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Home My WebLink About0141 BRIDLE PATH - Health 141+BRIDLE PATH, S Af B S LE OCATION �� SEWAGE # VILLAGE /��s��1 /"(� S ASSESSOR'S MAP & LOT AME&PHONE NO. SEPTIC TANK CAPACITY _� 1 LEACHING FACILITY: (type) /� /✓� (10e� NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: 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 of leaching facility) Feet Furnished by I �� . � � - ,��4 � �� ' ��6 �� V r � �� y � � �.s�� I •'" j~ COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTif NT OF I+1MRONNNNTAL pROTECTIrO1�Ff� h4S ABLE 05 J°JIN 2 0 Pi 115 9 UiVISION TITLE 5 MENTS r OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSES ds SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A I / /CERTII,�/hCATION Property Address: � �d /�� Owner's Name: i , e O 7 Owner's Address: 9' Date of Inspection: Name of Inspector; pdt) p,Yij Company Name.-.- E ' C Mailing Address: d p Telephone Number. �— RTIFICATION STATEMENT I ca*that I have personally inspected the sewage disposal system at this address below is true,accurate and oomph as of the time of the ' and that the`iffiormation reported Wining and experience in the proper fimctian and ��on �inspection was perfnance of on site sewage disposal ormed based on my aPProved system inspector pnrsaant to on 15Title S(310 CM[t 11000 ems.I am a DEP The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority F ' Inspector's Signature: Date: � r Te*Stem mspector shall submit a copy of this inspection report to the DEP)within 30 days of completing this inspection If the Ong Authority(Board of Health or gpd or gar,the r and the *,sue is a shared system or has a design flow of 10,000 DEP. on . system owner sbaan submit the report to the� office of the authority grnal should be sent to the system owner and copies sew to the buyer,if applicable,and the approving Notes and Comments ""This**This report only describes conditions at the time of inspection time'This inspection does not address how the system will perform in se at that conditions of use, the future under the same or different I_ ' Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY AS SESS SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM S PART A CERTIFICATION(continued) Property Address: Owner. t (le Date of Inspecdon: , f, Inspection Summary: Check A^C,D or le/ALWAYS complete an of Section D A.�16-- I v not found any information which indicates 15.303 or in 310 CMR 13.304 exist,Any failure criteria not evi odescriibed in 310 CM Comments; B• Sy Conditionally Passes: i7 repaired The system upon competi bed in the"Conditional Pass" replaced or replacement or suction need to be repair,as approved by the Boats of Heahh,will paw. Answer explain.yes,no or not determined(Y,N,�)in the for the following statements.If"not detCMinW plea3e The septic tank is metal and over 20 years old*or the septic tank w or unsound.exhibits substantial infiltration or ex6 w ltration or tank ( bather metal m not)is�, existing tank is replaced with a co System will pass inspection if the complying septic tank as approved 'A metal septic teak will Pass inspection if it is by the Board of Health. indicating that the tank is less than 20 years old is av�mod' leaking and-if a Certificate of Compliance ND explain: Observation of sewage backup or break out or high static water level in the distribution approval of Board ofHealth):obstructed pipe(s)or due to a broloen,settled or uneven button box System will:inspection if(with or breken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: Pass �. m required pumping more than 4 tines a year due to broken or obi pipe(s). on if(with approval of the Board of Health): The system will broken pipe(s)are replaced obstruction is removed ND explain: I . Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner: t le. G � ''¢'7 �a� C 4� Date of Inspection: r C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the envu o nmea I. System will pass unless Board of Health determines in acco system is not functioning in a manner which will protect with 310 CMR 13�303(iKb)that tim protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh Z. System win fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. -- The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or private water supply well**.Method used to determine distance more from a **This system passes if the well water bacteria and volatile organic ems,�o�at a DEP c�ifiW laboratory,for coliform 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 failure criteria are triggered,A copy of the analysis must be attached to this form that no other 3. Other: IPage4 of 11 OFFICIAL,INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: / �r07 Owner. �. �S�/�i�/fr Qc,C-,�� Date of Inspection: D. System Failure Criteria applicable to all systems: You mustindicate`Yes"or`no"to each of the following for as inspections: Yes No Dischar of sewage into facility or system component due to overloaded or clogged SAS or cesspool ISCIURSC or ponding of effluent to the surface of the ground or surface waters due to an overloaded or ogpd SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or — —G� depth in cesspool is less than 6"below invert or available volume