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HomeMy WebLinkAbout0005 STAYSAIL CIRCLE - Health 5 Staysail'Circle Marstoiis°Mills -- - _ - -- �� ------ - A = "058 - 016 —001 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r: ' 11 STAYSAIL CIRCLE ' Property Address fir, COREY FREDERICKSON r ,, Owner Owner's Name information is ,� � required for every MARSTONS MILLS MA 02648 06/25/2018 page. City/Town State Zip Code Date of Inspection;_',, loh.,', 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. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not JOHN GRACI use the return Name of Inspector key. GRACI SEPTIC INSPECTIONS, LLC VQ Company Name PO BOX 2119 Company Address TEATICKET MA 02536 Cityrrown State Zip Code 508-641-6694 S1468 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 16.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ -Needs Further Evalu i n by the Local Approving Authority 06/25/20183 Inspector's Signature Date The system inspector shf!ua bmit a copy of this inspection report to the Approving Authority(Board of Health or DEP)withinysof completing this inspection. If the system is a shared system or has a design flow of 10,0gpd or greater, the inspector and the system owner shall submit the report to the appropriateonal office of the DEP. The original should be sent to the system owner and copies sent to the b , if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins-3/13 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 11 STAYSAIL CIRCLE Property Address COREY FREDERICKSON Owner Owners Name information is required for every MARSTONS MILLS MA 02648 06/25/2018 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: SYSTEM PASSES TITLE V INSPECTION SYSTEM APPEARS TO BE STRUCTUARLLY SOUND AND FUCTIONING PROPERLY AT TIME OF INSPECTION. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): NA l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts N 4 . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 11 STAYSAIL CIRCLE Property Address COREY FREDERICKSON Owner Owner's Name information is required for every MARSTONS MILLS MA 02648 06/25/2018 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ 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): NA ❑ 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): NA 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 manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �~ 11 STAYSAIL CIRCLE Property Address COREY FREDERICKSON Owner Owner's Name information is required for every MARSTONS MILLS MA 02648 06/25/2018 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ 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: NA 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 '/2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 11 STAYSAIL CIRCLE Property Address COREY FREDERICKSON Owner Owner's Name information is required for every MARSTONS MILLS MA 02648 06/25/2018 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: . ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well, ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments V•y�< 11 STAYSAIL CIRCLE Property Address COREY FREDERICKSON Owner Owner's Name information is required for every MARSTONS MILLS MA 02648 06/25/2018 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): ND t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts U Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments '< 11 STAYSAIL CIRCLE Property Address COREY FREDERICKSON Owner Owner's Name information is required for every MARSTONS MILLS MA 02648 06/25/2018 page. City/Town State Zip Code Date of Inspection D. System Information Description: 1000 GALLON SEPTIC TANK DISTRIBUTION BOX AND 2-500 GALLON LEACH CHAMBERS. Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ® Yes ❑ No Water meter readings, if available last 2 ears usage TOWN 9 ( Y 9 (gpd))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: OCCUPIED Date Commercial/Industrial Flow Conditions: Type of Establishment: NA Design flow(based on 310 CMR 15.203): NA Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): NA 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: NA t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r< 11 STAYSAIL CIRCLE Property Address COREY FREDERICKSON Owner Owner's Name information is required for every MARSTONS MILLS MA 02648 06/25/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): NA General Information Pumping Records: Source of information: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: NA gallons How was quantity pumped determined? NA Reason for pumping: NA 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)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): NA t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r' 11 STAYSAIL CIRCLE Property Address COREY FREDERICKSON Owner Owner's Name information is required for every MARSTONS MILLS MA 02648 06/25/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1991 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 20"feet Material of construction: ❑cast iron ®40 PVC 40 PVC ❑ other(explain): Distance from private water supply well or suction line: GREATER THAN 10+ FEET feet Comments(on condition of joints, venting, evidence of leakage, etc.): SEPTIC TANK IS FUNCTIONING PROPERLY AT TIME OF INSPECTION Septic Tank(locate on site plan): Depth below grade: 14"feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: NA years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 GALLON Sludge depth: 5" t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w a 11 STAYSAIL CIRCLE Property Address COREY FREDERICKSON Owner Owner's Name information is required for every MARSTONS MILLS MA 02648 06/25/2018 page. Cityrrown 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 29" Scum thickness 4" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? MEASURED Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): SEPTIC TANK APPEARS TO BE STRUCTUARLLY SOUND AND FUNCTIONING PROPERLYAT TIME OF INSPECTION . RECOMMEND PUMPING NOW AND EVERY 2-3 YEARS DEPENDING ON USAGE. Grease Trap(locate on site plan): Depth below grade: NA feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain): Dimensions: NA Scum thickness NA Distance from top of scum to top of outlet tee or baffle NA Distance from bottom of scum to bottom of outlet tee or baffle NA Date of last pumping: NA Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments . 11 STAYSAIL CIRCLE Property Address COREY FREDERICKSON Owner Owner's Name information is required for every MARSTONS MILLS MA 02648 06/25/2018 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): NA Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: NA Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): NA Dimensions: NA Capacity: NA gallons Design Flow: NA gallons per day Alarm present: ❑ Yes ❑ No Alarm level: NA Alarm in working order: ❑ Yes ❑ No Date of last pumping: NA Date Comments(condition of alarm and float switches, etc.): NA *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts d Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 11 STAYSAIL CIRCLE Property Address COREY FREDERICKSON Owner Owner's Name information is required for every MARSTONS MILLS MA 02648 06/25/2018 page. Cityfrown 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 BOTTOM OF PIPE 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.): DISTRIBUTION BOX APPEARS TO BE STRUCTURLLY SOUND AND FUNCTIONING PROPERLY AT TIME OF INSEPCTION. 