HomeMy WebLinkAbout0063 CAMMETT ROAD - Health t13 Cammett ]R,.OA.D �r
- /1"arstons Mills
A = 079 — 027
COMMONWEALTH
OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
lop
DEPARTMENT OF ENVIRONMENTAL PROTECTION
r6v 9 N,�>
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: CGt tNJ,M t? Rj
Owner's Name:
Owner's Address: O ,
n'� r ✓ U��� t V f- 009
Date of Inspection: 3v n
Name of Inspector:(p elease print) l t� C/0
Company Name: 1/, G f r
Mailing Address: P o
Telephone Number O a? 1,7 _
CERTIFICATION STATEMENT
s_e
c2 r�
I certify that I have personally inspected the sewage disposal system at this address and '
below is true,accurate and complete as of the time of the inspection.The inspection was that the rrnation reported
performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: '
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature; D
_ ate•
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000
gpd or gieater,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
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: (S G Vy1 WI kd
Owner: al C k" ov�s i ' ���f 01�-
Date of Inspection: o 0
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. Syst asses:
I 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:
B. System Conditionally Passes:
/I/ One or more system components as described in the"Conditional Pass" or
repaired.The system,upon completion of the replacement or repair,as app oved by the Board of Hea lth,ewill pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please
explain.
The septic tank is metal and over 20 years old*or the septic tank(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:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipes)or due to a broken,settled or uneven distribution box.System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
TiNo G inenun*inn Lnrm�i�aijnnn 2
Page 3 of 11
,
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWA
GE DISPOS
AL SYSTEM
NSPECTION FORM
PART A
2 CERTIFICATION(continued)
Property Address: l9J Q�
Owner: 1 C 0V15 /fj/f cot 6�f
Date of Inspection: /0 O
C. Further Evaluation is Required by the Board of Health:
V Conditions exist which require further evaluation by the Board of Health in order t
is failing to protect public health,safety or the environment. o determine if the system
I. System will pass unless Board of Health determines in accordance with 310 CMR 15303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
_ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil 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 more from a
private water supply well**.Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered.A copy of the analysis must be attached to this form.
3. Other:
T;tlo G (ncnartinn 17-4/1;/innn 3
Page 4 of 11
OFFICIAL, INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: Vj 3 Cri! VVI WI
Owner: c oy
Date of Inspection: o
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No /
`/— kup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
�Dis hazge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
ged SAS or cesspool
_ _l��///���/// S ric liquid level in the distribution box above outlet invert due to an overloaded or clogged SA.S or
esspool
v uid depth in cesspool is less than 6"below invert or available volume is less than%day flow
Ref faired pumping more than 4 times in the last year NOT due to clo
/6f tunes pumped gged or obstructed pipe(s).Number
portion of the SAS,cesspool or privy is below high ground water elevation.
tiAny portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
ter supply.
by ortion of a cesspool or privy is within a Zone 1 of a public well.
y portion of a cesspool or privy is within 50 feet of a private water supply well.
_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. f This system passes if the well water analysis,
indicates that the well is free from pollution from that facility and the presence of am performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
monia
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.l
(Yes/No)The system fails.I have determined that one or more
of the ve failure criteria exist as
described in 310 CMR 15.303, therefore the system fails.The systemoowner 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)
Vhe system is within 400 feet of a surface drinking water supply
he system is within 200 feet of a tributary to a surface drinking water supply
e system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a ma ed
one II of a public water supply well pp
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 significant threat and p ator of an large under Section E or failed under Section D shall upgrade the y g system considered a
15.304. The s P� e system
stem Y m m accordance
Y owner should cordance d contact the appropriate regional office of the Department. '��310 CMR
Tit]a C �ncnnrtinn Rnrn.�/1 G/^fnnA d
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Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
/� CHECKLIST
Property Address: V�.� C—a '"l01e 6
Owner: 9 1 C�
Date of Inspection: Z p�
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes o
Pumping information was provided by the owner,occupant,or Board of Health
— _ Were any of the system components pumped out in the previous two weeks?
