HomeMy WebLinkAbout0132 SWIFT AVENUE - Health 132 SWIFT AVENUE, OSTERVILLE
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TOWN OF BARNSTABLE
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LOCATION�� ` l�P '�' SEWAGE #
Vr ,LAGE ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY /gr,000
LEACHING FACILITY: (type) l�1�� 71 Fv (size.) .Z�*
NO.OF BEDROOMS
BUILDER OR OWNER
PERMTTDATE: COMPLIANCE ATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and 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) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet ofelyhXcility) Feet
Furnished by
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DATE: 10/2.3./98
PROPERTY ADDRESS: A 3 2 'Swift Ave ��< < <- ,
Osterville,Mass. ,�
RE,66v ,�
f : ..
CT 0 1998 ,
TOWN OFBABIISTABLE Imo.
On the above date, I Insp-ected the "ptic system at t' above`T"�'&dreas��
This system consJsts of the following: ��'
1 . 1 -1500 gallon septic tank.
2 . 1 -1000 gallon precast leaching Pit.
Sesed bn my Inscactlon, I certify the following coridltlons:
3 . This is a •title five_ •septic system. ( ,.7.a; Gode
4 . The septic system -is in proper working order .
at the present time.
5 . Pumped the septic tank at time of inspection..
SIGNATURE: J ,
Name J P Macomber Jr, i , . .
-,— -------
Company:_`. _ _
P . MacorQber & Son•_Inc ;
Address:
--Sax-66-------- -------
__Cence_rville `Masg._02b32
Phone:___Spg� 3338_______ . I
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
L177,1�-33U.
H P, MACOMBER & S0" INC,
7ink�-Ceupools-Leachflelds
PUMP�d Il Instsl1w
Town Sewer Connections
x 66' Cenlervllle, MA 02632.0066
775-bd12
, J : C
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET, BOSTON, MA 02108 617.292•$500
i
WILLIAM F.WELD TRUDY C-
Govcmor Sect
ARGEO PAUL CELLUCCI DAVID B.STR
Lt.Govcmor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commiss:
PART A
CERTIFICATION
Property Address: 132 Swift Ave Ostervi1 le,Mass.Address of Owner:
Dale of Inspection: 1 0/2 3/9 8 (If differenq
Name of Inspector: Joseph P.Macomber Jr.
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: J.P.Macomber & Son Inc.
Mailing Address: BOX 66 Centerville,Mass. 02632
Telephone Number: 5 0 R_7 7 5_3 3 3 9
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accura
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function anc
maintenance of on-site sewage disposal systems. The system:
Passes
_ Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
_ Fails
Inspector's Signature: Date:
The System Ins shall submit a copy of this inspection report to the Approving Authority within thirty (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 subm
the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system om
and copies sent to the buyer, if applicable, and the approving authority.
INSPECTION SUMMARY: Check A, B, C, or D:
AI SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.30
Any failure criteria not evaluated are indicated below.
COMMENTS:
BJ SYSTEM CONDITIONALLY PASSES:
�D One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, up
completion of the replacement or repair, as approved by the Board of Health, will pass.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection;
R.
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or W
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
(revised 04/25/97) pay. 1 of 10
DEP on the World Wide Web: http:/Iwvrw.magnet.state.ma.us/dep
Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
'PART A
CERTIFICATION (continued)
Propeny Address: 132 Swift Ave Osterville,Mass.
Owner: Charles Manning.
Date of inspection: 1 0/2 3/9 8
e) SYSTEM CONDITIONALLY PASSES (continued)
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s) or due to a broken, senled or uneven distribution box. The system will pass inspection if(with approval of the
Board of Health). Describe observations:
broken pipes) are replaced
obstruction Is removed
distribution box is levelled or replaced
di") The system required pumping more than four times a year due to broken or obstructed pipets). The system will pass
inspection if(with approval of the Board of Health):
broken pipes) are replaced
obstruction is removed
Cl 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 procec1 t
public health, w1cry and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENTt
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES TH
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
�Q The system has a septic tank and soil absorption system (LQ and the SAS is within 100 feet to a surface water supply
tributary to a surface water supply.
