HomeMy WebLinkAbout0116 BAXTERS NECK ROAD - Health 116 Baxter's Neck Road, Marstons Mills
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DATE: 8./6/97
PROPERTY ADDRESS: .116 -Baxte Neck •Road -t - 1
Marst.ons Mills ,Mass . ®f
02648 AVC
� 9 19
9 a
TO"OFy� HNC E ITAB(f �V
On the above date, I Inspected the septic system at the •a address. ,*
This system conslsts of the following:
S ti
1 . 1 -2000 gallon septic tank.
2 . I -Distribution box.
Based on my Intkc, ction, I certify the following conditions:
1 . This is a title five septic • system: ( 78 Code )
2 . The septic system *is in proper working
order at the present time .
SIGNATURY7: �t�(
Name: J . P . Macomber Jr..
------ ---------------
Company: . P_Macomber &- Son_Inc
__Centervi1Le , Mass__02632 '
Phone: _Sa —7-7.5-..333a__-_-__ -- -1
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
rJOSEPH P. MACOMBER & SON, INC.
TankrC�upooIaLeschf lelda
Pump*d Q InSU11 d
Town Sewer C0nnection6
P.O. Box 66' Centerville, MA 02632-0066
775-3338 775-6-412
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION'
ONE WINTER STREET. BOSTON, MA 02108 617-292.5500
wILLIAM F WELD TRUDY CO\I
Govcmor Sc;retan
ARGEO PAUL CELLUCCI DAVID B STRURS
Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner
PART A
CERTIFICATION
Property Address: 1 1 6 BaxtersNeek Road M&M Address of Owner:John Lebel
Date of Inspection: 8/6/97 (If different) Box 1 01 1
Name of Inspector: Joseph P. Macomber Jr . Osterville ,Mass .
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) 02655
Company Name: Joseph P. Macomber & Son. Tri .
Mailing Address: BOX 66, Centerville , Ma . 02632-0066
Telephone Number:-775—j 3j 8
CERTIFICATION STATEMENT
I cenify 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 inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
/Passes
Conditionally Passes
Needs further Evaluation By the Local Approving Authority
Fails ,�
Inspector's Signature: jLZA Date:
The System Inspector all submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this
inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit
the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to ttie system owner
and copies sent to the buyer, if applicable, and the approving authority.
INSPECTION SUMMARY: Check A, B, C, or D:
A) SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
COMMENTS:
BJ SYSTEM CONDITIONALLY PASSES:
V 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.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection, or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
(revised 04/25/97) Page 1 of 10
DEP on the World Wide Web: http:1twww.magnet.state.ma usidep
Printed on Recycled Paper
91"
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 1 1 6 Baxter Neck Road Mars tons Mills Ma
Owner: John Lebel
Date of Inspection: 8/6/9 7
B) SYSTEM CONDITIONALLY PASSES (continued)
Sewage backup or breakout or high static water level observed in the istribution bo is due to broken or obsuucted
pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the
Board of Health). Describe observations:
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four 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
C) FURTHER EVALUATION 15 REQUIRED BY THE BOARD OF HEALTH:
A,'V_ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
426 Cesspool or privy is within 50 feet of a surface water
y� Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or
tributary to a surface water supply.
The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis 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. Method used to determine distance A14 (approximation not valid).
3) OTHER
(revised 04/25/97) Page 2 of 10
• SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 1 1 6 Baxter Neck Road Marstons Mills Ma
Owner: John Lebel
Date of Inspection: 8/6/9 7
D) SYSTEM FAILS:
You must indicate ewer "Yes" or "No" as to each of the following:
A/V I have determined that the system violates one or more of the following failure criteria as defined in 310 CN1R 15.303. The-bans
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
Yes No Backupof sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution box bove outlet invert due to an overloaded or clogged SAS or cesspool
Liquid depth in•del mess than 6" below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped Q
Any ponion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any ponion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E) LARGE SYSTEM FAILS:
You must indicate either "Yes" or "No" as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
Yes No
4 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)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 04/25/97) Page 3 of 10
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 1 1 6 Baxter Neck Road Marstons Mills Ma
Owner: John Lebel
Date of Inspection: g/6/9 7
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No
Pumping information was provided by the EDoccupant, or Board of Health.
