HomeMy WebLinkAbout0045 WATERSHED WAY - Health 45 Watershed
Marstons Mills
A= 059-009-001
I
�t47�TER= '
7-A/AT 7XAC—
.5.�/O!-r/�t/y,�.r2,EGLt/CGt�s•/pL YS {.�ir�,' �q�..,� � N c.,,� ' pA7� .
��pU/.�E�N�'•.t/Ts O.� TiY.F 727wi1/4� �.0 Ait! .��.�"'�—��it/C�
•Coc 4 i-, � �y�r�//N 7y� �,"loar�PL.a/ , ��1✓ ,� p
Ga4RA
TB 39dd A3-lNb1S TTbb-bEE-TSL-T 9T :50 9TOZ/ZZ/9T
No.
Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
application for Dioont 6pgtem (fowaructiott permit
Application for a Permit to Construct`( ) Repair( ) Upgrade( ) Abandon( ) El Complete System J,❑Individual Components
Location Address or Lot No. T 5— // 4A-,aA(e,® C� Owner's Name,Address,and Tel.No./�e t)
lllf
4k�617s A/11 s �s- �.v�.�� �v
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No -�/31 Designer's Name,Address and Tel.No.
oQ�, al elaa—la?s
Type of Building:
Dwelling No.of Bedrooms / Lot Size sq. ft. Garbage Grinder ( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures /
Design Flow(min.required) 7 yb gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank �( �,l�r, Type of S.A.S. ✓��
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) o
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 o the Envir ental Code and not to place the system in operation until a Certificate of
Compliance has been issued by th' oar of Hea ,Ag
Sig m 4 o Date AQ f''
Application Approved byX2t�l T�
40 Date
Application Disapproved by: Date
for the following reasons
Permit No. Date Issued
No.
Fee V
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: �I
PUBLIC ,HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
Rp Yicaltion for Woogal *pgtem Congtructiou Permit a
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) 0 Complete System ❑Individual Components
1
Location Address or Lot No. 04� Owner's Name,Addressr and Tel.No.keW 671�y#-
/Lt�,e���s . • ils �s 4�'�'� tc1.�y
Assessor's Map/Parcel fl—
Installer's Name,Address,and Tel.No.SCIr6�M Designer's Name,Address and Tel.No.
R, oge-f P R�. Co�� �06 -yaa-1a95
Type of Building:
Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder ( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) 7 �/U gpd Design flow provided gpd
u
Plan Date Number of sheets Revision Date
` Title
�Si e of Septic Tank 16)Ct> Type of S.A.S. /j
Description of Soil t .;
i
I
Nature of Repairs r l o Alterations Answer when applicable) ,
4 p ( PP )
i
Date last inspected'
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 o the Envir ental Code and not to place the system in operation until a Certificate of
Compliance has been issued by th oar of Hea
Sigy Date I
Application Approved by Date
Application Disapproved by: Date
for the following reasons
Permit No. Date Issued
r
THE COMMONWEALTH OF MASSACHUSETTS
BAR
NSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( Y Upgraded ( )
4�
-oxv
at has been constructe 'n ordance
with the provisions of Title 5 and the for Disposal Syst m Construction Permit No.
dated
i
Installer Designer
ILI
#bedrooms Approved design flow gpd
The issuance of this pe it shall not be construed as a guarantee that the system willLuncoWs�designedDate ) Inspector �t e�
-- ————— --------- ------- -- — --_---_
No " _; . Fee
E COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Digogal *pgtem Cougtructiou Permit
Permission is hereby gr ted o Co s ( Repair OR r�d Xb a�M-
System located at
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty
to comply with Title S and the following local provisions or special conditions.
Provided: Const do must be completed within three years of the date of this jet.
