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HomeMy WebLinkAbout0009 SHERYLE'S WAY - Health 9 Sheryle's Way A= 046 —015—001 Marstons Millsif Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal Syitern Form-Not for voluntary Assessments Property Address o G V7 ON ner Ow ner's Name information is required for every /-57 page. Cdyfrown ✓�`�— State Zip Code Date of Ifispedtion Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Ming out form A. General Information Bing out forms �/# 1/32 on the computer, use only thetab 1. Inspector /s e" / key move your ✓ ` cursor- � 0r-do not �'f use the return key. Name of Inspector company Name WOE( Company Address Jim L�� — Y--,S 4�'"', 1411 UdY/Town State Zip Code ego- ��10 4�o�POL Telephone Number License Number B. Certification 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. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5"10C15.000). The system: Passes ❑ Conditionally Passes ❑ Fails ❑ Nee Further Evaluation by the Local Approving Authority InspecTtem Signature Date The s 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 DER The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only aescribes 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. t5ns•3f13 Tile 5 Official InspeefianFom.Submfacesew3gs—USPOsal System•Page 1of17 t D P Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface sp�Sewage Di ` al 9 System Form -Not for Voluntary Assessments Property Address /�/� Vat ouv ner / !G� �Pe So �/ information is Owner's Name / required Ais 7 r �✓lS /` page. City/Town State Zip- Code Date of 1 lion B. Certification (cottt.) Inspection Summary: Check A,B,C,D or E i always complete all of Section D A) System" ystem sses: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or.in 310 CM 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: f3) 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. Check the box for'y+es",."no"or"not determined"(Y,.N, ND) for the following statements. If"not determined,"please ex0ain. 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 t6t the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): tries•3M3 Tlge 50fficial lnspecfion F arm Substrface S"e Disposel Sys9m•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form 4 Not for Voluntary Assessments 9 aerL /ems Property Address Joe- Owner ON ner's Name �uvredforev G►�S�o�S S / 0o)6 w ld- � every page. Cityrrown State Zip Code Date of Insoection B. Certification (corn.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ 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 ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ 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 ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): 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 pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a mannerwhich 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 t5irs•3n3 Titles official Impection Fart[Subsuface Sewage Disposal System•Page 3017 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not ibr Voluntary Assessments 9 lkelles t.✓a Property Address P- C/ y Ow ner Ow nees Nameinforrriation is required for every 7",4is A f/lS page. C11yfrown State Zip Code Date of N pectin B. Certification (cont.) I 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. ❑ 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 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 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 ❑ 0<13ackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effl uent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ tatic 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 Sns-3H3 Title 5Official Inspection Fart[Subysvfaw SevMe Disposal System•Page 4of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface SmArage Disposal System Form -Not for Voluntary Assessments Property le-5 Address a7'�Ie.So�I Ow ner Ow nees Name r is requived for every a✓� �S ��� /�n D�6�� �a page. URrown State Zip Code Date of Ir;spe6tbn B. Certification (cost.) Yes No ❑ Required pumping more than 4 times in the last year NOT due to clogged or /obstructed pipe(s). Number of times pumped: ❑ ,U,/ 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. ❑ 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. ❑ Anyportion of a cesspool or privy is less than 100 fee po po p vy t 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.] ❑ he 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 CM 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 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ns•3M 3 Title5 Official Inspection Form SutsufaceSeuosget)isposal Sim•Pdge5oT17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 ��iev wG Property Address "/�j' �Ow ner Owners Name 1 es OV/ informadon is required for every G✓I '7-3 l "/" page. CRyfrown State Zip Code Date of th s tion C. Checklist Check if the following have been done. You must indicate°yes°or"no"as to each of the following: Yes No ❑ mping information was provided by the owner, occupant, or Board of Health ❑ re any of the system components pumped out in the previous two weeks? ❑ as 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 WA) El 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, Ian at the Board f p p o Health. Determined