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.): NA * If pumps or alarms are not in working order, system is a conditional pass. p Soil Absorption.System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: NA t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts m Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 11 STAYSAIL CIRCLE Property Address COREY FREDERICKSON Owner Owner's Name information is required for every MARSTONS MILLS MA 02648 06/25/2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: NA ® leaching chambers number: (2)TWO ❑ leaching galleries number: NA ❑ leaching trenches number, length: NA ❑ leaching fields number, dimensions: NA ❑ overflow cesspool number: NA ❑ innovative/alternative system Type/name of technology: NA Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 2-500 GALLON LEACH CHAMBERS WERE EMPTY AT TIME OF INSPECTION. NO VISABLE STAIN LINES AT TIME OF INSPECTION. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration NA Depth—top of liquid to inlet invert NA Depth of solids layer NA Depth of scum layer NA Dimensions of cesspool NA Materials of construction NA Indication of groundwater inflow ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r 11 STAYSAIL CIRCLE Property Address COREY FREDERICKSON Owner Owner's Name information is required for every MARSTONS MILLS MA 02648 06/25/2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): NA Privy(locate on site plan): Materials of construction: NA Dimensions NA Depth of solids NA Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 11 STAYSAIL CIRCLE Property Address COREY FREDERICKSON Owner Owner's Name information is required for every MARSTONS MILLS MA 02648 06/25/2018 page. Cityrrown State Zip Code Date of Inspection 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 public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately 01'Lyv�In�Y �y� I g 2 FP O 4 0 0 3 0 AL 2-Za 4(0$ .3- 25 4 545 4_ 274 t5ins•3/13 Title 5 Otlicial Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments •''< 11 STAYSAIL CIRCLE Property Address COREY FREDERICKSON Owner Owner's Name information is required for every MARSTONS MILLS MA 02648 06/25/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: GREATER THAN 10+ FEET feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: HAND AUGER Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments yr 11 STAYSAIL CIRCLE Property Address COREY FREDERICKSON Owner Owner's Name information is required for every MARSTONS MILLS MA 02648 06/25/2018 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 4 o TOWN OF BAR STABLE 16 L.; A ON PZ SE GE # %/ O�-OA ®4VILLAGEdsf;,; s ASSESSORT o7-�� 11 INSTALLER'S NAME & PHONE NO. J4ti 19 SEPTIC TANK CAPACITY /tea LEACHING FACILITY:(type) hoc' a-zl 1,u,z 1W (size) NO. OF BEDROOMS_B&MA JZOMLL OR PUBLIC WATER /'yL lel BUILDER OR OWNER a►+ Cam;,s DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No ti S� TOWN OF BAR STABLE 6 68 S 54rL,,sA pA L.:::ATION SEWAGE # 6 VILLAGEOS 0 0 ASSESSO' AP & LOT- /! INSTALLER'S NAME & PHONE NO. Vti /7, SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) 41:k JU NO. OF BEDROOMS_ LL OR PUBLIC WATER BUILDER OR OWNER A/ DATE PERMIT ISSUED: I� $ ✓' DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No 1 , U- S�` No.?Y�n.v 0 S. D 4 -1001 7T/6 Fim..../ " THE COMMONWEALTH OF MASSACHUSE S BOAR® OF HEALTH 1 ...'