HomeMy WebLinkAbout0138 CHINE WAY - Health 138 Chine Way
Marstons Mills
A= 121 — 146
V
COMMONWEALTH OF NIASSACHUSETTS
kipExECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
�ob.
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address:
L'j 12
ME
Owner's Name: SCi, S
Owner's Address:c ��V\ m
CD
Date of Inspection: mo
77,
Name of Inspector:(please print)
Company Name: William E. Robinson Septic service .a
Mailing Address: P 'O Box 1089 X-
Centerville. MA --i
Telephone Number: ( 508) 775-8776
CERTIFICATION STATEMENT
t certify that 1 have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 ChIR 15.000). The system:
�/Passes
Conditionally Passes
Needs Further on by the Local Approving Authority
Fails
Inspector's Signature: Date: // 7
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Heatthvr
DEP)within 30 days of completing this inspection.if the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shalt 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 is 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—PLOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SENWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address
Owner: Svsck_�N
Dale of inspections _ l//3r/+,p p, 7
Inspection Summary: Check A,B,C,D or E/ALWAYS complete ali of Section D
A. System Passes:
`" 1 have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist_Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes: �VI/ r
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N ND)in the for the following statemenu.if"not determined"please
explain.
The septic tank is metal and over 20 years e old*y or the septic tank(whether meta or not)is structurally
unsound,exhibits substantial infiltration or exliltration 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 twbroken or
obstructed pipe(s)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 bmkea or obstructed pgre(s).The system will
pass inspection if(with approval of the Doard of Health):
broken pipe(s)are replaced
obstruction isirmotsod
ND explain:
f
Page 3 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
t _ CERTIFICATION(continued)
Property Address:
05 ,-Uti 1
Owner. )
Date of Inspection:. r f1 7
C. Further Evaluation is Required by the Board of Health: A,//.4
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health,safety or the environment.
I. System will pass unless Board of Health determines in accordance with 310 CMR)5.303(l)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
_ Cesspool or privy is within SO feet of a surface water
_ Cesspool or privy is within SO 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.functionin in a manner that y g protects the public health,safety and environment:
P h' -
_ 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 I of a public water supply.
— The system has a septic tank and SAS and the SAS is within SO feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but SO[eel or more front a
private water supply well** Method used to determine distance
'This system passes if the well water analysis,performed at a D£P certified Iaboratory,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 S ppm,provided that no other
failure criteria are triggered.A copy of the analysis must be attached to this form.
3. Other:
3
Page 4 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
Owner: So:!-�Cu� �-
Date of Inspection:
D. System Failure Criteria applicable to all systems:
You must indicate`yes'or"no"to each of the following for all inspections:
Yes No '
_� .Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
�Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
.__ clogged SAS or cesspool
Static liquid level in the distribution box above-outlet invert due to an overloaded or clogged SAS or
cesspool
_ ✓: Liquid depth in cesspool is less than 6"below invert or available volume is less than''/a day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
/.Any portion of the SAS,cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy is within 100-feet of a surface water supply or tributary to a surface
water supply.
V 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 portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private Katrr
supply well with no acceptable water quality analysis.(This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from(fiat 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.]
(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design now of 10,000 gpd to 15,000
gpd•
You must indicate either"yes'or"no"to each of the following:
(71te following criteria apply to large systems in addition to the criteria above)
yes no
_ _ the system is within 400 feet of a surface drinking water supply
_ 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 11 of a public water supply well
P PP Y
If you have answered yes x�
to any question in Section E the system is rrctdered a significant threat,ornswercd a -
"yes"in Section D above the large system has failed.The owner or operator of arty large system considered a
significant threat under Section E or failed under Section ID shalt upgrade(he system in accordance with 310 CMR
15.304.The system owner should contact the appropriate regional office of the Department.
4
f
Pagc 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
2C j CHECKLIST
Property Address: ✓ZS Ct1� L
Date of Inspection:
r
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Ye No
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 the system received normal flows in-the previous two week period?
V1 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 NIA)
Was the facility or dwelling inspected for signs 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 the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
_ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems
The size and location of the Soil Absorption System(SAS)on the site has been determined based on.
