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HomeMy WebLinkAbout0188 COUNTRY CLUB DRIVE - Health Country Club ,Drive Barnstable P Ol 15 ^ w e . Y. , r , ' r � .. •' �� ;y, �� .. u, `F ^, is�.. s.. p,. .. 4' ,, • [.R.L.,. R� .- � f `' ' � S� •� .Y 1,` \ �. •4 � .. • { „ 1. �� ' " - f F � + .' • w Y 1 y 0 > , i c x , t .., �f � ' .. - U - - a � � [� R,1. ,, !. .. 5 - ,l Ke" ` N .f'• c, v ' W a. • r. , n [ w y a v li PROPERTY ADDRESS:__� g_� E ,Q--- E �; �- - Z � �� �cL��na-_____----__ JAN 2 0 2004 ---a2-632---------------- TQ1h'N OF dARNSTABLE HEALTH DEPT. On the above date, I inspected the septic system at the above address. This system consists of the following: _ l 1. 1- 1000 ga. -Pon ze/2.t.io tank 2. 1 dizt2.igut.ion. fox 3. 2- 1000 yaieon /2,zecazi- eeach.ing 12.it6. Based on my inspection, I certify the following conditions: 4. th.i,3 .iz a tit 2e dive zept.ic 3y,3tem (78 code) 349 5. the eept.ic zyztem .iz .in R2o/2ea wo2k.ing olidea MAR `---"�-"" " '°4' at th.iz time PARCEL. �_ 6. waters :ih 48' eletow the .invent Ripe LOT SIGNATURE:'. Name:_J,P_ Macomber Jr____-__ Company: Josevh-P. Macomber_& Son, Inc . Address.- Box-66------ Centerville, Ma. 02632-0066 2004 ------- TOWN OF RAR- 'STAQLE HEAL rh DEPT. Phone:-__508_77_5=3338_______ THIS CERTIFICATION DOES NOT CONSTITUM,.A,. GUARANTY OR WAFt#IA;NTY JOSEPH P. ACOMBER & SON, INC. Tanks-Cesspools-L.eachfields Pumped & Installed Town Sewer Connections P.O. Box 66 Centerville, MA 02632-0066 775-3338 775.6412 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFiCE OF ENVIRONMENTAL AFFAIRS Z . DEPARTMENT OF ENVIRONMENTAL PROTECTION s a _ t TITLE 5 OFFICIAL INSPECTION FORM—NOT:FOR.VOLUNTARY ASSESSMENTS . SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A ° CERTIFICATION Property Address: 18 8 Co u n t a u r 2LL I 1_2n Cgmmac4uirl, No.sA_ Owner's Name: Fs Y o/ f a a An Owner's Address: same- Date of Inspection: 12 To, o Name of Inspector: (please print)j o z e l2 h P. 11 a c o m ie a 12. Company Name: 9 P (7acomgen & Son Inc. Mailing Address: Cen ezv.c e, azs 02632 Telephone Number: 5 0 8-7 7 5=3 3 3 8 CERTIFICATION STATEMENT I 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.I am a DEP approved system inspector pursuant to-Section I5340.of Title 5(310 CMR 15:000). The system: . . ✓.;,Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspectors Signature: ` Date: The system inspector shall bmit a copy of this inspection re orrto the Approving Authority(Board of Health or DEP)within 30 days of c mpleting this inspection.If the system is.a shared sys..tem or has a design flow of 10,000 gpd or greater,the inspector and the system owner.shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving. authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTLON:FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM' ` PART A CERTIFICATION (continued) Property Address:y RR,C nrja t,21, C Q„0. /-).,_ Owner: IE 6 t a s 4 a,2 A n n Date of Inspection: L�o Lea Inspection Summary.:-Check A B,C,D or.EJ ALWAY--complete all of Seetion:D ,A. System Passes: no 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. ti Comments: 7hv o . ea wo kin o/zcle2 _ .sv r�.t_.i�, .��.s#�.m .�.� �.n �2 /z 2 G of Yhv onn�.vn# Limp- 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 replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. The septic.tank is metal and over 20 years old*or the septic tank(whether metal or.:not)::i&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 tankas 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. ND explain: _ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection.if(with approval of Board of Health): broken.pipe(s)are replaced obstruction is removed distrtliuton box is leveled or replaced ND explain: The system required pumping m"er 4 times a year due to broken or obstructed pipe(s).The system will. pass inspection if(with.approval of the Board Of Health): broken pipe(s)',are replaced obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSA FORML SYSTEM INSPECTION.FORM PART A CERTIFICATION(continued) Property Address: 18 R o u nl n Owner:. FALe/7 failAnn Date of Inspection:_; 0 3 C. Further Evaluation is Required by the Board of Health: Q Conditions.exist which require further:evaluation..by the:Board:ofHeaithjn order,to:.deterrnine if the system is failing to protect public health,safety or the environment. A. System will pass unless Board of Health determines:in accordance with 310.CMR 15.303(1)(b)that the system is not functioning in.a mannerwhich:will protect public health,safety and the.