is less thaw%day flow �of times pu Pumping ions than 4 times in the last year 1VQdue to clogged or obstructed OXS).Number portion of the SAS,cesspool or privy is below hi gh ground_ — Any portion of cesspool or privy is within 100 feet of surface water elevation. water supply, supply or tributary to a surface Portion of a cesspool or privy is within a Zone 1 of a public well. AQW Portion of a cesspool or privy is within 50 fAnjeet of a private water su pply Portion of 8 cesspool Or Sup*well m&no acceptable water privy less than 100 feet gc than 50 fed w�a Private water performed at a DEp �ems. Mis system.Passes N the well water analysis, eertifled laboratory,for coliform bacteria and volatile organic compounds indicates that the well it tree from pollution from that! nitrogen and nid ate nitrogen Is equal to or less than S p and the presence of ammonia are triggered.A copy of the anal sits must be PPS Provided that no other failure criteria 3' attached to this form.] (Yes/No)The system faj .I have determined that one or nmre of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails,The e Health to d necessary to correct the failure etermine what will be owner should contact the Board of E. Large Systems; To be considered a large system the system must serve a f gp� acility with a design flow Of 10,000 gpd to 15,000 You must indicate either`yes"or"no"to each of the following: (The following criteria apply to Imp systems in addition to the criteria above) es no .— system is within 400 feet of a surface drinidng 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 Zone II of a public water supply well 1'ratectron Area—IWPA)or a mapped If you have ered"yes"to any question in Section E the system is considered a si"Yes"in Section D above the large system has failed.The owner or operator of system� �or answered significant threat under Section E or failedwxkr Searon.D shall s considered a System owner should contact the a =01%laaoc with 31a C R appropriate regional office of the Department, Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CSECI"T Property Address: / Owner. / l•'� QoZ C�-5� Date of Inspe�io : Check if the following have been done:You mast indicate es"or"no"as to each of the following: Yes o — _ Pumping information was provided by the owner,oocupeat,or Board of Health v Were any of the system components pumped out in the 'ous ✓ pearl two weeks — _. HS�e system re=ved normal flows m the peevwus two week period r" bW voh�of tamer been introduced to the system nay or as part of this inspection _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) Was the facility or dwelling mVected for signs of sewage back up Was the site inspected for signs of break out . Were all system components,exduding the SAS,located on site _ Were the septic tank manholes uncovered,Opened,and the mtenm of the tank inspec, d far the condition Of the ee tees,mgmla l ofdimensions.depth of kpd depth of sludge and depth of scam Was�ahnance a[they oa'sewa ner((andoaf ge disposrd .if different&can o provided with.Wormation on the ptoper The size and location of the Soil Absorption System(SAS)on the site has been determined based on: :Yes no x�sang Information,For example,a plan at the Hoard ofHealth. _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 Cho 15.302(3)(b)j I� Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C / SYSTEM INFORMATIDN Property Address ( !r Owner. Date of Inspecbioo: FLO CONNDIMNS R ENTiAi. Number of bedrooms(design):_j Niumber o f bedoppms(may DESIGN flow-based on.-3 10 CUR,15103(for exam 1,10 gpd x#of bedrooms): Number of current residents: ,/� Does residence have a garbage grinder(yes or no):/� Is laundry on a separate sewage system or no):Mv[if yea separate inspection required) Laundfy system irrspocted 9"no):,d Seasonal use:(yes or no):_ Water meter readings,i€ (last 2 years usage(gxl)): Sump pump(yes or no):' Last date of occupancy: t4y119j,;1 COMMERCIALIMUSTRIAL Type of establishment: Design flow(based on 310 CIVIR 15.203): and Basis of design flow(seats/persons/sgft etc.): Grease trap present(yes or no): Industrial waste holding tank preset(yes or no): Non-sanitary waste diwhugod to the Title 5 system(yes or no): Water meter reading,if available: Last date of occupancyAne: OTHER(describe): ftmping Records GENERAL INFORMATION Source of iniormation: A vv Was system pun4ed as part of the inspection(yes or no):_ Reason volume �A�p� - —How was quad*pumped determined? SYSTEM tank,distnb Mon box,soil absorption system —Single Cesspool _Overflow Cesspool —Privy —Spared system(yes or no)(if yes,attach previous Inspection records,if any) Innovativa/Ahernative technology.Attach a copy of the current operation and canoe contract(to be obtained from system owner) —Tight tank _Attach a copy of the DEP approval —Other(descnbe): Approximate 490 of all date (if Imown)and source of information: Tai� pfr ( ,Z fie+.-at- Were sewage odors detected when arriving at the site(yes or no): Page 7 of I 1 OFFICIAL INSPECTION FORM-NOT.FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM 1N SPECTION FORM PART C . SYSTEM INFORMATION(contim ]Property Address: `T I ,z, r Owner, c Date of In e ch BUILDING SEWER jlocate on siteplan) Depth below grade: _;�d // Materials of construction: iron Q Distance fi om private water supply wel:or=*on KW.