.......... ...................OF....... 4..r..�..J.?w.�i l-C...................................... G,91ED ow-Q Appliration for t to �t� irk C�a��t � tug Putt Application is hereby made for a Permit to Construct () ) or Repair ( ) an Individual- Sewage -Disposal ' System at: / D / .0 D f CO v G _ZS/ar If/ /C /y9+'J/�+ /�i//1 �IY OV 3 1989. .................................................................................................. ..................................•-------------------------------------.......................... Location.Address or Lot No. a n /f/Ie SLi9.r!.�..................•............... - - -•----------------------------------------•--...._.......................------ �� n Address ►Wa •........ .!.. .. ....•.......................... Installer Address 3 Sq. feet Type of Building Size Lot._ 0 .................._... Dwelling=No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) a'4 Other—T e of Building ............. No. of persons............................ Showers YP g -------------�- ---------------•--....P.... ( ) — Cafeteria ( ) Other fixtures ---------------•------•-•• ......----••...... W Design Flow...........................................gallons per person per day. Total daily flow------------- .. ................gallons. WSeptic Tank—Liquid capacity 'O?gallons Length.8_. . Diameter---------------- Depth• s`_'T" x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No-------L------------ Diameter. ..... Depth below inlet_. Total leaching area.Z.da.9....sq. ft. z Other Distribution box (X) Dosing tank ~" Percolation Test Results Performed by............ ... ............................................ Date...._`? !6/ - Test Pit No. I...... ---____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-_-_--___-____--_-_. r ------------------ ` / Description of Soil �_.3 -rc li .._S�6sQ- ------------------------------------------------- ----- x ------ . J ---------- - ---- r�Wi --•-------•-----------------••---•------�----Z---- -----,----------- <!/1.l!�t...:St_a-o—_------------------- ------ ..�4-e.o{/-�w-- /� q, a4Q 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 TITL% 5 of the State Sanitary Code— The undersigned f l:er agrees not to place the system in operation until a Certificate of Compliance h n i� b boapd of 1 �th. ........... ... --•-. 'U Application Approved BY....................................... -----•-�•--------•..................--=.............. �j �\ Date Application Disapproved for the following reasons________________ --------•---•-•--•••--------•-•-••-----•----•-•----------••-•---•-......•... ......-•-------- Date Permit No..... Issued.......... ............................. Date , it ASSESSORS MAP : 5g TEST HOLE. LOGS NOTES: t PARCEL: 1) THE INSTALLATION MUST BE IN SUBSTANTIAL COMPLIANCE WITH SOIL EVALUATOR- J.V {V1G✓ { -�7 C�I� THIS PLAN, 1995 MASSACHUSETTS TITLE V & TOWN OF �' a 3�00 1� L•E BOARD OF HEALTH REGULATIONS. Ro O FLOOD ZONE: NO�I (�{�Z t��it� WITNESS : '�.�-- (�J ]t� bp00 28 Cj9f Ao9 REFERENCE: pjY(� 15ul DATE: Upf 2) THE INSTALLER SHALL VERIFY THE LOCATION OF UTILITIES, os CaRt o r.