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HomeMy WebLinkAbout0309 MISTIC DRIVE - Health t 309 Mistic'Drive I Marstons Mills.) P A = 080 J022 Na 4210 1/3 YEL ,f a n d ff 9 r -SELT 1 0% n� G� g L( 'C�.��7,2 IIJ� Town of Barnstable Health Inspector FZHE T Regulatory Services Office Hours =ao o g Y 8:30—9:30 o� Thomas F.Geiler,Director 3:30—4:30 9B�NSTABLE• Public Health Division �p 039. a�0 Thomas McKean,Director TED MA'S 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 AMNESTY PROGRAM APPLICANT — SEPTIC QUESTIONNAIRE Date: 1. General Information: Size of Property: ! , 03 C,C rC 5 Address: 309 MISTIC DRIVE MARSTONS MILLS,MA 02648 Map 080 Parcel 022 Name:KATHRYN K GIANNO Phone#: 2a. How many bedrooms exist at your property now? M CA j y) 2b. Are you planning to add any bedrooms? If yes,how many? YYt rurst / 2c. How many bedrooms total are proposed at this property(including the amnesty unit)? 2d.Please include a copy of the floor plans for the entire property. Neatly use a straight-edge. Show all existing rooms in the home and the proposed amnesty apartment. Provide width measurements of any open doorways. Please label each room clearly. 3. Is the dwelling connected to public sewer? YES or If the dwelling is connected to public sewer,skip questions#4 through#9 below. 4. Location of dwelling is INSIDE or OUTSIDE a Saltwater Estuary Protection Zone? 5 . Location of dwelling is INSIDE or OUTSIDE a Zone of Contribution to public supply wells? 6. Is the dwelling connected to an ONSITE WELL or to PUBLIC WATER? 7. Is a disposal works construction permit on file? YES or NO 8. If yes,how many bedrooms were approved according to this permit? Bedrooms. 9. Were any building permits obtained for construction of additional bedrooms? YES or NO 10. Is there an engineered septic system plan on file at the Health Division? YES or NO 11. Has the septic system been inspected by a DEP certified inspector within the last two years? YES or NO ------------------------------------------------------------------------------------------------------------------- FOR OFFICE USE ONLY The Public Health Division has no objection to bedrooms at this property. Special Conditions: Signed: Date: Q:\GMD-Housng\Accessory Affordable Apartment Program\ADMIN\FORMS&LETTERS\Blank Forms amnestyapp I.DOC N Q � Town of Barnstable Health Inspector FIME T Regulatory Services Office Hours g yery 8:30—9:30 Thomas F.Geiler,Director 3:30—4:30 i lARNSTABLFE * Public Health Division �ATFn 3 ADO Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 AMNESTY PROGRAM APPLICANT - SEPTIC QUESTIONNAIRE'. Date: 1 ' 1. General Information: Size of Property: I, 03 c4—c e 5 Address: 309 MISTIC DRIVE MARSTONS MILLS,MA 02648 Map 080 Parcel 022 Name: KATHRYN K GIANNO Phone#: 2a. How many bedrooms exist at your property now? PA(A[h I Wu 2b. Are you planning to add any bedrooms? If yes,how many? a i'Y1 rt rS 2c. How many bedrooms total are proposed at this property(including the amnesty unit)? 2d.Please include a copy of the floor plans for the entire property. Neatly use a straight-edge. Show all existing rooms in the home and the proposed amnesty apartment. Provide width measurements of any open doorways. Please label each room clearly. 3. Is the dwelling connected to public sewer? YES or 0 If the dwelling is connected to public sewer,skip questions#4 through#9 below. 4. Location of dwelling is INSIDE or OUTSIDE a Saltwater Estuary Protection Zone? 5 . Location of dwelling is INSIDE or OUTSIDE a Zone of Contribution to public supply wells? l 6. Is the dwelling connected to an ONSITE WELL or to PUBLIC WATER? a C:) _;1 7. Is a disposal works construction permit on file? YES 'ore NO 8. If yes,how many bedrooms were approved according to this permit? Bedrooms. `j� 9. Were any building permits obtained for construction of additional bedrooms? YES or NO 10. Is there an engineered septic system plan on file at the Health Division? YES or NO 11. Has the septic system been inspected by a DEP certified inspector within the last two years? YES or NO ------------------------------------------------------------------------------------------------------------------- FOR OFFICE USE ONLY The Public Health Division has no objection to bedrooms at this property. Special Conditions: Signed: Date: Q:\GMD-Housing\Accessory Affordable Apartment Program\ADMIN\FORMS&LETTERS\Blank Forms amnestyapp 1.DOC C. yriec��wz�� D5 71 O D M � `�. `vimim �P U�b S mqwsxq�? s � DpUJ Td`O A-�t� 5 l3Cc�GT AgbbE fiNES77iT"�S p _ X �AVT Act Town of.Barnstable Health Inspector �FZHE r Regulatory Services office Hours g y 8:30—9:30 y�P os Thomas F. Geiler,Director 3:30—4:30 BARNSrABM i Public Health Division . 9 MASS' 1639. ago Thomas McKean,Director �AtEO MP'I 200 Main Street,Hyannis,MA 02601 . Office: 508-862-4644 Fax: 508-790-6304 AMNESTY PROGRAM APPLICANT — SEPTIC QUESTIONNAIRE Date: 1. General Information: Size of Property: ) 0 3 C�Ck'e 5 Address: 309 MISTIC DRIVE MARS'TONS MILLS,MA 02648 Map 080 Parcel 022 Name:KATHRYN K GIANNO Phone#: 2a. How many bedrooms exist at your property now? i)2� n h.ou.Sf-- 2b. Are you planning to add any bedrooms? (�,`j If yes,how many? —j--Lc,hn runs tz,j � �t 2c. How many bedrooms total are proposed at this property(including the amnesty unit)? 2d.Please include a copy of the floor plans for the entire property. Neatly use a straight-edge. Show all existing rooms in the home and the p oposed amnesty apartment. Provide width measurements of any open doorways. Please label each room clearly. 3. Is the dwelling connected to public sewer? YES or If the dwelling is connected to public sewer,skip questions#4 through#9 below. 4. Location of dwelling is INSIDE or OUTSIDE a Saltwater Estuary Protection Zone? 5 . Location of dwelling is INSIDE or OUTSIDE a Zone of Contribution to public supply wells? 