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0285 OST.-W.BARN. RD - Health
285��_per, W_. Marstons Mills '' -' ;.T A= 121-007-001 LOCATION SEWAGE PERMIT G0• 0a T-/ ©57 , 432 . z s / VILLAGE "AA S'7it9N S M iL C IRSTA LLER'S N A 0 E i ADDRESS G U I L D E R OR OWNER DA T E PERMIT ISSUED DATE C0M ►LIANCE ISSUED ,- Z� 2 Z& h a 3 �fk ' r j �fv No. A2 5�/j Fin...3 .......: X •�" g. THE COMMONWEALTH OF MASSACHUSETTS 1 BOAR® OF HEALTH % .. .............OF..I:-F` '/-�..--.. Appliratiun for Disposal Works Tonstrurtiun Errant ` Application is hereby made for a Permit to Construct (�or Repair ( ) an Individual Sewage Disposal System at: _....................... -•.....-------- --_.= •®. ../. . _..................._....__.._...... Location_Address or Lot qo. 00. 00 •-�................................ Own Address tf .............................. �r..,.111�... Of .rr`�'Glll . •Installer •• T of Building Address Type g Size Lot.,� Sq. feet Dwelling—No. of Bedrooms.._.....,..........................:...Expansion Attic ( ) Garbage Grinder Other—T e of Building ............... No. of persons_...._.__........_____..____ Showers ( ) — Cafeteria ( ) a' Other fixtures .......................•-••-•-...--------• .. Desi Flow-•-•-- P P P Y 3 -....................glo W gn . ............ gallons er erson er d Total daily flow_._.:.. WSeptic Tank—Liquid capacitx4k2Xgallons Length___'_.`__�_ Width. ._e. Diam eter________________ Depth_�S...__..... Disposal Trench—No.................... Width......._...__.... Total Length .. s ft. x - . -- gt .._..--•--•---._.._, Total leaching area--------------- --- q. Seepage Pit No...._./..._____.. D• meter_/C> ..__.__._ Depth below inlet.4e............. Total leaching area_ ,��..sq. ft. Z Other Distribution box (� Dosing tank ( ) '�' Percolation Test Results Performed by.. �,� ...�-�T'! ,1� � ,/�Z ---••--•-•--•__•-••- Date.__... a Test Pit No. 1 �___-_minutes per inch Depth of Test Pit..1' �,��. Depth to ground water.-__a!__ (� Test Pit No. 2.6.Z__minutes per inch Depth of Test Pit.t.�y y. Depth to ground water._n✓_ .�__..... a' -•P•-•....................... •-••----•••-_.... Description of Soil_ .---. ... ?.__..-c-•-•.1 ..._,gnpA. r.._l.._.�_.�/?�--S�C?�-- •---- ..................... "............................................................................-_....-- U Nature of Repairs or Alterations—Answer when applicable....................................................................._......................... ...-••-----•---•----••-----•-••-----••--•-•-•.............................•-•---•----•----------••-----......_....-----..._..----........_.._...........••.-•---•---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with -- a the provisions of TITAM 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Complianc een iss y the o th. geed �- - -----•---•••••---....... ••-•-_._.... �f J . to Application Approved By..... Date Application Disapproved f th follouring reasons:----------------------------------------••------..__._......--•--_-•------.....--- - -- -----__... --•...............•-•----•---•--•---...---....-----...-------•-•--•---•---•-----•-------•--•------------.------•-----...._....._.._..---------•-•-•...-------------..__........----------•--•-..__._..�. Date PermitNo........................................•........ Issued-..-•--•-----------D�-..._..---•--••-•-•----•-•-•-- r / THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH QLr/.J..............oF.. qi2 .. . ............................ Appliration for Disposal Works Tonotrttr#ion paean Application is hereby made for a Permit to Construct ((o)Olor Repair ( ) an Individual Sewage Disposal System at: Gl�- Location•Address - �- �No. ............6..............-............ o .ar[{ ..r?.�J.l.' ,�.�.p.................................. �C c�NIC9 4�j.q.0--r1... Owner Address a ...�Q...-....s�'�.E .. ............................