HomeMy WebLinkAbout0040 OLD MILL ROAD - Health t
40 Old Mill R ad (O'sterville)' •
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IN
UPC 12134
No.210�153LGN '�srco
HAATINOSS 94
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DATE: 5/15/01 ----
PROPERTY ADDRESS:40 Old Mill Road---------------
------------------------
on the above date, I Inspeoted the eeptlo ,sy3torb at the above address.
This system conslsts ofjhe following; G
1 . 1 -1000 gallon septic tank.
2. 1 -Distribution box.
3 . 1 -1000 gallon pre c st 1h}r�rR�the following oonditiona:
eased on my IanePe9$9
c ,
4 . This is a title five septic system. ( 78 Code ) _ ,
5 .- The septic system 'is in proper working order
at the present time.
6 . The waste water is 59". below the invert pipe '
of the leaching• pit.
Name:_,i,3.;-Aps.Qmktr- �U ------
Company: li Jo_s•� _P --_Nacomb_r_b Son, mInc ,`
Address:__Box 66_ -------
r
_-Cenc •ry11:10 aa_:_2 632-0066
Phone_ SOa_17,5„73�8-------
__TMI.S--_.C-E..FITIFICATI9N-.00tS- NOT CONSTITVTt' A OVARANT'Y OR WARRANTY
18. Laundry????
19. Size of septic tank.
20 . What size are the leaching p,it
21 , what size are the leach ' ,AS
cr) P, MRC r SON, LNC,
'T+nkt•C�+�poolr,•l�schll�ids - ;
Pumptd 4, In+tillod
Town $swor Conniotlona<
P.Or Box 6775•JJJ8o�ll1o, MA
775.641Z26J2-0066
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�.\ COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS .
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 40 Old Mi 1 1 Ro2d
SZ:�r�rq; IZA-r�866.
Owner's Name:
Owner's Address
Date of Inspection: 5 1 5/01 - t
Name of Inspector: (please print) .7�G� p er Jr.
Company Name:J P. MacomhPr R Gnn Inc.
Mailing Address: Box 66
r'pni-arvi T 1 e tut-.��-
Telephone Number: 508-775-3 JR
CERTIFICATION STATEMENT
1 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:
Z/Passes
.Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails-
Inspector's Signature: Date
: ��5'0
The system inspector shal ubmit 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
auihoriry.
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.
F
Title 5 Inspection Form 6/15/2000 page 1
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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: 40 Old Mill Road
ustervIlle, .
Owner: H.E.Whi e
Date of lospectioo:5/ 15/01
Inspection Summary: Check A,B,C,D or E/AL_ WAYS complete all of Section D
/A. System Passes:
F
I have not foun any information which indicates that any of the failure criteria described in 310 CMR
15.303 or to 3 10 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. `
Comments:
The septic system is. in proper working order
at t e nreGPnf time-
B. System Conditionally Passes:
_4�d One or more system component as described in the"Conditional Pass"section rieed 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.
d,?6 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
distribution box is leveled or replaced
ND explain:
/1 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:
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Page 3 of 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:40 Old Mill Road
s ervi e,Mass.
Owner: H.E. White
Date of Inspection: 5 15 01 "
•
C. Further Evaluation is Required by the Board of Health:
AM 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 wbich will protect public health,safety and the environment:
AQ Cesspool or privy,is-within 50 feet of a surface water
Vb 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 ofa',
surface water supply or tributary 6 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.
Alm 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
0 feet but 50 feet or more from a
private water supply well•'. Method used to determine distance ,rst!1q
This system passes if the well water analysis,performed at a DER certified labotatory, 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 anached'to this form., t
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3. Other:
' 3 a.
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Page 4 of 1 I
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:40 Old Mill Road
s ervi e, ass.
Owner: H.E.Whi e
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 No
_ /Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
R _ -�
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
/clogged SAS or cesspool
__e_/ Static liquid level in:the distribution,box above outlet invert due to an overloaded or clogged SAS or
cesspool l a'_?06j
_ squid depth in.sasspeet is less than 6"below invert or available volume is less than 'h day flow
: Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped .
�y portion of the SAS,cesspool or privy is below high ground water elevation.
y portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply. R
— �y portion of a cesspool or privy is within a Zone 1 of public well.
y portion of a cesspool or privy is within 50 feet of a private water supply well.
y 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 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.l
(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/
v the system is within 400 feet of a surface drinking water supply
!/th system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitro en'sensitive area(Interim Wellhead Protection Area—JWPA)or a mapped
Y g. P
Zone 11 of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a iignificant 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 3I0 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
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OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:40 Old Mill Road
Os ervi e,Mass.
Owner:H.E.White
Date of Inspection: 5 1 5 01
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 anv 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'?
Jz/— Were all system components, F—eluding the SASjo-cated on site?
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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?
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The size and location of the Soil Absorption System (SAS)on the site has been determined based on:
Yes ZExisting 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(3)(b)J
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OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:40 Old Mill Road
s ervi e, ass.
Owner:H.E. White
Date of Inspection: 5 1 5 01
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 10 Number of bedrooms(actual):
� 11 >1d 4All
DESIGN now based on 310 CMR 15.203 (for example: 110 gpd x p of bedrooms): '
Number of current residents.
D l'
oes residence have
a garbage grinder(yes or no): V •
Is laundry on a separate sewage system ( es or-no).-d&O (if yes separate inspection required)
Laundry system inspected(yes or no): ,ts
Seasonal use: (yes or no):.A-
water meter readings, if available (last 2 years usage(gpd)): n6
Sump Pump(yes or no): 9�s Q
Last date of occupancy:
COMMERCIALIUMUSTRIAL
Type of establishment:
Design now(based on 310 CMR 15.203): _gpd
Bans of design now(seats/persons/sgft,etc.): 1424 '
Grease trap present(yes or no):"
Indusrrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 system (yes or no): Q
Water meter readings, if available:t lable:
,
Last date,of occupancy/use: Aj_
OTHER (describe):
GENERAL INFORMATION
Pumping Records
Source of information: .1JDT.4v >
Was system pumped as pan of the inspection(yes or no): _
If%es. volume pumped: gallons •• ow was quantity pumped determined?
Reason for pumping: y0)' �,,��i
TYPtE OF SYSTEM
Z/ Septic tank, disrribution box, soil absorption system
Single cesspool -
Overflow cesspool
Privy
Shared system(yes or no)(if yes, attach previous inspection records, if any) F
Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract to be
obtained from system owner)
Tight tank Nl Attach a copy of the DEP approval ,
F
Other(describe): _ A/1� - e
Approximate age of all components,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 I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 40 Old Mill Road
s ervi e, ass.
Owner: H.E. White
Date of Inspection: 5 1 5 01
BUILDING SEWER(locate on site plan) a
Depth below grade:
Materials of construction: cast iron 4&40 PVC other(explain):
Distance from private water supply well or suction line:Ad
Y
Comments(on condition of'q nts, venting, evidence of Icaka e, etc.):
Joints appear T�ight.No evidence of leakage.System is
� V 7AA 11Z vented. through the house vent.
SEPTIC TANK: locate on site plan)
Depth below grade:
Material of constructio�ncrete rnetalt/hfiberglass polyethylene
AU
bother(explain)
lificate)rani: is metal list age:.�(� Is age conPtrmed by a Certificate of Compliance(yes or no)vjd (attach a copy of
certi
Dimensions: oi(D.C,i✓ �`/�r�A W6 6-
Sludge depth: 71.—
Distance from top of Judge tc bonom of outlet tee or baffle:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle: L
D.stance from bonom of scum to bonom of outlet tee or bafile:, �
How mere dimensions determined:' 5111ewl
Comments (on pumping recommendations, inlet and outlet tee or baffle condition. structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
;Pump the septic tank ever 2-3 years.Inlet & outlet tees are
in place.The tank is structura y soun an s ows no
evidence of leakage.
CREASE TRAPAI&Oocate on site plan)
Depth below grade:dd
!material of constructionWAconcrete do mew Lt&ftberglassAApo lye thylene Aother'
(ex pIa in):
Dimensions: Allf
Scum thickness:
Distance from top of scum to top of outlet.tee or baffle' aJi4
Distance liom bonom of scum to bottom of outlet tee or baffle: X/�9
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.):
Grease trap is not present
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Page 8 of I I r '
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 40 Old Mill Road
OstervilleRMass.
