HomeMy WebLinkAbout0240 WEST WIND CIRCLE - Health 240 West Wind Circle
j Osterville P
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TOWN OF BARNSTABLE
LOCXiON, ,,'`240 West Wind Circle SEWAGE # 5/1 /03
VTMLAGE Osterville,,Mass_ ASSESSOR'S MAP &LOTI 21 011 /023
Inspector
)MSTAMOSM NAME&PHONE NO Joseph P.Macomber Jr.
SEPTIC TANK CAPACITY 1000 gallons
LEACHING FACII.TFY: (type) 1 -LP-1 0 0 0 (size) 1500 as 1 lons
NO.OF BEDROOMS . 3
BUILDER OR OWNER Michael .Taylor
�. PER MTTDATE:TnGpP(•t-i c)n COMPLIANCE DATE: 5/1 /0 3
Separation Distance Between the:-
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist.
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet f leac c' ' Feet
Furnished b
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cul
►. Ge
cd� Q
IN
25/0 Wes
.e DATE: 4/ /�EACEIVED
PROPERTY ADDRESS:_240_West Wind Circle_ 10AY 0 6 2003
-- Osterville
Mass 02632
On the above date, I inspected the septic system at the above address.
This system consists of the following: {
1 . 1 -1000 gallon septic tank.
2. 1 -Distribution box.
3. 1 -1000 gallon precast leaching pit.
Based on my inspection, I certify the following conditions:
4 . This is a title five septic system. ( 78 Code)
5. The septic system is in proper working order at the present time,
6 . Pumped the septic tank at time of inspection.
7 . The leaching pit is presently ,dry.
SIGNATURE: ,�
Name:_J_P_ Macomber Jr .______
Company: Joseph_P. Macomber_& Son , Inc .
Address: Box 66
Centerville , Ma._02632-0066
Phone: 508-775-3338
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
JOSEPH P. MACOMBER & SON, INC.
Tan ks-Cesspools-Leachflelds
Pumped & Installed
Town Sewer Connections
. P.O. Box 66 Centerville, MA 02632-0066
775-3338 775-6412
•
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e
COMMONWEALTH OF MASSACHUSETTS
ID
fI = EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
,.Y
'TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address:240 West Wind Circle -
Osterville Mass
Owner's Name: Michael Taylor
Owner's Address: 31 malcolm Road
Jama_i_na Plain Mass 02130
Date of Inspection: 4/3 0/0 3
Name of Inspector: (please print) Joseph P. Macomber Jr.
Company Name: Joseph P. Macomber & Son Inc
Mailing Address: Box 66
rentervi 1 1 e Ma 02632
Telephone Number:_508-775-3338
CERTIFICATION STATEMENT
I certify that 1 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. 1 am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
/Passes
' Conditionally Passes
' Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: ^—w Date:
The system inspector shal mit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving
authority.
Notes and Comments
1 ****This report only describes conditions at the time of inspection and under the conditions of use at that
z time.This inspection does not address how the system will perform in the future under the same or different
i
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:240 West Wind Circle
Osterville Ma 02655
Owner: Michael Taylor
Date of Inspection: 4/3 0/0 3
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A S m Passes:
AM 1 have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
The septic system is in proper working order at the
present time.
B. System Conditionally Passes:
XL One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health, will pass.
Answer yes,no or not determined(Y,N,ND),in the for the following statements. If"not determined"please
explain.
_V.,p The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally-
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
'A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
k
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 pr 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
e ,
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 240 West Wind Circle
Osterville Mass
Owner: Michael Taylor
Date of Inspection: 4/3 /o-i
C. Further Evaluation is Required by the Board of Health:
IVP 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 will pass unless Board of Health determines in accordance with 310 CMR 15.303(i)(b) that the
system is not functioning in a manner which will protect public health,safety and the environment:
.—MO Cesspool or privy is within 50 feet of a surface water
�/I Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
i
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:
L,-)6 The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply. `
iU0 The system has a septic tank and.SAS and the SAS is within a Zone 1 of a public water supply.
�l/IJ The system has a septic tank andISAS and the SAS is within 50 feet of a private water supply well.