Has t ystem received normal flows in the previous two;week period?
_ _ Have large volumes of water been introduced to the system recently or as part of this inspection?
Were as built plans of the system obtained and examined?(If they were not available note as N/A)
Was the facility or dwelling inspected for sig
ns of sewage back up?
Was the site inspected for signs of break out?
(/ Were all system components,excluding the SAS,located on site?
Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum condition
Was the facility owner(and occupants if different from owner)provided with information on the
maintenance of subsurface sewage disposal systems? proper
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
sting information.For example,a 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 CMI R 15.302(3)(b)]
Titw C �ncnnntinn Fnrm�ii v�nnn 5
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Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: (fa rMtw
Owner: C i
Date of Inspection: �� p
RESIDENTIAL DLO V CONDITIONS
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: 0 h
Does residence have a garbage grinder(yes or no):/r0a
Is laundry on a separate sewage system(yes or no), cq [if yes separate inspection required]
Laundry system inspected(yes r no):IVO
Seasonal use: (yes or now
Water meter readings, if ava' able(last 2 years usage(gpd)):
Sump pump(yes or no): 4io
Last date of occupancy:
COMMERCIALA NDUSTRIAL L4✓t 2 �'
Type of establishment:
Design flow(based on 310 CMR 15.203): —d
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):_ C1701#MG Rc-j
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 system(yes or no):_
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
Pumping Records
GENERAL INFORMATION
// l
Source of information: /(i0 7— H, �,� C � `'L
Was system pumped as part of the inspection r _ tom
If yes,volume pumped: gallons--How was quantity
Reason for pumping: q ry Pumped determined.
TYP F SYSTEM
Septic tank, distribution box,soil absorptions stem
—Single cesspool y
Overflow cesspool
Privy
—Shared system(yes or no)(if yes,attach previous inspection records,if any)
_Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
_Tight tank _Attach a copy of the DEP approval
Other(describe):
Approximate age of all components, date in to e (if own)and source of�ormation.
9— ✓.So
Were sewage odors detected when arriving at the site(yes or no):
Titles inennntinn Fnrm ail ci�nnn 6
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Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
2 SYSTEM INFORMATION(continued)
Property Address: 6 C-441, d14M,
Owner:
Date of Inspection: 8 30 62
BUILDING SEWER(locate on site plan)
Depth below grade: //�
Materials of construction:—cast iron _4`4- PVC_other(explain):
Distance from private water supply welf or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK:c/ (locate on site plan)
Depth below grade: /
Material of construction:_concrete—metal fiberglass_polyethylene
—tank
—
If tank is metal list age:— Is aye confirmed by a Certificate of Compliance(yes or no):—(attach a copy of
certificate) / ,
Dimensions:
Sludge depth.
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: 0
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottoms of outlet tee or affle:
How were dimensions determined: /00( ,<�
Comments(on pumping recommendations,inlet and outlet or baffle condition,structural integrity,liquid levels
as r lated to outlet invert,evince of �ge, tc. :
n
►4 ✓VI
�N G
GREASE TRAP:&(,locate on site plan)
Depth below grade:_
Material of construction:_concrete metal fiberglass____polyethylene other
(explain): — _ —
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,liquid levels
as related to outlet invert, evidence of leakage, etc.):
Titla S Tncnui.tinn T:nrm Oil c/,)nnn 7
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
2 SYSTEM INFORMATION(continued)
Property Address: �J C -c-1 tmm �C/
Stion--
4-': a mil'�Owner: ,� ��Date of Insp
TIGHT or HOLDING �I
TANK:• ,t �-
/ (tank must be pumped at time of inspection)(locate on,site plan)
Depth below grade:
Material of construction: concrete metal fiberglass_polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: (� if present must be o ened 1 p )(ocate on site plan)
Depth of liquid level above outlet invert: 001117.4z--
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 l 'V
PUMP CHAMBER: (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
TitIA C Tnc»ort nn T'nrm!./1 c/)nnn 8
1
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1 Page
g 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: � yvl d1'!g�� R�
Owner: c � /-/f�7� t�i� 6 qy
Date of Inspection: or
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Typeleaching pits,number: C2 �!e— Cc,S
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure, level of ponding,
da
etc.): ►/ ` P g, mp soil,condition of vegetation,
10
5 t -
CESSPOOLS: & (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
PRIVY: 'IO (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
------------
T41. S inc„arrinn C....„�ii ci^fnnn 9
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: �74�) (M(Me` Yuri
c/`�i G►�S 005 ,
Owner:
Date of Inspection: $ 3o Q 7
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
b nchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building.