N The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 fret but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates 0
the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate niuogen is equal to
less than 5 ppm. Method used to determine distance �_(approximation not valid).
J) AOTHER
of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Properly Address: 132 Swift Ave Osterville,Mass.
Owners Charles Manning
Date of Inspection: 1 0/23/98
D) SYSTEM FAILS:
You must indicate 'Yes' or'No' as to each of the following:
_A_ I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is identified below, The Board of Health should be contacted to determine what will be necessary to correct
the failure.
Yes No /
y Backup of sewage into facility or system component due to an 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.
_.IWAJC Static liquid level in the distribution box above outlet Invert due to an overloaded or clogged SAS or cesspool.
_ Liquid depth in-�iss.less'than V below invert or available volume is less than 1/2 day flow.
V/ 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water arulysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen,
E) LARGE SYSTEM FAILS:
You must indicate either 'Yes' or 'No' as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to
public health and Wery and the environment because one or more of the following conditions exist:
Yes No;
the system is within 400 feet of surface drinking water supply
�l
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area • IWPA) or a mapped Zone II of a
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please.consult the local regional office of the Department for further information.
(r•vl••d 0//13/)7) )•0• ) of 10
SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 132 Swift, Ave Osterville,Mass.
Owner: Charles Manning
Date of Inspection:10/2 3/9 8
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No
Pumping information was provided by the owner, occupant, or Board of Health.
None of the system components have been pumped for at least two weeks and the system has been receiving normal
flow rates during that period. Large volumes of water have not been introduced into the system recently or
as part of this inspection.
As built plans have been obtained and examined. Note if they are not available with N/A.
_ The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow.
_ The site was inspected for signs of breakout.
All system components, !Vcluding the Soil Absorption System, have been located on the site.
_ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of
baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
—The size and location of the Soil Absorption System on the site has been determined based on:
-klThe facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of
Sub-Surface Disposal System.
_ Existing information. Ex. Plan at B.O.H.
_ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) 115.302(3)(b))
(revised 04/25/97) Page 4 of 10
OWN
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:132 Swift Ave Osterville,Mass.
Owner: Charles Manning.
Date of Inspection: 1 0/2 3/9 8
FLOW CONDITIONS
RESIDENTIAL:
Design 6.p. Jbedroom for S.A.S.
Number of bedrooms:
Number of current residents:
Garbage grinder (yes or no):Ms
Laundry connected to system (yes or no):A�
Seasonal use (yes or no):AD— ! p
Water meter readings, if available (last two (2)year usage (gpd): m O�o/IiG�1d c�� �/ ,
Sump Pump (yes or no):� l /,Q� 7 s-
Last date of occupancy:4�
COMMERCIAUINDUSTRIAL:
Type of establishment: A0
Design flow: .41,4 Rallons/day
Grease trap present: (yes or no)A!,Od
Industrial Waste Holding Tank present: (yes or no)-A&
Non-sanitary waste discharged to the Title 5 system: (yes or no)Z
Water meter readings, if available:_
ge4
Last date of occupancy:1
OTHER: (Describe) 144
Last date of occupancy: i(/
GENERAL INFORMATION
PUMPING ORDS ago source of infor. tion:
System umped as pa of inspection: (yes or o)
If yes, volume pumped: lions
Reason for pumping: a" / xj'S �i11�i9/If�
TYPE O STEM
Septic tan soil absorption system
— Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
VA Technology etc. Copy ol up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information:
Sewage odors detected when arriving at the site: (yes or no)Z_f/v
(revised 04/25/97) Page 5 of 10
T' �L
IL
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 132 Swift Ave Osterville,Mass.
Owner: Charles Manning
Date of Inspection: 1 0./23/98
BUILDING SEWER:
(Locate on site plan) �{
Depth below grade: aJ)
Material of construction: cast iron/40 PVC_other (explain)
Distance fro �rivate water supply well or suction line 1D'Y
Diameter
Comments: (condition of joints, venting, evidence of leakage, etc.)
