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HomeMy WebLinkAbout0046 SHARON CIRCLE - Health "46 Sharon Circle Osterville A= 122— 150 0 4 P r Commonwealth of Massachusetts 1o2a450 Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 4 46 Sharon Circle Property Address Copplestone ; Owner Owner's Name information is / X required for Cisterville V MA 02655 9/25/18 every page. Cityrrown State Zip Code Date of Inspection M Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. Inspector Information 5/4 133_'�5 Frank Nunes III Name of Inspector saa Company Name Box 841 Company Address East Falmouth MA 02536 City/Town State Zip Code 508.272.6433 13010 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5(310 CMR 16.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 9/25/18 Inspect Igna Date 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 has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. 15insp.doc-rev.,7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Sharon Circle Property Address Owner Copplestone information is Owner's Name required for Osterville MA 02655 9/25/18 every page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary : Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. . 1) System Passes: ® 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: 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. , The septic tank is metal and over 20 years old"or the septic tank(whether metal or not) is structurally unsound, exhibits-substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5insp.doc-rev.712 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Sharon Circle Property Address Owner Copplestone information is Owner's Name required for Osterville MA 02655 9/25/18 every page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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 ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(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 ❑ ND (Explain below): ❑ obstruction is removed ❑ Y. ❑ N ❑ ND(Explain below): 3) 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. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health; safety and the environment: t5insp.doc-rev.1/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 Commonwealth of Massachusetts �e F Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Sharon Circle Property Address Owner Copplestone information is Owner's Name required for Osterville MA 02655 9/25/18 every page. CityrFown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. 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. ❑ 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: **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. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No 0 ® 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18_ Commonwealth of Massachusetts i? Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Sharon Circle Property Address Owner Copplestone information is Owner's Name required for Osterville MA 02655 9/25/18 every page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS,cesspool or privy is below high ground water elevation. ❑ ® Any portion of 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 water supply 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. [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 and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CM 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. 5) 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"yes" or"no"to each of the following, in addition to the questions in Section CA. 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Sharon Circle Property Address Owner Copplestone information is Owner's Name required for Osterville MA 02655 9/25/18 every page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You.must indicate"yes"or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ 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)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Sharon Circle Property Address Owner Copplestone information is Owner's Name required for Osterville MA 02655 9/25/18. every page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms (actual): , 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 Description: , Number of current residents: 4 Does residence have a garbage grinder? ❑ Yes, ® No Does residence have a water treatment unit? ❑ -Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ® Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Seasonal Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments > 46 Sharon Circle Property Address Owner Copplestone information is Owner's Name required for Osterville MA 02655 9/25/18 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) , Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Pumped 3 yrs ago per owner Was system pumped as part of the inspection? ❑ Yes E No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts 0 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �o 46 Sharon Circle Property Address Owner Copplestone information is Owner's Name required for Osterville MA 02655 9/25/18 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® 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) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval.' ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 1983 per BOH record Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): 18" Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet feet Comments (on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w 46 Sharon Circle Property Address Owner Copplestone information is Owner's Name required for Osterville MA 02655 9/25/18 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 12"feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) H-10 tank appears to be structurally sound If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000g Sludge depth: trace Distance from top of sludge to bottom of outlet tee or baffle '12 Scum thickness trace >211 . Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle >2" How were dimensions determined? measured Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping suggested every 3yrs to prolong the life of the system t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form i' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Sharon Circle Property Address Owner Copplestone information is Owner's Name required for Osterville MA 02655 9/25/18 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: feet Material 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 Comments(on pumping recommendations;inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. 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 day t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Sharon Circle Property Address Owner Copplestone information is Owner's Name required for Osterville MA _ 02655 9/25/18 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ElYes ❑ No Alarm level.' Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0„ 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.): D-box Z below grade, no adverse conditions observed } t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments au 46 Sharon Circle Property Address Owner Copplestone information is Owner's Name required for Osterville MA 02655 9/25/18 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): ' Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑. No* 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. 11. Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type. ® Teaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Sharon Circle Property Address Owner Copplestone information is Owner's Name required for Osterville MA 02655 9/25/18 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Bottom of pit is 10'6" below grade, it is dry at this time, stain line 3' below invert, no indication of past hydraulic failure, cover raised to 6"of grade 12. 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 Comments (note condition of soil, signs of hydraulic failure, 'level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 46 Sharon Circle Property Address Copplestone Owner information is Owners Name required for Osterville MA 02655 9/25/18 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 1 y c Commonwealth of Massachusetts 190P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 46 Sharon Circle Property Address Owner Copplestone information is Owner's Name required for Osterville MA 02655 9/25/18 every page. City(rown State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide 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 where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately s 2 y U _3i 6 53 • (��5 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 'I Commonwealth of Massachusetts �v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Sharon Circle Property Address Owner Copplestone information is Owner's Name required for Osterville MA 02655 9/25/18 every page. CityrFown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground >12 d feet Please indicate all methods used to determine the high groundwater elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 1983 NGW 12' 'Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health-explain: 4' seperation per 1983 compliance ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: TOPO mapping, site is 40'msl and nearby surface water is 20'msl You must describe how you established the high ground water elevation: See above Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Sharon Circle Property Address Copplestone Owner information is Owner s Name required for Osterville MA 02655 9/25/18 every page. CityrFown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section.. ® B. Certification: Signed& Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4(Failure Criteria)and 6 (Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 Q W 4I ` COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL` AFFAIIZS DEPARTMENT OF EN VIRONMENTAL . . ,� 77 .V-t r TITLE 5 OFFICIAL,INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS i SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: / erv, Owner's Name; C Ci Owner's Address: Date of Inspection: �S 0 Name of Inspector:(please print). G Company Name: i o/Se Mailing Address: 07 Telephone Number: pj O�4(-t LI CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the below is true,accurate and complete as of the if training and experience in the proper function inspection.time of the o s sewage disposal so��on reported The inspection was performed based on my approved system inspector pursuant n Section maint a Title 5 site