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HomeMy WebLinkAbout0087 ROBBINS STREET - Health 87 Robbins Street _ O"t&ville P _. z A = 141 070 ��'. ^�• �' .inn W e COMMONWEAL - ExECL1TI TI-i of RECEIVE VE OFFICE pMASSACHUSETTS M DEP m ARTIVIENT OF EIwIR�NMENTAL A F SEP 2 ' d ENVIRON MENTAL PROT � X jq TM� TH L INSPECTjON FO TITLE S SUBS Oj� ,ct ,:SE R1VI_NO T FOVOL U , AGE DISPOSAL Sy NTARY ASSESS RT•A ST M FO MEN PA E RM TS " Property Address: C'ERTIFICATIO Owner's Na N 87 BOBBIN Name: ANTHOIVY Owner's Address: CAPOCCIA ERVILLE,MA 02655 Date of Inspection; 87 BOBBINS.ST OSTER VILLE,M I 1 -o {3 LO� g 8/29/02 A 02655 Name of inspector: ct P or:(Please print) Mailipany Name: , .,��OHN g Address: SEPTIC GRAC► INSPECTION Telephone Nu P'O' BOX 2119 TEATIC nC'. tuber:508_ CERTIFICA 564-6813 F T'MA. 0216 AX 508-564-7Z70 I certify that I It TION ST EME AT true,accurate and personally NT Y inspected ' experience in the complete as of the time he Sewage disposal inspector proper function and Of the ins system at this address and pursuant to Sectio maintenance ofOh Si'. The inspection that the infor 5•340 on site sewn was performed based on oration reported below of.Title.5(310 C ge disposal s MR 15.000), The Ystems. I am a DEP my training and is X Passes .`:; system: app►'oved s _ Conditional) . system _ Needs,FurthY asses _ Fails Evaluation by the Local q Inspector's S• /' Approving Sig., �. .`. . g Authority. The system inspector shall subm' 30 days of comPletin it copy of this ins Date' 8129102 inspector and the g this in sent to the system If the s Pection report to the system owner shall stlbn;it there tS a shared s or Approving Authority owner and co poi t to system has a h (Board Notes and pies semi to the buyer, the appropriate re design flow of 10 Of Health or DEP Comments ; yer, ifapplicable gaional office ,000 gpd or )within SYSTEM , and the pprovin of the DEP:The Original greater, the PASSED g authority, should be SYSTEMS USEFUL TITLE V INSPECTION. RECOMMEND LIFE ;R p \'`**This reportUMPING EVE 4ec tiOnhis only deiiribes does not a conditions EVERY TWO YEARS TO PROLONG THE the syste of inspection m will perform in and under the future the cundiliuns e under the same or different Ilse that tiate. conditions of use. Page 2 of 1 I 1 F` OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 87 ROBBINS-ST OSTERVILLE,MA 02655 Owner: ANTHONY CAPOCCIA Date of Inspection: 8/29/02 . Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X 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: SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. B. System Conditionally Passes: _ One or more system components as,d'escribed in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacenkepttorgepair,.•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. . n/a The septic tank is metal and o'v"Z r b bears 81d*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltratiol i 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 ol'd'is`available. ND explain: n/a J n/a 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 pipes)are replaced _ obstruction is removed _ distribution box is leveled or replaced ND explain: n/a '. n/a The system required pumping more thai 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval ofthek>3oarii`ofHealth): _broken.pipe(s),are replaced _obstruction is removed ND explain: n/a E , 1 Page 3 of I 1 _ OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 87 ROBBINS ST OSTERVILLE, MA 02655 Owner: ANTHONY CAPOCCIA Date of Inspection: 8/29/02 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`gnvironment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(I)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering'vegetated wetland or a salt marsh z_ 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 I00•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 I of a public"water supply. _ The system has a se}itic tank and SAS land 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 n/a "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached.to this`form. 3. Other: n/a i Page 4 of 1 OFFICIAL INSPECTION`FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 87 ROBBINS ST OSTERVILLE,MA 02655 Owner: ANTHONY CAPOCCIA. . Date of Inspection: 8/29/02 D. System Failure Criteria applicable to all systems: mu st ust indicate"yes"or"no"to each of the following for alLinspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of efflux nt 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 p e is less than '/z dayf(j X Required pumping more than 4`.imes in the last year NOT due to clogged or obstructed ip e s .Number of times pumped LESS THAN 1 YEAR BY OWNER. _ X Any portion of the SAS,cesspool or privy is below high ground water elevation. pp y X Any portion of 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:analysi's. (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.] I have determined that one or more of the above failure criteria