Yes/ no
Existing information.For example,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 CRR 15.302(3)(b))
5
Page 6 of I l "
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
Owner: SJSCn S}
Date of Inspection: ! ; .moo 7
IFLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#!of bedrooms): fit' 6-
Number of current residents: 1
Does residence have a garbage grinder(yes or no): yea - 6'-S A't&"-ld
Is laundry on a separate sewage system(yes or no):, (if yes separate inspection required)
Laundry system inspected(yes or no):
Seasonal use:(yes or no):! �0��(r� _ 37 i�0
Water meter readings,if available(last 2 years usage(gpd)):
Sump pump(yes or no): rus es;5 _ �COU
Last date of occupancy: G✓rrc.4
COMMERCIALINDUSTRIAL `
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgfl,etc.):
Grease trap present(yes or no):—
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):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part of the inspection(yes or no):
If yes,volume pumped:gallons—How was quantity pumped determined? S;Ze P iC74^i'
Reason for pumping:_ nVl\
TYP OF SYSTEM
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)
_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 installed(if known).and source of information:
Were sewage odors detected when arriving at the site(yes or no):AX,
6
I �
l'dgc 7 of H
OFFICIAL INSPECTION FORAI—NO,r FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SELVAGE DISPOSAL SYSTEM INSPECTION F0101
1'Awr C
SYSTEA1 INFORMATION (continue)
Property Address: `3 y" (21At np— V t
(_U i 11
Owncr:
Dote of Inspection:
BUILDING 5E)VEli(locale un silt plan)
DcpUt below grade.
Materials of construction:_cast isuts �4f3 t'VC_outer(cxptaat):
Distance Ruin private %valet supply tccll or suction Zinc:_
Cummcnts(oil condition of juints,vcr►ting,cvidcucc of leakage,ac.
i f
SEPTIC TANK: (lot ale on site )jail)
Depth below grade: j
Material of construction: ✓unctctc n►ctal fiberglass pulyedlylcne
_olhct(explain) — —
If tank is mesa)list age:_ Is age cunfunted•by a Certificate of Cumpliance()-cs or nu):_(allach a copy tit'
certificate)
Dimensions: /0 vo
Sludge depth:
Distance front 101)of sludge to buttunl of outlet ice of Wilt:
Sctun thickness:
Distance from top of scum to 101)of outlet lee or baffle: --
Distance Gotn butlum of scum to butrunl of outlet tee or battle:
I low were dimensions determine: t,� f j e,�
Cummcnts(oil pumping tecummnendatiuns,inlet and outict Ice or baffie cundilicn, slructwal inteblity,liquid kvck
as rclatcd to oullc(ulvcrt evidence of leak
age,etc.):
in4,�C+- j 4 ✓_ Cry
GREASE TIUPI'/`(fucatc un site plan)
131cpU1 below grade:—
Matctial of eonstiuctiou: Concrete cnctal IibcsglaSs_Isu(lctlt}tctte otlt€t
(explain): ___ — —
Ditncusions:
Scum thicksuss:
Distance (10111 tap of scull,to top of outict Ice or ballie:_
Distance hill butlumt of scum to Uollum of uutict ace of baflic:
Date of last_ pumping:
Cunullms(on pumping tccommcndaliuns,inlet and uutict tcc or isallic condillo.),stl utttll al illigllly,liquid ICVC13
as rclalcd 10 outict illvcll,ct-iticncc of Icakarc,tic.):
1'agc 8 of 1 I
OFFICIAL INSPECTION DORM-NOT FOR VOLUNTARY ASSE•NSNILN-FS
SUBSUIWACE SLAVAGE DISPOSAL SYSTEM INSPEICTION FOltNj
PART C
J YS"FEAI INFORMATION(continued)
rroperty-Address: (�J� O-Intnte CL- --
5v� ��
Owner:
Dale of lospcctloo: f( iro
71GIIT or IIOLU[NG TANK: L t`(arik must be purttpcd at lime of irsspcction)(lucatc on sitc plan)
DcpQ►below grade:
Malcrial of construction:__coMcrc►c_rnctal_fiberglass_lurlycthyfurc othcr(cxplain):
Uinrcnsions:
Capacil}: allvos
sign How. gallons/day
Alann present(ycs ur no):
Alarm Icvcl: Alarm in wurkin urdcr
Uatc of last pumping: 6 (}'cs ur uu):
Curruncnts(condition of alarm and float switches,CIE.):
DISTRIBUTION BOX:✓(if I)rescnt Must be opcacd)(locatc on site plan)
Depth of liquid level above oullct invert:t,
Conuncrrts(note if box is Icvcl and J' "rstnburi
ICa{,a a rrtlu or vtr tv outlets equal,an}•evidence of solid out s ca
ufbux,etc.): rryovcr,any cviJcnce ut
3L rsZ.1,t b, ,
PUMP Cl1AMBLIt:JIV� (locate on site Irlan)
PUMPS in wurking ordcr(ycs or nu):_
Alanus in working ordcr(ycs or nu):
Cununcnts{note condition of pump clsautbcr,kunditiuu of pungts and appurtenan(es,ctc.):
r
Page 9ofli
OFFICIAL INSPECTION.FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
//ll
SYSTEM INFORMATION(continued)
Property Address: �3� omffre
�t \1 Owner:
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan*excavation not required)
If SAS not located explain why:
Ty
T7leaching pits,number:
leaching chambers,number.