-environment: ns Cesspool or privy is within 50 feet of a.surface water s Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines:that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tahk 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. n"n The system has a septic tank and.SA&and the SAS is within,50 feet of a private water,supply well. 20 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 coli€orm 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: Page 4 of 11 OFFICIALINSPECTION FORM—NOT-FOR;.VOLUNTARY.ASSESSMENTS SUBSURFACE SEWAGE:DISPOSALSYSTEM INSFECTI N FORM J PARTA CERTiFICA'T ION (continuetl) Property Address: 9 R R C_o u C a.,a DIt. Owner: , toa /n�tinn r Date of Inspection:1?i 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-oil_the`.ground.or:surface:waters due to an overloaded or clogged SAS or cesspool �_ Static liquid level in the d'stribution box above outlet invert due to an overloaded, . or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or availabi�volume is less than I . _y flow -- .Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped y 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 14 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.5.0 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 :th t.fa l' :and.the reseflcerof;ammonia iom:from a Ci indicates:ahat the.well is.free from pollut. �y P 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'.] _(Yes/No)The system fails.I have determined that one or;:more of the.,:above..failure,criteria exist as described in 310 CMR 15.303,therefore the system.fails.The system owner.should.contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems-, To be considered a large system_the:system:must serve a::facility.with a•design flow of 1.,010.00 gpd to 15;000. gPd• You must indicate either"yes"or"no"to.each of the following: (The following criteria apply to large systems in.addition to the criteria above) yes no r - - the system is within 400 f f a surface drinking water supply — � the system is within 200 feet of a but to a surface drinking water supply — X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)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 bas failed.The owner or operator of any large system considered.a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional,office of the Department. 4 Page 5of11 OFFICIAL INSPECTION FORM-NOT FOR-VOLUNTARY ASSESSMENTS SUBSURFACE:SEWAGE D`ISPOSAT� SYSTEM iN FEC') ION FORM PART B CHECIU IST Property Address: Owner:F A4 i Date of Inspection: Check if the following have been done.You must indicate s or"no"-as-to each..ofthe.followin Yes No No Pumping information was Provided by the owner,occupant,or:$oard of Health x Were any of the system components pumped out in the previous two weeks? — X Has the system:received normal flows in the previous two week period? _ x Have large volumes of water been introduced to the system recently or as part of this.inspection? x Were as built plans of the system obtained and examined? (If they were.not available note as N/A) x _ Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? x 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? x Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems . System(SAS)on the site.has been deternitned based on: The size and location of the Soil Absorption Yes no — Existing information.For example,a plan at the Board of PIealth. 