�( ' Comte(on coeditian of joints; .M.&nce of leakage,etc.): -------------- SEPTIC TANK;_(]ocate on she per) Depth below grade: Material ceoonstrttc .on: _�1 m_polyet$ylene odWexplain) If tank is metal list age:_ Is aV mead ceztificate) � �`a�Of Compliance-(yes or no):_(attach a copy of mud DiStanNI Scum thi&nes. stndgefto bottom of nutlet tee or baffle: 0 Distance fmm top of scum to top of outlet tee.at bade: •r-�e DiDistance 5oom bottom of scum.to bottom outlet tee or baffle: �r•'�v� How Wete dlmeilslQnS determined; p(� ; / C (n g c o0s,inlet and outlet tee or, a eondition,�r . LpOlated to gee,.etc.): egritY;liquid levels e S e c v"v � % C/ ✓> ` a N G � GREASE '� 'r: (locate on site plan) Depth below grade:_ Material of eonsbractfon;_concrete (explain): meta!--fi _polyethylene_other Dimensions: Scum thicimess: Distance from top of to top of outlet tee or bete: Distance from bottom of scum to bottom of outlet tee or ba—__ Date of last pumping_ ---_ Comments(on P�P�g mcommendahons,inlet and off.tee or bye evidence of l conditioq t8rit3',lignid levels as related to outlet im+ert, eakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C / SYSTEM INFORMATION(contimred) Property Addr+em �� • j 0 W Mr.. I' IT, C C 6:::;) Date of Inspection, p TIGHT or HOLDING TANK:t v(tank must be Piped at tune of inspec,'tion)(lacate on site Plan) Depth below grade: Material of construction concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: Design Flow: sallocWday Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last punting Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: (if present must be opened)(iocate on site plan) Depth of liquid level above outlet invert:JZ*701 v"c Z— Commergs(note if box is level and asUftMon to outlets equal,any evidence of solids over leakage of out of box,etc. • �' , y evidence of ' 0 X �(� PUMP CHAMBERS `t/ oc ate on A sae plan) Pumps in wonting order(yes or no): Alarms in working order(yes or no): Comments(note cxon of pump chamber,condition of Pumps and appcuteoanoes,etc.): I page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE OiSPOSAL SYSIXM IlMIMMON FORM SYSTEM I14FORMATION{oc,e dmw* PnvertyAddnw , t 9/, /6 ba Owner: Date of Inapecrisr a SOa.ABSORrMn SVST.M,(SAS)., .(locate m.*g plan,awwadan oat if SAS not locatedopl*wily. l�cbmg pitw nawbar x lei: s��C, leaching fidk : overflow cesspool,number: system -I)pChowoff; Commcft(nose condition of soil,signs of hydraulic failure,level of etas ponding,damp soil,condition of vegetation, ply 0�1 ? i _ 6 C A v -' 1, C LS:,l/(cesspool mm be pumped as Pert of mspecaon)(ioca to on srte Plan) Number and : Depth—topoflipidta inlet roves Depth of solids to= Depth of scum lager_ Dimensions of cesspool: Materiala decoction: Indite of gmwxMzw mflow(yes or nod Comments Owle canftm of soil,signs of h *30fic fdWM.lewd ofpond;ng condom of m*etafeon,etc PRIVY: on side plan) Matediais off Dimes Depth of solids: comments(notecondition ofs*Sign Of*h &bilum kvd ofpondiB&condition ofveptadM etc.): L f • rage 10 of I I r OFFICIAL INSPECTION FORM—NOT.FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(coated) Property Address: )-Liaff/ 12 Owner. Date of I spec-a s: �2� SKETCH OF SEWAGE USPOSAL SYSTEM Provide a sketch of the sewage disposal system iachxhng ties to at least two pemmaneat reference landmarks or benchmarks.Locate all wells within 100 feel Locate where public water supply enters the building. q . A- - 3� y A3- o�3 r /j�� - / / r f. Page I I of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(co�nued) Property Address: /l d f Owner.- Date of inspection. SITE EXAM Slope Surface water Check cellar o Shallow wells Estimated depth to ground water few Please indicate(check)all methods used to determine the highpound water elevation. obtained from system design plans on record-If checked,date of design plan reviewed: 0�0sfte(abutting property/observation hole wiM 150 feet of SAS) with local Board of Health�giaw q Checked with local excavators,installers-(attach `on) Accessed USGS You must describe posy you efablished the high ground water elevation: go 140 -Jae f c, (� � N-62 , Of J v 0 R ece'4 .,� 000,0 00C 91 C'� �� 10 . f 0 cr 0� Sao® COMMONWEALTH OF MASACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIR �, s DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET BOSTON MA 02108(617)292-3500 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 141 BRIDLE PATH MARSTONS MILLS, MA 02648 M149 P142 Name of Owner SUSAN AND MARK SIMON Address of Owner: 208 NOISHOLE RD.MASHPEE MA.02649 Date of Inspection: 9120100 Name of Inspector: JOHN GRACI 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: SEPTIC INSPECTIONS Mailing Address: I P.O.BOX 2119 TEATICKET,MA.02536 Telephone Number: 508-564-6813 FAX 508-564-7270 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 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: X Passes _ Conditionally Passes _ Needs Further Evalfem the Local Approving Authority Fails Inspector's Signature: Date:9/27/00 The System Inspector shall submicopy of, inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of completing this inspection.If the ssa 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 