6. Is the dwelling connected to an ONSITE WELL or to PUBLIC. WATER? 7. Is a disposal works construction permit on file? YES or NO 8. If yes,how many bedrooms were approved according to this permit? Bedrooms. 9. Were any bu_lding permits obtained for construction of additional bedrooms? YES or NO 10. Is there an engineered septic system plan on file at the Health Division? YES or NO 11. Has the sepic system been inspected by a DEP certified inspector within the last two years?, YES or NO ------------------------------------------------------------------------------------------------------------------- FOR OFFICE USE ONLY The Public Health Division has li bjection to bedrooms at this property. Special Conditions: Sign e Date: Q:\GMD-Housing\Accessory Affordable Apartment Program\ADMIN\FORMS&LETTERSTIank Form anm styappl.DOC GOP Bk 244.72 Ps 285 �17162 DEED RESTRICTION Whereas, Kathryn Gianno, of 309 MISTIC DRIVE, MARSTONS MILLS, MA, is the ' owner of 309 MISTIC DRIVE,MARSTONS,MILLS, MA (hereinafter referred to as MS. GIANNO. MS. GIANNO agreed with the Town of Barnstable Board of Health to a restriction as to the number of bedrooms which can be included in any home built on said lot as a pre- condition to obtaining approval of said property into the AFFORDABLE HOUSING PROGRAM. NOW, THEREFORE, MS. GIANNO does hereby place the following restriction on above-referenced land in accordance with this agreement with the T OWN OF BARNSTABLE BOARD OF HEALTH, which restriction shall run with the land and be binding upon all successors in title: 309 MISTIC DRIVE, MARSTONS MILLS, MA, may have constructed upon the lot a house containing no more that FOUR(4) BEDROOMS. } BRIAN R LAWLESS Notary Public " ►;' . CC)MMONWEALTH 0� MASSACHU8ET�8 't�.• My commission Expires February 22,2013 BARNSTABLE .REGISTRY-OF DEEDS I I I i t i II ILL rN zm - i l 1-7 I. -1 �. r- - i 77 Ile o� 1 t OCT 15 2002 COMMONWEALTH OF MASSACHUSETTS TO'�:NN rf'PFi;;ivSTn6i_c EXECUTIVE OFFICE OF ENVIRONMENTAL AFF RS Hr--,A!TH DEPT.ki p DEPAR=ENT OF RNVIRONMENTAL PROTECTION MAP PARCEL ; TITLE 5 LOT _ OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 309 Mistic Drive Marston Mills MA 02648 Owner's Name: Kathryn Gianno Owner's Address: same Date of Inspection:October 2,2002 Name of Inspector: PATRICK NL O'CONNELL Company Name: SEPTIC INSPECTION SERVICES CO. Mailing Address: 189 CAMMETT ROAD MARSTONS MILLS MA 02648 Telephone Number: (508)428-1779 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.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: o � 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 DER The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Adder: 309 Mistic Drive,Marston Mills Owner: Kathryn Gianno Date of Inspection: October 2,2002 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X_ I have not found any information which indicates that any ofthe failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. The septic tank is metal and over 20 years old'or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broker,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced, obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 309 Mistic Drive,Marston Mills Owner: Kathryn Gianno Date of Inspection: October 2,2002 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. — The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form 3. Other. Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 309 Mistic Drive,Marstons Mills Owner: Kathryn Gianno Date of Inspection: October 2,2002 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _X— Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool —X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X— Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X_ Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow _ _X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface — — water supply. X_ Any portion of a cesspool or privy is within a Zone 1 of a public well. _X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ _X_ 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 conform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered A copy of the analysis must be attached to this form.] No_(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. LargeSystems: S tems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped. Zone H 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. Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 309 Mistic Drive,Marstons Mills Owner. Katbryn Gianno Date of Inspection: October 2,2002 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No X _ .Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks? X _ Has the system received normal flows in the previous two week period? X Have large volumes ofwater been introduced to the system recently or as part of this inspection? X _ Were as built plans of the system obtained and examined?(If they were not available note as NIA) _X _ Was the facility or dwelling inspected for signs of sewage back up? _X _ Was the site inspected for signs of break out? _X _ Were all system components,excluding the SAS,located on site? _X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of constriction,dimensions,depth of liquid,depth of sludge and depth of scum? _X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The sae and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no X_ _ Existing information.For example,a plan at the Board ofHealth. X Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 309 Mistie Drive,Marston Mills Owner. Kathryn Gianno Date of Inspection:October 2,2002 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 4_ Number of bedrooms(actual):_4_ DESIGN flow based on 310 CIVIR 15.203(for example: 110 gpd x#of bedrooms): 440_ Number of current residents: 3 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use:(yes or no): No Water meter readings,if available(fast 2 years usage(gpd)): 349 Sump pump(yes or no): No Last date of occupancy: Currently Occupied COMMERCIAL)INDUSTRUL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings,if available: last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records None Source of information: Was system pumped as part of the inspection(yes or no): No If yes,volume pumped:____fflffons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM X_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)No _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval —Other(describe): Approximate age of all components,date installed(if known)and source of information: 26 Years. Were sewage odors detected when arriving at the site(yes or no): No ,1. Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 309 Mistic Drive,Marstons Wdis Owner. Kathryn Gianno Date of Inspection: October 2,2002 BUILDING SEWER X (locate on site plan) Depth below grade: V Materials of construction:—cast iron _X_40 PVC other(explain): Distance from private water supply well or suction line: 22' Comments(on condition of joints,venting,evidence of leakage,etc.): No evidence of backup. SEPTIC TANK: X (locate on site plan) Depth below grade: 16" Material of construction:_X— —concrete_metal fiberglass—polyethylene other(explain) If tank is metal fist age:— Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of certificate) Dimensions: 1500 Gal. 6.2'a 9X Sludge depth: 6" Distance from top of sludge to bottom of outlet tee or baffle: 24" Scum thickness: 2" 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: 16" How were dimensions determined: STICK WITH HINGE FLAP. 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 structurally sound,Effluent level at bottom of outlet pipe GREASE TRAP:_(locate on site plan) Depth below grade:— Material of construction: concrete metal fiberglass__polyethylene—other (explain): — —metal - Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE_ SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Adder: 309 Mistie Drive,Marston Mills Owner. Kathryn Gianno Date of Inspection: October 2,2002 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: - concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: X_(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.): Bog set level,Effluent level with both outlet pipes PUMP CHAMBER: (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.): 1 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 309 Mistic Drive,Marston Mills Owner: Kathryn Gianno Date of Inspection: October 2,2002 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: Type X_leaching pits,number: 2(two)6'X 6' _leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovativelalternative system Typetname of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): No damp soil or excessive vegetation. 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 or no): 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.): Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 309 Mistic Drive,Marston Mills Owner: Kathryn Gianno Date of Inspection: October 2,2002 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. 309 R Ol - 04 5 �s 5y a Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 309 Mistic Drive,Marstons Mills Owner. Kathryn Gianno Date of Inspection: October 2,2002 SITE EXAM Slope Flat Surface water None Check cellar Dry Shallow wells None Estimated depth to ground water: IS Feet Please indicate(check)all methods used to determine the high.ground water elevation: Obtained from system design plans on record-Hchecked,date of design plan reviewed: X_Observed site(abutting propeatylobservation hole within 150 feet of SAS) Checked with local Board ofHealth-explain: Checked with local excavators,installers-(attach documentation) X_Accessed USGS database-explain: USGS maps and TOB groundwater contour map. You must describe how you established the high ground water elevation: Observation hole on previous report found water at 15 feet. Also checked town groundwater contours show water @ EL.41-42 checked USGS maps show property @ EL.56.Bottom of leaching pits nine to ten feet below grade. �\ COMMO\NVEALTH OF MASSACPUSETTS _ ? EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS e '>' DEPARTMENT OF ENWIRONME\TAL PRO I® ONE WINTER STREET. BOSTON. NIA 02109 15)"-29_ (1 T. OpF a %%-ILLIA%'F V1ILD l J TL'DY C0\1 Gocernc �y%V 1 Sere ary ARGEO PAIL CELLUCCI y�leo,gg�F 9`9T DA 1, B STRUHS Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION 'Q ornmissio= PART A CERTIFICATION 9 Property Address; 3o°t M►r-TiLlmt M0StsTaa4.#A%ljJ Address of Owner: �q, ,,s v`A %kA., Date of Inspection: t _ (If different) Name of Inspector: I 3)�ioro At sr, I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 Ch117.000) Iy*pgt�t4S Company Name:AA q r14-,•C E,1 A-"i^,-j+1 0-le.,, Maiiing Address: R p Aox -E-3Z Gt , H f544"_Q- H i9-© q Telephone Number: r5-e �- /��- / & P t7 --r CERTIFICATION STATEMENT I cenin that I have personally inspected the sewaee disposa' system at this address and tha: the information reported belovv is true, accurate and cornolete as of the time of inspec,o The inspection was performed based on my training and experience in the proper iunction and maintenance of on-site sewage disposa. systems. The syste-n: - Passes _ Coneitionai!