Owner: H_E_White
Date of inspection: 5 J 1 5 J 1
TIGHT or HOLDING TANK(tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: 469
Material of construction: yA_concrete VA metal fiberglass AA polyethylene&A_other(explain):
Dimensions: A/
Capacity: gallons
Desien Flow: AM -gallons/clay
Alarm present(yes or no):
Alarm level: A(,4 Alarm in working order(yes or no):
Date of last pumping: N�
Comments(condition of alarm and float switches,etc.):
Tight or holding tanks are not present.
DISTRIBUTION BOX:,( (if present must be opened)(iocate on site plan)
Depth of liquid level above outlet invert:1[�
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.):
Distribution box has one lateral.No evidence of solids
carry over.No evidence of leakage into or out of the box
PUMP CHAMBER4&(locate on site plan)
Pumps in working order(yes or no): 4)4
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.):
Ptimn rhamhPr is not C recant
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• Page 9 of I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:40 Old Mill Road
Osterville,Mass.
Owner: H_E.White
Date of Inspection: 5/1 5/01
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation,not required) s
If SAS not located explain why:
nc-.,
Type
aching pits, number:
leaching chambers, number:Q .
leaching galleries, number:Q_
leaching trenches,number, length:. n
leaching fields,number, dimensions:_Q
AOoverflow cesspool, number:
/� �—'
. irutovative/alternative system Type/name of technology: /`-/>P 77 •
Comments note condition of soil signs
( s of hydraulic failure level
g1 of ponding, damp soil,condition of vegetation,
etc.): - I
Loamy sand to medium fine sand No signs of hydraulic failure
or ponding.Veaetation is ..normal Waste water is 59" below the
the invert pipe.
CESSPOOLS&Q.(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: AA
Depth of scum laver
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.): _
Cesspools are not present .
PRIVY4&(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.): -
' Privy is not present. F
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• Page 10 of I 1 '
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 40 Old Mill Road
s ervi e,Mass.
Owner: H.E.Whi e
Date of Inspection: 5 1 5 01
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.
ay ?;IIw ago v�
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Page I I of I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C '
SYSTEM INFORMATION (continued)
Propem Address: '40 Old Mill Road
Osterville,Mass. '
Owner. H.E.White
Date of lospectioa: 5/1 5/01
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
_st:mated depth to ground water feet�D�
Please rndicate (check)all methods used to determine the high ground water elevation:
�brained from s stem design plans on record • If checked, date of design plan reviewed:
bdsee site abuain roe bservation hole within 150 feet of SAS)
_ ccked with local Board of Health-explain:
Checked with local excavators, installers. (anach docurnentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Used;
Gahrety & Miller Model
12/1F/94
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TOWk OF, WARE) OF IIEALTII
SUN_•.^^•.•'.'-•.11 -�gUttFACF, 9EKAGP I)I f'U9AL�9Y�9TF,M INSI'ECTION FORM -'PART D •- CERTIFICATION
�. _. I
-TY►C OA FAINT CLEA1 0-
PI?OPERTY INSPECTED
STREET ADDRESS 40 Old Mill Road Osterville.Mass. 1
ASSESSORS HAP , DLOCK ANU PARCEL _I
- - w
OWNER' s NAME H.E. Whites '
PART D - CBRrrFICATION
NAHE OF INSPECTOR _ Joseph P. Macomber Jr,
COHPANY NAME Joseph P. Macomber S"'Son, Inc.
COMPANY ADDRESS Box 66 Centerville MA. . 02632-0066
Sir•�t Tovn or City 1 W9 t P
COMPANY TELEPHONE ( 508 1 775 r 3338 FAX ( 508 J 790 - 1 578
CERTIFICATION STATEHENT
I certify that I 'have personally inspected the •sewage' disposal system nt
®rlecoinmendations
his nddress and that the information reported is true , accurate , and
omplete as of the time of -inspection . The inspection was performed and any
regarding upgrade, maintenance , and repair are consistent
With my training and experience. in the proper function and maintenance of• on-
site sewage disposal systems .