---------------
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Titlo 1 P-n 4Yi VIAM 10
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Page I 1 of 11
OFFICIAL, INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: C�j �,y e
Owner:
Date of Inspection:
SITE EXAM
Slope
Surface water
Check cellar O i
Shallow wells J,
Estimated depth to ground water Zj
Tj feet 0 V%
C
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:_
�ed site(abutting property/observation hole within 150 feet of SAS)
r/Checked with local Board of Health-explain: cam(
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the hi h ground water eleva on:
ro /
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Tula C ircra�tinn Fnrm�ii annnn l l
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yORC 7W A ,v /2 0,S&L.O
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SCOW As 4%0 SWAL At 8.E ARDyG/l T TO 4SJTA AD.F.�fi N ,=XTiRA
C0NCRCT0 P.vc. P/P-- h►E�WY CA ST/APOW COOLER SW,44L L3E US�--O
MIN._P/TCN /F/IV 17R/✓EWA y
--- C01vERSJL
2% N.W. c0NCi '- 7.
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JNJWRT AT 4ffU/LJ)PVC7 T
IN SEPTIC TANK OFT, ! Psi P'1_ �— F7 UJAM: . � C SEE TABUL.dTJOA/>
D��'LET SEPTIC TANK FT, TOno �- = �'SS.0 o G� r
�IVLET DJSTRJ13UTiDN BOX -dPd FT, SECT/QN OF a A?0VNo y4 7Z.1f 7, -,E
OUTLETD/5TR/BUT/ON BOX . FT ���.� A L SY.STEJi'p
/AILF7T LEACHING PIT. 9� �T. 7A64/4AT/40
/V
L�.4G'J�/NG �/7' 4
DE$/GN Cq/TL-RlA SCALE %`� = J -O~ D/M.IENS/ N $- 2 FT
N/JJNQER OF B�vR44MS � DIMENSION C FT.
GAR&AG.EDISPOSA4 41N/7-Y6 SO/L LOG
TOTAL EST/M'A"TED FL0*V jj 0.41./DAY SOIL TEST 0/ $o/L TrEs7-*'? .SQ/L..TEST
NUMBER OF LEACNhVC. PITS 2 -,FtE✓.�. EL�Y.� ,DATE
S/O.E L.EACH/NG ,�FR P/T SQ, FT. '�4FSULTS h//TNESSED BYE
0 '- 3 ' Tom o. '- 3' Too
BOTTOM LEi9CN/NG PAR P/7=_�_ __SQ, Pr PeACOLAWON IeATAW#/ M/NCl/NGH
TOTAL LEACHING AREA Z ,�q, FT. U�SD/G P1EI+YCOLA7'/ON RATE 2 MIN.1IJVCH
RESER1�ELe�4CJ/lNc�,4REASQ. FT. I `-
..,..�__- ,.Q •CIE-o/uM
7-0
DAVID P.
Ir
civ;L .t; t,'04ND
d� ,
LEVY & ELDREDGE ASSOCIATES. INC.
�'��` Jpl�gi �j ,EL . 87•_ E,C. .-�. 889 WEST MAIN STREET CENTERVILIE,MASSACHUSETTS 02632
X-w No GRouND YYATEA, LrNCOU/VTgRE'O CL/ENT: �'�.4SE DATE-
[3 GROuwo kvATE=R Al2- ELEv - JOB NO. 8 SHEETLOF 2
No �-_ �D F$a_.
THE COMMONWEALTH OF MASSACHUSETTS
f30ARD OF HEALTH
.....................................