X�d The system has a septic tank and'SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance ��Ct
"This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
i
3. Other:
f
3
Page 4 of 1 I
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Add ress:240 West Wind Circle
Osterville Mass
Owner:Michael Taylor
Date of Inspection: _4/3 0/03
D. System Failure Criteria applicable to all systems: .
You must indicate"yes"or"no"to each of the following for all inspections:
Yes N 01-11
• ackup 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
ogged SAS or cesspool
r/ Static liquid level in the distribution box above,outlet invert due to an overloaded or clogged SAS or
cesspool
,?Liquid depth in csscPeel is less than 6"below invert or available volume is less than 'h day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
- Zf times pumped :�> ,
- i�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
ater 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.
i/Any portion of a cesspool or privy is less than 100 feet but greater than SO 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.(
(YesfNo)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
�th system is within 200 feet of a tributary to a surface drinking water supply
_ the system is located in a nitrogen
trogen sensitive area(Interim Wellhead Protection Area— IWPA) or a mapped
Zone 11 of a public.water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered
"yes" in Section D above the large system has failed.The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
4
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
7 CHECKLIST
Property Address:240 West Wind Circle
Osterville Mass
Owner:Michael Taylor
Date of Inspection: 4/3 0/0 3
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No /� '
)/Pumping, information was provided by the owner, occupant,or Board of Health
ZWere any of the system components pumped out in the previous two weeks
Y Has the system received normal flows in the previous two week period?
'/ Have large volumes of water been,introduced to the system recently or as part of this inspection ?
i
Were as built plans of the system obtained and examined?(If they were not available note as N/A)
Was the facility or dwelling inspected for signs of sewage back up
Was the site inspected for signs of break out? ,
Were all system componentsep—wluding the SAS, located on site? :
q
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 facilityowner and occupants if different from owner( p )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,ia plan at the Board of Health.
Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [310 CMR 15.302(3)(b)]
i
5
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Add ress:240 West Wind Circle
Osterville Mass
Owner:Michael Taylor
Date of Inspection: 4/3 0/0 3
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):yo
Is laundry on a separate sewage s stem -t�( es or no) [if yes separate inspection required)
Laundry system inspected es or no
): 5
Seasonal use: (yes or no):
Water meter readings, if available(last 2 years usage(gpd))?0 01 =2 6, 0 0 0 ga 11 ons=71 . 2 4 GPD
Sump pump(yes or no): 2002=33, 0'00 gallons=90. 41 GPD
Last date of occupancy
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sqft,etc.): �61iq
Grease trap present(yes or no):,:�,o t /�
Industrial waste holding tank present(yes or no):4
Non-sanitary waste discharged to the Title 5 system(yes or no):,d/!!10
Water meter readings,if available:
Last date of occupancy/use: _
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part f the inspection(yes or no): f
If yes, volume pumped:/ D gallons--How was quantity pumped determined?
Reason for pumping: Heavy Scum & so1_; rl_ 1 ay rs wPre present. ,
1 -
TYPfsiOF SYSTEM
Septic tank,distribution box,soil absorption system
Single cesspool
.JO Overflow cesspool
.(JD Privy
Shared system(yes or no)(if yes,attach previous inspection records, if any)
.,Off Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
�O Tight tank -Uri Attach a copy of the DEP approval
Other(describe): Z)4
Approxirpte a e f all components,date installed(if known)and source of information:
Were sewage odors detected when arriving at the site(yes or no):f!j�o
6
Page 7 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:240 West Wind Circle
Osterville Mass
Owner:Michael Taylor
Date of Inspection: 4/3 0/0 3
BUILDING SEWER(locate on site plan)
f Depth below grade: .%� I
Materials of construction4 cast iron Z40 PVCV1>other(explain): 16/10
Distance from private water supply well or suction line: /t y
Comments(on condition of joints,venting,evidence of leakage,etc.):
Joints appear tight No evidence of leakage-The system is
vented through the roof vents.
SEPTIC TANK:Zoocate on site plan) i��E✓� nJS
Depth below grade:
Material of construction: concrete d)d meta WO fiberglass polyethylene `
i'JLother(explain)
If tank is metal list age;, Is age confirmed by a Certificate of Compliance(yes or,no)Wle (attach a copy of
certificate) ��
Dimensions: paw /�/ � 3 '/
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle: 0
Scum thickness:
Distance from top of scum to top of outlet tee or baffle: d
Distance from bottom of scum to bottom of outlet tee or baffle: 'a_
How were dimensions determined:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage,etc.):
Pump thP_ gRpti r tank a erL , 9-3�ga S. Iniet & Ieutlet tees
are in 01gce�The tank is r u -tural l y -,ntin(3 and shA4J�nn
evidence o__f,,))leakage.
