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Commonwealth of Massachusetts
W Title 5 Official Inspection Form o
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments /
49 Head of the Pond Rd
Property Address
Bill Hildebrand
Owner Owner's Name
information is required for every Marstons Mills MA 02648 3724-15
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
A. General Information n
1. Inspector:
Shawn Mcelroy
Name of Inspector
Upper Cape Septic Services
Company Name
P.O. Box 73
Company Address
E. Falmouth MA 02536
City/Town State Zip Code
1-508-495-0905 S13971
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation byV Local Approving Authority
3-24-15
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.
****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.
�/S
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
(A
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
49 Head of the Pond Rd
Property Address
Bill Hildebrand
Owner Owner's Name
information is Marstons Mills MA 02648 3-24-15
required for every
page. CitylTown 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:
System is in good working order with no sign of failure.
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND) for the following statements. If"not
determined,"please explain.
The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M s 49 Head of the Pond Rd
Property Address
Bill Hildebrand
Owner Owner's Name
information is required for every Marstons Mills MA 02648 3-24-15
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-.
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303,therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑. ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed.The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
{1
1 t
Commonwealth of Massachusetts
Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
p,�M 49 Head of the Pond Rd
Property Address
Bill Hildebrand
Owner
Owner's Name
information is Marstons Mills MA 02648 3-24-15
required for every
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate "yes" or"no" as to each of the following:
Yes No
Z ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
❑ ® Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
❑ ® Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
^M 49 Head of the Pond Rd
Property Address
Bill Hildebrand
Owner Owner's Name
information is required for every Marstons Mills MA 02648 3-24-15
page. City/Town State Zip Code Date of Inspection
D. System Information.
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: 12-2014
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 ❑ No
Water meter readings, if available:
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form -.Not for Voluntary Assessments
�M 49 Head of the Pond Rd
Property Address
Bill Hildebrand
Owner Owner's Name
information is required for every Marstons Mills MA 02648 3-24-15
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Owner--pumped 2011
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping: Maintenance
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract (to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
49 Head of the Pond Rd
Property Address
Bill Hildebrand
Owner Owner's Name
information is required for every Marstons Mills MA 02648 3-24-15
page. City/Town State Zip Code Date of Inspection
D. System Information (cont_)
Approximate age of all components, date installed (if known) and source of information:
1980
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 24"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.):
Good condition.
Septic Tank(locate on site plan):
Depth below grade: 18"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: 1000 gal
Sludge depth:
12"
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
/
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 49 Head of the Pond Rd
Property Address
Bill Hildebrand
Owner Owner's Name
information is required for every Marstons Mills MA 02648 3-24-15
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
2a°
Scum thickness
1"
Distance from top of scum to top of outlet tee or baffle
6"
Distance from bottom of scum to bottom of outlet tee or baffle
15"
How were dimensions determined? Tape
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank is in good condition with baffles installed and no sign of leakage.
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
1
Commonwealth of Massachusetts
W Title 5 Officiallnspection Form
m Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
49 Head of the Pond Rd
Property Address
Bill Hildebrand
Owner Owner's Name
information is required for every Marstons Mills MA 02648 3-24-15
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.).
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M , 49 Head of the Pond Rd
Property Address
Bill Hildebrand
Owner Owner's Name
information is Marstons Mills MA 02648 3-24-15
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
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.):
Good condition with water at working level and no sign of back-up from pit.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
i
t i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 49 Head of the Pond Rd
Property Address
Bill Hildebrand
Owner Owner's Name
information is required for every Marstons Mills MA 02648 3-24-15
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 20
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
® Checked with local excavators, installers- (attach documentation)
® Accessed USGS database- explain:
You must describe how you established the high ground water elevation:
USGS and town maps show groundwater at greater than 20'.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
r ,
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
49 Head of the Pond Rd
Property Address
Bill Hildebrand
Owner Owner's Name
information is
required for every Marstons Mills MA 02648 3-24-15
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
to
! r � r r,
- �
ly
4-Fm -,58
t5ins-3f13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
49 Head of the Pond Rd
Property Address
Bill Hildebrand
Owner Owner's Name
information is required for every Marstons Mills MA 02648 3-24-15
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of.Massachusetts
m W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
^M 49 Head of the Pond Rd
Property Address
Bill Hildebrand
Owner Owner's Name
information is required for every Marstons Mills MA 02648 3-24-15
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1-1000 gal
❑ 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, etc.):
Leach pit in good condition and holding 12" of water with stain line at 24" below inlet invert.
