HomeMy WebLinkAbout0076 FOXGLOVE ROAD - Health 7 5 Foxglove Road .
Marstons Mills
A= 149— 130 025
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COMMONWEALTH OF MASSAC1 USETTS
EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS John Grad
DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector
ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119
TeaTicket,Ma.
(508)564-6813
TRUDY COXE
Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 76 FOXGLOVE RD. CENTERVILLE MAP 149 PAR 130 L 27
Name of Owner RAUL GAGGEL
Address of Owner: SAME
' n r4•
Date of Inspection: 8/16/99
Name of Inspector:(Please Print)JOHN GRACI
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)
Company Name: n/a
Mailing Address: n/a '00 FQ
Telephone Number: n/a to
�,�`�tisr Ig9�
CERTIFICATION STATEMENT
�r
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below i u , ccurate
and complete as of the time of inspection.The inspection was performed based on my training and experience in the proper fund Ra0i
maintenance of on-site sewage disposal systems.The system:
X Passes The Inpection is based on criteria defined in Title V
Conditionally Passes code 310 CMR 15.303.My findings are of how the system Is
Needs Further Evaluati n By the Local Approving Authority performing at the time of the inspection.My inspection does
_ Fails not imply any warranty or guarantee of the longgevity of the
septic system and any of its components useful life.
Inspector's Signature: Date:8/17/99
The System Inspector sh submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of
completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner
shall submit the report to the appropriate regional office of the Department of Environmental Protection.The original should be sent to the
system owner and copies sent to the buyer,if applicable,and the approving authority.
NOTES AND COMMENTS
THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE.
revised 9/2/98 Page 1 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 76 FOXGLOVE RD.CENTERVILLE MAP 149 PAR 130 L 27
Owner: RAUL GAGGEL
Date of Inspection:8116/99
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated
are indicated below.
COMMENTS:
System passes Title V inspection
B. SYSTEM CONDITIONALLY PASSES:
nLa One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the
replacement or repair,as approved by the Board of Health,will pass.
Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not.
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 exilltration,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)
or 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
Wa 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
revised 9/2198 Page 2 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 76 FOXGLOVE RD.CENTERVILLE MAP 149 PAR 130 L 27
Owner: RAUL GAGGEL
Date of Inspection:8/16/99
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 16.303(1)(b)THAT THE SYSTEM IS
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:
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.
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 nta-(approximation not valid).
3) OTHER
nLa
revised 9/2/98 Page 3 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 76 FOXGLOVE RD.CENTERVILLE MAP 149 PAR 130 L 27
Owner: RAUL GAGGEL
Date of Inspection:8116/99
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 nLa.
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 ompounds,
ammonia nitrogen and nitrate nitrogen.
X The liquid level in the SAS is over the invert pipe,is in Hydraulic Failure.
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 Page 4 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 76 FOXGLOVE RD.CENTERVILLE MAP 149 PAR 130 L 27
Owner: RAUL GAGGEL
Date of Inspection:8/16/99
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.
X The site was inspected fo-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 constriction,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,
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 Page 5 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 76 FOXGLOVE RD.CENTERVILLE MAP 149 PAR 130 L 27
Owner: RAUL GAGGEL
Date of Inspection:8/16/99
FLOW CONDITIONS
RESIDENTIAL:
Design flow:-Q g.p.d./bedroom
Number of bedrooms(design): 3 Number of bedrooms(actual):34
Total DESIGN flow: 33Il
Number of current residents:I
Garbage grinder(yes or no):NQ
Laundry(separate system)(yes or no): NO If yes,separate inspection required
Laundry system inspected(yes or no):JKQ
Seasonal use(yes or no):JLQ
Water meter readings,if available(last two year's usage(gpd): nLa
Sump Pump(yes or no): NO
Last date of occupancy: nLa
COM M ERCIAL/INDUSTRIAL
Type of establishment: nLa
Design flow: n&gpd(Based on 15.203)
Basis of design flow: nta
Grease trap present:(yes or no):JLQ
Industrial Waste Holding Tank present:(yes or no): NQ
Non-sanitary waste discharged to the Title 5 system:(yes or no):NQ
Water meter readings.if available:Wit
Last date of occupancy: Wit
OTHER: (Describe)
D&
Last date of occupancy: nla
GENERAL INFORMATION
PUMPING RECORDS and source of information:
SPRING 99
System pumped as part of inspection:(yes or no):NQ
If yes,volume pumped nLa_ gallons
Reason for pumping: nLa
TYPE OF SYSTEM
XSeptic 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:
THE SYSTEM IS 16 YEARS OLD_
Sewage odors detected when arriving at the site:(yes or no): �LQ
revised 9/2198 Page 6 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 76 FOXGLOVE RD.CENTERVILLE MAP 149 PAR 130 L 27
Owner: RAUL GAGGEL
Date of Inspection:8/16/99
BUILDING SEWER:
(Locate on site plan)
Depth below grade: 2 6"
Material of construction:_ cast iron _40 PVC X other(explain)
Distance from private water supply well or suction line: TOWN
Diameter: nta
tl Comments: (condition'of joints,venting,evidence of leakage,etc.)