•-•-• ... . •- /. ,�i`�lZ♦1.G ... .. Installer Address Type of Building Size Lot_-.1 ySq, feet Dwelling—No, of Bedrooms.........3.........................:...Expansion Attic ( ) Garbage Grinder ( ) aOther Other—Type of Building ............................ No. of persons......._.................... Showers ( ' ) — Cafeteria fixtures ................... W Design Flow.......�r 5............... ..gallons per person per day. Total dais,flow....... ....... ............gallo . W Septic Tank—Liquid capacityallons Len h.,e ..'...�. Width.�...�.. ep S� '• 4 gt Diameter................ D th ti.... x Disposal Trench—No..................... Width-................... Total Length.....................Total leaching area---.-----.----------sq. ft. Seepage Pit No.....-/.......... Diameter�/.C?......... Depth below inlet.4...:.......... Total leaching area.,�'� -.sq. ft. Z Other Distribution box (G-Y"O" Dosing tank ( ) Percolation Test Results Performed ------ ................. Date"�ZO' ,.a Test Pit No. 1..4 2..r.minutes per inch Depth of Test Pit._a/y�� .- Depth to ground water....11!�.._... (i Test Pit No. 2_.d-12-._minutes per inch Depth of Test Pit. _. __.' Depth to ground water... a' .... ... ..........••.-- ..........--•••--•-•...._.._....._.• .._._._.. .............._.......... O Description of Soil. / � }.ram 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 T IIL LE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliannc een;issu y the b2axyd of health. - gned. y p to n Application Approved BY - ... - ------------------------ Application Disapproved f th follounngreasons:...... Date •-..--------------- - ............... -...... ------------------------ ------ --------.----•----------------- ---------------------- ----------- -•------------- •------ --..--.......................... - Date PermitNo.................................................._.... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH CY,ri�J... Tntif iratr of Tompliaurr THIS IS TO CERTIFY, That the Individual ewage Disposal System constructed ( Repaired ( ) .,7�4 �..�....... � - b Installer has been installed in accordance with the provisions of TITLE r p f 5 of The State Sanitary ...of as escribec in the y application for Disposal Works Construction Permit No....... .................PP P .-- .......... dated..:... .. --- ---------•--------• THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A UARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.......................... �L , �/. ........................ Inspector.•-----•--•••••-. ..............--........ •- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH T,C�Gc�. ...........OF... itZ �� G.��' -----........ No... `. " FEE.S.A�..•.......... Disposal Works Tonstrnr#ion Prrutit � } Permission is hereby granted_. .. �s41....----.4•-: - ...........................:..•-....•--...•--....... to Construct ( Q.ef'Repair ( ) an Individual Sewage Disposal System at No...,/-,S>... e r ..�... ;,�� _ -- .. .... ...... ; `fin` •--- ._¢.s .... et as shown on the application for Disposal Works Construction Permit No. Dated...; ...............••---......-----------...----------------------•-----........----------................._ DATE.............................................. :_.....--•-= Board of Health --....---=- FORM 1259 HOBBS & WARREN. INC.. PUBLISHERS 1 4l �� N 0a 23 12 u Pn'18 Q�e ?cP.4ST.l?!E CCUKTT - ':'ll:VTElES Loe,7S MAP MAP 121 ILL-7 - Q611X-LEf1AL zo.l6 boa G� Q�G.sap rw gy'1 S', u Zo,2.1-7 Totems p� C 9 a _ 2 a g 200+z 3G g NT I a of -,,Aeo e T R-pV oC L.A.-co 1 Gc2TiFV TLLaT THIS PJ+�I 1N µes ��, P��nAzra= �LL BAQNSTABL— co.i�z,�:rY W�nl rue RwEs ALLD CPLVIdT IOn.15 OF THE Foe Qt�v5T�5 Oi- Da2.00. P.:. nR> CE.SA2 A M6hlD1=S K,1416 .. c A�;-�L d u•a Luc. QFy ISTeZEt� LALLD S.M S A5S'3. [�6GJ 3CAetLc PE-DU�.IIUG 8oG¢D . pPPR.0�/Al V�1DEQ TVE SVBaVIS�OJ �\ G OLLT¢oL 1.AW tbT 4E0JiRE0. �� o+�� 0-7 8K. Z133 M.89 -• • - 'T716o y ST z COMMOMEALTH OF MASSACHUSS EXECUTIVE OFFICE OF ENVIRONIKENTAL AFFAI DEPARTMENT OF ENVIRONME � NT AL PROTECTI_O_N REUE ED FEB 0 8 2005 TOWN OF BARNSTABLE OFFICIAL INSPECTION FORM 1 1,TTT L S HEALTH DEPT. RM—NOT FOR VOLUNTA SUBSURFACE SEWAGE RY ASSESSMENTS DISPOSAL SYSTEM FORM =^ PART A , CERTIFICATION s Property Address; ' US e vi/�C - �✓ (ti�„s�a�vle ,QGI ' Owners Name: Owner's Address: p i Date of Inspet ice. — _ °���� -ARCEL..., ICo-YlwA; Name of Inspector.