the system owner and copies sent to the buyer""if applicable,and the approving authority. NOTES AND COMMENTS "The inspection is based on criteria defined in Title V code 310 CMR 15.303.My findings are of how the system is performing at the time of inspection.M,. inspection does not imply any warranty or guarantee of the longevity of the septic system and any of its component's useful life." THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. revised 9/2198 Paoe 1 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 141 BRIDLE PATH MARSTONS MILLS, MA 02648 M149 P142 Name of Owner SUSAN AND MARK SIMON Date of Inspection: 9120100 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: i, X I have not found any inform atiori'which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. i B. SYSTEM CONDITIONALLY PASSES: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion o 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. nla 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 complying septic tank as approved by the Board of Health. nla Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)o due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health). _broken pipe(s)are replaced _obstruction is removed _distribution box is levelled or replaced nLa 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 i revised 9/2/98 Page 2 of 11 , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 141 BRIDLE PATH MARSTONS MILLS, MA 02648 M149 P142 Name of Owner SUSAN AND MARK SIMON Date of Inspection: 9/20/00 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM I! NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER.IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: s:; . . 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. _ The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. s. 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 nla (approximation not valid). 3) OTHER n/a ?I !j revised 9/2/98 Paoe 3 of 11 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 141 BRIDLE PATH MARSTONS MILLS MA 02648 M149 P142 Name of Owner SUSAN AND MARK SIMON Date of Inspection: 9/20100 D. SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6 below invert or available volume is less than 1/2 day flow, X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped n/a. X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well, X Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. c: ri. E. LARGE SYSTEM FAILS: 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: 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 X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X 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 upgrade the system in accordance with 310 CMR 15.30412). Please consult the local regional office of the Department for further information. revised 9/2/98 Paoe 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 141 BRIDLE PATH MARSTONS MILLS, MA 02648 M149 P142 Name of Owner: SUSAN AND MARK SIMON Date of Inspection: 9/20/00 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No X Pumping information was provided by the owner,occupant,or Board of Health. X 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. X _ As built plans have been obtained and examined. Note if they are not available with N/A. X _ The facility or dwelling was inspected for signs of sewage back-up. X - The system does not receive non-sanitary or industrial waste flow. -�r X _ The site was inspected for signs of breakout. X _ All system components,excluding the Soil Absorption System,have been located on the site. X _ 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: X _ Existing information,For example, Plan at B4O,H, cl X _ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)1 5.302(3)(b)] X _ The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 9/2/98 Paae 5 of 11 I ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 141 BRIDLE PATH MARSTONS MILLS, MA 02648 M149 P142 Name of Owner SUSAN AND MARK SIMON Date of Inspection: 9120/00 FLOW CONDITIONS RESIDENTIAL: Design flow: 110 g.p.d./bedroom Number of bedrooms(design): 3 Number of bedrooms(actual):nla Total DESIGN flow: 330 gpd Number of current residents:0 Garbage grinder(yes or no): NO Laundry(separate system)(yes or no): NO If yes,separate inspection required Laundry system inspected(yes or no): Seasonal use(yes or no): YES Water meter readings,if available(last two year's usage): n/a gpd Sump Pump(yes or no): NO Last date of occupancy: n/a COMMERCIALIINDUSTRIAL Type of establishment: n/a Design flow: nla gpd(Based on 15.203) Basis of design flow: n/a Grease trap present:(yes or no): NO Industrial Waste Holding Tank present:(yes or no): NO Non-sanitary waste discharged to the Title 5 system:(yes or no):NO Water meter readings.if available: nla Last date of occupancy:n/a OTHER: (Describe) n/a GENERAL INFORMATION PUMPING RECORDS and source of information: n/a System pumped as part of inspection:(yes or no): NO If yes,volume pumped n/a gallons Reason for pumping: n/a TYPE OF SYSTEM X Septic tank/distribution box/soil absorption system _ Single cesspool Overflow cesspool _ Privy _ Shared system(yes or no)(if yes. attach previous inspection records,if any) _ I/A Technology etc.Attach copy of up to date operation and maintenance contract _ Tight Tank Copy of DEP Approval Other: n/a APPROXIMATE AGE of all components,date installed(if known)and source of information: 1994 PERMIT 94-341 Sewage odors detected when arriving at the site:(yes of iio): N6 '!