GREASE TRAP6( jAlocate on site plan)
Depth below grade:
Material of construction:rtconcrete,o,�m eta Lt/0 fiberglass,j,?n4,po lye thy Ienej!/ other
(explain): �lA
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: y�
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
Grease trap is not present.
7
Page 8 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 240 West Wind Circle
OwnerMichael Taylor
Date of inspection:4/3 0/0 3
TIGHT or HOLDING TANIC ,(tank must be pumped at time of inspection)(locate on site plan) .
Depth below grader
Material of construction: A4concrete/jJ metaW'9 fiberglass4 A polyethylene.42-4 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.):
Tight or holding tanks are not present
DISTRIBUTION BOX: Zif present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:/0
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of
leakage into or out of box,etc.):
Distribution box has one lateral No evidence of solids carry over.
No -evidence nf leakage into or out of the box
PUMP CHAMBER 6l 4(locate on site plan)
Pumps in working order(yes or no): -0
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
Pump chamber is not present-
8
Page 9 of 1 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 240 West Wind Circle
Osterville Mass
Owner:Michael Taylor
Date of Inspection: 4/3 o/o 3
SOIL ABSORPTION SYSTEM (SAS): Zlocate on site plan,excavation not required)
1 -1000 gallon precast leaching nit.
If SAS not located explain why:
Located: See page 10
Type �-N�
leaching pits,number:
ZZ leaching chambers, number: C�
leaching galleries,number: 0
leaching trenches,number, length: d
leaching fields,number,dimensions:
�{ overflow cesspool,number: 0v
innovative/alternative system Type/name of technology: � 'l
Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,
etc.):
Loamy sand to medium i n sand-No signs of hyd a it ifailiirt-
or ponding-Soils are dry-Vegetation is normal _
CESSPOOLS&4 (cesspool must be pumped as part of inspect ion)(locate on site plan)
Number and configuration: �}
Depth—top of liquid to inlet invert:1(
Depth of solids layer: A/
Depth of scum laver:
Dimensions of cesspool:
Materials of construction: 9.
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.):
Cesspools are not present_
PRIVyod&.j (locate on site plan).
Materials of construction: leAy
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,etc.):
PriyU is nni- present
9 T
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: 240 We,; Wi nrl Circle
OStervill_e _Macc
OwoerMichael Tay]nr
Date of Inspectioo: 4/3 0/01
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.
r
` \ L
�. � � .
C1\.
z 5'0
10
.Y
Page 11 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 240 West Wind 'Circle
Ostervillp Mass
Owner:Michael Taylor
Date of inspection: 4 f 1 B I B i
SITE EXAM s
Slope
Surface water
Check cellar a
Shallow wells
Estimated depth to ground water feet
Please indicate(check)all methods used to determine the high ground water elevation:
NO Obtained from system design plans on record-If checked,date of design plan reviewed: NA
yEL Observed site(abutting property/observation hole within 150 feet of SAS):
Na_Checked with local Board of Health-explain: NA
YES Checked with local excavators, installers-(attach documentation)
YZ _S Accessed USGS database-explain:-httn: //town-barnstable.ma.us.
You must describe how you established the high ground water elevation:
sed: Gahrety & Miller Model. 12/16/94 Ground water elevations above sea level.
sed: USGS_ Olaservation well data _ June 1992
sed: USGS• Techni cal hill 1 Pti n 9 2-0 Q n-1 P1 Ata ##2 Annul rangaG of grc)nndwAtpr _
n
January 1992
Leaching
Pit ��. .
.eet '
Vim{
Groundwater: Feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method
Therefore, the vertical separation distance between the bottom
of the leaching pit and the adjusted groundwater table is L t�
feet. '
11
y+•rrnr+.-rtl-rr'-.err- enrrlrr•nsrTr!-�rrt atnrs*nl:•r'+:nn�r+nr*e.we+ �rnrt>'+r�rrsertret+ .�'
-
TOWN OF BARNSTABLE BOARD OF HEALTH
SUIISURFACF SEWAGE DISPOSAL SYSTEM INSI)FCTION FORM - PART D .- CERTIFICATION
•••4••1-T••.••.' —T.111t-.�TT.1►11'R.'IYI T'1RiTfTITI'1:r•.t'I r'11Rwl�iT.IIT'1'f�-1A� �A^ I
-TYPO OR PRINT CI.EARLY-
PROPERTY INSPECTED
STREET ADDRESS 240 West Wind Circle Osterville Mass. 02655
ASSESSORS MAP, BLOCK AND PARCEL # 121 -011 -023 4
OWNER' s NAME Michael* Taylor
PART D - CERTIFICATION I
NAME OF INSPECTOR _Joseph P. Macomber Jr..'
