HomeMy WebLinkAbout0065 MOUNTWOOD ROAD - Health 65 Mountwood Road
Marstons Mills
A= 125-013
F
Common uea!th of Massachusetts
Title 5 Official Inspection. Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M . 65 Mountwood Road
Property Address
Paul Phalan
Owner Owner's Name
information is Marstons Mills MA 02648 08/04/2011
required for State Zip Code Date of Inspection
CI (rOWn �.:
every page. tY
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.Please see completeness checklist at the end of the form.
Important: A. General Information
When filling out
forms on the I
computer,use 1. Inspector: c�
only the tab key
to move your Michael T. Bisienere
cursor-do not Name of Inspector
use the return
key. A&K Septic Systems Plus
dt Company Name
565 Carriage Shop Rd
Company Address
East Falmouth. MA 0253
6
Citylrown State Zip Code
508 540-6706 S13938
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and thaftlie
information reported below is true, accurate and complete as of the time of the inspection The�nspeetlon
was performed based on my training and experience in the proper function and malntenance:of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section IS.340 0
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails: ,
❑ Needs Further Evaluation by the Local Approving Authority 7
w
08/04/2011
Inspector's Signature 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 toAhe_appr_opriate_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. -
f 17
t5ins•0910tf
Tina 5 Official Inspection Form:Subsurface Se4Dispotern•Page 1I
l
(`nm nnuin-lth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
M 65 Mountwood Road
Property Address
Paul Phalan
Owner Owner's Name
information is Mns A 02648 08/04/2011
arsto Millss
required for Ciarsto n State Zip Code Date of Inspection
every page.
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have 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:
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.
Check the box for"yes", "no" or"not determined" (Y, N, ND)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.
0 Y ❑ N ❑ ND (Explain below):
4
Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 2 of,17
t5ins•09/08
. 1
\ Color Mon:•:-aft Of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
wM 65 Mountwood Road
Property Address
Paul Phalan
Owner Owner's Name
information is Marstons Mills MA 02648 08/04/2011
required for State Zip Code Date of Inspection
every page. Cityrrown
B. Certification.(cont.)
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 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 ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
pass inspection if with approval of the Board of Health):
will a (
system p
Y p
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
b
C) Further Evaluation is Required y 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 accordancewith 310-CMR--
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
Cess ool 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
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
t5ins-09108
e
i
i
i
.. ealth ..f Massachusetts
�o�� —Ar
v �. Official Inspection Form
Title 5 p E
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
ww 65 Mountwood Road
Property Address
Paul Phalan
Owner Owners Name
information is Marstons Mills MA 02648 08/04/2011
required for City/Town State Zip Code Date of Inspection
every page.
B. Certification (cont.)
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 indicates absent 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:
D) System Failure Criteria Applicable to All Systems:
t -
1 You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
— -ackup-of-sewageAnto 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
-- - -- ----. .❑ -a ® --.or—clogged d SAS ool
_.or cessp _
Liquid depth in cesspool is less than 6' below invertor a&ail"abI6volume is ess-� ~�
❑ ® than '/Z day flow
Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 4 of 17
t5ins•MOB
Commo.^.wealth of!!�assa�!:::setts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
65 Mountwood Road
Property Address
Paul Phalan
Owner Owner's Name
information is Marstons Mills MA 02648 08/04/2011
required for
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® , Any portion of the SAS, cesspool or privy is below high ground water elevation.
El ® 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.
❑, ® 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 fecal coliform bacteria indicates absent 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
and chain of custody must be attached to this form.]
Q ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
El El criteria
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 16,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
a El ❑ the system is within 400 feet of a surface drinking water supply
ss ❑. ❑ the system is within 200 feet of a tributary to a surface drinking water supply
- --_- —the system-islocated in-a-nitrogen-sensitive-ar-ea (anterim_W�eJJhead_Protection
as Area-1WPA)or a mapped Zone II 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_CMR1-5 304 The-system owner-should-contact-the_appropnate-i- .- ; Y.-
regional office of the Department.
t5ins•09/08 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
commonwealth.ealth. -f massac.,.usett
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments i
M 65 Mountwood Road
Property Address
Paul Phalan
Owner Owner's Name
011
information is Marstons Mills MA 02648 Date of Inspection
required for State Zip Code Date of Inspection
every page. Citylrown
C. Checklist
Check if the following have been done.You must indicate"yes" or"no"as to each of the following:
ai
Yes No
® „ ❑ Pumping information was provided by the owner, occupant, or Board of Health
of the system components pumped out in the previous two weeks?