C sP yssyste I am a DEP � MR 15.000). The system: y Passes Conditionally passes — Needs Fails Further Evaluation by the Local approving Authority Inspector's Signature: I Date: � - The system inspector shall submit copy of this inspection report to the Approving Authority DEP)within 30 days of completing mP g thus inspection.If the system is a shared system or has a (Board flow Health or gpd or greater, the inspector and 00 the system owner shall submit the report to the appro riate reof I DEP. The original should be.sent to the system owner and copies sent to the buyer,if applicable, P gional office of the pplicable,and the approving Notes and Comments ****This report only describes conditions at the time of inspection time.This inspection does not address how the system will perform in the future under P and under the conditions of use at that conditions of use. the same or different Title 5 Inspection Form 61,512000 page 1 a Page 2 of 11 OFFICIAL FORM ON INSPECTI — a NOT FOR VOLUNTARY J>� SUBSURFACE SEWAGE DISPOSAL SYSTEM ASSESSMENTS INSPECTION FORM a PART A CERTIFICATION(continued) Property Address: C t Owner: �g,�o O 6��� Date of Inspection: aS Inspection Summary: Check A,B,C,D or E/ALWAYS complete all Of Section D A. Syste asses: I have not found any information which indicates that any of the failure criteria described ' =„ 15.303 Orin 310 ClvIIt 15.304 exist,Any failure criteria not evaluated are indicated below. ` in 310 CMR Comments: B• System Conditionally paw; One or more system components as described in the"Conditional repaired.The system,upon completion of the replacement or r Pass"section need to be replaced or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(y,N,ND)in the explain for the following statements.If"not determined" __The septic tank is metal and over 20 years old*or the septic unsound,exhibits substantial infiltration or exfiltration or tank(whether metal or not)is structurally existing tank is replaced with a co tank failure is imminent.System will A metalseptic Ilnng septic tank as approved by the Board of Health. Pass mspection if the tank well Pass inspection if it is structurally sound,not leaking and if a Certificate of Co indicating that the tank is less than 20 years old is available. mpliance ND explain: __ Observation of sewage backup or break out or hi gh obstructed pipe(s)or due to a broken,settled or uneven static water level in the distribution box due to broken or approval of Board of Health): distribution box.System Y will pass inspection if(with broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: __ The system required pumping more than 4 Pass inspection if(with approval of the Board of Her th)a yew due to broken or obstructed i e s .The system will P P () broken pipe(s)are replaced obstruction is removed ND explain: Titis. � inenontinn T?nrn �,/1 Q/7(1M 7 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ;1 PART A CERTIFICATION(continued) Property Address: b 'S Owner: Col Date of Inspection: s C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the B is failing to protect public health,safety or the environment °ard of Health in order to determine if the system I. System will pass unless Board of Health determines in accordance with 310 CMR system is not functioning in a manner which will protect public health,safety and be en3v r)(b that 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 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 surface water supply or tributary to a surface water supply. the SAS is within 100 feet of a 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. _ The system has a septic tank and SAS and the SAS is less than Private water supply well**.Method used to determine distance 1 00 feet but 50 feet or more from a 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 facili the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ty and failure criteria are triggered.A copy of the analysis must be attached to this form provided that no other 3. Other: Trt1A qT.Qnon}jAT ri..rm r`iicr,nnn 3 ` Page 4 of 11 1 ° OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY SUBSURFACE SEWAGE DISPOSAL SYSTEM INS C ION ®SMENTS PART A FORM CERTIFICATION(continued) Property Address: [� l f�GrO✓I �� �, Owner: �-r- C�✓'�Q '���j� Date of Inspection: s s D. System Failure Criteria applicable to all systems; You must indicate"yes"or"no"to each of the following for all inspections: Yes No backup of sewage into facility or system component due to overloaded or clogged SAS or _ — Discharge or ponding of effluent to the surface of the ground or surface waters due to cesspool ,,-Clogged SAS or cesspool an overloaded or Static liquid level in the distribution box above outlet invert due to an overloaded or clogged gged SAS or — c/ Liquid_ q d depth in cesspool is 1 » sP less than 6 below invert Or pumping more than 4 times in the last year NOT available oe to clogged Ior obstructed s less than day flow ,,-Of times pumped pipe(s).Number 'Y portion of the SAS,cesspool or privy is below hi — Any portion of cesspool or privy �ground water elevation. .,water supply. P �' 100 feet of a surface water supply or tributary to a surface Any portion of a cesspool or privy is within a Zone 1 of a public well. y portion of a cesspool or privy is within 50 feet of a private waters 1 Any portion