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Home My WebLink About0096 CINDERELLA TERRACE - Health 96 Cinderella Terrace, Marstons Mills - -- -- - - -- - _- � _- - A= d ? e a r V ECO-TECH ENVIRONMENTAL THIS FORM IS A FACSIMILE OF THE STANDARD SEPTIC INSPECTION FORM ISSUED BY THE MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION �\ a Z Property Address: 96 Cinderella Terrace,Marstons Mills Address of Owner Date of Inspection: May 12, 1997 (If different) ° WVEn Name of Inspector:David D.Coughanowr, R.S. M Company Name,Address,and Telephone Number: �y Y 1 4 1997, WNOFA§Tg�Eco-Tech Environmental TO HFA�B q TM Aq 6/ 43 Triangle Circle EPT Sandwich,MA 02563 e (508) 888-0185 CERTIFICATION STATEMENT: I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.The system: X Pas sP� GFQ IFy�Passe�, ids urti^riwalu 'on the Local Approving Authority Inspector's Signature 93� Date: m o v l �, 1192 NOTE=_> A septic s - is? egnedFP p ry tn� ,d + �p#ss is Real Estate Transfer Inspection if it does not trigger any of the failure criteria listed below.The se pU y� �'n Ulrb luated according to the conditions observed on the day it was inspected. No estimate or guarantee of syste J 's made or implied by a passing determination. The System Inspector shall submit a copy of this report to the local Approving Authority within thirty(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 Department of Environmental Protection.The original should be sent to the system owner and copies sent to the buyer,if applicable, and the approving authority. INSPECTION SUMMARY: Check A,B,C,or D: A]SYSTEM PASSES: X _I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B]SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired.The system,on completion of the replacement or repair,passes inspection. Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined", explain why not The septic tank is metal,cracked,structurally unsound,shows substantial infiltration or exfiltradon, or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced With a conforming septic tank as approved by the BOARD OF HEALTH. r - l SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 96 Cinderella Terrace,Marstons Mills Owner: Barbara Crevier Date of Inspection: May 12, 1997 B]SYSTEM CONDITIONALLY PASSES(continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)or due to a broken,settled,or uneven distribution box.The system will pass inspection if(with approval of the Board of Health): _broken pipe(s) is/are replaced _obstruction is removed distribution box is leveled or replaced. The System required pumping more than four 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)is/are replaced obstruction is removed 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 the public health,safety,and environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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(AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 foot to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone 1 of a public water supply well The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and that the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. D) SYSTEM FAILS: I have determined that the system violates on or more of the following failure criteria as defined in 310 CMR 15.303.The basis for this determination is identified below.The Board of Health should contact me to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overioaded 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. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 96 Cinderella Terrace,Marstons Mills Owner. Barbara Crevier Date of Inspection: May 12, 1997 D) SYSTEM FAILS (continued): Static liquid level in 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 1/2 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 SOIL ABSORPTION SYSTEM,cesspool,or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 foot 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 water supply 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.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen E) LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The design flow of systems is 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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 within a nitrogen sensitive area(Interim Wellhead Protection Area (IWPA) or a mapped Zone II of a public water supply well. The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00.Please consult with the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 96 Cinderella Terrace,Marstons Mills Owner: Barbara Crevier Date of Inspection: May 12, 1997 Check if the following have been done: X Pumping information was requested of the owner,occupant and Board of Health. X None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. _X_ As-Built plans have been obtained and examined. (Note if they are not available with N/A) —)L The facility or dwelling has been inspected for signs of sewage backup. X The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. including X All system components,excludin the soil absorption system.have been located on the site. X the septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,depth of liquid,depth of sludge,depth of scum. X The size and location of the soil absorption system on the site has been determined based on existing information or approximated by non-intrusive methods. X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of a Subsurface SEWAGE DISPOSAL SYSTEM. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 96 Cinderella Ten-ace,Marstons Mills Owner: Barbara Crevier Date of Inspection: May 12, 1997 FLOW CONDITIONS RESIDENTIAL: Design flow: 425 gallons Number of bedrooms: 3 Number of current residents: garbage grinder(yes or no): no Laundry connected to system (yes or no):yes Seasonal use(yes or no):no Water meter readings,if available: Last date of occupancy:current COMMERCIAL/INDUSTRIAL Type of establishment: Design flow: gallons/day Grease trap present: (yes or no): Industrial Waste Holding Tank present: (yes or no): Non-sanitary waste discharged into the Title 5 system: (yes or no): Water meter readings,if available: OTHER: (describe): Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS(and source of information): System pumped in November, 1996 System pumped as part of this inspection (yes or no) no If yes,volume pumped: gallons 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) Other(explain) APPROXIMATE AGE of all components,date installed(if known)and source of information. System repaired in 1984(BOH file 84-190) Sewage odors detected when arriving at site: (yes or no) no SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 96 Cinderella Terrace,Marstons Mills Owner: Barbara Crevier Date of Inspection: May 12, 1997 SEPTIC TANK: (locate on site plan) Depth below grade: 6 in Material of construction:X concrete metal FRP Other(explain) Dimensions: 8'x 5'x 4' Sludge depth: 8" Distance from top of sludge to bottom of outlet tee or baffle: 26„ Scum thickness: 10„ Distance from top of scum to top of outlet tee or baffle:4' Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity,evidence of leakage,etc.) Inlet tee could not be inspected because it was underneath deck Tank requires pumping to remove lame solids buildup Tank and outlet tee appear structurally sound and functional liquid level at outlet invert.No evidence of leakage in or out GREASE TRAP: none (locate on site plan) Depth below grade:_ Material of construction: concrete metal FRP 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: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity,evidence of leakage,etc.) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 96 Cinderella Terrace,Marstons Mills Owner: Barbara Crevier Date of Inspection: May 12, 1997 TIGHT OR HOLDING TANK: none (locate on site plan) Depth below grade:_ Material of construction: concrete metal FRP Other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: X (locate on site plan) Depth of liquid level above outlet invert: 0 Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) Line to it1(previously existing pit is slightly lower).Some solids in sumo No evidence if leakage in or out. PUMP CHAMBER:none (locate on site plan) Pumps in working order, (yes or no) Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 96 Cinderella Terrace,Marstons Mills Owner: Barbara Crevier Date of Inspection: May 12, 1997 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods). If not determined to be present,explain: Type: leaching pits,number: 2 (two) leaching chambers,number: leaching galleries,number leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) Both pits were excavated and examined.Pit 1 was found to be full of effluent.Pit 2,which was added during most recent repair,contained three feet of effluent.Soil absorption system was evaluated on the basis of nit 2 alone,which was sized to accommodate all flow according to approved design plan No surface ponding or breakout was observed from either pit. CESSPOOLS: none (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(cesspool must be pumped as part of inspection) Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) PRIVY:none (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.) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 96 Cinderella Terrace,Marstons Mills Owner: Barbara Crevier Date of Inspection: May 12, 1997 SKETCH OF SEWAGE DISPOSAL SYSTEM: include des to at least two permanent references,landmarks,or benchmarks. locate all wells within 100' CINDERELLA TERRACE LOCATIONS A B 1 13 ft 14 ft 2 27.5 It 36.5 ft 3 38 It 49 It 3 BEDROOM 4 42 It 41 ft DWELLING SEPTIC B A TANK 2 3 -LEACH PIT 4 -LEACH PIT NOT TO SCALE DEPTH TO GROUNDWATER Depth to groundwater: 12+ feet method of determination or approximation: No=undwater observed to this depth in witnessed soil test log(5/14/79) ' Sewer Permit No. Name Location . �? r d Installer's Name and Address Builder's Name and Address Date Permit Issued: r Date Compliance Issued: ��,��"�� s �.o Exc: IS 7 �l`�`� b� � ��} � � ,� f �'� r r� b � ,� "r. .--� � Fim THE COMMONWEALTH OF MASSACHUSETTS 1 BOAR® OF HEALTH ...•.............. .........------......O F..........................._........... ApplirFation fnr Di-gVog al Mirkii Tomitrurtion ramit Application is hereby made for a Permit to Construct ( �) or Repair ( ) an Individual Sewage Disposal System at: ......................-------------- --------------------------------------------------------- ----------------------•--....•----•--------•------•-•••-----•---------..........._._..------------ t� � P c io�t ess or Lot No. V� �( P. !e Address Installer Address Type of Building /�_ Size Lot.................... .....Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) a Other—Type of Building ........................... No. of persons............................ Showers ( ) — Cafeteria ( ) d Other fixtures - - W Design Flow............................................gallons per person per day. Total daily flow_----__--_---..._.__. .................gallons. WSeptic Tank—Liquid'capacity.._.........gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) t.-a Percolation Test Results Performed by.......................................................................... Date........................................ ►4 Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water-._---_-_--____-.-___-- 4, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water___---______--_-----___. a ........................................................•-------•--•----•-- 0 Description of Soil........................................................................................................................................................................ x W ---------------------•------•--•--------•---•••----------------•--• . x -------------- A V Nature of Repairs or Alterations—Answer when applicable .__::_ � «>\_ ... ve ___ !.................. —_ - -------------------------------------------------------------------- --------------------------•--...----------•-------••---------•-•---•--•••--------•------•-•-••--••-••-----•--•-•-•-........--•----• Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of i y t 1E 5 of the State Sanitary Code— ndersigned further agrees not to place the system in operation until a Certificate of Compliance has been issu d by board c, alt wed. ........•---- ..............�...... . .... .. ........ D to Application Approved BY - / C/- -------•------- Date Application Disapproved for the following reasons-.............................................---................................................................ -----------------•--•------------...-----...-------••--------...------------------....----...--------•-----....-•--------------•-••----•------•---•----•-•------•----•--••--•--•----•-- ........... Date Permit No............................................� Issued....... 1 No. .... Firm............._............ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ....... .............. .............OF............................._...._.......------------------..............-----•--•------- Applira#ion for Uigpusal Works Tonstrnrtion rrrntit Application is hereby made for a Permit to Construct (J) or Repair ( } an Individual Sewage Disposal System at: GLLPr ................--. .........._....-•----. ..........-----....... - --...---------------------------------.....-----------...------------.........-------•---.._..•--- Ml�,+n�� arti l r,�djess or Lot '�o. - ----------------------------------------------------------------------------------•------.------- ----------------------------------------- ............ ..........................•.....Address Installer Address dType of Building //_ Size Lot............................Sq. feet U Dwelling—No. of Bedrooms.............................. .. .....Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ---_______________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) a Other fixtures .............•-••------•-••••--- . ---------•----------- W Design Flow.............................................gallons per person per day. Total daily flow__..........._........_........._gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water_-___________-_____-___. (i, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a .......................................................... -.... ------------------------ -....... ..... ---.... •---------------------------- •-•-••.-------------- 0 Description of Soil........................................................................................................................................................................ x V W •--•-----•---------- --------------------------------------.................................................... U Nature of Repairs or Alterations—Answer when applicable______._ 1.Rt�/1_ ...Cp1l ?� _-_ .:.................... ------------------------------------------------------•-----------------------------•-••-•-•-------------------------------------------------------------------•---------------------........-------•-•- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE i of the State Sanitary Code— The undersigned furtlier agrees riot to place the system in operation until a Certificate of Compliance has been issued by the board of health. = Signed----------••-------•-•-------------•--...----•-....------------......_....-••••••••--- .......................... �= . Application Approved B _ ...�.��1� t� PP PP y-- -------- Date Application Disapproved for the following reasons:................................................................................................................ ..-•-•--•-----------••--------•-.._._..................-•........--••------•-••------•--•-•-•-••----•---I•-•--•---------------------••-•••-••---•-•-••••----•-•-•------....----•-c........-•---•--•-•- �• J Date Permit No.........................7-----.. - G Issued 1 a DSz't THE COMMONWEALTH OF MASSACHUSETTS BOARD_ OF HEALTH ..........................................of...... ................................................... Tnrtifiratr of Toutphatta THI Ss-TCEIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by------------- ' %• �J......_ •-�--Tnstaller } / ___ 1 at---•--------------------!`!- .....��'......=...... _ !a..