HomeMy WebLinkAbout0145 MOCKINGBIRD LANE - Health 145 MOCKINGBIRD LANE, M. MILLS
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LOCATION EINAGE PERMIT NO.
VILLAGE
INSTALLER'S , �M 0 ADDRESS
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21 ZZ :
R U I L D E A OR OWNER
DATE P ERFAIT IS E D
DAT E COMPLIANCE ISSUED �/�
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e f ° 'I
L No ........._......... FR$.. .j.....
THE COMWONWEALTH OF MASSACHUSt'IZKS r
BOAR® OF HEALTH
..........................................O F..._............................_......._.....
Appliratilau for Uh4pooal Marks T. w3trurtion thrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
..... ......------
......-----•-------------- ,...
p Location-Ariess or Lot No. -�
1S:h2 a
Owner Address
.......... 'C..........._...______...._...._...._..._..__..........................................1..........
Installer Address
Type of Building Size Lot............................Sq. feet
U No. of Bedrooms-__ .Ex Expansion Attic Garbage Grinder (
g— P ( Garbage Grinder a)a Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Q, Other fixtures ..-•----------- ----•-••----... -
W Design Flow.........5 ..........................gallons per person per day. Total daily flow......S3.0.........................gallons.
WSeptic Tank—Liquid capacityJ,QWgalions Length................ Width................ Diameter---------------- Depth................
x Disposal Trench—No..................... Width ....... Total Length......_....v....... Total leaching area....................sq. ft.
Seepage Pit No..1-------------- Diameter.... .............. Depth below inlet..._(9............ Total leaching areao? .........sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
W
Test Pit No. 1________________minutes per inch Depth of Test Pit.................... Depth to ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit...:................ Depth to ground water........................
O Description of Soil,-27_es+j....
W
Z. •--------------------•--------------------------------------.......----------...---------•----....-----------------....--------------------------•------------------------------------------------•-----
U Nature of Repairs or Alterations—Answer when applicable....__..........................................................................................
Agreement:
e The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
¢ the provisions of TITi IE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
E operation until a Certificate of;Compliance has een issued by the board of health.
Signed.__
'
Application Approved B ......_ �... Da e
-i� a,
__r f.._._. -------------- -•--•-"•______•__•_•D
i i? Date
Application Disapproved f r the following reasons=
--------------------•----------------------------------........................................................
.................•••...........................---•-•-••-•-------------....-•----....................................................................................................................
Date
f
PermitNo................ Issued.-----••-•--------i ---------•-------------------------^•-•- -------..._.._.........-----------...ti Date ,
..::............
* THE COM .ONWEALTH OF MA Py SSACHUSi S �
BOARD OF HEALTH'
..........................................O F........................................---.............---......................_........
ApplirFatiou for BiopooFal Works Towitrurtion Frrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
Systemat: -------•----_.... ....... -•------------------------------
�n
s { Location- dslress or Lot No.
W Owner Address
------- .......Z2 4e..................................................................................................
Installer Address
Type of Building Size Lot............................Sq. feet
v Boms___ ....____.__.Ex Expansion Attic Garba e Grinder
(� )Dwelling—No. of edro
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
p' Other fixtures .....................................................
Design Flow.........- ...........................gallons per person per day. Total daily flow.......33_0........................gallons.
WSeptic Tank—Liquid capacity)Vj00gallons Length................ Width---------------- Diameter................ Depth................
x Disposal Trench—No..................... Width_.r....------------ Total Length...........? Total leaching a rea....................sq. ft.
3 Seepage Pit No.-I-------------- Diameter....9............. Depth below inlet.....±............ Total leaching area-200.........sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
~' Percolation Test Results Performed by.......................................................................... Date........................................
aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water.............___--_-___.
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
----------------------------------------•-----...........--•---.....------------•-----......._..----.........................................................
ODescription of Soil..................................................................I
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 TITL%, 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance hasrbeen issued by the board of health.
Signed..s.210-Cv.nz a...-•-- -
Date
Application Approved By---•---....... �.../..�......... !y .r ------•-•----- --•---
Date
Application Disapproved for the following reasons:-------•-------------------•----------------•-•---------------•-----------------•-------------------------••....
....-•--••----------•-------------------------------••---......-----••---.....----...........-------•--..._.....-----------------------------------------------------------------------------------_-•---
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF.....................................................................................
Trrtifiratr of ToutpliFattrr
9
THI. IS 0 CER I�hat the Individ Swage spo y tem c ' structed ( ) or Repai ed ( )
by....._..... .•.... ..........
,"" ........ .... . � ..................................•--
linstal r '
has been installed in accordance with the provisions of TIT 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No...... ..'.""_. - dated................................................
THE FtE . F THIS CERTIFICATE SHALL NOT BE CONSTRUE® A GUARANTEE THAT THE
SYSTEM TION SATISFACTORY.
