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Home My WebLink About0059 CYPRESS POINT - Health 59 CYPRESS POINT,BARNSTABLE A= .n ,r o e� µ , i Commonwealth of Massachusetts Jolm Gi•ad Execu" Office of Erwiron"Mai Affairs D.E.P. Title V Septic It>spector P.O. Box 2119 Teaticket,MA 02536 t! (508) 564-6813 of SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR, ORT A CERTIFICATION '�1 NQv 59 Cypress Point Cumma uid Heights Property Address: YP q 9 Address of Owner: Date of Inspection:11120196 (If different) Name of Inspector:John Gracl James Devlin Delger Company Name,Address and Telephone Number: 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: x Passes Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: Date: 11/21196 The System Inspector shall s bmit a copy,of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. 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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B,C, or D: A] SYSTEM PASSES: x I have not found any information which indicates that the system violates any of the failure criteria defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: _One or more system components need to be replaced or repaired. The system,.upon completion of the replacement or repair,passes inspection. '4 Indicate yes;no,or not determined(Y, N,or ND). Describe basis of determination in all instances. If "not determined",explain why not.) _ The septic tank is metal, cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved. by the Board of Health. (revised 11115195) One Winter Street 9 Boston,Massachusetts 02108 • FAX(617)556-1049 9 Telephone(617)292-5500 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) P rope rty Address: 59 Cypress Point Cummaquid Heights Owner: James Devlin Delger Date of Inspection:11/20196 _ Sewage backup or breakout or high static water level observed in the distribution box is due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced _The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipets)are replaced obstruction is removed 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 the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER, IF APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ The system has a septic tank and soil absorption system and is within 100 feet to a surface of water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone 1 of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. _ The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria volatile organic compounds indicates that the well is free from pollution for that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm. 3) OTHER D] SYSTEM FAILS: _ I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage in facility or system component due to an 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 cesspool. SAS is in hydraulic failure. (revised 11115195) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 59 Cypress Point Cummaquid Heights Owner: James Devlin Delger Date of Inspection:11120196 D] SYSTEM FAILS(continued) 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 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Numbers of times pumped Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria: _ The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply 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) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. f (revised 11115195) 3 s SUBSURFACE SEWAGE DISPOSALS YSTEM INSPECTION FORM PART B CHECLIST Property Address: 59 cypress Point Cummaquld Heights Owner: James Devlin Delger Date of Inspection:11120196 Check if the following have been done: X Pumping information was requested of the owner,occupant,and Board of Health. X None of the system components have been pumped for at least two weeks and the and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. n1aAs built plans have been obtained and examined. Note if they are not available with N/A. X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout. X All system components,excluding the Soil Absorption System,have been located on the site. X The septic tank manholes were uncovered,opened, and the Interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions, depth of liquid, depth of sludge, depth of scum. X The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11115195) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 59 Cypress Point Cummaquld Heights Owner: James Devlin Delger Date of Inspection:11120/96 FLOW CONDITIONS RESIDENTIAL: Design flow: 490 gallons Number of bedrooms: 4 Number of current residents: 0 Garbage grinder(yes or no): Yes Laundry connected to system(yes or no): Yes Seasonal use(yes or no): No Water meter readings,if available: nla Last date of occupancy: nfa COMMERCIAL/INDUSTRIAL: Type of establishment: nla Design flow:0 gallons/day Grease trap present:(yes or no) No Industrial Waste Holding Tank present: (yes or no) No Non-sanitary waste discharged to the Title 5 system: (yes or no) No Water meter