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HomeMy WebLinkAbout0045 MIDDLE POND PATH - Health 45 Middle Pond Path Marstons Mills P j A = 080 021 'I ti, - fro P - Zt TROY WILLIAMS SEPTIC INSPECTIONS TO Certified by MA Department of Environmental Protection (508) 385-1300 19 Hummel Drive South Dennis, MA 02660 �-\ COMMONWEALTH OF MASSACHUSETTS EXECUTIVE. OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSES Pft EI�/E® SUBSURFACE SEWAGE DISPOSAL SYSTEM FOR PART A CERTIFICATION MAY 1 0 2002 Propert% Address: 45 Middle Pond Path TOWN OF BARNSTABLE HEALTH DEPT. Marstons Mills,MA Owner's Namc: James O'Hara �,8p Owner's Address: 45 Middle Pond Path )p EL WL Marstons Mills,MA 02648 \ Date of Inspection: May 8,2002 0 LOT ' Name of Inspector: Troy M. Williams Company Name: Troy Williams Septic Inspections Mailing Address: 19 Hammel Drive South Dennis,MA 02660 Telephone Number: (5b8)385-1300 CERTIFICATION STATEMENT I certify that I_have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP approi ed system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The sysrenv ✓ Passes Conditionally ['asses Needs Further Fvaluation by the Local Approving Authorir) Fails Inspector's Signature: ,, 'j�„,Q�,,� ,„Q Date: 51&ZpA The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of I lealth 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. Notes and Comments Although system meets the minimum requirements set forth by the Massachusetts Department of Environmental Protection,certification is not to be construed as a guarantee of future working condition of system:piping or components. This inspection represents the conditions of the system on the Date of Inspection noted above. ""This report only describes conditions at the time of inspection and under the conditions of use at that time. ]his 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 pace I r Page 2 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 45 Middle Pond Path Owner: Marstons Mills,MA Date of Inspection: James O'Hara May 8,2002 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: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to b eplaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board Health,will pass. Answer yes.no or not determined(Y,N,ND) in the for the following statement f"not determined"please explain. The septic tank is metal and over 20 years old" or the septic tank(w ther metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is ' minent. Svstem will pass inspection if the existing tank, is replaced with a complying septic tank as approved b e Board of Health. •A.metal septic tank will pass inspection if it is structurally soun 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 or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled uneven distribution box. System will pass inspection if(with approval of Board of Health): b en pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The syste required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspecti if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: _ 2 Page 3 of 1 I OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 45 Middle Pond Path Owner: Marstons Mills,MA Date of Inspection: James O'Hara May 8 2002 C. Further Evaluation is i1equired by the Board of Health: Conditions exist which require f inher 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 15.303(1) that the system is not functioning in a manner which will protect public health,safety and the en Aronment: 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 in sh 2. System will fail unless the Board of Health(and Public Wate upplier,if any)determines that the system is functioning in a manner that protects the public bea ,safety and environment: _ The system has a septic tank and soil absorption s em(SAS)and the SAS is within 100 feet of a surface water supple or tributary to a surface water ply. — The system has a septic tank and SAS the SAS is within a Zone I of a public water supply. — The system has a septic tank and S and the SAS is within 50 feet of a private water supply well. _ The system has a septic tan - and SAS and the SAS is less than 100 feet but 50 feet or more frorh a private water supply well"'. ethod used to determine distance •'This system passes a well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volati organic compounds indicates that the well is free from pollution from that facility and the presence of monia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure crite ' are triggered.A copy of the analysis must be attached to this form. 3. Other: 3 f Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 45 Middle Pond Path Marstons Mills,MA Owner: James O'Hara Date of Inspection: May 8,2002 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. _ Lld Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone l of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. 4dA 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 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.] No (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 ad ign now 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 crite ' above) yes no the system is within 400 feet of a surface drinkin ater supply the system is within 200 feet of a tributary t surface drinking water supply the system is located in a nitrogen se ' ive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone 11 of a public water supply w If you have answered"yes"to any que on in Section E the system is considered a significant threat,or answered "yes"in Section D above the large tem has failed.The owner or operator of any large systein considered a significant threat under Section r failed under Section D$4411 upgrade the system in accordance with 310 CMR 15.304.The System owner sh d contact the appropriate regional office of the Department. 