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HomeMy WebLinkAbout0171 SETH GOODSPEED'S WAY - Health 171 SETH GOODSPEED Osterville A =" .l 22 079 Commonwealth of Massachusetts j� /WW - 0179 Title 5 Official Inspection Orr Subsurface Sewage'Disposai Systen^ F,7,rrrn - Not `or Vo!untaary Assoss/ments / 6:00 i-r-e ��" r-•r� Property Address wy,-e v7 G e-, / z' �Ce t-10 Oar ner ON ner's Name information is LS 7�,�v► / l _ 0�6, a � required for every Sate' Zip Code Date off spect' page. Clyfrown ? Xj Inspection results must be submitted on this form. inspection forms may not be altered in any i'Ft way. Please see completeness checklist at the end of the-form. Inportant:Men A. General Information filfing out forms on the computer, use only the tab 1, Inspector. key to move your G`✓' / �/S Pi�// cursor-do not h' use the return Narne of Inspector ^/v > key.. /V ( 0 o Corpany Name w Company Address . �a City/Town Z Code sod State o�°� p Telephon tuber Ucense Number B. Certification 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 the inspection. The inspection was performed based on my training and expefience 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 R 15.000). The system: Passes ❑ Conditionally Passes ❑' Fails ❑ Needs Further Evaluation by the Local Approving Authority lnspector' Signature (kte The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The origi nal should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority, ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Tile 5Ofitdai In$pee ton Form SubsWace Sewage 040sel System•No 1ot17 t,5rs•W 3 Commonwealth of Massachusetts Title 5 Offigial Inspection Form. Subsurface Sewage D146saI System Form - Not for Voluntary Assessments Property Address Ae-IlB rr ✓/ infner oorrnation is �^'ner's Name �p l/l / (Job&,g required for every �`S' r f page. City rrown State Zip Code Date Inspectan B. Certification (coot.) Inspection Summary: Check A,B,C,D or E I'alwayscomplete all of Section D A) Syste Passes: 7I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304.exist. Any failure criteria not evaluated are indicated below. Comments: s I B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass'section need to be laced or repaired. The system, n completion of the replacement or repair, as approved by upon the Board of Health, will pass. Check the box for"yes°, "no"or"not determined" (Y, N, ND) for the following statements. If°not determined," please ex0ain. The septic tank is metal and over 20 years old" or the septic tank (whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass Inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Healt h. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a'Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below). t9re.3M3 Title s offciaf iris pecton F orns Subsufaoe Sewage Dlspoaaf$�mm-Page 2 of 17 Y . t - Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property Address / innffo►�mation Is Q^'ner s Name QS /i/6 // / od 6--c " CZ required for every G �C State Zip Code Date of I sped n page. Qty/rown B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ NO (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ NO (Explain below): ❑ distribution.box is leveled or replaced ❑ Y ❑ N ❑ NO (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)-are replaced ❑ Y ❑ N ❑ NO(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ NO(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 16.303(1)(b)that the system is not functioning in a mannerwhich 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 \,egetated wetland or a salt marsh Title 50fficial iris pectlm Form 3ubsLoaa+Sege Disposal System.rye 3of 17 t5ins•3M 3 I Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form Not for Voluntary Assessments 0/ SO �-6 V"C4 (1-7 Property Address /� //e✓/� infoner Owners Name ins � -/ 1c) / information is / O� d requrcedforevery State Zip Cafe Date loflnspeciii6n page. Cityfrown B. Certification (coat.) 2. System will fail unless the Board of Health (and Public Water Supplier,if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water ' supply well. li nd the SAS is less than 1.00 feet but 50 feet or ❑ The system has a septic tank and SAS a more from a private water supply well—. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other. fir. D) System Failure Criteria Applicable to All Systems: You must in "Yes" or"No" to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged'SAS or cesspool ❑ Static liquid level in the distribution box above outlet invert due to an overloaded / or clogged SAS or cesspool ❑ ,L+�,/ Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow T11e5Official iris Moon Form sub�udace sewage Disposal system-Page dof17 Sna•3/13 commonwealth of Massachusetts Title 5 official Inspection Form SUbsurfaCe Sewage Disposal System Form - Not for Voluntary Assessments Property Address //-v(of — O+v ner ON ner's Name ` information Is Os-�Q✓(/�l requiredforevery State Zip Code Date f Ins ion page. QtyfTown B. Certification (cunt.) Yes No Required pumping more than 4 times in the last year NOT.due to clogged or E] obstructed pipe(s). Number of times pumped: Cl Any portion of the SAS, cesspool or privy is below high"groundwater elevation. 'Any portion of cesspool or privy is within 100 feet of a surface water supply or El tributary to a surface water supply. ❑ Q� Any portion of a cesspool or pdw is within a Zone 1 of a public well. ❑ 94 Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ L7 Any portion ofa 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 fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other%!lurcriteria rit �d to rigs form.] copy of the analysis and chain of custody must be ❑ The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000g pd. ❑ 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. For large systems, you must indicate either"y'es" or.no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a suiface drinking water supply 11 Elthe 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 If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Tite5ofhcial impectlonForm Su"aw Sewage Disposal System•Page 5of 17 %Sms•3113 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Goo CJs Property Address ON ner Cw neres Name OS I �! / i/ 6 j� 4Date information is -fP,/ `requ�edforevery $fate Zip Code ct n page. ' ITow n �Y C. Checklist Check if the following have been done. You must indicate'Yes" or'no" as to each of the following: Yes Pumpinginformation was providedby the owner, occupant, or Board of Health ❑ . _ ❑ Were any of the system components pumped out in the previous two weeks? ❑ as the system received normal flows in the previous two week period? X-l❑ 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) Q/ ❑ Was the facility or dwelling inspected for signs of sewage back up? [g/❑ Was the site inspected for signs of break out? ❑ Were all system components, excluding the SAS, located on site? ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? �❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on:. ❑ Existing information. For example, a plan at the Board of Health. ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)1 D. System Information Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): TltlesofflCiai InspecbcnForm Substflace 59wageoisposa symm•PageOW17 t9ns 3H 3 Commonwealth of Massachusetts VjTitle 5 official Inspection Form Subsurface Sewage /Disposal system Form -Not for volurdary AssessmentS Property Address. Ow ner Ow ner's Name information is — requrced for every State Zip Code Date f tnspe tan page. City/Town D. System Information Description: / /ODD (�►`<0y7SP �t G w [ST/� Number of current residents: garbage Does residence have a rba a grinder? ❑ Yes L'7 No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes No information in this report.) inform , 'Yes O . . ❑ �� Laundry system inspected? Yes ❑ No Seasonal use? Water meter readings, if available (last 2 years,usage (gpd)): Detail: ❑ Yes No Sump pump? Last date of occupancy: Date Commercial/industrial Flow Conditions; Type of Establishment: Design flow(based on 310 CMR 15.203): Galions per day(gpd) n Basls of design flow(seats/personslsq.ft., etc.): Grease trap present? ❑ Yes Cl No Industrial waste holding tank present? „ _ ❑ Yes El No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑' No Water meter readings, if available: TO 50ftai Ins pectlm F am SUWXface sewage 0isposai system-Page 7 of 17 t5ns-3M 3 &\ Commonwealth of Massachusetts Title 5 official inspection c tr on For m Subsurface sewage Disposal System Form Not fore Voluntary Assessmtmts Roperty Address .L 2✓f �OOwner ON nees Nara �/� I ✓ ` Q�6�`j C�n inforrnation is _— requaed for every State Zip Code Date o Inspec ion page. CtyfTown D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): 4. { General Information i Pumping Records: CCCSSS ,e .