I nLa
SEPTIC TANK: X
(locate on site plan)
Depth below grade: 2`
Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain)
Wa
If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NO
nLa
Dimensions: L 8'6"H 5'7"W 4'10"
Sludge depth: L"
Distance from top of sludge to bottom of outlet tee or baffle: 3,f"
Scum thickness:4
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle: A
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.)
SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND RECOMMEND PUMPING SYSTEM EVERY TWO YEARS
GREASE TRAP:
(locate on site plan)
Depth below grade:
Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain)
n&
Dimensions: n&
Scum thickness: n(a
Distance from top of scum to top of outlet tee or baffle:ji&
Distance from bottom of scum to bottom of outlet tee or baffle n(a
Date of last pumping: n1a
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.)
n&
revised 9/2198 Page 7 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 76 FOXGLOVE RD.CENTERVILLE MAP 149 PAR 130 L 27
Owner: RAUL GAGGEL
Date of Inspection:8/16199
TIGHT OR HOLDING TANK: NO (Tank must be pumped prior to,or at time of,inspection)
(locate on site plan)
Depth below grade: nLa
Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain)
n(a
Dimensions: n&
Capacity: nfa gallons
Design flow: Wa gallonstday
Alarm present: N.Q
Alarm level:jila- Alarm in working order:Yes—No—: NQ
Date of previous pumping: n&
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
nla
DISTRIBUTION BOX: _
(locate on site plan)
Depth of liquid level above outlet invert:n&
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.)
nLa
PUMP CHAMBER: MQ
(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.)
nla
revised 9/2/98 Page 8 of 1 t
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 76 FOXGLOVE RD.CENTERVILLE MAP 149 PAR 130 L 27
Owner: RAUL GAGGEL
Date of Inspection:8L16199
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:
nLa.
Type:
leaching pits,number: 1000 GALLON LEACH PIT
leaching chambers,number: _nLa
leaching galleries,number: _nLa
leaching trenches,number,length: nta
leaching fields,number,dimensions: nLa
overflow cesspool,number: n&
Alternative system: nLa
Name of Technology: -nLa
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.)
THE LEACH PIT IS STRUCTU ALL SOUND AND FUNTIONING PROPERLY THE PIT WAS EMPTY AT THE TIME OF THE INSPECTION CANNOT
SEE HOW FULL 1
CESSPOOLS: _
(locate on site plan)
Number and configuration: n&
Depth-top of liquid to inlet invert: Wa
Depth of solids layer: nLa
Depth of scum layer. nLa
Dimensions of cesspool: n&
Materials of construction: n&
Indication of groundwater: Wa inflow(cesspool must be pumped as part of inspection)n&
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
nLa
PRIVY: _
(locate on site plan)
Materials of construction:n& Dimensions:n&
Depth of solids: n&
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
nta
Pa e9of11
revised 9L2/98 g
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 76 FOXGLOVE RD.CENTERVILLE MAP 149 PAR 130 L 27
Owner: RAUL GAGGEL
Date of Inspection:8/16/99
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)
n/a
�WA
AL
� 9
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)14
revised 9/2198 Page 10 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C -
SYSTEM INFORMATION(continued)
Property Address: 76 FOXGLOVE RD.CENTERVILLE MAP 149 PAR 130 L 27
Owner: RAUL GAGGEL
Date of Inspection:8/16/99
NRCS Report name: nLa
Soil Type: n/a
Typical depth to groundwater: n&
USGS Date website visited: WA
Observation Wells checked: MQ
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
revised 9/2/98 Page 11 of 11
LOCATION - SEWAGE PERMIT NO.
