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Home My WebLink About0121 MOCKINGBIRD LANE - Health '1021 Mockingbird Lane Marstons Mills J I I File 11umber 080905-6 UNREGISTERED LAND AUorn : COSTELLO& GREYDANUS Deed Book 17916 Pa a 75 Lender: FAMILY CHOICE MORTGAGE CORP. Plan Book 284 Pare 91 Lots 92 Owner: SANFORD&TRUDY FISHER REGISTERED LAND Reg,Book . Sheet Lot(s): Date: 9/8/2008 Certificate of 7i11e Assessor's Map 13 Blk: Lot 22 Census Tract MORTGAGE INSPECTION PLAN Scale. 1"=40� 121 MOCKINGBIRD LANE, MARSTONS MILLS, MA, N/F GIFFORD d 1�y 0 LOT 92 20,570 SF 0 s. LOT 91 Vy- U. •oo. N LOT 93 ca F; �Q. cr) z 93— co m TO O z - 0 3 C MOCKINGBIRD LANE r Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form Inspection results roust be submitted on this form or on the official Title 5 inspection Form dated 611512000.Inspection forms may not be altered in anyway, A. Certification COPY knportant When out 1. Property Information: forms on the / ND � �' �!n ��✓ computer,use ��CCC only the tab key Address re e I� to move your cursor-do not Owm ame use the return +s / ��r 1J &>Ld A °'I-V e, - - W-7 ��/ j� 0. / /�"s ''�f/ U''� /"' r`��F / � /'"• (P TLN Cityrrown Sta C) Zip Code ��e✓7 � v „in Date of Inspection: Date. 2. Inspector. NMof Inspector e11 �n Company 31 Comp City/Town YO 3 State Zip Code r r f" Telephone Number Certification Statement: ~' I certify that I have personal! ins sew c aN�F y inspected cted the age disposal system a that then formation reported below is true,accurate and complete as of :e diAMn n.The inspection yr performed based on my training and experience in the prop FfunctiorRand m me ofrQh site:• age disposal systems.I am a DEP approved system ins o f lR'LW§ A*t on I S-W of e 5(3 CMR 15.000).The system: \%;��, o o � M Passes ❑ Conditionally Pa 1 El N ds u her uation by the Local Approving Aut city 7 v Inspector's Signature Dale The system inspector Sid submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this Inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the Inspector and the system owner shall submit the report to the appropriate regional office,of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. *"*This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5imp.doe•111 M We 5 Official inspection Form:Subsurface Sewage Disposal System Page 1 of 16 Commonwealth of Massachusetts . Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certifications (cont) / drew ap dwe Ovmere Name Date of b> lon Inspection Summary:Check A,B,C,D or E!always complete all of Section D A) System Passes: e not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist Any failure criteria not evaluated are Indicated below. Comments: r C-� RC ,7 61U11 C B) System C ditionally Passes: ❑ One or more s em components as described in the"Conditional Pass"section need to be replaced or repai The system,upon completion of the replacement or repair,as approved by the Board of Health, ss. Answer yes, no or not determin ,N,ND)in the[]for the following statements.if"not determined;please explain. /'1�/ ! 4 ❑ The septic tank is metal and over 20 ye old*or the septic tank(whether metal or not)Is structurally unsound,exhibits substantial 11on or exilltration or tank failure Is imminent. System will pass inspection if the existing tank placed with a approved by the Board of Health. phring septic tank as *A metal septic tank will pass inspection if it is structurally nd,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years available. ND Explain: Wmsp.doc•1112004 Title 5 orilial Inspection Form:Sub�Sewage Disposal system- Paw 2 of 18 ' Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cons) f Property Aldress scare z�coda 710 Owners Name Date of Impection B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipes)or due to a broken,settled or uneven distribution box.System will pass inspection with approval of Board of Health): ❑ broken plpe(s a replaced ❑ obstruction is remov ❑ distribution box is leveled or repla ND Explain: ❑ The system required pumping m than 4 times a year due to broken or obstructed pipes).The system will pass inspection if(with vaI of the Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed / ND Explain: C) Further Evaluation is Required the Board of Health: ❑ Conditions exist which.require further luation by the Board of Health in order to determine if the system is failing to protect public hea ty or the environment. 