4 Page 5 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSALL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 45 Middle Pond Path Owner: Marstons Mills,MA Date of Inspection: James O'Hara May 8,2002 Check if the following have been done. You must indicate'yes"or"no"as to each of the followine: Yes No f::::aping information was provided by the owner.occupant.or Board of I leahl, 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: 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)13 10 CMR 15.302(3)(b)j 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: . 45 Middle Pond Path Owner: Marstons Mills,MA Date of inspection: James O'Hara May 8,2002 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): a DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): .3 30 Number of current residents: �2 _ Does residence have a garbage grinder(yes or no): Is laundn on a separate sewage system(yes or no): A/o (if yes separate inspection required] Laundry system inspected(yes or no): .v/.q Seasonal use: (yes or no): Water meter readings,if available(last 2 yearslrsage(gpd)):b ► = 7 ovo 72 It „s oo= 102,6 ou Sump pump(yes or no): vo Last date of occupancy: 4) ; COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,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 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( es or no): A& 1f 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) _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: -J�S-.,K -..A /.g;1- a,— c�:g;..ai .. ��H.,� 1..a �s-ba:It. Were sewage odors detected when arriving at the site(yes or no): Afo 6 Page 7 of 1 I s OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) i Property Address: 45 Middle Pond Path Owner: Marstons Mills,MA Date of Inspection: James O'Hara May 8,2002 BUILDING SEWER(locate on site plan) I Depth belo�+ grade: .�-' t Materials of construction:_cast iron ✓40 PVC ,/other(explain): I; <<„ Dktanrr fron. private water supply well or suction line: ,vig Comments(on condition of joints,venting,evidence of leakage,etc.): 219,—.A C.1 SEPTIC TANK: (locate on site plan) Depth below grade: 9 {��, Material of construction:Vconcrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):'_(attach a copy of certificate) Dimensions: S' ',c 9 x 6 ' /coo U." Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: P? 'e Scum thickness: _3 „ Distance from top of scum to top of outlet tee or baffle: 4 Distance from bottom of scum to bottom of outlet tee or baffle: liow were dimensions determined: P•,,d— /K.o.�i.l-..�. Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): II �� 'S ��r� .��..J. �..''1- W.0.-k; .� or.�.5.✓. ��Y t...Na n c_t....o� ��c.�t a ov _� s 2 4c, P-,P;� _iw r r e- c- o[ GREASE TRAP:_(locate.on site pla/etc.): Depth below grade:— Material of construction:_concrete_ erglass_poly ylene_other (explain): _Dimensions:Scum thickness: Distance from top of scum to top of outle:Distance from bottom of scum to bottomaffle:Date of last pumping: Comments(on pumping recommendatioutlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of lea 7 Page 8 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 45 Middle Pond Path Owner: Marstons Mills,MA Date of Inspection: James O'Hara May 8,2002 TIGHT or HOLDING TANK: (tank must be pumped at time of' ection)(locate on site plan) Depth below grade: Material of construction: concrete metal fibergla _polyethylene other(explain): Dimensions: Capacity: gallons Design Flog%. gallons/day Alarm present(yes or no): Alarm level: Alarm in working o er(yes or no): Date of last pumping: Comments(condition of alarm and at switches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 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.): Q' 0z)x -`3 7Av..J en w 0' 1—t ,So1: CA c--rrt,v✓�v v►� (� .cl�ul� c,iN.j 7�'ihcf o� �i ► f7��, 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,conditio f pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART C SYSTEM INFORMATION (continued) Property Address: 45 Middle Pond Path Owner: Marstons Mills,MA Date of Inspection: James O'Hara May 8,2002 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why. T✓eleachingpits.number:2 C 'x6 P,) �2 '�'fa:,� 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,damp soil,'Condition of vegetation, etc.): Ijo, f ✓ 1cv_t l w,`c.� T+i Jl !uw �►, n�✓ /cc� 1, � + J —sc _ —i✓;Yl, I :-!t'�c w�lw sue.. A//��a G u.a�t h e t u f' Y cR/tti✓l 44- 'Y�.c_ ,•+,t. c�/n .hS�7tc.'><io.,. CESSPOOLS: (cesspool must be pumped as pan of inspection ocate on site plan) Number and configuration: Depth—top of liquid to inlet invert: _ Depth of solids layer.- Depth of scum Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no . Comments(note condition c.f soil,signs hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions- Depth of solids: Comments(note condition of soil,signs of hyZicfailure, level of ponding,condition of vegetation,etc.): 9 s , � Page 10 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 45 Middle.Pond Path Marstons Mills,MA Owner: James O'Hara Date of Inspection: May 8,2002 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. A /?t c K i I � A C 26 ' 6 c. = 2 ' i LO —6— — 1000 L3 1 = 1-7 13ok Poo t. f/cw�� 1R ' Page I 1 of I l OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 45 Middle Pond Path Owner: Marstons Mills,MA Date of Inspection: James O'Hara May 8,2002 SITE EXAM Slope Surface water Check cellar ✓ Shallow wells I Estimated depth to ground water 36 feet Adjusted high ground water elevation 29. feet Please indicate(check)all methods used to determine the high ground eater elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: 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: ys c,s 2S7 zvh�E 3 f3.6 You must describe how you established the high ground water elevation: — us GS G.v .1 ti d� _ ramsJ-c�L.