Date Approved by
ommonwealth of Massachusetts
} ' 'y Title 5 Official Ins ection Form
�+ P
M Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
45 Watershed Wy.
Property Address
Kenneth Silva j
Owner Owner's Name
information is required for Marstons Mills ma. 02648 4/21/09
every page. CitytTown State Zip Code Date of Inspection
D. System Information (cunt.)
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
ac
^ar
«.,
II
t5ms•09/08 Tide 5 Official Inspection form:Subsurface Sewage Disposal System•Page 15 of 17
i.
,r�
MTitle 5 Officialr
Subsurface'Sewage Disposal System Form o Not for Voluntary Assessments
K
45 Watershed Wy.
Property Address
Kenneth Silva
Owner et's flame
information is repaired for Marstons Mills ma. 02648 4121109
every page. Cityfrown State Zip Code Date of Inspection
Inspection reseals must be submitted on this form.Inspection forms may not be altered in any
way.please see completeness checklist at the end of the farm.
Wporillin A. General Information
forms fitting out
forms the / n
computer,use 1. Inspector:
only the tab trey
to move year soott Campbell
cursor-do not flame of Inspector
use the return
key. Cardinal Construction
Company flame
32 Ridgetop Rd.
Company Address
Same ma 026fA .'�
Cityrrown State Zip CIEF0 --
Cotuit 508 4201295 s1388
Telephone Number License Number
W
4
B. Certification N
l certify that l have personally inspected the sewage disposal system at this address and thatie t—
information reported below is true, accurate and complete as of the time of the inspection. TMJ�Spation
was performed based on my training and experience in the proper function and maintenance Yon site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000),The system.
Passes [ Conditionally basses C1 Fails
�( ble4FUervaluation by the Local Approving Authority
I(/"P— /./,/. 4f21t09
Inspe Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or CEP)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®EIS. The original should be sent to the system owner
and copies sent to the buyer,if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future pander
the safe or different conditions of use..
t5ins•09M Title 5 Oficko Insp
ection Form,SubwFece Sewage Daspossf System•page I d 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
45 Watershed Wy.
Property Address
Kenneth Silva
Owner Owner's Name
rinformation is equired for Marstons Mills ma. 02648 4/21/09
every page. Citymown 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:
1 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:
8) 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.
El Y [I N [] ND(Explain below)-
t5ins-09= Tittes 5 Offidal inspect m Form Subsurface Smage UisposW System-Pap 2 of 17
----------- --------
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
45 Watershed Wy.
Property Address
Kenneth Silva
Owner Ownees Name
information is
required for Marstons Mills ma. 02648 4/21/09
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
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):
D-box will be replaced on 4/22/09
❑ 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 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-MM Title 5 official Inspectlon Form:Subsurface Sewage Dispose!System-Page 3 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
45 Watershed Wy.
Property Address
Kenneth Silva
Owner Owner's Name
information is wired for Marstons Mills ma. 02648 4121/09
every page. Cityrrown 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 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
Cl ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ❑ Liquid depth in cesspool is less than 6"below invert or available volume is less
than %day flow
t5ins•09/0S Tide 5 Officn31 tnspeaxion Fottn:Subsurface Sava®s Disposal System•Pege 4 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
45 Watershed Wy.
Property Address
Kenneth Silva
Owner Owner's Name
information is required for Marstons Mills ma. 02648 4/21/09
every page. Cityfrown State Zip Code Date of Inspection
B. Certification (cunt,)
Yes No
❑ 0 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.
❑ ED 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 forma
❑ ® 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 11 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•0901 rifle 5 Official in
spection Form;Subsurface Sewage disposal Systern•Page 5 or 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
45 Watershed Wy.
Property Address
Kenneth Silva
Owner Owner's Name
information is required for Marstons Mills ma. 02648 412V09
every page. Citylrown 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 NIA)
® ❑ 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.