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)] 5 Page 6 of 11 OFFICCIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL>SYSTEM INSPECTION FORM PART C SYSTEM:INFORMATION Property Address: 9 R R C o u n f a ll t'f,i f. DA _ Crzmm.iau1d, mom,A A_ Owner: F,s j v n f a n A n n Date of Inspection: 12/191n 3 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design) Number of bedrooms(actual):_3 DESIGN flow based on-310 MR 15.203(for example: 110 gpd x#of bedrooms): Z=3 3 0G. %. D. Number of current residents: _ Does-residence have a garbage grmder(yes or no): Is laundry on a separate sewage system(yes or,no):.,._o [if yes separate inspection.required]. . Laundry system inspected(yes or no): Seasonal use:(yes or no):n.^ Water.meter readings,if available(last 2 years usage(gpd)):��,0 of Sump Pump(yes or no):�q Last date of occupancy: /o A o n f- COMMERCIAL11TbUSTRIAL Type of establishment: na Design flow(baked on 310 CMR 15.203): n a gpd. Basis.of design'flow(seats/persons/sgft,etc.): n n Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): n Water-meter readings,if available:, TE6 Last date of occupancy/use: an OTHER(describe):. nc� GENERAL INFORMATION ._...;. - Pumping Records Source of information: l Aacom9P_aL3on 4 lA1wrL I nk 417103 Was system pumped as part of the inspection(yes or no):__zLo If yes,volume pumped: 0_gallons--How was quantity pumped determined? na Reason for pumping: _ TYPE OF SYSTEM y A Septic tank,distribution box,soil absorption system . n o Single cesspool n o.Overflow cesspool j u Privy n o 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) a o Tight tank _Attach a.copy of the , EP.approval no Other(describe): Approximate age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no):-�e 6 Pagc7ofII OFFIOIAL,,,I�ISPECTION-PORK NOT FOR.VOLUNTARY ASSESSMENTS SUB$' `RP'ACE SEWAC'E AISPOSAL SYSTEM INSI'EC"I''ION FORM PART C �* . SYSTEM INFORMATION(continued) Propen:Y A.ddresst 188,E CoL4rzt1g1{- C.Pi.j,6 :N. own'c.r: ri o A n.n _ Dste of Inspettlon. > i 9 Q /n BUILDtNG SEWER(locate on site plan) Depth b09w grade. 4 8.,.._._.---. Materials of cons etiott; , ,casi iron jy PVC ,,,other(cxplttln):. Distance from privau waist iuppty wcli of suction:litfe: zot Corttmcnts(on condition of joints,Ysnii.ng,cvidcnee of leiikage;atc,)i - . . 4-13 ven"tecl thao.ugh .the house Uen.tz SEPTIC TANK: (locate on site plan) Depth .below gn'de: 3 8_ M.ateriil.of conswetion: Y ,,concrete'M.ml _,ftbcrglass--polyethylene. �othst(.cxplaGl) If uv�c is mewl tlst age; is age conftrrne,by t+ critficats of Compliance(yes or no): (attAch a copy of ccrt•iftcate) , ,y � ,•� i� ,' � ©imcnsions: fe to �r Slud-g;depth.:P-is Dista.nsc-from top of sludge to bottom o outtci tic or bafflea•.gc\fg� Scum thictncss• 0 , Distance from top of scum to.top of outlet tee or baffle: Distance.f om.bonom of scum to bottom of outlet tee or ba. flc:V(A e- How ere dimensions determined; � comm.cnts.(on pum.pan.g.r.e.commcndt~tions, ui.lci and out.ct tee or baMc condition, structural integriry,liquid levels as rclitad.to outit:.t invert,wi;dcnce of•Icakagc,etc*. um . . .se t�.c dank — La j2Aarp.- .v .s.Lgnz off. .leakage GREASE TRAP. (10(l.ocatc on site plan Depth Wow grW;AA— Material of, struction: eoncrctc „metal fiberglass polyethylene „other (ex.plain) -" Dimon:.ions: z � Scum thicm'as: , Distanee from top of scum'to top'of outlet lc' -6r baffle: P[sunce from bottom f .cum to bottom of outlet tee or baf'ilc, Date of Last pwnpiug: to if uid levels comments ants(on pumping recommondati'gns,.inlet end outlet tee or baffle condition, structural in grtry, q as related woutict invert, cvidcnce'0, :Ie. Page 8 of I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SI BSU'I FACE SEWAGE DISPOSAL SYSTEM INSPECTION F O .RM PART C SYSTEM INFORMATION(continued) Property Address: gRr � r 0,i a D2. Owner:€-.3s�a�eta ctnn Date of Inspection: 9 2/9 9/()3 TIGHT or HOLDING TANK:-611Y. (tank must be pumped at time of inspe'ction)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day " Alarm present es or no): s Alarm level: A in working order(yes or no): Date of last pumping: Comments(condition of ai.arm and float switches,etc.): I 2ehent.' DISTRIBUTION BOX: X_(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.) Sox haz. .two eatelEa-ez, No evidence o� ca2ay e q o 2eaka e .in o 0A outo e , n»on_ No v_»'�rlonc 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, condition of pumps and appurtenances, etc.): nt. 8 o e e Page 19 of 11 . OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIONYORM PART C SYSTEM INFORMATION(continued) Property Address:188Coun-tau :l i m Owner:. FtifPn /n/.Snn Date of inspection:)2/19/0 3 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) 2- 1000 ga e eon eear_hTnq pitb /zaecaz;t If SAS not located explain why: -eoca;ted bee 12aae 10' TYPe - ,/ leaching pits,number: leaching chambers,numberAn' p —leaching galleries,number: Ur leaching trenches,number, : ® leaching fields,number,dimensions: overflow cesspool,number: �� innovative/alternative system Type/name of technology: �'ta•^P . Comments(note condition of soil, signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): - E?oamU band .to Ono Aanr/ Nn 02 1202dGl�l � O/1P day- Vpap��a iA nnnm�i0 CESSPOOLS:110 (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 cesspoo Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY:L�(locate on site plan) Materials of j ion: Dimensions: Depth of soli Comments(nition of soil,signs of by aulic failure,level of ponding,condition of vegetation,etc.): 2�v ib not aaezenL 9 Page'10 of 11 -OFFICIAL INSPECTION FORM.-.NOT"FOIL.VOLUNTARY ASSESSMENTS SUBSURFA.CE`SEWAGEDISP.OSAL SYSTEM`.INSPECTION;FORM PART C SYSTEM INFORMATION(continued) Property Address: 9 R R ( n ccn fay r.0„o- D2. Cummigli !j, aGLbb , Owner: rA;1 O n f 0 7 A A l7 Date of Inspection: 9 J/9 9/0 3 SKETCH OF SEWAGE.DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent ieference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters.the building. 7i 35 ---------------------- 1 - " +a>s . . . 10 r - Page I l of I I , OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL, SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued). Property Address:188 Coua;btu Lem& DIt. rilmr !a//irJ, NrlAA 0wDer:FA1Qn fnnann Date of IDspeccioa: 12119/n SITE EXAM Slope Surface water Check cellai Shallow wells Estimated depth to ground water feet ' Please indicate (check) all methods used to determine the high ground water elevation: W)Obuined 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 Health-explain: Checked with local excavators, installers. (attach documentation) ` Q�Accessed USGS database-explain: ' %%nwfl , (o , You must describe how you established the high ground water elevatlon: used m; geaa 47nr/00- 1�/9h/94 ,gaouncl watez e.eeya�-ionz aeove sea "Qevee u.6eel. o — azeCl: 7eeAft e6!9 i? 44 f O e Q7 nnn nOnfoJ, 4nnl/riO /lnQe OZ �/Zoun Lcac ing Pity, II ect Groundwater: heel Below Bottom of Pit* High Groundwater Adjustment 1.8 ft per Frimptcr Method Therefore, the vertical,separation distance between the bonom feet.the Icaching pit and the Adjusted groundwater table is, R • f " • rtfT'CTTnTTiS-n•9S TTA-TT.T,RTI .. • .• T7T•r9--t'1f"^1T'..�•.•—..•F L.r.P•r.'1 Tn.-�ni•P•T�-TT' ii':ltR'ITs+'T'r'a't*T.T•T'.'ir�TRT: 5 TOWN UR Barnstable [GUARD OF HEALTH SUIISOIIFACF 9ENA(,E DISPOSAL SYSTEM INSPECTION FORM - PART•D .-' CERTIFICATION I `` .•-.'-.--n.r.rm•n:rri ewre rrirrr'rr•.T—•.