O
ys em i ven e roug e ouse ven '
SEPTIC TANK./,/; Y44�J
(locate on site plan)
Depth below grade:
Material of construction: concrete _metal _Fiberglass _Polyethylene _other(explain)
If tank is metal, list age Is age confirmed by Certificate of Compliance (Yes/No)
Dimensions: /D'l"�o /P� --/-
Sludge depth: 0 Z4�
Distance from top of I dge 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 bott^ of outlet e or baffle:
How dimensions were determined:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.) Pump septic tank annually; Garbage disposal is
present; Inlet & outlet tees are in place;The tank is structurally
sound and shows no ' evidence of leakage;
GREASE TRAP:!�'&z
(locate-on site plan)
Depth below grade:
Material of constructionrl�concretey�metal, Fiberglass 4/4PolyethyleneNYXbther(explain)
Dimensions:
Scum thickness:_QZA
Distance from top of scum to top of outlet tee or baffle: 40
Distance from bottom of scum to bottom of outlet tee or baffle:40
Date of last pumping:,&,6*—
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.)
Grease trap is not present.
(revised 04/25/97) Page 4 of 10
SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:1 32 Swift Ave Osterville,Mass.
Owner: Charles Manning
Date of Inspection: 1 0/2 3/9 8
TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection)
(locate on site plan)
Depth below grade:
Material of construct ion:,(A,� concreteN&metal,6!ffiberglassA*olyethylene4gother(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm level: Alarm in working ordepVj Yes;4, Q No
Date of previous pumping: Wig_
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
Tight or holding tanks arp unt r®se;jt.
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet inven:
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)
Distribution box is not present _
PUMP CHAMBER:,&Af
(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 pumps and appurtenances, etc.)
Pump chamhpr i s nnf- p-riz tent
(revisal 04/25/97) Peg• 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 132 Swift Ave Osterville,Mass.
Owner: Charles Mannigg
Date of Inspection: 1 0/2 3/9 8
SOIL ABSORPTION SYSTEM (SAS):LW'0999�
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type:
leaching pits, number:_L
leaching chambers, number:
leaching galleries, number:_'
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number: D
Alternative system:
Name of Technology: jz 2T_411�
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
Loamy sand to medium honey sand;Nn Signs of hydranlir• failnra
nr e nnrii nT Al 1 -,>eCjai-ai-i nn i c onrma1 -
.W;astQ—;:tote w ;T1-_3" flew the Invert
CESSPOOLS:1�6LV4_
(locate on site plan)
Number and configuration: in
Depth-top of liquid to inlet invert: A64
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow (cesspool must be pumped as part of inspection)
Cesspools are not present.
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
Cesspools are not present.
PRIVY: d.,6y°tP.
(locate on site plan)
Materials of constru on: �� Dimensions:
Depth of solids•
Comments:.
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
Privy is not present
(raviaod 04/25/97) Page 8 o1 10
01)
SVBSVRfAC( SEWACE,0ISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMAYION (coniinvtd)
lropanr Address: 132 Swift Ave Osterville,Mass,
O,:ntr, Charles Manning
O+rt or Inrptc0oru
10/23/98
SKETCH Of SEWAGE DISPOSAL SYSTEM:
include sits to tl Itisl two ptrm�nt^! rtftrtncts Iandmuks or benchmarks
locale III wells within too (locale whtrt public watcr supply comes Into hovscl
a �
1000
/ 1
40
!r.•tr•� orb 1-/!)) /.p. � or 10
� i
SUBSURFACE SEWAGE DISP( A SYSTEM INSPECTION FORM
J :- C C
SYSTEM INFOI:'.. .!ION (continued)
Property Address: 132 Swift Ave Osterville,Mass.
Owner: Charles Manning
Date of Inspection: 1 0/2 3/9 8
Depth to GroundwaterAtY Feet
Please indicate all the methods used to determine High Groundwater EIC�vation:
Obtained from Design Plans on record
Observation of Site (Abutting property, bservation hole, baserrtzri,sump etc.)
