HomeMy WebLinkAbout0061 GALLEON WAY - Health F
eon Way
Mills38
. .T
r Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 61 Galleon Way V
Property Address
Frances Verocha
Owner Owner's Name
information is 9siePaifle MA 02655 July 16 2008
required for ,
every page. Cityfrown State Zip Code Date of Inspection
v Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.
Important: A. General Information
When filling out
forms on the
computer,use 1. Inspector:
only the tab key
to move your Patrick M. O'Connell
cursor-do not Name of Inspector
use the return
key. Septic Inspection Services Co.
Company Name
Q 189 Cammett Road ,
Company Address
Marstons Mills MA d648 s$
Cityrrown State Zrip`•Code r
508;428-1779 SI 12855 --�
Telephone Number License Number r
B: Certification
c� r
' I certify that 1 have personally inspected the sewage disposal system at this address and hat 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 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails .
❑ Needs Further Evaluation by,the Local Approving Authority
�--� July 16 2008
Inspector's Signa re Date
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 greater, 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.
""'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.
08-192 Verocha.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 61 Galleon Way
Property Address
Frances Verocha
Owner Owner's Name
information is required for Osterville MA 02655 July 16, 2008
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 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:
Tank is not in need of pumping at this time, leaching pit was half full at time of inspection with a high
stain line 8-10" above current level.
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired.The system, upon completion 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 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 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
08-192 Verocha.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
61 Galleon Way
Property Address
Frances Verocha
Owner Owner's Name 1
information is Ostenrille MA 02655 July 16 2008
required for
State Zip Code Date of Inspection
every page. Cityrrown
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ 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:
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System'will p;ss unless-Board of,Health determines in accordance with 310 CMR
15.303(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.
08-192 Verocha.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15
Commonwealth of Massachusetts
r Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 61 Galleon Way
Property Address
Frances Verocha
Owner Owner's Name
information is required for Osterville MA 02655 July 16 2008
every page. City(Town State Zip Code Date of Inspection
B. Certification (cont.)
C) Further Evaluation is Required by the Board of Health (cont.):
❑ 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 indicates absent 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:
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_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.
08-192 Verocha.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
w� 61 Galleon Way
Property Address
Frances Verocha
Owner Owner's Name
information is Osterville MA 02655 July 16, 2008
required for
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems (cont.):
Yes No
❑ ® Any portion of a cesspool or privy is within a Zone 1 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 water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent 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
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® 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 flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the
questions in Section D.
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 II of a public water supply well
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 of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CM 15.304. The system owner should contact the appropriate
regional office of the Department.
08-192 Verocha.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
61 Galleon Way
Property Address
Frances Verocha
Owner Owner's Name
information is Osterville MA 02655 July 16 2008
required for
State Zip Code Date of Inspection
every page. Cityrrown
C. Checklist
Check if the following have been done. You must indicate"yes"or"no" as to each of the following:
Yes 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?
❑ 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 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:
® ❑ 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 CMR 15.302(5)]
08-192 Verocha.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15
Commonwealth of Massachusetts
: Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
61 Galleon Way
Property Address
Frances Verocha
Owner Owner's Name
information is Osterville MA 02655 July 16 2008
required for
every page. City/Town State Zip Code Date of Inspection
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms (actual):
3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):
330
2
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Sump pump? ❑
Yes ® No
Currently
Last date of occupancy: Occupied
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe):
08-162 Verocha.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
wM 61 Galleon Way
Property Address
Frances Verocha
Owner Owners Name
information is Osteruille MA 02655 July 16 2008
required for
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
General Information
Pumping Records:
Source of information: Tank pumped last year.
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type 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)
El maintenance
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.
El Other(describe):
Approximate age of all components, date installed (if known) and source of information:
Compliance date: 6/28/83
Were sewage odors detected when arriving at the site? ❑ Yes ® No
08-192 Verocha.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
61 Galleon Way
Property Address
Frances Verocha
Owner Owner's Name
information is Osterville MA 02655 July 16 2008
required for
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan):
1'
Depth below grade: feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
1'
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
----------------------------------------------------------- ---------------------------------------------;-----------------
8.5' long x 5.2'wide- 1000 gal.
Dimensions:
2"
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
28"
1„
Scum thickness
6"
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
12"
Measured
How were dimensions determined?
08-192 Verocha.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15
f
Commonwealth of Massachusetts
= Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
61 Galleon Way
Property Address
Frances Verocha
Owner Owner's Name
information is required for Osterville MA 02655 July 16, 2008
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Liquid level was found at bottom of outlet invert outlet baffle is cracked recommend replacing.
Grease Trap (locate on site plan):
Depth below grade: feet
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: - Date
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain):
08-192 Verocha.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 10 of 15
Commonwealth of Massachusetts
= Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 61 Galleon Way
Property Address
Frances Verocha
Owner Owner's Name
information is Osterville MA 02655 July 16, 2008
required for
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Tight or Holding Tank(cont.)
