HomeMy WebLinkAbout0150 INDIAN HILL ROAD - Health 150 load
Barnstable CP
A = 318 621
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25 2--1
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRON-MENTAL AFFAIRS
d DEPARTMENT OF ENVIROIWNIENTAL FROT.)f~�GTION
G
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
a PART A RECEIVED
CERTIFICATION
Property Address: 150 Indian Hill Road OCT 2 0 2004
Cummaquid MA 02637 .
Owner's Name: Patricia Blair TOWN OF BARNSTABLE
Owner's Address: Same HEALTH DEPT.
Date of Inspection: .September 10,2004b • ��
Name of Inspector: PATRICK M.O'CONNELL F ARC EL
Company Name: SEPTIC INSPECTION SERVICES CO.
Mailing Address: 189 CAMMETT ROAD LOT >�
MARSTONS MILLS MA 02648
Telephone Number: 508-428-1779
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 a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The syste �gt11111 tak,
Vk
Passes
_X_ Conditionally Passes ''', •�;�y
Needs Further Evaluation by the Local.Approving Authority
Fail
• .—+—
•�
Inspector's Signature: Date• 9/10/04 % •l •Q, ��
• FS INSPEo`°
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of If ( 1"Jim1��
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: System functioning properly•under current flow conditions. Distribution box is decayed
and leaking needs to be replaced.
****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 INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 105 Indian Hill Road,Cummaquid
Owner: Patricia Blair
Date of Inspection: September 10,2004
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes: Distribution box needs to be replaced
_XX One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired.The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please
explain.
M
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally-
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
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 .
_XX distribution box is leveled or.replaced
ND explain:
The system required pumping more than 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:
'y
Title i inenantinn Fnrm 411 1�/In (n 2 4
e
Page 3 of 1 I .
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION.(continued)
Property Address: 105 Indian Hill Road,Cummaquid
Owner: Patricia Blair
Date of Inspection: September 10,2004 a .`
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)that the
system is not functioning in a manner which will protect public health,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
t
2. System will fail unless the Board of Health (and Public Water.Supplier;if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:,.
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
_ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and SAS and,the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
"This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria 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:
TitIP C Inena,6nn Rnrm A/1 S/7M/1 3
Page 4 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY,ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued) .
Property Address: 105 Indian Hill Road,Cummaquid
Owner: Patricia Blair
Date of Inspection: September 10,2004
r
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
_X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
—X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
—X_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
_X_ Liquid depth in cesspool is less than 6"below invert or available volume is less than ''/2 day flow
—X— Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
X_ Any portion of the SAS,cesspool or privy is below high ground water elevation.
_X_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
X Any portion of a cesspool or privy is within a Zone 1 of a public well.
_X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
—X_ 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 waterquahty analysis. 1This 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.]
No_(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 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 criteria above)
yes no
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 11 of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system has failed.The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The system owner should contact the appropriate regional office of the Department.
Titles i lno-tinn V—m 411 ennnn 4
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,Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 105 Indian Hill Road,Cummaquid
Owner: Patricia Blair
Date of Inspection: September 10,2004,
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
_X_ _ Pumping information was provided by the owner,occupant,or Board 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?
_X_ _ Was the site inspected'.for signs of break out?
_X. _ Were all system components,excluding the SAS, located on site?
_X _ 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
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
_X_ Existing information. For example,_a plan at the Board of Health.
_X _ Determined in the field(if any of the failure criteria'related to Part Cis at issue approximation of
distance is unacceptable) [310 CMR 15.302(3)(b)]
Titla i lnanartinn Fnrm 4/1 C/Innn 5
Page 6 of 11
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 105 Indian Hill Road,Cummaquid
Owner: Patricia Blair
Date of Inspection: September 10,2004
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 ,
Number of current residents: 1
Does residence have a garbage grinder(yes or no): No
Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required]
Laundry system inspected(yes or no): - {
Seasonal use: (yes or no): No
Water meter readings, if available(last 2 years usage(gpd)): 2002—41,000 gal.2003—26,000,gal.=91 gpd.
Sump pump(yes or no): No
Last date of occupancy: -
COMMERCIA UIND USTRI A L
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd r
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 system(yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe): *.
GENERAL INFORMATION
Pumping Records: Tank pumped 2-3 years ago.