rA
INSTA LLER'S NAME 8 ADDRESS
941 get"
B U I L D E R OR` OWNER
4
DATE PERMIT ISSUED
® DATE COMPLIANCE ISSUED
N4 .
r
r
I
Fox cl �(
r TOWN OF STABLE a
LOCATION ES QJ WAG #
VILLAGE A SS RS M A)
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY -L
LEACHING FACILITY: (type (size) L®b
NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DA
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
�W&A
35
No. ..�':-7�d.... _ _ � ItFRs....91 ..............
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
.....--�"0W.1V...............OF..... .a _ '.....
, pphration for Uwpoottl Works Tonitrurtion rprutit
Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal
System at:
..........avrrm.1.0E------M-A S------kqT 17.. ......F;oo� ojvC...dapo.............................................
Location.A ress or Lot No.
C&M f l?A_..V i rX...... Eh��Y1 .............. ...........
W Owner Address
..........Ta P---— - ---------------------------------•---------
� Installer Address
UType of Building Size Lod.S..................Sq. feet
Dwelling—No. of Bedrooms........ ...............................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons............................ Showers
a YP g --------•----•-------------- P (•--)--- Cafeteria ( )
dOther fixtures --------•---------------------•---•-•--•-- •. -•---.--•---------•--••-••--------------•-•---•-•--•-•..----- ------
W Design Flow..............5-1.......................gallons per person per day. Total daily flow.:............�.3Q.-_----:.----_--gallons.
WSeptic Tank—Liquid capacity.110P...gallons Length.__,-4-:.... Width!t/:_1�...._ Diameter................ Depth..�.�.�Y.:".6..._.
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
1
Seepage Pit No........I........... Diameter.........:....... Depth below inlet... ..._.......... Total leaching area...2, ._sq. ft.
Z Other Distribution box ( ) Dosing tank (
Percolation Test Results Performed by.......A:. .. �_P� ?.................................... Date.....10AZI$3..............`.,�
Test Pit No. 1. .._-.2_.minutes er inch De th of T s �Ek
t p p e t Pit -13..__..._... Depth to ground water_._Q..............3`6
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
9 y-------------------•----. ................p........
-avr...... ---........... .................-----•------......••...
Pa -P......M ..... ........................ A � v �O Description of Soil......&�5 k!! .. . .x
w
I --------------------- ----------------------•---•••--••-----•••-•••••-•-------•--••••....•----•••-----•-------•--•-----•-------------•••---------•-••-•--•----•-••----•------------••---•----••...•---
V Nature of Repairs or Alterations—Answer when applicable...............................................................................................
-----------------------------------------••---------------•--------•-----------••--••----•---......•----------•------------••--•-•.....--------•-------•--------••------------------••-•---•-••-•--•...
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of 71T= 5 of the State Sanitary Code— The undersigned.further agrees not to place the system in
operation until a Certificate of Compliance has bee by the oa d f health. ppss
Signed-
. � .. o3
Application Approved By..................... . . -•-•• ----1r--7.
--------
Date
Application Disapproved for the follow' g re s:-----••-------•--•--------•••-----------------------------•--------•--•--•--------------•-•-------•••....•--.._
..............•-------------••-------•-------------•-----•-----------•------•-----------•--•--------.....-•---••-•------------------....----•--------------------•-------•----------------•---.
