HomeMy WebLinkAbout0270 INDIAN TRAIL - Health 270° Indian 'Trail
111337.602 Barns'table
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('$ $MO"^^''��gg���+.A'XF =°)� I'vWSACHLSETTS
: ExEc TivE OFFICE OF ENVIRONMENTAL,AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ys� ASSESSORS MAP N0.
PARCELNO:
TITLE 5
OFFICIAL INSPECTION'FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address:.1U I 'e Tral l
33BbISNCI H11b�H
Owner's Name: i i �IbB 10 NMO_L
'Owner's Address: (.Wo- ff y F�i� �oOZ
— ,pler o 1 30s in�
Date of Inspection:
Name of Inspector: lease print) �� 7 03AI333a
Company Name: �a k r ja s��f wwS
Mailing Address: LI
v�b Y/
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 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 15.340 of Title 5(310 CMR 15.000). The system:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: (� 7
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report 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 I
Page 2 of 1 I
OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: oZ 7f7 A 1 f-4-A
n U �n VyV%e4 01
Owner: AA
Date of Inspection: 6 1916 1 oN
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
I have-not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system,components as described in the"Conditional Pass"section nee o be replaced or
repaired.The system,upon completion of the replacement or repair,as approved by the oard of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following s ements.If"not determined"please
explain.
The septic tank is metal and over 20 years old*or the se pti (whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank ure is imminent.System will pass inspection if the
existing tank is replaced with a complying septic tank as." ved by the Board of Health.
*A metal septic tank will pass inspection if it is stru sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is av ' le.
ND explain:
Observation of sewage backup or out or High static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,se or uneven distribution box.System will pass inspection if(with
approval of Board of Health):
Token pipes)an Biased
obstrnctkm isszemoved
distribution box is kweled or replaced
ND explain:
The system r ired pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND,explain:
2
I
Page 3 of l I
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM
FART A
CERTIFICATION(continued)
Property Address: a1 /V �n��ari rac
Owner:
Date of Inspection: /k16
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 i e 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 1 . 03(1)(b)that the
system is not functioning in a manner which will protect public health,safety an he 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 'alt marsh
2. System will fail unless the Board of Health(and Public W er Supplier,if any)determines that the
system is functioning in a manner that protects the public alth,safety and environment:
_ The system has a septic tank and soil absorption stem(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water pply.
_ The system has a septic tank and SAS an he SAS is within a Zone i of a public water supply.
_ The system has a septic tank and SA and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank an AS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well".Meth used to determine distance
"This system passes if the w water analysis,performed at a DEP certified laboratory,for coliform
bacteria and volatile organi ompounds indicates that the well is free from pollution from that facility and
the presence of ammonia trogen and nitrate nitrogen is equal to or less than 5.ppm,provided that no other
failure criteria are triaa ed.A copy of the analysis must be attached to this form.
3. Other:
3
Page 4 of l l
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISP WSTEM INSPECTION FORM L.
PART A-
CERTIFICATION(continued)
Property Address: 0202 %a- (`a�
.�N1N?4G eJ e
Owner• Mp 1a�y'
Date of Inspection: b tad Off(
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
jf Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
of Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
T Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
Y Liquid depth in cesspool is less than 6"below invert or available volume is less than'/z day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s)_Number
of times pumped
Any portion of the SAS,cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water suPP supply..
..
,t 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.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis.(This system passes if the well water-analysis,
performed at a DEP certified laboratory;for cow bacteria and volatile organic,compo�ds
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 S plim,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
r
00(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 fa ' ' with a design flow of 10,000 gpd to 15,000
gpd, E
YOU must indicate either"yes"or"no"to each ofthe fo
(The following criteria apply to large systems in.addi' n to the criteria above)
yes no
— _ the system is within 400 feet of ace drinking water supply
the system is within 200 fe of a tributary to a surface drinking water.supply
— _ the system is located. a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a publi ater,supply well
If you have answered' es"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D ove the large system has failed.The owner or operator of any large system considered a
significant threat der Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304,The sy m owner should contact the appropriate regional office of the Department.
