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HomeMy WebLinkAbout0200 STURBRIDGE DRIVE - Health L00 �tur,bridge ll'�Usterville)� 66-088 A=1 e TOWN OF 13ARNSTABLE SEWAGE # :w VILLAGE r�DU ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) 'f (size) NO.OF BEDROOMS BUILDER OR OWNER V ei�dl.PlO.� PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) 7 Feet Edge of Wetland an Lea ng Faci ' (If any wet an exist within 300 feet 1 n ty) Feet Furnished y c r I �� act �� _ — c1r) OA7E:8/14/01---------- - P R O P ER T Y A 0 0 A E s s:200_Sturbridge-_Drive--- ' 'Osterville,Mass. --------------- r_�2655..----------- - On Iho aboyo date, I inapeoted 'the aepllo OyltorM at the aboyo address. Th13 ayslom conslali of the lollowln9, 11 . 1 -1500 gallon septic tank. 2. 1 -Distribution box. 3. 1 -1 000 qallon leaching pit. 6 'X1 pp ' EC ( la Be�to on my Inipec Ion, I oortlly the following oondlt once 4 . This is a title five septic system. ( 78 Code ) AUG � 5Qd� 5. The septic system is in proper working order ' at the present time. TOWNOFBARNSTABLE HEALTH DEPT. SICNATURt't„/ Company: *Jos _N•comD.r_b .Son , rnc , Addreaa : Box 66 :_ w__C�n� • rYlll � � Nei-02632r0066 f Phone __ 509- 115-„)�)8 _ Tnlg CIRTIFICAYION OOE$ NOT CONSTITVTC A OVARANTY OR WARRANTY JOSEPH P. MAOOMBER & SON, INC, . Y+nx��0�ttpoolrl +chll+ld1 Pvmpfo 1, Init llt!d Town Stwfr Conn+o�Ioni P.O. Box 66 CtnfirYill+, MA 026JZ-0066. rrs �a�e r7s64r2 -\ COMMONWEALTH OF M.A}SSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL' PROTECTION i TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 200 Sturbridge br;vA Osterville.masc Owner's Name: James Flynn Owner's Address: Same Date of Inspection: 6714/01 Name of Inspector: (please print) Joseph P_Macomber Jr. Company Name: J.P.Macomber P, Son Inc. Mailing Address: Box 66 S'PntPrv; 1 1 o P4aGG. 02632 Telephone Number: rnt••ur, 8��8 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 the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to ection 15.340 of Title 5(310 CMR 15.000). The system: Passes f Conditionally Passes Needs Further Evaluation by the Local Approving Authority ail Inspector's Signature: Date: — The system inspector shall ubmit a•copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the-buyer, if applicable,and the approving authority. Notes and Comments ; ****This report only describes conditions at the time of inspection and under the conditions of use at that/} time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 r Page 2 of 11 OFFICIAL INSPECTION FORM—'NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 200 Sturbridge Drive Os ervi e, ass. Owner: James Flynn Date of Inspection: 8 Inspection Summary: Check A,B,C,D or E/ALWAYS complete ail of Section D A. System Passes: Ak- I have not found an information hich 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: x The septic system is in proper working order At the nr s _nt time. B. System Conditionally Passes: .X)A 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. Answer yes,no or not determined(Y,N,ND)in the 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. ND explain: .,L)A Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution boxis leveled or replaced ND explain: A0 The system required;pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address- 200 Sturbridge Drive s ervi e, ass. Owner: James Flynn Date of Inspection: 8 1 4 01 C. Further Evaluation Is Required by the Board of Health: Conditions exist which'requ•tre further evaluation by the Board of Health in order to determine if the system is failing to protect public health,.safety or the environment. I. S,N•stem will pass unless Board of Health determines In.accordance with 310 CMR I5.303(1)(b) that the system is not functioning In a manner which will protect public health, safety and the environment: Cesspool or privy is within SO feet of a S'urtace water Cesspool or privy is within.SO 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: if/D 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. /0 The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply. The system has a septic tank and SAS and the SAS is within SO feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than I W feet bu 50 feet or more from a priN-ate water supple well". Method used to determine distance t,��� , 'This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than S ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: NONE 3 I Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 200 