Dimensions:
Capacity: gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
0"
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.):
No solids or high stains present Liquid level at bottom of single outlet pipe.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
08-192 Verocha.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
w 61 Galleon Way
Property Address
Frances Verocha
Owner Owner's Name
information is Osterville MA 02655 July 16, 2008
required for
every page. Cityrrown State Zip Code Date of Inspection.
D. System Information (cont.)
Comments (note condition of pump chamber, condition of pumps and,appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
® leaching pits number:
One 6x6 pit.
❑ leaching chambers number-
leaching❑ 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, damp soil, condition of
vegetation, etc.):
Leaching pit was half full at time of inspection with a high satin line 8-10" above current level.
08-192 Verocha.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15
i '
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
61 Galleon Way
Property Address
Frances Verocha
Owner Owner's Name
information is Cisterville MA 02655 July 16, 2008
required for
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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 ❑ No
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
-Al
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
08-192 Verocha.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15
\ Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 61 Galleon Way
Property Address
Frances Verocha _
Owner, Owner's Name
information is Osterville _MA 02655 July 16 2008 _
required for
State Zip Code Date of Inspection
every page. City/Town
D. System Information (cont.)
Sketch Of 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.
Galleon Way
Water
Service
4 46
33 51
43 59
• ' x Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .
61 Galleon Way
Property Address.
Frances Verocha
Owner Owner's Name
information is required for Osterville MA 02655 July 16 2008
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
20
Estimated depth to ground water: feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers -(attach documentation)
® Accessed USGS database-explain:
USGS topo map and town GIS.
You must describe how you established the high ground water elevation:
Town groundwater contour map shows water at el 25 and topo map shows property at el. 50.
08-192 Verocha.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15
i
y
1HE
Town of Barnstable
Tp .
o„ Regulatory Services.
BnxxsrABM : Thomas F. Geiler,Director
9� MAM. `0�
iDTE��.(A Public Health Division
Thomas McKean, Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
REGARDING SEPTIC INSPECTIONS BY PRIVATE CONTRACTORS
DISCLAIMER
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 or copy of the report;
this Division does not warranty the functionality of the septic system in the future nor does
this Division agree with any technical observations 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 Works
Construction Permit".
If you should have any questions regarding this report, please contact the certified Septic
System Inspector who conducted the inspection.
QASPPTIMisclaimer Private Septic InsR ections.D0C
o
TOWN OF BARNSTABLE
LOCATION (�P/ SEWAGE -7 d?
VILLAGE �tJ\ ASSESSOR'S MAP&PARCEL
l�ER'S NAME&PHONE NO. "r ®G a�► �- — .�"1`7
SEPTIC TANK CAPACITY 1600
LEACHING FACILITY: (type) 17�) (size) J 000 a c r
NO. OF BEDROOMS 3
OWNER
PERMIT DATE: C6 E DATES,,--,P �,JU10�
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
Galleon Way
I .
Water
Service
a
i
i
4 46
w` r
33 51
' 1
43 59
TOWN OF BARNSTABLE
LOCATION SEWAGE #
`VILLAGE 0.5"e-VI&e M ASSESSOR'S MAP& LOT f9 438
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY = 0 ®3�
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland.and Leaching Facility(If any wetlands exist
within 300•fee of leaching facility J Feet
Furnished by �-a'w} -�' ��`�
r
Zr
0
r�oAl
I G,:R Ile 04/ CcJ•�
T lOC A ION SEWAGE PERMIT p0.
p
ILAGE
I N S T A LL, R'S NAME i AD RESS
BUILDER leftu OWNER
DATE PERMIT ISSUED
DATE ,rCOMfPL1ANCE ISSUED ��
QX
o
P7
L-0CATION SEWAGE PERMIT NO.
VILLAGE
ynA9 -s'-r�N �
INSTAL ERIS NAME i ADDRESS
BUILDER OR OW- -NEV -
OAT E PERMIT ISSUED
DATE COMPLIANCE ISSUED � �3
7S
a r3
�7
. oe
i40 u1-6
W#y
Q.:_ ..._
3 Q THE COMMONWEALTH OF MASSACHUSETTS �!
g (SOAR® OF HEALTH
..................•--•........-----
Appliration for Dhip sai IUM6 Towitrurtiun runfit
p Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at: j
T.......... ...........................................o^/ ''e jT� S � ..................................................
--------- ...-
Location-Address / / o Lot
- `�'Q --��nl sr c / a ------- ..................... ,C=n....... d
Owner Address
Installer Address
Type of Building Size Lot.o24R,,P.".,o.......Sq. feet
U Dwelling—No. of Bedrooms......................................Expansion Attic ( ) Garbage Grinder ( )
a`4 Other—T e of Building Na., of persons -
YP g ------•--------------•------ P �-----------•-----.. Showers ( ) — Cafeteria ( )
Otherfixtures ------------------------•------•---•------------------•-••-•------------•----•-•-------------•-•------------------------•....----------•.......•-•-•-
W Design Flow............. 5......................gallons per person per day. Total daily flow........... 3 a gallons.