Aplilutttion for Dhivoottl Iforko Tonotrnrtion Permit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
-
�(A r Location-Address or Lot No.
:1... ___ .............................................--____•--_-.............._--.... ...._.
..... � .._..._—Owner ....................•___._....._.._..-
Address
.......................................................••-............_....._........_..._.._'••- '..._........_......_._.__..........__._...._..•__._..._......._..__.......__•__...__.-..._._....
�il•••---111 Installer Address
Type of Building Size Lot............................Sq. feet
V Dwelling—No. of Bedrooms........................................Expansion Attic ( } Garbage Grinder
aOther—Type of Building No, of persons---------------------------- Showers ( ) — Cafeteria ( )
Otherfixtures.....•.--_-_-_ -•-•----••-•---•----...-•--------------------•---•-----------•------•-----•-••--• _......_....
W Design Flow........ .........gallons per person per day. Total daily,flow.........�40_...--•--••_•------•-••--gallons.
WSeptic Tank—Liquid"capacity./..gallons Length................Width................Diameter................Depth................
x Disposal Trench—//No.....................Width....................Total Length....................Total leaching area....................sq.ft.
Seepage Pit No.S..c?............. Diameter.......... Depth below inlet....................Total leaching area............_.._.sq.ft.
Z Other Distribution box (L<' Dosing tank ( )
Percolation Test Results Performed by-------------------------------------------------------------------------- Date.......................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water_.....................
fi Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water ................
W � �....� :.,._._..••- ........................................................
t ......
... .........
Description of Soil.....YV`�` �,,,rr'?,...
W ...............................................................................................................................................................................
UNature of Repairs or Alterations—Answer when applicable...............................................................................................
......................................................................................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code—The undersi ned- rther agrees not to place the system in
operation until a Certificate of Compliance has be issued by e bo of alt
a2(aJ7
Application Approved By............................ ........ ........ .P^..... ......................... .......J�-. .... ..
Date
Application Disapproved for the following reasons:............................................................. •---•••-••---
......................................................_........................------......---.•......---............ a
------............-
te
PermitNo............... _�.._. .G._.. Issued.......................--•-•-_--•-----._..._.__._.._.
Date
THE COMMONWEALTH OF MASSACHUSETTS
— BOARD OF HEALTH
U G..1 'nJ
..........................................OF.............
..........................._ .....................................
Tertif irate of Tomplittnre
THIS iS TO CERTIFY, That the Individual Sewage Disposal System constructed( ) or Repairedby ( }
•
............................................................................................•--•---------------•--..._..........---•--.._......---........
.....----
' ...._Installs 1 1� --
jj --'' (�.
at 1 `� ...// I.
has been installed in accordance with the provisions of TITIZ 5 of The State Sanitary Codg-as described in the
application for Disposal Works Construction Permit No.........T a.:..7_'.._ 1. .. dated...... X. ............__.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT 7HE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE......................<---- ......................... Inspector..... ( -cc� V ..........................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
,7- .7��
..........................................OF............................ ......:.......................
`0 ::..7................. FEE........................
i9iopoottl 10orko Tonotrartion Permit
Permissionis hereby granted..............._.....................................................................................................................
to Construct. ( ) or Repair ( ) an.T'dividual.Sewag Disposal ystem
PP P Street I
as shown on the application for Disposal Works Construction Permit Nc�7._.!...._.�.nDated.//.a.!)..........7
•'.•......__..-. 4% ...._:Win...............
Board of Health
DATE.....................---.--.------------------------.................._._.....
FORM 1255 HOBBS.& WARREN, INC., PUBLISHERS
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LOCATION /� '' SEWAGE #
VILLAGE AASSESSOR'S MAP & LOT ve Z
INSTALLER'S NAME PHONE NO. elp h - fi�.��C) f -,
SEPTIC TANK CAPACITY
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LEACHING FACILITY:(type) (size)—lcleK-444
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NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER `- m� A�//"
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No L--
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THE COMMONWEALTH OF MASSACHUSETTS
RD OF HEALTH
gall, Applica is hereby made for a Permit to Construct ( )CRepair dividual Sewage Disposal
System_4Z
Owner ess
Z Other Distribution box ( L<__ Dosing tank ( )
1-4
The undersigned agrees to install the uforcdescribed Individual Sewage Disposal System in accordance with
the provisions of'T'T'_4' 5 of the State Sanitary Code—The undersigned ' rther agrees not to place the system in
operation until a Certificate of Compliance has bef)issued byj�e bo of tlt
Date
.............................................................................................................................---..............---'............ ...........................