��mry arrtve'�"n*^"R''*+r i*n°^'Tste�°r� ' . Mm n4mR1T«O'RT.Rrrr.:r.rrrr•�• �•. -TYPE OR PRINT CLEARLY- PROPERTY TNSPGCTED STREET ADDRESS ASSESSORS MAP , DLOCK AND PARCEL # q ^� t OWNER' s NAME PART' D - CERTIFICATION NAME OF INSPECTOR Joseph P. Macomber Jr . COMPANY NAME Joseph P. Macomber &ton Inc COMPANY ADDRESS Box 66 Centerville Mass 02632 Street Torn or Clty State UP COMPANY TELEPHONE ( 508 1 775-3338 FAX ( 508 ) 790-1.578 • n] CERTIFICATION. STATEMENT I certify that I have personally inspected the sewage disposal system at " ;. this address and that the information„ reported is true , accurate , and omplete as of the time of ,inspection-. The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one : System PASSED The 'inspection ►rhich I have conducted has not found any information which indicates that th.e system fails to adequately protect public health or the environment as defined in 310 CMR 16 , 303 , Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form . System FAILED* The inspection which I have con :acted has found that the system fails to Protect the j)ub.lic hen th and the environment in accordance with Title 5 , 3.10 CMR 15 , 303 , a d s specifically noted on PART C - FAILURE CRITERIA of this ins ectlon form . N . Date s ector Signature In p .. z� of this c c.ification must be provided to the OWNER , the BUYER 07copy where applicable ) And the 130/>RD OF HEALTH, * It the inspection FAILED , thle owner or operator. ehall upgrade.' the eystem r within one year o (' the date of the inspection, unless allowed or required otherwise as provided in 3.10 CHR 16 . 306 partd . doc - o , ; 0cATION SWAGE PERF411' NO. 1LLAGL ASSESSORS MAP NO: 3y 1 S T A LLEB'S NAME A ADDRESS DACE PEIIMiT ISSUED �� DA -f E COMPLIANCE IS S U E D �/�� • � ,._ ' � t io �. � �, � 'Q �; SEWAGE INSPECTIONS t�,t,.00AnON `ate CAW,) 1 Q2 C k..Q G 17Q DATE 1Z ) p 3 ',V3.LAGE ASSESSOR'S MAP do LOT 34c� —,�TNS'PECTOR 3k�-4-kEl>r\ \NNKC,�.,� SEPTIC TANK CAPACITY LEACHING FACILMY: (type) (size) LNO.OF BEDROOMS PUILDER OR OWNER OWNER MAILING ADDRESS I J 5A' A No.... :; Fss... ._ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......... ...........O F......Aiat).,vwh.)_kp...................................... Appliration for Riyviial Works Tonstrur#ivit Famit Application is hereby made for a Permit to Construct ( ) or Repair ( I-Kan Individual Sewage Disposal System at: 1 ..., � Lo: lion-Address orLotNo.� -•.-_-.-- ---------------------•-.----------------------- .--- ---- ------ - -------------- AddressOwner --------------------------------------------------- -------------------------------------------------------------------------------------------------- Installer Address UType of Building Size Lot............................Sq. feet Dwelling o. of Bedrooms............................................................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type T e of Building No, of persons............................ Showers P., YP g ----•----••--•-•--•-------•• P ( ) — Cafeteria ( ) a' Other fixtures .............•---•-----••-----•. • . 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........................................ aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Gr, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ .- -----•--------- ------------------------------------•--------------------------------•------------------ Description of Soil_________ ___ __ ---------- V UNature of Repairs or Alterations—Answer when applicable.............. .......... .� .._....v . ,e. ...................... .............................................-.......................................................................................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System.in accordance with the provisions of iITL U 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 oard of healt Signed /7/- fir....._ Date 1 r-( Application Approved By._...... ��(<- - . . --- .......................... ... Date Application Disapproved for the following reasons:------------•---------------------------------------•---------•---------------------------•---•-•••-•..._..... ......-•------•..................•-------..•.........----------------------•-----•-----•---..............---•-•-•-............_......-••--••-•-•...-•-•--•---------•----•-•-•-••-••----_._.......