� Passes Neecs Furthe• Evaluat:on B\ the Lccal Approving Authority Fa.,s Inspector's Signature: 114 Date: „__ Svste^ Inspector shal' subma, a copv of this inspectior reoor, to the Approving Authority within thirty (30) days of completing this ins:�ectior.. If the system is a shared vstem o, ha a desig- flow of 10,000 gpd or greater, the inspector and the system owner shall submit the repo-: to the appropriate regional office of the Department of Environmenta! Protection. The orig:na! should be sent to the system owner and copies to the buyer, if applicable, and the approving authoriry. INSPECTION SUMMARY: Check A, B, C, or D: Al SYSTEM PASSES: 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 be�ow. COMMENTS: BI SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upw complet.on of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes, no, or not determined (Y, N, or NDt. Describe basis of determination in all instances. If"not determined", explain why r The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificat Compliance (attachedi indicating that the tank was installed within twenty (20) years prior to the date of the inspe !' the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltratio, failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming se ;r as approved by the Board of Health. (rev:aad 04/25/Y7) Page 1 of 10 DEp on the Woma Wiae Weo httA.rrwww magnet state ma.usroec 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Add.-Ws: 44 Owner: *" Date of1,nspectioC � B] SYSTEM CON�DITIIONAL �€ PASSES tcontin;red _ r Sev`age,backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipets)or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system recurred 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 replacec obstruction is removed C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which rewire further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safer• and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM 15 NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or pr;%, ,s within 50 feet of a surface water _ Cesspool or pr:%. ;s 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 PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system ha: a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a sL;.-race water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I 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 sL;oply 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 4 (revised 04/25/97) Page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: �Bg rTiv Owner: WN8+N Date of Inspection: BUILDING SEWER: (Locate on site plan) Depth below grade. Material of construction: cast iron _40 PVC _other (explain` Distance from water rvate supply well or suction Ii P Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK: (locate on site p ll Depth below gradeJE Material of construction: 4concre:e _me:a _Fiberglass _Polyethvlene _othertexplain If tani, is me-a!, I.s: age _ is age confirmec b\ Ce-t:f;cate of Compt;ance _(Yes"No Dimensions Sludge depth _ N ba�ie�� D;siance from top o: s!udge to bottom of curie: tee o Scum thickness: n" �( Distance from top of scum to top of outle: tee or ba^ie n Distance from bottom of scum to bo-o^n o-outlet tee or bane.1 how dimensions were determined Comments trecommendatiorr for pumping, condition , ini t rid outlet tees or baffles. depth of liquid level ir. rela on to outlet in v rt, stru urai integrity, evidence of Ikage, e;c.t Me ms Irul v.1 170 I)l 4 14-1 GREASE TRAP: (locate on site plan; Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle. Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level ir.relation to outlet invert, structural ;ntegrity, evidence of leakage, etc.; i i i} it t (rev:iad W25.91) Page 6 of 10 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION O Prop ertN Address: , 3 � uMsr c, Owner: uUA Date of Ihspectiiln: l) 1,5 w1 FLOW CONDITION'S RESIDENTIAL: Design flo\ .'440 g.o.d./bedroom for S.A-S Number of bearooms Number o°current r i es dents —03 Garbage g,. der (yes or no,: Laundry cor•^ected to system (yes or no' .. Seasonal use (yes or no!: Water meter readings, if available (last two i2: year usage tgpd): 0 Sump Pump Ives or no):� Lai: date o occupancy COMMERC rr4 1NDUSTRIAL• Type of establishment Design fio%% _ga!ions/da,, Grease trap present. (ves or no' Industna! l%aste Holding Tani; present. eves or no `:on-sanitarti waste discharged to tr,e T!t,e ; system. ;ves or no hater meter readings. if availabie Las:Pate o: o c::panc, OTHER: .De_cribe Last care of occuaanc. GENERAL INFORtitATION PUMPING RECORDS an source f mfornation. , System pumped as par, of rnspec-on: Ives cr no. If yes, volume pumped gallons Reason for pumping TYPE OF SYSTEM _ Septic tank,/distribution box/soil absorption system Single cesspool P Overflow cesspool Prny Shared system (yes or no), (if yes, attach previous inspection records, if any) I/A Technologv etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: ray Sewage odors detected when arriving at the site: (yes or no)�u (revised 04/25/9'7) Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: DJ SYSTEM FAILS: You must indicate either "Yes" or "No' as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determin what will be necessary to correct the failure. Yes No ® Backup of sewage into facility or system component due to an overloaded or cl ed SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface wate due to an overloaded or clogged SAS or cesspool. Sta:ic houid level in the distribution boa above outlet invert due to an erloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available v ume is less than 1/2 day flov.. Recuired pumping more than 4 times in the last year NOT due clogged or obstructed pipes:. Number of times pumped Any portion of the Soil Absorption System, cesspo/asurace below the high groundwater eievanoc I Arr por,:on o'a cesspool or privy is within 100 fe water supply or tributary to a surface water supply. Any portion of a cesspool or prntiv is within a Zon well. ® _ Am. po�io-. o-*a cesspool or prnti• is within 5 feet of a private water supply well i ® Any pon,or. of a cesspool or