�-� p � PERCOLATION RA E::_`- 2- nn►ry I✓tG¢{ SEWER INVERTS AND SEPTIC COMPONENTS PRIOR TO RY "`CIR C l r' q Gt'A-S5, --r S6I S C'T-)94-=0'7�VPd��—�.Y INSTALLATION. a �UK/v tt TH_ I EL: (0; Cl j TH_2 3) THIS PLAN SHALL BE USED FOR SEPTIC SYSTEM INSTALLATION � [,� 0F A'�U_ __6 _ �•- �l�OS�iGV� !N� � SANS DETERMIN� - AND IONHALL NOT BE USED FOR PROPERTY LINE S�►�� �� - 4) ALL PIPING TO BE 4" SCHEDULE 40 @ I/S "J FOOT. (UNLESS LOCAT I ON MAP P-T-S. ,, . `ow'% SPECIFIED QTHERWISE) 5) THE DESIGN OF THIS SYSTEM DOES NOT ALLOW FOR THE USE OF A GARBAGE DISPOSAL. N11�.Ojvm �P SJk-t�� 6) SEPTIC TANKS AND DISTRIBUTION BOXES (WHEN INSTALLED) C (` MUST BE PLACED ON A MECHANICALLY COMPACTED BASE OR ON A BASE OF 6"OF CRUSHED STONE. l.-A-t e PIT ID P,;E pump6.� (4vS4lep J w 07i�i,Ur ��-No Mowt1 rRa VA TE. W .-V7 w f 0) 1,r, of Rap. CPa c�r� SEPT I C: SYSTEM DESIGN G; 1�0 rVET BENCH MARK FLOW ESTIMATE .`� - GAS ftQ-ttsT� f3t,- E �D. or- F�A'LTlj �S TOP 0. GATE 2J BEDROOMS AT I(U GAL/DAY/BEDROOM - CAL/DAY _ELEVi\ i;u+4 i USGS DATUM ASSUMED `-- SEPTIC TA;;K r �j�j� G,iL/DAY x 2 DAYS - 0 GAL 66 S TA YSA IL / O� f 66 USE ( GALLON SEPTIC TANK- EWSTI NG� - ,JI°L�[E w/ !i 500 irQ:!ov) 92. / CIR CL IF I'�j t 6)9, o�A- cv 04 11 66 GAS14�1 SOIL A?St)RPTION SYSTEM UN>7�y�S[2E� ,l — 64 AT G E F p, _ o \�G w �1� off SlCES 4'S7�i�.� oivnS (ZS L x IZ��JX Z1D) �� :>;DE AREA: 25� +�lz��-fix 2 xS- Ex15TtN �P� 5�� �� BOTTOM AFEA: Z, x ( 2 x D���! 2 ZZ �o�' 6a1� GF I • --o 64 allN Q �< 4�N r 33o (�PU r� o/L� �o �m _ - SEPT I C �')YSTEM SECT I ON o 66 • Al z 70 13�{ c vies Ta O l t / r ty �� (p GT `IY J.s � Ya�1� 3G''�+tkX o/� / x Io. IhS�,I( I� EL- 65.C) o vvW ski e- �5 Ba�f(e>► �0(0.1�{ Ni O GAL �pS.7y �(Na�ar fcSt 3o D BOX / 6 9. L_l. = n = = �2. 3b SEPT I C TANK l Fa y 1,vge14esS S u r - E /S n�✓ - -! tk(e + z Da WOLSh e4 t he s.33i Z51 x 1 z 1w ---I - O T 2 Z;' ' - /l/ARE _ 1026 +- F0 •yI oN 7ESTH"d&C- "OFAfAS � S I TE AND SEWAGE PLAN 3 5� 70 N ," 7 E LOCATION : j /771- 561(. 6I1LO-GLa; . 1140 07,646 SgNITARN PREPARED FOR : N DARREN M. MEYER, R.S. SCALE:P:- l P.O. 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INOICAT£>S rNotcAT£8 SEPTIC TANK DETAIL. D o r, �a �, o } . . NOT To SALE • P£r+c. -y oeaaERVEo NO•T TO SCALE NOT TO SCALE -c4.,,'...1-..,./;.�",I.­.,Ie.-I4�,.J 1 " N . . ;­��/pr,­1l-�.-,.1­.1.'k.,.0.r.,. ,).0,.*,.'. I_? ".1-.. .I"-�!Ir i;i� JIfi II Ii I;I I: TEST' : OROUNOW�ITER NO. OF OUTLETS: �_ 21 " ! BROUGHT TOVFMi3H .GRADE LOAM 6 SEED ' T TANK ALL BE STEEL - ♦. INLET AND OUTLET TEES TO BE CAST rRON OR F-OR PA, - T I . . . NOTES:"1. SEP K S}l I -� REMIFORCEO CONCRETE. SCHEQ AO PVC. TEES TO BE CENTERED UNDER NOTES ---- �- ^' •- 0 51 rO 5D'a 2 SEPTIC .TANK TO WITHSTAND N•IO LOADING MANHOLE COVER r- -�- 1--- I. DIST. BOX TO WITHSTAND H-10 LOADING 2' MIN OF118' ! i GRO. EL. A2'­5._ • GRD. EL., .- ^ GRD. EL•--_.� GRD- EL. . UNLESS UNDER PAVE WENT, DRIVES OR•' UNLESS UwOER PAVEwEKT, DRIVES OR TO I/.`.• ' 1 r2"MIN FILL Gw. EL. __ P_ GW. EL. _r� _�___ ' GW' EL• ..N1�►___ GW. EL.: _ D` TRAVELED WAY9,WHEREIN H-20 LOADING I I I TRAVELED WAYS'.WHEREMI H•20 LOADING WASHED _ ' oRECnST SONF •,'- O Q I h ` Ai I SMALL-APPLY. I �' SHALL APPLY. __ - 10=90w rlr f I DI$T I _ ��r . «. 70r4a1 _' I.5 0(5 . . 5 �'S 3 ALL PIPE CONNECTIONS AND CONCRETE r.•uNoLc cov[R 5 ) BOY I 1 2. PROVIDE INLET TEE OR BAFFLE WHERE SLOPE OF PVC- INLET PIPE p r c, o c� c3 a . � ILLY CONSTRUCTION TO DIE WATERTIGHT. �Ro�arrT ?o rrr.rs•• •A•o[ I 1 INLET PIPE EXCEEDS 0.06 FT./FT. OR IN �' r ,� _ ` ! .? I "j Y 14 8601 I. r, C)ILTY (.� 1 L. i I _ , PUMPED SYlTEM. ,r,-1 `�J .�,. 4� . NOTE o o c� u' c� o a �� GENERAL NOTES. ? L- - -,--• --J �:. (i.'• a G/L 1-l.P i� r e LEACHING PIT TO . hU a47f L_ . 2• t> �i' y J��' _ 3. . R3T TWO FEET .OF PIPE OUT OF DIET •- +' ' ' WITHSTAND N-i0 LOADING . I THIS ,PLAN IS FOR DESIGN AND ,1'MIR FI 1. .,:, '��.rj Ci11P�ib I V I� rl f covcA 80X TO EIE LAID LEVEL. a a o cD cn .c� a n n UNLESS UNDER . . .