HomeMy WebLinkAbout0025 JUBILATION WAY - Health 25 JUBILAfION WAY, MARST.MILLS
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET, BOSTON MA 02108 (617)292-5500
TRUDY CORE
Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Governor 1,7 1 Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 49
PART A
CERTIFICATION
Property Address: 25 Jubilation Way, Marston Mills, MA Name of Owner: Robert F_1berQ
Address of Owner: Same
Date of Inspection: July 6, 2000 ''�t t"4" ?vo �!
Name of Inspector: (Please Print) James M.Ford
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) y
Company Name: James M. Ford
Mailing Address: P.O. Box 49, Osterville, MA 02655-0049 Maps 098
Telephone Number: (508)862-9400 Parcel:'063
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 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:
✓ Passes
Conditionally Passes
Needs Further Evaluation a Local Approving Authority
ails
Inspector's Signature: Date: July Z 2000
The System Inspector shall submi Fopy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days
of completing this inspection. If th 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.
NOTES AND COMMENTS
revised 9/2/98 Page 1of11
Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 25 Jubilation Way, Marstons Mills, MA
Owner: Robert Friberg
Date of Inspection: July 6, 2000
INSPECTION SUMMARY: Check A, B, C, or D.
A. SYSTEM PASSES:
✓ I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 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,will pass.
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,unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or
the septic tank,whether or not metal, is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
"'Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)
L 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)are replaced
obstruction is removed
distribution box is levelled 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)are replaced
obstruction is removed
revised 9/2/98 Page 2of11
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 25 Jubilation Way, Marston Mills,MA
II Owner: Robert Friberg
Date of Inspection: July 6, 2000
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 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 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.
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2) SYSTEM WELL.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 AND SAFETY AND
THE ENVIRONMENT:
The system has a septic tank and soil absorption system(SASS and the SAS.is within 100 feet to a surface water supply or
tributary to a surface water.supply. ti
The system has a septic tank and soil absorption system and the SAS is within a Zone 1 of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS 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 the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm. Method used to determine distance (approximation not valid).
3) OTHER
revised 9/2/98 Page3of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 25 Jubilation Way, Marston Mills, MA
Owner: Robert Friberg
Date of Inspection: July 6, 2000
D. SYSTEM FAILS:
You must indicate either"Yes"or"No" as to each of the following:
I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.301 The basis for this
determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
_ Backup of sewage into facility or system component due to an 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 1h 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.
_ T Any portion of a 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. 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:
You must indicate either"Yes"or"No"as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 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:
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 H of a public
water supply well
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Department for further information.
revised 9/2/98 Pap 4of11
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 25 Jubilation Way, Marston Mills,MA
Owner: Robert Friberg
Date of Inspection: July 6, 2000
Check if the following have been done:-You must indicate either"Yes"or"No"as to each of the following:
Yes No
✓ _ Pumping information was provided by the owner,occupant,or Board of Health.
✓ _ 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. Large volumes of water have not been introduced into the system recently or as part of this
inspection.
✓ _ As built plans have been obtained and examined.- Note if they are not available with N/A.
✓ The facility or dwelling was inspected for signs of sewage back-up.
✓ _ The system does not receive non-sanitary or industrial waste flow.
✓ _ The site was inspected for signs of breakout.
✓ _ All system components,excluding the Soil Absorption System,have been located on the site.
✓ _ The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for conditions of baffles
or tees,material of construction,dimensions,depth of liquid,depth-of sludge,depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on:
✓ _ Existing information. For example,Plan at B.O.H.+
✓ _ Determined in the field(if any of the failure criteria related.to Part C is at issue,approximation of distance is unacceptable)
[15.302(3)(b)].
✓ _ The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of
SubSurface Disposal Systems.
revised 9/2/98 Page 5of11
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 25 Jubilation Way, Marstons Mills, MA
Owner: Robert Friberg
Date of Inspection: July 6, 2000 -
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 110 g.p.d./bedroom.
Number of bedrooms(design): n/a Number of bedrooms(actual): 4
Total DESIGN flow n/a
Number of current residents: 2
Garbage grinder(yes or no): Yes
Laundry(separate system)(yes or no):n/a; If yes, separate inspection required
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings,if available(last two year's usage(gpd): 1999-144,000 ftals.; 1998-14Z000 gals.
Sump Pump(yes or no): No
Last date of occupancy: occupied
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow: ¢ud(Based on 15.203)
Basis of design flow
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:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
Punwed months alto-per owner.
System pumped as part of inspection(yes or no): No
If yes,volume pumped: gallons
Reason for pumping:
TYPE OF SYSTEM
✓ tic tank/distribution box/soil abso• tion s
_ � absorption stem Y
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) (if yes,attach previous inspection records,if any)
I/A Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
-APPROXIMATE AGE of all components,date installed(if known)and source of information: July 19178-per as built card.