Were any
❑ ®
® ❑ 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 not
If the w
tans of the system obtained and examined ( y
built y
® ❑ Were as P ICI
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, excluding 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 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.
® El approximation
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(5)]
D. System Information
Residential Flow Conditions:
' Number of bedrooms (design): umber of bedrooms-(actual):—
------- -
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):
Title 5 Official Inspection Form:Subsurface Sewage Disposal system-Page 6 of 17
t5ins-09108
/Ja\ ('`�mmnn�un�lth of Massachusetts
Title 5 official Inspection Form
R
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
65 Mountwood Road
Property Address
Paul Phalan
Owner owner's Name 02648 08/04/2011
information is Marstons Mills MA
required for State Zip Code Date of Inspection
every page. City/Town
D. System Information
Description:
System consists of a Septic Tank, D-box, soil absorption system
2
Number of current residents:
Yes No
Does residence have a garbage grinder?
❑ ®
Is laundry on a separate sewage system?[if yes separate inspection required] ❑
Yes ® No
❑ Yes ® No
Laundry system inspected?
® Yes ❑ No
Seasonal use?
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
❑ Yes ® No
Sump pump?
. Currently
Last date of occupancy: Date
CommerciaUlndustrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present?
-- — --❑__Yes_❑ No --
Yes No
Industrial waste holding tank present?
❑ ❑
Non-sanitary waste discharged to the Title 5 system? ❑^
Yes ❑ No
Water meter readings, if available:
Title 5 Official Inspection Fonn:Subsurface Sewage Disposal System•Page 7 of 17
r t5ins•09i06
o Ma. -achuse Li'3
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
w 65 Mountwood Road
Property Address
Paul Phalan
Owner Owner's Name
information is Marstons Mills MA. 02648 08/04/2011
required for State Zip Code Date of Inspection
every page. Cityrrown
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection?
Yes ® No
If yes,volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system ,
Single cesspool
0 Overflow cesspool
a
Privy
i [] 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)and a copy of latest
} inspection of the I/A system by sys of m operatorander-contract --: —
Tight tank.Attach a copy of the DEP approval.
Other(describe): _
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
t5ins•09/08 -
.�
C#%r" .:o^.:•:__a!#h of Massachusetts
Title 5 Official. Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 65 Mountwood Road
Property Address
Paul Phalan
Owner Owner's Name
information is Marstons Mills MA 02648 08/04/2011
required for state Zip Code Date of Inspection
every page. cityfrown
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
16
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):
1
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
1000 Gallon ST
Dimensions: -
i
Sludge depth:
Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 9 or 17
t5ins-09/08 -
i
b
i
C#%ry%Mr%n,-•:ea!th of Rmassachuset*.,s
Title 5 Official Inspection Form
r Voluntary Assessments
Subsurface Sewage Disposal System Form -Not fo ry
wM 65 Mountwood Road
Property Address
Paul Phalan
Owner Owners Name.
information is Marstons Mills MA 02648 08/04/2011
required for State Zip Code Date of Inspection
every page. CitylTown
D. System Information (cont.)
Septic Tank(cont.)
23"
Distance from top of sludge to bottom of outlet tee or baffle
2"
Scum thickness
10"
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
20"
Field Instruments
How were dimensions determined?
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Recommend Pumping everV two years
Grease Trap(locate on site plan):
Depth below grade: feet
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: Date
Tide 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 10 of 17
t5ins•09108
i
Ca.m. ;;onvuealth of R.!assachusetts
Title 5 Official Inspection form
Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
65 Mountwood Road
Property Address
Paul Phalan
Owner Owner's Name
information is Marstons Mills MA 02648 08/04/2011
required for State Zip Code Date of Inspection
every page. Citylrown
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
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 per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
,.
