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HomeMy WebLinkAbout0801 MISTIC DRIVE - Health 0711-Wisisc Drive " Marstons Mills P A = 079 056 1 i i r - r DATE : 616103 PROP'E-RTY ADDRESS: 801- Mi,6t.ic /DIt.ive - Na.3.6. 026 4 8 On the above date, I inspected the septic system at the above ad msa `____ This system consists of the following: _RL7 , 1. 1- 1000 gai-Pon ze/at.ic tank. 2. 1-Dizt2.igut.ion 9ox. JUN 2 0 2003 3. 2- 600 gaPion /22ecazt .Peach.ing p.itz. 121X4 ' N OF BARNSTABLJE Based on my Inspection, I certify the following conditions: T�WHEALTH DEPT. �4. 7h.iz .i-6 a t.itie live zept.ic zyzt�em. (78 Code) MAP r5. The ze/2tic zyztem .iz ,.in /22ol2elt wotk.ing o2dea at .the /22ezent time. PARCEL 6. Pum/2ed ze/2tic tank at time o/ .inz/2ection. 7. Raised loth 12it cove2z at time o/ .ine/2eet.ion. LOT SIGNATUR Name : - J__ P__Macomber_Jr ___-- r, Corripany :, gatph _?J_M_�g4mt€r 8_ Son, Inc . Address : _@Qx _r�------------ --Ce_11CPLYLLtit ,,_ Na--2Z632-0066 Pnone : __508- 775- 3 338 THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY JOSEPH P. MACOMBE R & SON, INC. Tank$-Cesspools•Leachilelds Pumped & Installed Town Sewer Connections P.0 'Box 66 Centerville. MA 02632.0066 775.3338 775.6412 COMMONWEALTH OF MASSACHUSETTS = EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION i TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL, SYSTEM FORM PART A CERTIFICATION Property Address: 801 Ni,6t.ic D.,z.ive Ng zzton.e Owner's Name:!ou.ise Zadwtny Owner's Address: STlmv. Date of Inspection:6/6/0 3 Name of Inspector: (please print) aozel2h %, /'lacomge2 a2. Company Name:I. 1. Nacomge2 R Son Inc. Mailing Address:lDox 66 ,0. 02632 Telephone Number: 5 0 8-7 7 5-3 3 3 8 CERTIFICATION STATEMENT I certify that 1 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 lv'�� sp for s Signature: v Date: ` � The system inspector shall ubmit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner.shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does_ not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page I Page 2 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:801 N-i-s.t.ic Dlt ive uit.6 on , Mazz. Owner: Lou.ize Zadwoliny Date of Inspection: Inspection Summary: Check A,B,C,D or E/ALWAYSS complete all of Section D � 1 A. System Passes• t /, I have not found an r 1� y information which indicates that any of the failure.criter))a described in 310 CMR r / 15.303 or in 310 CMR 15.304 exist. Any failure criteria not'evaluated are.tndicatedbelow. / Comments: The 3ent.ic 3y6.tem i.s .in /22open wo2k.ing a¢de,z rlf tho Me,6en.t t.eme �- t � B. System Conditionally Passes: One or more system componenu 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. 'kirictal 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: e!Q-6 Observation of sewage backup or-break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: AThe 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: 2 I Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 801 tTizz t i c DlLive Owner:Lou..,se ZradwoAni Date of Inspection: 6/6/0 3 . C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(l)(b) that the system is not functioning in a 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: AloThe 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. .(Jd The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. qd The system has a septic tank and SAS and the SAS is less than,/100 Dfeet but 5 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: 3 Page 4 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL, SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 801 N i zt cc D1t ive Na2,ston.a Owner: LQu ',6 ad1 g zaU Date of Inspection: _ 616103 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _ — Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or Jcesspool � J d - 600' .6 with at Peazt 3' o,z at one aii a zoand. ' d iquid depth in ee66pool is less than 6"below invert or available volume is less than h day flow r Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped Cb r/ Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface /water supply. r/Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for 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.] r110 (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303.therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes n _ _L the system is within 400 feet of a surface drinking water supply _ Ythe system is within 200 feet of a tributary.to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 1 1 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 801 Niz.t.ic Dz-ive ¢ltz ones R777z, 77azz. Owner: Lou.i,.e Za wo2ny Date of Inspecii6n: 6/6 3 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes /Pumping information was provided by the owner, occupant, or Board of Health Were any of the system components pumped out in the previous two weeks? Has the system received normal flows in the previous two week period? ZHave large volumes of water been introduced to the system recently or as part of this inspection ? 