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THE COMMONWEALTH OF MASSACHUSETTS
,;. BOARD OF HEALTH
_Jt ....................OF_....1- ,:::,........ :-----------------------------------------•----------
Appliration for Dispatial Works Tnntrn.rtinn rrntit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
{
y9 a { Location-Address or Lot No.
l � r1:. ..._....... ----•---•----•-•........................... .....•-••-••---•---------•-•--............. -••-------........_.........................------
Owrer Address
W
Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms____.__*---------------------------------Expansion Attic ( ) Garbage Grinder ( �/
aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures -•-•---••---•-•-•..........................•-----------•----•----•----•--•-•••----•-•-•-•---•--•--••-• -----••••-•------••-•••-•••----••-••-•------
W Design Flow____4 _ _._ x. _________._gallons per person per day. Total daily flow..___.__�%,®!q
%
WSeptic Tank—Liquid capacity/ ___gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No_.................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No __---_-____- Diameter.�.�----------- Depth below inlet____________________ Total leaching area..................sq. ft
z - Other Distribution box (t-T-- Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water_--__________________-_.
fi Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
p �/'."r,�-�� �.. :�-ram ..� �`c. ,�.....................................•--------.....--•----....------
Descriptionof Soil--- =-�................................................' __ --------------------------------------•---------•-•----•--------------------------._..._••-_---_..
x -----••-••-•----•--••-----•-•••------•--•-•••-•••-•-•--•---•--•••-------•-••-•-••-••....------•-••••--•------••••---•----._.-•--•--••..............•••••.----------
W
UNature of Repairs or Alterations—Answer when applicable----------------------_........................................................................
...............--....................................................................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TT' , 4 of the State Sanitary Code— The undersigVher agrees not to place the system in
operation until a Certificate of Compliance-has been(i sued by th boarh. -�� � 7
D e
Application Approved By______ _________ ...................
Date
Application Disapproved for the following reasons:_______•______________________________________________••__________._________.-..i________•__ .____________
--------------•.-.--.•..-:..-•---....----..-----._....-------------•-----....--------------•----------------------------------------------------..•-.------------------------------------------...------
Date
tea= <�# Y
PermitNo----------------=-,..:................................._ Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
r
..............OF....................: ......fa,( `;
Trrtif irate of Toutpliatta
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( }
by.................................................................................................................................................... ....•.........................................
_ 3 P Installer /1 5
has been installed in accordance with the provisions of T i T IE j of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.�.__=-___�[_.'__....f_Co. dated__-.-f_/.. -�`?� __�________________
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT YHE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE--•---•---•-•----....<_... ......................... Inspector...__ c-^�� J'`'---_-- ------•-••---------•--•----
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
` OF................... E.'
.._.........................................................
....
No.. ................ FEE........................
Dispoul Workii TDnntrnrtuan Errant
Permission_ is hereby granted......................................................-----••---.._..-•----•••-----.-.-•_...---•-------•........•--•-•._................_....
to Construct. ( ), or Repair ( ) an,Individual-,Sewage Disposalz§ystem
p
Street ',._,...._•..—,, ,..,,
as shown on the application for Disposal Works Construction Permit No"" !__ ��Dated...... '____�_......_.
Board of Health
DATE.................................................................................
FORM 1255 HOBBS,& WARREN, INC., PUBLISHERS
_ ..