• _,,.,,. y µ._:me ,v:�_ _,,,,, _Attach copy,of.current pumping contract(required). Is copy attached? .❑ Yes , ❑ No
t5ins•09108 ' Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 111 of 17
of Masssachusetf.S
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
65 Mountwood Road
Property Address
Paul Phalan
Owner Owner's Name
information is Marstons Mills MA 02648 08/04/2011
required for
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(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.):
Liquid level is normal
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•09108 T ^..^.Form:Subsurface Sewage-Disnnsal system•Page 12 of 17
.�
rv9'''!. .r~%n.sj,alf ^.f RA nSSaC�:::SS�
Title 5 Official Inspection. Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
65 Mountwood Road
Property Address
Paul Phalan
Owner owner's Name
information is required for Marstons Mills MA 02648 08/04/2011
_
every page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number:
One
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
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 ❑ No
!^s;.e ro....[Subsurface S--age DiT—A$vstem•Page 13 of 17
t5ins•09108 """""""" ' - - - -
Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
65 Mountwood Road
Property Address
Paul Phalan
Owner Owner's Name
information is Marstons Mills MA 02648 08/04/2011
required for State Zip Code Date of Inspection
every page. City/Town
D. System Information (cont.)
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.):
..P.. :St -e-agn Disposal System•Page 14 of 17
' � - ^ wn !8!a L!A .. rL�vess+l-fit"
.;LZ �►�Ji ii iiiiiiili i�ial U3 vi iii� .siGvi.wvva.w
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
65 Mountwood.Road
Property Address
Paul Phalan
Owner Owner's Name
information is required for Marstons Mills MA 02648 08/04/2011
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view 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. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
NI.
3 = <3vf ,6,-
3
a
Tilta.5 Official Inspection Form:Subsurface Sewaae Dlsoosal System-Pace 15 of 17
l� �`nmmnmun�lth� of RA- S2C1-U--+.tS
odc. u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
65 Mountwood Road
Property Address
Paul Phalan
Owner Owner's Name
information is Marstons Mills MA 02648 08/04/2011
required for State Zip Code Date of Inspection
every page. City/Town
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
11 plus
Estimated depth to high ground water: feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
.a I
You must describe how you established the high ground water elevation:
Augured hole to 11' no ground water-T of seperation
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 16 of 17
t5ins•09108
dC-m.iioniv e"-ft i of M�.JYf�Av^uJra+w
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
65 Mountwood Road
Property Address
Paul Phalan
Owner Owner's Name
information is Marstons Mills MA 02648 08/04/2011
required for
every page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary:A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t
..,....._.....
c Offid,i!nspectie.Form:Subsurface Sow?pP.Disposal System-Pape 17 of 17
» "t
L0CALION _ SE ? GE PERMIT NO.
0
V I I I A G E
f'
IN A LL R'S N ME ` & - ADDRESS
4 / 1Y
� R U I L D E R OR OWNER
') DATE PERMIT ISSUED '�
DATE COMPLIANCE ISSUED
I
I
F/zo
C
a
I�_
b
LOCATION CGS SEWAGE✓ PERMIT NO.
VILLAGE
-'�'- S ��o,�un'1"'o++� Y� g� �?3� �ia�-5 �on5 JV�rJ/S.
INSTA LLER'S NAME i ADDRESSTrucbng & Bulldozing
Hyannis, Mass. 775-0828
S U I L D R
��//�E Olt �,
OwNR
4 /4 cr 15�ti t
OA T E PERMIT ISSUED
DATE COMPLIANCE ISSUED / nit- wlam
v
• `T 7
Ar
a
�7 .. /.1..... FIz$. 6......_-..........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
-. -.....OF... .. ........................
.� 'Appfiration for Disposal Works Tonstrnrtiun Prrmit
Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal
System at:
. .�. ...AM --------•-a..—A. . ..�- .... ....................................
17 Locat' -Address, or Lot No..._.. _ r�� .. ..................................
...........-...............