® Ej 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): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440
t5ins-09M Idle 5 Official Insp
ection form:Subsurface Sewage bisposa!System-Page 6 of 17
Commonwealth of Massachusetts
lugTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
45 Watershed Wy.
Property Address
Kenneth Silva
Owner Owners Name
information is required for Marstons Mills ma. 02648 4/21/09
every page. CitylTown state Zip Code Date of Inspection
D. System Information
Description:
1000 Gal. Tank db-3 1000 Gal. Leach Pit
Number of current residents: 1
Does residence have a garbage grinder? ❑ Yes No
Is laundr
y on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ❑ No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Currently 4/21/09
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft.,etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes 0 No
Water meter readings, if available:
t5ins•09= TItle 5 Offidal tnspeCtim Form:Subsurface Sewage Orsposal System-Page 7 of 17
CommonweaM of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
45 Watershed Wy.
Property Address
Kenneth Silva
Owner Owner's Name
information is requited for Marstons Mills ma. 02648 4121/09
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Currently occupied 4/21/09
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 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/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 I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
I
ems'09M Title 5 official In
spection Form:Subsurface Sewage Disposal System-Pam 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
45 Watershed Wy.
Property Address
Kenneth Silva
Owner (Miner's Name
information is required for Marstons Mills ma. 02648 4/21109
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components,date installed(if known)and source of information:
8/14/89 Asbuilt town of bamstable B.O.H.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: feet
Material of construction:
❑cast iron ❑40 PVC ❑other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade: 8"feet
Material of construction:
®concrete ❑ metal ❑fiberglass ❑polyethylene ❑other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
Sludge depth:
t5ins OM rifle 5Offdat In spection Fomt:Sfibsutfaoe Sewage Disposal System•Pege 9 of 17
Commonwealth of Massachusetts
Tile 5 Official Inspection Fora
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
45 Watershed Wy.
Property Address
Kenneth Silva
Owner Owner's Name
information is required for Marstons Mills ma. 02648 4/21/09
every page. Citylrown State Zip Code Date of Inspection
D. System Information (cone.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle no scum layer
Scum thickness 0
Distance from top of scum to top of outlet tee or baffle n1a
Distance from bottom of scum to bottom of outlet tee or baffle n/a
How were dimensions determined? Visual Inspection
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Inlet TY in place Outlet baffle in place Tank working properly at time of inspection
Grease Trap(locate on site plan):
Depth below grade: feet _
Material of construction:
❑concrete [] metal ❑fiberglass ❑polyethylene ❑other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•agraa U115 ofircia)fnsped.F..&fturtece sewage Oisposa)system•Page 10 W 77
Commonwealth of Massachusetts
Title 5 Official Inspection Farm
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
45 Watershed Wy.
Property Address
Kenneth Silva
Owner Owner's Name
information is required for Marstons Mills ma. 02648 4/21/09
every page. Cityrrown State Zip Code Date of inspection
D. System Information (cons.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Inlet and outlet inverts working properly no signs of leakage
Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑polyethylene ❑other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•09= Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pap 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
45 Watershed Wy.
Property Address
Kenneth Silva
Owner Owner's Name
information is required for Marstons Mills ma. 02648 4/21/09
every page. City/Town State Zip Code Date of Inspection
D. System Information (cunt.)
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.):
Distribution Box failed being replaced on 4122/09
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.):
Soil Absorption System(SAS)(locate on site plan,excavation not required):
If SAS not located, explain why:
1000 Gal. Leach Pit with Z11"of liquid at time of inspection
t5ins•09M Title 5 Official t 'on forth:Subs nspecU urtace Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Fora
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
' 45 Watershed Wy.
Property Address
Kenneth Silva
Owner Owner's Name
information is required for Marstons Mills ma. 02648 4121/09
every page. City[Town State Zip Code . Date of Inspection
Q. System Information (cunt.)
Type:
❑ teaching pits number: 1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
leaching fields number, dimensions:
❑ overflow cesspool number.