prnti• is less tan 100 feet but greater than 50 feet from a private vvater supoiv well with no acceptable Ovate, qualm analysis. If the ell has been analyzed to be acceptabie, artach cope of well water analysis for cohiorm bacteria. volatile organic com ounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: You must indicate e,:her "Yes' or "No" as to each iof the following: The folioK:ng criteria aopi\ to large sy.tems in.addition to the criteria above: The systern serves a facile with a esign flow of 10,000 gpd or greater (Large System; and the system is a significant threat to p&ic hea!th and safety and the 'nvtronment because one or more of the following conditions exist: Yes No the system is wi, in 400 feet of a surface drinking water supply the system is ithin 200 feet of a tributary to a surface drinking water supply ® the syste is located in a nitrogen sensitive area (Interim Wellhead Protection Area- IWPA) or a mapped Zone II of a public vyater supply well) The owner or operator �fany such system shall bring the system and facility into full compliance with the groundwater treatment progra requirements of 314 4.1R 5.00 and 6.00. Please consult the local regional office of the Department for further information. �± r (revised 04/25/97) page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Propert. Address: 30c, 6t'1 sin— , Owner: �kA1(/q Date of Inspects n: 11 5-7 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: s 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 roen obtained and examined. Note if they are not available with N/A. The facili-,.. or civ.-Ohng was inspected for signs of sewage back-up. ... X _ The s%-stem does not receive non-sanitary or industrial waste flow. _ The site was inspect"! for signs of breakout. _ All s.sterr. compone-t_, excludine the Soil .Absorption System, have been located on the site. The septic tank man-.oies N&ere uncovered, opened. and the interior of the septic tank was inspected for condition of baffies or tees. mate-.a; o' construction. dimensions, depth of liquid,,depth of sludge, depth of scum. The size and locat,on of re Soil Absorption Svstem on the site has been determined based on: _ The facJit,, ov,ne• ;a-a occupants. if dirterent trorn owneri were provided with information on the proper maintenance of Sub-Suriace Disposa Svstem. Existing information. Ex. Plan at B.O.H. X _ Determined in the field if am of the failure criteria related to Part C is at issue, approximation of distance is unacceatabie (15.3E2.31.b'l trevimad 04/25/5?1 Page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: c36� U�It6T� Owner: Date of Inspecti n: tj�e �j. TIGHT OR HOLDING TANK: Tank must be pumped prior to, or at time, of inspections (locate on site plan, Depth below grade: Material of construction. _concrete _metal —Fibergiass _Polyethylene —other(explain) Dimensions: Capacity:_ galions Desir flow, gahons.da, Alarm level Alarm in Horking order_ Yes; _ No Date of previous pumping Comments (condition of snle tee. condition o' alarm and float switches. etc.) DISTRIBUTION BOX:..JAtS (locate on si.e par oel Dept� of lia.u•- le e•. aoo,.e outie: ime': Comments ` mote ,f level a.;d d tnb'j'o evidence 91 soilds rover, evidence of leakage t to onout f b x, etc.) i J WO PUMP CHAMBER: (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.) f (revised 04i25/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM .PART C n SYSTEM INFORMATION (continued) Property Address: Owner:UW Date of Inspecu :it15 SOIL ABSORPTION SYSTEM,(SAS): (locate on srte.plan, if possible, exca,Jison not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits. number.-a`(,)k(; leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensio.^.s. overflow cesspool, number Alternative system Name of Tecnnologv. Comments. t ote condition o soii, s!gr.s of hydraulic failure, lever of ponding, con rti , of vegetation, tc.) 1 r� d t ti CESSPOOLS: (locate on site plan Numbe• and configura:-on Depth-too of liquid to inlet inver, Depth of solids layer Depth of scum layer. Dimensions of cesspool Materials of constructior Indication of groundwate- inflow tcesspool must De pumper as par, of inspection 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.) (revised 01/25/97) Pago a of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Properh Address CF �\ Owner: ` Date of InMpecti n: SKETCH OF SEWAGE DISPOSAL SYSTEM. include ties to at least two permanent references landmarks or benchmarks locate al; wells within 100' (Locate where public water supply comes into house) LC y -----�J L l • . 5 �q- 35 94 -�o lreviaee 04'75!S") page 9 of 10 j SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Propertm Address• 3619 mis-Vic, . . Owner: V� Date of of spenion:t Depth to Groundwater Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained irom Design Plans on record Observation or Site (Abutting property, obsen•ation hole, basement sump etc.) Determine it from local conditions CneC� %%ith loca! E:,ard o, nea(tn Chec'K FE.MA maos Check pumping records Check local eacava:ors. installers Use LSCS Da-.a Describe in vox o..-. no,.• <o;: established the High Groundwater Elevation. (Must be completed, 4o cSt 6 LuJm %o roI (zev:aod 04,'2519-. Pag• 10 of 10 .i� /C" _ __LO.C&.TjO.N. _ ._ 5EW6,69_ PERMIT_MO. Lod"— 1— - - cam __ _.i1�ST_QLLER�S IJ�tJIE. _� _.ADDRESS_._ _ .BUILDER 5 _1J11ty F— 4-.ADD.RE.SS_ I�ANN i N -Eo JgLN Ems!Nc — — — — —_ .Dt►TE PER"VT 15SUED DATE'COMPLIAMCE ISSUED '� � -��, y �e P .:� _�, ,yo 3t ,� . 7 53 � �-- 13'°i�0 g,e� �ti� ' . �1 ����b�� � ��T� �' i LOC&T10N ' 5EW6,.C4E PERMIT Qo. VILLAGE IKISTQLLER 5 WWAE hDDRESS — bUILDERS L1 &MF- ADDRESS Mi.-TE PERNA T 15SUED D ATE ' COMPLI WACE ISSUED - /-� ' Pa , ,3® 3t 25 LOCATION ' SEW&C,E PERMIT M0. 111 Lq7' !