exist as described in 310 (Yes/No)The system fails:_ CMR 15.303,therefore the system fails.Tie 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 :r X the system is within 400 feet of a surface drinking water supply X the system is within 2t00 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 If you have answered'"yes".to any.question in Section E the system is considered a significant threat,or answered "yes" in Seclir►n tihove the Inr e SyI'eiii h�_�S.failed, The mvner rn'nrerator of any l+irge system considered a significant threat under Section E or failed under Section D.shall upgrade the system in accordance with 310 CMK 15.304."l'he system owner should contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 87 ROBBINS ST OSTERVILLE,MA 02655 Owner: ANTHONY CAPOCCIA Date of Inspection: 8/29/02 Check if the following have been done. You must indicate "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 Were any of the system components pumped out in the previous two weeks'? X _ Has the system received normal flows in the previous two week period '? 4 X Have large volumes of water been introduced to the system recently or as part of this inspection ? X _ Were as built plans of the system obtained and examined?(If they were nct available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for,signs of break out'? X _ Were all system components,excluding the SAS, located on site X _ Were the septic tank manholes uncovered,opened,and the interior of t ie tank inspected for the condition of the baffles or tees,material of construction,dimensions, depth of liquid,depth of sludge and depth of'scum ? X _ 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 L'een determined based on: Yes no X _ Existing information. For example,a plan at the Board of Health. X _ Determined in the field(if any of the failure criteria related to Part C is ui:Issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] Page 6 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM lfiSPECTION FORM PART C SYSTEM INFORMATION Property Address: 87 ROBBINS ST OSTERVILLE,MA 02655 Owner: ANTHONY CAPOCCIA Date of Inspection: 8/29/02 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 2. Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):353 Number of current residents: 2 Does residence have a garbage grinder(yes or.no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): NO Seasonal use: (yes or no): NO Water meter readings, if available(last 2 years usage(gpd#4*4. 02 -��� O A Sump pump(yes or no): NO Last date of occupancy: n/a U _ j t d� �� `-t r COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CM 15..203.): n/agpd Basis of design flow(seats/persons/sgft,etc.`: n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of infonnation: LESS THAN 1 YEAR BY OWNER Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: n/aga(Ions'-=How was quantity pumped determined? n/a Reason for pumping: n/a TYPE OF SYSTEM X 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) _Itmovative/Alternative technology.Attach• a copy of the current operation and maintenance contract(to be obtained fi om system owner) _Tight tank Attach a copy of the D'P approval Other(describe): n/a Approximate age of all components,date installed(if known)and source of inforo-Cation: 19 YEARS BY OWNER Were sewage odors detected when arriving at the site(yes or no): NO Page 7 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continli6d) Property Address: 87 ROBBINS ST OSTERVILLE,MA 02655 Owner: ANTHONY CAPOCCIA Date of Inspection: 8/29/02 BUILDING SEWER(locate on site plan) Depth below grade:36" Materials of construction:_cast iron X40 PVC_other(explain): n/a Distance from private water supply well or Faction line: n/a Comments(on condition of joints,venting,evidence of leakage,etc.): TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade:30" Material of construction: Xconcrete_metal fiberglass_polyethylene other(expla:n'rda If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: 150OG L 10' 6" H 5.' 7" W 5'8"" Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle:33" Scum thickness: 1" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum`to bottom of outlet tee or baffle: 17" How were dimensions determined:MEASURED Comments(on pumping recommendatiors, inlet and outlet tee or baffle condition,s.ructural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUI,i)AND.FUNCTIONING PROPERLY. RECOMMEND PUMPING EVERY WO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. GREASE TRAP:_(locate on site plan) Depth below grade: n/a Material of construction:_concrete_meta,_fiberglass_polyethylene_01her(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet t;.