.STRUHS
Governor Commissio
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 7
PART A
19
CERTIFICATION
Property Address: 6 NATHANS WAY OSTERVILLE MAP 122 PAR 052
Name of Owner MARY DALEY
0
Address of Owner: 38 CAPTAIN DORE RD.S.YARMOUTH MA.02664
Date of Inspection: 312199
Name of Inspector:(Please Print)JOHN GRACI s ,
1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)
Company Name: John Graci Title V Septic Inspection
Mailing Address: P.O.Box 2119 TeaTicket,Ma.02636
Telephone Number: (608)664-6813
CERTIFICATION STATEMENT
I certify that I have personally Inspected the sewage disposal system at this address and that the information reported below is true,accurate
and complete as of the time of inspection.The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems.The system:
X Passes The inpection is based on criteria defined in Title V
Conditionally Passes code 310 CMR 15.303.My findings are of how the system Is
_ Needs Furtheiubmit
lu ion By the Local Approving Authority performing at the time of the inspection.My Inspection does
_ Fails not imply any warranty or guarantee of the longgevity of the
septic system and any of Its components useful life.
Inspector's Signature: � � Date:3/3199
The System Inspector shall a copy of this inspection report to the Approving Authority(Board of Health or DEP)Wthin thirty(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 Department of Environmental Protection.The original should be sent to the
system owner and copies sent to the buyer,if applicable,and the approving authority.
NOTES AND COMMENTS
THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING SYSTEM EVERY TWO YEARS TC PROLONG THE SYSTEM'S USEFULL
LIFE.
-revised 9098 Page 1 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 6 NATHANS WAY OSTERVILLE MAP 122 PAR 062
Owner: MARY DALEY
Date of Inspection:3l2/99
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated
are indicated below.
COMMENTS:
System passes Title V inspection
B. SYSTEM CONDITIONALLY PASSES:
_ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the
replacement or repair,as approved by the Board of Health,will pass.
Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not.
NO The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or
the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank
failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
NO Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health).
_ broken pipe(s)are replaced
obstruction is removed
distribution box is levelled or replaced
NQ The system required pumping more than four 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
revised 9/2198 Page 2 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 6 NATHANS WAY OSTERVILLE MAP 122 PAR 052
Owner: MARY DALEY
Date of Inspection:3/2/99
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.
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 ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
_ Cesspool or privy is within 50 feet of 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone 1 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 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,Method used to determine distance n/a(approximation not valid).
3) OTHER
nla
revised 9/2/98 Page 3 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 6 NATHANS WAY OSTERVILLE MAP 122 PAR 052
Owner: MARY DALEY
Date of Inspection:3l2/99
D. SYSTEM FAILS:
You must indicate either"Yes"or"No"to each of the following:
I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is
identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool.
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow,
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped nla.
X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
X Any portion of a cesspool or privy is within a Zone I of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well,
X Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality
analysis.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic ompounds,
ammonia nitrogen and nitrate nitrogen.
X The liquid level In the SAS is over the invert pipe,is in Hydraulic Failure. .
E. LARGE SYSTEM FAILS:
You must indicate either"Yes"or"No"to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and
safety and the environment because one or more of the following conditions exist:
Yes No
X the system is within 400 feet of a surface drinking water supply
X the system is within 200 feet of a tributary to a surface drinking water supply
X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone 11 of a public
water supply well)
t
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the
Department for further information.
i
revised 9/2198 Page 4 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 6 NATHANS WAY OSTERVILLE MAP 122 PAR 052
Owner: MARY DALEY
Date of Inspection:3/2/99
Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following:
Yes No
X Pumping information was provided by the owner,occupant,or Board of Health.
X 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 part of this inspection.
X As built plans have been obtained and examined.Note if they are not available with N/A,
X - The facility or dwelling was inspected for signs of sewage back-up.
X The system does not receive non-sanitary or industrial waste flow.
X The site was inspected for signs of breakout,
X All system components,excluding the Soil Absorption System,have been located on the site.
X 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:
X Existing information,For example,Plan at B4O,H,
X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)
(1 5.302(3)(b))
X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of
SubSurface Disposal Systems.
revised 912/98 Page 5 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 6 NATHANS WAY OSTERVILLE MAP 122 PAR 062
Owner: MARY DALEY
Date of Inspection:3/2/99
FLOW CONDITIONS
RESIDENTIAL;
Design flow:-=g.p.d./bedroom
Number of bedrooms(design): 3 Number of bedrooms(actual):
Total DESIGN flow: X39.
