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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS '
DEPARTMENT OF ENVIRONMENTAL PROTECTION .
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 41;Verynegr Ca%&rr RECEIVED
Owner's Name:
Owner's Address: JAN 2..2 2001
flS Iry►i 1<:�.YYI n o a�b'S5� - .- ,
Date of Inspection: TOWN OF BARNSTABLE
HEALTH DEPT.
Name of Inspector:(please prin�t_) R E I D C . E L L I S
Company Name: E L L I S B
Mailing Address: 23 ENTERPRISE ROAD, P.O. BOX 59 , YARMOUTH PORT, MA.
Telephone Number: 5 0 l3-3 62-F 2 3 7
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 Section 15.340 of Title 5(310 CMR 15.000). The system:
V Passes
Conditionally Passes
Needs Further Evaluation bylthe Local Approving Authority
ils
Inspector's Signature: Date:' 6
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. r ,
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. L4 10
Title 5 Inspection Forst 611Y2000 page 1
j
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: _CT;
6sT�,
Owner: caCL.QYlY1 T�ict
Date of Inspection:
Inspection Summary: Cbeck A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes: -
I have not foun 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:
B. System Conditionally Passes: M'
r
One or more system components as describYithe"Conditional Pass"section need to be replaced or
repaired.The system,upon completion of the replace t 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* r the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration r tank failure is imminent.System will pass inspection if the `•
existing tank is replaced with a complying septic tank approved by the Board of Health.
'A metal septic tank will pass inspection if it is Ily sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is avai le.
ND explain:
Observation of sewage backup or break out or igh static water level in the distribution box due to broken or,
obstructed pipe(s)or due to a broken,settled or uneve distribution box.System will'pass inspection if(with-
approval of Board of Health):
broken pipes)art replaced
obstruction is rem Dved '
distribution box' leveled or replaced `
ND explain: "= °
The system required pumping more than 4 tim a year due to broken or obstructed pipes).The system will
pass inspection if(with approval of the Board of H ):
broken pipe(s)are placed ^.
obstruction is rem ed
ND explain:
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: yC X&V% ► er CT,
�Te.rv�ilk mY� o abs5� � b .
Owner: Wit' Ahv,,Try sL
Date of Inspection:
y
C. Further Evaluation is Required by the Board of Health:Conditions exist which require finther evaluation by the BHealth in order to determine if the system
is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect p blic 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 vege d wetland or a salt marsh
2. System will fail unless the Board of Health(and Public W er Supplier,if any)determines that the
system is functioning in a manner that protects the public heal h,safety and environment:
The system has a septic tank and soil absorption system(;AS)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 wit a Zone 1 of a public water supply. '
_ The system has a septic tank and SAS and the SAS is wit in 50 feet of a private water supply well.
_ The system has a septic tank and SAS and the SAS is les than 100 feet but 50 feet or more from a
private water supply well".Method used to determine distan e
"This system passes if the well water analysis,performed at DEP certified laboratory,for colifonn
bacteria and volatile organic compounds indicates that the we I is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equa to or less than 5 ppm,provided that no other
failure criteria are triggered.A copy of the analysis must be al iched to this form. .
3. Other:
7 '
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM x
PART A
'CERTIFICATION(continued)
Property Address:
Owner: YY1 C1zl�Rtrt�Tir•�� .
Date of Inspection:
D. System Failure Criteria applicable to all systems. a
You must indicate"yes"or"no"to each of the following for all—inspections:,
¢r
Yes N
ackup of sewage into facility or system Component due to overloa)?J6 ded aded or clogged SAS or cesspool
Vcischarge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
logged SAS or cesspool n _
static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool ' I . . '' - - ,
Rquid depth in cesspool is less than 6"below invert or available volume is less than%Z day flow
equired pumping more than 4 times in the last year NUT due to clogged or obstructed pipe(s)r Number
/of times pumped ;
�/ Any portion of the SAS,cesspool or privy is below high ground water elevation. c
Any portion of cesspool or privy is within 100 feet of a surface water su 1 or tribu ^ to p
4"Any
water supply. ppY a surface
portion of a cesspool or privy is within a Zone Ir of a public well, a
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 froin 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, ppm,provided that no other failure criteria . }
are triggered co y of the analysis must be attached to this form.)