_IZDetermine it from local conditions
Check with local Board of health
Check FEMA Maps
heck pumping records
/heck local excavators, installers
Use USGS Data
Describe in your own words how you established the High Groundwater Elevation. Must be completed)
Used Gahrety & Miller Model
12/16/94
I
(revised 04/25/97) Peg, 100f 10
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TOWN OF Barnstable BOARD OF HEALTH
�-SU[1SU[►FACE SEWAGE DISPOSAL SY�3TEM INNSPECCTION FORM - PART D .- CEwrIFICATION I
.�y_=.r•,+-ter�..A
-TYPE OR PRINT CI.EARLY-
PlIOPERTY INSPECTED
STREET ADDRESS 132 Swift Ave Osterville,Mass.
ASSESSORS MAP, BLOCK AND PARCEL �`�c-r— �--3 o .
OWNER' s NAME Charles Manning
PART D - CERTIFICATION
NAME OF INSPECTOR Joseph P.Macomber Jr.
COMPANY NAME J.P.Macomber & Sow INC.
COMPANY ADDRESS Box 66 Centerville,Mass. 02632 .
Stravt Tom or city state Lip
COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX (508 ) 790 - 1 578
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at
this address and that the information reported is true , accurate ) and
complete 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 one:
__z/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 Lhe environment as defined in 310 CMR 16 - 303 . Any failure
criteria not evaluated are as 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 , 310 CMR 15 . 303, and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form .
le ,
Inspector Signature < Date J �.
One copy of this certification must be provided to the OWNER, the BUYER
( where applioable ) and the I30ARD OF HEALTII.
* If the inspection FAILED, .th-e owner or""operator shall upgrade pgrade ' tho a s one year of the date of the inap•ection u Y
Riess allowed
otherwise or required her ise as provided in 3,10 CFJR 16 . 306 .
partd -doc
Si
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07
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THE COMMONWEALTH OF MA.SSA.CHUSETTS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BE IT KNOWN THAT
Joseph P. Macomber, Jr.
Has satisfied the Department's qualifications as required and is hereby
authorized to use the title
CERTIFIED TITLE S SYSTEM INSPECTOR
as provided in 310 CMR 15 .340 and Section 13 of Chapter 21 A of the
General Laws. Issued by The Department of Environmental Protection.
lunc x IVVS -
nct�ity. DIrCCtOr uC tlu- I) i iuti 01' W;rtcr 1'ullutiUn ('Ontrol
� -1
No. .:. Fss :
THE COMMONWEALTH OF MASSACHUSETTS
�,. BOARD OF HEALTH
ems✓
A4®, .................0F.. ....._.... --......--------_----._.--_-----
Apli irafioat for Diapoa al Works Tomitrurtioat Prrutit
Application is hereby made for a Permit to Construct (Y) or Repair ( ) an Individual Sewage Disposal
System at:
�,�v �T
..........f -- ate_ • -1•--•----- •..........2- � -• wff ------------------------
QQ r Location-�Address or Lot No.
1..'�Lvrrl° ..............................................................
/ Owneii
Sew....-•-------•---•------••••--••--..... ...4._ _
Installer Address
Type of Building Size Lot---------------------------- q.._ _ S feet
U Dwelling—No. of Bedrooms......_..._ .......................•-.Expansion Attic ( ) Garbage Grinder (x)
`4 Other—T e of Buildin No. of persons............................ Showers — Cafeteria
Q' Other fixtures ---------------------------------------••-......--
W Design Flow.............4,9 -...........gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity/ ..gallons Length................ Width................ Diameter................ Depth.................
x Disposal Trench—No. .................... Width.................... Total Length......._._ . .. Total leaching area....................sq. ft.
Seepage Pit No..... -. Diameter..f4-1........ Depth below inlet......� ..... Total leaching area-__�t9....sq. ft.
z Other Distribution box (X) Dosing tank ( ) 1ZJ-1 1-1-q t
aPercolation Test Results Performed by.......................................................................... Date.........................................