•--•--._ ,f�_s:CCr.............._--- --••----A .I................................................... has been installed in accordance with the provisions of TIT-e� 5 I,The State Sanitary Cod . as described in the application for Disposal Works Construction Permit No.......................................�....�...... dated--------�� Z.................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE........................ 'd..'.. .. _-.. ...................... Inspector----------------------------I. . .......................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .................... ........................................... ................t........... FEE...........-•-••- Raposai nrk ��n rttr Ilan ernti Permission is hereby granted....... i.?........................................................................................... to Construct ( o/�'Repair ) an Indvidual Severe Di po al Sys�pT at No..................... . ........ t �?_T�_ ......�-------------•.-.............................................................................................. Street ��•,X� as shown on the application for Disposal Works Constttttction Permit No................. Dated............... ` .. G._. ... .--- ..... I ...............•---------------------••----- -----------------•---------...-----•-----•----••--•--...._ Board of Health DATE................................................................................ FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS `l0 CA T ION SEWAGE PERMIT NO. VILLAGE � OY7- / 6 INS T-kcLj LER'S AME i ADDRESS t L D E R OR OWNER l` DATE PERMIT ISSUED DATE COMPLIANCE ISSUED LL _ ~1 J\ :f �I pprry 159 ® Sir S 1 N 0 0..,) FRic ......................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .............OF...7:�Dar.o..5 \e— .......................................... Apfiration for Bhipviial Workii Tontitrurtion Permit Application is hereby made for a Permit to Construct ( Vror Repair an Individual Sewage Disposal System at: .......C'nAtA.L.................... .. .......... ..... ..),................................ .. ....... ........................................................................ Address ,�_(N,400 Lot No .......o.a.int. . ....... ....... ........ owner— �>t_C) % -%Ck(0 Address ...qe—) C> ....... ........................................ ....... . .....S......C ---------------"------ --------- -- ------------------------ "'_j.11er Installer Address Type of Building Size Lot.QQ-..200-01....Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder (0p Other—Type of Building ............................ No. of persons............................ Showers Cafeteria PLOOther fixtures ...................................................................................................................................................... Design Flow...............klQk....................gallons per person per day. Total daily flow.........33®....................gallons. 1:4 Septic Tank—Liquid capacitR ..gallons Length................ Width................ Diameter................ Depth................ Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. f t. Seepage Pit No...................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. f t. Z Other Distribution box Dosing tank .. Percolation Test Results Performed by......... 5.LLIW-.VM......k.. ----------- Date........................................ Test Pit No. I................minutes per inch Depth of Test'Pit.................... Depth to ground water..--................-... Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water---................----. P4 .........\..................................................................................................................N ............................ ��.& n.— 0 Description of Soil...Qma........ ......A -1.1..... .............. . ... ..........................A— .................................... ...... .......C--- 5m.....kl--� U CA ...................................................................................... ............;)....... ........ ......... ck U Nature of Repairs or Alteratio2__=Answer when applicable............................... ............... . ....... ..................................................................................................................................................................... ...................... Agreement: The undersigned agrees to install the aforedescribed. Individual Sewage Disposal System in accordance with the provisions of THTILE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. ed.....�-CVCN�. k kk-, ... ....................................... Y.. ....... ApplicationApproved ............A.......................................................................... ........ ate Application Disapproved fo the o lowing reasons:................................................................................................................ ......................................................................................................................................................................................................... Date PermitNo......................................................... IssuedL........................................................ Date No.•----`-.................. FEs.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH (' ..............OF... •�..(n.., �.e-.............----------....