HomeMy WebLinkAbout0037 TANSY CIRCLE - Health ! 37 .Tansy Circle
OsteNille „F
'A = .121` 070 +
a ,
a
0
r
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE:OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
,.. M
PARCEL, - O7 a
t
PAR(':i
LOT
L
TITLE 5
OFFICIAL INSPECTION:FORM-NOT FOR VOLUNTARY ASSESSMENTS,
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address:.,-. �
Owner's Name:
Owner's Address:
Date of Inspection: 00 0
Name of Inspe or• please rint) �' r°�'�J �0 . [RECEIVEDCompany NamMailing Address: A ! R 0 9 2002Telephone Number: �{��• ` -7/• ��� OF BARNSTABLE
CERTIFICATION STATEMENT EALTH DEPT.
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 D-EP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.00.0). The system:
Passes
Conditionally Passes
Needs-Further Evaluation by the Local Approving Authority.
ils
Inspector's Signature: ,. Date:
%All�
The system inspector shall submit a copy of this inspection report to.the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the.
DEP.The original;should be sent to the system owner and copies sent to the buyer, if applicable, and the approving
authority.
Nq,tes and Comments 7
""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
`Page 2 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A . qA"r,
CERTIFICATION (continued)
Property Address:c'�f7 _1XA01,e _ _11ze;y-1 TDJ
Owner ' '
Date of Inspection: q
Inspection Summary: Check A,B,C,D or E/ALWAYS complete.all of Section D
A. System Passes:
I have not found any information which indicates that,any,of the failure:.crite.ria described in 310 CMR
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
B. 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 Healthy 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(wheiher'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:
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 box is leveled or replaced
ND explain:
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 l'l
OFFICIAL INSPECTION.FORM-.NOT FOR VOLUNTARY`AS,SES$MENTS
SUBSURFACE.SEWAGE DISPOSAL.SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: r
Owner:
Date of Inspection: (�
C. Further Evaluation is Required by the Board of Health: -
Conditions exist which require further evaluation by the Board of Health in order to.determine if the system
is failing to protect public health,.safety or the environment.
1. .System wift pass unless Board`of•Health determines in accordance with 3.10.CMR.15.303(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 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 zbsorption 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 feetyor 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 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: .
3. Other:
3
Page 4 of 11
OFFICIAL INSPECTION FORM,"NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE-SEWAGE`DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: _R?� L( /0/r��4
Owner' ;
Date of-Inspection: �Gc�
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes Nq�
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
1/ 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 '/x 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 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 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.]
(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
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
If you have answered"yes"to any questibn 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
Page 5 of 1.1
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGEDISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: '
Owner:
Date of Inspection:
Check if the following have been done.You must indicate"yes or."no". as to each of the following:
Yes No
Pumping inform
ation.was provided by the owner,occupant,or.Board ofHealth
Lf—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?
-kl'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 ? Y
Were all system components,excluding the SAS, located on'site
V1 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 th,e.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)].
5
Page of 11
OFFICIAL•INSPECTIONIFORM=NOT FOR VOL'UNTARYASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM`INFORMATION
Property Address: r
Owner:.
Date of Inspection; Q
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms.(design):_ Number of bedrooms(actual):_ _ ,
DESIGN flow based on 390 CNIR�5.203 (for example: 11:0 a d x#of bedrooms):
Number of current residents:
Does residence.have.a.garbage grinder(yes or no)
Is laundry.on a separate sewage system(yes 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)):100. Q!0/�/
Sump pump •
Last date of occupancy:
or ncupancy: � �?�'� & Ze �
COMMERCIAL/INDUSTRIAI�
Type of establishment:
Design flow.(based on 310 CMR.15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
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'.
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source.of information:. (���
Was system.pumped as part of the inspection(yes or no)�,J�- '-a`J
If ves,volume pumped: gallons--How was quantity.pumped determined? ri,
Reason for.pumping
TYPE OF SYSTEM
eptic 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)
—Tight tank _Attach'a copy:of the DEP.approval
_Other7(describe):
Apo 'm to age of all components,date installed(if known)and source of in o ation: '
Were sewage odors'detected when arriving.at the site(yes or no
6
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION-FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
ckv
O,
Owner:
Date of Inspection:. Oa
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of.construction:_cast iron_40 PVC other(explain):-
Distance from private water supply well or suction line:_ c
Comments(on condition of joints,venting, evidence of leakage,etc.)