Number of current residents:I
Garbage grinder(yes or no):NO
Laundry(separate system)(yes or no): NO If yes,separate inspection required
Laundry system inspected(yes or no):M
Seasonal use(yes or no):JLQ
Water meter readings,if available(last two year's usage(gpd): n&
Sump Pump(yes or no): MQ
Last date of occupancy: nLa
COM MERCIALIINDUSTRIAL
Type of establishment: n1A
Design flow: n&gpd(Based on 15.203)
Basis of design flow: n&
Grease trap present:(yes or no):M
Industrial Waste Holding Tank present:(yes or no): NO
Non-sanitary waste discharged to the Title 5 system:(yes or no):MQ
Water meter readings.if available:n(a
Last date of occupancy: n&
OTHER: (Describe)
nLa
Last date of occupancy: Wa
GENERAL INFORMATION
PUMPING RECORDS and source of information:
THE SYSTEM WAS LAST PUMPED 3 OR 4 YEAR AGO
System pumped as part of inspection:(yes or no):NO
If yes,volume pumped nLa- gallons
Reason for pumping: nLa
TYPE OF SYSTEM
X Septic tank/distribution boxisoil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no)(if yes.attach previous inspection records,if any)
I/A Technology etc.Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other: n&
APPROXIMATE AGE of all components,date installed(if known)and source of information:
1976
Sewage odors detected when arriving at the site:(yes or no): MQ
revised 9/2198 Page 6 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 6 NATHANS WAY OSTERVILLE MAP 122 PAR 052
Owner: MARY DALEY
Date of Inspection:3/2199
BUILDING SEWER:
(Locate on site plan)
Depth below grade: ZLE
Material of construction:_ cast iron _40 PVC X other(explain)
Distance from private water supply well or suction line: TOWN
Diameter: Wa
Comments: (condition of joints,venting,evidence of leakage,etc.)
nLa
SEPTIC TANK: X
(locate on site plan)
Depth below grade: 2
Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain)
n/A
If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NQ
Wit
Dimensions: L 8'6"H 5'7"W 4'10"
Sludge depth: Z `
Distance from top of sludge to bottom of outlet tee or baffle: 2"_
Scum thickness:A
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle: A
How dimensions were determined: MEASURED
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,
etc.)
SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND RECOMMEND PUMPING SYSTEM EVERY TWO YEARS
GREASE TRAP:
(locate on site plan)
Depth below grade:
Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain)
nta
Dimensions: nLa
Scum thickness: nLa
Distance from top of scum to top of outlet tee or baffle:ji&
Distance from bottom of scum to bottom of outlet tee or baffle nLa
Date of last pumping: n& '
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,
etc.)
nLa'
revised 9/2/98 Page 7 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 6 NATHANS WAY OSTERVILLE MAP 122 PAR 062
Owner: MARY DALEY
Date of Inspection:3/2/99
TIGHT OR HOLDING TANK: NO (Tank must be pumped prior to,or at time of,inspection)
(locate on site plan)
Depth below grade: n& }
Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain)
nLa
Dimensions: n&
Capacity: n& gallons
Design flow: n& gallons/day
Alarm present: NO
Alarm level:jila- Alarm in working order:Yes_No_ NO
Date of previous pumping: nla
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
nla
DISTRIBUTION BOX: _
(locate on site plan)
Depth of liquid level above outlet invert:xi&
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or-out of box,etc.)
n&
PUMP CHAMBER: NO
(locate on site plan)
Pumps in working order:(Yes or No): NO
Alarms in working order(Yes or No): NO
Comments:
(note condition of pump chamber,condition of pumps and appurtenances.etc.)
nLa
revised 9/2/98 . Page 8 of 11
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 6 NATHANS WAY OSTERVILLE MAP 122 PAR 062
Owner: MARY DALEY
Date of Inspection:3/2/99
SOIL ABSORPTION SYSTEM(SAS): X
(locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods)
If not located,explain:
Wa
Type:
leaching pits,number: 1000 GALLON LEACH PIT
leaching chambers,number: -n&
leaching galleries,number: -nLa
leaching trenches,number,length: n&
leaching fields,number,dimensions: n&
overflow cesspool,number: n&
Alternative system: n&
Name of Technology: _n/a
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.)