( tease Rtfut) [ G' , Company Name: !if/ ,o L—C Marling Address: �g f t A Telephone Number. CERTIFICATION STATEMENT I certify that I have personally iced the sewage disposal below is hue,a�urate and complete as of the time of the' system at this address and that training and experience in the the information approved system i proper function and mamten moo MSpectioa was performed based Q reported n,Pector pursuant to Sec ' of TLtle S j310 CMR 5.00 _disposal site sewage systetn;am a DEP Passes Conditionally Passes Needs Further Evaluation by the Local APlxaving Authority Fails Inspector's Signature: Date: — 13 — COS The system inspector shall su OEP)within 30 t a COPY of this inspection report to the Approving gPd or f s of co Veti�a the� ion lf the system is a share em r has Authority(Board of Health or DEP,The on ' moor and the system owner shall submit the r design flow of 10,000 a ority. 1pnaL should be seat to the system owner and copies sent tott t buyer, applicable,gonal Orce of the d the approving Notes and Comments *"*'This re port Only describes condition,at the t' time,Thi'in,peedoa doe9 not addregg how the sy9tern will me of st and under the conditions of use at that conditions of use, perform in the future under the same or different Paine 2 of 11 OFFICIAL INSPECTION FORM S NOT FOR ypLUNT SUBSURFACE SEWAGE DISPOSAI,SYSTEM INSPECTION ASSESSMENTS PART A FARM Q r CERTIFICATION(continued) PrOWINY Address: U> 0-5 vl/lee, 1,,/ 8a I've S�4 Ovveer: a r v�6 S3 �� Date of bspectles: 1- 1-7- o Inspection Summary: Check A^C.,D or E/ ALWAD complete aU of Secdoa D A. System A39ey; I have not found any informltion which indicates that any .xisL Any failu of the failure Criteria described in 310 CUR 15.303 or is 310 t,14)R 1530a ere criteria�evaluated am below. Comments: B. System Conditionally Passes; —(L Qoe or more system cotnponetUs as described is t ��rep a red TU system, upon completion of the repJacenent m impair aS-11 al passe section need to f replaces l lx+u',as approved by the Board of Health,will pass. Answer yes,no or not determined MN,ND)in the explain, for the following statements.If"not det ermined"please The tic teak is metal and over 20 years old*or the or unsound,exhibits ti inf Mtkm or ead'iltration septic tank(whether metal.System not)is ;� crepi a with a complying septic tank as approved!bey nothe B� Heal,L will Pass in structurallyn if the will Pass inspection if it is Board of indicating that the tank is less than 20 years old is aav ale end, �g and if a Certificate of Compliance . ND explain: Observation of sewage backup or break out or hi obstructed piPe(s)or due to a broken,setded gh static water level in the distribution box doe to broken or approval of Board of Health): or uneven distribution box. System will pass inspection if(with broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain; The system required pumping more dmn'4 times a year Pass inspection.if(with approval of the Board of Nealtb,): Y due to broken or obstructer Pipe(s). The system will broken pipc(s)are replaced obstruction is removed ND explain; PoV3of11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A p CERTIFICATION(continued) Ps'oPergr Address: t s 0'S4 r✓i 14e �e S Owner. IG:r-- � Date of inspection: — o r C- Furthe EvWuattoa is&4ulred by theBoardofHealth;ALIConditions exist which require hirther Mal ultion is fWUn fto p �tk safety-or the the Board of Health in order to determine if the system L System will pans unless Hoard of Health determines in accordance with 310 CMR 13.30 1 system is eat- uvAiOJdng in a-manner which wilt{rreteet public heal th,sate aed )(bb)that.the _ Cesspool or privy is within 50 feet of a surface water — Cesspool or Privy is within 50 feet of a bordering