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Home My WebLink About0174 COUNTRY CLUB DRIVE - Health��t',:lifi.:�,',re'tAr'�a+rh..�p.Mawt n•'"�..rer"`,*' r.•,Y,^A u:p•.t_'�.,.cm,'W',,x y°„1�.�m¢^`,.�"aC�ri t}t{"..'"y•.u�,�.�'am.�C'p"4 ,.wh a,�o��,�,!di��•,-i.r. 'd-1;_�.y..�r�z,•,`t.,"11aS�yt, 'a f�rr,�a a''•r^•.R.;`�r f'L, a�1 7' A� 4,.v ^)C,''t Y.F o4��' •Y u". 1..n tx'yr'.!y r. C l uI A�-.,""•�, b r�•',�r�• Drive rive Barnstable P , A 350 44 Ok fd: N4 n •d.{y,1•tn�� ,fi.,r.a:. ,{#I yyV.`nnF,.1��'•�=ti i,t,.�.D_,,'[�TCp,".k .�' .f^.. T�,.rVfWp�fI. Y•am„:...'�.F 1... W r �i � �•'� t 'y � �i 'm - ..��1 A. ti' '''4 tT ., �. Gv, p " �; f�Y• � ''µ, , ta. ! .My� . /d u� .. ,x�„_ a - 3� .x° .. -.y 1, 'i n, r , , �r a " % e {' ra'' to O ��a� r�4 T.. .;:" ,�. o .�t` a�#, 'v. �� f,; `:�r ? s. ,o, { •�.+f a • r n; l?xl ._, _ , h ''.,. .. "Y ., °l.��4 ry'°t' ,.y1i ...., ... -. Y� :.';. '� ` ,c 1'd �, a _ '� ,��,.. :'_.•. ._ - __— nT. ',:iB,y" .�" �J,. TROY WILLIAMS SEP 1 0 2003 � R: h SEPTIC INSPECTIONS TOWN OF BARNSTABLE y� ALT Certified by MA Department of Environmental Protection (508) 385-1300 { 19 Hummel Drive South Dennis, MA 02660 f 5 2- COMMONWEALTH OF MASSACHUSETI'S EXECUTIVE, OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION -` TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 174 Country Club Drive Cummaquid,MA Owner's Name: Annette Flaherty Owner's Address: 174 Country Club Drive Cummaquid,MA 02637 Date of Inspection: September 9,2003 ® \' Name of Inspector: • Troy M.Williams O v Company Name: Troy Williams Septic Inspections Mailing Address: 19 Hummel Drive South Dennis,MA 02660 Telephone Number: (508)385-1300 CERTIFICATION STATEMENT 1 certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 1 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 Loral Approving Authority Fails Inspector's Signature: Date: 'I/ct/o 3 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of I iealth 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 Although system meets the minimum requirements set forth by the Massachusetts Department of Environmental Protection,certification Is not to be construed as a guarantee of future working condition Of system,piping or components. This inspection represents the conditions of the system on the Date of Inspection noted above. ****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 pace iorll Page 2 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) . Property Address: 174 Country Club Drive Owner: Cummaquid,MA Date of Inspection: Annette Flaherty. r September 9,2003 inspection Summary: Check A,B,C,D or E/ALWAY§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 CK4R 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"ConditionZthe on need to be placed or repaired.The system,upon completion of the replacement or repair,as he Board Health,will pass. Answer yes, no or not determined(Y,N,ND)in the for the followi "not determined"please explain. The septic tank is metal and over 20 years old" or the septic tanktal or not)is structurally unsound,exhibits substantial infltration or exfiltration or tank failure isstem will pass inspection if the existing tank, is replaced with a complying septic tank as approved b he Board of Health. 'A metal septic tank will pass inspection if it is structurally soun of leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break t or high static water level in the distribution box due to broken'or obstructed pipe(s)or due to a broken,settled uneven distribution box.System will pass inspection if(with approval of Board of Health): en pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The syst required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspect' if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2" t Page 3 of I 1 t OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 174 Country Club Drive Owner: Cummaquid,MA . Date of Inspection: Annette Flaherty September 9,2003 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the.environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) hat the system is not functioning in.a manner which will protect public health,safety and the envir ment: — 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 mars 2. System will fail unless the Board of Health(and Public.Water S plier,if.any)determines that the system is functioning in a manner that protects