readings,if available: nla Last date of occupancy: nia OTHER: (Describe) nla Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System has not been pumped in the last two years. System pumped as part of inspection:(yes or no)Yes If yes,volume pumped: 1500 gallons Reason for pumping: Maintenance . TYPE OF SYSTEM x Septic tank/distribution box/soil absorptions system Single cesspool Overflow cesspool Privy Shared system(yes or no) ( if yes, attach previous inspection records,if any) Other(explain) APPROXIMATE AGE of all components,date installed(if known)and source information: original 1984 with two new pits installed in 1994 Sewage odors detected when arriving at the site:(yes or no) No (revised 11115195) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 59 Cypress Point Cummaquid Heights Owner: James Devlin Delger Date of Inspection:11/20/96 SEPTIC TANK: X (locate on site plan) Depth below grade: 7' Material of construction:X concreate_metal_FRP_other(explain) Dimensions: L16'6"H 5'7'W 5'B' Sludge depth:6' Distance from top of sludge to bottom of outlet tee or baffle: 21' Scum thickness:3' Distance from top of scum to top of outlet tee or baffle:6' Distance form bottom of scum to bottom of outlet tee or baffle: 1V Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) Septic tank and all components are structurally sound.Recommend pumping system once every two years for maintenance. GREASE TRAP:_ (locate on site plan) Depth below grade: rda Material of construction: _concrete_metal_FRP_other(explain) Dimensions: n1a Scum thickness:nfa Distance from top of scum to top of outlet tee or baffle:Na Distance from bottom of scum to bottom of outlet tee or baffle: nla Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,Aepth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) Na (revised 11/15195) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 59 Cypress PointCummaquld Heights Owner: James Devlin Delger Date of Inspection:11120196 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: n1a Material of construction:=concrete_metal_FRP other(explain) r Dimensions: n1a Capacity: n1a gallons Design flow: n1a gallons/day Alarm level: n1a Comments: (condition of inlet tee,condition of alarm and float switches,etc.) Na DISTRIBUTION BOX: X (locate on site plan) Depth of liquid level above outlet invert: Liquid level with bottom of pipe. Comments: (note if level and distribution is equal,evidence of solids carryover, evidence of leakage into or out of box etc.),, D-box is structurally sound PUMP CHAMBER: (locate on site plan) Pumps in working order.(yes or no)._ Comments: (note condition of pump chamber,condition:of pumps and appurtenances, etc.) Na (revised 11115195) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) - Property Address: 59 Cypress Point Cummaquid Heights Owner: James Devlin Delger Date of Inspection:11120196 SOIL ABSORPTION SYSTEM(SAS):X (locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: Na Type: leaching pits,number: 4-1,000 gallon leach pit leaching chambers,number:n1a leaching galleries,number: n1a leaching trenches,number, length: Na leaching fields, number, dimensions:n1a overflow cesspool,number:n1a Comments:(note condition of soil, signs of hydraulic.failure,level of ponding, condition of vegetation, etc.) The leach pits are structurally sound and functioning properly. CESSPOOLS:_ (locate on site plan) Number and configuration: n1a Depth-top of liquid to inlet invert: n1a Depth of solids layer: n1a Depth of scum layer: nla Dimensions of cesspool: n1a Materials of construction: n1a Indication of groundwater: nla inflow(cesspool must be pumped as part of inspection) n1a Comments:(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.) n1a PRIVY: (locate on site plan) Materials of construction: n1a Dimensions: n1a Depth of solids: n►a Comments:(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.) PrivyComments I (revised 11115195) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 59 Cypress Point Cummaquid Heights Owner: James Devlin Delger Date of Inspection:11120196 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or.benchmarks locate all wells within 100' AA IMP `i3 06 , 6V �Y gE l3 DEPTH TO GROUNDWATER Depth to groundwater:12 feet method of determination or approximation: USGS Maps and Charts (revised 11115195) 9 t �F, TOWN OF BARNSTABLE a LOCA�TIt N S do,'/7 SEWAGE # 9�Ff VILLAGE ASSESSOR'S MAP LOT0T(Y-Qgg' INSTALLER'S NAME & PHONE NO ,-, /I, � SEPTIC TANK CAPACITY LEACHING FACILITY:(type) �//jLs (� SJeC� (size) /Q NO. OF BEDROOMS ' PRIVATE WELL PUBL:IC:WAT R BUILDER R OVNNE � /U1�¢� DATE PERMIT ISSUED: �� DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes CZNo 1 N b ss �fJ�� - - PPRO Z 8a�- _ nse►.ation Depanmert �sm�gHE COMMONWEALTH OF MASSACHUSETTS oat- a BOARD OF HEALTH TOWN OF BARNSTABLE ,��lirtttilait fnr �i��n�tt� larl�� Cn��t��r�r�"tun �Cpruttt Application is hereby made for a Permit to Construct ( ) or Repair (!.4 an Individual Sewage Disposal System zat: .-•--•••`-.