(� o��w `10 1 c✓ liu . _per.+ a�. i•ie r U O G uvOJO p•S� Ile 5 1,3r1r So.9 lyy ' 79 11 TOWN OF BARNSTABLE I' LOCATION YS M% WW, SEWAGE # h VILLAGE AA G r s 1z a s A:l 1 s. ASSESSOR'S MAP & LOT ,Po _2 t INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /0t90 LEACHING FACILITY: (type) (size) 2' NO. OF BEDROOMS -2 BUILDER OR OWNER d PERMITDATE: lD l23 /K6 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility I y Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) N/,g Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) w'/rn Feet Furnished by "-1-,w; 4► �.N., S/�l�o z. l �13 p4�K I P-s �fl -3o•s' � OG 89 A � 3� (7 � :rz,' pry �o0L- oG (8 ' ar s. V TOWN OF BARNSTABLE LOCATION y� //1,�otF �o,�m -�i2��ii SEWAGE # VILLAGE �Zazvl /22fe1 s ASSESSOR'S MAP & LOT SO —O,Z I INSTALLER'S NAME & PHONE NO. PAC —E�FVrtop^n Z/ -7700 SEPTIC TANK CAPACITY &,VSuzzr 6:/7W,5-,c /DOD LEACHING FACILITY:(type) �2 em `pgy 64/,21 NO. OF BEDROOMS_ PRIVATE WELL OR PUBLIC WATER TV&vN BUILDER OR OWNER DATE PERMIT ISSUED: /,f/ DATE . COMPLIANCE ISSUED: r VARIANCE GRANTED: Yes NO "r.4A'Jc r�v 7 A "p�G�t �G ' e � � d 1;:.aVcac 'PbS�, m O Ln Pry co'r rULD "'TANkc Ovr 7 A 30 r6.° �7 '9 -7r9n f aSESSORS MAP NO; S_4��._�_.._. ' gC _11 ?�, 'AROEL NO.: - 5 No. --- •'OWN 1338yc, Fim$.............................. THE COMMONWEALTH O6kiM;A'Sp lygTTS �X ;BOAR® OF HEALTH ...........taw.N.............OF.... .............................................. , pphratiun for Diipua al Morks Tomitrurtiun Fermi# Application is hereby made for a Permit to Construct (>6 or Repair ( ) an Individual Sewage Disposal System at: Lo lion-At ss or Lot No. +1... T �CLG.._..... ...... i?i/�e....................... Owner p ddress •--•---� L �l��� lr✓ ...... ®:._.. I..�J� /_.'/�a!L�IL. T.f... st�(�� Installer Address U Type of Building Size Lot_.M�!Y .....Sq. feet �-, Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) `4 Other—Type T e of Building � yp g ......................:..... No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures ------------------------------------------------•-----•-•••=•••--•......-•.....------•--•--••- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity�.�.._S___gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No---------C-------- Diameter.7�W 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....................... 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 1:+4 .-•••••-•-••-••-----••-••••••-•-•-•-•••••-••••••-••••••---••••---•••--•-----...----•---•..................•••...-•••-•-••-•---•••--••••..........------•••••. xDescription of Soil.......................................................................................................................................--------------------------•••--- U -••••••••••-•-•-•--•---•-••-•-••••-••••--•---•--•--•••--••-•-••---•-------•-•-••---•--------------•-------•••--••••--••----••-------••••-------•--••••--••-••---•-•••--••••••------•......••-••••...••-- ------------• --------------------------------------------------------------------------•---------•----------------...-------------------------•----•---------------------------------------------•-•-- U Nature of Repairs or Alterations—Answer when applicable.......NS7294ift...__.._ ?!.._.__.� ? _.�" t.._�tvK_. Agreement:` The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of i:.i'1JE,_j "of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been i e b the d of health. Signed l'- s__.... . " ' Date Application Approved B ...................................... .:... ---••-....... ................... --•-•--1 'Z .-_' Dat Application Disapproved for the following reaso s:.................................--........................................................................... t Date PermitNo......................................................... Issued:...................................................... Date No......................... Fim............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD �OF` HEALTH ............. ..0.�.ti...............OF........L r.).Arf5� 1<;! C Appliration for 11iipo, al Works Tonstrurtion rrntit Application is hereby made for a Permit to Construct (>) or Repair ( ) an Individual Sewage Disposal System at: ......L - .............. ....... - ..... .........._... S or Lot No. ._.....� , ezv ........................•----------...----------••---.... Owner ' Address t/C4 /�t ,^,r G(�� G/I ,sa Installer - Address Type of Building Size Lot_.�� . ......Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers — Cafeteria QI Other fixtures ................................. . W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity6 _.gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No--------t........ Diameter 7 11?_C.._ Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) ~' Percolation Test Results Performed by.......................................................................... Date........................................ 1.4 Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water_--__-_-___-_-__-------. Gz., Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a •---------••--------••-----•--------•-----------------------------------------•----------------•-•--......................................................... 