1. System will pass unless Board of Health rmines in accordance with 310 CMR 15.303(1)(b)that the system Is not functioning in Fin� h 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 we nd or a salt marsh t%nsp.doc•1112004 Tithe 5 Of kcal Inspection Form:subsurface Sewage Disposal system Page 3 or 16 Commonwealth of Massachusetts Title 5 Official. inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) Nocl ,�Vj �� -s I,j kq�US �'V IS �Yo ,. / State— ZIP t� �p Ohs NaIrne Date of Inspection C) Further Evaluation is Require by the Board of Health(cont.): 2. System will fa unless the Board of Health(and Public Water Supplier,if any) determines that system is functioning in a manner that protects the public health, safety and envImn t: ❑ The system has septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a sulfa water supply or tributary to a surface water supply. ❑ The system has a septic k and SAS and the SAS Is within a Zone 1 of a public water Supply. ❑ The system has a septic tank an AS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS an a 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,performer 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. 3. Other: �/ Mzp.doc•112004 TWO 5 Official ial Inspection Form:Subsurface SwmVe Disposal System- Page 4 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) Address � Citylrown �1 r Statef ZJpCode TZ�2C� (J e-t 7 OwWs Nam Date of ImpedW D)System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for ff inspections: Yes No ❑ Backup of sewage into facility or system component due to overloaded or dogged SAS or cesspool ❑ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or dogged SAS or cesspool ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or dogged SAS or cesspool ❑ Liquid depth in cesspool is less than 6"below invert or available volume is less than%day flow ❑ Required pumping more than 4 times in the last year NOT due to dogged or obstructed pipe(s).Number of times pumped: Any portion of the SAS,cesspool or privy is below high ground water elevation. ❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ Any portion of a cesspool or privy Is within a Zone 1 of a public well. 10 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 pion,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this forma Yes No ❑ The system fails.I have determined that one or more of the above failure criteria east 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 corned the failure. t5insp.doc-11JPOD4 TWO 5 Official Inspection Form:Subsurface Sewage Disposal System Page 5 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. CertificationJ (cont.)) / • V � 1` !� �In ��,� -� ' gym► cltylT sta Zip code OwnWs Name Date of Iron I E) l a Systems: To be considered a large system the system must serve a facility with a design f.10,000 gpd to 15,000 go. For large syste ,you must indicate either'yree or'no*to each of the following,in addition to the questions in Sectio YES NO ❑ ❑ the system i in 400 feet of a rface drinking water supply ❑ ❑ the system is within feet of a tributary to a surface drinking water.suppiy ❑ ❑ the system is located in a n n sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone of a public water supply well If you have answered'yes'to any question in Section E the s is considered a significant threat, or answered'yes"in Section D above the large system has failed. owner or operator of any large system considered a significant threat under Section E or failed under n D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate. regional office of the Department. Mlnsp.doc-1IMM T09 5 oifidal Inspection Forth:Subsurface Sewage Disposal System- Page 6 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Checklist Property Address ram C)a 6 VOO state Zp Code Owners Name Date of Inspection Check if the following have been done.You must Indicate'°yee or"no'as to each of the following: YES" NO K] ❑ 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? R ❑ Has the system received normal flows In the previous two week period? ❑ Have large volumes of water been Introduced to the system recently or as part of this inspection? ❑ Were as built plans of the system obtained and examined?(If they were not available note as WA) ❑ Was the facility or dwelling inspected for signs of sewage back up? ❑ Was the site inspected for signs of break out? ❑ Were all system components,excluding the SAS,located on site? Y ❑ 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? Ex, ❑ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ❑ Existing information.For example,a plan at the Board of Health. Determined In the field(if any of the failure criteria related to Part C is at Issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] t5insp.doc•11=04 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System Page 7 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information z*code Cr7u E-41 da Owners Name Date Residential Flew Conditions: Number of bedrooms(design): - Number of bedrooms(actual): DESIGN flow based on 310 CMR 15203(for example:110 gpd x#of bedrooms): Number of current residents: Does residence have a garbage grinder? ❑ Yes t—RAo Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes [ No Laundry system inspected? TS(Yes ❑ No Seasonal use? Yes ❑ No eS Water meter readings,if available(last 2 years usage(gpd)): Sump pump? ❑ Yes No oats Last date of occupancy: CommercialAndustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 