the public health afety and environment: The system has a septic tank and soil absorption syst (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water su y. _ The system has a septic tank and SAS and a SAS is within a Zone 1 of a public water supply. — The system has a septic tank and S and the SAS is within 50 feet of a private water supply well. _ The sv stem has a septic tank d SAS and.the SAS is less than 100 feet but 50 feet or more from a private water supply well**. M od used to determine distance "This system passes if t well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile anic compounds indicates that the well is free from pollution from that facility and the presence of onia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other .failure criteri a triggered.A copy of the analysis must be attached to this form. 3. Other: r �' Page 4 of 11 µ OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 174 Country Club Drive Cummagwd,MA Owner: Annette Flaherty Date of Inspection: September 9,2003 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 cesspool _ ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than%:day flow _je!� Required pumping more than 4 times in the last year N2T 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. _ /v/.q Any portion of.cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. /vm Any portion of a cesspool or privy is within a Zone 1 of a public well. - - wg Any portion of a cesspool or privy is within 50 feet of a private water supply well ' g,(d 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.) Iyv (Yes/No)The system fails. l 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 alarge system the system must serve a facility with esign 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 c 'eria above) f yes no the system is within 400 feet of a surface dr' ng water supply _ the system is within 200 feet of a trib to a surface drinking water supply _ the system is located in a nitro sensitive area(Interim Wellhead Protection Area—I WPA)or a mapped Zone 11 of a public water su y well If you have answered"yes"to question in Section E the system is considered a significant threat,or answered "yes"in Section D above th arge system has failed.The owner or operator of any large system considered a significant threat under,S .tion E or failed under Section D shall upgrade the system iq accordance with 310 CMR 15.304.The system o er should contact the appropriate regional office of the Department. 4 Page 5 of 11 - r OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 174 Country Club Drive Owner: Cummaquid,MA Date of Inspection: Annette Flaherty September 9,2003. Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No ('::;:-.ping information was provided by the owner. occupant,or Board of I Icaltll ✓ 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? r ✓ 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 N/A) — Was the facility or dwelling inspected foi signs of sewage back up? r ✓ _ Was the site inspected for signs of break out . x. Were all systerri 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 frbm 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: 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 CIAR 15.302(3)(b)J Page 6 of 11 OFFICIAL INSPECTION.FORM-NOT FOR VOLUNTARY ASSESSM ENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 174 Country Club Drive Owner: Cummaquid,MA Date of inspection: Annette Flaherty September 9,20013LOW CONDITIONS RESIDENTIAL Number of bedrooms(design):-LL Number of bedrooms(actual):_zl DESIGN flow based on 310 CMR 15.203(for example: l 10 gpd x#of bedrooms):_yyo Number of current residents: t Does residence have a garbage grinder(yes or no):. YES (Al.