0 Description of Soil........................................................................................................................................................................ x W U N!aVure of Repairs or Alterations—Answer when appplic�ayble....y. M:��_//-y«.._.___..'v�~w......._/ 7/G �/c•---�n� _... Tr-- /( J- %/G1C� ! _d�� ��4 J ( ��//�� 7 Agreement• � ��T�=-� ��i o C✓ C-.�f ��.� . / G ' �' '� The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iT�p 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 the rd of health. Signed----- r l�� '�r .__.... Date Application Approved By...... .... - ----- --------------------------- ....... a•D f b al Application Disapproved for the following real s:................................................................................................................ .............-........................................................................................................................................................................................... Date PermitNo....................................................... Issued-....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS r BOARD OF H. ALTH ��(�.......................OF.............. ............................................... Tatifiratr of Bunt lionrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired} b ...............................P'1`(f,.c t z. �z owt `� -- -----. . Installer at It's... iM I t. ..�•�-------- .. ._P'4....�.--••----------•----...----•---------------------•------------------------- has been installed in accordance with the provisions of Ti T E j of The State Sanitary Code as de•cribed in the application for Disposal Works Construction Permit No......_a ..... .............. � '� '�dated ---------- --- • -�-------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUA ANTEE THAT YHE SYSTEM WILL FUNCTION SATISFACTORY. a DATE.-------!j 2.....zd ........................................... Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH U OF..................................................................................... ��''. No....... / FEE........................ Disposal Works Toaiotr ion lerntit Permission is hereby granted_______ _f _LK........._..........v�'.'"L�l to Construct ( ) or Repair ( ) an Ind•vi 1 Sewa AA% C7Disp al t S ys (� Ate- Street C. ii J as shown on the application for Disposal Works Construction Permit No�'___��_��'{i_ Dated_____j� _ .?._L_v_<. --•e -•---••-- ----.. -- ---- -........................................ Boi rd�of ealth ` DATE------------------•--- - .ICI FORM 1255 HOBBS & WARREN. INC., PUBLISHERS THE COMMONWEALTH OF MASSACHUSETTS , BOAR® OF HEALTH 0) _... -- ------------- OF........................... Appliration for Raposal Works ( onotrurtion Prrutit Application is hereby made for a Permit to Construct ( j or' Repair ( ) an Individual Sewage Disposal .�le System at, .--- ........ ....................... ....................................................................... _r Q �• :ation• dress e57 r c or� tpNo . 4�. .,......, .�1. 4�.71�Ja+^.t............. `�D .��, 3.%U .....:1 lllwi?�'..:a.......................... ...... owner Address a ............. .,` . ,. ..........: °c ... . .............. ►? s�. ........ .. ..........-•---•---..... Installer Address.. U Type of Building Size feet �-� Dwellings-No. of Bedrooms........ --...........................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures ................................. . W Design Flow...... ... ...........................gallons per person per day. Total daily flow...__.._..3oQ......:.................gallons. WSeptic Tank—Liquid capacity/APC)..gallons Length................ Width................- Diameter---------------- Depth................ x Disposal Trench—No ______________ Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit .................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water-___._---_-_-_-_---_-_-. �14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-----_______-___-_._._-. rx .-------•--•--------------------------------------------••--••--•--•-----------............................................................................. 0 Description of Soil...............5A9 .c............ileA&64....................................................................................... U •-------------------------------------•----•--•-------•--------•-----------•-•-----------------------------------------------------...------------------------------------------.-•-..: W U Nature of Repairs or Alterations—Answer when applicable................................................................................................ --- -----------------------------------------------------•---•- -•---- .......................................................... ---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitar Code—The undersigned fur her agrees not to place the system in operation until a Certificate of Compliance has en ' sued by the board f zealt Signed.. = ... ... . _7.................. Date ApplicationApproved By................................................................................................. ........................................ Date Application Disapproved for the following reasons-------------------------------------•-•------------•---•--•-.-•-------------•------------------------•-•-•..... .................•---------------•-•-----------•--------- Permit No. Date ��----L Issued----------------------------••--.................._..... • •............................. Date No.......