Sturbridge= Drive 0sterville,14ass. Owner: James Flynn Date of Inspection: 8/14 f o 1 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No ]Vackup 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-1.IO—1000 11 , _ Liquid depth in.cesspeal is less than 6"below invert or available.volume is less than h day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped . Any y portion of the SAS,cesspool or privy is below high ground water elevation. portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface — water supply. - y 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 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no.other failure criteria are triggered. A copy of the analysis must be attached to this form.] I (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no // the system is within 400 feet of a surface drinking water supply !� a system is within 200 feet of a tributary to a surface drinking water supply f� 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. 4 r Page 5 of I 1 {. OFFICIAL INSPECTION FORM.—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 200 Sturbridge Drive ; s ervi e,Mass. Owner: James F ynn Date of Inspection: 8 14 01 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No _ WP mping information.-was provided by the owner; occupant, or Board of Health; ere any of the system components pumped out in the previous two weeks^: _ Has the system received normal flows in the previous two week period.? ave large volumes of water been introduced tothe 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? f _ Was the site inspected for signs of break out? _ Were all system components,4luding 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: Yes no/ !/ 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(3)(b)] x - 5 ` Page 6 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION. Property Address: 200 Sturbridge Drive s ervi e,Mass. 7 . Owner:James Flynn Date of Inspection: 8 14 01 , FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMI� 15.203 (for example: 110 gpd x# of bedrooms): AVV JV Q��l/ Number of current residents: / Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system ( es or no): [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use: (yes or no): Water meter readings, if available(last 2 years usage(gpd)): ¢ y1C 4 /9i ") n� Sump pump(yes or no): hI.1" Last date of occupancy: r COMM ERCIAL/WDUSTRIAL Type of establishment: ; Design flow(based on 310 CMR 15.203): . d ' Basis of design flow(seats/person�sg/sgft,etc.): 414 dCLr Grease trap present(yes or no): 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: .4/�¢ Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records 11 Source of information:Z ,�4.�J"7 Was system pumped as part of the inspection(yes or no): If yes, volume pumped: _gallons-- How was quantity pumped determined? .e4 Reason for pumping: TYP OF SYSTEM OF tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy - AV 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) Tight tank Attach a copy of the DEP approval tiWther(describe): Approxim to k2g of all comp n s,date in ailed(if own and source f" formation: l� Were sewage odors detected when arriving at the site(yes or no): ,. 6 Page 7 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 200 Sturbridge Drive s ervi e, ass. Owner: James Fl nn Date of Inspection: 8 1 4 01 BUILDING SEWER(locate on site plan) At Depth below grade: 240 Materials of construction:N9cast iron PVCA�/ .Ath r(explain): Xf Distance from private water supply well or suction line: 0 Comments(on condition of joints,venting,evidence of leak a etc.): Joints appear tight.No evidence o? ieakage.The system is ventedroug the House vents. SEPTIC TANK: (locate on site plan) l8G!�f M Depth below grade: la / ZtM erial of construction: concrete, metalC/D fiberglassU�polyethylene other(explain) i( If tank is metal list age:&�" Is age confirmed by a Certificate of Compliance(yes or no):4(attach a copy of certificate) Dimensions: Sludge depth:-:��� Distance from topSJ_&Wdge 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.): Pump the septic tank annually.Garbage disposal is present. ,^ inlet outiet teesare in p ace.T e tank is structurally sound an s ows no'evi2lence of leakage.,The liquid level at the outlet invert is 51 " GREASE TRAM"locate on site plan) Depth below grade: Material of construction: t//Iconcretenl�! metal�ftberglas s4;ypolyethylenefoother (explain): /1fi9 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: �i1D Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels 'as related to outlet invert,evidence of leakage, etc.): Grease trap is not present. 