�VILLAGE — �'1�es?ns IWSTQLLER�S W&& AE ADDRESS ULM BUILDERS Q &VAE ADDRESS �AAM DDkTE PERMIT 15SUED O ATE COMPLI LANCE ISSUED : 1)_ �_ 76 �Po ., 3 73z � 53 O , �T oQQ nWA-Uita 1n I No.........----•-••-- F . .................... THE COMMONWEALTH OF MASSACHUSETTS 0 BOARD O HEALTH �r1 �,...............oF............ ......._............. ................. Appliratioo -for Bi,ipoottl Works Tontitrurtion Vrrotit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: q r Locate 7—at—in-Add or or Lot No. /�1�!.....CM .........'°:"R R-------....1_. �!_�....... �?`^ ...................................................... � Owner Address C . ...................................... a .o- � .=. Installer Address T Type of Building' Size Lot--.-.;--,. P---Sq. feet U Dwelling—No. of Bedrooms______________ ___________________________Expansion Attic Garbage Grinder ( ) Other—Type of Building __......................... No. of persons............................ Showers ( ) — Cafeteria ( ) a Other fist res _______.- --- ------------- W Design Flow__ ______________ �_D .__� ._gallons per person per day. Total daily flow........ WSeptic Tank Liquid capacity];U_ _gallons Length................ Width_._ ............ Diameter-----........... Depth_............. x Disposal Trench—No. .................... Width--- ___.�_. _ otal Total leaching area..............------sq. ft. area-----------------sc it. - ---• --- Seepage Pit No...... .."._.. Diameter-___� ._. pth eW 0�4 Total le chill 1. z Other Distribution box ( ) Dosing tank ( )Percolation Test Results Performed by........................... a --•-•-----_.. Date Test Pit No. 1----------------minutes per inch Depth of "Pest Pit.................... Depth to ground water_-__-_--__-._..-._..-. (1 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water......-_-__.___._____. - a -------------- - f) ------------------- O Description of Soil-------- --0-- .1 V -----------------------------------------Z-.:".._ ...Z 'r _ ` tdE G �{• W ------------- ------------ -------------------------------------------------•-----------------------------------------------------------------------••---------------------------- •------------------- U Nature of Repairs or Alterations—Answer when applicable.............__________________________________________________________________________________. ---------------------------------------------------------------------------------------=-------------------------------------------------------------------•------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article NI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been iss ed by the board of health. -............ ................. Date Application Approved By----------- --- ----- --- - -------=---•---- 4 .4 ----T..Y ,�i� Date Application Disapproved for the following reasons----------------------------------------------------------------------------------------------------------------- Date PermitNo......................................................... Issued........................................................ Date No........`............... THE COMMONWEALTH OF MASSACHUSETTS BOARD 0 HEALTH ­­........ OF........... . . . ...................................... ApVfirafion -for Uhipoiial Marko Tomitrurtion Vanift Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: .................................................................................................. ............................................................................................ Location-Address or Lot No. ...................................................................................o............. .................................................................................................. Owner Address .............................................................................I..................... .................................................................................................. Installer Address Type of Buildibg Size Lot----------------------------Sq. feet Dwelling—No. of Bedrooms-------------- ----------- --------------Expansion Attic Garbage Grinder Other—Type of Building ---------------------------. No. of persons...._....._..._.......__..__ Showers Cafeteria Other fixtures ------------------------------------------------------ Design Flow...................371-0...............gallons per person per day. Total daily flow---,---.-% -­--------------gallons. 9 Septic Tank Liquid capacitvPYw_gallons Length................ Width Diameter_.___...._...... Depth._.._._____.._. -- ----------- Seepage Pit No......._'l........ Diameter... _/---------- Total leaching area....................sq. ft. Disposal Trench—No. .................... Width- � ri�' ...al end �4 Ivto le area Total leaching -----------sq. ft. Z Other Distribution box Dosing tank ,.-I Percolation Test Results Performed by--------------_ ......................................................... Date---------------------------- --------_ Test Pit No. 1................minutes per inch Depth of Test Pit.._..........._____. Depth to ground water...---..------_._.._-... O-A f14 Test Pit No. 2................minutes per inch Depth of Test Pit................___. Depth to ground water-_._...______.._-_-_.._. Ix ..............) .............. ......------- 0 1­1­4------ ----T----------A....................------ Description of Soil.......... ------- ---------- ----- -------------------------- .......................... ---------;4�.�.­ _q_r ---V U ------------- --------- .......................... ..... . --------------------------------------------------------- ------------------------------------- ------................................................................................................................................I--------------------­---- U Nature of Repairs or Alterations—Answer when applicable...._............................................................ --------------------------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of 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 of health. ZS' ...... ................................ n;e .......�----- ....... ......................................--------------- Date ;Z 6 - 7 Date Application Disapproved for the following reasons:............................ ............................................................................ Application Approved BY----------- .." - ------------------ ......................................................................................................................................................................................................... Date PermitNo......................................................... Issued---------------------- ................................. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF EALTH ...... . ........ 4 ...... OF.... ............. ..... ........ Tutifiratr of Tkompliana TH,e(O CER2 qted or OF , That the Individual Sewage Disposal System const�,,u -Repaired /.>..........V. ...... Z........ �7--------------- .............. 6------- -- -------------------- al has been installed in accordance with the provisions of A icl' XI of The State Sanitary Code as described in the '710_ 74.................. a --�t application for Disposal Works Construction Permit Nc & dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE-------- .......................... Inspector....C------ ------- ------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD HEALTH ...... 0 F................... ....................................................................... No� ......... ....... .. . FEE. Binvolial orkis Permission is hereby granted........ 0—,7... ......................................... ------------------------------- to Con7str 'ct ( Ar�'or,4epair oi an IvjAual Se a Dis , Sy em -- at No.- ------67,,----Y.. 9j 0 as shown on the application for Disposal Works C6nstruction rul Nollfe� .............. Dated.......................................... ............... ..4 or .. ........................................ DATE..­�_--Z.13......7.( Board of alth ....... ----------------------------------- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS No......................... FE$............................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ... .... .................OF........ ............................. ............................................... Appliratiuu -fur Ripuuttl Marks Tuuitrurtiuu Vrruiit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ----•-•------------------•-•----------•--.-.......-----....---------..-...........----------•-•--- ....................................................--------------------------------------------- Location.Address or Lot No. ....----•-••--------------------------•------..-.........---•--••---•----------------------......- ------------.....••-•--••--•-----------•-------------•-----....................------------------- Owner Address W 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 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 Pile oRisults nPn tes'eainch De th------------------------------------------ Date y--------- p p f "Pest Pit-------------------- Depth to ground water------------------------ (14 Test Pit No. 2................minutes per inch Depth of Test Pit.----------_---_- Depth to ground water............---------.-. Ix •-----------------------------------------------•-------•••---•---•--•----------•---••-••-•---••-•--......................................................... ODescription of Soil..................................................................................................................................................................... ----------- ----------------------------------------------------------------- - U Nature of Repairs or Alterations—Answer when applicable licable...----......................................................................................... Agreement: The t:-ndersigned 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 of health. Signed...................................................................................... ................................ Date ApplicationApproved By-------------------------------------------------------------------------------------------------- ---------------------------------------- Date Application Disapproved for the following reasons:............................................................................................................... .............--•------•-•............. ...•...... .............................................=....................................................................................................... Date PermitNo......................................................... Issued........................................................ Date 4w.w.r.•Jw9...wwww.r..rr..O...rrwrr.ww.wr........r.:�..wr.•.rw.....n�!.w.ww.w..........rr.....�.r1..w..r.wr.....i.w..w..........+ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... T.rrtif irate of T5,umPliaurr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by......................................................................................................................................................................................... Installer at........................................... -•-------------------••--•-•••-••-••-•--••-----------•------------•------•-----------•-------•-------•--•-•---•---............•........ .................. has been installed in accordance with the provisions of Article XI 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 CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.................................................................................... 00....... . .0•••..9.I..•..........w......04.;.e••owrw....*so.1.•.O.r•••w....O...N..w...•.•.r.1..♦..•...r J w..w w..w 00.6.006600.4 THE COMMONWEALTH'OF MASSACHUSETTS BOARD OF HEALTH ...................................I......OF....................-----.--............--..----.--.--...................----....... No......................... FEE........................ Bispurittl Morkti C11uuitrurtiuu Vrrmit Permissionis hereby granted-----------------------------------------------------•----••--••-•-...---••-....•••.....------------••••---•----•-•-•--•---•-••---•---...... to Construct ( ) or Repair ( ) an Individual Sewage Disposal System atNo............................................................................................................................................................ Street as shown on the application for Disposal Works Construction Permit No..................... Dated.......................................... -------------------------------------------------------------•--•--------•••••-••-•---•-----•--........_ Board of Health DATE................................................................................ FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS No......................... Fa$.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........... _...............OF......................................................................................... Appliratiun -fur Dispuuttl Works Tomitrurtiun Punift Application is hereby made for a Permit to Construct ( ) or Repair ( } an Individual Sewage Disposal System at: --------•-------------------------------------------•--•--------------•-•----•--------•-....--•--- .................------•---•-•-•------------•-•••--------•----•--•--------------••--••-••.------ Location.Address or Lot No. ...................•-•-----•------••---.....................---•-•.............................•• ........................................................... .......................... Owner Address w Installer Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. o persons---------------------------- Showers ( ) — Cafeteria ( ) Other fixtures ......................................................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 ( ) aPercolation Test Results Performed by----- ----------- --•--------------..._--------........_......--_•-•-- Date........................................ Test Pit No. 1................minutes per inch Depth of "Pest Pit-------------------- Depth to ground water...._._.-.__-_----..---. rXq Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground water-_._..--__-_____--.-.--. 9 ••------------------ ---------------------------- ---------•----- .......................................................................................... ODescription of Soil------------------------------------------------------------------------------------------------------------------------------------------------------------------------ x c, w U Nature of Repairs or Alterations—Answer when applicable................................................................................................ -------- ------------•--------------.-._.-----_..-.--.---------------------------- ... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of 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 of health. Signed-------------------------------------------------------------------------------------- ................................ Date ApplicationApproved By-------------------------------------------------------------------------------------------------- ......................... ----- Date Application Disapproved for the following reasons----------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------•-•---------------------------------------------------------------------------------------------------------------- Date PermitNo......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... �rrtifirate of VmJ.11mV1ianrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by........................................................................................... -- --------------•--•------••-•-•--•----•-•-----•---•••---•-----•----------------••......-----•------•-- 'InStaller at......................................... has been installed in accordance with the provisions of Article XI 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 CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE......................................... ...................................... Inspector------------------------------------------------. .................................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .........................................OF................................................................-----------......... No......................... FEE........................ Ris:pusttl NorksCnuu trnrtiaan rrutit Permissionis hereby granted----------------------------------------------------•--•-------...------•-----------------........-----------•••---•-----•--------••••-•-_... to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at No. Street as shown on the application for Disposal Works Construction Permit No--------------------- Dated.......................................... --------------------------------------------------- .............................................. Board of Health - DATE.-•--•----....-•..................................................•----....... FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS t I.yl�/_9/Y , I h E i_17 — o; r�,.Ssa_ , ► I A izi • I I � t