❑ innovative/attemative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Dry soil no signs of hydraulic failure no ponding or damp soil no veg.over s a s
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
t5ins-03168 Title 5 Orriaal inspection Form:Subsurraoe Sewage Disposal System•Page 13 or 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
45 Watershed Wy.
Property Address
Kenneth Silva
Owner Owner's Name
information is required for Marstons Mills ma. 02648 4/21/09
every page. City/Town State Zip Code Date of Inspection
D. System information (cunt.)
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.):
t5ins•09/08 Title 5 Ofndab inspediart Form:Subsurface Sewage Disposal System•Page 14 0117
Commonwealth of Massachusetts
Title 5 Official Inspection Farm
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
z
45 Watershed Wy.
Property Address
Kenneth Silva
Owner Owner's Name
information is required for Marstons Mills ma. 02648 4/21/09
every page. City/Town State Zip Code Date of inspection
D. System Information (cunt.)
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
F_
3r
3J-1
5b'
t5ms-09= Title 5 Official In
spection farm:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
d Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
45 Watershed Wy.
Property Address
Kenneth Silva
Owner Owner's Name
information is required for Marstons Mills ma. 02648 4/21/09
every page. C►tyrrown State Zip Code Date of Inspection
D. System Information (cons.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: 12+'
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 Ian revie
wed:
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:
Before filing this inspection Report, please see Report Completeness Checklist on next page.
t'ims-09108 Title 5 Official Ins
pection 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
45 Watershed Wy.
Property Address
Kenneth Silva
Owner Owner's!Name
information is f@QUlfed fof Marstons Mills ma. 02648 4121/09
every page. Gh+/Town 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 16 or attached in separate Me
t5ins-09= Title 5 official Inspection form:Subsurface Sewage Disposal System-Page 17 or 17
, S
-\ COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
rc DEPARTMENT OF ENVIRONMENTAL PROTECTION
y
TITLE 5
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
®'
Property Address:
? 4.
Owner's Name1
Owner's Addre s. j �. e.Jl (..
r)
Date of Inspection:
Name of Inspec4or. (pie se rint) ?; Wf"k�1
P
�. e
Company NaWl"
Mailing Address � a
Telephone Number:
N.
CERTIFICATION STATEMENT E
1 certify that I have personally inspected the sewage disposal system at this address and that t ie inforrgiion reiorted G
below is true,accurate and complete as of the time of the inspection. The inspection was perlirmed bwd orally
training and experience in the proper function and maintenance of on site sewage disposal sy tems. I% a D' P
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). Th' system:
r1 Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date:
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies.sent to the buyer, if applicable, and the approving
authority.
Notes and Comments
****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.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of 11 !'
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS`
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: � ,� &QhJ A., f
Owner
Date of spection:
Inspection Summary: Check A,B,C,D or E./ALWAYS complete all of Section D
A. System Passes:
I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist.Any failure criteria,not evaluated are indicated below.
Comments:
B.. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired. The system, upon completion of the replacement or repair; as approved by the Board of Health, gill pass:
Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined"please
explain.
The septic tank is metal and over 20 years old" or the septic tank(whether metal or not) is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent:System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out.or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with .
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than'4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with.approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
I
Page 3 of 1 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: , �. )
�' -%C. .s
Owner
Date of pection: (. .' I " �alh
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(l)(b)that the
system is not functioning in a mariner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health ( Supplier, if lier and Public Water Su an determines that the
Y)
system is functioning in a manner that protects the public health,
Y g p safety and environment:
PJ
_ The system has aseptic tank and soil absorption.system(SAS)and the.SAS,is within 100 feet of
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 aseptic 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' ore from a.
private water supply well". Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
3
Page 4 of I l
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: _/ C.j( /c,�L )a L
Owner: (e/ . , 0
r�
Date of In ection: y 1 -
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
d+' Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow
Required pumping more than 4.times in the last year NOT due to clogged or obstructed pipe(s).Number
/ of times pumped
Any portion of the SAS,cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
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.