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/altemative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.):
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.):
/,v
PRIVY: (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.):
9
Page 10 of l i _
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION-FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 3 C 1 l V\e— k dLk_\
owner.•
Date of Inspection: 7
SKETCH F O SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building.
0,:,
C
U !a,
co
T �,►
Z Al v-4
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10
Page I i of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: `a)-� C\r\.\nE- L
�.-
Owner. SUSD-4r\��`K,^c�E
Date of Inspection:_ / /
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estunated depth to ground water t feet
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:
Observed site(abutting propertylobservation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
ll
Town of Barnstable
�p tHE 1p�
ti Regulatory Services
m �,� ;, Thomas F. Geiler,Director
9� •�� Public Health .Division
Thomas McKean,Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
This septic system inspection report was completed by a private inspector who is certified
by the State of Massachusetts, Department of Environmental Protection.
Although the Town of Barnstable Health Division received the original/copy of this
report; this Division does not warranty the functionality of the septic system in the future
nor does this Division agree with any technical observation s and interpretations
contained within this report.
In addition, by receiving this report the Town of Barnstable Health Division does not
automatically approve the number of bedrooms listed within this report. The actual
number of bedrooms approved at a particular property would-be listed on the "Disposal
Work Construction Permit".
If you should have any questions regarding this report,please contact the certified Septic
System Inspector who conducted the inspection.
ZN
SEWAGE PERMIT N0.
YIILAGE.
0 2-CoLoloc M ,
I N S T A LLER'S NAME IR A0DttES�S
BUILDER OR rOWNER p
DA T E PERMIT ISSY E`D
DATE COMPLIANCE ISSUED .Zljdz-
G
b
�� _ _
.ter.
Y�
v� "�. �,e
.:
�� . .
a , � -;, ��� ���� may �G ►y �
+ No.�_�---- ptp FElm....3 �....
THE COMMONWEALTH OF MASSACHUSETTS 3 �rd�do�IS
BOARD QF HE �hAe
�r Doha M.
IA'QlI) - ----- .............OF.......... ...1�-��
Appliratiun for lliipnottl Worko Tonotrnrtiun Prrmit
Application is hereby made for a Permit to onstruct or Repair ( ) an Individual Sewage Disposal
System t:
......................................Y X -76 a,......... __..
Location-Ac}di a ( or Lot I`To p ` - .. /�
--•• . --
................... ' vt ----------G_.-/{.�•TJ- -(....................... ___ --•-•-- -- -- - ---- ------ e!I /
Owner Address
f -
� Installer Address
Q Type of Building Size Lot... �c ____Sq. feet
V Dwelling—No. of Bedrooms._________.........................Expansion Attic ( ) Garbage Grinder (4-l'
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Other fixtures ......................................................
Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons.
WSeptic Tank—Liquid capacity------------gallons Length................ Width_.___..___...___ Diameter---------------- Depth__--_-_-_-------
x Disposal Trench—No..................... Width.................... Total Length-------------------- Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet..................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation
14
Test Pit NoRisults minutes p Performed inch Depth of Test Pit.................... Depth to ground water_______________-____---
Test Pit No. 2................minutes per inch Depth of Test Pit________--_-__- _-- Depth to ground water_______________-_____-_.
a -------•---•----------------•-•-----••••-•-•-----------•-•-----••-••---•---•-•--•-••----------•--•--.....................................................