_,Test Pit No. 1. %..minutes per inch Depth of Test Pit....,/. ..1._.._.. Depth to ground water.A.941-404/m/L
(% Test Pit No. 2................minutes per inch Depth of Test Pit--_____.___.__•..•-- Depth to ground water-------_-__-_------___.
O Description of Soil.--- = �=' / �-... -- - - - --- ---
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 iITi TIE 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 bo d of health.
Signed....... ...........•. - -•--•----------------•- g
ApplicationApproved By...... -=" -�---- ............................................................. 2, .7 ......
Date
Application Disapproved for the following reasons:................................................................................................................
..............•--------------•---------------------•--------------------:....---------.......------------•••---••••-•----•-----------•-••----•--•-----------------------------------•-----•--------_....
Date
PermitNo........ -•c--------- -�--------------- Issued........................................................
Date
r
No...r���....=5
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........ ......OF.. .............................
Appliration for Biupuiia1 Workii Toustrortiuu ramit
Application is hereby made for a Permit to Construct (y) or Repair ( ) an Individual Sewage Disposal
System at
L—
c to ddre or Lot No.
�J2 s .. C?
res
Pres
} Installer Address
Type of Building Size Lot............................Sq. feet
aDwelling—No. of Bedrooms...........J...........................Expansion Attic ( ) Garbage Grinder (h')
CL4 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria
Q' Other fixtures.............
W Design Flow............'fil........................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No. .................... Width.... Total Length....... ___.. Total leaching area....._.. .._ sq. ft.
Seepage Pit No.... __t__� Diameter__!__�'E__..__..... Depth below inlet.................... Total leaching area ,sq. ft.
Z Other Distribution box (X Dosing tank ( ) 4
Percolation Test Results Performed by........................................... ..... ... Date........................................
Test Pit No. 1...�f._�_.minutes per inch Depth of Test Pit----1".......... Depth to ground water._A�?.Av.�
(r Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-___----___-_-_.---____.
. .
- / �D escr tion of Soil....._ ' _... -- - - -
rJ ----------
•----------------•------------------------•------------------------------------------
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 TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been i ue by the bg* of iealt
Signed ------------------------------------••- ----------------------- --
Dat
Application Approved By------ .-.r .4 _'v -�....-•---•---------•.............................•--. -•---•- -�---�----r`�
" c�C.
- - -•--------•--
Date
Application Disapproved for the following reasons:_...---•----------------------------•--------------------------------._...--•--•------------------------........
•------------------------ ..---•----•-•---.. ..-�'--------+..-•--•-�; ......-----............-------------------•----------------...----•--------------------------------------------------•---
Date
PermitNo.---- - - .. Issued.......................................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....... 7? pt,�.....OF tj��9�.`." s::.......................------.
(Irrtifiratr of Tompliana
THIS•IS�TOI CERTI Y, Jhat the Individual Sewage Disposal' System constructed ( ) or Repaired ( )
by-••.......t �s..l....! - '.... ----- ...................................................................................................................
_ f _ > Installer
Vt
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... -C.*.,." - ---- dated_...... --? _.� ----------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION, "SATIS FACTO RY.
A*1
DATE... /.�--...-•---._..... Inspector..-•---... ..:............•---•---....---.............---•---•-•------.......--
•THE COMMONWEALTH OF MASSACHUSETTS
^^ BOARD OF HEALTH
...........!.::ta W.....OF....._: 4 ' '� ?.
No .... ....... FEE
� utr�rttio�t prutit
Permission is hereby granted..¢ * ._.._...L __.._=: ...........................................................................................
to Construct ( 1_4,-:or epair ( an-Indivi�3 1 Sewage Disposal System
atNo........... ...... ----------------------•----------------------------------------------------...............
Street
as shown on the application for Disposal Works Construction Perm or _' Dated ----------------------------
........................................... . III 9 m:r ..............._
r Board of Health
DATE.....<;;.�.`','.-.".;US1. ......................................
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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PARCEL NO..
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8 U I L D E H OR OWN ER
OATS PERMIT IS5UEO
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