2one .1system: PASSED
The inspection i+hich 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 CHR 16 - 303 . Any failure
criteria not evaluated are, as stated in the FAILURE CRITERIA section of
this form )
System FAILED*
The inspection which 'I -have con rioted has found that the system fails to
protect the Eiublic health and the environment- in accordance - with Title
5 , 310 CHR 15 , 303, and as specifically noted on PART C -. FAILURE
CRITERIA of this Inspection form
�J✓`~'
Inspector Signat-ure Date
...,,
copy of this certification must be provided to the OWNER, the BUYERDn6
where •pplloeble ) and the BOARD 07 HBAL'1')l,
• If the inspection FAILED, thv owner or operator shall upgrade ' the system
within one year or the dnte of the inspection , unless allowed or required
otherwise as provided in 3.10 CHR 1613061
partdldoc
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TO . " ARN5TABLE
LC'ATION . J��� � SEWAGE #
VILLAGE � ��� -� ���� ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY ;
i
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS
BUILDER OR OWNER 4. (®•
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
` on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Le ching Facility(If any wetlands exist
lvithin 3s0 feet 1 hi cility) Fo t
Furnished by
i
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<Q .
��
AS?ESSOR'S MAP No. , / f PA'ROEL d
LOCATION SEWAGE PERMIT NO.
�Vb W &&
VILLAGE
3 y
INSTA LL R'S A M E Z ADDRESS Y'26 �2763
0R OWN'ER
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED a
:- F _i
e�'
A
No... 6......�.�...�® Fps...... ..
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
.......... ..............OF...... .` .........
App irFation for Dispas al Works Corm rnrtinn Errant
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
.... t. .ti - - ...............-...............------•- ---------......_.....-----------•------•...........--
Location-Address
or Lot No.
.. A'1�{A�v ... .:. Y. -1w'l:s--.........-•-------------- F ._. ? ....?4.---...W. 2 4�i:4iPY�A
W caner Address
a .........-. %J.......................................... r,� ,_�. . N \� ---......................
InstallerAddress
UType of Building Size Lot...........................Sq. feet
�., Dwelling—No. of Bedrooms-------I...................................Expansion Attic ( ) Garbage Grinder ( )
'14 Other—T e of Building .._..... No. of persons a YP g --------•----------- P �...................... Showers ( � ) — Cafeteria ( )
d Other fixtures .................................................................................... --------------------------
--•-•-----------------------
w Design Flow............................................gallons per person per day. Total daily flow.._......._............................_....gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No..................... Width.................... Total Length.....................Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box (;-I Dosing tank ( )
Percolation Test Results Performed by........................................................................... Date...........>............................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
fT4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water..........:-------___-_-
P4 ------•-•-----•-------------••........•---•------•------....---•-----••---------.........--•-------•.........................................................
0 Description of Soil........................................•-----•-----•-•........ .
x
w
U Nature of Repairs or Alter ti' s—Answer when applicable...._ .d ...� ....._ \_ ......_°?`_._.._____..
Agreement
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iI'L YL 5 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 _ ........................................ ....... -1
Application Approved�By
---------------------a-12—D. .. -•------ ............. -------•-- ..Yato
V
Application Disapproved for the following reasons-----------------------------•-------------------....--•------••-------=--------------•-•----••-•--..._------....
.......---•--•---------•-........-•---------------------•---...---------
Date
PermitNo......................................................... Issued....................................I.........--•--......
Date
No........ ..
•.. ....... Fizz..........................._
THE COMMONWEALTH OF MASSACHUSETTS -
BOARD OF HEALTH
--. -...... aW Y�:..:..... oF...... c-Vim ._... = .
Apli iratiou for Uiipusal drks• Tomitrurtiun rr t r
Application is hereby made for a Permit to Construct .( ) or Repair ( ): an Individual Sewage Disposal
System at• r ----•-- ..
Location-Address or Lot No.
��_...���........._\'�f-1 l ..=::.---•------------•-------... --- ...---� �,.t. '4.1 r C:tl.j t\A
................
ner Address '
w1. - �, . .............. s. 4....... ------......-----------------------
Installer Address== €
UType of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms_•_.•-:1.................................Expansion`Attic ( ) Garbage Grinder ( )
per, Other—Type of Building ............................'No.. of persons_.::�_.__:_.._,..___.__.____ Showers (:� ) — Cafeteria ( )
P4 Other fixtures ..................... -`:.......:
_ -----------------•-----------------••-----------..................._..
W Design Flow............................................gallons per person per day. Total daily-'flow..................................0.........gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width:. ..._. Diameter__..._ ..... Depth................
x
Disposal Trench—No. .................... 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
Percolation Test Results Performed by =--------------------------•---•-------------------....._....._........ Date........................................
aTest Pit No. 1................minutes per inch Y.Depth of Test Pit.................... Depth to ground water........................