Sewage odors detected
_ . (y _
when arrivingat the site: es or no) No
III
revised 9/2/98 Page6of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 25 Jubilation Way, Marston Mills, MA
Owner: Robert Friberg
Date of Inspection: July 6, 2000
BUILDING SEWER: _
(Locate on site plan)
Depth below grade:
Material of construction: _cast iron !40 PVC _other(explain)
Distance from private water supply well or suction line
Diameter
Comments: (condition of joints, venting,evidence of leakage,etc.)
SEPTIC TANK: ✓
(locate on site plan)
Depth below grade: 16"
Material of construction: ✓concrete _metal _Fiberglass Polyethylene other(explain)
If tank is metal,list age_ Is age confirmed by Certificate of Compliance_(Yes/No)
Dimensions: 1500 gal.
Sludge depth: 0"
Distance from top of sludge to bottom of outlet tee or baffle: 32" _
Scum thickness: 1"
Distance from top of scum to top of outlet tee or baffle: 9" _
Distance from bottom of scum to bottom of outlet tee or baffle: 14"
How dimensions were determined: Measuring stick .
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.) The tees were present. The liquid level was even with the outlet invert. There were no sign of leakage. Scum and
Adze were minimal.
GREASE TRAP: None
(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:
(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.)
revised 9/2/98 Page 7of11
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 25 Jubik don Way,Marston Mills,MA
Owner: Robert Friberg
Date of Inspection: July 6, 2000 *.
TIGHT OR HOLDING TANK: None (Tank must be pumped prior to,or 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:
Alarm level: Alarm in working order: Yes— No_
Date of previous pumping:
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
DISTRIBUTION BOX: ✓
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) The box was not duff up.
There were no sirens of failure in the leach pit
PUMP CHAMBER: None
(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.)
revised 9/2/98 Page 8ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 25 Jubilation Way, Marston Mills, MA
Owner: Robert Friberg
Date of Inspection: July 6, 2000
SOIL ABSORPTION SYSTEM (SAS): ✓
(locate on site plan, if possible;excavation not'required, location may be approximated by non-intrusive methods):
If not located,explain:
Type:
leaching pits, number: I-6'x 6'
leaching chambers, number:
leaching galleries, number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool, number:
Alternative system:
Name of Technology:
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.)
The nit had 4'of water on the bottom. The scum line was at water level. The bottom to rtrade was 96". There were no sign of failure.
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.)
revised 9/2/98 Page 9of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 25 Jubilation Way, Marstons Mills, MA
Owner: Robert Friberg
Date of Inspection: July 6, 2000
Map: 098
Parcel: 063
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
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8�- 3�
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y
revised 9/2/98 Page 10of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 25 Jubilation Way,Marstons Mills, MA
Owner: Robert Friberg
Date of Inspection: July 6, 2000
NRCS Report name
Soil Type
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells
Estimated Depth to Groundwater Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observed Site(Abutting property,observation hole,basement sump etc.)
Determined from local conditions
✓ Checked with local Board of Health
Checked FEMA Maps
Checked pumping records
Check local excavators, installers
✓ Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
The bottom of the pit to grade was 96". Using the USGS map, the Barnstable topographic map and water contours map,
the maps were showing apprazimately 33' +/-to groundwater at this site. Using the Cape Cod Commission Technical
Bulletin, the high groundwater adjustment for this site(SDW 253,Zone C, 5/00)was 6.7'.
This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty
or guarantee that the system will function property in the future. There have been no warranties or guarantees, either expressed,
written or implied, relating to the system, the inspection and/or this report.
revised 9/2/98 Page 11of11
TOWN OF BARNSTABLE
LOCA'P,0N 25 JVt o I ^ W SEWAGE #
VIL:c ✓V1• ✓Y1► IS II I ASSESSOR'S MAP & LOT 063
INSTALLER'S NAME&PHONE NO. �r'Gh►b/�)
SEPTIC TANK CAPACITY S�
LEACHING FACILITY: (type) ►r (size) (ex(D
NO.OF BEDROOMS 41
BUILDER OR OWNER QO �Ltt-
PERMTTDATE: GCi7 COMPLIANCE DA'TF:
Separation Distance Between the: SeP ` t^S�cC+i o '1 b
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
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at- 35'
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LA VAT ION �� ° S E W A 7& PERMIT NO.
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5.2O
V1LZAGE
I N S T A LLLER'S NAME S ADDRESS
B UILDE R / OR OWNER '
DATE PERMIT ISSUED
DAT E COMPLIANCE ISSUED
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No.60)m
THE COMMONWEALTH OF MASSACHUSETTS ~
BOARD OF HEALTH
............................ .........OF...................................--....................................................
Appliration for Elispustt1 Wilms Tomitrnrtion Vrrutit
Application is hereby made for a Permit to Construct (" ) or Repair ( ) an Individual Sewage Disposal
S stem at A
--�
0_. l -------- ------- .