. � ;;;�• .. .c_ ,A•K 07"€ /F- E/TNL=R TN,E SEPT/C TANk OR
G�i4CNING P/T ARE MORE 71NAW /2"AELOA00
lD Fsr'M/N. ` 4oi.9. GRAOEj A24"O/AMET.ER CONCRET.S COi�ER
ScE/EovLE.00 SIVALL B.E 0J?00GyT TO 4SMA Z>0-& EXTi A
CONCRG'TE, PVc. R/PE hiEAVY CAST/RO/Y C0 Sf/ALL- ak: US4:',0
S Aq",. P/TCN /F/N ,b.4/VEy1/A Y
COVERS aFR ter.
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2' MIN. CO/VG'R�TE
A' �#J�gpE CO VER CLEAN .SANG
. • BACk,=
' � • � L/QU/D LEVEL •' • ••
'A � - •.• zL Y
/�Y.f. P/PE i 1JOO. GAL. 3 0 00 OF
MIN.PJTCN ' a • • • • . . • ► b �„�
%4"Pew SEPT/C TA/VK DIST, o , w •.• • . • • • • • y b q IYASHPD STt7N�
BOX c • • 8 • . • • • • .gyp "
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br; e r ?6 0 • • •EFFECT/VL° • • • - 314 - �2
• n • • • OFPTN ' • • • • v p WASHED STO�YE .
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• • a • • • • • p p PRECAST SEEPAGE
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SO X%, O = S1J. O �f O y o • • • • . •.• • • ' a n - OR ,EQU/V.
imv4mT z4RvAT/DNS p o a �L
INVERT AT BUILDING Q�T '�"� � +
INLET SEPT/C TANK Pay F7 O/A1'9• C(SSE 7A8L/LATJON>
OUTLET SEPT/C.7ANK 4 FT. o GPf�
INLET.W5TR/J3UT/ON BOX •mod ,&T. SECT/ON OF GROuNO WATER TABLE
oc�TLErolsTfz/®UTianr BOX ter.
/IVt.4157r LEACH/N!s P.'T D l:T. S'Ed�VAGE OIS O.�A L Sl�.ST�/�'1 -rA4&4 L.ATlD/V
LRACH11V45r F'/T F'T t
- SCALE %a"' DIME N NSIO A "�•
DEslGN CN/fER/A
NUAlSER OF BFORo4Ms DIMENSION G�FT.
'` GARBAGED/SPOSA L U/YIT SDIL LD& SST
TOTAL E,ST/MATEo FLodV11 6> 6AL.IDAY SOIL TEST A/ S014 TESTT*2�/
1 ArUMBEi? OF I•EAC/hVa ,o/TS 2 �f^EGEY. ELFY,L�Z ,DATE OF SOIL TEST / ./�S- �
S/OE 4,-ACH/NG P.-R PIT SQ. FT. / FSULTS J•t//TNESSED BY/=L_e�
e0T•TOM Lj'ACAfING PER PIT ..w. pT. O 3 TAp O 3 To AFACOLAWON RA7-Z:At l MIA11INCH
TOTAL- LEr4CN/NG AREA _ Z SQ, FT.
�. U/? u^fL E 5U6Sd/L PENCOLAT/ON RA:rF Ak2 MIN. INCH
RESERYELFACNlNG,4REASQ. FT.
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s'j9nIDMM.c AO I
�f CIVIL /t/Q�{
No.31115
Irw
LEVY & ELDREDGE ASSOCIATES. INC.