-or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Continents(on pumping recommendations, inlet and outlet tee or baffle condition,so uctural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.):, n/a Page 8 of 1 1 ' s OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 87 ROBBINS ST OSTERVILLE,MA 02655 Owner: ANTHONY CAPOCCIA Date of Inspection: 8/29/02 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches, etc.): n/a DISTRIBUTION BOX:X(if present must be opened)(locate on site plan) Depth of liquid level above outlet inverct LEVEL WITH BOTTOM OF PIPE Comments(note if box is level and distrib0an to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): D-BOX IS STRUCTURALLY SOUND. PUMP CHAMBER:_(locate on site plan) Pumps in working order(yes or no): NO t Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a i , Page 9 of 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY-ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 87 ROBBINS.ST OSTERVILLE, MA 02655 Owner: ANTHONY CAPOCCIA Date of Inspection: 8/29/02 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type 1000 GAL 6' X 4' leaching pits, number: 1 n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a. n/a ' overflow cesspool, number: n/a n/a innovative/alternative system Type/name of technology: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): LEACH PIT IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.SYSTEM SHOWS NO SIGNS OF FAILURE.PIT HAD 1'OF LIQUID.IN IT AT TIME OF INSPECTION.STAIN LINES INDICATE PIT HAS NEVER HAD MORE THAN I O F LIQUID IN IT. BOTTOM IS AT 11'. CESSPOOLS: (cesspool must be ptimped''us part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum,layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): ` u/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil., sig►is of hydraulic failure,.level of ponding,condition of vegetation,etc.): n/a Page 10 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM IN SPECTION FORM PART C SYSTEM INFORMATION(cont;nued) Property Address: 87 ROBBINS ST OS3 ERVILLE, MA 02655 Owner: ANTHONY CAPOCCIA Date of Inspection: 8/29/02 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two perma-.wnt reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply.enters the building. 4. a � At Ll tl 6C 3`l Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 87 ROBBINS'ST OSTERVILLE, MA 02655 Owner: ANTHONY CAPOCCIA Date of Inspection: 8/29/02 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 12+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record-if checked,date of design plan reviewed: n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of I?ealth-explain: n/a NO Checked with local:excavators;installers-(attach documentation) NO Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: HAND AUGER- 12+FT. - . ( 7 LOCATION , / / SEWAGE PERMIT p0. hk71/� S Imo. '° - VILLARE d,T±e-a v INSTA LLER'S NAME D ADDRESS IBC t7 P#) BUILDER OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED r� 1 Q 9 r> THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........OF.... e—......................... Appliratiou for Bitipuia1 Works Toutitrurthitt Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: .......................Z_. .0..------.. Z................... -•---------------- ............------.T.................................................. Location-Address or Lot No. j ij/... ....t..r.......... .................................... ....................... Owner _ Address / Installer Address j Type of Building Size Lot--- ..Sq. feet Dwelling—No. of Bedrooms...........L---____•.__--_•---___--____Expansion Attic ( ) Garbage Grinder (Y4 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a Other fix5ures .....----••-------•------•--•--- • . -• ....... .._ -------------- ------------ �.. f "LZv�5a` W Design Flow.___..._�. ____________________________gallons per person per day. Total daily flow......... � Septic Tank—Liquid capacity! gallons Length l�._ (,__ Width_.6."-V- Diameter..'. . W Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. x Seepage Pit No-------............. Diameter_.___A?----------- Depth below inlet._.i�.sr..... Total leaching area.... _ _sq. ft. Z Other Distribution box ( Dosing tank '-' Percolation Test Results Performed by&M. J?M'j-__ ........... 14 Test Pit No. L 4.!��___minutes per inch Depth of Test Pit---- ....... Depth to ground water._ 1!✓ . 44 Test Pit No. 2_ -__-_minutes per inch Depth of Test Pit----/�-____•__- Depth to ground water__ a .)>e _.. aAV ............................dp_:aa......................................................... 0 Description of Soil------ -'A!!Vgja... vet` ----------------------------------------�:".0...... .1219AO_.4.4 ..1.C2.t`.4-. UNature of Repairs or Alterations—Answer when applicable----------------------------------.............................................................. -----------------------------------••-------------------------------------------------------------------------•------------•------•---------•--•-----------•------•---•--.....•••---•--•--------•------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'T E, 5 of the State Sanitary Co The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been Ysue by e boa of iea Signe .