SEPTIC TANK: locate on site plan)
Depth below'grade: / -
Material of construction:_concrete_metal_fiberglass polyethylene
other(explain)
If tank is metal list age:_ Is ale confirmed by a Certificate of Compliance(yes or no);_(attach a.copy of
certificate)
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle: -i'g
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 baffler
How were dimensions determined- �-, ,e� jc�
Comments(on pumping.recomme arre tions, inlet and outlet tee or baffle condition,structural integrity, liquid.levels
s related to outlet invert,evidence of leakage, etc.):
GREASE TRA�ocate on,site plan)
Depth below grade:_
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.
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert, evidence of leakage,-etc.):
7
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM'INFORMATION(continued)
Property Address: C�
Owner:
Date of Inspection: d O
TIGHT or HOLDING TANJ J"t2nk 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/day
Alarm present(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 site plan)
Depth of liquid level 1above outlet invert. .4 -41
fi
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of
akagp into or out of bo e ..):
PUMP CHAMBER] 4(ttlocate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes.or no):. � , r
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
i
8
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 3 7 � 14C e
Owner
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS): ocate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching.pits, number:
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,
tc.):
r
CESSPO.OLS`\7J�j&cesspool must be pumped.as part of inspect ion)(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 cif vegetation;etc:):
PRIVYJ (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.):
9
Page l0'of 11
OFFICIAL INSPECTION:FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
M
Property Address:. 7
Owner•
Date of Inspection:,
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.
lb
gU
,o
Eo
10
Page l l of l l
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C .
y SYSTEM INFORMATION(continued)
Property Address: . /
A
Owner•
Date of Inspection: 5Qm2WO
SITE EXAM
Slope
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:-
Obtained from system design plans on record-if checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS).
Checked with local Board of Health-,explain:
,Checked with local excavators, installers-(attach documentation)
Accessed U.SGS database_explain:
You must describe how you established the high ground water elevation: is
4= -
R
11
Y � '
��
Permit Number: Date:
Completed by: � �
HIGH GROUND-WATER LEVEL COMPUTATION
Site Location: Lot N'o.
1 � �
Qwner: (/Q'. Address.' �G—
Contractor:_ROLP e / Address:
Notes:.
STEP 1 . Measure depth.to water table l
to nearest 1/10;ft: ....................... . .Dater ��-
rronth/day%year
STEP EP 2 Using.Water-Level.Range Zone
and Index W611.,Map:locate
site and determine:
O Appropriate index well.....................................................
�f
CWater-level range zone........................:..................... ......
STEP:;:3. Using month ly.report,"Current
Water Resources Conditions"
determine current depth to �
water level for index well ......................... e9z
month/year
STEP. 4. Using,Table.of.Water level Adjustments j
for index well (STEP 2A) current depth
to water level for index well (STEP 3),
and water-level zone (STEP2B)
determine water-level adjustment ...:.................:.......:......:.....:..................:........:....................:.
STEP:, 5 Estimate depth to.high water
by subtracting the water
level adjustment....(STEP 4)
from measured.-.depth to water
levelat site (STEP 1) ...........................................:.......................:............................................ a
Figure' 11--Repraducible computation fo;m.
0-3
LOCATION SEWAGE PERMIT NO.
gyp'/"-"- - - -
VILLAGE
INSTA LLER'S N ME i ADDRESS
ge
0 UILDER OR OWNER
4 )
DATE PERMIT ISSUED -9-7�1
DATE COMPLIANCE ISSUED
_ 11-72
,
F/✓cam
�.
. �'
'' �o�� (�
� `�'y
� � '��
V �. „y «• .
,q „� J°
No...._.......---.�.... kl�1,2 2,5
Y , Fims..............................
THE COMMONWEAL—K—OF`MASSACHUSETTS
BOAR® µOF HEALTH
....... ........OF...-...... i31--,----------------------------
Appliratiou for Disposal Murks Toustrurtion ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
......... ... 1- --•------------------------•-................................................
Location-A4dress Lot No.
—tOwner �Q�' Address `
W "_!�S- __-__---__•-•----------•-•_______________ ..........._._ !!/\_d/.V�l......... .......................
` Installer Address
Q Type of Building': Size Lot_._v ®Cl_t2_o_...._Sq. feet
U Dwelling=No. of Bedrooms................
_______._._______.____Expansion Attic ( ) Garbage Grinder (vo)
Other=';Type of Building ---NZA.............. No. of persons............................ Showers ( ) — Cafeteria ( )
a' Other fixtures ------------------------------------
d $ 44.00;a---------------- ------------ -------------"__y----------------------------------_...
Design Flow_____________/l_0...................gallons per �1 per day. Total daily'flow
Diamet fir._- ____. De th_.gallons.
Septic Tank—Liquid capacity, ®s',�_gallons Lengt Vital Lengthidth--�`-��----Total leaching area.______P____....sq. ft.
x Disposal Trench—No _________...