of a cesspool or privy is less than 100 feet but eater 50 Y well. supply well with no acceptable water qualitylid than 50 feet from a private water performed at a DEP certified laboratory,forcoliform bacteria nd volatile is system passes If a well water analysis, 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 organic compounds are triggered.A copy of the analysis must be attached tpopt�provided d that no other failure criteria v (Yes/No)The system fails.I have determined described in 310 that one or more of the above failure criteria exist as 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. gpd to 15,000 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 — — the ystem is within 400 feet of a surface drinking water supply system is within 200 feet of a tributary to a surface drinking water supply — — e system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zon of a public water supply well PP If you have answered"yes"to any question in Section E the system is considered a significant "yes"in Section D above the large system has failed.The owner or operator of any large system considered significant threat under Section E or failed under Section D shall u threat,or answered 15.304. The system owner should contact the appropriate regional office of the system Department em In ac accordance with 3 0 C�1R T;t1. C incnunt;..., _ tteinnn.. A Page 5 of 11 • OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY AS w SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM SESSMENTS i PART B ! CHECKLIST Property Address: Owner: c_�r/10 S e� f Date of Inspection: Check if the following have been done. You must indicate" es"or"no"as to each of the followin Yes o _ Pumping information was provided by the owner,occupant,or Board of Health _ _ Were any of the system components pumped out in the previous two weeks? _ Has the system received normal flows in the previous two week period? — v Have large volumes of water been introduced to the system recently or as art m of this inspection spechon . J" Were as built plans of the system obtained and examined?(If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? V — Was the site inspected for signsof break out ut . Were all system components,excluding the SAS,located on site? Were the septic tank manholes of�ba or tees,material of construction,dimens opns,depth oli uiddepth lud�e depth ofscum dition as the facility owner(and occupants if different fro ma m 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: Yes o xisting information.For example,a plan at the Board of Health. _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)J T410 i inenarfinn T.'nrm Ail ai,)nnn 5 r Page 6 of 11 OFFICIAL INSPECTION FORM—N OT FOR VOL SUBSURFACE SEWAGE DISPOSAL S S EM IN AR ASSESSMENTS TION FORM i PART C SYSTEM INFORMATION Property Address: Owner: Date of Inspection: S o RESIDENTIAL FLOW CONDITIONS RESIDENTIAL ' Number of bedrooms(design): N E DESIGN flow based on 310 umber of bedrooms(actual): .> Number of current residents:C D 15.203(for example: 110 gpd x#of bedrooms): 3�� `'' �e Does residence have a garbage grinder (yes or no): /f/o Is laundry a separate sewage system(yes or no): [if yes separate inspection required] Laundry systst em inspected(yes or no):/L�J Seasonal use:(yes or no): P1 Water meter readings,if avai ble(last 2 years usage(gpd)); SUMP Pip(yes or no)-A[ j Last date of occupancy: COMMERCIALANDUSTRIAL "Type of establishment: Design flow(based on 3 00 CMR 15.203): Basis of design flow(seats/persons/s opd Grease trap present(yes or no):_ gft,etc) Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): Pumping Records GENERAL INFORMATION Source of information: /t'a( �,�, Wass stem pumped part (Y r Y p d as art of the inspection es or no):If yes, volume pumped: --How was Reason for pumping; ----_gallonsquantitY pumped determined? T�YP�ySYSTEM —" SePtic tank, distribution box,soil absorptions stem _Single cesspool Y _Overflow 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 maintenance contract to obtained from system owner) Tight tank _Attach a copy of the DEP approval ( be Other(describe): Approximate age of all components, date installed(if known ) d oyrfe of information: // / / ell Were sewage odors detected when arriving at the site(yes or no): /I j TINP S TACTA/}jAn TiArM ��� /7A/lA ` n Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INS PECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: CC 610 ✓ti,. 0�65 Date of Inspection: �` �"s� i BUILDING SEWER(locate on site plan) Depth below grade: O� Materials of construction:_cast iron _ _ ,f 04 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: c/ locate on site plan) t/ Depth below grade:-Itt �^ Material of construction:_ Oncrete_metal—fiberglass—polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no):_ certificate) ' (attach a copy of Dimensions: A 6" Sludge depth. �7 Distance from:tOpTy—slud-ge to bottom of outlet tee or baffle: Scum thicknes ess / I i Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to botto of outlet tee or baffle: 01 How were dimensions determined: 0/(f / Comments on /2" Q NPv� ( Pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as_rplated to outlet invert,evid race of leakage etc.