11 Any portion of.a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen.and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
/U( (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails: The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with.a design flow of 10;000 gpd to 15,000
gPd•
You must indicate either"yes"or"no"to each of the following:
(The following.criteria apply to large systems in addition to the criteria above)
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 sliall upgrade the system in accordance with 310 CMR'
15.304.The system owner should contact the appropriate regional office of the Department.
Page 5 of I I
OFFICIAL INSPECTION FORM-NOT.FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
Owner:, . r. /C/IX
Date of/, spection: .td
Check if the following have been done. You must indicate"yes".or"no"as to each of the following:
Y / 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 ?
1 . Were as built plans of the system obtained and examined?(If they were not available note as N/A)
t/ r of sewage back u ?
Was the facility or dwelling inspected for signs p
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?
V _ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems
The size and location of the Soil Absorption System (SAS)on the site has been determined based on:
Yes 'no I'
/_. Existing information. For example, a plan at the Board of Health.
t/ 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(3)(b)]
i
5
Page 6 of] I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 1�: c l g ,11)62ky',
1-14
Owner:
Date of Ioection: --Aalf, Q_, " 1
FLOW CONDITIONS
Number . (`
Number of bedrooms(design): �'� Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203 (for example: 11.0 gpd x#of bedrooms):
Number of current residents:
Does residence have a garbage grinder(yes or no): '(A
Is laundry on a separate sewage system (ye or-no) .[if yes separate inspection i egiiired]
Laundry system inspected(ye ..or no):
Seasonal use: (yes or no):.r
v
Water meter readings, if avai-able(last 2 years usage
Sump pump (yes or no): 1
Last.date of occupancy: I, e ' )Lj° �,, (�G�G,�t
�� ,
COMMERCIAL/INDUSTR1ALjA.,/J
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no):_
Non-sanitary waste discharged to the Title 5 system (yes or no):-_
Water meter readings, if available:
Last date of.occupancy/use:
OTHER(describe):
GENERAL) INFORMATION
Pumping Records
Source of information: .Ib Alr a,,"
Was system pumped as part of the inlspection(yelf or no):,
If yes, volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
TXPE OF SYSTEM
Septic tank, distribution box, soil absorption system
_Single cesspool
_Overflow cesspool
_Privy
_Shared system(yes or no)(if yes,attach previous inspection records,if any)
_Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
—Tight tank _Attach a copy of the DEP approval
Other(describe):
proximate age of all co. pon nts, da e install d�t1f known) and source of information:
_.
s
Were sewage odors.detected when arriving at the site(yes or no)
41
Page 7 of 1 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 1� 6�t? ,fw 91,L''6,4
Owner:
Date of 141 . ( A� ,'
BUILDING SEWER(locate on site plan) V
Depth below grade:
Materials of construction:_cast iron _40 PVC_other(explain):
Distance from private water supply well or suction line:
Comments (on condition of joints,venting, evidence of leakage, etc.),.-
SEPTIC TANK: (locate on site plan)
Depth below Grade:
Material of construction: _metal_fiberglass_polyethylene
—other(explain)
If tank is metal list age:— Is age confirmed by a Certificate of Compliance (yes or no): _(attach a copy of
certificate)
Dimensions: • '. x
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:
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:
How were dimensions determined: r -lu , e
Comments(on pumping recomme ations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage, etc.): -
/ r
GREASE TRAP/:(]locate on site plan)
Depth below grade:_
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:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
7
Page 8ofII
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: c-! �
��.
Owner: '
Date of "Ispection: V do of �4oC`- s
TIGHT or HOLDING TANK (, (tank must be pumped at time of inspection)(locate on.site plan)
Depth below grade:
Material of construction: concrete metal fiberglass._polyethylene other(explain):
Dimensions:'
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches, etc.):
DISTRIBUTION BOX: (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert� �Z � �; �`'�r
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of
I kag e into or out of box,-ete. : _
✓ w�� l-�r/tee"_L'
zumj � SST
PUMP CHAMBER:4(locate on site.plan).