•�--------•................... ................................................................................................. ion-Add es or.Lot No �r s. ------•-••_..._ 40 ri'I e,s/Vl Installer Address d Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms----------------- -----_ . _ __-Expansion Attic ( ) Garbage Grinder ( ) ______________ No. of ersons-_--_-.__--_______-__-_.---- Showers — p`�,,, Other—Type of Building ____________ p ( ) Cafeteria ( ) dOther fixtt W Design Flow................... --_-________._____gallons per person per day. Total daily flow_.----------V4142-------------------gallons. WSeptic Tank—Liquid capacity/S gallons Length................ Width---------------- Diameter................ Depth................ x Disposal Trench—No_ ____________________ Width._._...J_..__..._.. Total Length-------------------- Total leaching area....................sq. ft. 3 Seepage Pit No.._.....e�--- Diameter....../a..__... Depth below inlet......a.......... 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........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ a --•-•------•---...--•--------------••---•-..._...__....-----------•--•--•---•............................................................................... 0 Description of Soil........................................................................................................................................................................ x _... U : W ----- ................................ --------------------------•-------------- ------------------------------------------------------------- -------------------- U Nature of Repairs or Alterations—Answer when applicable... 0---.-----sue �.. �D®-_ ...... - _._____.. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance s een -ssue by t and of health. Signed ------- - 1��9 . Application Approved By ............. ...'. _ <... g --- .- ... t------- Application Disapproved for the following reasonr: . ------------------------ ---------------------------------------------------------------*.................................. ......... ............................. ......:--.......... ........................ .. . ----- - --------- -..----------.... Permit No. �''./.. ..................... .. Issued .--- ate...... /A ../.. are 13 �/ 0f7 NO.-- ......._....... , FE$....- ....G............... i �1� 4fHE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Disposal Works Tomitrnrtton ramit Application is hereby made for a Permit to Construct ( ) or Repair (4 an Individual Sewage Disposal System at: _ ................ l,%r�................................� . ..............................•.... C/S;SL v r rho .......................... or Lot No. �•` Otvner _e-� Ad ess /d � Installer Address UType of Building Size,Lot............................Sq. feet Dwelling—No. of Bedrooms_________________�<-________.___--__._Expansion Attic ( ) Garbage Grinder ( ) aa Other—Type of Building ---- No. of ersons___________________________ Showers — YP g ---------------------- P - ( ) Cafeteria ( ) dOther fixtures --------------- ------------------------------------------------------------------------------------------- ........-...... •g .~.............gallons per person per day. Total daily flow..._........ W Design Flow -Is 5 �*'��'!� gallons. p 1 WSeptic Tank—Liquid capacity/SQggallons Length---------------- Width................ Diameter-_..._..._..._. Depth................ x Disposal Trench—No. .................... Width.................... Total Length..................... Total leaching area.....................sq. ft. it Seepage Pit No ...........__ Diameter.__.../ _____.I Depth below inlet.....�........_. Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date.................................... Test Pit No. 1................minutes per inch Depth of Test Pit--------------------•Depth to ground water-____..______-_____-_--- Gi, Test Pit No. 2............__..minutes per inch Depth of Test Pit_................. Depth'to aground water........................ W •----•-••-•------------------•-----••----•----•-------------......-----•------------•-••-•-----••---.........••-----------•------------------ DDescription of Soil.............................................................................................................. ...................................................... x w ` U Nature of Repairs or Alterations=Answer'when applicable._.A_O.�..._._.. _____________1.LU0 e. --_-i ! .5 ..-•--------•• ........................... ` r ................... Agreement: � y The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the prow"isions of TITLE 5,of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has een issue4 by the board of health. - { Signed . r f � .Application Appioved By ......j.. ��7;..I "1 �/X u. .......---_------------------------ -�a� ..eS �`� w. �//. __ .-.. �.-� ..1........ Application Disapproved for the following reasons- ------------- ------ -------- ------ --------------------------------------------------------------------------------------------- .... ................... ........................_................._....... -------- - / Date �../J Permit No. .�- .. ... ..G_............. Issued ....... ;e - - _........... --------------------- --------------- THE COMMONWEALTH OF MASSACHUSETTS +- BOARD OF HEALTH TOWN OF BARNSTABLE Q-Ter#tf ra e of Complianre THIS IS TO CERTIFY, That the-Individual Sewage Disposal System constructed ( ) or Repaired Insrdler� ..... �7•Z�� <��"t .... ._'...tlli�yt/4-��J.v�....------------ at � ------------------ -------------------------------- -----------------: f G has been installed in accordance with the provisions of TITLE FONS he NR Environmental Code as described in the application for Disposal Works Construction Permit No. . . p....... dated ----- ....... SHALL NOT BEEEA AS A GUARANTEE THAT THE THE ISSUANCE OF THIS CERTIFICATE SHA O SYSTEM WILL FUNCTION SATISFACTORY. Ir DATE---.....��..l...... ........ ..... 1 Inspectac . �-- J.�� f � THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH --q� TOWN OF BARNSTABLE No.--.t--...i...........L FEE... ...... ..... �\ �i��oo�tl �rko �un.�tr�grtion �rrmit _ Permission is hereby granted...................!.. ................................. _...?......`...._ to Construct ( ) or Repair (,N/—) an Individual Sewage Disposal System at No....................................................... �e.y :�-`S '�'--`� ,a } (L!U14 M4 4 U18 -..�--- Street / �I as shown on the application for Disposal Works Construction PF��)(/--- -------7-, - '�edp--------------------�------•---•-••-- s a ............"� Bord of Health DATE------=------ -- �.. .................................... FORM 36508 HOODS 6 WARREN.INC..PUBLISHERS No.._. :'.So 7 Fes .................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 'a i t Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: 1 �.Caeioon�,............. ----........... .....-Address Lot No. ------,Pe..eje,� �. �.v.................26A...� c .� it_v ... , . ................... �� ].Owner ;• Address W r l u-t.p ............. ._._.........._....._..._-_......._T=....................................... --...................---.............................................................:............ Installer Address PQ V Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms.............�.................._......Expansion Attic ( ) Garbage Grinder (,�}— 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 capacityJSWg Ilons Length............... Width................ Diameter................ Depth................ x Disposal Trench—No .................... P.Width.................... Total Length:.........._........ Total leaching area-----_-_ .-...____sq. ft. Seepage Pit NaI ..._...... Diameter----/ ........ Depth below inlet....._........... Total leaching area... q. ft. =R Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date-----------------........---------...... Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ (i Test Pit No. 2................minutes per inch Depth of Test Pit..................... Depth to ground water........................ ---------------------------------- ----------------------------- •-----------------•------•---------------- •-•--------------•------..........----------=-...... 0 Description of Soil----•--------•----••--•.................•---.........-----...-•--•-----•----------•-----------------------------•--.................................................... W v , W x ----------------------------------•-------------------------------------•--•----------------------------------------------•-----------•----------•--------•--------------...--------------••----•---•-- U Nature of Repairs or Alterations—Answer when applicable................................................................................................ ---.........................................-........................................................................................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Co e—The u de signed furt.er agrees not to place the system in operation until a Certificate of Compliance has bee sued by t e and h Signed '... � ... .... 1 Application Approved By........... i . .....--•--•------------------- ..------ ��atee y Application Disapproved for the following reasons-...............................-----------------------•------------------------••----------....-----.,......._. ...............................I......................................................................................_........--•-----------------............---•--------------.•-- ...----------- Date PermitNo......................................................... Issued-....................................................... Date ``b A ION � �'``,�" , S E WPG E PR i� to. 207-,V79' Gjp�e�s i�� 6V7 VILLAGE nzyl-J -Jc,/1 �y 1 N S T A LLER'S NAME A ADDRESS �h8UILDER OR OWgER DATE PERMIT ISSUED. DATE COMPLIANCE ISSUED -- 1 t. f + j r THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ----- -------------....................OF r Appliration for Disposal Works Tonstrurtion Errant Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal. System at: ............ ... ...... .. G�_►'qH 4'I'! -•--------•............................... •ocation-Address ®� � - . ¢ Owner Address W Installer Address Q Type of Building !!�� Size Lot............................Sq. feet Dwelling—No. of Bedrooms..............S................._'..____Expansion Attic ( ) Garbage Grinder ( e; Other—Type e of Building .........J................. No. of ersons__........_..___ .. Showers — W YP g --•---------••---...---P ----•----- ( ) Cafeteria ( ) Q Other fixtures,.;:,,--- Design -'` --- ------•_. ---.-•--•--------------•-_----------- -------------------•••----•-----------_--•---.._.........---- W Flow._._____.q__.__._._......:y_•__.._.____gallons per person per day. Total daily flow..........................................__gallons. WSeptic Tank—Liquid ca acit /, Ogallons Length________ ____ Width __.______.__._ Diameter................ Depth_____._____.__. x Disposal Trench /—/ No. ............„. Width .............. Total Length .„.... Total leaching area sq. ft. Seepage Pit No.(A'Q..._____: Diameter.._/A....:.... Depth below inlet______........... TotaLleaching area...M�..sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by a ----•------------•--•-..._•••-•-----•...••---_•-•••...............•----•.. Date..................... a - Test Pit No. I...........:....minutes per inch Depth of Test Pit.................... Depth to-ground water------------------------ GT.I Test Pit No. 2.............___minutes per inch Depth of Test Pit____________________ Depth to ground water........................ .......................................................................................ti---------------------•----•-•-•••-----------------••--•••---.---- O Description of Soil.•..___..„........ ...............................•-------.....-------------_------................................................................... V _.=__=___--•-•----------•---_-_-•-•-------------•---•---•_•....._._ v ..........._---------------------_........................._....................................................................................................................._______________________ V Nature of Repairs or Alterations—Answer when applicable.______...__-•__---_____-_4............:..:..................................................... ---------------•-----••-••-•---•_•_--•---------- ........................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Co e— The u de signed fur er agrees not to place the system in operation until a Certificate of Compliance has bee sued by t e oar Signed..,. ..... / ..... ••-•-•---•-. :��/�Dat eApplication Approved BY •-- ---•-•-••-•--•-•-•.....--.••---- .•_.. t'�'. Date Application Disapproved for the following reasons:...................................................................... ...................... ........ --------------------•-----....---•--------..........---------...-•--••---.....:_......----••-•------•----•-•---=•--••••-••-••-••.....----•--••-•-•----•----•-•--•••. . Date PermitNo......................................................... Issued......................................................_ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF. HEALTH`. ..........................................O F.................................................. ............................... 0rrtifiratp of Toutplianrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) bY--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- In alter i has been installed in accordance with ze provisions of TIT F 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No------ ---_--_S!- --------------•_-__-.__ dated_.............................................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE...........ZP•- .......... Inspector....................=-----------•----•------------------••--•--••-•-•-•----••-•..... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........................................OF.............................................................................. .--.... No......................... FEE........ n Disposal Workii Tonutrudion rrutit Permissionis hereby granted...............---------------------------••-.--•--•---•-•••---•-•------•--•----•.......--_•--•-----•...---------••-•----..............„._.. to Construct ( or,,Re air ) an Individual Sewagg Disposal System at No.-----.... •• `s°v~v-- StreetzT„ as shown on the application for Disposal Works Construction Permit No..................... Dated.......................................... 4 } oard of Health DATE........................................:..................................... :. s� --- FORM 1255 A. M. SULKI,N, INC., BOSTON r - { i`\ r, - I • . _ - - i • /'18 T_� ��` � 7 a a! 1. e" 12 ,; rr R . dJUl _ � , s4 is r ;.. .• _ I I� X ��_ �'�'�' i`l cr r ��:c �, _ • L! is