_ V None of the system components have been pumped for at least two weeks and'the system has been receiving normal
flow rates during that period. Large volumes of water have not been introduced into the system recently or
as part of this inspection.
_ As built plans have been obtained and examined. Note if they are not available with N/A.
_ The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow.
_ The site was inspected for signs of breakout.
_ All system components,
luding the Soil Absorption System, have been located on the site.
The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of
baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
— The size and location of the Soil Absorption System on the site has been determined based on:
The facility owner (and occupants, if djfferent from owner) were provided with information on the proper maintenance of
Sub-Surface Disposal System.
Existing information. Ex. Plan at B.O.H.
Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) (15.302(3)(b)J
(revised 04/25/97) Paq• 4 of 10
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Properly Address: 1 1 6 Baxter Neck Road Marstons Mills Ma
Owner: John Lebel
Date of Inspection: 8/6/9 7
FLOW CONDITIONS
RESIDENTIAL:
Design flow Y?�)�ns p.d./bedroom for S.A.S.
Number of bedrooms: 07
Number of current residents: 0
Garbage grinder (yes or no):'V—o4
Laundry connected to system (yes or no): S
.r
Seasonal use (yes or no): �QCAvY ��f-1 q-7 el �I/I
water meter readings, if available (last two (2) year usage (gpd):
Sump Pump (yes or no):-Z'20 J%�p�� . ' �' 6,�?`�
Last date of occupancy: dAX-
COMMERCIAUINDUSTRIAL:
Type of establishment:
Design flow:kgallons/day
Grease trap present: (yes or no)A2,4
industrial Waste Holding Tank present: (yes or no)A)-19
Non-Sanitary waste discharged to the Title 5 system: (yes or no),&—/4
Water meter readings, if available:
AA
Last date of occupancy:
OTHER: IDescr,be) vA
Iasi date of occupancy:
I II
GENERAL INFORMATION
PUMPING RECORDS and source of information:
A)n„ y y�oAiL,41oka
System pumped as pan of inspection: (yes or no)-�O
If yes, volume pumped: _—�allons
Reason for pumping:
TYPE OF YSTEM
Septic tank/d"t. but. —" v— soil absorption system
76 Single cesspool
_V29 Overflow cesspool
---!�Q Privy
,61 Shared system (yes or no) (if yes, anach previous inspection records, if any)
i(j I/A Technology etc. Copy of up to date contract?
Other
M��
of all components, date installed (if known) and source of information: lly6��
Sewage odors detected when arriving at the site: (yes or no)
(revised 04/25/97) ➢age 5 of 10
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 1 16 Baxter Neck Road Marstons Mills Ma
Owner: John Lebel
Date of Inspection: 8/6/9 7
BUILDING SEWER:
(Locate on site plan)
Depth below grader
Material of construction: _ cast iron 4/40 PVC — other (explain)
Distance from pr vate water supply well or suction line A1
Diameter q_
Comments: (condition of joints, venting, evidence of leakage, etc. ,
s
-I'h
SEPTIC TANK:AmQ/#VIV- ;4G kkiA�'
(locate on site plan)
i/
Depth below grade:
Material of construction: concrete _metal _Fiberglass _Polyethylene _other(explain)
If tank is metal, list age 11,4 Is age confirmed by Certificate of Compliance.+ (Yes/No)
Dimensions: Y
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:r (✓'
Scum thickness:
Distance from top of scum to top of outlet tee or baffle: 'PJ
Distance from bottom of scum to bosom of outlet tee r baffle: y-
How dimensions were determined:
Comments:
(recommendation for pumping, conditiqq of inlet and outlet tees or baffle , depth of liquid level in relation to outlet invert_, structural
in egnty, gvide ce of I akage, etc.)