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
49 Head of the Pond Rd
Property Address
Bill Hildebrand
Owner Owner's Name
information is required for every Marstons Mills MA 02648 3-24-15
page. City/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 15 or attached in separate file
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
TOWN Pf BARNSTABL
LOCATIONswcE
V3I:I.AGE ASSESSOR'S i# .OT '. p
IN18T'ALLER'g t'fi M c&PHONE NON
SEPTIC TANK'CAPAC£iy I
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}3U=)FR OIt fl f�iER
PERMUD�sTE CO Liam gr�Tl
Sepazat�an Distance 8ei�xopn the
Maxiniium AdNsted Crroundwater Tula to the Bottom pf Laacl ing Fat,'ility l~eet'
l?ntrai �Iaief Supply Wei and l na Facilaty ((df any exss�: c
on,Ishe or within 2t ftwt bf leaching faccl ty)
Edge of Wetland and Leaching f-Adluty(If any Yietlands exist t
u%ithan 3t14`feec af'Ie
qpluau Iacility)
aeritished by '
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF .HEALTH
�fG.c:,•.^ .............OF...... Yn _.._.. /-C�
Applirattion for Dftiposaal Workii Tontrnrtion thrutit
Application is hereby made for a Permit to Construct (K) or Repair ( ) an Individual Sewage Disposal
System at /
�+ Location-Address ! ` Lot No f/
--. ---- .. .... ..-..---- - - ----.......
. / ....... ..�..�.--
---------- -- -
Owner --------------••--•--..........-Address
Installer Address ®� /6
Type of Building Size Lot.:.........................Sq. feet
Dwelling—No. of Bedrooms.._..................................Expansion Attic Garbage Grinder
Other—T e of Building No. of persons............................ Showers — Cafeteria
Q' Other fixtures ----------------------------•-_--.
W Design Flow........... ........7.........gallons per person er day. Total daily flow----- ____�J gallons.
WSeptic Tank—Liquid capacity Q gallons Length___.. a..'+ .. Width..�?_..._...._ Diameter................ Depth...6...
x Disposal Trench—No..................... Width.................... Total Length............-_o.... Total leaching area....................Sq. ft.
...._.... Total leaching area.......... ....s ft.
� Seepage Pit No....... ----------- Diameter.... ............ Depth below inlet.......�z_ g � q.
Z Other Distribution box Dosing tank YY�C>
~' Percolation Test Resu s Performed by..... :.�.C'.%'V�=A_)!._.._!.-�3______________________ Date._.�i.1- z.��_____..-.
a Test Pit No. ::!��_-------minutes per inch Depth of Test Pit...._..�.�..... Depth to ground water__/ l _ Iry
._
�, Test Pit No. 2...............minutes per inch Depth of Test Pit.................... Depth to ground water................_.......
------. _ ----- --------- -t
_ •
Descriptin Qf Soil °/ o?a_ 3:_ -. --------------------------
�s y
/ j` --
W -----------------------------------------------------------------------------------------------------------------------------------------------------•--...............................................
UNature 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
---` operation until a, Certificate of Compliance has b n issued b e oa of health.
3a ��
�e Date
Application Approved By....... -- ---•- -- -JO -_.77...
Date
Application Disapproved for the following reasons----------------•----•----•-•---------------•------•---......------------•--------------•••--•--•-•••-•-•---------
------•---------••--------------••••-•------••-•---...---•••-•-•---•----------•..._.............-----------••-•--....----•-•--•••-•---••--•-••-------•-------------------•-----••......•-•--•......-•---
Date
4>
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
/ . ...............OF....... N .................................