=•SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM revised 9/2/98 Page 6 of 11 PART C SYSTEM INFORMATION(continued) 4 M149 P142 Address: 141 BRIDLE PATH MARSTONS MILLS 8 Property , MA 026 Name of Owner SUSAN AND MARK SIMON Date of Inspection: 9/20/00 BUILDING SEWER:X (Locate on site plan) Depth below grade: 18" Material of construction: _ cast iron X 40 Pvc _ other(explain) Distance from private water supply well or suction line: nla Diameter: nla Comments: (condition of joints,venting,evidence of leakage,etc.) THERE IS TOWN WATER SEPTIC TANK: X (locate on site plan) Depth below grade: 12" Material of construction: X concrete_ metal_ Fiberglass_ Polyethylene_ other explain: n/a If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NO Age: n/a Dimensions: 1000G L 8'6"H 5'7"W 4'10 Sludge depth: 8" Distance from top of sludge to bottom of outlet tee or baffle: 26" Scum thickness: 13" st ; Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 0" How dimensions were determined: MEASURED 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.) THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING NOW AND EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE GREASE TRAP: _ (locate on site plan) Depth below grade: nla Material of construction: _concrete_ metal_ Fiberglass _ Polyethylene_other Explain: n/a Dimensions:nla Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle n/a Date of last pumping: n/a "s' t 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.) nla t�. revised 9/2/98 Paoe 7 of 11 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 141 BRIDLE PATH MARSTONS MILLS, MA 02648 M149 P142 Name of Owner SUSAN AND MARK SIMON Date of Inspection: 9120/00 TIGHT OR HOLDING TANK: _ (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: n/a Material of construction: _concrete_ metal_Fiberglass _Polyethylene _other Explain: n/a Dimensions: n/a Capacity: n/a gallons Design flow: n/a gallons/day Alarm present: NO Alarm level:N/A Alarm in working order:NO Date of previous pumping: nla Comments: (condition of inlet tee,condition of alarm and float switches,etc.) n/a DISTRIBUTION BOX:X (locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) THE DISTRIBUTION BOX IS STRUCTURALLY SOUND. PUMP CHAMBER: _ (locate on site plan) Pumps in working order: (Yes or No): NO. Alarms in working order(Yes or No): NO Comments: . (note condition of pump chamber,condition of pumps and appurtenances.etc.) n/a revised 912/98 Paoe 8 of 11 • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 141 BRIDLE PATH MARSTONS MILLS, MA 02648 M149 P142 Name of Owner SUSAN AND MARK SIMON Date of Inspection: 9/20100 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: n/a Type: leaching pits,number:(2)1000 GAL 6'X 6' leaching chambers,number: (n/a)n/a leaching galleries,number: (nla)n/a leaching trenches,number,length: (n/a)n/a leaching fields,number,dimensions: (n/a)n/a overflow cesspool,number: (nla)n/a Alternative system: n/a Name of Technology: n/a Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE LEACH PITS APPEARS TO BE FUNCTIONING PROPERLY.SYSTEM SHOWS NO SIGNS OF FAILURE. CESSPOOLS: _ (locate on site plan) V_ 11; Number and configuration: n/a Depth-top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer. n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater: n/a inflow(cesspool must be pumped as part of inspection)NO 4 Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) n/a PRIVY: (locate on site plan) Materials of construction: nla Dimensions: n/a Depth of solids: n/a Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) n/a t revised 9/2/98 Paoe 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 141 BRIDLE PATH MARSTONS MILLS, MA 02648 M149 P142 Name of Owner SUSAN AND MARK SIMON Date of Inspection: 8122/00 SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes Into house) i . 4C �eC k Sere e�1 0 6 < b CIA �1 a 3)q a� A y q �o �a 1 �r revised 9/2/98 Page 10 of 11 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 141 BRIDLE PATH MARSTONS MILLS, MA 02648 M149 P142 Name of Owner SUSAN AND MARK SIMON Date of Inspection: 9120100 NRCS Report name: nla Soil Type: n/a Typical depth to groundwater: n1a USGS Date website visited: nla Observation Wells checked: NO Groundwater depth: Shallow_ Moderate_ Deep_ SITE EXAM _ Slope _ Surface water _ Check Cellar _ Shallow wells Estimated Depth to Groundwater 12 Feet+ Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site(Abutting property,observation hole,basement sump etc.) Determined from local conditions _ Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators,installers X Used USGS Data Describe how you established the High Groundwater Elevation.(Must be completed) USGS MAPS AND CHARTS-12+FEET r revised 9/2/98 P.aoe 11 of 11 TOWN OF BARNSTABLE LOCATIONZ�� &"A SEWAGE # VILLAGEG}(,S ASSESSOR'S MAP LOT A�—�7` INSTALLER'S NAME & PHONE NO. 6/b 54 SEPTIC TANK CAPACITY 1060 /, 1oeed LEACHING FACILITY:(type) i � , u NO. OF BEDROOMS PRIVATE WELL R PUBLIC WATER BUILDER O OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: 9Ly VARIANCE GRANTED: Yes CNQ 1 y/ yy ys' 0 Algid 0, No..... --.