70
Q
GREASE TRAP:AAve-
(locate on site plan)
Depth below grade:A/e
Material of con struct ion 7fAoncret&&metal��iberglassW,4Pol yet hylene-4//?other(explain)
Dimensions: AW
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:A�
Distance from bottom of scum to bottom of outlet tee or baffle:
/Q
Date of last pumping: 12-114
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity evidence of leakage, etc.)
7I-w a J'S >D l'" r S ea2 i
(revised 04/25/97) Page 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 1 1 6 Baxter Neck Road Marstons Mills ma
Owner: John Lebel
Date of Inspection: 8/6/9 7
TIGHT OR HOLDING TANK:jg,�&6(Tank must be pumped prior to, or at time, of inspection)
(locate on site plan)
Depth below grade:AZ
Material of construction:L&concrete Llametal _Vf iberglass,AF`olyethyleneAzj4other(explain)
Dimensions: pU
Capacity: rQA gallons
Design flow: A/R gallons/day
Alarm level: MP Alarm in working order Yes;NR No
Date of previous pumping: 0//7
Comments.
(condition of inlet tee, condition of alarm and float switches, etc.)
t 4 er /9/'E -,yel
DISTRIBUTION BOXAI'Ive,
(locate on site plan)
Depth of liquid level above outlet invert: //W
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)
i6Ti^1 t'1 LA,?) �;( /.5 rl/27�veCNnIT.
PUMP CHAMBER:A&ve—
(locate on site plan)
Pumps in working order: (Yes or No)—&�V
Alarms in working order (Yes or No)_,&.,,&
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
$
(revised 04/25/97) Page 7 of 10
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v
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 1 16 Baxter Neck Road Marstons Mills Ma
Owner: John Lebel
Date of Inspection: g/6/9 7
SOIL ABSORPTION SYSTEM (SAS): 49 't+���-aC4g7 '
d n plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
� �ovate o step p q
If not determined to be present, explain:
Type:
leaching pits, number:_
leaching chambers, number
leaching galleries, number:
leaching trenches, number,length:�_
leaching fields, number, dimensions:
overflow cesspool, number:0
Alternative system:
Name of Technology: ImAe-
Comments:
(note condition of soil, signs of hydraulic failure, level of pondi g, co dition of vegetation, etc.) r
f
r L
CESSPOOLS:AZU-16
(locate on site plan)
Number and configuration: AW
Depth-top of liquid to inlet invert: A j)
Depth of solids layer:
Depth of scum layer: !
Dimensions of cesspool: 'VA
Materials of construction: 492
Indication of groundwater: ✓�M
inflow (cesspool must be pumped as part of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:
(locate on site plan)
Materials of construction: XI/`� Dimensions: iUA
Depth of solids:_
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised 04/25/97) Page 8 of 10
r
rl
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:! X 16 Baxter Neck Road Marstons Mills Ma
Ownef: John Lebel
Date of inspection: 8/6/97
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
w��� Xo
,r
(r wi@•d 04/25/97) Page 9 of 10
• I
`J
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Properly Address: 1 1 6 Baxter Neck Road Marstons Mills Ma
Owner: John Lebel
Date of Inspection: 8/6/97
r
Depth to Groundwater 5' Feet
Please indicate all the methods used to determine High Groundwater Elevation:
--oz/0btained from Design Plans on record
Observation of Site (Abutting property, observation hole, basement sump etc.)
Determine it from local conditions
Check with local Board of health
Check FEMA Maps
Check pumping records
�eck local excavators, installers
Use USGS Data
Describe in your own words how you established the High Groundwater Elevation. (Must be completed)
See pages 9A&9B No water encountered at 121 .
House is on hill. High above Prince Cove.
Used Cape Cod Commission GIS SERVICES MAP.
September of 95.
Water table contours and Publuc Water Supply Map.
Monomoy Lens.