2 Were as built plans of the system obtained and examined?(If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up Was the site inspected for signs of break out? — Were all system components, �cluding the SAS, located on site? Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees, material of construction,dimensions,depth of liquid,depth of sludge and depth of scum ? _ Was the facility owner(and occupants if different from owner)provided with information on the maintenance of subsurface sewage disposal systems? proper The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes no/ / Existing information.For example, a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) (310 CMR 15.M(3)(b)) 5 Page 6 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:801 N i s.t.ic Dz ire Owner: Lou.i,6e Zadwoliny Date of Inspection: 616103 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 7 Number of bedrooms(actual): 7 �D DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 4/X4 A Number of current residents:_le— Does residence have a garbage grinder(yes or no): �1 Is laundry on a separate sewage system(yes or no):ti'0 [if yes separate inspection required] Laundry system inspected(yes or no):/_S Seasonal use: (yes or no):_VO Water meter readings, if available(last 2 years usage(gpd) 001=3 6 8, D00 ya 2 tons=1008. 2z C/�!� Sump pump(yes or no): �d 2002=306, 000 aiion.3=838. 36 gPD Last date of occupancy:71� S/21Linkge2 zys.tem ie /22ezent. COMMERCIAL4"USTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): /0 gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):, Industrial waste holding tank present(yes or no):.C� Non-sanitary waste discharged to the Title 5 system (yes or no):,'ej'4 Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: —✓�-9� /� /� Was system pumped as part of the inspection(yes or no): If yes, volume pumped/gallons-- How was quantity pumped determined? Reason for pumping:/lea vq .ecum R 3oeid.3 eayen.6 weae /22e,3e2 .` WTYP OF SYSTEM eptic tank, distribution box,soil absorption system Single cesspool Overflow cesspool . Privy Shared system(yes or no)(if yes,attach previous inspection records, if any) 12Q Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank :(l/' Attach a copy of the DEP approval XL f Other(describe): Approxiln to age of all components, date installed(if known)and source of information: v -Py' Were sewage odors detected when arriving at the site(yes or no)+'l_)� 6 Page 7ofII OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 801 ill,3t.ic DIt-i.ve Malz.6t6ni (7.iU-6, Na.sz. OWner:Lou.iae Zadwol y "'e T Date of Inspection: 616103 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction:&1 cast iron _40 PVC_other(explain): W Distance from private water supply well or suction line: Comments(on condition of joints, venting,evidence of leakage,etc.): jo.int.s aRReaa .t.igh.t. No evidence o� Leakage, The bybtem .iz vented thaough the houhe venth. SEPTIC TANK:—Zlocate on site plan) Depth below grade: Material of construction: oncrete /,LD metaIA0 fiberglass,r polyethylene ,�Jother(explain) Ash If tank is metal list age: Is age confirmed by a Certificate of Compliance (yes or no)-AA(attach a copy of certificate) l , , Dimensions: ��`.dcr� �GViI �����1 Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: C� Scum thickness:_0 Distance from top of scum to top of outlet tee or baffle: O Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: Pumped at time o7—n.s12ect,i0a. Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of.leakage,etc.):- `Pamp the 4ept.ic tank annuaiiy. Gaa age d.ieozai .i,3 p/Le•sent. In Pet 8 niit0ot tov.s nap .i_n Piace. The tank .t•3 h1-2uctultaiee pound and .3how.6 no evidence o� .leakage. GREASE TRAP4�10ocate on site plan) Depth below grade:XM Material of construction;xAconcreteV4 metaW,4 frberglass./ypolyethylene�(/�(/ other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: /f)h Distance from bosom of scum to bottom of outlet tee or baffle: 4)A Date of last pumping: ,1_ Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): amaze t/za/2 .is not pnezen 7 I Page 8 of I I OFFICIAL INSPECT ..,ON FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE S:�',VAGE DISPOSAL SYSTEM INSPECTION FORM PART C STEM