PermitNo......................................................... Issued............... --------
Date
No_` 3 �11F
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
Appliratinn for Disposal 30nrki Cnnnitrudion rrntit
Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal
system at:
CEtdT'CRV1kkr MASS 1,0T2`7 Fo )(6kolic" 66AP
-- _..• ......-1..........................•------------•---•••-•....-----•-----•-- ....---•-----------------...................----------------------.......---•-------............-•--
C0MtA e"tN 1
jtarAi�RbpkRT"1E51N X C . Ra7Zo CkOrt?? IJ°ELLC H/�S
........................................••-- --------------------------------------------------- -..-r---•-----_-------•--..-----...-----------•-•----------.------•--- ..................._
Owner Address
Installer Address l S OQQ
Type of Building Size Lot.......A...................Sq. feet
U Dwelling—No. of Bedrooms................................ .Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No. of persons............................ Showers — Cafeteria
a' Other res ---------------------•-----
Design Flow.................................. gallons per person dray er . Tota a lSiow--.-..._..__..__.__._...................... ns.
9 Septic Tank—Liquid ca.pacity............gallons Length................ Width................ Diameter................ Depth................
W Disposal Trench—.To. .................... WidtJl.4--..-.--.--.-.--- Total Length _ Total leaching area.................... ft.
x P '� g t g 1,00
q.
Seepage Pit No--_---------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq- ft.
Z Other Distribution box ( ) Dosing t00 to WE-5 AIA/83
`4 Percolation Test Restilts .Performed by..................... ....._._.__._._.....-- .1....................... Date.................... e=
z,-v' R--t3-+n
0_� Test Pit No. 1..-/..:...47.-minutes per inch Depth of Test Pit................... Depth to ground water........................
0:4 Test Pit No. 2................minutes per inch Depth of Test Pit.--................. Depth to ground water----................---.
O v-;5 ( nq + S U! 5, t X„ — �� O h J.. �------•-----
Descriptionof Soil------•------•--------------------------------•-----•-•-•--•------••---•---••---------------- ------------•---•-------•----•-----------------------------•-----•..-----
W -------•-------------------------------------------------------------------------•••--------------------•-•--•-----•------------------------••---------------------•-----------------------••-•---.•----
UNature of Repairs or Alterations—Answer when applicable-----------------------------------------------------------------------------------------------
...............................................................................
--- •--•------- •---•-------- - _ .-..----•--•-•-------------•-•----------�
Agreement:
--------
The undersigned agrees to in afo,peescribed Individual Sewage Disposal System >n�a cc4idance with
the provisions of Ti T f a.
p 5 of the Stat an' Code—The undersigned further agrees not to place the system in
operation until a Certificate of Com 'ance has been�issu by the •oa d lth.
r , —
Signed �:-.......•.................... ......................... ................................
Date
ApplicationApproved By.................................................................................................. -••--------------------•...............
Date
Application Disapproved for the following reasons:--------•---------------------------------------------••----...-------------•--•-----...---------•.._...........
-•-•----------•---------------------------•-•--------------------•---•---....-------•----------------••-----•-----••---.----
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
AR OF HEALTH
r
I... ............ ....................................................................
r/1 ate #1 O)appaurr 14/
THIS IS TO CERTIFY, That the(I ividual Sewage Disposal System constructed ( or Repaired ( )
by............................................................................................. -•-------••--•••--•.......----...--••-...........•-•-•-•--•-...-------•-••----•••......•-•----•---••--
Installer
at_----•--._-----•--------•-•-•----------------------•-------------------------------•----•--------------------------•----..-------------------------------------------------•-•--•.-------------------
has been installed in accordance with the provisions of TITLE j of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No----------------------------------------- dated--------------------------------------..........
THE ISSU NCE OF THIS CERTIFICATE SHALL NOT BE CONSTRU AS A GUARANTEE THAT THE
SYSTEM ION SATISFACTORY.
DAT ................................................ Inspector.... .... .. --------------------------------G... ...............--
THE )NWEALTH OF MASSACHUSETTS
OF HEALTH
l
No.... a^ !/ ��. .......
Permission is hereby granted........................... _" _fir - "'.._......
.....---•• .--- ----•---•- . ---•--
to Construct ( ) or Repair ( ) an Individual Se /�isposal System
atNo............................................................... ... ..._.__....---------•-------•--------------------•---••--------..............-•-----------•-•--...........
Street
as shown on the application for Disposal Works Construction Permit No..................... Dated..........................................
---•----- ------
Z�Z Board of Health
DATE------ -••---•--------------••--•----
----------------------
FORM 1255 HO MBS & WARREN. INC.. PUBLISHERS
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