vegetated we tland or a salt marsh Z• System will fail u01M the Board of Health(and Public Water Su bar it system is functioning in a manner that Protects the Public heal PA � any)determines that the health,safety and environment; The system has a septic tank and soil absorption system(SAS)and the SAS is within,too feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. — The system has a septic tank and SAS and the Sm is less than 1Qo feet but 50 feet or more from a Private water supply well**.Method used to &tance "This system passes if the well water y Ae bacteria and volatile or ate analysis, rfgrmcd at a DEP Gertifod laboratory,for colifgrm the Presence of ammonia metro �the well is.free ffosn pollution from that fac. . ty and failure criteria are triggered.A�PY of the analysis m gen is equal to or less than 5 Y must be attached to this f that no other 3, other. c P9e4of11 OFFICIAL INSPECTION FORM_NOT' FOR VOLUNTARY ASSESSME NTS SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continues gr l�ertY Address:- 02 . OS� //e l les ) P✓v pfvner: '/Girl �7o Diate of LtsPW_ ; D- System Failure Criteria applicable to all IYstems; Yea Mug indicate"Yes"or-no~to each of the fallowing for all inspections: Yes No/ Vv of sewage into facility or system component Dischar$e or ponding of effluent tO the sarface of due to overloaded or clogged SAS or cesspool SAS or cesspool ground or surface waters due to an overloaded Or Static liquid level in the distribution box alcove outlet invert due to aut overloaded or clogged SAS or 4md depth in cesspool is less than 6"below invert or available v l — pnunping more than 4 times in the lab e .o ume is less than���,flow f tunes pumped Y�NUT due to clogged or obstructed pipe(s).Number ArW Portion ofthi Ste►cesspool or pvvy is below high groin water elevation � pottion of cesspool or privy is within 100 feet of a surface water Supply or tributary to a surface ater PY. 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 — �portion of a cesspool or Private water supply well. Privy is less than 100 feet but greater than 50 feet from a supply well with no fable water quality analysis T� private water performed at a DII:P ce I system passes if the well water analysis, Indicates that the well is lahoratory,for coliform bacteria and volatile organic compounds ren and nitrate nit from pollution from that facility and the presence of ammonia are triggered.A copy of theeanal ig yssis must be ual W or t than S ppmi provided that no other failure criteria attached to this form,} (Yes/No)The system t4ft I have determined described in 310 that°ce or more of the above failure criteria exist as CIvlit 15.303,therefore the system fails.The Health to determine what will be necessary to correct the failW,e stem owner should contact the Board of E. Large Systems; To be considered a large system the system meat salve a facility with a design flow of 14 gpdL 000 gpd to 151t100 You must indicate either`Yes"or"no"to each of 0►e following; (The following criteria apply to large systems anition to the criteria above) Yes no — the system is within 400 feet of a surface ddnldng water supply the system is within 2(10 feet of a tdbutaty to a surface drinking water supply _ — system is located in a nitrogen sensitive area(Interim Wellhead proection Area-IWpA)or a mapped If you have answered"yes"to any+c}uestion in Section E the"Yes" in Section D above the large system hu failed. he ownereoC ape�ra considered a far e significant threat gnificant threat,or answered 15,304.The system�owner should contact or failed under Section D shall u ' g in considered a Pgrtde the system in accordanCe with 310 CNM pprolniate regional ofltcc of the Dep,artmCV1. page S of I I OFFICIAL,INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL, SYSTEM INS PECTION FORM PART B CHECKLIST Property Address: c�2 85 O.S7 ey vi//e — w d OJ erv,' � Owner. - Date of Inspection: 7-7- —oS Check if the followin have been done.You most indicate• es"or"no"as to each of thefollowin Yes �Ido Pumping information was provided by the owner,occupan%or Board of Hcalth _ W/ere any of the system components pumped out in the previous two weeks v— Has ae system received normal flouts.in the pious two weak period — = ' 1XI"olmnes of water-been uemduoed to the system r'00eeti3'or as part adshrs inspection ex as built plans of the system obtained and ��_�A: examned?