INFORMATION(continued) Property Address: 801 Mizt.ie Chive a rts ('-ttts, Plaza. Owner:Lou.eze a wozny Date of Inspection: 6 6103 TIGHT or HOLDING TANKR _i (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: 1014 Material of construction:�34 con,. ...AIA met;alW.IA fiberglass4M polyethyleneiih other(explain): JJA Dimensions: JA Capacity:_ ,.S Design Flow: /day Alarm present(yes or no): 24 Alarm level:_J,!d Alarm in. order(yes or no): 4,14 Date of last pumping:�� Comments(condition of alarm anc :-witches,etc.): 7.oht o2 hoidinU tanke ate not fl2ezen . DISTRIBUTION BOX: Z ! a must be o ened locate on site P )( plan) Depth of liquid level above outlet :. ..: 4411 Comments(note if box is level '.,,uuon to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): I2.L.s.t7_19 Lion Sox haz .two iateaaiz. No evidence o� zoiidz ca22y n,w4 Nn o>»rjPLP Q_/ .PeirLkaae .into o2 out o e ox. PUMP CHAMBERtbA/—Q.(loc::tc plan) Pumps in working order(yes or nc, Alarms in working order(yes or ,: Comments(note condition of pu:n, .jer, condition of pumps and appurtenances, etc.): 8 f Page 9 of 1 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL, SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 801 Pl.c,6t.ic N ive a2-6 one Owner: Lou.i,6e Zaclwonny Date of Inspection: 616103 SOIL ABSORPTION SYSTEM (SAS): _jZ(locate on site plan,excavation not required) 2- 7000 a(2.P.Pon nnvrrisf Pgorhina p.;iA If SAS not located explain why: fnrnig'd - sea nnng 10 Tye leaching pits,number: A .,I&leaching chambers, number: 0 9 leaching galleries,number: D .�A leaching trenches,number, length: Q leaching fields,number,dimensions: d) overflow cesspool,number: �-- innovative/alternative system Type/name of technology:1i�,�r� /—�Fj,� ( ?�-� Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Loamu sand to medium line .sand No zign,6 nhy gala 21 r 4rj1.PiZAP n2 !?r2C/in .sniP.t rino r/n54.�yof nfinn ;A nn�..,-Q_. Pit 1-3� .t0 znUe2i- pipe. I it -2 day. — 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: /L1Q Indication of groundwater inflow(yes or no): Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): Ce,6,612oo.2.6 ate no /2 .6n f_ PRIVYX,"(locate on site plan) Materials of construction: �U/9 Dimensions: Depth of solids:—IA — Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.): l 2.LIJU .ib nOt /22e�P_nf _ 9 Page 10 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 801 tl i,st is DIL-ive alLe orz s c a, Ma% .e. OWDer: Lou-ize ZadwoAny , Date of IDspectioo: 616103 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 publie.tivater supply enters the building. 16 Rol fYlHshc iJfiYc Q%3m' or.s tKAk% ti \ 30, , _ 0 10 Page I I of 1 I OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 801 tTizt is Dlt ive Ma2.3ton.3 l'li rlazz. Owner: Louihe Zadwo2ny Date of Inspection: 6/6/03 SITE EXAM Slope Surface water Check cellar Shallow wells c Estimated depth to ground water D feet Please indicate(check) all methods used to determine the high ground water elevation: N0 _Obtained from system design plans on record- if checked,date of design plan reviewed:NR qLS Observed site(abutting property/observation hole within 150 feet of SAS) NO _ Checked with local Board of Health-explain: NR q(ES_Checked with local excavators, installers-(attach documentation) gES_Accessed USGSdatabase-explain:h_L#/? ohin. P(zl?nAtagee. ma, ups. You must describe how you established�e 6/9 ground water elevation: U,6ed: C�ah2et X Li2Pe2 Model• / 4 q ound e.Pevat.ion,s agove .sea 2eve e. dzed: � )9G .eeltva con we ata. ,rune 1992 Uzed: CISgSr 7echn.ieaP fuePet.in 92-000- 1 Piate #2 ,4n ua ae•t o4a2oi ad wate2 e eva n s_ 7%urr y 1992 Leaching Pits t Groundwater: Feet Below Bottom of Pit High Groundwater Adjustment 1.8 fter Frim ter e p p Method Therefore, the vertical separation distance between the bottom/ y Of the leaching pit and the adjusted groundwater table is feet. 11 I • •rnr+•-rt.rrr.•rr•mrn.r•ntnrr.r�+rtrm.rn+rrnr•.+*.•rr++r*�.•r.n nrra�u*�r�rsn n-n •�• TOWN OF a znztak.2e BOARD OF HEALTH SUI)SURFACF SEWAGE DISMSAL SYSTEM INSPECTION FORM - PART D •- CEII'fIFICATION I rn-r••.•: •-r...r<••.rr•tr•n•.,•.rnn rn�+mr,w�nr.—ti�r�un,*�wnwr�•r++.