(revised 04/25/97) Page 10 of 10
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CERTIFIED PLOT PLAN
( .CERTIFY THAT THE`) LOCATION /'4 `� �� �/�5
SHOWN HEREON COMPLYS WITH SCALE BATE 5 -2- =
:THE SIDELINE AND SETBACK
REQUIREMENTS OF THE TOWN OF PLAN REFERENCE
AND IS ,,-167-
LOCA •ED WITHIN THE FLOODPLAIN• ����� '`�� � � �'• R-CL
DATE : •BARTER NYE, INC.
THIS PLAN IS NOT BASED ON A REGISTERED LAND SURVEYORS
INSTRUMENT SURVEY AND THE
OSTERVILLE MASS.
OFFSETS SHOWN SHOULD ' NOT BE
USED TO DETERMINE LOT LINES, APPLICANT
.. ` ..+�r, n rr 1^.-.rn-nr.n m rs-..n rn..m n:-.�.+.+r:+..r-e.,+n1..r*�v'.�-R.v.1. RT..�'--vn*vv r...-•--•-- '-- -
I'UNN OF Barnstable WARD OF HEALTH
SUMONFACF SEWAGE DISFUSAL SYSTFM INSPFCTION FORM - PART D - CEIZT1FI CAT iO'
�_ �...._.^.T..-..•-�iil.^^T,T.�•n:iT TT.S'TTTTT1'�-11-1.T.1R.IlR'^.".!�..rI AT'I.rnlTT'nTY T..n''rnr.^'1i4^m-.�.+�'-rr-- r- - -
-TYPE OR PRINT CLEARLY-
PROPERTY INSPECTED
STREET ADDRESS 116 Raxtpr NPnk Rnnd Mnrsfnns Mills,Mass.
ASSESSORS MAP , BLOCK AND PARCEL #
OWNER' s NAME John S. Len 1
PART D - CERTIFICATION
NAME OF INSPECTOR Joseph P. Macomber Jr .
COMPANY NAME Joseph P. Macomber & 'ion , Inc .
COMPANY ADDRESS Box 66 Centerville , Ma . 02632-0066
5tr9Qt Town or City
COMPANY TELEPHONE (508 1 775 -3338 FAX ( 508 ) 790 -1 578
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system n :
this address and that the information reported is true , accurate , and
complete as of the time of ;inspection . The inspection was performed and an.:
recommendations regarding upgrade , maintenance , and repair are consisLen �
with my training and experience in the proper function and maintenance o � on-
site sewage disposal systems .
Check one :
)MXXXXYXX XX System PASSED
The inspection hhich I have conducted has not found any information
which indicates that the system fails to adequately protect public
healLit or Che environment as defined in 310 CMR 15 . 303 , Any failluFe
criteria not evaluated are as stated in the FAILURE CRITERIA section o `
this form ,
System FAILED* \
The inspection which I have con\__�ucted has found that the system f�, _ ' s :o
Protect the 'public health and the environment in accordance with Ti . ie
5 , 310 CMR 15 - 303 , and as specifically noted on PART C - FAILUR--
CRITERIA of this inspection form .
.Inspector Signature Date 8/9/97
,;ne copy of this certification must be provided to the OWNER , the BUYER
( where applicable ) and the BOARD OF IILrALI'l
• IC the inspection FAILED , the owner or operator ehall upgrade the eyote-
ir•hin one year oC the dote of the inspection , unless allowed or require-_'
otherwise as provided in 310 CMR 16 , 306 .
partd . '�_
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THE COMMONWEALTH OF MASSACHUSETTS
DEPARTMENT OF E ONMENTAL PROTECTION
BE IT KNOWN THAT
Joseph P. Macomber, Jr.
Has satisfied the Department's qualifications as required and is hereby
authorized to use the title
CERTUTED TITLE S SYSTEM INSPECTOR
as provided in 310 CMR 15.340 and Section 13 of Chapter 21A of the
General Laws_ Issued by The Department of Environmental Protection.