1520 G W day�) Basis of design flaw(seats/persons/sgft.,etc. Grease trap present? N� ❑ Yes ❑ No 9 Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Titie 5 system? ❑ Yes ❑ No Water meter readings,if available: Last date of occupancy/use: Date Other(describe): tsnsp_doc•1112004 Title 5 0MCIal Inspecom Form:Subsurface Sewage Disposal System page a or 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form _ C. System Information (cont. r Address_- -� �v M r cityr �/— s�� ZIP Code r .4 ,1 / IT �'� woe t1 Owners Name Date of inspection General information Pumping Records: i Source of information: Was system pumped as part of the inspection? b�hes ❑ No If yes,volume pumped: Z 11"'" 0 gaBo&s How was quantity pumped determined? L��`.�- Reason for pumping: rl .�.r� �1� n•� C Type of System: Septic tank,distribution box,soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no)(if yes,attach previous inspection records,if any) Innovative/Alternative technology.Attach a copy of the current operation and ❑ maintenance contract(to be obtained from system owner) ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components,dattee in tai (if known)and source of information: ve Were sewage odors detected when arriving at the site? ❑ Yes No Misp.doc•I WIM Tile 5 Ofboial inspection Form:Subsurface e Seweg Deposal System. page 9of16 Commonwealth of Massachusetts Title 5 Official. Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) z .) 0 C- K /3tkid PMpftAAklrM Cdy mown zip code t e f s Name DA of Inspection Building Sewer(bate on site plan): Depth below grade: � ) feet Material of construction: ❑cast iron ❑40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints,venting,evidence of leakage,etc.): Septic Tank(locate on site plan): Depth below grade: feet Material of construction: crete ❑metal ❑fiberglass ❑polyethylene ❑other(explain) If tank is metal,list age: yeas Is age confirmed by a Certificate of Compliance?(attach a copy of Yes No certificate) la Dimensions: / Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle / Scum thickness 1( 2 Distance from top of scum to top of outlet tee or baffle —� r2 Distance from bottom of scum to bottom of outlet tee or baffle U How were dimensions determined? t5insp.doc-1lrZW4 Title 5 Official inspecOon Form:Subsurface Sewage Disposal System Page 10 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form. Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Infor ation cont.) a/ �� r , o- l PropeftAddress cxytr /0 �� ( -r r2. sr�o code �� /T C� Owners Name ® Dam oYInspection Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Grease Trap(locate on site p n): Depth below grade: feet Material of construction: ❑concrete ❑metal ❑fibe s ❑polyethylene ❑other(explain): Dimensions: Scum thickness ` Distance from top of swim to top of et tee or baffle . Distance from bottom of scum to bottom o t tee or baffle Date of last pumping: Date Comments(on pumping recommendations,inleX r baffle condition,structural integrity, liquid levels as related to outlet invert,evidence : Tight or Holding Tank(tank must be mped at time of Inspection)(locate on site plan): Depth below grade: Material of construction: ❑concrete ❑metal ❑fiberglass ❑polyethylene ❑other(explain): t5insp.doc-l i rn 4 Title 5 OWW inspection Form:Subsurface Sewage Disposal System- Page 11 of 16 Commonwealth of Massachusetts Title .5 official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System information (cons Property Address' 'fin � A � �s e�2, �e 11 Code Owner's(dame Date of inspection Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gWbns per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order. ❑ Yes❑ No Date of last pumping: e Comments(condition of alarm and float switches,etc.): Distribution Box(if present must be opened)(locate on it _plan): Depth of liquid level above outlet invert c�L V l 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.): i ac, S .110 s Pump Chamber(locate on site plan): Pumps in working order. / ' ❑ Yes ❑ No Alarms In working order ❑ Yes ❑ No t5insp.dm•11/2004 We 5 019dal inspertim Form:Subsurface Sewage Disposal System Page 12 of 16 ' Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) / /1;10CK/-1,j 4,je-p P dperty Add Cityr r wn / State Zip Code 1 -6 , d^)c-(7/-Q OWrs—Name Date of I- nspection Comments(note condition of pump amber,condition of pumps and appurtenances, etc.): Soil Absorption System(SAS)(locate on site plan,excavation not required): If SAS not located,explain why: kul Type: leaching pits number. ❑ leaching chambers number ❑ leaching galleries number: ❑ leaching trenches number,length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number. ❑ innovative/altemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.): t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 13 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cons) Properly Address— ` 1145 j�J Oc4) I 'rer ! `S1f _�� 7U c• �' state 7 C2 zrpcode �� /-cam � � e�2.