*vwo �+w� .. -TYPE OR PRINT CLEAALI'- PROPERTY INSPECTED STREET ADDRESS 801 N4zt_.c DILive NaaaLonz (7�P2�, Nae.s. ASSESSORS MAP, BLOCK AND PARCEL # OWNER' s NAME Louize Zadwoany PART D - CCRTIFICATION I NAME OF INSPECTOR Joseph P. Macomber Jr.. 77 COMPANY NAME Joseph P. Macomber & Sofi ' Inc COMPANY ADDRESS Box 66 Centerville Mass 02632 Street To or City COMPANY TELEPHONE (508 ) 775 - .3338 State I I P FAX ( 508 ) 790 _ 1 578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate , and omplete as of the time Of * inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance site sewage disposal systems , of on- Check one : System PASSED The inspection l+hich I have conducted has not found any information which indicates that the system fails to adequately health or Lhe. environment as defined in 310 CMR 15 , 303 , Any protect public lure criteria not evaluated are as stated in the FAILURE CRITERIAfai sectio» of this form , System FAILED* The inspection wllicli I have con tacted has found that the system fails to Protect the public health and the environment in accordance with Title 5 , 3.10 CMR 15 . 303 , and as specifically noted on PART CRITERIA of this. inspection form . C - FAILURE Inspector Signature Date �— ne copy of this cert.tfication must be provided to the OWNER, the ( where appILoable ) and the BOARD OF HEAL71I1, BUYER * .n... on FAILED, the owner or operator shall upgrade ' the system within one Year of the date of the inspection , unless allowed or required otherwise as provided in 3.10 ChIR 15 . 306 . partd . doc SEWAGE INSPECTIONS "� DATE 6/6/03 079'0� . LOCATION 801 1liztic Dzive VILLAGE 2a'"Laz (rli U,3, Na-6,s. ASSESSOR'S MAP & LOTS '��►' INS SC'POB �o.6eizh P. 1?aC,..om9e z J2. SEPTIC TANK CAPACITY 1500 +Box "LEACHING FACILITY: (type) 2-Ll-600'�3 (size) 2500 gaeeon-6 I! NO. OF BEDROOMS 4 I BUILDER OR OWNER Lou.i-3e Zadwo zny OWNER MAILING ADDRESS Same RDI MH541c 'Dave (Y1 rs�-Ms 5\k:\\s w1 i 6r 4,1 I ' ASSESSOR'S MAP NO. PARCEL S G L-O CAT ION SEWAGE PERMIT NO. . )7- S-4 ,�!,Z�77C VILLAGE { l�l1S 7Z7/lS INSTA LLER'S NAME A ADDRESS R U I L D E R OR OWNER 4� DATE PERMIT ISSUED 4 :2 _3Z�L DAT E COMPLIANCE ISSUED r-0 GAS >s c MOUSE • 70 �, r �i Lail( _ ,, RNST, BL . MASS. Fps f_ THE COMMONWEALTH OF MASSACHUSETTS MAP 07 Q BOAR& &ft1k9Ai11rH PARCEL _._ w..H.................OF......;�SAre.s.74w_.. /e---------------------------LOT... n Appliration for Dispasal Works Cfnnstrurtinn rrmi# Application is hereby made for a Permit to Construct (�Q or Repair ( ) an Individual Sewage Disposal System at: OO 7LNvc....T.......d.�! ... Lati Addres or LtNo.j -••.--,•_•._--•--- ............................................-•-••---•...........................•... Owner Address W Installer Address QType of Building Size Lot.!YZ..yZ Z....Sq. feet U Dwelling—No. of Bedrooms.................�e-•---.-_ -Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building ......................... No. of persons......................... Showers — Cafeteria a' Other fixtures ................................... Design Flow............... ...............gallons per person per day. Total daily flow..............I_�_� ...............gallons. WSeptic Tank—Liquid*capacity/.Z.Vgallons Lengthy.L10.�� Width S La'. Diameter................ Depth✓V--�-7 x Disposal Trench—No..................... Vidth.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No......2-......... Diameter/z'-C'_. Depth below Total leaching area...J_4�.:2.sq. ft. Z Other Distribution box (AQ Dosing tank ( ) I=,,- 4/2.5-0 aPercolation Test Results Performed by. �d!'e� t_-•__ hyr',_ _<< /tic__- Test Pit No. 1..... .....minutes per inch Depth of Test Pit._: .?.......... Depth to ground water. Lo_KC _. (r4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 •••-----•--------------•---•-----------------•-•-----------•---...........-•----•---••......-•.....•........................................................ O Description of Soil....P..".3.... Tg P ._V...�J.---....... f ' V �Z............ ... ...� 1.✓...!.!.... .Slit/. ------................................................................................. ..........................................................-0----------2'r''' w5��--L.......... ................................... 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 TITL iE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has beeq issued by the board of health. SC i `/ Signed-------- .. _ !:. u' -- . •---- --------••---•------------• ... Application Approved By-----------------•------•-----.......--------- . V. Date Application Disapproved for the following reasons:.......... - ----•--•-••-------...-••------•---•---•---------•----------•-••-••••---•-•-----•-•.............. .................................••-------•-•---------•.......-----------•••••........_.._.._............._..._.........•--•--•----••---•-•.........---•-•----•--------•--••-•-....•- ......•---••---- Date PermitNo......................................................... Issued....................................................... Date No................