D
Do 6d
(Tes/No)The system fails.thave determined that one or more of;the above failure criteriatexiat `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 sery a facility with a design flow of 10,000 gpd to o o00#
gpd. ,
You must indicate either"yes"or"no"to each of the fog wing V
i4 A
(The following criteria apply to large systems in additio to the criteria above)
yes no x S 3 r
— — the system is within 400 feet of a surface J g water Lsup pty
,
the system is within 200 feet of a.tributary to m surface drinking water supply . '
_ the system is located in a nitrogen sensitive (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. a
{
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL 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 N
umping information was provided by the owner,occupant,or Board of Health
t
Were any of the system components pumped out in the previous two weeks?
VH as 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 dwellinginspected for signs of sewage backup
Was the site inspected for signs of break out?
Were all system components,eluding the SAS,located on site?. ti
7Was
Were the septic tank manholes uncovered,openedand the interior of the tank inspected for the condition'
of theor tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems 9 ;
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Ye o
_ Existing information.For example,a plan at the Board of Health.
Determined in the field(if any of the failure criteria related to Part.0 is at issue approximation of distance
is unacceptable)[310 CMR 15,302(3)(b)]
C
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: y-e V�Ymeer Gi
Owner:nCk�,,ghw�rtT
Date of Inspection•
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):
Number of current residents: �
Does residence have a garbage grinder(yes or no):**�
Is laundry on a separate sewage system(ye or no�[if yes separate inspection required]
Laundry system inspected(yes or no)-
,%�
Seasonal use:(yes or no):�J
Water meter readings,if available(last 2 years usage(gpd)).4:;2 _
Sump pump(yes or no):,el�j7
Last date of occupancy:_�vK�v. 41"
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): zDd
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( or no):
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe): y
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part of the inspection(yes or no):
If yes,volume pumped�lJLV Qa ns How as n' cidetermined? G Off _
Reaso for pumpmh / r �/ LDS
E OF SYSTEM
Septic tank,distribution box,soil absorption system
_Single cesspool
Overflow cesspool
_ivy
_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
_Other(describe):
AppLqximate a of co gpents, to talled if kno )an ce of infotmatio
AUAAb
Were sewage odors detected when arriving at the site(yes or-no): 04149
f
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: Lf `V rmeff C-"•
05
tJ�l na• .
Owner: VA A_A:fi: j-_
Date of Inspection:
BUILDING SEWER(Iocate on site plan) '
Depth below grade:
Materials of construction:_cast iron 40 PVC other(explayFt}:
Distance from private water supply well or suction line: f
Comments(on condition of'oints,venting,evidence of leakage,etc.):
SEPTIC TANK: 4. ocate on site plan)
Depth below grad _
Material of construction: concrete. metal_fiberglass_polyethylene
other(explain)
�/(� tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate) i
Dimensions: �k '
Sludge depth: s�
Distance from top o'sludge to bottom of outlet tee or baffle:�_.
Scum thickness: - �_
Distance from top of scum to top of outlet tee or baffle: y
Distance from bottom of scum to bottom of MI tee or b e: �� •
How were dimensions determined:
Comments(on pumping recommen ons,inlet and outlet t or bafffie con tion,structural integrity,liquid levels
as related to�tlet inytt,a 'dense ofjeakage�tc.): /zz-
& -Al
6 v s
GREASE TRAP: (locate on site plan) „
Depth below grade:_
Material of construction:_concrete metal_fit glass___,polyethylene mother
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffl
Distance from bottom of scum to bottom of outlet tee 4 ir baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and o Alet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: S Vermeer CT
Owner:
Date of Inspection:
/4
14-
TIGHT or HOLDING TANK: (tank must be pum d at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fi ergiass_polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallonstday
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: �f present must be openedXlocate on site plan)
Depth of liquid level above outlet invert;/
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
^;eaka_gDe into or gut of etc. ��@ �� B� i
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,condi n of pumps and appurtenances,etc.):
Page 9 of l 1 , „
OFFICIAL INSPECTION FORME—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C G
SYSTEM INFORMATION(continued)
Property Address: < a/2trmter Cr
Owner: -
Date of inspection: .