rm ned in the field (if an f❑ (' y o the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): �$ 1 � o (e ��-y13 Title5OfficiallmspectionForm S Disposal System-Page 6of17 Commonwealth of Massachusetts wiTitle 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Iall f 5 Address auner a I �l�2Sa✓� Om nei's Name information is required for every �c/S��I S f Oa 4 page. My/Town State Zip Code Date of&p&fion D. System Information Description: / /Soo //oH c c&I Number of current residents: a Does residence have a garbage grinder? ❑ Yes Er--No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes L�No information in this report.) Laundry system inspected? ❑ Yes Ill Seasonal use? ❑ Yes No Water meter readings, if available (last 2 years usage(gpd)): Detail: Sump pump? ❑ Y 0--90— Last date of occupancy: Me Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM R 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: 3 Time 5 officid Inspection Form Suburface Sewage Disposal System•Page 70f 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 9 Property Address a 62 0 CW trer ON oar's Name information's IFIr, requiredforevery page. CRyfrown State Zip Code Date of lnspeftn D. System Information (coat.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: ' // Source of information: / 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 Sy m: 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/Altemative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the VA system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins-.3113 We S Official Inspection F arm Subsurface Sevrage Disposal System-Page SO 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address ices o Cw ner Ow ner's Name ��99 informationlil-C,irS ti • � XrequiredforeveryJ page. Cdy/Town State Zip Code Date of h6peobon D. System Information (cunt.) Approximate age of all components, date installed(if�k own and source of information: 6 -- /moo PIS, f-ff 86 S3 Were sewage odors detected when arriving at the site? ❑ Yes ❑ No Building Sewer(locate on site plan): Depth below grade: _ feet Material of constructikP-VC ❑ cast iron ❑ 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): Depth below grade: feet 7en 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 Dimensions: Sludge depth: t5ns•3M3 TitleSgffiaal IrspeCtianFarm Subsirface Sewage Disposal System•Page 9017 I 1 ' Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form a Not for Voluntary Assessments UV ��f G Property Address 9 C54,�[, Owner Ale. I4iPSo kl inforrreWn is Ow nets Name J_ /j/f required for every G✓,f f //S /'/14 0007 page. Cdy/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance,from top of sludge to bottom of outlet tee or baffle Scum thickness / SC u ------------- Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? o eJL Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 41 crt. ees ! ►il 6 00.s c✓i 7�i , Grease Trap pocate 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 Mrs•3H3 TitleSOffidal IrepectonForm;Subsurface SewageDisposel S)wem•Page 10 of v Commonwealth of Massachusetts HMO Title 5 Official Inspection Form Subsurface Sewage Disposal System VVjForm -Not for Voluntary Assessments sk'ee s Property Address 6-la L-) Our ner Owners Name G• r2.S o 0 tion is requiredforev ery �S Al /PC V9' /c2 '> page. Citylrown State Zip Code Date of ns tion D. System Information (cost.) 7 Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, eHdence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: P Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in worldng 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 t'm•3h3 l V65orfidalIrs peCtian Farm SUb5tIf2C@ S9Vage DiSpOsa1 System-Page 11 d 17 i' F; i i Commonwealth of Massachusetts Title 5 Official cal Inspection Form Subsurface Sewage Disposal 7ey m Form Not for Voluntary Assessments 9 �J G Properly Address 67- Om ner Ow ner's Name PS p k7 inforrnation is 6 57 /'-'1 required for every 1111117s O` 7` page. tStylTown State Zip Code Date of Inspection D. System Information (cont.) 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.): /�/O So s /(/0 'z-pa,�s Pump Chamber(locate on site plan): Pumps in working order. ❑ Yes ❑ No" Alarms in working order. ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t61ns•3M 3 Title 5 official Inspeoficn Form SubsWace Sewage Disposal Sfsfem•Page 12 d 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal Sy m Form-Not for Voluntary Assessments S Property wa operty Address / Owner Gt�NIPlo information is Qw ner's Na me requIred for every a�� ✓� i�S 6�� �oL �j� page. City/TownState Zip Code Date of n D. Syste f rmation (cont.) Type. 6�11, S via ❑ leaching pits numb er ❑ leaching chambers number. ❑ leaching galleries number. ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number. ❑ innovativelaltemati%e system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): / C o yr�►� �1 ,,,� �`I� G'N so, 4 C-14 Cj C4t,7 . 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 tars•M3 rffle50fficial ImpecfionForm submiacesevrapeoisposel System•Page 13of 17 Commonwealth of Massachusetts Title 5 Official Inspection For Subsurface Sewage Disposal Syste o -Not for Voluntary Assessments////���� rY r 9 Ter R-o Add � ""op perty Address Ow ner / `�tes a hfornation is Ow nees Name requ'ved for every q,i�jo ✓II /a j page. C1lylfown '/f uo� State Zip Code Date of In pec n D. System Information (cont.) 