Pumps 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.):
8
Page 9 of 1 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION
S ECTION FORM
PART C`
SYSTEM INFORMATION(continued)
Property Address: ('',
OwnerQ—)4,1W.4 ,{ ebli
Date of I W ection: ��n .�(?Rr .�,,- 0
SOIL ABSORPTION SYSTEM (SAS): - .(locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:
leaching chambers,number:
leaching galleries,number:
leaching trenches, number, length:
leaching fields,number, dimensions:
overflow cesspool,number:
innovative/alternative system_ Type/name of technology: _
Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of vegetation,
5�c): r //I
1
CESSPOOLS(cesspool must be pumped as part of inspect ion)(]ocate 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 or no):
Comments(note condition of soil, signs of hydraulic failure, level of pond ing, condition of vegetation;etc.):
PRIVY;f Cd .(locate on site plan)
Materials of constriction:
Dimensions:
Depth of solids:
Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): .
9
Paae 10 of 1.1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM
FART C
SYSTEM INFORMATION(continued)
Property Address: AIA
_ 9 4u,41A
J.
Owner.
Date o Ii pection.:
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet.Locate where public water supply enters th building.
6 (
L
w4on
a tt......�''Lze^FJ )
tl
10
Page I I of 1 1
OFFICIAL INSPECTION FORM.-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property,Address:
U..
J
Own
er:• .i
Date of pection: A
SITE EXAM
Slope
Surface water
Check cellar
Shallow.wells
Estimated depth to ground water feet
Please indicate(check).all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked, date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with.local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
vr0fel
r .
11
Permit Number: Date:
`u
Completed by:
HIGH GROUND-WATER LEVEL COMPUTATION
Site Location: f Lot No.
Owner: Jaw� ,�� �f � c Address:
Contractor: G3a`1�% e9 �/`/� �J/ Address:
STEP 1 N.leasure depth to water table _
to nearest 1/10 ft. .............................................................................. .Date /GS Z
month/day/year
STEP 2 Using Water-Level Range Zone
and Index Well Map locate
site and determine: �+
CA) Appropriate index well..............................9_ 2) ...
....... 4�✓�
CWater-level range zone ..................................................... �.
STEP 3 Using monthly report "Current
Water Resources Conditions"
determine current depth to
water level for index well...........................
month/year
STEP 4 Using Table of Water-level Adjustments
for index well (STEP 2A), current depth
to water level for index well (STEP 3),
and water-level zone (STEP 2B)
determine water-level adjustment .........................................:................................................ �7
STEP 5 Estimate depth to high water
by subtracting the water
level adjustment (STEP 4)
from measured depth to water
7i�
ilevel at site (STEP 1) ............................................:.................................................................
Figure 13.--Reproducible computation form.
15
L
i
I
14'4'AE SW S MAP NO. PARCEL FL -.I-
L 0 CATION SEWAGE PERMIT NO.
VILLAGE . .,� - i 66y_ 007•6ol
I N S T A LLER'S NAME i ADDRESS
r
BUILDER OR OWNER
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED ,�1
i_
� �
l
9
� 1
^`� \ � �
. � ,�,� ?�
:;'f�.
i.
i �•
F$'
s
MR7 S� 1
No - �-�-- C--r �— Fss
THE COMMONWEALTH OF MASSACHUSETTS
_ BOARD OF HEALTH
e, c..................o F.....� ��u6.Tpcz. .z�...............................
Appliratiou for Diipuual Works Tnu rurtiurt Errant
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
y
System at: \ muamwa.. lU,. L oT k7
...... ation- d ress
........... .c8 � - .S.�. ..... .........................................
v li _ . Owney?� dr
.s
Installer Address
U of Building 3Type Size Lot.`I����....Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic (6 Garbage Grinder a�
`4 Other—Type of Building No, of persons............................ Showers — Cafeteria
Q' Other fixtures ..................................
Design Flow..............15.57.......................gallons per person per day. Total daily flow.......53 0.........0......._..._..gallons.