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)`: A
If SAS not located explain why:
3
leaching pits,number
r
leaching chambers,number "
leaching galleries,number: ' .
leaching trenches,number,length: yi
leaching fields,number,dimensions: z.. ,:
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-1� D !/d/ /�/N �I/G � //:. 'J, S/41,6-
// AW-Irp"-s
CESSPOOLS: (cesspool must be pumped as part inspectionxlocate on site plat
Number and configuration: f
Depth-top of liquid to inlet invert:
Depth of solids layer. -
Depth of scum layer:
Dimensions of cesspool: t
Materials of construction: w
Indication of groundwater inflow(yes or no); y. '
Comments(note Condition of soil,signs of hydraulic fail we,level of ponding,condition of vegetation,etc.):,
PRIVY: (locate on site plan)., ;' a
a ,.
Materials of construction: `r .
Dimensions:
Depth of solids: zy. c
Comments(note condition of soil,signs of hydraulic fail ,level of ponding,condition of vegetation,.etc.):
Page 10 of.i 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: US •
Owner: tlQh 71ru�`j"" -
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM s
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.
3s 6"
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OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM-INSPECTION FORM
' PART C ti
{•s i
SYSTEM INFORMATION
Addmwl
/�.,.��� Vyl{wlR edit R; °� �"� .w /„41;
Owner.
��
Date of
SrM IXAK
surboo water
Check ceDar
. Estimated
dq*w Swund wat«.25 het c '
Tease indicts(ckock)all and ds used to debam Qe the high ground warner elovatim
obtained fim system design plans on recaed-3f dedo A date of desiga plain revue• ,
Obsuv ed sire(abutting hole within 150 he of SAS)
Cbecked with loaf Bood of H=W"tq bin: �s
,with local eawatmsy' ( doctor on) .. a r
Acted USOS
You sum 6esa3be bow YMN IF wader�de+rattoon: '/ e s/�' !7/1.•���•+�.�d
9 d<,t
tr � »� y
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LOCAT ION ��M ` SEWAGE PERMIT NO.
4/Z
VILLA E -�
1 S LLER'S N E tkDDRESS
S U I L D E R OR OWNER
c
DATE PERMIT ISS 'E0
DAT E COMPLIANCE ISSUED �/ ��
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--......�.,�.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.....0..........................oF ........,.....-.....1 / ........ ---- .. ....................
Applira$ion for Disposal Works Toustrurtinu Prruld
Application is hereby made for a Permit to Construct ( ) or Repair ( } an Individual Sewage Disposal
System at:
................__------------------......-------_-•--------•••----•----••--.`................. ----.....-•••-___........•-•------.......---- .... ...
........Loc ion A dress or Lot No.
.............•••--•---. -tt _13 - J/� ................................
_ l --...�. . .......-----
r
Ocyiaer�-' Address
................................................... ................ Q�t x_S c.al�...•............•.....................X.,%#:- ,..-..........................
Installer Address
d Type of Building Size Lot----F,57 q7/_Sq. feet
r- - - -
Dwelling—No. of Bedrooms............................................Expansion Attic (�� Garbage Grinder (l_(})
aOther—Type of Building ............................ No. of persons.-_--___-_-_-___.___--_____- Showers ( ) — Cafeteria ( )
Q, Other fixtures ----------------------------•-•• -
W Design Flow.................5.1....................gallons per person per day. Total daily flow.................... ..........gallons.
WSeptic Tank—Liquid capacity.1'.0-o..Itgallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area------..............sq. ft.
3 Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( ) (/ f/�/
~' Percolation Test Results Performed by------------------_--_�� �!a-�.----- Date............./ -1 PAS...
minutes per inch Depth of Test Pit--------- Depth to ground water.-...
Test Pit No. 1.....�-_:�SS ... ._ ..
Test Pit No. 2.........z....minutes per inch Depth of Test Pit.................... Depth to ground water----- 11
------------------------------------•---..•-••• -•-................................... ..........---.-•--
O Description of Soil -• - ..--------- /��`, t T 'S f- - - - - -----
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 TITi12 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 healt
714
--•--.......................