Trrtifiratr of TontpliFanrr
TH I TO RTIFY, That the Individual Sewage Disposal System constructed (ZI-'or Repaired ( )
by.•---• 64•' ..:.--•------------------------- --•- /
al
has been installed in accordance with the rovis' n�TIT r of�T.�,e State Sanitar Code as described in the
application for Disposal Works Construction Permit No..`.._�'...A� ............ dated_...Je '30.-.7.7___._____..__..
THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE........ �- ..----...... Inspector-- `- `' 1--
-------------------------
T
No.._._...... .... Fxs..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEA TH
" �.
Applirtttinn for Disposal Works Tonstrnr#inn Prrutit
Application is hereby made for a Permit to Construct (X)- or Repair ( ) an Individual Sewage Disposal
S stem at /
.�.... _ . . :. ... _. ... -----••------ ---- -
�a boon Address "� !} ±' / ry �}�/L•ot No
-• ... --- ... ._..
W .+
Owner Address
Installer Address ,f�
Type of Building Size Lot____ Sq. fee
Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder
O r—T e of Building No. •of ersons____________________________ Showers
G.1 �P yP g ------•-•-•------•---------- P ( ) — Cafeteria ( )
p4 Other fix
ure
Q -- -------------------------------- -------------------- -----------••----
/7 -
W Design Flow_________________ .• gallons per person er dax Total dall flow_.__:__ galhgns.
WSeptic Tank—Liquid capacity A!�gallons Length.:__8" Width:; ! Diameter...... ......... Depth___
x Disposal Trench '�Io_____________________ Width__y._..,_._.______ Total Length ._•__. r Total leaching area.... ---------sq. ft.
3 Seepage Pit No ____ ___________ Diameter....__.__............ Depth elow inlet......... Total leaching area__!,___r,___sq. ft.
Z Other Distribution box (�) Dos ng kLA
Percolation Test Res ts. Performed by •._.._< _N _ Date__�f___ 77_
Test Pit No. ._.____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........................
Description f Soil dii
dJ 3 y f` �+t•+t !� --
(� { t
-1
w ---- -- - ---- - : (- -------
C), Nature of IR pairs or Alterations—Answer when applicable-- -------------------------------------------------
••. --------------------------------------------
Agreement: -^4,
The undersigned agrees'to install the aforedescribed Individual Sewage Disposal System in accordance with
.,., :,-the provisions of TI.¢LL 5 of the State Sanitary Code— The undersigned further,agrees not to place the system in
operation until:a Certificate of Compliance has ben issued b-,tht'•baa!j of health.
y. I Si .... !1 �a -��-----
Application Approved By....... • -•-•--•.. .................
`., Date
Application Disapproved for the following reasons:...................................................................................................................
..........................•-------_._._....--•--•-------•..........••-••......----------••-•-----------_..__....._...---••------------------•-•-•--------------------••••-•----
• _... -------------
Date
M ,Permit No.........................................................
\\ Date
THE COMMONWEALTH OF MASSACHUSETTS
r .-- BOARD HE
..............................O F..............r......................................................................
_ (Irrtifiratr of f ompliFatta
I TO C TIFY, That the Individual Sewage Disposal,System constructed ( or Repaired ( )
Zy �2 stall .✓js� .ram a %�/( /;/I 4
at-
has been installed in ac r ance with the provisions of TITI >Pf�� State Sanitary Co)e5Lasyl" - in the
application for Disposal Works Construction Permit No_________________________________________ dated-------------...................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE®.,AS A GUARANTEE THAT THE
SYSTEM:-WILL.eTUNCTION"SATISFACTORY.
DATE................................................................................ Inspector....:;..............................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O HEA T
•
r a4_0 =�4......
AW �- . .......... . OF..... _........ ........
No.......... ............ FEE....... ............
l nr
t .-
Permission is hereby granted-=--`-_-- - •-'__t?l _-:--
P ( -........... ,----- --- -- •...... ---•---__-
to Construct or Re r an I I al a I sal Sy
at No..... r Gro
Street / -11 �r�* r ►
as shown;on the application for Disposal Works Construction Permit
ff ''
L� /��— 7 �/ Board of Health
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS
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