+ Is Iaundn on a separate sewage system(yes or no): ^!u (if yes separate inspection required. Laundry system inspected(yes or no): 14/,9 Seasonal use:(yes or no): ova Water meter readings,if available(last 2 yearsltsage(gpd)): 01-o - GS Do u 3 166;o00 j Sump Pump(yes or no): 6ks-, .,. L, rt, A-A La, ) Last date of occupancy: rt COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): ,gpd Basis of,design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 syste (yes or no): Water meter readings,if available: — Last date of occupancy/use: - OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the i spection�or no):Ate- If yes,volume pumped: gallons-- How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tank,disigibldlankaiL,soil absorption system _Single cesspool _Overflow cesspool —Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Altemative,-technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval _Other(describe):. Approximate age of all components. date installed(if known)and source of information: IU 1101- /Ut�.tJ�r �ua.c�. h �oL�Li of 0, Were sewage odors detected when arriving at the site(yes or no): No ' 4 6 `- f - Page 7 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 174 Country Club Drive u Owner: Cummaquid,MA Date of Inspection: Annette Flaherty September 9,2003 BUILDING SEWER(locate on site plan) Depth belo% grade: Materials of construction: ,'cast iron -Z40 PVC ✓other(explain): dra.h�`�✓rs ( SL t,i«« fuhk,J Distance fron,private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): + I IVS�s-.( ( iNc S w 1 ��.�.t /L��.✓ Uh ih S -1 c,�•on /v/>•�'a• 6l�c�r. yro` Ck O'I,+v1 ►''�y hot �� o F ��. ��✓�, ., fit, ,,��,,,—� • �' SEPTIC TANK:,�(locate on site plan) Depth below grade: 02 •S Aw s r:s / . Material of construction: ✓concrete_metal fiberglass__polyethylene _other(explain) If tank is metal list age:_ is age confirmed by a Certificate of Compliance(yes or..no):-(attach a copy of certificate) Dimensions: 5 9 'x G ' /000 4—//0h Sludge depth: - y 7-7 Distance from top of sludge to bottom of outlet tee or baffle: a 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: 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.): c .,..//.1f 'o s.Ap eTo— �� n [�Ji�,1.e.�e� c� 7'�' /t�(t-�s t n✓' u�.,y.. o e - `� yio✓✓f 6�. / `''"'s� W w S 1t a �- i h h.�t� o,JC' ,7�•Mn � h g - GREASE TRAP:_(locate on site plan) Depth below grade:_ Material of construction: concrete_metal fiberglass p ethylene_other _ (explain): — Dimensions: Scum thickness:. Distance from top of scum to top of outlet tee or baffl Distance from bottom of scum to bottom of outlet or baffle: Date of last pumping: Comments(on pumping recommendations, ' et.and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of le age,,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 174 Country Club Drive Owner: Cummaquid,MA Date of Inspection: Annette Flaherty September 9,2003 TIGHT or HOLDING TANK: (tank must be pumped at tim f inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fib glass---polyethylene other(explain): Dimensions: Capacity: gallons Design Flo%%. gallons/day Alarm present(yes or no): Alarm level: Alarm in worki order(yes or no): Date of last pumping: Comments(condition of alarm a float switches,etc.): DISTRIBUTION BOX:N/n (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 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.): PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,conditio f pumps and appurtenances,etc.): i a • Page 9 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 174 Country Club Drive Owner: Cummaquid,MA Date of Inspection: Annette Flaherty September 9,2003 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain w'h). Type I - 0 7*• 'x6 ' ��^ p,t ,, ; 2 '1< *"' . leaching pits, number: I e L t. Y; r ; Z• S -D 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.): nn 1 l ww3 flu .c w'' 11. bt!!ow ov4- S 11 tti wi R, 4- 'h �'`i`" G � roJG mac. 6 c �o o..� � h �t >`. �. r...c_ /t!o •G v. �`!cCr.�✓ 1.`L �' i I✓ rt u✓ .�ry II �c.s,i c t D F e-.r ceu�✓L v „C 0. CESSPOOLS: (cesspool must be pumped as part of inspection cafe on site plan) ��[[ Number and configuration: i.�+ s�✓.�C- Depth-top of liquid to inlet invert: `— Depth of solids layer: Depth of scum layer:_ Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or n Comments(note condition of soil,sign 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 hydrau failure,level of ponding,condition of vegetation,etc.): r 9 `' 4a, f Page 10 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 174 Country.Club Drive Cummaquid,MA Owner: Annette Flaherty Date of Inspection: September 9,2003 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. A A 3s 2'. E = 3 ' _ O C �r X6 , u l XC oo� j r. Ja✓ S''fC lt. act p,y Page I l of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) . Property Address: 174 Country Club Drive Owner: Cummaquid,MA Date of Inspection: Annette Flaherty September 9,2003 . SITE EXAM Slope Surface water Check cellar ✓ Shallow wells Estimated depth to ground water /8.s' feet•. 