Width_ e i
Seepage Pit No_________ ________ Diameter........
Depth below inlet........ Total leaching area. ....sq. ft.
Other Distribution box Dosing tank ( )
Percolation Test Results Performed by.Rafsm_ti6___. Date.___
aTest Pit No. 1.__�.?-...minutes per inch Depth of Test Pit.... .. Depth to ground water_____ AP.M Ef,___
Test Pit No. 2..<._'Z_._minutes per inch Depth of Test Pit....!_ ........ Depth to ground water---sUr0AI__C._..__
----------------------------------••--------•-•--..._._.._........_._........_....................--.........................................................
O Description of Soil......0_-__3...'..... ........... ...... ..........
C,G�' nJ-._.A�d_ �Ca��`�1
x !9n�.3�... .� � =/� --------�dY_1--•----G�'n�h�.f__�a .........4!�----... �Y.--•--... 's
V
--------------
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 TL I HE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee sued by-die board of health.
-'
Si ed---- ......
--• -- .............. •-----------------------•--•---•----•-------• rl
Date
Application Approved BY - ....._..---•-------•. -- V
a
Application Disapproved for the following reasons:...................................................................................._...........................
....................••---.....-•-•-----------•--•-•---------•-------------•------•-=.._..--••---------------------------•---------•---------------•-----------------------------------------------------
---j•- �--Date
PermitNo......................................................... Issued_--- 7 f --•
Date
'
� f
C7j
No........j.............. ............... ..�.........
THE COMMONWEALTfq'OF'MASSACHUSETTS
s BOARD OF HEALTH
Application for Biipnaal Workfi Tnnitrurtiun Prrutit
Application is hereby made for a Permit to Construct ( )�,.or Repair ( ) an Individual Sewage Disposal
System at:
�1. ---. 'Z&C.4 ��-` J .Y�� -•------- .................Z..6.r.........-1'-?...--------...-----------------
Location- ddress t No
r Owner Address .....+
a ------------•-•--..............ins
� taller Address
d Type of Building .,,., Size Lot____iL0,0020.......Sq. feet
U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder kvp)
__A).1'<9............... No. of ersons__._________________________ Showers — Cafeteria per., Other—Type of Building p ( ) ( )
Q' Other fixtures --------------------------------
d ---------------------------- -----------------
Design Flow_____ jet''__ ____________________gallons per sen per day. Total daily flow............................................!_________.__..__.___gallons.
W s.
Septic Tank—Liquid capacit/A0 __gallons Length .r�'"._ Width�_"�.'_... Diameter__-_::_ _PP`_:_:______ Depth. _` ��-
x• Disposal Trench—No No _!__________________ Width_ :: ____.__._.___ Total Length. Total leaching area___________ sq. ft.
P g g
Seepage Pit No________ _________ Diameter.._.... ...._ Depth below inlet.._.....___....... Total,leaching area.o.?O ....sq. ft.
z Other Distribution box i( Dosing tank ( )
'-' Percolation Test Results Performed by7to^?ADO..... :-_.cr:-IA A....:&A-t_ Date.... ....9.z1?28_-.
Test Pit No. 1__25t_:-:____minutes per inch Depth of Test Pit.../=..._..__..Depth to ground water____!1�.,► __..
(i Test Pit No. 2_:_.: :___.minutes per inch Depth of Test Pit..!R`,..........Depth to ground water:..evaA I_.__._
a •------- .....................................................................................................................
D Description of Soil.....-.0. �1;24-'? nu_'�....----._ ..... ' t 'lf
U .......... h!- ------------------- S.r �-�•-••_._ ,V -... ---------!e'------&0�`'- --------`- --
_..,,. .
W //-<-A•f" -----------•..............................................................................................................
U Nature of Repairs or Alterations—Answer when applicable................................................................................................
-•---------------------•--------•--••-•---•---•--•-•----•---------------------------................•--_.....------•••••-•--------------•---•------•----••-•-----•--•••-••••••••-----•••-•............--
Agreement:
The undersigned agrees to install. the aforedescribed Individual Sewage Disposal System in accordance with
I-r T=-�
Z the provisions of T m , 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.
Si e 7�
-- ------------
Date
Application Approved By. • .......... �. --------•------- --
•-•--•---
APPlication Disapproved for the following reasons:------•----------------------------------•-------------•------------------------------•-•-.Dat ............•.
............................... ..................... •----•------•-------------•---.............-•-----
Date
PermitNo......................................................... Issued................................... ..................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF.... Ir44 40104,...............::.............................
Trdifirax#r aaf Taantlifianrr
THIS S CERTIF , hat the Indio al Sewage Disposal System constructed ('" ) or Repaired ( )
by.�...