}: GREASE TRAP:s1A(locate on site plan) Depth below grade:_ Material of construction: concrete metal_fiberglass—polyethylene_offer (explain): _ — Dimensions: Scum thickness: Distance from top of scum o top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or bafll�— Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural irate as related to outlet invert,evidence of leakage,etc.): zesty,liquid levels Titlr+S Tncn<ntinn An,.,,,�/1 c/7n/1n 7 h� t, Page 8 of 1 l " OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART C 3 SYSTEM INFO RMATION(continued) Property Address: % !1 of f oL'i C� / S rvi Owner: C-�r�o v,,� + Date of Inspection• j Tom"f 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 g _polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: allons/da resent F y Alarm P (yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: // (if present must be opened)(locate on sit e plan) Depth of liquid level above outlet invert: �Qe Vt-j ti L Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage ' or out of bo etc.): O PUMP CHAMBER:./locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of groups and appurtenances,etc.): 12 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM i PART C 3 SYSTEM INFORMATION(continued) Property Address: Owner: �+.,-�s� o.�, � Oak 6� � Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) 4 1 If SAS not located explain why: I Typ 1`- eachin g P number: its numb / y / leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): P l'ceti I`C �+ Ga✓� CESSPOOLS:A/—�(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 or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY:k�oocate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level ofponding,condition of vegetation, etc.): T;*lo G T..... --- _r._� citeinnnn U f Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: s4 a r4 t/% CI ,,. OS e✓vi e pa6�jr Owner: Cam+✓✓o r., Date of Inspection: fI SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. G�G1GiY r 1 - 311 ,i J r e �. ; ,r a /� 30 ' �y_ a 9. Titla G Tncnar+;^n 17^r 4/1 v1nnn 10 t ' E Page 11 of 11 9 F� OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FO MNTS PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells 7L Estimated depth to ground water �p1 feet Please indicate(check)all methods used to determine the high ground water elevation: 0 intabe d from system design plans on record-If checked,date of de ' �Observed site(abutting property/observation hole within 150 feet of SAS)lam reviewed. Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe�w you established ttie hig� r and w er elevation: 7�� �T egC q © v� G Ce Q T:tlra i i^c++orlinn�nrm rig`i�nnn 1 1 e�tir.1G�c {J o G A ca,s A►G E G cza r.I D E iz. -�7 _ - •S-3 0O - [�Ao oW s Ilo x 3 - 73oG,po jEPT1G TAkJK = 330ac15C>% : A97G.P. I Jl _`� use l o0o GAL. / /Soop�f" I G oO v I AL. ot5po5nL PI't" v5E .150�5 F ALL z 5e - 13�5•G.P Z9 ��' • . goTTOM AREA- o 'TbTA L. b�SIC.N - .4-25 G.P. D. f ""', / Q• -Te5TAL DA 1 L%( F%--ONE/ PE2GOLATIbiJ RATE � i iN 2MIn1 os`LESS � �_� � / �) I Per � i r RICHARD Ile I A. w. RAXTER 10Ni Na 2 1.048 — tit�c gym► /oo•oc '. 4RD SUa� ` OOLr- 7//S/ ,�Z• o �� L44AlF Ioov INd. So�S(vc _ DIST. GnL. •3 Z 6uX IUJ. 56PrIG y� i i avo INJ, -� TA1J4C tiIEZ� GaL. 39s. LGAGu S4^Z> c ` I W I T LI 7 � WA�,NGD • 670 Pit GEQTIFIGI7 PL07 PLA.Q I L G- Z.5; S Flo SCALE ScALS VA.Tt_nk • `ER 1 cGQTI Y Tfit.AT D'TNaFRCV06c1.4s8.541awo pL. N REFE2ENGE NE,REO►.t GOn�1(='L`�s y�lIT1-1 "CWE SI oFLlt�1 � �/ A W P 5G:7r'a C, 2_GQUIQ-SMA W`i'> OF 'fN� �4=)7 7oWN C7� 3AQru'Z-;V,3Lir Aw-o 1S Na-r— �L.$L!3ZG LOCp.TED Wl-rWQ TqG C�I.00IC' PL&IW b AT E t $: �.� f_-�A�TC=cZ.e I�•J`(E INCH 6LEG 5-Tr &'D'LAW p S u 2N EYoes TUIS K1 i t>STE2VILL.E r MASS, �►i�rDt1MA i _�VEY E- -THE !? Ur's '$woULD r N�o THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......................:.................O F Appitrtttiutt fur Dip i�uuttd urk.s Application is hereby made for a �uttutr�trtiutt...�rrmit Permit to Construct (� or Repair ( ) an Individual Sewage y tem at: g Disposal .................... .....__._.�...._. Q�� ..._....`CtvS A...................... .... J)nn Ai 4��.......__._.._.......RIM__......_......_...... it Owner ••• l.a) .r...._r......................................... Addres nstallera_ f• ... I � Type of Building ............................. .................................................................... Dwelling N . of Bedrooms .........._ Addresa Other 3 Size Lot................ Expansion Attic ( ) -•- . TY of Building n.-1 fyet g At..CR-.......... No. of persons........ Garbage ther fixtures .................................. .. Showers (eD) — Ca ............. � Design Flow............................................gallons per person per day................................_....................................._...._._........._.._._....._............_.. Septic Tank—Liquid capacity./.11oy. allons P Y Total daily flow..././.0 X Disposal Trench—, g Length............. _ 3 ...........gallons. 'Vo.....................Width....................Total Length.-•-•....__. .._Width................ Diameter ............. Depth................ Seepage Pit No......._.x—(. ...._...Total leaching area....................sq.ft. •-•-.- Diameter...................• Depth below inlet_._.__.-,,,,•„-_--•Total leaching area__.••,,,,-„_ Other Distribution box ( ) Percolation Test Results Dosing tank ( ) .................sq.ft. Performed by._.......... Test Pit No, 1................minutes per inch Depth of Test Pit......