1:4 Septic Tank—Liquid capacitylCM..gallons Length.-71().. WidthA"(Q__ Diameter_-.t' ...... DepthS:::.1.8..
Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area........... ...sq. ft.
Seepage Pit No..._.__.I-------._.. Diameter......1:.-4........ De t i below inlet.._6:&.7...... Total leaching area.31.k.....sq. ft.
Z Other Distribution box ( G5 Dosigg tank ( j(j
'-' Percolation Test Results Performed by )S7- 1�. ��-i,._.tki,<........... Date....:"..�p. . ?...
Test Pit No. 1_44:�r.....minutes per inch Depth of Test Pit.... :. ... Depth to ground
�Tq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.....................
---•----------------------------- .....- .---- .•. . . _
0 Description of Soil.......'.` .€-.......LbAvS1M--�-- 3
x
U -----•---•-•----------------•----------•------------•-•--------...................-------•---•--•----•---------------------•------•-------•--•..............................................................
w
------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------•--•-••-------
VNature 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 TITLE 5 of the State Sanitary Code The undersigned further agrees not to place the system in
operatio u •1 Certificate of Compliance has been issued by the board o health.
r Signed 'yam . . ,`tiL--•--...---.•... -- ....._...-
/ Date/
plication Approv C I{/ -L-" ....
Date
Application Disapproved for the following reasons:.............................0..................................................................................
---------------------•--•---•-----•--•--•-•--•--....-•••--------••---------------•-•---•-......._._.._.....--•-•--••................•--............-------------•----------------------......---•........
Date
Permit No. ...yZ ----------•----. Issued............--- z l--�} - .....
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�nN-`\\1`3
-- - .................................................
Appliration for Disposal Works Tonstrnetion rtrutit
Application is hereby made for a Permit to Construct ( . or Repair ( ) an Individual Sewage Disposal
System at: i
----i-->��1\:'/` - k��1:�.,': ¢:�.�.... ...........................�=r-'--------�� .........................................
Location-Address
_ owner
a V .l... itD - .......... . j �: <.TXI rec:_................. ..........
Installer Address
�-
U Type of Building �4 Size Lot.A'.:.:.:'� .....Sq.Cfeet
1-� Dwelling—No. of Bedrooms.......................:....................Expansion Attic (I )� Garbage Grinder
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
dOther fixtures -----------•-•----------------------------------------.--.......---------------------•--....----.......
W Design Flow.............`?.` ..:...................gallons per person per day. Total daily flow.........` .._....................g-allons.
W Septic Tank—Liquid capacity ACC_ gallons Length_' .?U.. Width._f?.:::!a%1 Diameter__-" ._____ Depth....? Z�.
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area ------..sq. ft.
Seepage Pit No.................... Diameter...... ........ Depth below inlet...:`..A.: ..... Total leaching area....L.*.,�.....sq. ft.
Z Other Distribution box ( r_) Dosil4g,tank (N))
`-' Percolation Test Results Performed by..:L:?j".K:.�Q ��.:.........:� �- i jet -.......•.. Date._........... .. �-- �
- . .............. ...l.... =-
Test Pit No. 1._ ......minutes per inch Depth of Test Pit...�.: ._ .... Depth to ground water.
f=, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
D Description of Soil. .. .?.....�.....-•••........ .... . .......)J `,l.........................................................\ ---1 '/ f~ , ) �� C -; r .�
x __ ....
--------------------------------------------
-------
------------
-------------
...........
------------------
----------------
--------
--..---•--...------.--------••---------------------
-----------------------------------------•-•------------------------•--....---------••----......--------------••--------............---•--.....----•-------..........---.........--•--•--•-----:......_.
U Nature of Repairs or Alterations—Answer when applicable.........................................................:..:...............................:..