---- AVp iration for BhiVaaal Workii Tonotrurtion Frrutit Application is hereby made for a Permit to Construct ( l-11"'or Repair ( ) an Individual Sewage Disposal System at: Location-Address n r Lot No. . -.._..... a. .nx ------------------------ �U_ \, Owner r ss a ..........V. .L.l ........................................................7 ....�c.1C C�.._. .. a. --............................................... Installer Address U Type of Building Size Lote; f L?......Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( p aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures -------------------------------•---•--------•-•----•-......-----------------------------.---------•---•----....----••------..._........-•••••-•.••---- W Design Flow............... ....................gallons per person per day. Total daily flow......... ?'.3.9....................gallons. WSeptic Tank—Liquid capacityV� ..gallons Length.......:........ Width................ Diameter................ Depth................ x Disposal Trench—No. ................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.............;_.._... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) a Percolation Test Results Performed by.......... .L .. ......�... ... ................ Date.....--..............__..__..----------- ,_l Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.......____._........_-- 0-4 rX4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ...... ..................................... ...................................................•-- O Description of Soil... ..... ...... . .. .......................... V Nature of Repairs or Alterations—Answer when applicable................. ..............................................................---------•--.....•-•----•----•.......••--.....-----------------------••--------------•----•---•--.....c..>......_._.. 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 further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. n Signed--- ..... ...................... ................ �/3 Date ApplicationApproved By.................................................................................................. ........................................ Date Application Disapproved for the following reasons---------------------•--...-•-•---•-••-------•-----------------...--------------•--------._....-•--•..........._ -------------------------••------•----------•------•---- ---•-------------....-----------...........----.._.....--------•---------•---------•----...-•-----------------•-------------•------•-------•--•- Date PermitNo......................................................... Issued-....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH (Inrtif iratr of T antpliattrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ✓)`nor Repaired ( ) by-----..... . e. ?.c.:.n. ............. - .......................................................... -•-•-•--•-•...:......:....•---.....----•--------•---•--•-••-------•-•----••---•-•---.... ........ ------- Installer.;•---- at-- ? `Z-`-....---.�1_'�r�-�..n.l.l�.0 4..------------ -�+ , �", �Ckll/�_�'i(l'L.►...��..s.__......_ has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......................................... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRU D AS A GUARANTEE THAT THE SYSTEM 1Al L F i/1 CTION SATISFACTORY. DATE-_..?y•-�`.............................................•-..---- Inspector.... .::.......... ... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No......................... FEE........................ Disposal Works Toni nrtion amit Permission is hereby granted.........-u--Q-AokI n-s?..........•---- 5...................................................................... to Constr ct ( or Repair ( ) an Individual Sewa a isposal Sys yI M Street as shown on the application for Disposal Works Construction Permit No..................... Dated.......................................... ---••-•-•---------------•-----.......-------------------•-----•-----•-•------....•-•----•..........----- Board of Health DATE . . -•--•- FORM 1255 A. M. SULKIN. INC.. BOSTON I <,IQGLC FAMILY - BGORooM ,I ►,.ID GARBAGE= (�Q.JI.IDE2 t� DA►�-Y F%..0WG.P c? II SEPT►G W_% a30x15c>% = Ag5;6.Po i� ' v5E l000 GAL.. •97�o ZS � I I . o�5Po5A►- PIT v5E l000 GAL. I �. I � , 5►po.WALL AQCA - IgcS.F; nj I , _ ,� /�,3• <r.c�•G, I I 150 S.F, x �•5 - 3?5 G.PR `�C I •E , t 05,F 0� BOTTOM0TBOTTOMAREA: IN I j� 5O SF �. K 1* 0 5 O G.P p• . I _N II , 'ToTA1.. DESIGN 25 G.P. D: �A ' II -TOTAL DAIL YFLOW 3306,PD, ► V) 9 •S' i PF- Zco�.AT►ON RATE 1''IN 2MIN off.��55 f,�jJ �o' o.oQr.T I�• , I tN M Uf OF ASS �o ALAN RICHARD GN 9� JONES A. yl. V I . � ' � �! NBAXT04B �n o No. 25100 41 / hp so TOP Fwozko1,0 NOL�-mac ✓c- GG,= 99 �A�� .C•44�/ &MAI Ale 1000 r�� INS. G a L � � IUao INJ Dux 97� . -TANK ��Np GAL. LEAGI.1 �GT GSA✓EL PIT INV. INV. r G G 9C a wl u 9 it ANa .S/G/G'A• WASN6D Y f I I : $4Np 6T�H 6 7�a CE9-TIFIGD PLoT PI-Aw . G�✓EL # PR.UFIL� LoL47IoN /VO�Jf� N O. S C A L E 5 cA L G �'�,jf�' �AT t~ 0 19�3 _V_St4 GE >r>e15-'E (jallo WN HERCzD1•l GOMPL�(5 �n1lTN HE S I DEL1N .SOT_. 2 ZI T AWP S6T'E ►GK R-sRvIR- MENT� of TµG -(o W N O F �A►Z►�c � A N'D I St�6:7— L •C. G• ✓��3d C LOGp.T D �WITE�IIJ TI•i6 FLopD PLAIN DA"Te: �� I Q �° BAXTGZQ WIM INC. RE6 E-5-T F_-7-6U'►.AW D'5 U 9-Y MA15 PL& J 1 '1 NOT 5t"5r`D o►d AN 06TGP_VILLE IuSTRuMENT 5v2V>~Y -tNE l.�I=F.SETS 5u0►JL3> T.4�_-S Il. NoT DE- U5E:O'To Of'Te?,/^I►-I� L. -INE.S APPLICA►-IT