THE LEACH PIT IS STRUCTURALL SOUND AND FUNTIONINC PROPERLY
CESSPOOLS: _
(locate on site plan)
Number and configuration: n&
Depth-top of liquid to inlet Invert: nla
Depth of solids layer: n&
Depth of scum layer. n&
Dimensions of cesspool: n&
Materials of construction: n(a
Indication of groundwater: Wa inflow(cesspool must be pumped as part of inspection)n/A
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
n/A
PRIVY: _
(locate on site plan)
Materials of construction:n(a Dimensions:WA
Depth of solids: n/A
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
Wa
revised 9/2198 Page 9 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 6 NATHANS WAY OSTERVILLE MAP 122 PAR 062
Owner: MARY DALEY
Date of Inspection:3/2/99
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes into house)
n/a
0C,
14A 2Sy
�c N�
revised 9/2198 Page 10 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 6 NATHANS WAY OSTERVILLE MAP 122 PAR 052
Owner: MARY DALEY
Date of Inspection:312/99
NRCSReportname: nLa
Soil Type: nLa
Typical depth to groundwater: n&
USGS Date website visited: n&
Observation Wells checked: NO
Groundwater depth:Shallow _ Moderate _ Deep _
SITE EXAM _ Slope
_ Surface water
_ Check Cellar
Shallow wells
Estimated Depth to Groundwater 12 Feet
Please indicate all the methods used to determine High Groundwater Elevation:
_ Obtained from Design Plans on record
X Observed Site(Abutting property,observation hole,basement sump etc.)
_ Determined from local conditions
_ Checked with local Board of health
_ Checked FEMA Maps
_ Checked pumping records
_ Checked local excavators,installers
X Used USGS Data
Describe how you established the High Groundwater Elevation.(Must be completed)
USGS MAPS AND CHARTS
revised 9098 Page 11 of 11
No. ................
�. THE COMMONWEALTH OF MASSACHUSETTS
d sue - ..... of ...--...
1 Appliratiun -fur Uhipu.iat Workii Tomitrurttutt Vanift
n) Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System' z'' � 1! Q ��
o(Y0 �� ................................. -•----------------------.-..--•-----------------•---------------------------••-•-------..
cation-A or I of �o-
...:........... ..�.---...--•-• •..................... ..--------••------- - ... • ---- ----• ....... --
r
a ` O/pn ......... _...Address-—•-VCR -••-•----•---------•-
Installer Address
UType uilding'- Size Lot............................Sq. feet
Dwelling—No. of Bedrooms------- -------------------------------Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building _---_______________________ No. of persons--__:______________-___-___ Showers ( ) — Cafeteria ( )
0.i Other fixtures ----------wry .
W Design Flow....... ............:.lJ._.__._ Mons per person per day. Total daily flow..._._.._.__._._�j-_0___�?_-_.--_--gallon}.
WSeptic Tank—Liquid capacit}!_-___� allons Length................ Width........_---._.- Diameter------.......... Depth----_-____-_---
x Disposal Trench—No--------------------- tli--•---------_"� tal Leng .__::__-_• __-- al leaching area-.3 Z__-�p'._ _.sq. ft.
Seepage Pit No.__.l 000__-�' = ''1e'ttw i et____________________?'."Total leaching area sq. it.
z Other Distribution box ( Dosing tank 12 1- `-7 e •
aPercolation Test Results Performed by-•_________________....................................................... Date---------------------------------------.
Test Pit No. 1----------------minutes per inch Depth of "Pest Pit.................... Depth to ground water---___-_-__----__-_---.
r3:4 Test Pit No. 2----------------minutes per inch Depth of.Test Pit.................... Depth to ground water---------------._____---
:; �; ri ;; -..-..
O _71-
Description of Soil �? ... L�7J �2 - �-,i �: ; a -
W
------------------------------------------------------------------------------------------------------------------------------
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 Article XI of the State Sanitary Code— The undersigned further agrees not to place the system it]
operation until a Certificate of Compliance has been issued by the kard of healt
j
Application Approved By---- - ---- ._ am-
= -..-
Date
Application Disapproved for the following reasons______________________________________________________________
________________•-•--•--------------•------------------------..._...._-•----------------------------........__._.._..----••-----•--...-•----.......-•----------------------•--.-..._..--•-----------
Date
PermitNo........................................................ Issued---------=----------- ----------------------------.....