Test Pit No. 2................minutes per in& Depth of Test Pit....................I Depth to ground water........................
.................................
-•-----• ---------._... -=--------......................................................
Descriptionof Soil ..................•-•-----••••---•--••--•••••-••-•=•-•----•-••••-••-•••-•---=---•--•••••................••-•----••••---•-
U -••-------------•-----------------------------------------------••......•-•--- ................................................
W -••-------------------- ------------•-••••--••••......--•--•-------•-------- . ------ ...-- . ' -• ---•-••------•••.........
U Nature pairs o Alter io —Answer wl--n pplicable ` 4 OLD G __.� . ... :...........
----------
Agreement: 3f
The undersigned agrees to install the aforedescribed/Individual Sewage Disposal'System in accordance with
the provisions.of TIT1Z 5 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 -------------•-•-----------------------• -• -..
Application Approved BY ....................... ......=.......................,....... .......... ....... .
-------• .Date •--•--•-7t--
Application Disapproved for the following reasons-.....................--....................--------------------------------•---------------------•-•-----•-_.----
...............•----••-------•----...----•--•------••--.......................---------------------------------------------- ----------------------------------•------------------- -----------------
Date
Permit No. ` �Y ® ....... Issued........................•.
�v_....-
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
......................................... OF......................................................................................
THIS IS TO CERTIFY, TfiitL e Individ 1 e e sposal System constructed ( ) or Repaired ( )
�i� M
:y-------------------------------------------------------•------------------------- -- ---
7�'� -.............
-----------.............I...- - ...................7--------
4-C) vLd 01. 1( 1 .....................
-at...........................................r.-...........................................................................................................................................
has been installed in accordance with the provisions of TIT _5,(�f jb State Sanitary Cofig cue ed in the
application for Disposal Works Construction Permit No.......................... dated------- I.........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE _
SYSTEM WILL FUNCTION SATISFACTORY.
r.a
DATE................-3......J ...-Z ................ Inspector. --------------------
l1 THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............................................OF.. .. : - J 05
No......................... FEE....7.................
Disposal Workv %Tuptrnr#inn Upumit
Permission is hereby granted. --.•-•----...-----�--`-.-.• --------------------•----••------•-------------------................_.......--•-----
to Construct ( ) or Repai, ., � ) an Individual Sewage Disposal System
V-
at No.............................................................. J__1.-••••••......•••---•--••-•-------. } --------...../.--•-•----.......
Street- ����i'�t� f � "U
as shown on the application for Disposal Works Construction Permit N ... Dated.._.. .1...........................
_ 7 ........................•----------------•----------------------.......-----......-----•-------•-•----._
� " !1-7, ( Board of Health
DATE................................................................................
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
Y; ......
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
................. ...............O F.........................---.................---...........
Allp iration for Disposal Works (futt.5trurfiutt ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System
a�J a , : .. � :...._-_-•------------------•--••-_-_--•--- N .--•••--------•............._.. ....._
Address Lto_ Loa or-- ---.......................... ......... -------�
a Installer Address .10
U Type of Building Size Lot'--= �- --Sq• feet
Dwellingi am .
-
of Bedrooms.41;L— Attic ( ) Garbage Grindeq.t,,:r).
'04 4 Other—T e of Building No. of persons____________________________ Showers — Cafeteria" 1..
04
Other fixtures .---•--------------------------•---•------------•-----....------------------------------.•----------------•-----------•--•-•------------......> '
Design Flow............................................gallons per person per day. Total daily flow............................................gall s. y" .
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter_ -_-______ Depth....... X
Disposal Trench— o ____- Width.................... Total Length........ Total leaching area....................sq.
i
Seepage Pit No. Diameter________ _______ Depth below inlet... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......... --------•----------------------------------------•------------- Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth.to ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a
Description of Soil 4- ?" %`lh ..'i ,� �!�. .-•-----------------------------•------
V ----------------------------
•-•----------------------------
-•---•----------
•----------------•-----•-------•-----------------------------------••.....• __--------------
W ------•--------------•------•...•-----•---••----•--••---•--•----•-•----•---------••--•-•--•••-----------•----- }}� •---•----... .......................
