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Home My WebLink About0295 SEAPUIT ROAD - Health 295 SEAPUIT ROAD,OSTERVILLE h I a V ' 1 Commonwealth of Massachusetts Executive Office of Environmental Affairs Dept. of Environmental Protection One winter Street,Boston,Ma. 02108 John S D.E.P. Title V Septic Inspector P.O. Box 2119 Teaticket, MA 02536 wILUAM F.wELD (508)564-6813 Governor3 ARGEO PAUL CELLUCCI � Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ORT A ✓ CERTIFICATION N t� , A, Np Property Address: 295$eapuit Rd.Osterville Map 95 Lot 003 Address of Owner: l A ��yg9y 1 9�p Date of Inspection: 6/22/98 (If different) OFplTye tT Name of Inspector: John Graci Estate of James Ross Thompson lF I am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000) Company Name, Address and Telephone Number: 6 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 This Inspection Is based on criteria defined In Title V _ Conditions y Passes code 310 CMR 16.303.My findings are of how the system is performing atthe time of the inspection.My Inspection does _ NeeKbmit Evaluation By the Local Approving Authority not Imply any warranty or guarantee orthelongevltyofthe Fell septic system and any of Its components useful life. Inspector's Signature: Date: 6122198 The System Inspector shallopy of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. 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. INSPECTION SUMMARY: Check A, B, C,or D: A] SYSTEM PASSES: x I have not found any information which indicates that the system violates any of the failure criteria defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,passes inspection. Indicate yes, no, or not determined(Y, N, or ND). Describe basis of determination in all instances. if "not determined",explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Colhpliance(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 conforming septic tank as approved by the Board of Health. (revised 04127197) One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 295 Seapuit Rd.osterville Map 95 Lot e113 Owner: Estate of James Ross Thompson Date of Inspection:6122199 _ Sewage backuR or.breakout.or. high.static water level observed.in.the distribution box is due to a broken: or obstructed pipe(s)or due to broken,settled or uneven distribution box.The system will pass inspection if (with approval of the Board of Health). Describe observations: broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced 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 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 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 a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface of water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply well. The system has a septic tank and soil absorption system and 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 presense of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method usedto determine distance (approximation not valid) 3)Other D] SYSTEM FAILS: You must indicate either"Yes"or"No"as to each of the following: _ I have determined that the system violates one or more of the following failure criteria as defined 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 Backup of sewage in facility or system component due to an overloaded'or clogged SAS or cesspool. Dinchnrge or ponding of effluent to the surface of the gro(Ind or surface waters due to nn ovnrlonded or cloaaed —, cesspool. SAS is in hydraulic failure. (revised 04127l97) n L SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 295 Seapult Rd.osterville Map 95 Lot 003 Owner: Estate of James Ross Thompson Date of Inspection:6122198 D]SYSTEM FAILS(continued) Yes No Static liquid level in the distribution box above outlet invert due to an overloaded or cogged SAS or cesspool.. Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Numbers of times pumped Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion 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 compounds,ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"as to each of the following: The following criteria apply to large systems in addition to the criteria: _ 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 the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the-system is located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of1he Department for further information. (revised 04127)87) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: 295 Seapult Rd.ostervllle Map 95 Lot 003 Owner: Estate of James Ross Thompson Date of Inspection:6122199 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: ,c_ — Pumping information was requested of the owner, occupant,and Board of Health. x None of the system components have been pumped for at least two weeks and the 