Date
No......................... Fsa.../.....................
LTH
MASSACHUSETTS
` THE BOARD AOF OF
HEALTH,
.......OF........
. ; i2 � '�'
Appliratiun -fur Ripuiittl Works Tontrnrtion Vrrniit
Application is hereby made for
/aif Permit to Construct( ) or Repair ( ) an Individual Sewage Disposal
System at_: ,,/ "��— { ,!� � '
.......... ...••----•---••-•..................... /' .�L'
bca ..............................................sk..................................................
tion.Address or Lot Ylo.
.1-----•-------•--------
W O -ner /'�� dre ss
. ,
Installer Address
UType of,Building Size Lot----------------------------Sq. feet
Dwelling—No. of Bedrooms------- - -----------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
d Other fixtures ----------
Design Flow._.._.__'.... .............................gallons per person per day. Total daily flow--------------.__�-0 ........gallons.
WSeptic Tank—Liquid capacity/o_� allons Length................ Width.--------------- Diameter------ . . Depth.._-----_.-....
x Disposal Trench—N�o........�.........`Wi � ��tal Lengtlh_� 3/al leaching area--��0._Z-.sq. ft.
T Seepage Pit No.... .....-__a__ - ia?ne 4er.....................lie th beTifc�/ir%le __-______________._.Total leaching area._-----.__.......sq. ft.
2 Other Distribution box ( :)- Dosing tank ( ) O - �/- 2 F- - 7 G . 7 C
aPercolation Test Results Performed bY------- ------------------------------------------------------------------ Date---------------------------------------
,� Test Pit No. 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water...---._--_-.-._-.-__.
41 Test Pit No. 2................minutes per inch Depth of Test Pit.----_--___-___..._- Depth to ground water--.--.-------.------..__
- f �=--------•-•-----•--•-----------•-•-------------------•- _
O Description of Soil----- - = - o�/c. `�`' .. �� " �� x `= ---
-,�'[/� ----------------
- � -•-•------••-----•-----•------------------------------•---•--...-----......--------------------
r� --------------------------------- ------•-------------------------------------•--•------------------------------•-------------- -•-------------------•-•--------- ---------- _-------_----•--------
V 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 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;
/c
/ -----y ...... -----D--a-t-e
1 - i 1�/V _-.aC._-
-_Application Approved BY----- ----- . v - - ----------------------- ---- --
Date
Application Disapproved for the following reasons:................................................................................................................
•...............•-----------•---•---•--------•----•-••--------•-•--•----------•-•--......----••---------•..-----------............---.•--•----------•---. -----------------------------------------------
Date
Permit No........................................................ Issued........... --_--i- 2�
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O �HEALZ i
f �,u�•-� g ,
..................................... OF....../....................1'o t.....................................................
C9rdif iratr of Q.Tkomphattrr
THIS`IS TO�CERTIFI' Th tale Indivfidual Sewage Disposal System constructed (� or Repaired ( )
'���� r
Instal er
at ..... ... :.. �J - --------------------•-••---•-•--•-•--• ............................................................
has been installed in accordance with the provisions of Ar * XI of The State Sanitary Code as described-in the
application for Disposal Works Construction Permit No---- -------- - ............... dated....- ..-- --`..- L.._.__........
THE ISSUANCE OF THIS CERTIRCATE SHALL NOT BE CONSTRUED AS A GU RANTEE THAT THE
SYSTEM WILL FUNCPr SATISFACTORY.
DATE----7----4�-------------------------------------------•--•-•--•-------- Inspector.--"!- - ..... --------------------- ----- -----------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEALTHY
( ............ T. OF.. r . . ............ ..... .--------- . ------------.•No. '�---s FEE_........................
R-puiittl urk� ( utr'�trtHt rrn it
Permission is hereby gra -----------------------------------------/ ----------------F `'...
to Constru=t> (_*_ or Repair ( ), n;;;,' ndivid I Sewage�Disposl System
at No. �� �. �� .,,�gs.�� k...`.
Street
as shown on the application for Disposal Works Construction P riytit No--------------- -- Dated_...5:---.-2-(.--7-L-•--•--_.__
✓ .. I
----- ��.... ----�.. -- �'`��1 -------------------------------
DATE. ................•--••-•-•------......---. ................................... Board of Health
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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