__.....___..., Depth to .............................................................. Test Pit No. 2................minutes per inch Depth of Test Pit.. Date.._....__ Depth to ground water....................... ••Description of Soil......................... ...............................................................••..._................ ................................... Nature of Repairs or Alterations—Answer when applicable ................................ ....................................................................... . . . PPlicable................. The undersigned agrees to install the aforedescribed, Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sani tar _ Individual Operation until a Certificate Of Compliance has been issued by the board of health. The undersigned further agrees not to place the system in tgned.. .. _ Application Approved B JL; PP Y 1`f ............................. .. ............ Application Disapproved or {ie ollourin .......................... D ) g reasons:...._._. ----•............... ..................................................... Date ............................. ........................•.___._ .............................................................................. Permit No....._._ ,",---,•- IssnCd....................ate _ THE COMMONWEALYH-vr BOARD OF HEALTH ..........................................OF................................................:.................................... -- �r iftrtt f�umtrlittnr>e THIS . RTIFY, hfat -e Indio' swage Disposal System constructed ( or"Repaired ( ) by..........- r -e+ •--•--•-- Instaliv has been installed in accordance with the provisions of TIT 5 of T1leState Sanitary ° es�Srtbed in the application for Disposal Works Construction Permit No...k��....-T..a'.j.......,----„ dated. .....: ',r/.7_. .................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE........................................_......_............_.................... Inspector--'' ..:................. THE COMMONWEALTH OF MASSACHUSETTS ✓//// BOARD OF HEALTH ?J._.!..- ...........................................OF.......................................................:. No............... Ftss........................... ifs,pat Murk, TomArWiatt rrrmit Permission is herPe' . �� ....... .._ ... ................ to Constttt' rair n Indio' I Sewage Disposal Systemat . /:_l/t f1t.. ,._.eAr............................................................--...--- :. � Street �" / ` ................ Dated,.- as shown on the applicatio for Disposal Works Construction PermiLNo....._ ..;.. -b"ated� :;, ................ /Z/DATE... / . Roard of Health FORM 1255 A.M.SULKI , INC., 130STON �' �� IN G 1J _Q ATA=-- T ��rrJGLC- F-Am;LY - 3 Bc oczooM S3oo Flo GA2�,o.GE DNiL%,r P=Low z IIoY, 3 - 730G,PD �jE�PTtG TAQK = 330x15D% = A976.P. o U5� I000 oi5Po5AL ►�1-r vsl~ Ivoo SAL. S DCW,4LL A2GA 150 S.r i ----- -BOTTOM 5� 5.r- x I a - 5.0 •T aT A L. i •Tc,-rAL. DAILY F�-OW - 3306,17C) .1 PC -riot RATE : 1 tN 2MIn1 or.LESS Ole Pir i i il OF Mq '+61 RICHARD df, AlA14 I / at A. W. i BAXTER u, JONC _ t1a 2."8 O ? C 12) 9p SURV i -t -r #.o z/pc� yQ `To a Fuv=�{3•o r-,� LAt�cJF 1 o ov IW. Sa�,SD✓c_ DIST. IWV. GAL, yo.3 Z t ovo IN,/ �`•� TANK NIEz� GaL. 39S l S�� I Lcacu \ INV. INd, v/t T u �y G C i s7c;pG .Ci 5.4� ---i'•i~ � '1''f I GESZ•TIFiGD PLoT PLAID i �L i4ZUFIL� l.o�A,-rlotJ vSTE.e�/LL-�- Z�S I`Jo n-r T IiA�PQoPbS�-n IASE•5"o mi - NE2EOr.1 L01r�F U/, yJiTNTk1E SIt>5--U 1�s -'ro W N o F AN-D If, Na-� ,oL.8.t!.3ZG �6, 7/ LOCN•TED WIT11t�'1 T1-lE G1.00D PLAIIJ D AT E �►C�� l _ .� `�` —' AT 6 2 e 1�.1`(� I N C. ST f�Q 6b'G AN D•$ 2N E`(oeS THIS P1.��1 ;c r C3l��j�n OId AN �STE2VILLE• MASS. ` -rNEnI-�SET5 Suou� EL/T4c31�'r.5/J. �i/SE%Q r " THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..............................I...........OF.......................................................................................... Appliration for Dispatial Works Tomitrnrtiun anti Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal Sy tem at 11 L .. ........Z ar 9..--•.aUlkit.......1 ... .�j�? � . ........................ '-Q ...... ....................................... ion.:.. es Lot o. ... .... s A----------------------------- ..... rs n'.n Owner Address W .. ...........................................•.... ...---------.....-•---••.......--••••---•................................................---•-.... Installer Address dType of Building Size Lot....................... ... Dwelling N of Bedrooms ......... .--------•............Expansion Attic ( ) Garbage Other Tye of Building ...19a!?G ._.......__. No. of persons...........�.............. Showers (�) — Ca a ther fixtures -----•--------- -------- d -. ........-•-------•----•-•---------------------•----•-----._.....---------------••---------------------- W Design Flow...........................................gallons per person per day. Total daily flow---`Y©X 2..=...0.2.Q..........gallons. WSeptic Tank—Liquid capacity.&PS ..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 ( ) `4 Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ (% Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 0+ •-••----------•--------•-•-•-••--•-•.................. •......... .----------- •.......................