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. _c_ — 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. x The size and location of the Soil Absorption System on the site has been determined based on The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal Systens. x Existing information. Ex. Plan at B.O.H. x Determined in the field(if any failure criteria related to Part C is at issue, approximation of distance is — — unacceptable)(15.302(3)(b)] (revised 04127)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 295 Seapuit Rd.Osterville Map 95 Lot 003 Owner: Estate of James Ross Thompson Date of Inspection:6122198 FLOW CONDITIONS RESIDENTIAL: Design flow: 330 g•p•d./bedroom for S.A.S. Number of bedrooms: 3 Number of current residents: 1 Garbage grinder(yes or no): Yea Laundry connected to system(yes or no): Yes Seasonal use(yes or no): No Water meter readings, if available:(last two(2)year usage(gpd): n!a Sump Pump(yes or no): No Last date of occupancy: nla COMMERCIAL/INDUSTRIAL: Type of establishment: nla Design flow:0 gallons/day 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: We Last date of occupancy: nra OTHER:(Describe) roa Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: nla System pumped as part of inspection:(yes or no)No If yes,volume pumped:0 gallons Reason for pumping: nra TYPE OF SYSTEM x Septic tank/distribution box/soil absorptions system Single cesspool Overflow cesspool Privy Shared system(yes or no) ( if yes, attach previous inspection records, if any) I/A Technology etc.Copy of up to date contract? ' Other: APPROXIMATE AGE of all components, date Installed(if known)and source Information: 1994 Sewage odors detected when arriving at the site: (yes or no) No (revised 04)27l97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 295 Seapuit Rd.osterville Map 95 Lot O03 Owner: Estate of James Ross Thompson Date of Inspection:6122198 SEPTIC TANK:X (locate on site plan) Depth below grade: t' Material of construction:x concreate_metal_FRP_Polyethylene_other(explaih) If tank is metal, list age nia . Is age confirmed by Certificate of Compliance No (Yes/No) Dimensions: Le'6"H5'7"w4'10" Sludge depth:3" Distance from top of sludge to bottom of outlet tee or baffle: 24" Scum thickness:O Distance from top of scum to top of outlet tee or baffle:6" Distance form bottom of scum to bottom of outlet tee or baffle:ria 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 ere structurally sound.Recommend pumping system every two years. GREASE TRAP: (locate on site plan) Depth below grade: rda Material of construction: _concrete_metal_FRP_Polyethylene_other(explain) Dimensions: rva Scum thickness:rda Distance from top of scum to top of outlet tee or baffle:rda Distance from bottom of scum to bottom of outlet tee or baffle: rda Date of last pumpingril, 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.) rda BUILDING SEWER: (Locate on site plan) Depth below grade: vw- Material of construction: x cast iron_40 PVC_other(explain) Distance from private water supply well or suction lin0o- Diameter: nia QaImments: (conditions of joints,venting,evidence of leakage,etc.) (revised 04127197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 295 Seapult Rd.Ostervllle Map 95 Lot 003 Owner: Estate of James Ross Thompson Date of Inspection:6122198 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: rva Material of construction:_concrete_metal_FRP_Polyethylene—other(explain) Dimensions: rre Capacity: da gallons Design flow: n'a gallons/day Alarm level:_nra Alarm in working order?_Yes_No Date of previous pumping.- Comments: (condition of inlet tee,condition of alarm and float switches,etc.) rda DISTRIBUTION BOX: x (locate on site plan) Depth of liquid level above outlet invert: Llquldlevelwithbottomofpipe Comments: (note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box etc.) The dlstributlon is structurally sound. PUMP CHAMBER: (locate on site plan) Pumps in working order:(yes or no)No Alarms in working order(yes or no)_ves Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) n1a (revised 06127)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 295 Seapuit Rd.Ostervilte Map 95 Lot 003 Owner: Estate of James Ross Thompson Date of Inspection:6122f9& SOIL ABSORPTION SYSTEM (SAS):x (locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: rda Type: leaching pits,number: to0D gallon leach pit leaching chambers, number:rda leaching galleries, number: nla leaching trenches,number,length: nfa leaching fields, number, dimensions:nla overflow cesspool,number:nla Alternate system:-rda Name of Technology:_Ha Comments: (note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation, etc.) Leach pit and all components are atructurally sound and functioning properly.System never had more than 3'or water In It CESSPOOLS:_ (locate on site plan) Number and