U Natu of Repair or Al r t ins—Answer w e applicable._._ ( '._.__.-_�__
� �, ��, "
...........L.J. Z .P ----•--•------------------------------------------•---------•---•-----•------------•---•--••-•-----
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iiTL is 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been iss ed b the oar o health.
l
Signed -------•-----�•- -- 1 `
Date
ApplicationApproved BY----------L.11A............................................................................ -•••---.._
Date
Application Disapproved for the following reasons:-----••........................•-•-•--------•--...-----------••----------------•----------------..._....._....�
--------------------•---•,•--•--------------••-•---•---------•----•-•-•---------•---•-----------•-•--....__.._._....._....--•-------•----------------•- _ -•7•--......_....------.Date--•--....-----
Permrt No............ -��I Issued.... .. ( {
Date .............. ate....---
o el,
No.......2J..Y-.A.... Fim
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............. ......... .................OF..................................._...
Appliration for Dispaiial Works Tonstrurtion "pamit
.—Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
Systeni tit:
.................................................................................................
T
Locat* AddreS% ii or Lot No.
........ .. ... ---------- . .. .................... ............ ....... .................. .... ........
r .....d-�ress
................................... . . . . . ..........
. ......... ..................... .......... . ..........
Installer Address
Type of Building
U Size Lot.a---------------------Sq. feet
�_-of Bedrooms.-oz..................................Expansion Attic Garbage Grinder
Dwelling. .<o- 9
aOther—Type of Building ............................ No. of persons_______._._.___________.____ Showers — Cafeteria
04 Other fixtures ......................................................................................................................................................
Design Flow............................................gallons per person per day. Tot I daily flow............................................gallons.
1:4 Septic Tank—Liquid'capacity............gallons Length________________ Width.__............ Diameter__-_..___.___.__ Depth__._.__ ......
Disposal Trench—Np.,.................... Width................... Total Length............ .... Total leaching area....................sq. ft.
Seepage Pit Diameter........4P .. Depth below inlet..... ........ Total leaching area..................sq. ft.
Z Other Distribution box Dosing tank
Percolation Test`•Results Performed by.......................................................................... Date........................................
Test Pit No..1................minutes per inch Depth of Test-Pit.................... Depth to ground water...________.__.._._____.
fs, Test Pit No. 2................minutes per inch Depth of Test Pit._.._....._________. Depth to ground water._.____.._...__._____...
-0— ..............#*........................................
--------------- ------------------------------------------------
0 Description of Soil__.:.__................... ........................................................................................................
W
U .........................................................................................................................................................................................................
.......................................................I..................................... •.................. .....
U NatuLw of Repair or Alt rN i s—Answer w le....- ....Papplical ...4--op-, .........................................
A*4
... ................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in
n accordance with
the provisions of TITLE 5 of the State Sanitary Code "'The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been''iiss d b the b andealth y....................
Signed. ........ .............................
Date
ApplicationApproved By.............4-t.,A.......................................................................... . ..............✓...... ...................
Date
Application Disapproved for the f ollowing reasons:.............................................................................................................
......................................................I...................................................................................................................................................
Date
Permit No.. . . ............................. d......................................... ............
...........el. ... Issue
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.........OF.........
....... ................................................
Tntifiratr of Tompliana
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired
by.......................f ......................................................................................................................................
Installer
at..
.......................... ....................I........................................ .......................................................
has been installed in accordance with-the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works`,Gon9Trfii&ion Permif'�No...!. ......... -_cad.. ..............
....... dated------/Zt.z� .
THE ISSUANCE OF THIS CERTIFICATE SHACL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE... //7- 7, /0
......--------------------------------------------- Inspector............... .............................................
. ... ......... " "" ......
,wvg� C OM4
,,A,1*)yEALTH't_OF1MASSAC
BOARD 0 LTH
6—eXel
0 F...........A"All't r,0,4de_
.......... ............ ...........................................................................
No............ FEE..............
Permission is hereby granted........ enz.....
------------- -------*...... ............"...............*"'**............
to Construct or Repair an Individual Sewage Disposal System
at No.............. V, j;
I....... ..........cz Z4�1-------2.. ....................
!,.....I................... ...........................
4�fz�fe, Street
as shown on the application for Disposal,- orks Construction P No------
�7 ............. Dated....... ....................7.i...........
"9
Q_ X
�//4o .........................................Boa; alth........................................
DATE..-.......................................................................
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS
%