Junc s. 1995
Acung Dimctor of tIlc ion of Watcr Pollution Control
WN OF BAR STABLE
LOCATION Ica SEWAGE # 10
VILLAGE2&A-4 XNO.
OR' A 6LOTINSTALLER'S NAME 6� PHONE 7SEPTIC TANK CAPACITY �
LEACHING FACILITY:(type) (size) L�
NO. OF BEDROOMS P I AT , WE O PUBLI- WATE
BUILDER OR OWNE r
DATE PERMIT ISS (U
DATE COMPLIA CE ISSUED: 1
VARIANCE GRANTED: Yes No z
TOWN OF BARNSTABLE 44>Lk cvy
LOCATION ���Awzi 4k--e Aa ;—f8WAGE#
VILLAGE l�i��''�T.r1 s �y,L,�S• ASSESSOR'S MAP &LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY A2b
9�
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS ,
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the: r
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 30�feeto lea n fa Feet
Furnished by
ti.
ASSESSOR S NAP NO. !Ste= PARCEL
- :'OCATIO �J SEWAGE PE IlMil,, N0
VILLAGE
INSTAejUE 'S NAME i ADDRESS
R U I L D E R R OWNER '
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED ✓ fir — �,
f Al-
L a
No. ..: �.7
Fim
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........._j_0W'0........OF....... ------I...........Appliration for Bispwial Works Tongtrurtion Prrutit
Application is hereby made for a Permit to Construct ( lt-Kr Repair an Individual Sewage Disposal
Systemat: A..................... L L.. (---------::....... ...................................... ........!�. ....A..................
cation ddress or Lot No...............W
........................ ................. 2...... ........... ..........
------------------Address
Installer Address
Type of Building Size Lot.. 4eet
Dwelling—No. of Bedrooms..............S........................Expansion Attic Garbage Grinder
Other—Type of Building ............................ No. of persons___..__...____________._____ Showers Cafeteria
Otherfiixtu-res ......................o......................................................................................................0........................
Design Flow.............SS------- gallons per person per day. Total daily flow____.___.___6-:?r�..................gallons.
1:X Septic Tank—Liquid capacity C.7gallons Length________________ Width._..__._._______ Diameter_......__.______ Depth___.____.___._..
Disposal Trench—No..................... Width.................... Total Length............It"---- Total leaching area__._.___._.. sq f t.
Seepage Pit No._______. .._ meter.........10---- Depth below inlet.._._..(P......... Total leaching area--- -'S'q'ft.
ria
Other Distribution box Dosing tank
Percolation Test Results Performed by.-- ...... ......... Date______ 7-------------------
Test Pit No. I.....:?:-:!.....minutes per inch Depth of Test Pit........I.Mm. Depth to ground water_................. .....
Test Pit No. 2................minutes per inch Depth of Test Pit__.__._.______.__... Depth to ground water._____..._..___..____._.
...................................................................................................................................0.........................
0 Description of Soil...............................................S*......*"*'*'**'*----------------------------------------------------------------------------------------------------
�4 —
................... .4........... .....................................................................................................
-------------
......................................................................................................................................0.................................................................
U Nature of Repairs or Alterations—Answer when applicable--------------------- .........................................................................
.....................................................................................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
f M In
the provisioi3�� 1 1 1 LE 5 o the -S to Sa i ary Code—The undersigned further agrees not to place the system in
'ope .1 C n i a ca f Co lia as been issued by the board of health.
............................ ...................................................... ...............................
D t
t.�
Application Approved _y............................................ ......................
Date
Application Disapproved for the following reasons:...............................................................................................................
.........................................................................................................................................................................................................
PermitNo..... ........... IssuedL...........................................D.ate..................... .................
Date
/y
f
Fss.......: .
THE COMMONWEALTH OF MASSACHUSETTS
a ' BOARD,-OF HEALTH
r- ..;., :�: ........OF...........