__ __•_ _ ..J .. •^ �' • i" CONSTRUCTION' OF THE SEWAGE I C.L�Y 4-1. �.--- - g -_- .�_ ___ ....�. ~� T PLAN VIEW . . `�' ! PRECAST 4e PAVEMENT,DRIVE OR ► .W 3/4"TO I•1/2" o o 1c-j r D = ,L.-I cam G n ' TRAVELED WAY WHEREIN DISPOSAL FACILITY ONLY. I L Rf I H-20 LOADING SHALL A 1l ... • MOlEABLE- L ,4 't7ll ,� I. �, .., �,,,-. N T- .0 ►. "AL WATER LEVEL _ - . Y --1 - -- - .OVEit � '1 A . DOUBLE LEACHING PIT ,,, 2- ALL CONSTRUCTION METHODS AND M5. r _ . _ - _ - _ _ _ _ _ _ _ ~ '1. • ''RID -_r.. ,, `. W f••� STO ED o a r I c� rm =7 rm m a rp APPEY. MATERIALS SHALL CONFORM TO MASS. yt _�_ f ��, ` _ ,� - D.E.O:E TITLE 5 ANO LOCAL BOARD ' 1 1 1� PRCYV,u • • • ' Lk I , FAO IoM-0 GG . I wL[T �c[ i _f. wATERTIG►+T OF HEALTH REGUL ATIONS .0 V • r , -- ... _ I 1 JOIN"S(r ) ,� I. •i �, W ;.o o o c� r� r_7 c� �7 c� O Ef' '" r ` �j,, m � • "' I.• •'-o Y'M.-' 4OUTLET " ♦ 1 l , r[[ I , �.i ��' . 9 3 ALL P..IPES LO_CATED•UNDER PAVEMENT ►11QCA�t(� :, fi►TK + i. f 1r0�►r0 o[►1NT[[ ♦' INLET ' �T[ j �.• ` �T�T .� , r 1 j , Y.o 0 o O r-] c t� .C7 C] II ' �, OR TRAVELED WAY SMALL BE (J 4, 1 .ji r oQ e - SCHEDULE 40 OR EQUAL. r• 1 1 ,• I. .. . • I z I�} 1 5 .;, N L- 1A 0 J __ __ ��• _ , t. - _ . - - - - - - - ... _ _ - -. --- I - - I L_' •L - - ► �_wTTbA ON _•_ , . . �� D1A. � ... • _ ,,..i , �p► N Alftt SOT TOY OM l[VEl 1TA�L[ (1•l[ .J.w., _ LEVEL STABIJE r , . . J _ o BILSE I I T f ION Y C kOS S SZ C , CROSS-SECTION VIEW _ . Pl,At+f VIEW _ "O55-SECTION 6 1" j,o �),'IT (-- . wD k ' � ;. 0C 0 .T1 V-- I . NO LJkfF,pf CONSTRUCTION NOTES 1L a 5 lf a :. 1� 311• o IZ �jp.v _ ) V ATt�.JNS. I"�� ;. . 3 f ^; OItTE: SATE: DATE: DATE: ' LC ( VATIOi vS: INVET ELEVATIONS. LOT iNVF�T ELEVAT1Of�S. �' INVERT EL ,, 1�,g I; . S A 14 a� 9 �� es INVERT EL.EVATIC�NS. r _ INVERT ESE �' �_ � t k'�. 55 5 INVERT AT BUILDING I---;- I . >� TEST BY: TEST BY:•'.. TEST BY. T ST BY: . - n Ar-' � '�•ei'''I� ------ tLDING +.-• INVERT AT BUILDING �'--• IttiVERT AT BU{LOING INVERT AT BUILDING _____,�_ 4�i-• G5 �IAA�. Pc _�N� Ass Eel . INVERT AT BU S, 4 ;Iq 1• 15 ` i7- I INVERT AT SEPTIC TANK(in) T 'A7 SEPTIC 7ANK(in) INVERT AT SEPTIC 7JlNK(in) INVERT AT SEPTIC TANK(in) .. � 4-0 ���►� D I� �/' WITNESSED 8Y: WITNESSED BY: WITNESSED BY: • WITNESSED Y: INVERT AT•SEPTIC TANK(in) Il INVER ,� '� ` ,440. Flo INVERT A7 SEPTIC TANK(out) f 1 (� .1� p,� �1t,J ►J(.- • E a n j ' 39.90 AT SEPTIC TANK(out) '� , If INVERT AT SEPTIC TANK(out) - INVERT'AT SEPTIC TANK(out) -Sr _r . J -_-_ .-170_ J-_ _.j_._L -j....__. _- .�Il.JL _ -^' INVERT AT SEPTIC TANK(out) - INVERT ___ r .ao � •80.'..' {NVERT AT DIST. BOX{in) C � H I &A I PER�ATE: PERC. RATE: PERC. RATE:' PERG. RATE: . �. , - ,�.� D RT AT. DIST. BOX(in) 4 �- � INVERT AT DIST. BOXGn) ` ' INVERT AT DIST. BOX(in) f_ • I MIN./M1C ____MIN./INCH __ �.�IMl:/INCH MIAI:/MlCH MVERT AT DIST. BOX(In) _ INVE . . - . 4-1> ( A4,.,,Ip �,6f INVERT AT DIST._BOX(out) . - 41 - �`0 INVERT AT DIST. BOX(out) --=- INVF-RT AT DIST. BOX(out) ' INVERT AT DIST. BOX(out) -- ' , ___._ ____ _ _-_ -__ -_,__ I .INVERT AT DIST. BOX(out) - c t- . 5a A LEACHING ' PIT ' '� ' 1NVER'F AT LEACHING' PIT INVERT AT LEACWING PIT _ ¢4 Od �i9�Jo INVERT AT LEACHING PIT IhVhRT T INVERT AT LEACHING PIT- . So . .. .. s�-3,0o •2 .01J BOTTOIv! OF LEACHING PIT O.OD F LEACHING PIT . . BOTTOM OE, LEACHING PIT I . DATUM. F 'ILEACHING P]T' • :. •' _ . �(c,0� • BOTTOM . OF LEACHING PIT 60TTdAR 0 . f . HOT'FDM 0 U .S.G -S.