Application Approved By............ ••••. . ereason's.:
---•---••••---......•••••.................................. --a-mod. .....---...._..--
Date
Application Disapproved for e f owing ....---•
....................•-••--•••-••----•-•--------------•-•--•-•...-•••--•-•--------•••-•.......--•-----•-..._.....-•-•-•--•••------••-------••-•••.•••---------•-•---•--•-•-•...•••---- -------._...._
Date
PermitNo......................................................... Issued.......................................................
Date
_............
THE COMMONWEALTH OF MASSACHUSETTS
w BOARD OF HEALTH
Applutttinn for Uiipnsal Works Tonitrnrtiun Vamit
Application is hereby made•for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
................_..__............................................................................ .................................................................................................
Location-Address ; :)r Lot No.
Owner— r Address
W � r'y .w3 1,+? r S r�A �_ rr
Installer Address
Type of Building Size Lot...............t�.......1 5- .Sq. feet
Dwelling—No. of Bedrooms............................_...............Expansion Attic ( °,}> Garbage Grinder 0—t)1
aOther—Type of Building ____________________________ No. of persons............................ ti owers ( ) — Cafeteria ( )
Q' Other fixtures -----------------------------------------••••-
` r _______________gallons per person per day. Total daily flow...................77,._ `t_.:�>_____._.___gallons.
W Design Flow..................... g P P P Y Y
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...._............... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank
.,.:..:•�dt-.Gra',...c� Date Percolation Test Results Performed by....................................................--.---.-•--�---- '--`•-..---��-
Test Pit No. I.....L_':''minutes per inch Depth of Test Pit..........Aft.i____ Depth to ground water_.....__________;..__-_.
fz, Test Pit No. 2.........::�. minutes per inch Depth of Test Pit____________________ Deptz to ground water..........Z_._--_----- r.
--------------------------- ------------ .....................................................................................:...................
O Description of Soil--•---•---•••---••••----•-•••--..-J_:.. � �.xJ .4, -A -_1-0 f'''_��+�.� .
x o ---•---__-•-
4 ._
U ,s i .
... --_••-• _•-•• ----•--- -•••-- ..........................................
------------------•-----......__._._....._._...-------------•---------•-------------•---•----•----__.-•---..._._..----....----._...•--..---•--.--•-••-------•-.._.._•-••-•---•-------------••--
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 TITLL 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., Ir
to
Application Approved B
Date
t Application Disapproved for t e f of wing reasons__________ __________________
.....................•-----------....----.....--------------•----------------------•--.....--------------..--•-•--•--------------••------------------------------------------------•••••-•••-•--...._.._.
Date
PermitNo......................................................... Issued......--...............................................
4
Date
4—
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
T' rrtifiratr of Tompfianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal to jX System constructed (A) r Repaired ( )
by.................. ...................•--•-.,.._..,.._._.....---_•-- _ ..
Installer 0
•---•t,- ................................................. . i f�
has been installed in accordance'with the provisions of TI`"Lr. 5 of The State Sanitary Coda/as des abed in the
4-_
"ti= application for Disposal Works Construction Permit No----- _;�� _. dated-__. 2--- .- _
THE ISSUA CE O THIS CERTIFICATE SHALT. NOT BE CONSTRUE A A GUARANTEE THAT THE
SYSTEM WILL UN N SATISFACTORY.
:. DATE`. ....... :.. .. ............:.....................••---•--.. Inspector........ ....... ---------•-------•-------•-----.......-•---•--.....------........
'yy v ✓
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............................ ......OF.............................................................
No ' FEE....d0- #------------
Dispont Iforkv TDnmitrnrtion ramit
Permissionisy.h&eby granted........................-- .............................................................................
to Construct ( f)j or Repair ( ) an Individual Sewage Disposal System
atNo... '----------... --------•-••...............•-----=•-••-•-•---.`•--==---------.. .--- ...-= -- -"-J '--=M° .---------------...........
` Street
as shown on tlTe application for Disposal Works'Construction Permit N{- o ,_.__. _____ Date __________.Z'__ .....................