configuration: rda Depth-top of liquid to inlet invert: nla Depth of solids layer: Iva Depth of scum layer: nla Dimensions of cesspool: nla , Materials of construction: rda Indication of groundwater: rda inflow(cesspool must be pumped as part of inspection) rda Comments: (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.) rda PRIVY:_ (locate on site plan) Materials of construction: rya Dimensions: rda Depth of solids: rda Comments: (note condition of soil, signs of.hydraulic failure,level of ponding,condition of vegetation, etc.) rda (revised 04127)971 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 295 8eapuit Rd.Osterville Map 95 Lot 003 Estate of James Ross Thompson 0J22I98 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references, landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) T 100 /V6,; 0644 a e A� (7 Pay 9 of 10 (revived 04127197) , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 295 Seapult Rd.Ostervllle Map 95 Lot 003 Estate of James Ross Thompson 6122198 Depth of groundwater 10. Please indicate all the methods used to determine High Groundwater Elevation: x Obtained from design plans on record. Observation of Site(Abutting property,observation hole, basement sump etc.) Determine it from local conditions Check with local Board of Health Check FEMA Maps Check pumping records Check local excavators, installers x Use USGS Data Describe in your own words how you established the High Groundwater Elevation.(MUST be completed) Engineered plane (revleed04)2T197) save 10 of 10 L1,CAT10N `�" , . SEWAGE PERMIT NO. MCP--5 VILLAGE INSTA LLER'S MAME i ADDRESS 17. 41 B U I L D E Rc / OR OWNER r DATE PERMIT ISSUED ._ � gy DAT E COMPLIANCE ISSUED �a �� -�� \ O ;�1/ ,S/ / �.� i I � .��L�� s i� �� Y� i� No.. � �Ta l cV 4 (e •ram Fps.. ...................... THE COMMONWEALTH OF MASSACHUSETTS t�� I BOAR® OF HEALTH V-�+� ..................OF........ A=e- Appliration for Disposal Works Tonutru.rtiun Prratit Application is hereby made for a Permit to Construct ( ✓) or Repair ( ) an Individual Sewage Disposal System at: Location- Lot No. ....................._.......�_:... .:.----• + ...... ........................OF .j o� k............... ............ Owner ................................Address Installer Address U Type of Building ?� Expansion Attic Size Lot__Gader feet Dwelling gNo. of Bedrooms............. p ( ) g Sq.(� aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Ga Other fixtures ---------------------------------------------•.... w Design Flow.....................%S_..............gallons per person per day. Total daily flow......................49.'�?_......gallons. WSeptic Tank—Liquid*capacity]570._gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. iameter---_-___ Depth below inlet.............. Total leaching area.....•---_ . .� Seepage Pit No.___...__.1.._ p g �9.sq. ft. Z Other Distribution box (✓) Dosing tank `" Percolation Test Results Performed by�QX'EZ.. _...14YA............................... Date........ !_ /8 ---_-. Test Pit No. 1......�.....minutes per inch Depth of Test Pit--------I.Z..... Depth to ground water-------------•---_------ f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ R+' •---•-----•---------------------•-•-----••-•----••-----••----------.......-•----•---._............••......................................................... O Description of Soil..................................... --------- - w UNature of Repairs or Alterations—Answer when applicable............................................................................................... -------•-------------------•----------•------------•--•-••-•--------..........----...--•--------------------------------.......................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITL% 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 beard of health. Signed. •------------------------- -- -- `... ApplicationApprov -• -•--•--••••-••••••....................••--... 1 at Application Disapprove or the following reasons-.............................................................................................................. - ....................................... ...................................•-•-•-•-•----•-------.................................................................................................... Date Permit No... �. ............. _._.. Issued..-•---..q---•6 ---------------- Date -- - --- -- - ----- ------------------ r + No.--J�--4.... ,✓'- .� - Fps. .......`................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF........................................................................................•- Appliration for Disposal Works Tontrurtion ramit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: ............. -fir= --•-�1.-a.'.?+J.1.`� F* ...... '.��: �` ��f .: - ttg - - ............ pcation-Address or Lot No ............................�......le"'-----...... _.. :.. .....,.. ----- ' r.t t �1. t� J l .............................°....--......•-- A Owner Address ....................•--•---•--•---•--•-•�. .E �:` ...------------.................... ---............-----................--•---.....---......-•------------�---------•--.......•..•.. 14 Installer Address d Type of Building Size Lot... €.:................Sq. fee ' Dwelling—No. of Bedrooms......_..._. %..........................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures ............................ . Q' :G -------•------------ W Design Flow_____________________ .......... 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.........f.... Diameter.......... ....... Depth below inlet..... �.......... Total leaching area......" . sq. ft. Z Other Distribution box ( ) Dosing tank ( ) `., x�. � l 1.1 tom' �, �7.r�A Percolation Test Results Performed by... ............ Date________ -------------------------- Test Pit No. 1..... --:-___minutes per inch Depth of Test Pit........_. :...... Depth to ground water_---__� �-__-_.-. 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ x --- ....-••--•_..... Description of Soil.................... . ...................... ` " T ' � ' _-i................. ............ Fj111. _ A 4 -' U •..... ::. -•-•---- - ---^- W .._2...._f ' .............................................................................................•......_...._......-----.-----.............---..................••............................_..____.__... 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 T IT11E 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.l ____________________________ ------•--------------------•-------------------•--•----•--•. _ Date Application Disapprove or the following reasons---------------------------------------•----------------------------------------••-----------•--•-----•......---- ....................................... I.............................................................................................................. •-------------•------- .......................... 44 . Date Permit No....---...11 _ ... .�.................. Issued------I .... z..` ................. Date THE COMMONWEALTH OF MASSACHUSETTS ._----a BOARD OF HEALTH ............. ...F� .. `...........OF....... `.r 't`05' .................. .. ............................. (9rdif iratr of Tontplinnrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( �`) or Repaired ( ) by 1 - 'ri 0 �� . ( ... .............. ............................ ............................... Installer ) "_I dam, at••-••-•--••----••-•---•-!-----•••...--•-----...r ---•-•--• -•--- ---------- -•-----'---------- •----------------- .e ..................................................... has been installed in accordance with the provisions of TI ,LY �o :The-State Sanitary Cod as de cribed in the G application for Disposal Works Construction Permit No......................................... dated.._.._�. ._._�. ..�- .............. ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CO TRUE® AS A GU RA EE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE------..�.... ... `. .,.,z. ----------•-...._-•---- Inspector---.--_... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH d / t l � OF............................................. . ........................ FEE Cry No........... ............ ................... •--- �i��ro � o�� C�onn�rttrjtion rrntii Permission is h eby gxanted_. tu'��_= _.. to Construct��7.�� r Repair '( an/Indite age_Disposal System Street � .�qs as shown on the application for Disposal,,Works Construction Permit .............. Dated........... .. :: :./--........ DATE. ✓ " / 46 Board of Health FORM 1255 A. M. SULKIN, INC., BOSTON No.._._.1=1.., ..... Fxs. ... ........ THE COMMONWEALTH.OF MASSACHUSETTS BOAR® F I-1E TH 't.........OF....... Appliration for Disposal Works Tontrnrtion Prrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual' Sewage Disposal System at: Au� . : . .............. .......•-••...-------•••..........__.........---•--•------•---•--....---••-------.._.. Location-Address or Lot No. Owner Address a ..............: ---- ' .................•-•---- -----•--- •--•... -••..............-------------------------------------•------------------- a � ••• M Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building ...__..... No. of persons............................ Showers a YP g ---------------•-- P ( ) — Cafeteria ( ) dOther 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 ( ) Dosing tank ( ) Percolation Test Results Performed by-_----------_---------- � -------•---•-•-----•-------•--------.......... Date................................=....... Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth f T t Pit.................... Depth to ground water........................ x Description of Soil-••-••--•-•-= d ••.•.. .lam ----------------•- U •••........................••---....•••••-••-----•---•..................••••••••-••••-•-•------•-•••--•-•••-••----•-••••-•-•-•-••-••......-- W U Nature(of epairs or Alterations—Answe when !1I e... _ J.0.. es Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITI.j 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 ••••-• ....••••••...................•---•--••-•-••••......•--................- Date n Application Approved BY - �L 1....��_...0''�!.. Date Application Disapproved for the following reasons:...... ............. ............................••-------...-•----------•-----------••---•-••----------•-•--------------------••••••-•-•••-•••----•-•--•------•••--•••••-----------......-•-•------•••••--••----•-......•••. Date Permit No.......................................................... Issued...._ ...1 - Date .. i THE COMMONWEALTH OF MASSACHUSETTS BOARD O H E �4T........ ...... ----....OF......... ..... ........................ Appfirutiun for Eliipuiitt1 Works Tunutrnrtiun Vamit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at ............. -------------------••-•--•..........._----- -__---•-•------_--__-••_..•...•••-•--•-•- Location-Address or Lot No. 5---------------•--------...-------..... ......-----...............------------••-- •••--..........-•--•------....---.....-•-- Owner Address a4:...... .................................................... ------........_.....------...........-•- Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms................................ .Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building _ No. of persons............................ Showers — Cafeteria a' 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 ( ) Dosing tank ( ) , Percolation Test Results Performed bY----------------------------------------------•••------------------------- Date........................................ aTest Pit No. 1................minutes per inch Depth of Test Pit..__._.._..__...__._ Depth to ground water........................ (s, Test Pit No. 2................minutes per inch Depth of Te t Pit__.._..........._... Depth to ground water........................ ODescription of Soil.................... .4�... ... L � Lt W..................................................................... W _.-------••----- --- ---------------------- ------------••••--•-•--•----------------------•---------•-- -- --------------- •----- . -------- -...---------- U Naturef epairs or Alterations—Answer when licab _.. >r l -• r Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT TIE5 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. igned_ , ..-. Date Application Approved BY---------- ----- J-- - --= ./. ��---•----- ------`------------- ----•�•�-�-��''`--•-�- ......--' Date Application Disapproved for the following reasons_________________________________________________________________________________________________________________ ....................••----------...-----...•-•-_......---------------------------•-•-•---.....--------------------------•---------------------------•------------------------------------...---•------- Date PermitNo..................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD HEALT dL.l .......... .....OF. ................... v• Tnrtifira of (9jampfiana THI I TOE TI That the Individual Sewage Disposal System constructed ( ) or Repaired �j i Installer. +» �. �i at..... . Br - �� O �t< ` ---------------- has be n installed in accordance with the provisions of 5 of The State Sanitary Code as described • the PP P ... dated .` J' .`. ' -application for Di's osal Works Construction Permit No _____ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OFj HEALTH lP.� ..... .. .. .............OF.............. . .........:.. FEE ............... iu uutt� �k %Q'I'u tun ami# - � . -; Permission is hVebb anted----------- - ��+� -•--•----...........-�'-------.......................................... to Const t� air ( an I divldual S :wage Dispos y 1 j at No... �..f/x ------`-- j . --- ................ ' S reet as shown on the application for Disposal Works Construction Perm No_ .... 17ated...f.........2.......................... Board of Health DATE......:..............•••----------•--...........---•--------------............. FORM 1Z55 HOBBS,& WARREN. INC.; PUBLISHERS r b�^'4wtJ `bA - -**7, 6 -file. T M ?rr (Cora 2'Z•G )C 1. r Tv? Fav 211 P, �.'] /,5 \ • 1 �� _..._._r _.___. _ -�3«'• :► ;�.:: y i-- 1•_G�. .+.�..._ «o .- .7� D �' rf I tI •'L �k��S , \ . . ' l.�Ac.• �►fd tug �_____� ..� _ �".____ � �c. 4-4 Al I I r t rl zq _ - - fins lowJu i , S tAlq l r { r y� r-"ILI J IL law, (STW l..Ai� e)vl�+/�0fL5 a fA' 1A, ti,N Of ILq rFfuCEN b, A"TEA u N 29916