• . ... . • . /"�r ---
*+Inst / f/ �.,,�
at - _: . •..... . . ---41V--_----------•---•--
has been installed in accordance with th rovisions of T + 5 of The State Sanitary C de as described in the
application,for Disposal Works Construction Permit N0. I—a. ........... dated_--. 'I . ..... ---r..................
THE:-ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE.THAT THE
SYSTEM WILL FUNCTION-SATISFACTORY.
DATE............................................................•----..._......--... Inspector....................................................................................
~ THE COMMONWEALTH-OF MA46CHUSETTS
BOARD OF SALT
r
No.... -'.......... FEE... ................
iaa�raaaatt W 1 nr'uaYt it
Permissio is ereby granted - ----- ....................................
to Construct or Repa ): an Indivi al SPvlra ,, Disp s yst ,,�
at No. �s. - � � x�%0. ._... ._.. .. .....
r
as shown on the application for Disposal Works Construction Pe m' __________ __ ____ d...�0_.................................
K
Board-:of;'Heal th
DATE................................................................................
x.
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
-a«......_--�,. wry.—.�.:�.d«rem,a,.�...-.. .--.�.-r-!•�-.�..�..•�.,........,..��,, �--1 /� ,
1/0 ;fiveCl/ C ZZ NOV, 9 , 19 76
00 .. PA,uL GA RDNER SNsP'
C. a� AssuM
5 U6 01,E
1 3. /a CLE,4N
TEST
Rop MODS
?^ ._ LEREN tr TER"
3V- --rA
p,TLF-LEV,fs
TIC
aox K N 0 L�..1 A TER,
3o#b 32 tz
A,-. Al ^-Y C//t/!
r3 u/c_L7//VG S E7-, �AC�.
_ F'/20NT 5i Z7E /t� T64T�
.. Gl2O Po SED
.. .� • E3;E_D 1200M5
SE P T/C 6 yS TE M CONS T2 lJE T/ON
SHA [_L G'ONFO2M TO MASS , DES/GAL/ �LOu! _ GALj �Y
C-AJV/,eONM.E/VrA[. .CODE T/TLL' �T L o�
2.4 rE M/A/. i/vcy,
BAIL N s to
P2COr�oS�L`� EQU/:eGD LEACN: �i�f4 ,/ o
TOP of /�E�tLTf1 Tz��UL.<t TiONS
3 5 0 2 of p�4 STOAIIC
r i`�IANNOLE COt�ET� Tp' -)C.TEn!b Tp �/�I;oG�✓/OUS. GOVE
r WI TN/A/ /� OF F//�//5</ t7 !�IZA D TO �2E V,5At/T /-/Al/C"--S
�20M F/LT2,4T/A/-
CoV�.ZS - /OAJ
�
6..M,jJ 4 D i --�
r P /0 L C-
/7�f/ G[ OL✓ LINE M"N .diTCt/ _tL .c .� l
`OOT /0"M/N "2 Mini !�
XrO07 XI/ F" ^ DIA.
Foor � ,wAs•ya0
/iVVf2T GAT-SAG% Ty
Ar2oUA10
!i .
�L1lATG�T/GNT). /NVE.eT• - ,. .��L-�SC�
: 80710o,4 OF
VE�r NO . GA,6A6F 'G,2)AJDzc Z 3.a
7 l�LAN FA�
Lac .,4 71d. U I3 TA&J_.(Q5 E&VU Lt.) M,4
13E1 L 7 A S
CC�-LBLV�_ 3 SED�./ _ TAiN;Ke''D:YT�/�3,UT/CON 80X.
- N_ -.-. S O U T�ETs
y
_ J t;�r�t, � Via€ C0 c- -;2ETE .5T,2E.vG
j Q ckl:VfFo } STEEL
O • _ �St n, :t
,�+ .W.. -'_ Dom'/,. y' %T07'• TD B � A, Y ;
✓E.G S-`7S`TEM
S NC3l�cJl c'. 1 °t>° d:Q •�E- � L.04C)'Av6' /S:vS�I5.
Y TNi`S. PLAN`� % PRO P0546 ? �� ,�"NE
F 4t,1 C r
cw M
a.
A 5 ff tfa�)lt,�+l �Ar/V{D� �yl��T! Doles+ y�CON y
L)I,T i4 .r�.77rG. !%7'R�/ t.,.t.IN Cr
T 4J 1 ti.+\
c� n
li C�?UI t'v'IYt IUT.S or. T"HE TOWN O�
L3 fl RlV :'T E3 C E t} le9 ;' 4; 4 D,4 TE E:Q L Th/
y.�78 4 ¢ �Q Vet
T' ri r