• � `� Owners Name Date of inspection Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet' vert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ 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 ing,condition of vegetation, etc.): t5insp.doc•11/2004 Tdle 5 Official Inspection Form:Subsurface Sewage Disposal System Page 14 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cunt.) J Property Address ' Jai r(� 1'Lt�ff SW Zip coda owner's Name f A of inspectlon 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. se kn 1� 7 �a 13V �s Ad 3Tq Ic s .13ri ol, r A 0 t5nsp.doc•1912004 [(�C7(� //�vti+�� C/ Tide 5 Officiai in spection Form:Subsurface Sewage Disposal System Page 15 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 2d / M 0 6K "'-V r2 i-,-k Property Address - AA i.s /a�✓ 1�1% Cis �'t�( City[town o Staff Zip Code owa4rs Name Date of Inspection Z— Site Exam: Slope Surface water Check cellar Shallow wells Estimated depth to ground water: C) Please indicate all methods used to determine the high ground water elevation: Obtained from system design plans on record �J If checked, date of design plan reviewed: =—�"2 Date Observed site(abutting property/observation hole within 150 feet of SAS) Checke h local Board of Healt�xplain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You m t describe how you established the high grou water elevati /�— r 'ek C� 1 t5insp.doc•1 a/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 16 of 16 r Town of Barnstable GF'T E Tp� Regulatory Services swxNsrnsie, : Thomas F. Geiler,Director 9 MASS. E16 9. Public Health Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 REGARDING SEPTIC INSPECTIONS BY PRIVATE CONTRACTORS DISCLAIMER This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original or copy of the report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observations and interpretations contained within this report. In addition, by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would be listed on the "Disposal Works Construction Permit". If you should have any questions regarding this report, please contact the certified Septic System Inspector who conducted the inspection. QASEPTIC`Disclaimer Private Septic Inspections.DOC IN3 -O7- r LOCATION / SEWAGE PER IT N0. VILLAGE -A INSTA LLER� NAME i ADDRESS l9 ' � ,11 BUILDER OR OWNER DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED 1 r y 1 i + P � l " i i LOCATION / SEWAGE PER IT NO. rJc�/11/ 93�R I-) �— VILLAGE INSTA LLER' NAME i ADDRESS BUILDER OR OWNER DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED V / i . I� _ . it ,.. � ,� i F9s.... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ✓. . ---....OF........6.t..��."�.:L.:!'ll...c %� .U:.i...............:.... Applira#ion for Biipasa1 Work,. (fou,itrurtinri rrutit Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal System at: Lo n-Ad or Lot No. ...... ..• .. .A.....- _ ....... ....................... ......................... caner Address --•-------•-•............................... Installer Address 2®S7 C5 d Type of Building Size Lot............................Sq. feet aDwelling—No. of Bedrooms.................-_._____---_---________-Expansion Attic ( ) Garbage Grinder ( ) p., Other—Type of Building ............................ No. of persons.-__-_______-__-_-__--______ Showers ( ) — Cafeteria ( ) Other fixtures -----------------_----- ------ - Design Flow---------- .....5.5....gallons per person er day. Total daily flow..--------z�' gallons,W ► .t WSeptic Tank—Liquid capacityl00Ogallons Length___ __.�'i-a.___ Wldth..'.`�..1.(?.__ Diameter_5___�.____. Depth.......... ... x Disposal Trench—No. .................... Width....... .............. Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.......1.......___.... Diameter--------g_..._..__ Depth below inlet.....6.1......... Total leaching area.Z-0.Q....sq. ft. z Other Distribution box ()C) Dosing tank ( ) ~' Percolation Test Results Performed by.... ?..iq:.�''- � 6—D.....Si Date_..g'. _.-? ......... a� Test Pit No. 1...:—...2..minutes per inch Depth of Test Pit------ ...... Depth to ground water A2?✓�Z.. (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-.__-______---_-..___--. ---------------------------------------------------- --••-•-•-.....-•--------------••-•••-•--.............................................................. O Description of Soil..........o_."._��O..... ��IL_ x v a_. �. ( � "'-?Z> J f1'1 V -•--•-•------•----......•. ..... -_--•------•------------ ----- . ---•-•--------•-•-•--•---•---------•-••---•---- W d y- :...... x fl`+ � U Nature of Repairs or f terations—Answer when applicable................................................................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with T/`1� '• the provisions of 'I'^I� t Z 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed.... ---- --------------•--.--• ................................ �1 /��0 Date Application Approved By........�:. � _ f•% 2 Date Application Disapproved for the following reasons:................................................................................................................ .............................................. •••---•••--------•-•-•-----..........---------.............. Date PermitNo................. ........ '' . _ Issued....................................................... - C/" _ ate t �. 04 No. .... :.. Fra... .....�............... THE COMMONWEALTH OF MASSACHUSETTS A BOARD OF ,HEALTH OF....... ... . . 6 ,. ............. ApV iration for Dii#niial Works Tomitrnrtian rranit Application is,hereby made for a Permit to Construct ( ti) or Repair ( ) an Individual Sewage Disposal System at: Loc i n-Add or Lot No. -------------- ner Address Installer Address �I� Type of Building Size Lot___��______________ - S q. feet U Dwelling—No. of Bedrooms................. ............ .Expansion Attic ( ) Garbage Grinder ( ) aOther'=Type of,Building ........................... No. of persons---.-__-____--_-_-______-___ Showers ( ) Cafeteria ( ) QI Other fixtures :__. W Design Flow._... . r .... .-.gallons per person per day. Total daily flow.............. ...............gallons. 04 W Septic Tank—Liquid capacity_f.0-00gallons Length-__+°�a._. _._. Width---''�i0'_._� .'Diameter-_V _-.V Depth.._. _P. x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No-___--.I....-------- Diameter........ `...... Depth below inlet......1�..e......... Total leaching area.2 0.0._.sq. ft. Z Other,.Distribution box O Dosing tank ( ) '-' Percolation Test Results Performed by. Date... .n"7t ........ ,aa Test Pit No. 1....4__:;�__minutes per inch Depth of Test Pit......j_-t------- Depth to ground water.lulGA1 (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-.____---_---___-__--- x ---------- -------------- -------------------------------------------------------------•----...._......................................................... O Description of. Soil........... ` . '. U ------------------------- l --- - '` `�` : U Nature of Repairs or erations—Answer when applicable................................................................................................ ---------------------.--............-----..............---•--------------------...._..--------------------------------------•------------------................ Agreement: The..under e'd agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'TTL7, y g g p y 5 of the State Sanitary Code— The undersigned further roes not to lace the system in operation until a Certificate of Compliance has been issued by the board of health. ?' Signed._..:' _ Date Application Approved By-------- �•--441 - -... » z./ - _.. � Date Application Disapproved for the following reasons-...........................-..................................................................................... .. �,. Date PermitNo.................................. .................... Issued-.............................. ?s Date THE COMMONWEALTH.,O:F MASSACHUSETTS BOARD" OF HEALTH ^�..........OF..... .rvr3 . - .................. ' .... . . (9rdifirFatr of TompliFaurr T IS S TO FY, That the Individual Sewage Disposal System constructed ( or Repaired ( ) Xby.... /"-- ....... .... . ....... . ..... ---- ..................................................... rt Install � " .. rf has eon installed in a ordance with the provisions of T j of The State Sanitary Code as'described in the f application for Disposal osal`works Construction Permit No. - -...__._.... dated_._.. _�' . __ .7_GG _._.... PP P .. , F 1 THE ISSUANCE OF THIS CERTIFICATE SHALT. PLOT BE CONSTRUE® AS A G,BJARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE... .... ,Inspector �* 5ytk+ a: Ki r r 2 a=,r ,t�f�FWsf;zt4;ac ?+x> u4-LsF d"'>, s, tE4l�as t a +a `"': x a 'J 44 vfi 1' Y, s. `k s".e� -f•,'Y�"s t�` 1... #j '`e�.y, r>.tiiro'rZ.h�, Elff� F. X >a&wrs„ a �»vRMV�Wii+YY.'Y 4.N+'#I a�r1L, '�•�� .. - .., f THE COMMONWEALTH OF MASSACHUSETTS rri a BOARD OF HEALTH ' ...........................................OF..... ........... ............ 2 No. •...............�. FEE...................... t fi ork n trnduan "unfit u. Permission is hereby granted--- .. . � T._. •-••--•--•--••• ....................................................................to Cons ruct/I Zr r air ( Individu Sevt ag Dispos SyZ04 at No. >. �7 �... - d1 � `-- �-• ---------------•------•••-•-....... •-y /�� Street Pp . ... ;: °n Pe No ... DateFd : �._i�.`7r` =.._. as shown-on-the application fo r Disposal Works Constructs �,� ^r 79, a. �, ti .. Board ofHealth, - DATE..... •-• ............... ........................................ Y FORM 1255 HOBBS & WARREN, INC., PUBLISHERS WILLm HARVEY Septic Specialist -2f"of eo.ea- cell 508-265-3483 LICENSE # S13107 �ICN7f1 FULLY INSURED a� .�-- fir, tj 0A YL-11 41f cr 7 e r_ A U& iZ,l /9 79 a0 4, i PAIJL mL)rZ ? 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