�e � Source of iriformation: Was system pumped as part of the inspection? Yes C3 No if yes, vol ume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of Sy Septic tank, distribution box, soil absorption system s ❑ : Single cesspool ❑ Owflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) Innovative/Altemative technology. Attach a copy of the current operation and and copyof latest maintenance contract (to be obtained from system owner) a inspection of the VA system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. [] Other (describe): Yl1le S official Im peaum F arm subsL.rface sewage Disposal SyA%m•Page 8of 17 - t5ns•3113 r s Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �� Sod�Go�Gls Prop"Address Ow nerrm Owner's Name information is ��J 021j /5 �f�.✓�� � required for every page. Cly/Town State Zip Code We of I spec' n D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ❑ No Building Sewer(locate on site plan): C;� Depth below grade: feet Material of gfructi:440 �].�st iron PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): / Depth below grade: feet Materia construction: concrete ❑ metal ❑ fiberglass ❑ polyethylene El other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No �r � Dimensions: Sludge depth: 15re•31'13 Title 5 Offtai Ins pec don F am Su tsuf aca Serrage Disposal SYMM•PNe 9 of V Commonwealth of Massachusetts Title 5 Official Inspection_ Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments See-' Property Address Owner Owners Name information is /��b O a requiredforevery State Zip Code Date of In pectin page. A'ty/Tow n __ 6-.System Information (cons) Sepdc Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or, baffle How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to'outlet invert, evidence of leakage, etc.): �. �_eo, s Grease Trap (locate on site plan): Depth below grade: feet Matefial of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ns•3h3 TMe 50ftial Inspecton Form subsurface SewageDispesel System-page 10 of 17 Commonwealth of Massachusetts .H Form - Tale 5 Official Inspect ion ion Subsurface Sewage oisposal System Form -Not for Voluntary Assessments Property Address Owner Ow ner s Name S ✓Vl �l� d />r Information is ruieq edforevery State Zip— Code Date of nspect n re Q1yrtown D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition$,structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: . Material of construction: ` ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per dad % [] Yes' ❑ No Alarm present: ; Alarm level: Alarm in woridng older: ❑ Yes ❑ No Date of last pumping: .,Date Comments (condition of alarm and float switches, etc.):f `Attach copy of current pumping contract (required): Is copy attached? ❑ Yes ❑ No Tito 50f ial Iropoc6onForm Subsurface Sewage Disposal Symm•Page 11 a 17 Os•3'13 Commonwealth of Massachusetts • Form icial Inspection ctio nF 0 Title 5 Off p Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Pi /l2l�l Ow ne< ON Hers Name Ds /lama c s Information is V Date of spection required for every Czty/Town State Z�2 Zip code page. D. System Information (cont.) Distribution Box (if present must be opened) (locate on.site plan): Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan):. ❑ Yes ❑ No' Pumps in working order. ❑ Yes ❑ No. .. Alarms in working order, Comments (note condition of pump chamber, condition of pumps and appurtenances,etc.): • If pumps or alarms are not in working order, system-is a conditional,pass. Soil Absorption system (SAS) Qocate on site plan, excavation not required): If SAS not located, explain why: Tile$Oftloiaf trrpecaoiFomc Subsulwe SewegeDispoaal System-Page 12d 17 t5im•Y13 Commonwealth of Massachusetts III Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for V untary Assessments F, 90 c)�. Property Address / l�Vl ✓, Owner O+v ner s Name O� /, �� _ information is r b required for ev State, Zip Code Date of pection page. Cly/Town D. System Information (cont.) Type' leaching pits � number: ❑ leaching chambers, number: ` ❑ leaching galleries number. ❑ leaching trenches, number, length:, leaching fields number, dimensions: ❑ overflow cesspool number. ❑ innovativelaltematiw system Type/name of.technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): I to Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): . Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ns-Y13 Title 50ftldA impectcn F am subsurface sevage Disposal system-Page 13 d 17 Commonwealth of Massachusetts - Title 5 Official Inspection, Form v Subsurfaee Sewago Disposal System fro/rm -Not for Voluntary Assessments Property Address - �7 � I/ek-t ON ner CW ner's Nameinfomiftn is requQed for every page. City/Town State Zip Code Date of nspect' n D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan):.' Materials of construction:. Dimensions Depth of solids Comments (note condition of soil,'signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t8re•3'13 Title50Mcid lrepec bon Forrn Sutsuface Sewage Oisposal System.Page 14 d 17 �I Commonweafth.of Massachusetts Title 5 official Inspection Form subsurfaea sewaaa Disposal system Form - Not for Voluntary Assessments Property Address / Ale <�v�✓1 inf nm�ation is Owner s Name /„S /� / , o) 1.5 required for every case. �yfTown State_ Zip Code Date of Ins tbn D. System Information (cont.) Sketch Of Sewage Disposal System: Pra�A de a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate ; hand-sketch hey public water supply enters the building. Check one of the boxes below. in the area below ❑ drawing attached separately t5ns,3M3 Tide 50fftid Impec6mFam Sub!Wace Sewage DispasO System•Page 15d V Commonwealth of Massachusetts Title 5 Official l,nspection Form . . Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address iOw ro Q"r>er s Name information is required for every page Citynown State Zip Code Date of pectic D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water Check'cellar W ❑ Shallow wells Estimated depth to high ground water feet Please indicate all methods used to determine the high ground water elevation: �I ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ �0bserved site (ab"utting property/observation hole within 150 feet of SAS) Checked with local Board of ealth -explain: ❑ Checked with local excavators, installers - (attach documentation) - El Accessed USGS database- explain: You must describe ho you established the high ground water elevation: .. �o ✓Vc✓ S If � Before filing this Inspection Report, please see Report Completeness Checklist on next page. Title50ffidal Inspection Form Subst0aceSewageDisposal System-Page 16d 17 Orr. y13 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address ON is rn owners r�asne infome /1,4 0�Creq S� " tian V S��/l uired for every �yJTown State Zip Code Date t hs n E. Report Completeness Checklist D Inspection Summary: A, B, C, D,. or E checked pZspection Summary D(System Failure Criteria Applicable to All Systems)completed 0 System Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate Ile TMO50MCN l MPOCOMFaem SUUW8W$8W8QeDi P0W system-Pegs 17 d 17 1(18.3M3 LOiCATI N S WAGE PERMIT NO. 'r VILLAGE �® INSTALLER'S NAME & ADDRESS B UI-LDE R OR OWNER © ATE✓`. PERMIT ISSUED DATE COMPLIANCE ISSUED fb-l/- 72 7C 3p � THE COMMONWEALTH OF MASSACHUSETTS BOARD F 2HA! - H OF...... --- -- --- ------ ---- -------------------------------- Appliration -fur Uiipnsal Workii Tomitrurtion Vrruift Application is hereby"made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal Syst t- ••----• ...... ---------- ••.... -- ----- -----•-•-•--•-•--•--- ......... ........................... .... W c ocation-A ss or Lot,,N o. .... ..... ....... .... ............•.............. --....... ....... -----------••----------- O Or Addr •--•••....... �'' t/•7f`2> ......... •.. •... ....... ....................... ....................... Insta ler Address `— S UType of Building Size Lot...___J/._�7�✓.........Sq. feet Dwelling—No. of Bedrooms____..._..:............................Expansion Attic ( ) Garbage Grinder ( ) pa., Other—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) 04 Other fixtures W Design Flow.............5. ..................._._.gallo s per pet-son per day. Total daily flow---------- ....gallons. WSeptic Tank—Liquid capacity__.____ allons Length---------------- Width..._............ Dilrneter_-.--. - . Depth..-.------.----- x Disposal Trench—No. .................... NNE' .................... T Length__......._...... -_ To 1 leaching area.._.-.--_--_--.___-_sq. f t. Seepage Pit No..._,T .'t1.�`'D' _ .------_......_ i 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...----.---------------- �14 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water-----._..--.--.-_--_---- P4 - 0 Description of Soil....0.T0_-_fir_-___-__4PM4_ ..SU.$______________ ---------------------------------------------------------------- U ------------------------------------------------------------------------ 'FT--TO------�F�------- ------------- --_ �� �9V .............. ---------------------------------------------------------••------3 .- ---•-•--- - T --------- •- ------------r U Nature of Repairs or Alterations—Answer when applicable------------------------------------------------------------------------------------------------ ------------------------------------------------Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the boa d of h lth. Signed. - --�--- ------------------- �C Date Application Approved By-------- - lt� Date Application Disapproved for the following reasons----------------------------------------------------------------------------------------------------------------- ..