Source of information: Owner
Was system pumped as part of the inspection(yes or no): No
If yes,volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
—X_Septic tank,distribution box, soil absorption system.
_Single cesspool ,
_Overflow cesspool
Privy
_Shared system(yes or no)(if yes,attach previous inspection records, if any)
_Innovative/Alternative 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:
33 years
Were sewage odors detected when arriving at the site(yes or no): No
•
Titles i Inewantinn Anrw�f./1�/7(1!1(1 6
r
Page 7 of 11 '
P ,
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C a
SYSTEM INFORMATION(continued)
Property Address: 105 Indian Hill Road,Cummaquid
Owner: Patricia Blair
Date of Inspection: September 10,2004
BUILDING SEWER: X (locate on site plan)
Depth below grade: 4' (under slab)
Materials of construction:_X_cast iron 40 PVC other(explain):. .
Distance from private water supply well or suction line: 40'
Comments(on condition of joints, venting,evidence of leakage,etc.):
SEPTIC TANK: XX (locate on site plan)
Depth below grade: 4'
Material of construction:_X_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: 8.5' long x 5.2' wide—1000 jai. _
Sludge depth: I"
Distance from top of sludge to bottom of outlet tee or baffle: 29"
Scum thickness: 1"
Distance from top of scum to top of outlet tee or baffle: 7"
Distance from bottom of scum to bottom of outlet tee or baffle: I
How were dimensions determined: STICK WITH HINGE FLAP.
Comments(on pumping recommendations, inlet.and outlet tee or baffle condition,structural integrity,liquid levels_
as related to outlet invert,evidence of leakage,etc.):
Tees intact and clear.Tank shows evidence of prior backup likely due to cloe which cleared All pipes
are clear at this time.
GREASE TRAP: No (locate on site plan) !
Depth below grade:
Material of construction:_concrete_metal_fiberglass polyethylene_other.
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations, inlet,and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
Titles G rnenantinn Fnrm 4/1 riinnn 7
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Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
.Property Address: 105 Indian Hill Road,Cummaquid `
Owner: Patricia Blair
Date of Inspection: September 10,2004
TIGHT or HOLDING TANK: No (tank must be pumped at time of inspection) (locate on site plan)
Depth below grade:
Material of construction: concrete -metal fiberglass_polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches, etc.):
DISTRIBUTION BOX: XX (if present must be opened) (locate on site plan)
Depth of liquid level above outlet invert: 0"
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.): ,
Liquid level at bottom of outlet pipe. Box is deteriorated,leaking and needs to be replaced.
PUMP CHAMBER: No (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.):
Titla C Incnartinn Anrm All 8
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 105 Indian Hill Road,Cummaquid
Owner: Patricia Blair
Date of Inspection: September 10,2004
SOIL ABSORPTION SYSTEM (SAS): XX (locate on site plan,excavation not required)
If SAS not located explain why: +
Type
_X_leaching pits,number: One 6x6 pit.
leaching chambers, number:
leaching galleries,number: t
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.): Observed 16"standing water in pit with a high stain 2' above current level
CESSPOOLS: No (cesspool must be pumped as.part of inspection) (locate on site plan)
Number and configuration:,
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no): x
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
PRIVY: No (locate on site plan)
Materials of construction: a
Dimensions:
Depth of solids:
Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
f
Tit1a f Inenam;nn Pnrm 4/1 C/7nfln 9
a
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEMINFORMATION(continued)
Property Address: Indian Hill Road,Cummaquid
Owner: Patricia Blair
Date of Inspection: September 10,2004 "
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.
Indian Hill Road
13 •
r
1000 gal tank(inlet cover at grade)
Distribution box
1000 gal pit(cover 16-18" below grade)
_ F
Titles i lncnAr in,,'Fnrm!./1 C/innn 10
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Page I 1 of I l ,
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
• i
SYSTEM INFORMATION(continued)
Property Address: 105 Indian Hill Road,Cummaquid
Owner: Patricia Blair
Date of Inspection: September 10,2004 '
SITE EXAM
Slope None
Surface water None
Check cellar Dry
Shallow wells None
Estimated depth to ground water: More than 12 feet ;
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
_X_Observed site(abutting property/observation hole within 150 feet of SAS) _
Checked with local Board of Health-explain:
Checked with local excavators, installers-(attach documentation) '
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Low area at side of property bordering marsh 2.9'.lower than bottom of leaching pit.