__.._.. Date Permit No........Rgrs-.. :�-� Issued ... - Date Fimic THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........lr/: ...........OF....... �1J Appliration for Disposal Works Tonstruriion ramit Application is hereby made for a Permit to Construct ( ) or Repair ( d. an Individual Sewage Disposal System at: ' •LocStion-Address ----or Lot NO. -•.....••...... ... . ...:. ............................................•-••------ ............................................ -• Owner Address ...................««................ a -•-- E�n__d s�'n:T�':a?"'. J --------•----•--•-•-•-'---•........................ ..................................................................... .......... -.--------------- Installer Address UType of Building Size Lot............................Sq. feet .-� Dwelling o. of Bedrooms-------- ............................Expansion Attic ( ) Garbage Grinder ( ) a Other—Type T e of Building� yp g ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures ..-•-•---------•-•-----------------------•-•-•-•-----.......--------•--------•---•-•---- 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. 3 Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box (. ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ a Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water.....::....._._......._. fs, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ x � DDescription of Soil....... •----:.e6?..----•--••---------------.............................................................................................................. U -----••-•------_--_-- .................................•-------•-----........_.......-----------....------....------.......................................................... - W ----•-------- .... ------------ ----------•---- U Nature of Repairs or Alterations—Answer when applicable........`:.,! .. �� ��'..._ ve � ..................... -•------------------------•--......------........._....----•-------.._..............._.........----•-----------••----------------....---------------..:-----............---•--...........-•-•--......... 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 b the Poard of healt ' Signed. d ' ' �,F!�! 9 �i �. Application Approved By._..._:... ___ � Date Application Disapproved for.the following reasons:--••-----------------------•----..._.......-----...-•--•---•---......------.....-------•...------•---...:.__« ...----•-•---•----------•---••----•-•---•••.................•--••-........---•---•-••--•...................................-.------------•-•--------------------------.------- .« _ Date Permit No........ - -.«..« Issued... -• - •-- ---•------•---- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......... ............OF...... + .......................... '��''"� a'At , 'fir.' , :. wrtifutt#r of Taamliliatt ae THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or .Repaired by.....7,1 . i ' ................................................................................................................................... .«....« f Installer e�.._ ✓wf-i'. ------------•---•-•-- .... has been installed in accordan e with the provisions of TITLE 5 of The State S itary Cod? as described in the application for Disposal Works Construction Permit No..... �,.......�..` ....... dated..............,_:..i�. P,G . ............... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. f a DATE t/11..�.ec.................. ........... Inspector....... ............................................................................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No /,' .......OF... / ........................ Disposal orks (90 strurtion raerntit Permissionis hereby .----•--••--•---•............................................................_««.. to Construe ) o Repair an4pn ivi` al Se age Dispose System at No._/.22.....L allzwx.- In A4,.,v` •: i a!�' '�-�+�' a «r? = � r�............. ::............. Street e,,—�as shown on the application for Disposal Works Construction PerJ _No C%� Dated.......................................... DATE.. ' Board of Health FORM 1255 A. M. SULKIN. INC.. BOSTON