� MAXIMUM GROUND ' n . . ; UM GROUNI? U.S.G.S, MAXII�+tUl4I GROUND : _ U:S G.'S: MAXIi+AtaM GROUND• , �/� Y'� �✓ � . . . U . G.S:- MA GROUND G.S, MAXIM U.S WATER, ELEVATION . � , .. . C.�''� WATER ELEVATfON - VERTICAL DATUM: . WATER ELEVATION WATER ELEVAT3ON' ._.._.._. , ION, ' .__;____ ' . OBSERVE D . •GROUNDWATER ; . -WATER .ELEWAT A A4, or�� MII4ti . ". . . . , . . , . . . . . . . G UNDWATER -OBSER1rEIr? G# OUNDWATER „ ; " /'� L r . B ERVED GROUNDWATER OBSERVED RO . .. . . NDWATER O S C/ ) . ELEVATIO'N . . OBSERVED ' 4�i�R U `� BENCH MARK. : . ELE�/AT,IflN E USED �� VAT30N .- . I `6 -- E L E -.-..- �----- . ELEVATIO . N ., . '' '� . __.______ • AT{ N . . .. LE V 0 E I .. --. _ , , . . . • . . . . . r . ' . . . - . . . . .. .. .. -P • • - . . - - . �'. .. f -- , . .. '9, . N \Y . R T . E VA T V \/ t . . VE E�. T P T P T : - P 1 '`� 5 . P �.. . T - . , .. � _ Erg Q�1E3 a INVEST ' GRD. El.. .GRD. EL.:...�_ G , .Et, - �1• 15 ' I GW:-EL. . . Gw. El. QW. EL. - INVERT`AT-SEEPTIC- TANK(in) - .. . . . . --Gw E�.. " . • . J a14 � M� 5+t - f,� o c L- . . l.•90 ' . i I +- PTIC. TAN•K(out) . AT E I . ..Il�t VER S r, 5 . T140(L". til . INVEAT .AT DIST.'BOX60 . fir- =�°- . 1' ♦ INVERT A''r D=3T. BOX(out) ---- . . . 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I : - I . .1 , - I . 7L, : 't � , : , , ...q I 1. � I I 'll I*. I I . I , I . I . . I I I � I . .1 . I � . � ': - I 11 . . I I I . I . ,., I . . . - � . � 1, " . : I I It-I I I � I . I I I I � I � I I -A I . � I . - � . , . .�.� 'I', � , , i I I I I I l. .." , . I . . . . j : t ',4 ' � I. - . I . . I � _. I I r .1 . . '' I I , I . . . , - I I � . , , I. - ,� I , � , , I I � 4. THIS TOPOGRAPIHIC SUR�EY WAS MADE ON ThE GRGUNL) ON AND BETWEEN JUML 19,1987 ---,.--. I I . . if - , - 1. I . - � ,:. .., , I I � I � 11 , , , - I I , �, , � I . I I I , I . . . .1 I t, " ., .; ,I* P, , - I . � Q . Z. I I . . . . I. , 1. .I . . I 1. V,��i::;,,,,, ,�.,r .i ­. I I 1 . 1� I I 1, I � :* , I � .I . I� . � I I I . . ., , , I ,, , I., . I I . Ja I I - �l I � ." , � . 1 ., i '' .. . �AND XNE 30,1987, .. I .- � - . k". 1, I - : I I . '.. I I . . I � ­ I . . _1� . I f*".! .! I�\ I I ": .". .- I . �­ . I �. , � 11 . :... � , ­1 �"'" � . I . � , , � . � I I - 0 . I . 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I I , , � r ,, ,, , , I : , .,,��,�-.. . �l . ; �,- . � _ . i. � � I � � I I I . .I I �I I� .t � 1. ti. " I .. ,- . . . r � . � � I I I I - . ­ ­1 1­1 _____ ,,.- - � - ....,-.-----.------."�--�.--"--.-.-,�I-_ ­--1.1__­_­--,--______---------I�-� -11 .I 11------­­-1 I I I . I . I � 1, �1, ,., , , � I . . , � I I . I , -` 11 1�e I-----___­-1-: I � . � __­­ ____ _____'_ _____ I____-1 --------- __ ­-- -11 I - ____-, __________ --,__ __ ,__ ,__ --,---- __ __ �,_,____________-�--� - -- � -___ I I-__ --_____� --­__ I______ I__ _­-------- _____ - ___�_______,________________ , i , , ___7­­`­­--­'-­ —7-7 —_— - 1_� _________________-----------,- ______________.__ -____,_________ ____ _ . e No......................... FEs.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..... .... - ................OF....... c'i•'t?.. -- 2.1Z �...... Appliration for Disposal Works Tonstrurtion Prrutit Application is.hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal System at: / ....................••.....-••--••...........__................................................... ...--•--•-•-•-••----.......•••-••••--•••-•--•--•----•---••----...•--•-•......•...............•.._. Location-Address or Lot No. -----------Jo A n /...c ShV ,-+- .................................... ................................