�� L ti ddre � � _(�� ^� or Lo�No. .....a
---- l/ .. / sf/�Y/ ---- --------- f'F
Owner Address
a -•-------•--.... -----------------------------------------•-•-•------- ------------------------ S1................ -•-•-----------•-------•---------
Installer Address
UType of Building Size Lot---- .,. .... Sq. feet
Dwelling—No. of Bedrooms___-___: .....................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________No. of persons............................ Showers ( ) — Cafeteria ( )
QOther xtwes --------------------------------•--=------------------........................ --------------------
WDesign Flow.......... ........•--------_____....___.gallons per person per day. Total daily flow___.___ ..............................gallons.
WSeptic Tank.-t Liquid capacity�Q'�___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 ( ) - 1e"
Percolation Test Results Performed by..................................-------••------•-----••-•--------•---- Date.......................................
Test Pit No. 1.. .__._.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 of Soil Q~' .' - (------------- -
U -------------------------------------------------------------------
---------------•----------------------------------------------------------------------------------
----
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 Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been iss d by th and lth.
,,,,)Signed ........... ......... ................................................. ...44�/
Application Approved BY = D�
Date
Application Disapproved for the following'reasons:•---•-----------•--•-------•-•--••------------•-------------------------•---------•---------••................ C.
Date
PermitNo................................................--....... Issued....7"I�`...............---Date
No.--- ............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............... .......................OF.....................................
Appliration for Diaputial Marko Tomitrurtion Permit
Application is,,hereby made for a Permit to Construct.O or Repair an Individual Sewage Disposal
System at:
.............................. ......................................................
......... ...................................................................................................
/re, ....
...... Location or Lot N..�
.. ..........
...... . ....... ...... .................................. ............. ........ ..... ................. ........ ................. ............................
Owner ...Address
7............................................................................................ .......w.........................................................................................
j-7taller Address
Lt----o '7
Type of Building size ......Sq. feet
U
Dwelling—No. of BV-drooms_____________- .......................Expansion Attic Garbage Grinder
Other—Type of BdIding ............................ No. of persons............................ Showers Cafeteria
i
Other—fixuares ..................................................................................................
Design Flow, ...IS .....................gallons per person per day. Total daily flow_..._ age---------------------------------
......................................gallons.
9 Septic TankT'Liquid capacity......I....gallons Length................ Width___-_____.-..... Diameter..........._____ Depth.._.._.._.._....
Disposal Trench—No..................... Width.-_..__.._.......... Total Length._........._..._.___ Total leaching area....................sq. f t.
Seepage Pit No.--",/........... Diametef.................... Depth below inl-4-.0
_7A... Tot4jeaching area------------------sq. ft.
Other Distribution box.'
Z Dosing tank
Percolation Test Resulyj_., Performed by.......................................................................... Date----------------------_...............
Test Pit No. ---minittes per inch Depth of Test Pit.................... Depth to ground water__-_-•_____-_-_-_-___---
fsl Test Pit No. 2------ ...._..minutes per inch Depth of Test Pit.................... Depth to ground water........................
. 0
f4cription of Soil.......... .. ........ --------------------------------------------------------------------------------------------------------------
........................................................................................................................................................................................................
......................................................................................................................... w-------------------------- .................................................
U Nature of Repairs or Alterations—Answer when applicable.....................I.......................I----------------------------------------------------
.................................................................. ...................................................................................................................................
Agreement:
The undersigned agrees, to install the aforedescribed Individual Sewage Disposal.System in accordance with
the provisions of Article XI 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,ofh:aIth
/o? 7 � _
ig/n .... .....4.S, . ................................4.................................
7V'
Application Approved BY--- ... •......... .. . ..... ........... --------------------------- ----------------------------------------
_51A Date
Application,�6is• ap roved for ;he following reasons:................................................................................................................
p
..................... ...................................................... ............................................................................................ -----------------------
Date
PermitNo.......... = t5..................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
' BOARD�,PF HEALTH
..................... . ................................. ......................................
0 F....
Q.1prtifirate of Tompliana
T is 1:4 ER Y Th' e I ividu ewage Disposal System constructed or Repaired
by----- . .. .. ... ... .... . ... .. .......... ................ ... ------/.... . ---- ............... ........;.�......�._
at... ... .... ------------------ ............. ..!t........... ........
Or
has been installed in accordance with;the prov'i i ons of e ob The State Sanitary C 1.e d. pribed in the
applicition.fot,Disposal Works Construction Permit No......... ..................... dated.....�q.....................................
--------- .....
T14E -ISSUANCE OF THIS' CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION—SATISFACTORY. ,
DATE---------------------- ----------------- ............. .................. Inspector...........................
- ------------ --------7..... ----------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD HEAL";
........OF... ............................ ..................
FEE. ...................
No.........................
Per miOKis ere rant
--------------- ------ - -------- ---- ---
. ............. ....
to Cons rR1r d .. ..........
ispos'al
. .........
at No.7 ...... ------------- .................. ... ............
F- -- ----------------
stredt"
as shown on the application for Disposal Works Construction 06?1 " j - -_ Dated-_ -.-_----, .........................
0 0 or
0 I/F -1
'o 0
.......... . .... ....
........>P
--------------------
Board He7
DATE .Lz�..............---------- ---------
........................................ o , aIT
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