Ow Address
--------------- ------------------------- --- ..--------•--•--------------------
�e�
Installer Address
Type of.Building Size Lot.A,5.'lP0.-0`- ..Sq. feet
Dwelling—No. of Bedrooms.........�...................•...•.........Expansion Attic ( ) Garbage Grinder ( )
`k Other—Type T e of Building No. of persons............................ Showers
Pa YP g --------•---------------•-•- P ( ) — Cafeteria ( )
p' Other fixtures ......... Q----------------------.-----
W Design Flow......... ..-a.........................gallons per person per day. Total daily flow..............3.0d..o..................gallons.
WSeptic Tank—Liquid*capacity- lons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No.................... idth•...._._.......... otal Length...... To 1 leaching area....................sq. ft.
Seepage Pit No..l�°`- . _ -------- 1 leaching area..•;?a_&._sq. ft.
z Other Distribution box ( Dosing Lnk .�L' !� a x' 77
a Percolation Test Results Performed b �.._ � % Date.•.• d
y ! :-..�
Test Pit No. 1.. ..._..minutes per inch Depth of Test Pit.................... Depth to ground water........................
Li, Test Pit No. 2................minutes per inch Depth of Test Pit................. Depth to ground water........................
-
Description of Soil.. /� ............. �Lz'
x ,� =-------------------------------------------------------------- ......-----•----•---•-------------------------------------------------------------------------------------------------------•••--
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
f
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 been issued by the board of health.
Sign y� .�f. .. .�
_. ---��.-- -/ - --••-- --------• ate
Application Approved B /
Date
7
r"F Application Disapproved for the following reasons: ... -•-••---••---•-••-----•-----•------•••---••-----•...................••••-
--------------•---•--•---:----•-----------•---•-------------•-----•---•--••----••----------...-----------'•-•------------------•--------•--.__---•----•-----------•----------•---..__Date-•---------'--
.... ------. Issue.......................................................
Permit No.--•...........................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.....OF.... ,... ........ ...............................................
wnrtifirtt#e of Toutplianrr
TH15 IS TO CERTI y, T the Individual Sewage Disposal System constructed r Repaired ( )
by-------- ...... ....
--••--------
I-n-s----�-�--
....._,.................................... ..... .... -.---..-------..--------
} at. *....w.• --.. .... --- -----• --- ---- -- -
has beenristalled in accordance with the pro isions of T 7 5 0�The State Sanitary C e as described in the
application for Disposal Works Construction Permit No. ..... .-------`y7._.IK----------- dated.__.__�l- �/_'_ �..............
T,H`E<1SSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
9 'S1fSTER+I WILL FUNCTION SATISFACTORY.
DATE.............................................•------•---•--•-................... Inspector....................................................................................
r- W• � JF
77... ,...... Fps �......`..".�..:"....
THE COMMONWEALTH OF MASSACHUSETTS
BOAeR® OF HE LT
..........0F..I r --... -•--•• ........................
Appliration for Eliipos al Works Tonstrurtion Permit
Applicatiow is hereby made for a Permit to Construct ) or Repair ( } an Individual Sewage Disposal
S ...... .........-� -- • ...........
p001
__-••Coca Address or Lot Np.
-•••••• — .. .....
.._+�......................................
- ---•--•----•-•-•............. ........................... -- •----•--••--•---•-•-•-....-----...._......---
O Address ;
� Installer001
Address
� Type of Buildin
g Size Lot_?I,, ---Sq. feet
Dwelling—No. of Bedrooms______________________________________Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ____________________________ No. of persons............._.............. Showers ( ) — Cafeteria ( )
Q' Other fixtures -----r ----_----•----_ ---
W Design Flow........ _.........................gallons per person per day. Total daily flow..____.___.__0_!Q__._.______________gallons.
WSeptic Tank—Liquid capacite gallons Length................ Width................ Diameter________________ Depth................
x Disposal Trench No .................... idth otal Length _____ . T leaching area_____ ____sq. ft.
Seepage Pit No. 1 leaching area__.d te...sq. ft.
Z Other Distribution box ( ) Dosin%nk ( D 'Pit
01
77
Percolation Test Result Performed by.___ '.._ ..___�.__ ,tom-_ EL Date__�`__."'_� _''_�_7..