DATE...... ,1.... Inspector ..: .....
THE COMMONWEALTH OF MASSACHUSETTS
h� BOARD OF HEALTH
.r ...........................................OF....................................................................................
.....
No. . z.............. FEE. ---0--.....----••--
Dispoo�af for � �onotrttrtio rut'
Permissio is,hereby granted.... :.. .......
to Constrk. or Repair ( ) an IndividualSewage Disposal Sys em o
at No........ yr.......
t _
Street
as shown on the application for Disposal Works Construction Permit No..................... Dated..........................................
a. r Boa Health
DATE..................-... ........................................................
FORM 1255 HOSES & WARREN, INC., PUBLISHERS
r� pESIGI.J bATA
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SI►l,CsLE: FAMI P-00 i
,
DA,lLy F=Low : llo x 3 = 33oG.Pp
5EPT1G TA�JI< = a30xl5o% = a45�.P
ts51`- 100o GAL.
01•5PoSAL PIT v6E 1000 6AL.
S DGv+/ALL AQca 1 5o s.1i 4Ee �A IJ vl.luc.. �I 3? �rL. =
150 5.t+ x �•5 = 5 G.I-
50TTOM AREA t . j 0 5•F,-
50 S,F x 1. 0 5 o G.p C? �v7 46u� ,F D '
i
G,pD-
-ToTA%-- DA 1 L-Y F>r-ovd $ 33o G.Po.
PER-cot-ATION RATES ►''IN ZMIN or,-LE55
'By e04tiw GIFT rz.s.
Vj T+jVA By PAL- AAvFZ41A�/
i
RICHARD
.?.tip �:;��;, ;''�`,'!.._ — •'::, •'Q
4�.r A
SAX"FLR
No.2:;48
Q�STE GQ-�t
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'T65T 8/�917 TOP FNp Ioo.O
HoLC—
10040 INV.
s LvaN� DIST. INS. G41.. 9G•b'
5J�}yok� BuX 9G G 56P��G
I oao INV. TANK
3' GAL.
LEacu ��
I/ p ITINV. INV.
VErL-I W T14 9G 'z' yC 4
WASWED 4
670H@
CERTIFIED PLOT PL..A.W
PRvFIL6 L044-T10N a "rMl MIL�.5
NO SCALE
I CE GtT1FY THAT THE �w���N` SuorYN
NEREOPl GOMPL�(5 YJITNZ "1LL
AQP SETeAGK R.6Qv►R-EMENT�
'(oWN OF 'fiSA2►�5TA►'j5 ANC IS OT" PLIL
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REG I S'T�Q6U'1.AN 0 s u K.Y RN'Dr-'S
Tu1g PLQN 115 NarT oa AN os-1-Ec�vI�LE - MP►Ss•
IuSTRUMENT 5u2VG-Y THE 0r—5ET5 6u6ul3>
i .�..... zr- „c.r n-rrti n�-rr_v_Mltil� t_nt LIf lC APPL.I ell A►J r ( I�i��t� 4 0�
01.3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Address of property / V 5 /V) o c k;ii 9 l; ,•-d L am, AA AS
S
owner's name J Oe G r a s s vu o� h
Date of Inspection
PART A
CHECKLIST
Check if the following have been done:
Pumping information was requested of the owner, occupant, and Board of
Health.
None of the system components have been pumped for at least two weeks
and the system has been receiving normal flow rates during that
period. Large volumes of water have not been introduced into the
system recently or as part of this inspection.
As built plans have been obtained and examined. Note if they are not
/ available with N/A.
V The facility or dwelling was inspected for signs of sewage back-up.
V The site was inspected for signs of breakout.
_V, All system components, excluding the SAS, have been located on the
site.
1! The septic tank manholes were uncovered, opened, and the interior of
the septic tank was inspected for condition of baffles or tees,
material of construction, dimensions, depth of liquid, depth of
f sludge, depth of scum.
V The size and location of the SAS on the site has been determined based
on existing information or approximated by non-intrusive methods.
The facility owner (and occupants, if different from owner) were
provided with information on the proper maintenance of SSDS.