. 4
{
{
y }
J
Titles Rnrm 1;/1�/Innn l 1
No. >pY Fee U' dV
l
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
Zfpprtcatton for 30topogal 6potem Con0truction i3erm it
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) 1kC'timplete System ❑Individual Components
Location Address or Lot No. /$-D jrj Owner's Name,Address and Tel.No.
C�J!?iJ/�iQ�dse
Assessor's Map/Parcel
Installer's Name,Address and Tel.No. Designer's Name,Address and Tel.No.
R v,-, 9 5
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design.Flow gallons per day. Calculated daily flow -gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or ratio (Answer when applicable) i_r✓/krcl� -- 13ax' 1,0 6_�
Zo iT
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with.the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this oard f Health.
Signed Date
Application Approved by Date—l°-_2 5
Application Disapproved for de following reasons
Permit No. y — Date Issued to -D 0 r 0 ;�
r
� Uu
No. 2 00`/ ^IV Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in�computer:Z_
Yes
PUBLIC HEALTH-DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
ZIppYicatton for 33igpoal &patent Cou!5truction Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) IgA20IM'plete System ElIndividual Components
Location Address or Lot No. h��y J,{i m
// i2 Owner's Name,Address and Tel.No.
Assessor's Map/Parcel U v/� ►�/'itfi��� g�'��r
�/g, 000�
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
9Wr�-v 5
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.Hof Persons Showers:( ) Cafeteria( ) .
Other Fixtures s4
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title +
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or teratio s(Answer when applicable) /2�T �E�=T�4 =
u
Date last inspected:
Agreement: a }
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal
system—,
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this Board of Health.
Signed _ Date
Application Approved by - Date » . _
Application Disapproved for a following reasons
,ir "
Permit No. u v Xr 11� V_vs) Date Issued ,,_ —U ti
ri(ja� THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS L�
�V/ 0-WX
Certificate of Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired(X )Upgraded( )
Abandoned( )by 7-. 4 nD r ae .
at od Q_ 1 _, _4I a has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No.9&n t! kl dated
Installer Designer
The issuance of this permit shall not be construed as a guarantee that the s s e will f nctioAs designed.
Date 11 I r\i,I Inspector I."
No. 00 — Fee lot)
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
Di5poml *p$tem Construction permit
Permission is.hereby granted to_Construct( )Repair(X)Upgrade( )Abandon( )
System located at
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this permitAv"
Date: _ h- g— uo Approved by ��"
N01 ........... Flas:✓� ..........
THE COMMONWEALTH OF MASSACHUSETTS
712 BOARD OF HEATH
.7� i� .................OF.... ................................
Allp iratinn for Biiipniia1 Works Tonstrurtinn Pumit
Application is hereby made for a Permit to Construct ( ) or Repair (t) an Individual Sewage Disposal
System at*
ed. --•--1 _f`.S li .�e.. ..1.'.�1�SS----------------------------
I� LIL` � ... _l�lrress .... � _ e�.oz '.No V�`. �^ fCao/45�.
]� ( �t
K ...._...�W.eL.................. ��Xk?�1�._P� .AaS1
Installer Address j d /�Type of Building Size Lot.___.. .h R'.._..-Sq. feet
V Dwelling—No. of Bedrooms.............4---------------------------Expansion Attic (V/) Garbage Grinder (
Other—Type- of Building ---h0 Wl_c._--_______- o. of persons-------4----------------- Showers (�L) — Cafeteria ( )
a' Other fixtures ..kJjXS.L4L p
WDesign 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_t,�n ( )n _ /
Percolation Test Results Performed by..... l_SI-Q(4__ -onS ................................•.. Date------sf/jNf----7;L------
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water--.-__-.-_---.--_------.
fX4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------
O ------ -.-------`---f......c...............................................—
Description of Soil----------- "r
U ------------------------------------------------------------------------------------------ ---------------•------------------------------------ ----------------------------------------------------.
W
VNature of Repairs or Alterations—Answer when applicable..........................................:.....................................................
---------------------------------------------------------------------------------------------------------------------------------------------=---------------------------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed-In`dividual Sewage Disposal System in accordance with
the provisions of Article XI of the State. Sanitary Code-The undersigned fu,`ther agrees not to place the system in
operation until a Certificate of Compliance has been issu d b th boa> h h.