__..._. Fps... �.:�..... pR...VEO THE COMMONWEALTH OF MASSACHUSETTS ig nse BOARD OF HEALTH =;I�OWN OF BARNSTABLE T-7ig ned Date Alipliratiutt for Di-nVinittl Work Tvastrurttun Prrutit Application is hereby made for a Permit to Construct ( ) or Repair (c><an Individual Sewage Disposal System at: 0l •••-'••' ..------ Jatiott-• ............... '•----`-•-�..... -•-----K/_ ✓J ��: - %t//!/LiL.J .--- A dress �A (Sa �.� vi.............. � 7 / ] e% ✓'r! Installer Address UType of Building Size Lot............................Sq. feet .� Dwelling—No. of Bedrooms.__-_..-----------------------------------Expansion Attic ( ) Garbage Grinder ( ) a Other—Type, of Building ---------------------------- No. of persons-------------------_-------- Showers ( ) — Cafeteria ( ) Other 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......f------------- Total Length.................... Total leaching area_---_-__.-_---------sq. ft. Seepage Pit No------- Diameter-----q-------. Depth below inlet.... ............Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ Li, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P+ --•••-•-----....•------------------------•-•--•------------•---•-•-•-••--•-----••--•--------................................................................. ODescription of Soil........................................................................................................................................................................ x U W ------------------------------------------------------------------------------------------------------------------------------------------------- U Nature of Repairs or Alterations—Answer when applicable.-.__. --------�4-__.......L D r— U PL -Gx` �11 Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance i be n issued tb<7board of health. Signed .......... . ........ ........... . ............. ...�... _.:.......- Dace Application Approved By ------ --- ------- -- ----- -- ---- --- - ---- --------- -------- .. "-- -- — —------- -----------................ ............--- .................. ice Application Disapproved for the following reasons: ..... . .. .. --- ---------------------------------------------------------------------------------------- - - �� Dace PermitNo. . ............................................................... Issued ...... ........ . THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliratiun for Diinpuittl War1w Towitrur#iun rrrmi# Application is hereby made for a Permit to Construct ( ) or Repair (rkf, an Individual Sewage Disposal System at: --------------------------------------------- --•-------- ----•-------•-•-•••--•-•------.....----------------._..._....-----•---•-------••--- Location•Address or Lot No. ..y�G. / .. / y/ 'll T p _.._..... •--------------- ............. --------•-------------•--.....-••---------•-•------.--••-- owner _ Address t ✓1i1 I t t,Q ------------------------------------------------------------- --------------••---•--...--- -----.- 5............................... ;---- ............ Installer Dwelling Building of Bedrooms------- --------------------------Ex Expansion Attic Address Sq. feet d Type of Buildin Size Lot............................ U g p tt c ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures --- ----- ---------------------------------------------------------------------- --------------------------------------------------------•--•- W Design Flow.................. ram_..__-----.._----gallons per person per day. Total daily flow_-_.___--___.i�..................gallons. WSeptic Tank—Liquid capacity /-tiV_� _g _gallons Length---- Width................ Diameter.......:........ Depth................ x Disposal Trench—No. .................... Width-------------------- Total Length.................... Total leaching area....................sq. ft. Seepage Pit No....... -_.... Diameter___..�U.-____.__ Depth below inlet_._.(..r-......._. Total leaching area..................sq. ft. Z Other Distribution box ( ) I Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I________________minutes per inch Depth of Test Pit.................... Depth to ground water........................ fN Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ----------------------------------------•----------•----•---------------•-•-•---•-•---------••--............................................................. 0 Description of Soil....................................................................................................................................................................... x U ••-------------------------•--------------•----••---•---------------------------------•-•--------••---•--------------------------••--------------....----•------------••-----•-----------------•...--- x ----------------------------------------------------------------------------------------------------------•-----._...-----------------•---------------------•---- U Nature of Repairs or Alterations—Answer when applicable__ O--------A------------�UbQf -•----...t /v..............................' <,,.�------------------- -------- <'`- iV.1 = ..... % �� S.