---------------------------------------------------•-----............------...--------•---•-------....................--------------•---......---....------•-----------•--------......_..----........._.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TI TIE 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in
p f Compliance has b n issued by the board of health.
o eratio u 1 a ertihcate o_- - /
Signed..... ..., v� 1. / s 2 :Z " -
...... ........••.... ... ..- -
le
-_.
PI
ication Approve yam.___-;,= . ....... - 1
Date
Application Disapproved for the following reasons:.............................................................
.......................•-•----------.......--•-------........-----.........---.....-----•--•--------..........-•--•---•-------.......-------•---------..........._:..................................._
c-- _
- Date
.Permit No... �- - `�-`- ...._.._ r Issued............ IL: . ..--.-)k
----------------
THE COMMONWEALTH OF MASSACHUSETTS
--/-�-- BOARD OF HEALT9,H�l, '
......1 ......OF.......A
................................' -'.........................
(Irrtif irate of T-am rlittnrr ✓'
THIS,I,� TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
bY- ...............................................--............---..................... ............... ` ._...._
.... .._.
�' Installer
U !Nd///v/�
at... .....�'. ' ------------- . . ---j�f ... .. -
.....
has been installed in accordance with the provisions of RTLE of The State Sanitary Code as described in the
... %.`i (
application for Disposal Works Construction Permit No....�?.__...._.���- 2-:..... dated......s�r c'
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE........................7 .... ...................................... Inspector....................... ...).. ....-•--•------••---......_.....•----.......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEAL.Ikl
= LL � `'Z . ....:..`�.....................No ..............
.OF ... Fn..... - �'
.:..'....,
Disposal Works �pns
Permission is h reby granted.............�f ?.'- '�1..... /
to Construct (�r epair ( ) atitivd .wage isp .sal Sy tem
Street 1 '
as shown on the application for Disposal Works Constructio ermit No.._...... Dated....._..7 . .l.( ,•-
- ..... ......
��•• ,
Board f Health
DATE...--- s.
FORM 1255 A. M. SULKIN, INC., BOSTON -
I `
ti
41,7
t ..
. / 7 dea ��• _
l0 3
•o.
•,' �o'.
IT
640
OF
J 1
:.,., PETER
o SULLIVAN "
s l NGzLS :FAM I L.Y 3 B c-,M
U' NO. 29733 .
STr�'C �44�
Y FLDW t lox 3
:.:: S EP1'1 G T.d,t�1K� �j'�X t A% c��� G,P, [�• ,:s... ,;•y-"` ,
�_U5.1✓:: ACOO:(xA\L. -rAN`IK
t?l51?` ._PtT:._•L.: US>=
_2 . 5
�i�
O. yt R D•
rdTAL -SIG-1►M -- �,�-'57 G-�.P•D. � ��x�r' .
_... 't 1,4Mom '>�"c: 1" rN 2Z ht,rN Ck LE.55
TIME
oe
-A
GcAL.. •. INV Imv
PlTN (,/.�7 63.b ;SEPTIC 3 .Z
_A l63
_. ._�_..... ....... ... .r.
wrrm y INV. INv, . ,A1JK
STowe
-EF LE LpfAmoN Mamsnn45 IlILuj
No ALE j..E .. 0`
.. . . (�iZOposEo
i Gar)F-Y 'T}-1 r -MEE Pw4t>AT1oO showN Z NY 1 !1z
H=1z'150hl CL7MMYS 1NITH TEE SiI>SUWt~ 9S4ISTL'V-4 D L.ANI:) 5URyc-Yoz.-%
At►J>7:SETgA,G�C REQUI��M t1-s OF TNT OSTCKVILLE MASS.
TOVJN oI:: ��►z+JSt-A�c..�ANp ! s cJor
TNT FLDOD Pi.,l N,
TN 15-PL,4N �5 Ncrr'StAs.pm ON
a1J 1 NSTIz
4(✓� ME�!'t' SUrz�Y ANI� Ti.}� O��S>r T 5
To�a�U H SI}OULb T �3E u!5'eb
_.�.. . . ; - LOT L.I►VCS