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 Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t9rs•3M3 Title5officialirspeefien Form Subsurface Sewage DispeselS)GWM P89e14Of17 . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal Sys#e Form Not for Voluntary Assessments 9S �G Property Address I,/ G 7 IiI 12S o Vr Ow ner OW ner's Name required for every4"115 / page. Ctyy/Town State Zip Code Date of In tiection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where pu water supply enters the building. Check one of the boxes below.h and-sk etch in the area below ❑ drawing attached separately . Il � i 3 -?o2 —6 5 IX3 , C5 Mr.-3M 3 Title 50fficial Inspecdm Form Subsurface Sewage Disposal System.Page 15 d 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address �q Owner 4 1�ilf o ✓7 arformation is ner's Name 1 / required for every A/at✓fjrtl i lS N f�oc6�� /d 3 15 Page• i5i-frown State Zip Code Date of Inspection D. System Information (cost.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high 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 ❑ erved site(abutting property/observation hole within 150 feet of SAS) Checked with I I Board of Health-explain: S ens Ale ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe/ h y established the high ground water elevation: v11' /e �✓ ni r0 rt Before filing this Inspection Report, please see Report Completeness Checklist on next page. t9ns•3H3 Title 50ffid InspectcnForm SubsWace Sewage Disposal SYMM-Page 16 of 17 Commonweafth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments SY 60 �Q1 Roperty Address Ow rter Cw nees Name hf onrebon is requaedforevery Gt✓,Sj�or�s i/1 /� yd �� �v2 /S page. �yrrown State Zip Code Date of E. Report Completeness Checklist 2- Inspection Summary:A, B, C, D, or E checked a inspection Summary D(System Failure Criteria Applicable to All Systems)completed 5'Y rmation—Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file 15ie•3fl3 Tmesaft 11MP=dmFc=Suftowe sereaen;Wsd sysbm•woe 17e<17 ASSESSOR'S MAP NO. y�PARCEL 1,5- L� L0CAT10N es SEWAGE PERMIT NO. YILLAGE ill �/ 64 ( - 6 -&b[ INSTAL E 12 � N A M E IL ADDRESS C p d D dUIILDER OR OWN /R / DATE PERMIT ISSUED SAT E COMPLIANCE ISSUED 9 � , w �6 .l l No. ::: Flcs............... �. . THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ../�eV�c'h..... .....oF........ rn� bfrrr /Yl;�ls G - ApplirFation for Daspos�al Work, Tonstrortion run fit (� o Application is hereby maoljefor a Permit to Construct (L.-for Repair ( ) an Individual Sewage Disposal 0 y System at: Location-Add r ss or t No. .. :+ j.. :..,.1 _ �....., -c.r�� .......- .1.. t-�l�,�J� Qua ver..........._ W Owner Address �.p!.t. 8..s.C: .. •--•-------••-••--•-•••---•- ..._.._.. Installer Address UType of Building Size Lot_. Z -�......Sq. feet �--� Dwelling—No. of Bedrooms.............3.._._.__._.__._..___.___.Expansion Attic ( ) Garbage Grinder (/Vf 0 aOther—Type of Building ............................ No. of persons........4�............... Showers ( ) — Cafeteria ( ) Otherfixtures�.......................................................................................................................... W Design Flow.................. ................gallons per person per day. Total daily flow.__......._3 3.0....................gallons. P4 Se tic Tank—Liquid capacit/OPF.gallons Length/g!�_. Width....C__�_.. Diameter________________ De WG � rench—No.........�r__.._.. Width... 2° .._.. Total Len th_.1:�.�_____ s ft. x ''7 T g a.__ Total leaching area._.__�,_.... q. Seepage Pit No-_----------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box (/ir' Dosing tank ) Percolation Test Result t Performed b ---.._.. " __ �—��� �w^._._... Date._..__ '� a Y a 14 Test Pit No. 1.-_____________minutes per inch Depth of Test t.__-_______. th to ground water_._":---_....__. Lrq Test Pit No. 2................minutes per inch Depth of Test Pit.l.. . p� o ground water...... ._...... Pa' ......................................................... .--------••------------•-•...............•----•-•-••-•. � $ ................................................. 0 Description of Soil........ ....... -•••-••------- W . 1 ' ` . .5..�.1 hie -- -_---•----------•-----•-- -•-t=- -• ------ bA .. ..........;a --•------- - �L6 •^---"`-'NY_--CAP ...................................................... --•---.°...... .e:----------- U Nature of Repairs or Alterations—Answer when applicable_ J__. .. . .... ............. ............................ •---------------------••--•-•---•---------------....------......-••------••-•-•---_...: T R Agreement: y The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iI1`1E 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has Hissued e board health. _. ._� ----__•••. ••----------- -----•---•- ......_••••....._ .._ aApplication Approved By..-•----------• ------ ---- .----------- ................... _________---- xt ate Application Disapproved for the following reasons:------•-----------------------------•-------------------.....-----------------•------------------------...._. .....-•-•-------------------•-----------......-----------•-----......_..