-----•---•-•-••••-•....•-------••--•-•----....-----....•. 0 Description of Soil.....................................................................................-------•---------•----•--••-----------.....-------•---------------............._.. U --------------- •---------- •-------- -------------------- ............. :.------------------- ....... --------------•-------•-------... -------- •----------- ._............................... W VNature 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 MILL 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. igned.. .. . .h ;Il !... .:. • -------- 9.._y e . . ........ Application Approved B . --G- ---•-••... --`�--------------•------ Date Application Disapprovedwing reasons:............................................•---•---•--•-----------•------•-----•-------._...............--•.. --------•-----------------••-•-•---•-----.....-----••----•--••--••---•----...---••-------......----.....................................---------•------------------------------------•--•...••••........ Date PermitNo......................................................... Issued......................................................... Date >�.P`..............:.... Fps j- _.... ........ I THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..._......._.. ..............----.OF...................................... Applirattun for Di,gpusal Works Tomitrnrtiun Vamit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: . 1 �. c..a ��c.�.r......��►�.���----------- -------------------------- ------------------------------- -��. .�1y........................................... ...........1t_l\.�.Q�."Q. .... ......�Q� x............................. .�.� ..---- ro.'l�-Q.t.4... .�Q.Y.�._...lY..r.. ,:, ��.i..d.:'! Owner Address W __...__^............................... ........•----•-••--••----.........r..... =-...__ -_................................................ •..... ••-•--•........................•---..... ....-.`- Installer ^:�'� Addre`�s Q Type of,,Building -•; Size Lot.............. C�a __!. q,' f et U Dwellin No. of Bedrooms............ ........................... Expansion'Attic�--� g— _ p ( ) GarbageiI}de ) aOther—Type of Building ... ............ No. of persons.........._1.............. Showers (� ) — QOther fixtures -------------------------------------------------••---••••---•=-----•-•••••-•---•-•-•---•--•-----•-•-•------------•-••--••-•••......--...........-- W Design Flow............................................gallons per person per day. Total daily flow__./� ,K_`.3.:=__ 3_ ..........gallons. WSeptic Tank—Liquid capacity./(A2!—_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 ( ) nt Percolation Test Results Performed by........................................................................... Date........................................ Test Pit No. I................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........................ ------------------------------------------------•-••-------•---.....--------...................-•-•------•-••-----•--•-----................__.....--•--.--•- 0 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 board of health. Signed .J:L�L/� •. • ..........•..--- .--- Date Application Approved BY ----- f ...._:/� - ••-•••...._.... / Date Application Disapproved orAe following reasons:.................................................................................. r -.................... .. --.....-•••••-••••••--•••••-••••••-•--•-•-•••--••---•---••••-•---•---------•••------•-••--•-••••----•-•....-•••-•-•-•-••-•••••-••----------•--------•-•••••••------..................................... Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... �r ifirat Bunt hatta THIS. CF.RTIFY, Q t -e Indio' al.-Sewage Disposal System constructed ( -or Repaired ( ) j Installer at............................................................................................................................................... .................... has been installed in accordance with the provisions of TIT F 5 of T;sc-State Sanitary 0o 0,ff&de ribed in the application for Disposal Works Construction Permit No._ .-�� �j.............. dated........ f ... ......_..................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.....................................................:.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............O F.......................... .... `/'10 ............................... .......... ............................ No.. ............... ... FEE........................ Ot anal Vorkg Tanngtrwiott rrntit Permissionis heret<iy gar. ••----................. --•--........--.--...-•----•--•--------------....---•--•---•------•--_......-----......--•-•-•---....----...... to Construt-( f or epair n Individual' Sewage Disposal System at I . ... = = - 1---- ........... as shown on the a licatioR for Dis osal ��'ork Street / n r /,/ pp p s`Construction Permit No.._ ' ..__ Dated`._..____ .'./.. ................•---- / Board of Health DATE.......... ...•• .-•-- ---•.----.-----•----------------•-•---•-------- FORM 1255 A. M. SULKIN. INC.. BOSTON LM4 q� . � �zk � 3 ---- 11 '��5- �/� T ION_��Z S E W A G E PE RMIT NO. VILLAGE I N S T A JYER'S NAME g XDDRESS BUILDER OR OWNER 41/ DATE PERMIT ISSNED DATE COMPLIANCE ISSUED 13 .� //: race /moo AV 1 a