(lftlaywerenot available note as N/A) _ _ the facility or dwelling inspected for signs of sewage back up Was the,site inspected for silos ofbreak out _/_ Were all system comMnents,excluding the&U,located on site L �.LWere the septic tank manholes uncover4 of the or tees,material of construction,dimensions,depth Oplened,and the mtenor of the tank inspmUd for the condition `/ iqWd depth of sludge and depth of scorn Was the facility owner ftm maintenance of m disposal q� a owner)provided with information on the proper mace sewage The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yesy1no m , Xastmg information For example,a plan at the Board of Health. Determined in the field(if any of the faihue criteria related to part C is at issue approximation is unacceptable)P 10 CMR 15.302(3)(b)] of distance 1 l?age 6 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: a os , ",// ,� �i� 1Lf ✓v,' e, �lA 001 `S'5 Date of Ingwxdon: ky-MENTIAL aW CONDITIONS N"*ff of bedrppms(dui 3 �/G H DESIGN flow �}'— Number of bedmon�s(actual): .� G ��� based on 310 CMR 15.203(for example: 1 l0 gpd x#of�ms): 3�p Number of cume<g n�idemts: / Dd:�ft reddemce Lave a garbs Is on a separate �lade(yesor no}:r�Q l:aturdry system insPocteda ory stem MD es°t m°):,� [�yq separw ,don r+eqi Seasonal U5e:(yes Water meter if SosnP °� a(last 2 years usage(UM), (yes or no):X Last due of vpang:=CH COMMERCIAUMUSTRIAL Type of establisLmer,t: Design flow(based on 310 CMR IS.203): Haws of design flow(��p�onVsgft et-7 Grease trap Present.(yes or no):— N��rial waste.�&u8.�present.(yes or no):_ W�waste charged to':be rite 5 system(yes of no):_ Lam date o, eadiuM�ailable• OTHER(describe); PnmPtng Records. GENERAL INFORMATION Source of infotmation: A e o/ Was as part of the inspection(yes.or no);If ycs,Volumie Pumped: �O x Reason for pumping _gallons—How was quantity Pumped deterngnea (T OFSePtk SYSTEM tank&M'bution box,soil absorption system Overflow cesspool privy ShIred system(yes or no)(if yes,attach previous Innovative/Alternative technology. gttacL a nnspeetion records;if any) o�t tg� system copy'of the current operation and maintenance contract(to be a copy of the DEp approval —Other(describe). Awe age of all compo installed(if known aqc[source of infonnation: Were sewage odors detectcd when arriving at the site (yes or no)�if � U P9070flI OFFICIAL INSPECTION FORM— SUBSURFACE SEWAGE DISP NOT FOR VOL OSAL,SYSTEM IJNTARy ASSESSMENTS PART INSPECTION FORM SYSTEMFORMATION(cominued) Property►Address � SYSTEM 8� Ile- Owner. , �G✓�h o ' /Tl- Od,o - &64J/Cf DAte ofInspoction; /- /_ O r BUILDING SEWER ao! Qn site pjan) Depth below made: Materialls of Distance from nstniction:—cast iron �4�P-VIYC- Pill _offerComments onwaterf y well or suction line: ( )' ( condition o joints,venting evidence of 1 �etc.): SEPTIC TANK C/ _pacate oa site plan) Depth below 9mde- Material of Other(wiliplain!f tank is ) —coac'ete---metal ���—p°ly�ylene certnii�) a!>e' Is age confirmed by a Certificate of Compliance(yes or no): S deptk a _(attach a copy of Distance from WP Of SCUM fc� �udge to bottom of outlet tee or bsfrle: from top of scum to 'i Dish from bottom of scum twoHow of outlet tee or ba81e: were dimensionsof det outlet baffle: as gents(°a Pimping recommendations,inlet e v�`ie- lated to outlet iavetr outlet tee or baple condition, �N �"► ,„ lI?1V ri� etc.): structural integrity.liquid levels i✓i o doµ GREASE TRAP: (locate on site plan) Depth below grade:Material _ (explain)of ceastrucaoa—concrete_1new_sbeiglass�lyeMy� Dimensions: --other Scum thicknejj; of scum to_ Distance from b4ottom two of outlet tee outlet t tee o____ . Date of