•------------•---•-------•-••- ---------------------------------------------
-
Board of Health
DATE _.. __ _7.. •-
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS
s. «� ;`.° ys ,.:,r ?D I=T. /y/IY•': /YOTF /F Ea/TNER Ts,IE SEPT/C TANK OR
_EAGf//ivG P/T A.�E MORE Tfl A:•/ /2 BELO w j
!O 5R/f OE, 24.0/AM ETER CONCR ETA COYE
SNALL BE BROUGHT TO G.gAOE.`4,Y
r <` GpNCiRCTQ 4"PVC' P/PL h�EAVY CAST /RO/Y COVER SfY.4 L L L3E C/S 4=
- A?.IN. Alrcm
COYERS` •P�Sp FT /F//v OR/✓E WA y.'r 2J M/IV. CO, CRE7 f
CO VER C L EA/V SANG }
L 1ptleo LEY.Ldw
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TOTAL !•TTU~TED` PAOrV 3 3 v G.4L.�QII Y. 50/L. TEST /" SQ/L.TFST/fE
35.3 �.3 r
XUMB�,e OF L,E�lCXtNG PlZ�_ l ^EGEY. �t83v C�.4TL� OF SOIL TEST / /
S/OF L,EAGH/AI6.PEf�PIT FF 'M PT. RESC/tTS J�//TNL'SSFD BY ??c• cJa4cd3
OoTTo/+w A.Z4CNING PER PIT -7r S4. FT /C1.9- -7 PERCOLAT/O/v AA7AF of �css MI/1SIINCK
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No.10951
�F �� �� EL.DREDGE ENGINE RI'va co,/NC.
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No.10951`O Q
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LEGEND 1 �, ,
44' s s x i s ,�i.- V ,z
"� C�RTIFI ED • P LOT PL AN
EXISTING SPOT ELEVATION Q,�O ,, `,, f
SHA,y
EXISTING CONTOUR --- O -,.-- =z t �, [ oT`=36 yErv►r� .cv�rj7' s;
FINISHED SPOT ELEVATION I �-,11- , I - �,, ,:'957,�I— ,LLC
FINISHED. CONTOUR . 0 -� - } � a 1� s�0c
IN
n S t g "i?IDRED.G y
. APPROVED t BOARD OF HEALT" r ' , ` "��` �`
43' �l %,
SKr >,: 1 $CAI.Ej , ".. .T DATE G�i /S-
DATE AGENT , A r
0 EDGE ENG/NEERIAIG: CQI:/�l ,t� r�i--,A , iv� � - ��
F CLI9NT . ' t CERTIFY+f TNAT THE PROPOSED
EGISTERE REGISTEREQ; � r rS,z 6 , 3
JQ,wNO# BUILDING SHQWN O.N THIS PLAN ,
CIVIL LAND"max, , -CON =T0 THE .:ZQ.NIN:G _LAI<YS
ENGINEER SURVEYO QR.®Y''f +�� — F 8
ti x t , -- — 4. ARNSTA �.yE .!MASS.
r A :
712 MAIN STREfTr� CHF0Xt -
H YA N N I S, MASS °{ gMEET.,.L Qf + '�" A E- EG.. 'LAND SURVEYOR ,1.
y t
t'F`.r f h .h' +'S3'�j''e.
c•
C
/ No..._...... .. Fss. .......s...........
; .
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�C ....... ...............OF.......................................
Applirtttiun for Di,gvuiittl Workii Tunutrnrtiun Vamit
Application is hereby made for a Permit toConstruct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
7 �j'leG -O" /O1 Alm" ___ _ _ _
-..........................................................
,n Location-Address or Lot No.
Owner Address
;W .v �A•G T'e� ---•• ..............•---••------•---.....................---..........-•----
Installer Address
Type of Building Size Lot............................Sq
U,f . fe
Dwelling/-No. of Bedrooms._..___._ _____________________________Expansion Attic ( ) Garbage Grinder ,.
Other—Type of Building �4.4._ No. of persons............................ Showers
a YF• ng �----.. P (. ) — Cafeteria ( )
Q' Other fixtures .....--•• .
d
W Design Flow............................................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....=....__.__..... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.................................................•----•---•-•......_-•-•-- Date.......................................
�-1 - .
Test Pit No. 1................minutes per inch Depth of Test Pit.._.............__.. Depth to ground water........................
Gz, Test Pit No. 2................minutes per inch Depth of Test Pit............ :'Depth to ground water........................
_>.
O Description of Soil.............................
---------------------------------------•-------------------------.....-------•----......•-•••••......_._.....•. -• ---- --- ----•- ------.------
------------------------------------------------•---. --• .