•-------.. Owner Address W Installer Address d Type of Building Size Lot. -------Sq. feet Dwelling—No. of Bedrooms............... .........................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures -----------•-------------------• - W Design Flow.................... :� _,..___.__gallons per person per day. Total daily flow.._...._._._. '. ..o_..___.____._._gallons. WSeptic Tank—Liquid'capacity!.'a.pgallons Length ". Widthy../r> Diameter................ Depth.$ ._7 x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... DiameterZ . _.. ..... Depth below inlet__ __..�... Total leaching area.Z.......el....sq. ft. Z Other Distribution box (X) Dosing tank ( `" Percolation Test Results Performed b �_..�_C............................................. Date------ %� __ `` ...... Test Pit No. 1.....Z.......minutes per inch Depth of Test Pit-__l'` y Depth to ground water-----�,��__- rX4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ------------------- ` 'T----------------------------•-•-•-----•••.....------------•---......................................................... 0 Description of Soil........! 2 ' 5�//-"..S�Gs u, / ,•---------- --- --•-- ------------------------------------------------------------------------- . .................................-............................................... ..�,v L/W.. -eti z - / z ' 3 — W .........................................../ /a ......._.................� /.!v_�..._......�l.--____________----_____-----.-•--_____. lJ__f.(_ye. _. x r f!n 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 TITLi, 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance h en i sua bv the board of health. . -------------• _ /-------------------------'-------------...---- D to Application Approved B ....................................... G-------------•--........-•---=_-................. ----// r �" Date Application Disapproved for the following reasons-----------------------------------------•--•-----------------.....-•-----•---------•-•----......--•---........-- / - Date PermitNo......................................................... Issued......... ................................. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF.... l� . ..'VC-�..�.. ��...................... Tertifiratt of Toutpliattrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (�r ) or Repaired ( ) Installer has been installed in accordance with the provisions of T-1 '7 el 5 of The State Sanitary Code as d cribed in the application for Disposal Works Construction Permit No.__..1_6.*.....a?_C2_b--------- dated...../_/_ _e� 2.`................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CON UED AS A GUARANTEE THAT THE SYSTEM Wl"N ION�TISFACTORY. ._. ::. _. ....-~ ...............•-------••... Inspector----- DATEa a , THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ?... ....?.. ........OF..... ' -=.._/1 C N .... ---•---•------•.... FEE.._.._....:- ....... Disposal Vor Tonstrudiott Wrmit Permission is hereby granted........... ----............. ------------------------------------------------------------•--------...-----------------•--- to Construct ( or Repair ( ) an Individual Sewa e Disposal System at No......... -......L-_.. .t1�'-----•-_-- _= e�ar ......... .7_1 - ----------.......................................... Street as shown on the application for Disposal Works Construction Permit N�� 66( ' Dated.L!J-'!:)/�`�..................... --•-•-------------------•. ,n- --------•- �/ Board of Health DATE............... . ...... ............................................... FORM 1255 HOBBS & WARREN. INC., PUBLISHERS '