8 Adjusted high ground water elevation Is.6 'feet Please indicate(check)all methods used to determine the high ground «ater elevation: Obtained from system design plans on record- If checked,date,of design plan reviewed: -�Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Ilealth-explain: _ _ Checked with local excavators, installers-(attach documentation) i Accessed USGS database-explain: 14 1 You must describe how you established the high ground water elevation: yl- ✓4�t N� I• �tt✓ 1 �� - / 2.y This report has been r tired and the system. Inspected as of th P eP a date Y of insp ection. P pact ,This report is not a warranty or guarantee that the system will function properly in the future. The re have been no warranties or guarantees,either expressed,written or Implied, relating to the system, P gthe inspection and/or this report. Il , cp,5 C A T ION - SEWAGE PERMIT., NO. Arl 341 VILLAQE ASSESSORS MAP N0: 3 L( PARCE, Mg. tlNSTA LE S NAME ' .6 ADDRESS�G s7dA; c B U I L D E R OWNER DATE PERMIT , ISSUED_,. DATE COMPLIANCE ISSUED -cam;{a e� �l:�a`t -- OYCATION. SEWAGE PERM T NO. %;7�- CGU o �� — GO 'VILLAGE ly I N S T A LLER'S NAME A ADDRESS �i A C 0 ,M 3 e � D U I l D E R OR OWN ER 14eiZT DATE PERMIT .ISSUED 9S- DATE COMPLIANCE ISSUED 12 _.Z �.c �� ' � �� i �z � �. � � t � � ` b � 'I� � . , No THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HE LT ............ OC ! ........OF........A . .. ... . ..�/ Appliration fnr Mir niittl Works Tonstrnrtiun rnmit Application is hereby made for a Permit to Construct ( ) or Repair (l�an Individual Sewage Disposal System at: ....:. .7 ....��. .. f..... �� .... .......................................... Address or �Locatio� Add Lot No. !. .......�---.�LId/C 1.... ............................... - Owner Address a - Tr-----•• ............................................. ..------•-••••............ Installer Address dType of Building Size Lot.................... ......Sq. feet U Dwelling tzNo. of Bedrooms.......................:....................Expansion Attic ( ) Garbage Grinder ( ) pa Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) P4 Other fixtures .--•-•-••-•-••-••--•....._...... . W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) '~ Percolation Test Results Performed by.......................................................................... Date.................................... 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.......................-- Descriptionof Soil---••-...••• --.......--•---•--•---•.................•-•---•-------•---•---------------.....------.......--------------------------•-.-•_.. U Nature of Repairs or Alterations—Answer when applicable � ..........� .. _ ...:..�........................ •-•-------------••----- �4.... z. fd - . Agreement: l The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITLL 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 th oar - f heal . i Signed-- Date Application Approved By•••••••••--•... - -. . :�1`'� --••---•--_ =-^--� •----- Date ^` Application Disapproved for the following reasons:................. ................•---..__...--•--......__......_..-•--•.................................................................................................................................................. — I IQrO f Permit No.......... ...._ Issued.-----•------------------------------------------------- Date ------------------ --- t NoDfL.-!1G'C) Fss ..V:... .. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HE ,LT ' . ,1.......0F........1 �L� k....;t f.. '.-. ...................... Appliration for Disposal Works Tonstrurtion "prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( }'man Individual Sewage Disposal System at:07 /"f ......................... .'� „ate� tWv /J°;..._... L�f�Pi�� :?. l��f.'......d....l... _. i �Locatio -Address .. ...... .. .._... or Lot No...........................-..........._.. ;" ..........�"... .?�:r�.�..._.�.�J'x:....._.. - _........................----- ------ -- a -• Owner Address ,-a --------- --------------------------------------------- --------------------------••-----------......:....................................-........ ._..... Installer Address Type of Building Size Lot............................Sq. feet U Dwelling-4�o. of Bedrooms......................... ___..Expansion Attic ( ) Garbage Grinder ( ) Other—Type T e of Building No. of persons............................ Showers W YP g -------------•---------•---- P ( ) — Cafeteria ( ) G4 Other fixtures ---------------------------------------- -------•-----•---•---------------------- ------------------- ------------------------ ... W Design Flow........................:...................gallons per person per day. Total daily flow_.__.........__----------------------------gallons. WSeptic Tank—Liquid capacity.......:....gallons Length................ Width................. Diameter................ Dept h................ x Disposal Trench—No_____________________ Width.................... Total Length,................... leaching area...................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by........................................................................... Date....................................... 1.4 ,..a Test Pit No. L...... ....minutes per inch Depth.of Test Pit.----------:_....... Depth to ground water.........._............... LLI Test Pit No. 2................minutes per inch Depth of Test Pit...................... Depth to ground water........................ �+ _-::_..•.............1.--••--------........-----•------....._..----•-------•-•----••--•--•-......................................................... D Description of Soil..............1 al %% . U -----•----••--------•-•- ....... _____---------------------- --------- _.------ -------------------------------- -------- __.......... ________-•------------- W -• Nature of Re airs or Alterations—Answer when a licable_.-- _./ e r .�..__ .. U P PP s' ` ............................................. ......-•--------•-----••---•----•••-••.............. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITIS 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 cif health Signed ., ;.!!%!. _.. ` . ,�r" lf� - --....' ,� `. » Date Application Approved BY aa.:.�. ::,rj/ y��-- 1--7-- -7 ..............:•-•----•--------» -----•--- ........ Date Application Disapproved for the following reasons_____________________________________________________________________________:_______-__..__..._...._......»»» ........-•---••......................:.................•----------•-•-•---•-----.....----..._.:..._...._..__....._..._........---...-----.....-----•--•---------•-------......--••-•-......_--.......... Date Permit No....... Issued............................................--........- { 4 Date \ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............... ...OF...... p°,, �?t! ,� N t ..................... Tlertif ratr of 09outplittnrr TH1 %TO,. ETIFY,� atthe Indidual Sewage DispoJsal�System constructed ( ) or Repaired ( l by..... ....� ....� - ---- ----..... F .... ... : . ........................................................»», ......_ F dd N . 4 �'f G Instaper r .�- at - tom ' :_ Z! .. .�G' %.......... ---------------------------- has been installed in accordance with the.provisions of TITLE 5 of The State SanitaCry Code as described in the application for Disposal Works Construction Permit No.�c :v:_:__�._l:_�. _�_..... dated_....-__�:?,:__ 2. .......... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE...................... .Z�- .................................... Inspector..._.._.�.......... -................,..... THE COMMONWEALTH OF MASSACHUSETTS ..�� BOARD 0F HEALTH �/� N0....�.....:�........i.. Fay..:�'..2.:: .... �io�ro or Tonotx ' nrrit �✓ r �- Permission is hereby granted : . . ...-_ ,-----------------✓��:...._---.s.:�,:-,��...........___.. to Constru �( ) o epair an Ind d S age Dis System ,1 L' at No.: 'c. •_--- W Zzo- `._._... 1 Gam' ........... -..!.1� '/!. ✓ ::... ...G . ................. Street `- 2_�I'J �) as shown on the application for Disposal Works Construction Permit No..................... Dated........___.1�?� _.:-...__.._.-.. n --------------------•-........_....» 1 �- /2 / � � Board of Health DATE............................•---._..............._....._........-------•--: FORM 1255 A. M. SULKIN, INC., BOSTON , r t I - AsBuilt g' Page 1 of 2 r - y : :` s .V07 J.OATION SEWERMIy NO. ASSESSORS MAP NO 3�G JNSTA LE S NAME ADDRESS 4or�i D 63 8 UlLDE, R OWNER DATE PERMIT ISSUED 'DAT 'E ; COMPLIANCE ISSUED �'..tj i 1, http://issgl2/intranet/propdata/prebuilt.aspx?mappar-350048&seq=1 5/4/2016