Test Pit No. 1_ __.____minutes per inch Depth of ,Test Pit____________________ Depth to ground water..___._______._________.
fi Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water......--................
.44
rI
---------------.................--- ------. .....................................
Description of Soil .
x - -
U -----------------------------=---=•----------------------------•-----------•--•----•--------------•-----...----
W 4
UNature of Repairs or Alterations—Answer when applicable.................................•..____________._.______.___._._..___._..__.__.__..__._.__.___.
Agreement
The undersigned•agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 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. ,, ..•- .
R
Sign El .+ �._--i. -- •
Application Approved B ..... 7Daa-ttee ..
•a=
Application Disapproved for the following reasons_________________________________________________ •'
•----------------------------••--:;--•--------•----••--•---------••--••----•-•----•------._..--------....--•-•-----------------------••-•---------••••-••--------•-------•-----•_.-------------•-------
Date
PermitNo......................................................... Issued--------------------------------------------------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........1 -.'.......6F...:. .... ....... ...............................
Tntifirate of Tontpliattre
THIS IS TO CERTI t the Individual Sewage Disposal System constructed nor Repaired ( )
by &----- ........................................................----- -•----- -•---___. -----------•--
i�J -- - ---- --
at - i` In ------------ �•-
has been installed in accordance with the provisions of T r j) The State Sanitary cfiepLs 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 F HEAL H
.
go7//..:. _ FEE/ .._.......
MoVaiial Workii To of • ion Prrutit
Permission, is Y granted--- �divi
_. ._
to Construct or Repair ( nSewage D pos S stem at
re
as shown on the application for Disposal Works Construction P, r it Dated_.//`__f'7 _________________
Board of H
DATE / i / --.._...---•-
FORM 1255 HOSES & WARREN, INC., ,PUBLISHERS
`-f=F-'T-lG -f A�1LC = 330 r Ir7G °/o 4-9Cj 6.P.D. 'V \
CJS�_ l UOC� 64LA 41
\\
,I ,FcXAt_ FAIT ask= 1000 GA.(_ .
£17 A/ALJL AV-E-A = tSo s.t=. J V
St= •c 2.S CIS
I rJo C?.P D. P•T I J' .
ToT'AL -C leSIGk.I = 425 G.pa. N
-r oTA t_ mat L�r r-Lr�•.A-1
r p N
C'>✓!1GDLQT10t�1 t�l�T� ���tu �Mi u 02 ASS, h '£ .
3n.
14
`•`.:- tee` , '7 O
TEST F� 99.o Tor Fwo =too.,,
F^.M J QPe I oaa IWV.94.7 A
r -Boy Sc--Qric
tuv. TANK
I oop 9�• 9a ttuv.
GAL. y� a�
c eA LsAc N
�A
P�-r
i WASHED
I STONE Fb YO
C-CQTtI=tGL7 PLb`f' t`'L Li,IJ
L_f-- LOCATId�-J
ScA.L.�- GOAL t= I = G o 1
Wo WArez- bATi✓ /�:f
I C U:V T t E=',{ P't-- ),1,j TZ 1 =p-V E►'I c a
t-!i{'C��1_1 G��ti�I�l_�fS �l/ i l"I-1 T►-t` �j I D C Ll t-1� L O `j- G
Atii� `:ETI'_�hCl'� S:GrJt CMc �iTti U{= C uC DST a
-TO Vl Li Or- LE-
CJ A T C, t°•2�=T� ���,, ( cam,•-.� 1 ,�O�tC�..w
XT C
Tt-AI h I_A y-! i r, I-I OT LA.7 � Ut. pN
' ,+.!•:(�'Jtl�l:1.1�' �jtJG:�/t'�`t' '�, •'(t�1L- L:�l=�%.("�i ik.{GWI� 114�Il1_1 CtS.ti_I'C'
I t.. ,C L',t l.1• L(-) ii, 17['=}'i_E�/t/1►�11- LD'Y (_11�1�a — _-CA''E 1hI'• ✓ t rE E. _ r