` a ...... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be n issued bf' the-)board of health. Signed --------------------------- /------?fey' -----------.-...... ..... Dare ApplicationApproved By __._: ------------- ------------ ----- ........_....�/!/'��....... _'. ............................ --------.......Dare--------------- t Application Disapproved for the following reasons- -------------------------------------------------- .......................................................... ...............................................::.......!...............,.-...............—."..------........---..............................._...------...----...-----/--`---- ------.... 1-- Dace Permit No. .7-------- --------------- Issued .....(�....... .... f e �`e' r /----------------- ---—— ——————— — ———— — —— ———— ———— ——— —————————— ——— —— ————— ——— ———I THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE LLErtifirate of (110mytianu THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) r by ........................................._...------------.-_ ls/ `�7>c °-----------------------�-'v-----5��'Y`��---rums--------------------------------------------- --------- h,�aue has been installed in accordance with the provisions of TITLEA of The St t—e E v:ronmental Code as described in the application for Disposal Works Construction Permit No. �...�'?!".... - - .. .. 1 .. dated ....... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE--------------..-.L..f. .. -.-....;f..-j1�. -- Inspector ------- = ----------..-- ------------ -------------------------_...... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH y9-/yam C� �1ir3 TOWN OF BARNSTABLE �a No......................... FEE........................ � r iopmal World Tunitrudiurt "Vantit _ Permission is hereby granted---------------� c'��?TJ.keg27 %.---------- -_'.-<_nlS_/iN'.___ � c 1 to Construct ( ) or Repair (-A- an Individual Sewage Disposal System at No... f /...-...... -,-, 1 .. . Street L�t-/�,. / r �J Gj as shown on the application for Disposal Works Construction Permit No. ___..»............. Dated.. �_!.% -t'^ �_!-- ...... y�I � � �--vrl..--�v---r �,,�� - 1 Board of Health DATE-------------// r.. 1 -••r-----_...»..--------------... t � o FORM 36508 HOBBS&WARREN.INC..PUBLISHERS I L 9 CwvA ON � � �` ' �' SEWAGE PERMIT NO. V1LL. AGE N.STA LLER'S NAME & ADDRES;S gSDOLLATA1082,Old �_ Stale B UI,LDE R OR OWNER DA T If P ERMIT I S S U ED DATE CO-MPL. 1ANCE ISSUED 7 /�� i 0 ti No........1f`....�.�......... �� -''L:.....-.,�..-•� Fps..... ............................ ' THE COMMONWEALTH OF MASSACHUSETTS BOAR F HEALTH v �v tj ,s ..................... ..............-....of......... .....f}........--... 1 ��-r` ................................... AvOratiou for Dh4p oul Works Tomitrurtiun ramit Application is h/ereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System. 1...Q..��..-. 19.T�(. fJ>a�C�//!�/ ......................�.............----------------...--------------------.....------------ f Location-Address �'/ or Lot N .... t� 1 ....,r' .0.. .P�' ._ ' 1/1 AAiL ...... .- �2a'°^c�"� -' .... ---1 .C��' � - ,7- ...- Qw er � > � dream �1-------------------------- --��°C S�d..!5!TeiL....L!-!-`:-_..ii//may.�r.:_ [_.�.. v�`:.�` Installer Address UType of Building 41 Size Loi .¢.�`---I ...--._._._Sq. feet Dwelling—No. of Bedrooms.........ZL.............................Expansion Attic ( ) Garbage Grinder ( ) ` 4 Other—Type T e of Building ............... No. of ersons....._....__................ Showers p., yp g ------------- p ( ) — Cafeteria ( ) a' Other fixtures ---------------------------••-•• . ------------------------ ----------------------- W Design Flow.../,/.0................................gallons per person per d h_Y. Total daily flow..__..�..�.Ca'_.......................gallons. WSeptic Tank—Liquid capacityl�`__.gallons Length._.......__ . Widt ..___.__.. Diameter_______________ Dep1Vh................ xDisposal Trench—No. .................... Width.................... Total Length.................... Total leaching area..le_._.__.._._.sq. ft. Seepage Pit No--------------------- Diameter.-______-___-___--- Depth below inlet.................... Total leaching area..;?44........sq. ft. Z Other Distribution box ( ) Dosin tap�c ) ~' Percolation Test Results Performed by- ---- ------- °.a!_��.f..................................... Date......................... _. ..... a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water..__............................ C3� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ . ------- ...........------------------------ ----------------------------- 0 Descri ti of Soil-----• • 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 iIT 1E 5 of the State Sanitary Co e— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee -sued by the / iealth. Sign / ........... Date Application Approved By....... �s- _ �- Date Application Disapproved for the following reasons-----------------•....----------•-----------------------•-------......•---------•-------------------............. ................•------------.......•......----------------:-.....--•------------•--...-----------=--....