,Xpp iration for Dh4posFal Works
Tonstrnrtinn amit
Application is hereby made for a Permit to Construct ( 4d)" or Repair ( ) an Individual Sewage Disposal
System at 3
.... ....
Liocationp-Address �+ ] for Lot�o
......................».�:::r.................--.....I...................:.........•............ ............ .-y.-.. _ ....................... ... ................ ..._..._........
a
— � Addres--•------------------- !* . Owper.._.. :.... c-:--------------------- •...--•...._.........---•------••......---... ---.s...........................................
Installer Address
d Type of Building ,•- Size Lot..__.......
:._°- ? * Leh°
U Dwelling—No. of Bedrooms............. %.........._.............Expansion Attic ( ) Garbage Grinder ( e
Other—T e of Building No. of persons............................ Showers — Cafeteria
P I Other fi tujes •-----•-•--•... -•------•-------------•----------
WDesign Flow................:.: ---------.._._......gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity.!-:t'H:f§Agallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No. .................... Width.................... Total Length..................... Total leaching area................. s ft
f-- q.
Seepage Pit No....___.. __. ameter......... �. ... Depth below inlet______ ___________ Total leaching area..:' :sq. ft.
Other Distribution box ( ) Dosing tank ( ) t
Z Percolation Test Results Performed by.-_*"°---i-- '-1: f,... i:( .....__ ?! ..... Date....... ".. ......................
aTest Pit No. L___-- .....minutes per inch Depth of Test Pit--------'...Zmv. Depth to ground water.......""'"0.....
(% Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
.............-........................................_.....................................................................................................
ODescription of Soil............................................... ....--••--•-•-••....••-•...------•---•---•-------•-•-•-••--•----•---------------•-----------•-•------._...........---
x "k
. t
V Nature of Repairs or Alterations—Answer when applicable................................................................................................
----------------------------•-------•------•-----------------------------•-•-------•--...----•-•--...----......-----------------------•-----•-•---------------------------------._.......-•--.......-•--
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provision��of TITIE 5 o�the S to,,S�anitary Code—The undersigned further agrees not to place the system in
operation uri it a C.e tificate of Co lianil. as been issued by the board of health.
Da
Application Approved By--- .. -.. :... ....... ls �A.._..
Date
Application Disapproved for the following reasons-------------------------------------•-------------------------•-----------------•----------••----•--------.•••-
--•--•...............•--•---•----....----------••----•••-----...----•-•-•---•--•--------•---------....•----•----•---•--......-------•-------------------------•-•-•----•--------••••---•------•...._..--
Date
PermitNo.--------. ....... .......... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEALTH
OF 1
%'-wrr#ifirFa#r of Tomplianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( or Repaired ( )
by.............. _ •-- r .-� "'---------------------------------- --•--•------.----------•---•--
ns ller
at --
,;;,has been installed in accordance with the provisions of TIT 5 of The State Sanitary Code as d •cribed in the
application for Disposal Works Construction Permit No.... ~... ._1.. :a da.ted.......Lj .1-Qir�. 0.............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUA_iANTEE THAT THE
SYSTEM WILL F CTION �A ISFACTORY. I
DATE................ 7 �- ................--•-----------...-•--- Inspector........_......_. ....!!!
---------L CI ................................
THE COMMONWEALTH OF MASSACHUSETTS
�-- - `BOARD OF HEALTH `
OF.....,f.%.......r�...•r.:r... ...7->�.��...........�...........................
No .�............. FEE..
i �r� irk n union rrnti#
r
Permission is hereby granted............-mot � - r •---------------------------------------•--•----.......-•-•-•---....to Construct ( �r Re air ( ) an Indivi ual Sevtrag Ispos stem
atNo.-----_----�" .............. 1 ........................................................
Street
as shown on the application for Disposal Works Construction Permit Nrv_ Wit.?.. D ted---- -__.
PP P ..( ._._....
j�� =-
cl� Board win:
DATE-- ------• 1-------------•----••--.........------.....••.•-
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS
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