WSeptic Tank—Liquid capacity.P�PP.gallons Length_An 1! _`__. Widths-...,......... Diameter................ Depth... .........
x Disposal Trench—No..................... Width......:............. Total Length.................... Total leaching area.___-, J_...sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
a Percolation Test Results Performed by...... ._.. .
--....---- Date.-�9------ ----------------
Test Pit No. 1.......7 ......minutes per inch Depth of Test Pit-----/.Z_.----- Depth to ground water.....X�:t�.
fZ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
.._
O Description of Soil.............�-=`L ---------�.. -- `� � ---- .
U ---•••-•-•--•----•--•-••--•-----•--•--••••---•---•---------------•-----------------.....••-•••••-•--•....-----------•-•---••--•-•---•--.
W
UNature of Repairs or Alterations—Answer when applicable................:...__!^.._..___-__.._.._....____........_.__................._..........___.
- r
---.........................=..........................................................................................................................................................................
Agreement:
The undersigned- agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITf,;_. 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been i ed by t b and f health. /
Si ._ _..--••-•-------••_.._...--- /Date . ...._....
> L
Application Approved By---- --��C�-/�.e---- . --- -------------•--•--•--- --/Z'= �---•-----------
Date
Application Disapproved for the following reasons-......................................--•---------------------•---------•----••---•---•---•---•-•-•----------._
------------------------------------------•--------....--•--------•---•--.....--------------•------------...-----•---•-•-•-------•----------..__.........-------•---•-••----••----•-- -----•---••-•-
Date
PermitNo.............. .................................... Issued.......................................................
Date
f � f
'w
No---
N `/•-,?. ? Fps :..' .......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD 9F HEALTH
✓..._-------------------0F,d���... -7.3-t-P---•--....------................------
ApplirFation for Disposal Works Toustrurtiun thrutit
Application is hereby made for a Permit to Construct (,�) or Repair ( ) an Individual Sewage Disposal
System at: / !�
......................................................, G /�'S 7 ��S /1i f l�
�
Location•Address _ •���• ••••-
JnL Y /�o
ner Address
W < .Z..__._a_ ,Installer '
.•
� Address
UType of Building Size Lot.cPoar.dg2........Sq. feet
., Dwelling—No. of Bedrooms......................................Expansion Attic ( ) Garbage Grinder ( )
a
aOther—Type of Building ............................ No. of persons....-h................... Showers ( ) — Cafeteria ( )
QOther fixtures -------••--•------------------------•--•---•----•----.....------------•---•-------------------------..._.............---....•-•-----•...........----
W Design Flow............ ..�'_.............._........gallons per person per day. Total daily flow....... - . ..............gallons.
9 Septic Tank—Liquid"capacity10�a.gallons Length l4'..�.._.. Widths. .......... Diameter________________ Depth...
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.. �
a Test Pit No. I...... minutesperinch Depth of Test Pit..... ?....... Depth to ground water.....lelv _ '_-
Gi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
--------------- -----------------
•----•-•----•--•--------••---••--••-----
Description of Soil ._... :--•---•-----•....... G ! -' t` r'1
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.L T . 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
board of health.
operation until a Certificate of Compliance heas been
�e�-
PY
f' / _/_. ! ..........................• - .......
�/ � � `Date
Application Approved By. .e..... 41
' y
7-
Application Disapproved for the following reasons:...............................................----•---------•--•--------•-----_••-•. •-----••-•._...._-••-•-
......................................................-..................................................................................................................................................
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.........................OF.... �,k 1 J e.................................
...........
Tnr#ifirFa#r of ToutpliFanrr
TIIS IS TO CER IFY, hat the, Individual Sewage Disposal System constructed ( or Repaired ( )
+ ,✓'
Installer
47/
at........................... .....•------Z7........................ ............................-------•-- --------------•-----......--•-----------•---
has been installed in accordance with the provisi6ns of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.,Z:n_?..;M................... dated-...............................................
THE ISSUANCE F THIS CERTIFICATE SHALL NOT BE CONSTRU A GUARANTEE THAT THE
SYSTEM F� TION SATISFACTORY.
DATE.... .. ...{...... ... Inspector....... ...
------------------------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD, F •HEALTH
No......................... FEE_. ...........
Dis pos tl urge . u�a�� inn rrutit
Permission is hereby .ante = .._.i /
g .............
to Construct (4 or Repair ( an Individual Sewage Disposal System
---------------------- Street
as shown on the application for Disposal Works Construction Permit No..................... Dated..........................._..............
Ioard of Health
DATE...................................... -----•--•----•••-•---
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS -
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