_....... Fina............................. THE COMMONWEALTH OF MASSACHUSETTS _ BOARD OF HEALTH ...........................................OF......' -----------------OF...... .F!.l'....?.:........... c Appliration for Utoponttl Warkii Tonfitrnrttnn Famit Application is hereby made for a Permit to Construct (�o or Repair ( ) an Individual Sewage Disposal System at: ..................._...... i s _...i•`'•e................... ......p�--s------......f-------/�/�-•-lS---------------............................. Location-Address/ / / ja or Lot No. .... .............. __.......... _. ................_._......................................................_.. Owner Address W Installer Address y y/ d Type of Building Size Lot._._..7...................Sq. feet Dwelling—No. of Bedrooms................ ......................Expansion Attic ( ) Garbage Grinder ( ) p., Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures .................................. W Design Flow................ ..... .__--._._......gallons per person per day. Total daily flow_._.........._.1..��Q. ............gallons. WSeptic Tank—Liquid capacity/Z,5 11ons Lengthlv..': U Width. .l:U.. Diameter................ Depth. .�.��r x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Z-- /:Seepage Pit No....... Diameter .. -k..... Depth below inlet..`'............ Total leaching area...: P.sq. ft. z Other Distribution box ( Dosing tank Z.S'O Percolation Test Results Performed by................... .................I.1.':...........:....." .... Date... �e 5!• 9��r Test Pit No. I......!; .....minutes per inch Depth of Test Pit...! .......... Depth to ground �X4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 --•------•---•----------•-•--•----•------------•••---•-••-----......_•--•---•-••-•••-------•--•-•••-•.._......•-•••...---•.................................. -p �- Description of Soil p T G..r> •---•--•--- ' `' '/` = ------------------------------------------------------------------------------ W ---•---•-------------------------------------------••--••• b.........- .,.0 =� f/ GG f� G-ar e-r• e.6 _� .` = Lr_......--`•---CG[lh---••---•-------�-••-•--•----------•-•------•--•-. 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 TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee issued by the board of health. Signed........... Application Approved B . nab ~ Date Application Disapproved for the following reasons------------- -------••--••---•--------•----------...-••---•-••----•-•-......•--••--•------•••-•----•. ---•...........................•---•------........-•---------...--•--•----•-----.........----............._...................---•------------------------------....--------------•--•-••---.....--•----- Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .....................................OF.................................................................................... Trrfifiratr tit Tontplinnrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (4 or Repaired ( ) Installer at................................................ ,...... I D .•.........S..i..----•--M t5A e �L.. �?..........�i*-------------------•---------------------- has been installed in accordance with the provisions of TITLE 5 of The &ate Sanitary Code a descri ed in the application for Disposal Works Construction Permit No.............�.?.-�......�r.. ._.. dated__.._._.._.....I_..xt_ .�f'.._....•... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.�.....-•-•--•......................•---•-•-•--•-• - ... Inspector.................................................. ' 4 1rr% f /� #� Oesr'Jv'ti'1 1 iH�Cyr !'` bV1� V—A l W\ �HE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH pt,� r �<�E� itSf3u�1� OF..................................................................................... Disposal Works (ton ' n ranti# Permission is hereby granted-- �:+� --•-•--••--------------•-•---•-•--.............................,_.: to Construct (� or Repair ( ) an Individual Sewage Disposal System atNo..............-•............< ..............h-=>i'-L.---•----..C)T •`l--G...-----...... r --r............................................................... Street QS 3 as shown on the application for Disposal Works Construction Permit No............. ...... Dated Health_..___.._._ .1 � .... ------------- ------••••---•- ��of �............... I Bar DATE....................... ------�- ---•-- .. d......... . FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS01.: - ASSESSOR'S MAP NO. PARCEL S j L O CATION S E W A G E PE RMIT No. 353— VILLAGE I ,�1'�f11eS��S �iLG�S j INS..TA LLER'S NAME i ADDRESS C21n 1714-77- Go4/S'77,C>c7- A/ f t U i L D E R OR OWNER l 0. 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