-----•... .. .... ---------....... --w?=�..-----•--- -X ...---••-- Application Approved By.. . -... f.<...�..` ......... ........... 12 Date Application Disappro d t following reasons--------------------------------•------------------------------•----------------•--- ....................... ................................ ... -• •---...__......-----------------------.......---•------------•-•-----•-----•-----------................------------......------------ ......-------- Date PermitNo......................................................... Issued....................................................... Date br M THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ....................OF... F'r�.vS-r�� < Appliratiun for Di-spuual Works Tonstruriion ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal yl System at: ............ ....G,._.............. .... .....__._..._............._........... .............. _._.._................_...____ ...................._..................... ocation-Address r Lot No. jj u C S 7 Owner Address a / 7S`Sa/� ..2clr_ 12 ��� ........... Installer Address Type of Building Y Size Lot_.,l �..H__!__.._..Sq. feet U Dwelling—No. -of Bedrooms____._..... ......_. Expansion Attic ( ) Garbage Grinder 0-1 Other—T e of Building No. of persons............................ Showers — Cafeteria Q' Other fixtures -----------•••• -•••-••--•..... . . " d .......................gallo1ns per person,per day. Total daily flow...........3. _rz___..._...._...... WSeptic Tank—Liquid capacity/C'` _.gallons Length v'4_ Widths`_" .Diameter_ `* Depth..`$../1 x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area.....................sq. ft. Seepage Pit No......./----------- Diameter-------lam......... Depth below inlet.. !S'...... Total leaching area._/.d... .....sq. ft. Z Other Distribution box (ii) Dosing tank ( ) '-' Percolation Test Results Performed by: � .�r.. z o �c-//- F�Jz�t!✓�-1--01-- Date_._.1�� `l�%.�............. ,4 Test Pit No. 1._. .. ....minutes per inch Depth of Test Pit----- ......... Depth to ground water.... -____--- Li, Test Pit No. 2...L._ _.._minutes per inch Depth of Test Pit...../.:?n........ Depth to ground water--- ------- ........ O Description of Soil.......... 01" Z,�_...t1�e - •_4Ji_...... �?___3._ Lc�.�r%n.y.�wh......,'..................... U --------•••-----•---•-----•••••--•---•--7 ... _.� rv.r(� r`c,Y =r F--................................. . /' / W r-/,� A i } / I......................Ldh9c d ,� ------------- .....................---- �.rc- r� ......--._........2.�--, ..................... 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 l: t L_:. 5 of the State Sanitary Cod The a dersigned.furtl:er agrees not to place the system in operation until a Certificate of Com 'ance has been is ued by t boar of 1 ealh�lY, t,- Si ed. ............... �.. ........ . .. ............. 14 ................. ApplicationApproved.. •----- ------------------------ - f� --------•--------------------------------. / D ,- ate .Application Disap ro...'f the following reasons:................................................................................................................ ............................ ---- . •-•---••---•-•-•.....................•-•--------••••••-- ------------------ Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............/. v. ............OF.. i;. >rQ.d. ..................:.............................. .... (IrrfifirFa#r of TumpliFana IIS 94ERTIFY, That the Individual Sewage Dis osal System constructe ) or Repaired ( ) b _ l............. aU- -----.---------•--•---•--••-----------------------------------•-.---------•------- ............................................ ................................... has been installed in accordance with the provisions o IT•,V,j�r�-`. 5 of The State Sadnt r C e described in the application for Disposal Works Construction Permit d �.`'.!�....................... . _- _ '............................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE...............................'y..--S/+ ............... Inspector........R'� ' THE COMMONWEALTH OF MASSACHUSETTS _ BOARD OF HEALTH ........ D...4✓1. ..............OF.......��4ia.v ...................................... No......................... FEE........................ �t��tl �1� ���Y��rl�r$IlaYa rrntt� . Permission is ereby grante - j ............. - - ----------- - r. ...----------....-•---••----.......... to Constr or,--Repair ( 4a>,�' dividual, e Disposal 0st rr_ �r�+� atNo. ......••••----...•------•-------••••....................•-.................._••-----• Street ` as shown on the application for Disposal Works Construction Per ..................... Dat .. ......................... .. �-- . ........................................ Boar Health DATE...............------�---� .................. FORM 1255 HOBBS & WARREN, INC.. 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