---------------------------------------•------------------------------------------------._._... Permit No. Issued f- ............................. Date No. .. .......»....--- FEs............._............... THE COMMONWEALTH OF MASSACHUSETTS BOAR F HEALTH . ................OF......... .................................. Appliration for Disposal Works Tnnitrnrtinn .ermit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System/a .. U/ �. /ir . � .J __ � • ...a._._o.r/Lot .___._........_....�....,../...�..e.�.._.... Location-Add, ............................................... .. ..._..- w " 6 $dr l2t211 ..__ _ Installer Address 3 Type of Building J Size LoV. ......... ..........Sq. feet Dwelling"--, No. of Bedrooms-----------L_----------------------------Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building No. of persons............................ Showers — Cafeteria w `>vtg P ( ) ( ) Otherfixtures --------------•------------------------•--------------••••--•-••••-•-••----••-------•--.....•----•-•-•-•-c......•••-••..................•...--•-••--- W Design Flow._.��d.................................gallons per person per day. Total daily flow------- ........................gallons. WSf ptic 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 ( )` ..Dosin to k_W _ ~' Percolation Test Results Performed b 9�� fig'^° f�!. ...................•._-.-_._•__...... Date._.. �.. . ...... Y... = ------ -- ••. . aTest Pit No. I..........:.....minutes per inch Depth of Test Pit....--.............. Depth to ground water--.---------'.--.------ (i Test. Pit No. 2................minutes per inch: Depth of Test Pit.................... Depth to ground water........................ �+ •••-=......•-----------• •-••-•......••. .... .......•••-••••••••---------------- ---• ......................... O 0 # E , .+ . Descripti, of Soil ;��...___.. _fir J....... `l = / Yj...... . ..... ....... W ----------------------------------------------------------------------------------------••-••............-•--•••. k�_ ------------- - --- - UNature of Repairs or Alterations—Answer when applicable..:............................................................................................ Agreement: The:undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE: 5 of the State Sanitary Cl/ Q e—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be issued by the bvXrc health. P' f /Slgn .... . -- .....-•-••----•----•--•-••-•••--••- Dal '� �-.�.�..... Application Approved By...... .._--------- ---- �_.•-- -. ..... __ Date Application Disapproved for the following reasons:......__:; '`______________________________________ ..................................... ------------.. ..................•-•••-...........•-••••-••..........................••••••----•••.......... l`...••••.•----••--••••-•••----------------•-••-•••-•••••••----•-•-••-----•----------------••••••..._.._. Date PermitNo.......................................................'' Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEAL�^TH i4j "a .............................OF. :.i...:..:.....:...::::............................................... ....... Tatifirate of Tamplianrr THIS IS TO CERTIFY,,T at the Individual Sewage Disposal System constructed 4--o-r Repaired ( ) Mir i r �3 ±�v ,q S' ... ..... ..X'_ Insta �^ at-•--...�a--1 .......... " I 'R t = has been installed in accordance with the provisions of ` of The State Sanitary .de as desc ibed in the application for Disposal Works Construction Permit No -.... . _..._A............ dated-.. .............. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE........................................................••-••--------•----...... Inspector.................................................................................... THEICOMMONWEALTH OF MASSACHUSETTS BOARO OF HEAL_TH iJ ..........OF...�...... �•.�l� NFEE........................ Disposal luorks onotr Uan Fermi# Permissionis hereby gragted...` ''` t J.........1,.............................. ----------•------------------------•.---------------........................ to Cons,truipt ( -�1_or Repair, o� ,) an,, >dn 1�Sevcrage Disposal System at No..t9.-.---•-•••._i. ` l ec, f/ `T Street as shown on the application for Disposal Works Constructio P rmit ...... .... ... Dated... .�-�-� ........ - ----•---------------------------- /" � o rd of Health DATE.._... ---- ---------- --- ! FORM 1255 HOBBS & WARREN, INC., PUBLISHERS - �-rl:1. +w�i°d'r k:s Va4:}3w / � `M i c h nr,a�cs�,s.�.s:.,<,..h r ts, r�+ _ ° L < -^,.w•; ,.:..h.. � _ . , ti Ad _ 1 l3o, ' 3 IDOO 6 4EACH/N4 fi .o Di57- BOX •! ��.' ;, '^ G \ P/T ,N `� /UOO GAL so r /3 v, o �.'S .4 u36f.4y ,l , t'k � f—srr�,• Y y � ..�5 �,•v € rt > y'rri y!}� F` 1'n ( j t - f t�' ' •a `> i t f c'.��;�P' 1 ;fir i 1 f F ` 7 e ±' Y �' ..�.: x ,•• rp F e; km•t �trSx'G /r ji- � kt l�rl�aa�,� �/ i,i:"x��,/'r �a n• a �* ' z -, ��`'� a {L`EGENDF h nk "-MST IN'G?'SPOT. ELEVATIO.N ;. OXO z ' CERTIFIED PLOT. LA-W tXi'.SlrM0 C0NTOUR y IFIIaSHJ`D SPOTr E�EVA�TIOW 0.0 ;� TH �� 'ISN D.: CONTOUR 0=_ ` �5 _ i � IN �A` 01 -VED BOARD OF HEALTH ��® x 1 7 , +,rYY�!(F�-,i rJ^rkv.if �..x..� r 5* � • 3 SA y-•' � : ®� 1�®� 4 . 0,e ' 'f `1 �`E 'a ,r , AGENT', a. SCALE / /�=4.0� DATEt � ICE GE, ENGINEEl4/N,G CO. 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