COMPANY NAME Joseph P. Macomber & Svfi ' Inc
COMPANY ADDRESS Box 66 Centerville Mass 02632
Street Town or CSty Sttt�
COMPANY TELEPHONE (508 ) 775 - 3338 cIP
FAX ( 508 ) 790 _ 1 578
CERTIFICATION STATEMENT
I certify that I have personally` inspected the sewage disposal system at
this address and that the inforination reported is true , accurate , and
omplete as of the time of .inspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience , in the proper function and maintenance of on-
site sewage disposal systems .
Chec ohs ;
Vy System PASSED
a
The inspection which I have conducted has not found' any information -
which indicates that the system fails to adequately 'protect public'
health or the environment as defined in 310 cm 15 - 303 , Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form ,
System FAILEll*
The inspection which I have con t7cted has' found that_ the system fails to
Protect the hublid health` and the environment in accordance with Title
5 , 310 CMR 151303', and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form .
Inspector Signature
lr�� Date / d
Xcopy of this certification must be providedto the OWNER, the BUYER
re applicable ) and the DOnRD OF 11RALT'1I.
* If the inspection FAILED, the owner or.".operat 1.or shall upgrade '
aYate
within one year of the date of the inspection,, unless allowedorthe requiredm
otherwise as provided in 3.10 CFIR 15 . 306 .
tt partd .doc
ffowro- a4 2
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L 0 C 4"d`N � ACE PERMIT NO.
UTa 3~ w Qsf c.v ti A I rc(e 3'4/—
v, VILLAGE its£ zoo
SINSTA LLER'S AME i ADDRESS
M,�
PRUILDER OR OWNER
so. �6Ap"1700
DATE PERMIT ISSUED .
DATE COMPLIANCE ISSUED A Ile) S(o
-�
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No...........1........ ..........................«.
THE COMMONWEALTH OF MASSACHUSETTS
� a� --•� BOARD ®�` �-I E A T I�
1 Y ........1 &U/_14...---OF.... ...-- ,�.------.
r Appliration for Disposal Works Tnnstrnrtiun Prrutit
Application is hereby made for a Permit to Construct (�or Repair ( ) an Individual Sewage Disposal
System at
Location-Ad-dress r t N
ner Addr ss
a �P. R .r0.".111,041----- ...............��....Yr�.R���..�-�--.....-----------.....
--...-•••..........
Installer Address
Pq
U Type of Building Size Lot....1,,r�751V._Sq. feet
Dwelling—No. of Bedrooms.__._._._.____ _______________________Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building �. /9__.�� -No. of persons--------- Showers 1) — Cafeteria ( )
Otherfixtures • •i/----------------------••--•-•••-•••-••-•••-••••-••••••--•••-••--•-••-•----•--•-•---••-•--•-••••......•-•••......--•-
W Design Flow.................. ... ... gal
ins.
� 3-tom}-�-'-----•----•---- ins.,
WSeptic Tank—Liquid capacityI&W.gallons Length___ Width.. --- Diameter................ Depth....
x Disposal Trench—No..................... Width......../.......... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No---------I---------- Diameter.........Z,li------- Depth below inlet......,r........... Total leaching area... 1 P..,�-..sq. ft.
Z Other Distribution box ( r) Dosing t k ( )
`-' Percolation Test Results Performed by....... �.R.Q•!r .......T_1)1-C2.,C-1114r,,*. 10ate.....•.l�_..-
Test Pit No. 1________________minutes per inch Depth of Test Pit___ _ Depth to ground water........................
rZo Test Pit No. 2................minutes per inch Depth of Test Pit. ..... Depth to ground water-_t/.!;r /,e
P4 ••. ••-p--. .......------ ........................................................................................................................
0 Description of Soil----------- 1,/�!_ -------ct .lY----------------------------------------------------------------------------------------------•-----------
x
U -----------------------------------
•---------------------------------------------------------------------------------------
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.----•---•-------------.------•---
W
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
-----------------------------------------------------------------------------•--•-•••---•-.........••-•-.....•---•--•- •-•-••••------•••-•••••••-•-•••-----•-•••-•-•-•--•-•----•------•---•---.......---
Agreement
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITL4 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 sued by the board o health.
Signed � � ^ -----------------------------••.
Date
Application Approved By--•-•--•------•--•••-----•. ................................ ,,./ .........