SUBSURFACE SEWAGE DISPOSAL SYSTEM 'INSPECTION FORM
PART B /
SYSTEM INFORMATION
FLOW CONDITIONS
If residential
number of bedrooms 3 + A"^
0 number of current residents
1J11 garbage grinder, yes or no
yES laundry connected to system, yes or no
NO seasonal use, yes or no
If nonresidential, calculated flow:
Water meter readings, if available: 9 y = 10 y w
✓` in Last date of occupancy
GENERAL INFORMATION
Pumping records and source of information:
!Jo r��� �; ,., y roc o✓�lS , I �. c. 4
_ System pumped as part of inspection, yes or no
if yes., volume pumped
Reason for pumping:
of system
V
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) "
Other (explain)
Approximate age of all components. Date installed, if known. Source of
information: � S Te /I•, O J ✓J fc S 4 l tA
4—
'i
j i
Ny Sewage odors detected when arriving at the site, yes or no
9
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
/ SYSTEM INFORMATION continued
SEPTIC TANK: y
(locate on site plan)
depth below grade:
material of construction: /Concrete metal FRP other(explain)
dimensions: S A X 9 / .X 6 / l ao o y �`
S sludge depth
C-5 " distance from top of sludge to bottom of outlet tee or baffle
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
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles,
depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, recommendations for repairs, etc. ) /1
C. c r c fi{�S �-o.��. r .-. c A..�� J u,� �( ,VJ S. O rc� G v
6 O c./cA� Kau G i c .� •-. ,�..
rv� h i / r o o ` - 4 i h s v
DISTRIBUTION BOX:
—z
(locate on site plan)
g-v 6�� A depth of liquid level above outlet invert
Comments:
(note if level and distribution is equal, evidence of solids carryover,
evidence of leakage into or out of box, recommendation for repairs, etc.)
PUMP CHAMBER:
(locate on site plan)
pumps in working order, yes or no
Comments:
(note condition of pump chamber, condition of pumps and appurtenances,
recommendations for maintenance or repairs,etc. )
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORK
PART B
SYSTEX IN70RKATION continued
SOIL ABSORPTION SYSTEM (SAS) : V
(locate on site plan, if possible; excavation not required, but may be
approximated by non-intrusive methods)
If not determined to be present, explain:
Type.
leaching pits and number f w a S�oti t
leaching chambers and number
leaching galleries and number
leaching trenches, number, length
leaching fields, number, dimensions
overflow cesspool, number
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding,
condition of/ vegetation, recommendations for mainLtenance or repairs,etc. )
o \ I V C U V Y -�- O�N pti V.N J�9 C�/t.
✓'P J v t!✓ c r- C ✓al i S '. o u.o�.c
CESSPOOLS (locate on site plan) : /l//jf
number and configuration
depth-top of liquid to inlet invert
depth of solids layer
depth of scum layer
dimensions of cesspool
materials of construction
indication of groundwater
inflow (cesspool must be pumped as
part of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding,
condition of vegetation, recommendations for maintenance or repairs,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, recommendations for maintenance or repairs,etc. )
11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SKETCH OF SEWAGE L_SPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 1001
ro'^
3 �
3 �
d
33� 3a'
wi
/ IOpV 9
ys,
. y9
w
DEPTH TO GROUNDWATER
depth to groundwater
method of determination or approximation:
y
I
'SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
FAILURE CRITERIA
Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of
determination in all instances. If "not determined", explain why not)
Backup of sewage into facility?
/V Discharge or ponding of effluent to the surface of the ground or
surface waters?
N Static liquid level in the distribution box above outlet invert?
N Liquid depth in cesspool <6" below .invert or available volume< 1/2 day
flow?
Required pumping 4 times or more in the last year?
number of times pumped
N Septic tank is metal? cracked? structurally unsound? substantial
infiltration? substantial exfiltration? tank failure imminent?
Is any portion of the SAS, cesspool or privy:
below the high groundwater elevation?
within 50 feet of a surface water?
within 100 feet of a surface water supply or tributary to a surface
water supply?
within a Zone" I of a public well?
H within 50 feet of a bordering vegetated wetland or salt marsh
(cesspools and privies only, not the SAS) ?
/ y within 50 feet of a private water supply well?
less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis? If the well
has been analyzed to be acceptable, attach copy of well .water analy;,
. for coliform bacteria, volatile organic compounds, ammonia nitrogen
and nitrate nitrogen.
13
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART D
CERTIFICATION
Name of Inspector j ro y
�' • S
Company Name �yo �. Sep � c
�- :.��5� e -
fro �
Company Address l d 61 S
so"t�
sztiv� � Si
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
complete 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
manitenance of on-site sewage disposal systems.
Che�c one:
�1// I have not found any information which indicates that the system fails
to adequately protect public health or the environment as defined in
310 CMR 15. 303 . Any failure criteria not evaluated are as stated in
the FAILURE CRITERIA section of this form.
i
I have determined that the system fails to protect public health and
the environment as defined in 310 CMR 15. 303 . The basis for this
determination is provided in the FAILURE CRITERIA section of this
form.
Inspector' s Signatur S
Date
Original to system owner
Copies to:
Buyer (if applicable)
Approving authority
i
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L 0 C A:.t ION SEWAGE PERMIT NO.
Z/1
VILLAGE
INSTA LLER'SM & ADDRESS
d U.-tL;:fl:E R OR OWN R
GATE: PERMIT IS ED
OATE:> COMPLIANCE ISSUED
OV
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