0 Description of Soil......................................................................................................................................................................
x
U -•---••••••--•••••-•••••-•-••••-•••••-••--••--•••-•••--•••----••--••--••••-------••••-------•----•---•--•----••••-•---------••-•-----•-••-•--•-•---•-------•-----------•-------•-•----------------------
W -•••------•--•---•----•-•----------------------••-•--•--•-••••••-•••--••-•••--•--••-----•--------••-----------•------•---•--••••----•-•---..........-••••-••-•---- -------------------------------------
UNature of Repairs or Alterations—Answer when applicable.-__•_____________!_________--•_______•______--____•-_-__________-_._______._._____________-...
---------------------------------------------------•••-•--•-•••--•-••-•••••-•-•-••••--•--•-----------------•••••--------•-------•-••-••-•...-••---••---•••-••--------- .....................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been i sued b ar�oft
Si , ed. �/
• - ---
Application Aerfo
- ` 1� �z_
. •••. ------
Date
Application Dlowing reason : •-- -••----•-•---• -•---•------•-----•-•-•-•-••--•--••••-••••-••...------•-------•••_...
•---•-----------•-•_.... ...--••••-••-------•--•-....:...-•----------••--••--•••------•••-••--•-•••---••------•••-•--•-••••-••-••---•--......---•-•---•-•-----------
Date
PermitNo......................................................... Issued........................................................
Date
w
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH/
jam,
...............0F......... JG/< /I /.-i= .----------------------------
Appliratiun for Disposal Worko Tonstrnrtinn PPrntit
Application is hereby made for a Permit to Construct (1,11)or Repair ( ) an Individual Sewage Disposal
System at:
/"), "As/�lil I......................................... -•_.... ---- --- �
Location-Address~•� U j or Lot No.- /
Owner ,/ Address
Installer Address
Q Type of Building �''} Size Lot___> .-` '�-�.._.Sq. feet
U Dwelling—No. of Bedrooms._..._.....�`-...........................IJxpansion Attic ( ) Garbage Grinder (G-�'
` 4 Other—T e of Building No. of persons............................ Showers — Cafeteria
04 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.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area------------------sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date----------------------------------------
,� Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water__________--_.---._____-
rX, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water_______-___-__------__-.
a' •-------------------------------•--••--------•••------••--•••-••••••••••--•--•----•-----••-•••-•-••-------------...-•.......................................
0 Description of Soil------------------------------------------------------------------------------------------------------------------------------------------------------------------------
x
U •-•••-•--•-••-•--••--•----•----------------------------------•-•••••-•---•-•--•••--••••---••----•--••-••••--•--------•-•-•-•--•--•------•-•---------...---•••----------------------•-------------•---••.
W ----------------------------•-......--•-----...------------------------•--••••••---•-•-••----••--•--------------•-•-------------------------------•---------------------------•--•--•-------------------
UNature of Repairs or Alterations—Answer when applicable-----------------------------------------------------------------------------------------------
........................................................................................................................................................................................................
---------------------------------•----•-••-•------•--•-•••-•......-----------••--•-•-•-••-------••-•----------•----•••-•-------•-------------------•-----------------------_._.....--------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the-board of health.
fined.
D e
4-
Application Approved -
�B, - ! �'`' -
- --------------• ;` l ._cc •' --.
Yr , . o� / ate
Application Dis PPr d f dr the following reasons, -G' '»/,1f �
......................-----...--......................................................................................................................................................................
�;• Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
~?�< :..........................O F.... ..:.... L:
(Intif irate of Tomplittnrr � y
T 0`IS IS TO C<i�Y, That the Individual Sewage Disposal System constructed (�or Repaired ( )
by ( .... .... --•--- ......................
at
has been installed in accor 1 nce with the provisions of Article of The State Sanitary Co ��cribed in the
application for Disposal Works Construction Permit No "� �"'-------------------- dated_// /� ... .._...
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® A UARANTEE THAT THE
SYSTEM WILL U CTION SATISFACTORY.
DATE......J'—/ �................................................. Inspector------• •-•--
THE COMMONWEALTH OF MASSACHUSETTS
BOAFOAF�HyE, H
.44
Biglu 1;
Permission is hereby granted .- ----(->--r--l-a--n-------t--x---n----r--t--t--n----n---- P�nttt
.........................
to at Constr/u�t L or Repair j 'n Ind• Sewage Disposal System
r ___________________________________________A_--.-_-__-_--__________, ___... .__....__....__..
Street
as shown on the applic}ti for Disposal Works Construction Permit No__________ ___ D/at !�_ �%- 2-___._._..__.__
.....................................
r <¢ ----------------------------------------
Board of Health
DATE..............................................-=----------•------._._........_.
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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