U Nature epaarAlterations—Answer when applicabl �.. :_. .. ._ ..:�.........
•
✓ 11 ..........................................................••------------•------------------......... ----....... •----------- . -----------------•---•--....-----
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of ITLi; 5 of the State Sanitary C 'de—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee issued b board of health.
--- --
---- --•---------------
SigneDate
Application Approved By... ...... .....�......
.............................................................. ..--•--...-•---•----Date------......._
Application Disapproved or t e following reasons-----------------------•--------•------------------------------•--------------------------- ................
•--------------------•-------.........---•--•----...-----...........----•-•-----••----------•-------............------------•----•---------------------------------------.-•-----•••••••._............._
Date
PermitNo......................................................... Issued.......................................................
Date
--- - - - - ___ _ -- .�.��._..............�..�._�
No...... .I..^// FEs......�.........I....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................O F................................_............---------------......-
Appfiration for Diapo,itti Work,5 Tonitrnrtion ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
7 ..�'. o...
Location-Address or Lot No.
............... .•••••---•----•-•-•-•-...••---••............. ...............................................
Owner Address
.��!... �.✓�.�i 6i
� W Installer Address
d Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms------+ Z.............. ___..Expansion Attic ( ) Garbage Grinder
Other—Type of Buildin,',neA -_---_____-. No. of persons............................ Showers "
a YP � •-•--••--`�.._._._...-•----•--.-.... ( ) Cafeteria
dOther fixtures ... ....--•---...... --•.•---•-•...-•..............•-•--•-----••---•.........•••-----•---•...........--•---•-•---•-----.
W Design Flow...........................................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.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ' ) Dosing tank ( )
~' Percolation Test Results Performed by-------------- -----------.----. Date........................................
Test Pit No. 1................minutes per ingVXDe t f Test Pit.__.__..........._.. Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P4 ------•---•--•----------------------
-----•--------..:•--- -•----•----•-----••---•---•------•••.........................................................
Descriptionof Soil--•-•---•-•---------•--•-•--•----...----•---•-•-•••.........--•-••--•-...............................----_----------•--•-•-------------------••----•---••-......•------
x
c, - -
W -- -------------------------------------------------------------- ' =-
UNature I fig air .or Alterations—Answer when applicably --C.__. K,.
------------..-----•----•••--•-•-----•-•-------••••---•-•-•--•--•-•---------••••----.....•••------•--•.-•-•------•-......-•.....---•• -=--.............................................................
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 Complian a has een issue he board of Health.
• Date
Application Approved BY-- •----- -- ...........
Date
Application Disap?roved for the following reasons-----------------------•--------•----------------------....------------------•----------.._....--•------...----•-
Date
PermitNo......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.....................................OF.................................................................................
J� Trrtifiratr of Tontphatt r
14 CERTIFY, That the Individual Sewage Disposal System constructed (. or Repaired (• )
by . --• •--••-••.... ..... -•-...... -•--•-.....----•.......•---••••.....--•.................
.........
r ..istaller
07 at------------------------------
---------•----------=- -------- ••--•-•-••----••--•---------••-----•---------•----------••-•--•••-------•----------•....-----• ......................
has been installed in accordance with th visions of T � o The State Sanitary C d`e d ribed in the
application for Disposal Works Constr c 'on Permit No.--................. ................ dated?.. _ ��.____.........._.....
THE ISSUA CE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE AS A GUARANTEE THAT THE
SYSTEM W L UNCTION SATISFACTORY.
DATE.... .l.D. •-----•---•------•-------.---•-----••------••-----------. Inspector.. ..... .......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.....................................OF.....................................................................................
............ ...... FEle................
Big orkv Tontrnrtion famit
Permission ' her y rant --------•• .......................................................
to Con/tt��gct„ 1 r ( ) an Individual Sewage Disposal Sy
atNo •----/......-----------------•.----...... _._.........----...---...----•-------...--•------.----------- ............ --- --
st a :Yl
p p on P it o__ 'as shown /the h tron for Dis osal ��'orks Constructs ecp .....
�� .. B rd of Health
DATE.. -•- -- .•--••---...-•-------------••-•-----------
FORM 1255 A. M.'SULKIN. INC.. BOSTON
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