Date
Application Disapproved for the following reasons-----------------------------------------------------------------------------•-----------------------------.._...
---------------------------------------------------------------------------------•--------.........-----..__.................------------------------------------------------......-----------------.....
Date
PermitNo......................................................... Issued.......................................................------------•-•-------to----------------•----------•---.
�-, r•..., _�,.,.
L '
No......................... a V ..........................._
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEA THZ?
77
......O F... --�- -`- - _----------
Appliration for Dispati al Works Tnnntrnr#iun Vamit
Application is hereby made for a Permit to Construct O or Repair ( ) an Individual Sewage Disposal
System at
--•-! `f...►_.A-':ter � ...__.... ?. .. E ': 2.
..- .._.
Location-Address or Lot No.
.... .. ...............
r Y
� �• ........
p� f
E ms!'/ J C C 7' " - - .1 ./ r ; /`l�� ,7f -s�
Owner Add ess
a h'. 1� .z !'Y1 �, .11..7",
Installer- - ..... =° ....• s
� Address
U TypeDwelling Building Size
of Bed Size Lot_._l- ..Sq. feet
g— rooms.............. ..___._..Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building Pwir_. � No.- of persons-------- --------------- Showers ,(?) — Cafeteria ( )
Otherfixtures ----------------------------------------------•---•---------------------•--•-•-•••----
Design Flow.................. .... ____..__._._gallons per person per,day, Total daily Cow............. gall ,,
WSeptic Tank—Li ui ca acit t, _ _gallons �Length..�f1._�..g Width ........_ Diameter___- -•--..._. Depth:..�_q
x Disposal Trench q No.........y_ .. Width._.._. Total Length.................... Total leachingarea....................s . ft.
Seepage Pit No......../-.-.-_-__-- Diameter......... ........ Depth below inlet..... Total leaching area=6_4_e..sq. ft.
Z Other Distribution box Dosing tank
'4 Percolation Test Results Performed b). !�..s __ :I�c....... �'% !/, ..- i
414--
Test Pit No. I................minutes per inch Depth of Test Pit..._:xm._ __." Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test ------ Depth to ground water. l?.j.4 le
. •••• ----•-------....-•••••••• --••••••----•-•-....••••-•----.......•-•----•---------------------•...........----•-••-•----••--•---........_._....--
DDescription of Soil............. 1 �--. .._ ..t ,/1f/.::........................................................
•--------------
U --.................................................
---------------------------•---------------•---------------•-----•---------------- ------------------------------
•---------------
.------------------••
W
U Nature of Repairs or Alterations—Answer when applicable--..............................................................................................
----------------------------•---------------•-----------------------------------.....---....-••-
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of 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 issued by the board of health.,4`
Signed----. Ac.-4,0........
Application Approved By-------•---..... zp Date
1 Date
�~ Application Disapproved for the following reasons:------•--------•-----------•------------------------------------------------•--•----------------....•-••-.......
....................•------•-•---..........------------------...-•---------------....----.......--------•..----------------------------•-......--•--------------•-------------------------------•--------
Date
Permit"IP......................................................... Issued.....................................................-
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.. �r
f�
i, 1,1Z.10......OF...... .............
Currtifiratr of TantpliFanrr i
THIS IS TO CERTIFY, T at the Individual Sewage.Disposal System constructed (^ or Repaired ( )
by------•-- I •F :{�..........7...1!.:,�'�` :� • `! e ..__...... -- ..._ ......
' I stalle t
.--. .
at '- - t-rf/ 'd am 1' e :'----------- - :. ............f -y-.�._.__.._. _. _.t_______y_t _. _... r -.r t __. _
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.__---•---------------------------------- dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CO STRIKE® AS A GUARANTEE THAT THE
SYSTEM 1lll LL FU - TION SATISFACTORY.
DATE......... Y.•----•---•-----•------•----•--...._..---•-------..... Inspector-----_. ... .m✓-
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALT
No....�..�.`..A:...
M ........ FEE........................
Dinv.nna,� Vorkg 106onsfrndilan Vanfit
Permission 's hereby granted........ I...... t_ -?...... `:'✓! _�_...G 1` l Y'.
to Construct (Ity or-Repair ( ) an Individual Sewage, Disposal System, ,
rat . Street =
as shown on the application for Disposal Works Construction Permit No..................... Dated..........................................
��--•----•----•-•-•-----•---••••--•-•--•-•--.....•....................._
.........................
........ Board of Health
DATE.........................16-•-".1i-�$�
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