------------------•-•-------..._..._..•.--•----------------------•----------------------•--------------------------------------•- Date Permit No. -••••••••............. .2-.•••-----• Date Permit Date No......4..... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........... ...!%.0 eu l.---.........OF.........r;.' ? ?'r "4! '-£ .. --...... a=Y'.1`4" Appliration for Disposal Works Tonstrnrtinn ramit Application is hereby made for a Permit to Construct O or Repair ( ) an Individual Sewage Disposal System at: Location-Addr ss or t No. , - } . .....�. '... �... .,..CG�r ►^a e!i�� ± 1�!.......... �l! sp°'rla�t.�l.� �?�....Y' "Q ". Oe. 'E:1°........._- ..... Owner Address .:....................................... --.........-----...---------------•---------••---..........-------•---------------•-----.......... Installer Address UType of Building Size Lot._ f 0./......Sq. feet �-, Dwelling—No. of Bedrooms........................................Expansion Attic ( ) Garbage Grinder (A/)0 Other—Type T e of Building ......... No. of ersons...._...47................ Showers � YP g ------------------• P ( ) — Cafeteria ( ) dOther fixture�s, -••••--------------------••-••---------........•-----..-------------------••--•-•--•---•----------••....-----........---•------••-------..._•---_._... W Design Flow.................. p+'�_...._........._..gallons per person per day. Total daily flow...........: -. a_.�?_._.........._._..gallons. Chi Se tic Tank Liquid capacit}��+�'�®.gallons Length//!._.._.. "r 0... ��PP _ � Width_...«t_r_._. Diameter................ De th____.�_e_�.. l�.is9p6 IlTrench—No. ........4t....... Width..t�.b�..... Total Length../6_:..�?... Total leaching area.ZFA q, ft. �: . Seepage Pit No..................... Diameter.................... Depth below inlet_................. Total leaching area..................sq. ft. Z Other Distribution box (G. Dosing tank ( ) Percolation Test Results Performed by........ .. �....... Date.___... ..a.:_�.?__ ..... °' _... _. Test Pit No. I......-t.....minutes per inch Depth of Test At... ......... Depth to ground water....""'=......_ Test Pit No. 2................minutes per inch Depth of Test ground water___......................... --------------------------------------•-------.....•-•---•--..................... ..... . D Description of Soil---•-•. - •• ;' ' 3 ..--•...............•----....------. x it.si,._caGr,L-- T. ••••• ..... :,:, \ 1 (� --------------------------- ---------------------- ---------------- •---.......--------•-----3-- %I-`---- `�`^-�J-� ��:��------. ----- I:APMAA..._ � �1�� r'`4' .._..._.... U •� Nature of Repairs or Alterations—Answer when applicable......... ��Nn._7 ........ ..................... ..---•------•----....---•..................••-•-•------•--...:•...--•-•-----......_.._..._.................. .... -- .................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage isposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued y the board jA health. C `-.. ............. ................................ P•,_. Date Application Approved BY............... � -tace iti Application Disapproved for the following reasons----------------------------------------•----•---•-----------•--------------••--------•-••- •---•--------•--. .........-•---------------•------•-----------------...-•----...._-_.....-----•--.....--•----•-----------------------._...._....•-----••-------•-•-•-•-•-----•---•--------•--••---•--•----------...---.._ Date PermitNo.-----.....-•-'...........�3a ........... Issued-....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH . .........OF.......... + ............. Tn tifiratr of Tompliaurr THIS I TjO ��1jTFFU, That"the Individual Sewage Disposal System constructed ( ) or Repaired ( ) bye( # ---------------------------------------------------------------- ...................................... �•- Installer - P at - -- - -----�-�------- -- has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code descri ed in the application for Disposal Works Construction Permit No ___ j 2......... dated_...._- - --- _'�1/�`�.________-- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUAR NTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE...............................1..- '........................... Inspector........................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH - ff.0.........OF"...M. ..� ����......... ........ ..._. ... No . FEE. . .......... Dispsal Workiiinn rnr uan ernti# Permissionais hereby granted......1,)-1..(.., .... ---•-----------•-•----- •--•---••-••-•................................... to Construct t( ) or Repair. .,) n Indivldu ewa e Disposal Sys f�� at t^ * Street as shown on the application for Disposal Works Construction Permit st .. _ Dated._ ? _________ Board of Health ' DATE. --------- ...... ........ `* 1 ' FORM 1255 HO S & WARREN, INC.. PUBLISHERS ` .�r' Q. rel T. i // ' Y CNN No- 702 el ` M 3 i 3., f L 4r �•8C,-8�3� , z_ •Flew S�eT�c��s� SAC Sr L oS•3o Z Z dr - nl�ci x� �a I.00 Zv , o L S O• o -- — 4 M„ p,✓.G. s'c h • $o , �-�, �� .qc PY C C t S —T----- - _ 't (•r. ��. fox� �•�+—•---"' `y�� • „s. o o �' v tnv Jam' ti st G LLB y - i � s Q. 9A. ES ' !� d► i (L �- :�oo•c�c+ s rc' SAS �,�e.•v. \. , �C- CD , n G J3•S© P i �.\ InQ. 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