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ----------- . .... .................... OF......................................................................................... Applivativa f1jr 15i.spasal Works Tonotrurtion Vamit Application is hereby. made for a Permit to Construct or Repair an Individual Sewage Disposal System at: -,44%-t............RZ --------.......... '4. .. .............................................. ............................................ Location-Address . or Lot No. Zk...........7t...... .1............ ....... Owner Aa&es-s '—S .................. ....... ...... f .......................4; ........... Installer ess Type of Building Size Lot.._ feet U ✓ Dwelling" -No. of Bedrooms.... .......................Expansion Attic Garbar Grinder ( ) Other-- Type of Building ............................ No. of persons............................ Showers Cafeteria ( ) PL4Other fixtures ...................................................................................................................................................... Design Flow..........-41--Z2. ..........................gallons per person per day. Total daily flow...........t2......__...-_.-_......___._gallons. 1:4 Septic Tank—Liquid capacity.1i..1",.gallons Length................ Width......._..._.... Diameter----------------- Depth............_.-. Disposal Trench—No. ................... Width....._..........._.. Total Length.................... Total leaching area....................sq. f t. 412 . Seepage Pit No..... ....:-Ziameter.................... Depth below inlet.._................. Total leaching area.................sq. f t. 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.--__---__-------_---._. f4 Test Pit No. 2................minutes per inch Depth of Test Pit...._............... Depth to ground water....................._.. P4 ..................:-............................................I.,............................................................. ............................. .0 Description of Soil. - ....................... .. /. ........................................................................................ ...... .... U ........................1.............................. .................................................................................................. W . . .........................................................................................................------------------------------------------------------------------------------------------ �31 . ... U Nature of Repairs or Alterations—Answer when applicable................................................................................................ ........................................................... ................................................................................................................................ Agreement: The undersigned agrees to ins-tall 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 131eh-,issued,by the board fhealth ...... .......Signed_... `W- - Date ApplicationApproved By................................................................................................... ........................................ Date Application Disapproved for the following reasons:................................................................................................................ ......................................................................................................................................................................................................... Date Permit No.------ K;:-J.. /- Issued........................................................ ---------------------------------- Date THE COMMONWEALTH OF MASSACHUSETTS. BOARD OF HEALTH .......... 0 F....... ..... .......I.. .......................................... Tertifirate of Toutpliattrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed O or Repaired by.............. .............. ............................ .................................................................................................. ........ ..............at................ ...........4�L . ---- ----• C--------- ... ........12n----�. .............................. has been installed in accordance.with the provisions of Article XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit No........;:g... ...................... dated---------/...;--,;------------------------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM. WILL FUNCTION SATISFACTORY. DATE---- -------- ............................................ Inspector. /e .... ........................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH , .............................. ...... ..OF........A . ....... ........t,-..4,4 e.-. ................... ............................ No ... ... ,..... ........ FEF ...... Permission is hereby granted------------------ ..........I-!................ ................................................................................ to.Construct (-,4) or Repair A'n'Individual Sewage Disposal System at' o....... ? - ;/ ........ .. W �.- .1", T<'- - -N ........................... ..... ....z...... ... .....................................�..!:.............. . ... ................................................... Street'! 'as shown on the application for Disposal Works Construction ;,Permit No Dated..... _":.` ................. �14..i; ----------—�4 DATE-,.- ............... ........... FORM 1255 46B13S & WAPREN INC., PUBLISHERS a-axg PT• �lAn SO IS r A-ra0 4Xro PT. 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