4
Page 5 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE IDISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 01 In •a, ' w;`
Owner:Ad leJ&r
Date of Inspection:
Check if the following have been done.You must indicate`yes"or"no"as to each of the following:
Yes No
_ 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?
J( _ Has the system received normal flows in the previous two week period
.9 Have large volumes of water been introduced to the system recently or as part of this inspection?
J Were as built plans of the system obtained and examined?(If they were not available note as N/A)
Was the facility or dwelling inspected for signs of sewage back up?
_ Was the site inspected for signs of break out?
Were all system components,excluding the SAS,located on site?
_ Were the septic tank manholes uncovered,opened,and the interior of the.tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
_ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
Existing information.For example,a plan at the Board of Health.
Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)[310 CNR 15.302(3)(b)]
5
OFFICIAL INSPECTION.FORM-NOT FOR VOLUNTARY ASSESSMENtS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PANT C
SYSTEM INFORMATION
Property Address:_? 1
Owner:
Date of Inspection: (2 &L4oy
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): yyd
Number of current residents. o?
Does residence have a garbage grinder(yes or no):4t-5
Is laundry on a separate sewage system(yes or no):_gb[if yes separate inspection required]
Laundry system inspecteds or no):A�o
Seasonal use:(yes or no): a5
Water meter readings,if.available(last 2 years usage(gpd)):
Sump pump(yes or no):ND
Last date of occupancy:
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.2fl3 gpd
Basis of design flow(seats/persons/s etc.):
Grease trap present(yes or no):
Industrial waste holding tank sent(yes or no):_
Non-sanitary waste disch d to the Title 5 system(yes or no):_
Water meter readings,' vailable:
Last date of occup /use:
OTHER(des be):
GENERAL INFORMATION
Pumping Records
Source of information:
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
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:
Were sewage odors detected when arriving at the site(yes or no): Ji�O
6
Page 7of11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURtACE SEWAGE DISP®SAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 70 /rd is..,r
((�� I
Owner: ACi l eaue-
Date of Inspection: 6 I�T_
BUILDING SEWER(locate on site plan) .
Depth below grade: o1 7��
Materials of construction:_cast iron A 40 PVC_other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK:_C (locate on site plan)
Depth below grade:
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: /5"0O Gp,'
Sludge depth: 1 `1 . '
Distance from top of sludge to bottom of outlet tee or baffle: 30
'9
Scum thickness: a
Distance from top of scum to top of outlet tee or baffle: 1 �,• ,
Distance from bottom of scum to bottom of outlet tee or affle: I
How were dimensions determined: Mea—s i%
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc_):
t o V A-4 c 1A Xd6r,*-
Q a.
r
GREASE TRAP: (locate on site plan)
Depth below grade.
Material of construction:_concrete m _fiberglass,polyethylene_other
(explain):
Dimensions:
Scum thickness: "
Distance from top of scum t op of outlet tee or baffle:
Distance from bottom of um to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on purr ng recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outle invert,evidence of leakage,etc.):
7
Page 8 of I!
OFFICIAL INSPECTION PORK—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 0 f rai Cat
� p
O wn er: l� 1 e-r'm
Date of Inspection: aO`o`9
TIGHT or HOLDING TANK: (tank must be p d at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete etal fiberglass__polyethylene - other(explain):
Dimensions:
Capacity: Xalarnmn
s
Design Flow: s/day
Alarm present
Alarm level: g order(yes or no):
Date of last p
Comments(c switches,etc.):
40,
(DISTRIBUTION BOX: (if present must be opened)(locate on site plan)
Depth of Iiquid level above outlet invert: ey etlt
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.): Sr
l �.� �c WaS 2�ttl 0. 1A1 f�7C tJ.6 h0 S gt v� Q
,tY`tn r1Kk.
PUMP CHAMBER: (locate site plan)
Pumps in working order or no .