-•--•--•--••---•----•••-------••---------------•--••-------••-•-----•----•-•---••-•------------------------------------------------------------------------------------------------------------------ Permit No------- -5..................................... Issued...... •.......Date ate....•-- Date • 6.r f y' THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH f `` OFrf ''`.x;'......- . ...�� ,��S��ir�t#i�rtt �f�r �i������ larks Cn�tt,�tr�tr�i�tt rr�tit Appliation is hereby made fora Permit to Construct �O or Repair ( ) an Individual Sewage Disposal System�at Location-;A!ddress • r"�.� or Lot No. -- f�--- rr e j. ' ............ •. . • " Installer Address Type of Building Size Lot------- ---------------Sq. feet Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) Q, Other—Type of Building ............................ No. of persons--------.__---..-.._-._----_ Showers ( ) — Cafeteria ( ) a � .,�w- tom:-._. d ---------------------------------------------------------------------------------------"---° W Design Flow ...................... ..........;�ul-gallons per person per day. Total daily flow-------------------------.--.._...-.----_-gallons. Other fixtures _...... 5 U WSeptic 1 calk Liquid capacity___:_.__-gallons Length---------------- �1�idth.._- lliameter_...___.....--._ Depth.__--_-.__.._.. x Disposal Trench—No. .................... Width al Length_- _ • . taI leaching area--------------------sq. ft. Seepage Pit No..__..--_- D mefer------------------ Deph below Arnlet-...-.- .._.--_.3'' o'tal leaching area...-. ...____..sq. it. z Other Distribution boxw'' .) Dosing tank ( ) ~' Percolation Test Results Performed by--------- ---------------------•----------------------------•- ----------- Date----------------------------------------- Test Pit No. L---------------minutes per inch Depth of Test Pit Depth to ground water.._........._...._.___- (_, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth,toj�ground water_.._._...___-.-._.__--- p, Description of Soil-- t3 '2 --- 40AM + SV5------------------------------------------- .._.----------------- -_--------------- - s:fi' C - ------- ---- - - ------- --- W -------------- --------------------- --------------------_--- -------- -------3�`--=1b � � r"T' x 5AAV� ---------- U Nature of Repairs or Alterations—Answer when applicable-------- - ---------------- _._._._. . ---_._..._._....--------.... ------.----- . . -------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by,the board of health. :.rc�-cam; Signed ''� r ' = ! '1 ' ,7 Date Application Approved By _-A.................•-----••-------------•-•--•-------=-------------=--------- -------- op �fit., --�-'? Date Application Disapproved for the following reasons----------------------------------------------------------------------------------------------•----....---•------ -----•-------------------------------------------------- --------------------------------------------------------------------------------------------- ------------------------------------------------- Date PermitNo.........� ------------------------------------------ Issued........................................................ Date Ptb Th COMMONWEALTH OF MASSACHUSETTS' y; BOARD OF' HEALTH 0 F. .I.,f...iz'� !'+ �.4" ....` ....... b THIS TO CERTIFY�fTlat /Individual Sewage Disposal System constructed r(f�or Repaired ( ) _l.,f` �j ��' '•-"- - I� ,/ Installer has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.....- !�5._..--_..�........ dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL. NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. ' DATE �_ .... ----- Jnspector--- ----- ----------------------•----------------_-------------- THE COMMONWEALTH qF MASSACHUSETTS ; BOARD OF HEALTH 11 l.x..,t No......................... FEE __- ._ . sa %s la ttl Norhaq Tl tt rixr i� t rrmit Permission is hereby granted--_-.�'.j__.{.-` '-z�_._.___...... V - ..._...••.................... --•- -- to ConstructL( ) Repair (�) an ndtvl Sewage Disposal System �/ J / i � /{r atNo. y .... ....�-•---• - .�� f ;%r /'.. --- ................................................. l✓ /'� ✓�.,.-w�° t.." ... as shown on the applicat for Disposal Works Construct Permit No._�_..f � Dated------ ._. -� --7 ! ' ---- '------------------------•--------- Board of Health FORM 12'55 HOBBS & WARREN. INC.. 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