7 Page 8 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ° SYSTEM INFORMATION(continued) Property Address: 200 Sturbridge Drive s ervi e,Mass. Owner: James Flynn Date of Inspection: 8/13/01 TIGHT or HOLDING TANK(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: ` Material of construction: concrete Jt metal Ay fiberglass jig polyethylene 4�4_other(explain): Dimensions: AMN Capacity: AA gallons Design Flow:_ Agallons/day Alarm present(yes or no): Alarm level:__&�L Alarm in working order(yes or no): Date of last pumping:_ %$ Comments(condition of alarm and float switches,etc.): Tight or holding tank is not. present DISTRIBUTION BOX:�(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: ,. .Y Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Distribution box is not present No evidence of o1 ;dG carry over.No evidence of leakage into or out of the - box. PUMP CHAMBE (locate on site plan) s Pumps in working order(yes or no): AM Alarms in working order(yes or no): Comments(note condition of pump chamber, condition.of pumps and appurtenances,etc.): Pump chamber is not present. 8 r Page 9 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address?00 Sturbridge Drive s ervi e, ass. Owner:James ynn ' Date of Inspection: 1 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required) 1000 gallon leaching pit. V X10 ' If SAS not located explain why: Located. Type leaching pits, number: _&Za leaching chambers, number: _dLVleaching galleries,number: AA91eaching trenches,number, length: AIV leaching fields,number,dime ons: AV overflow cesspool,number: innovative/alternative system Type/name of technology:/ // G Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil;conditio of vegetation, etc.): Loamy sand to. boney fine sand No signs of hydraulic failure or ponding Soils are dry.Vegetation is normal CESSPOOLSe"(cesspool must be pumpe&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. 4 Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of-vegetation,etc.): Cesspools are not present. PRIVY.4f� (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): Privy is not present. 9 Page 10 of I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORM.AT.ION (continued) Property Address:200 Sturbridge Drive : Os ervi e, ass. . Owner. James Flynn Date of Inspections a 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 I00,reet. Locate where public water supply enters the building. I \ 00 5' -OAb',tZid 6_e x 10 p Page 11 of I 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address'. 200 Sturbridge Drive s ervi e, asss.. Owner: James Fiynn Date of Inspection: SITE EXAM Slope Y Surface water Check cellar Shallow wells Estimated depth to ground water�feet " Please indicate(check)all methods used to determine the high ground water elevation: AU esi lans on record-if checked,date of design plan reviewed: erve a a roperty/ bservation hole within 150 feet of SAS) hecked with local Board o ealth-explain: :Zcchecked with local excavators, installers-(attach documentation) Accessed USGS database-explain: r You must describe how you established the high ground water elevation: Used water contours map- Gahrety & Miller Model 12/16/94 11 • r,•nTnr•i.-n,•rr�.•-- rrr.-inr•r.tnrnrrnra�.rmr,-.r++rRri�..•+'n.rr ner�v ss•�s��n w-e+ .rn-rrr•�r:..-..�... TOWN OF Barnstable WARD OF HEALTH SUIISURFACR 9FWAGF DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION I -•rn-r••••. -r.,,r.-.rrn.�n�-rt.rn rwR�e+rrn�errr.�+-vrn��w�-•r+a++-�,►�+ww��� �n •'.+rrrr--., -..A -TYPE OR PAINT CI.EAeLY- PROPERTY INSPECTED STREET ADDRESS 200 Sturbridc#e Drive Osterville,Mass. ASSESSORS MAP, BLOCK AND PARCEL # OWNER' s NAME James Flynn PART D - CERTIFICATION NAME OF INSPECTOR Joseph P. Macomber Jr.. COMPANY NAME Joseph P. Macomber &ton Inc F COMPANY ADDRESS Box 66 Centerville Ma 02632 Strevt Town or City State LIP COMPANY TELEPHONE (508 ) -775 - 3338 FAX • (508 1790 - 1 578 CERTIFICATION STATEMENT I certify that I have "person•ally inspected the sewage disposal system at this address and that the information reported is true'-, accurate , and omplete as of the time of:�inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check ne . , System PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public healLh or the environment as defined in 310 CMR 151303 . Any failure criteria not evaluated areas stated in the FAILURE CRITERIA section of this form , System FAILED* The inspection which I have con cted has found 'that the system fails to Protect the .public health and the environment in accordance with Title 5 , 3.10 CMR 15 , 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection fWo m •{ r , Inspector 5ignatu're - Date ne copy of this c Ification must be provided to the OWNER, the BUYER ( where app1 icable ) and the 130ARD OF HEALTII, , * If the inspection PAILED, the owner or operator shall upgrade %the eyetem within one year of the date of the inspection, unless allowed or require(i . otherwise as provided in 3.10 CMR 16 . 