Y. _ 889 WEST MAIN STREET CENTERVILLE.MASSA.CHUSETTS 0263Z'
DATuNOGROUNt7 Lt�,4TEli' L'�NCOUNTL�REO CL/.ENT:
G1 GM U VO PVATE,? AT E4j6V. .JOB NO. � SHEET,�OF 2
I —
r _ 2D FT. M/N. /VOTE' ~/F E/TNER THE.SEPT/G TANfC OR
,L,SffCN/ivG PIT ARE MORE TNfiN /Z"BELOl'V
-- ✓D f�': M/N' 4"D/.q GRAD&.,4 ?4-O/AM ETER CONCRETE CODER
�_ Scr{EouLE.tO SHALL BE BR0&4SNT TO 6RADE.64/✓•-X7,VA
CpNGRLTE P.vc• P/PE JYEAVY CA ST/A OW COVER SW,44L C3E US�17
ex. �0�. 0 M/N. P/TGN
_ COMERS �6 w pF,P FT /f/N OR/VEli/A Y
o,-
2�r MiN. G'ONCRETE
:, a G�CADE CO►iER CLEAN .SA NO
. • ' _ BACaCF/LL
-E= L/QU/D LEVEL
„D/A >.r •
4 SCHEoULS40 %BSR�B
b M/N.P/TGN GAL. • e 1 • • • OF . • . . `.'SHED 57VNE
SePr1C TANK D/ST, o o s •,• • . . • • • , y e . q
- BaX v a. o • . $ • . � • • � .•p
e r p 1 • •EFFECT/✓E ♦ o 3�4
_ ..._ , n � • . DF_PTt/ • • • � � v e WASHED STa�YE
-4^0a e�°e • • • . • • • . • o p o PRECAST SEEPAGE
�r ya P/7 DR wV
if r • • • • • • • • f a .
' EA / s a L• / 4!A/V�r
Nf�,ERT AT BUILDING �DAT t�/T CAPACl7l�"' "� / ` S l'�pf� D/AM. -
INLET SEPTIC TANK OFT, Pe✓ _� FT O/AM. C�SEE TA8UL4TfON,
/
Ot/TLET SEPTIC TANK . G FT. 7mr ` z V O GTIF
INLET D/5TR113UT/ON BOX ��d PT. SECT/aN 4F GROUND ytl,4TEK TABLE
�r. DUTLETD/STR/BtIT/ON BOXY. FT.
/A/LE•T LEAC!•1/NG PIT FT. SEya/AGE L7LSd�OSA L ,SY.5TE/s? 7A,641d,ATID
L EACH//VG AV T s
SCALE : %" = / - O" t7IMENS/OA/ A /- FT.
AE51CsdV CR/TES/A DLmI.ENS/.oN -- --FT.
AlvmaER OF®EOPo4M5 D/ME'NS/ON C FT.
G�4R4&A4GEO/SPOSA4 UN/T 50/L. LOG
TaTAL. EST1."1 -r46Z> FZ.0W j[=)` G.4L.1,DAY SOIL TESTA/ SOIL TESTT*2 TO/4 ��ST
/41UM8.-Al OF LEAC:/!NG P/rS_Z �/^FLEY. EL�Y.L ,DATE OF SOI S L TET
S/DE LEACH/NG Pd�R PT/ �SQ, FT. I� O '- 3 , T6 O •- 3' Too RESULTS JR/ITNESSED BYE
60TTOM L•S4C/ IN*PER P/T G__So. Fr / -,EgC0Li4T/O!V l�AT,ti�y�EI � l•j/Ny�/NCH
eue c°'f�.. F �U�
SQ. SD/G PEFa°GOLi47"/ON R.�7'E 1�2 MIN. INCH '
:TO?AL LEACH/NG AREA. f-----2 SQ. FT. `'
,•tESERVE LE.4Cd//N6 A,�EA F T.
AP A1113/ 9
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: C A
A ;y No.3111 (�f' a
LEVY & ELDREDGE ASSOCIATES. INC.
WEST MAIN STREET CENTERVILLE,MASSACHUSETTS 02632{'
IPA 7,
_9:�NCGRO[/ND Yt1i47'ER Er/VCOlJ/VTFRED GL/E'vT
l G1 GmO UNO YvL1 TER AT ELE(/.
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6-3 TOWN OF BARNSTABLE
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LOCATION j�J SEWAGE #
VILLAGE U ` .
ASSESSOR'S MAP LOT ems'
INSTALLER'S NAME & PHONE NO: '
SEPTIC TANK CAPACITY ���
LEACHING FACILITY:(type) + (size)
NO. OF BED ROOMS
------
PRIVATE WELL OR PUBLIC WATERj� .
BUILDER OR OWNER � �� �� ���
DATE PERMIT ISSUED: /— "' 7
DATE COUPLIANCE ISSUED; % _ '7•
VARIANCE GRANTED: Yes No
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