last Pumping_— bottom of outlet toe or bade: Comments(on pumpgommendatio as related to outlet invert,evidence of leak inlet�and outlet tee or baflle conditioq � sty,liquid levels Vic' PS$F 8 of 11 • OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Pr""Addeess: � �f��v,/� �I ✓vr' .4 Od 6f j 0"ner: 70 Date o(Inspection: TIGHT or HOLDING TANK:N (.m be pumpedtime of'mspectionxlorate on site plan) Depth below grade: Material of construction concrete metal rP _polyethylene �(exltiain). Dimensions: tmLis Design Flow: Alarm present(yes or no): Alarm level:. Alarm in working order(yes or no): Date of last pumping: Comments(oonditiort of alarm and float switches,etc.): DISTRIBUTION BOX v(if pia joust be opened)(iocate on site Pin) Depth of liquid level above outlet invert: a ,L ' COmmeft(note if box is level and distribution to outlets leaks into or out box, ): col / anY evidence of solids carryover,any evidence of x o eve l(/0 PUMP CHAMBER,!/ (Ion on site plan) Runps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): CJ Page 9 of 11 OFFICIAL INSPECTION FORM_ SUBSURFACE SEWAGE DISPOS T FOR VOLU111TARY ASSESSMENTS AI•SYSTEM INSPECTION FORM SYSTEM PART C FORMATION(contim,4 P"PMV Addr+ew: C2 OS-,�r&-, Owner. �cz✓, h,o /� 0, 6�� Date etInspeC _ 3 oS SOIL ABSORP17ON SYSTEM(SAS): (locate on site Plan,excavation not required). If SAS not looted �Ix leaching , leaciting Vffaie%mmAxr — C eve-1.P leadtingfielc 8e4 number,length; cesSMOk number. Comments(note condition of Stem Til a of technology: etc): Q / � hydraulic failur level of Pon damp soil.Condition of vegetation, CESSPOOLS:��(Cesspoo]mast be pumper as pm Of inspe�tion)(lopte on site plan) Number and configuration: Depth-top of liquid to iNet:-- Depth of Aids layer. Depth of scum layer: Dimensions of cesspool: Materials of constmcfion Indication of g<+oundwMer i;#ow(yes or no):Comments(note condition of soil,signs of hydraulic fail ure,level of pon ft condition of vegetation,etc.): pRM':kpocate on site plan Materials of construcaom Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level ofpondin g,condition of vegetation,etc.): i IPame10 of 11 • OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(contimwM Property Address: 110s h✓✓i// (,/ — Owner: Date of Inspection:_ f—�?_or SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent refermOe landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. / - ' e' e.3- 3_3 PSG 11 Of 11 . r OFFICIAL INSPECTION FORM'NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE-DISPOSAL SYSTEM INSPECTION FORM PART C pp SYSTEM INFORMATION(wntim�od) parmperty Address owner: /�G►��r,o O� 6 s a matte of hupection: SIM UCAM sicnm Suafaoe water Check cellu Shallow wells ��/. Estimated depth to ground water a/ feet �O <o c� Please' (check)all methods used to determine the high ground water elevation: / Obtamod from system design Plans on record-If checked,date of design phn reviewed: gbserved site(abutting property/observation hole within 15o fees of SAS) Checked with local Board of lfealth-explain: ✓"i ,nS o Checked with local excavators,installers.(attach 8ocum umrt on) Accessed USGS database-explain: You must o' i ou es�shed the� water eta plg� %9� fx�o�✓ �w �1e , lOVlr Wo' ✓ J CA [�V1 C O/ G� of �f 0 f G► O� Q // 7o it 7-0 70 � • c9000 �1( `, 1 O�Cro S�S46-7 ,�5�� Il . i / � .J a� • i i �, :Q g �w. *v+!T �4 :•%' k me 111 F �'* +'« ✓e4' yt..,�..,tr'.?',pA,+ice": S '�` i s. ! ,[ �' {:.A 1_F i ...1. lit �'�; ,� `fit o r' 1 s r_4 { 1 .) 1k 1 - ti,• 4Y k _7` C µ•a! 'i i s>f was y .J :W. .. 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[„ .. �'` "I��• �e���� ��.�r .E �j-�� ,`"J..1 �` 9w. �.w`y+,�y�'tir. 3, 4-��'Nv:{ .. rf v. >'S+.c�pP.^:° � y k�L.''`�,�,r��'j/�/T y � l may.• ,•'. ' � ,. h� �. "��,�,,,:;. a.. _. .:;,. `_ .:,,�-�fti i!'" . • ' � r Z,`.. r.' - V� .r.•. "�'.�!!a,a � �"''ty •,^I���lA.�` a r'I'•17- :.+ r ,") / I� t. aascatier Type of Building Address Dwelling—No. of Bedrooms......_.,..............................Expansion Attic Size Lot-1- 4"OC�0-:4q. feet Other—Type of.Building ............................ No. of persons.................. Garbage Grinder Other fixtures ......... _....... Showers ( ) — Cafeteria DesignFlow.......5.-5........... ... .................................................................................................... ....:................gallons per person per Y. TOW daily flow........ ............. Septic Tank—Liquid capacitXA2&:kWlOnS Length. gall ........... ------- �4 Disposal Trench N ....... Width..4-2�?L Diameter.................Depth..,S_`21 ..........&....... Width_ •Total Length....................�Total leaching area-------------------sq. Seepage Pit No...... eter,/x2.......... Depth below iWet.j,-- 2� Other Distribution box ............. Total leaching ayea,�-,p - Percolation Test Results Dosing tank sq. ft. .4 Performed by.. 1.4 Test Pit No. ................. Date-4. .. I-04-Z—. .minutes per inch Depth of Test Pit--/61-05e . Depth to ground m Test Pit No. 2..,-e.- /�� -minutes per inch Depth of Test rater...... _,e.... .... Depth to gTound water.. 0 ............................ Description of So il. ------ .................................... .............. ......................... 6� r IL . ...................... U ................................................................ Answer when applicable...... ...... Nature Of Repairs or Alterations .......... ............... ................................... ......................................................................................... Agreement: .....................................a........................................................................................ The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisiong of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system mi operation until a Certificate of Complianc n iss ............... the gn 0 th. . ....... . ....... Application Approved B ..... ... . .... .............. te ...................... . ........................................... ..... Application Disapproved t 0110wing reasons: . Date ........................................................................................................................................................................................ . Permit No....-----.................-.». Date Issued..... ........» Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF. HEALTH ...............OF.. (4rMfirate at Ton't ft THIS IS TO CERTIFY, That t' V. mr he Individual'ual sal ........ 6vag6 Dispo . System constructed (44-OF Repaired ................. ....77----------------.................................................... has been instai Installer lle in accordance with the pro ............I............ application for Disposal Works provisions. TITLE .5-of The State Sanitar as ou rks Construction Permit , -.4, - scrl in the No......y....... y as .......... dated... ...01 ............................ NOT 6E CONSTRUED AS A UA AIM THE ISSUANCE OF THIS CERTIFICATE SHALL ARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE Inspector........ .................................................................. THE COMMONWEALTH OF MASSA CHUSETTS BOARD OF HEALTH ......7T2,(4LA-,Z1........... 4 ................. -Con-- FJ.................. foov, Permission is hereby granted..Z�A�. ....... to Construct ( 400fgepair A�. ...........t........ ............. an Individual Sewage Disposal System ....................... ....... ............ as shown on the application for Disposal Works Construct 1 4.2A. Dated... . ....... .... DATE..................... ............. ................................. .......................................................... Board of ......... ................... FORM 1255 HOSES a WARREN, INC., PUBLISHERS . t� - -. r__ . +. -i - _ _ ., - .-, __ -'_ -. • __.- =c.--�..-:.moo r.-f.�t- y- -a - ++o. _ ^ ` j` ! i r{.> �_� I j t,. - -..,:I: r! ,,;.•-}' r. �+, . + ' c.... r-''r+'vv_...,, ter•' ,I" 111 �" f. 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