306 , partd .doc r� 177 l( -� LOCATION SEWAGE PERMIT NO. VILLA INSTALL DDR E RJ.&N A. AANBAEKHOE ER IICE SS ---1541.In-it Street West Barnstable, Mass. 02668 GUILDER OR OWNER Jug �s VT,' �h DATE PERMIT ISSUED , DATE COMPLIANCE ISSUED F r ,fin �73 Igo.... ....._....... FEE............... #" THE COMMONW ALTH',OF„MASSACHUSETTS t.r Y. tp- B®AR®,f E HEALTH 0"F.­b , plifiration for 11Wpnaal Morks Ton rn.rtinn Vamit Application is hereby made for a Permit to Construct (� or Repair ( ) an Individual Sewage Disposal System at: l �6 � 05/;-V/L LC ................_...... �. ••---.....• ......................................... -------------•-•-------.............•---------••••----•-------•------------•-----......--••------- /�y /Coca' Address .....Lot No. --------- ------ ow Address W v'-d humi3�L .......... ............. ............ Installer Address �� ��v r_�.. d Type of Building �S ze_Lot_ _____e..................Sq. feet Dwelling o. of Bedrooms............... _________________________Expansion Attic (kb Garbage Grinder K) Other—Type of Building ............................ No. of persons............................ Showers Cafeteria QOther fixtures ---------------------------------••-•......•--• t------_- ----------------- Design W Flow.......................... .•�i_........gallons per person per day. Total daily flow................... ---fg lions. WSeptic Tank—Liquid capacity.k"O gallons Length................ Width................ Diameter....................Depth Disposal Trench—No..................... Width.................... Total Length........• --•• Total leaching area.........U_� sq. ft Seepage Pit No.... /._..._.. Diameter...........i.._. Depth below inlet.....R......... Total,l'eaching area..aZ.66...sgq. ,f Z Other Distribution box ( ) Dosin tank a Percolation Test Result Performed by--- _. ... ._..-._�. ...._.' Date._... _ _...... '__1� 91...� ,.a Test Pit No. i................minutes per inch Depth of Test i ___6�«._.._..__. Depth to ground water.__Q_ .__�'l, Test Pit No. 2----------_.....minutes per inch Depth of Test Pit......:............ Depth to ground water.___..._._.........._..Q - --------•- •• ••-• ............................ •- O •-t-- Description of Soil �� - Cam` U/.Z�. 1 � x ---------------------------------------------------- -•-•------------ U 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 TITI.;=. 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate Hof Compliance has been issu d by th board of health. Signed ... ----• ..... . Date APPlication Approved BY-------- ---��----•-•---•---------------- � Application Disapproved for the following reasons---- --------------------•---•-------•------------•------•------------------------------------------------------- .........---••--•-••••-•--•--•-•-•---•...............••--•---•-•---•••--•--••••••---------•-•------•-•-•-•--•-•••••-•••••••-•••-••---••••-•-•......-••••••••-••••-••---••••-••--•--•-.................. Date PermitNo...... ,.............. 7 7..._...._--•-••-----... Issued....................................................... Date ti No._A�.. 7 7. X.— ..... ............ THE COMMONWEALTH OF MASSACHUSETTS BOARD ..... �OF. H.E.....A.......L. ...T......H )A)...................OF... -eE ppliration f or Uhpoiial ................................... Vorkfi Tonstrartion Prrmit Applicationhereby made for a Permit to Construct or Repair an Individual Disposal is age, Systeidat: A/6 Z Z1,J ........................ .......................................... .................................................................................................. Localt'aff-Address or Lot No. .... . ..... ............................. .................................................................................................. Address ............... ................................................................................ .................................................................................................. Installer Address Type of Building Size Lotict,k-30-----Sq. feet Dwelling;;?�o. of Bedrooms.................:5.........................Expansion Attic Vb Garbage Grinder (41) P4 Other—Type of Building ............................ No. of persons__.._....._.........._..__.. Showers Cafeteria Other fixtures . -------------------------------------------------------------.... *------------------------------------------------------------­------------------------Design Flow.....I.................... .........gallons per person per day. Total daily flow.................:Ya.6.............g?dlon,s. Septic Tank-7-L .. iquid,capacity... .. .gallons Length................ Width................ Diameter.............__. Depthy.76__..'.'. Disposalfi�rr Width................... Total Length............111... Total leaching area....................sq. ft. Seepage Pit No.......... ................ Diameter...........:w..... Depth below inlet......____..___.._.. Total leaching area..9.2..C45....sq. ft. Other Distribution box Dosing tank et)... pp lr:�n....... Date Percolation Test Results. Performed by..--.11-Y........ :?� _ L__ .... ........... ..... ........ Test Pit No. I................minutes per inch Depth of Test i ...150......... Depth to ground water... (Tq Test Pit No. 2................minutes per inch Depth of Test Pit._........._....____ Depth to ground water....................__.. Ix ........... ........................ . ............../.... .... ..........r,............................... Description of Soil.... 0 ...M..../ h........... ......... ..................- ---7* X 'A 2--- ---- ...24 t--.................... U ............................ ........................................................................................................................................................................... ......................................................................................................................................................................................................... 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 ITTILE 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..... &................................... ............... q Date Application Disapproved for the following reasons:..-------- H........................................./'� ................ .......................................... ......................................................................................................................................................................................................... Date ------------------------ Permit No._ .1A.m.....07........................ Issued...... ............ Date COMMONWEALTH OF MASSACHUSETTS�­' BOARD OF-,.,HE_.jkL XH y. ...........OF_........... rzYe4.t...................................... Trrtffiratp of Toutpliattrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired by..................T.ehul'r:........... .................................................................................................................................... Installer at...............4e_r!�.........141.......... j�............Cjv. ......... ........................................................................ has been installed in accordance, with the provisions Of-TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No..A Z;7 :.L�............... dated-. -!!Z.......... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A ��UAR,ANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE......................................rev---------... Inspector...... ............................................................. THE COMMONWEALTH OF MASSACHUSETTS BOARD dFIFIEALTH ...................... .........0 4r*_4'Z-e...................................................... FEE........................ Disposal Varks Tywanstrudion pumit Permission is hereby granted............N:7&4>= ........ --------------------------------------------------------------------------------------- to Construct (,i( ) or Repair ( ) an Individual Sewage Disposal System atNo.......... 70----­-------- ....... ------------ .............................................................. Street as shown on the application for Disposal Works 4C'-A;-stiir ukii0h Permit No Dated.._.._.1)v�_ 4 o - t,',ft �p.........;..... ...... ................................................................ 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