Sid... .. . ...... .............. ---------------------• ---_9 -
ed!a � / ......
/ D�ae
Application Approved BY = �' YI�......_.
D
Application Disapproved for the following reasons----------------------------------------------------------------------------------------------------------------
..----•--•-•--•--••••----------•----------••-•-------------•-----------.......-------------------------- -----------------------•-----••-•--•-------•••-------•--------------------•--•-•---••----------
Date
PermitNo..--............................................-....... Issued........................................................
Date
N ................ `FE a.........................
THE COMMONWEALTH OF MASSACHUSETTS Q\
BOAV, 0 Ig I H
............ ......................OF...................................... ...................................................
Application is hereby made for a Permit to Construct or Repair (4") an Individual Sewage Disposal
System at-:
i
n+_ac fo
77 ------ ------------- - --..... --------------------------------7 . . --------------- -
ddress ----I L 0�'y
-i,�......................................
------------------------------------------- ------------------------------------------
-
-
---------------------- - -------------- -- ---I------- -----------I-------- . .. .
Installer 1,....................................................................
Address
Type of Building Size Lot._._.. .....................Sq. feet
U V,
Dwelling—No. of Bedrooms............................................Expansio!4Attic Garbage Grinder ( )
QI Other—Type of Building,-ZI-dt Ivi-I............. tNo.1 of I)ersons---------------------------- Showers Cafeteria ( )
Otherfixtures --------------------------------------------------------- --------------------------------------------------------------------;---------
Design Flow.:..........................................gallons per person per day. Total daily flow--------------------------------------------gallons.
9 Septic Tank—Liquid capacity------------gallons Length---------------- Width________________ Diameter_____-_.__--____ Depth----------------
Disposal Trench—No..................... Width_----------------- Total Length.____-___-_---_--_.. Total leaching area---------------------sq. ft.
Seepage Pit No____________________-- Diameter................__.. Depth below inlet._....... Total leaching area------------------sq. f t.
Z Other Distribution box- Dosing-rpnk
Y�i �,k".
Percolation Test Results Performed by-_.._.__.`'.. ............................................................. Date..... ......----------------
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth,to ground water-----------------------
Test Pit No. 2----------------a&utes per Inch Depth of Test Pit.................... Depth to ground water------_-------.---------
I..............................I.......I.........f.........................................................
Descriptionof Soil----------,----------- --------I......L........M_M........ ------------------------------ ----------------------
U ...................................................................................................................................................... -------------------------------------------------
------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------ -----------------
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 Article X1 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 boafra Of
T/
Wi , ---
.......................-------------------
A
Applii�';it* A proved By-.........n. p --------------------------j-----------------...... -------------------------- ............. ........... ----------
P ......
Date
,APOkaii6fi Disapproved for the f ollowino reasons:----------------------------------------------------------------------------------------------------------------
....................................................................................................................................................................................... .................
Date
PermitNo.................................................... --- Issued.----------------------................................
Date
THE COMMONWEALTH.
OF MASSACHUSETTS
BOARD 0 1,
..........................................OF...................................................................................
5649�to.C&FY, Ua?the 1-ndi constructed ( ) or Repaired (
by........................................................................................................ ....................................................... ..................................
..
I ;t 01 W
at.... ... .J___ .....14 ---------------------------------------------------------------------------------------------
has `been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No....................V-�--V-4.........dated-- s" /--- ------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. 0
DATE--------- 73........................................ Inspector...Tt! .............
THE COMMONWEALTH OF MASSACHUSETTS
ti
BOARD OF HEALT- .6 F.... _ ...... ......... ......17 - 7No...... . FEE-^. .................
r 04onstrurtion fi,rmft
Permission is hereby granted_-------147 4--f,------ � ... ...............................
to Construct or Repair an Individual Sewage 1 spbs;il. ystem
at No
�f -•.
et
r e W
W_-�y-- q) I D as shown on the application for Disposal Works Construction Permit Dated._ 2_ n
p .............
�_ _-V�:
------
c,...... -------------------------------
ealth
DATE------...--------------------------------------------------I.....................
FORM 1255 HOBBS & 'WARREN. INC., PUBLISHERS
till