Alarms in working or (yes or no):
Comments(note c dirion of pump chamber,condition of pumps and appurtenances,etc.):
8
I \
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSUI&ACE SE*AGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
r' �
Owner: n�"TVI er
Date of Inspection: lk laA"Qq
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number._
_leaching chambers,number. �(
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/altemative system +Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.): `
t-' 11 AA-1 tL e
A,S n T-
CESSPOOLS: (cesspool must be pumped asp f,inspection)(locate on site plan)
Number and configuration: _
Depth—top of liquid to inlet invert:
Depth of solids laver:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwate nflow(yes or no):
Comments(note condi 'on of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc_):
PRIVY: (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of il,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: K i A
Owner:
Date of Inspection: 4�jj OU
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 ebters the building.
f
q 6
. 3
r
Page l l of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE,SEWAGE DISPOSAL, SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: e?70 �4ti
qq m► '`
Owner: A Mi eUxetr
Date of inspection: 11044
SITE EXAM[
Slope Vo$
Surface water
Check cellar Y QS
Shallow wells NO
4
Estimated depth to ground water 7. 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:
ae 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:
40 R.O
?• 7 eel
li
I --
Permit Number: . (late:
Completed by:
HIGH GROUND-WATER LEVEL CO%1PUTATION1
Site Location- OZ 70 / i e�.nTi1G►• \ _ Lot No.
Owner: Address: _
Contractor: Address:
`Dates:
STEP 'I Measure degr:h to water table
tonearest I/10 I't. ...................... .............................. . . .................. Date It otcp{ y 0
month/, ?year
}
}
STEP 2 'Using Water-Level Range Zone 1
arm Index dell Map locate € —
sae and determine: _I`
A. Appropriate index wet!--- ------- }•.ZYW
. , }
Water-level range zone .......... ..... ................
i }
STEP 3 Using monrthl;r report"Current
t
Water Resources£andi*Irsrss"
.� determine cz,rrent depth to
s
water level for index wel< ----------- -------------- ��ID�/ �q7 aZ
maasth?year i � I
1
STEP 4 Using Table zf Atater-level Adjustments
for index well (STEP 2A),current d i { }
to water level for index well (STEP 3).
and water-level wane (STEP 28) _71t�
determine neater-level ad.lustment ........ ............
i
STEP 5 Estimate dejAh to high water 1
by subtractitaq the Water-
level,adusmient (STEP 4)
from:measured depth to water
revel at site i'STEP ?) ............ .... . ......... l 7. 7 I
FQM b& ! . . ,
P ' ` �f' R TOWN OF BARNSTABLE 0
LOCATIONS 70 SEWAGE #
VILLAGE ASSESSOR'S MAP & LOT '--3.3
INSTALLER'S NAME & PHONE NO.AZG,el
SEPTIC TANK CAPACITY 5 D �
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER 40 /G
BUILDER O OWNER ? 7 X /Z l ��41-2
l9 vF
DATE PERMIT ISSUED: - /
DATE .COMPLIANCE.,ISSUED:
VARIANCE GRANTED: Yes No
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No.12.P.. .a- Fms...... ,,
THE COMMONWEALTH OF MASSACHUSETTS
-- BOAR® OF HEALTH
... -- - ...................OF....................--....---..........-------------•---------.._._............._.....-_.
Appliratiou for Dispaiial Works Tonst=an
rrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( dividual Sewage Disposal
System at: /
L Locatiy As dress or Lot No.
,�►T 1� / 1,04 NG(✓ /9 fi 6_-L.•------•..................C - . ..
Owner Address
----------------------------..... ........................................................... .....---...._._... _------------------------------ ------
Installer Address
d Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms.._...._.-____________________________Expansion Attic ( ) Garbage Grinder ( )
Other—Type T e of Building No. of persons............................ Showers
P� YP g ---------------------------- P ( ) — Cafeteria ( )
Q' Other fixtures ..---•---------------------•••--••-••-----•-----------
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
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. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit......:............. Depth to ground water........................
444 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P4 •-------------------------------------------------
•••••------------
•-•-•------------------••---•-•-•-----------------
•---------
•-----------
-•--------------
0 Description of Soil.......................................................................................................................................................................
W
U --••-•---•-----------•-------•----•------•-•---------------•----•••-----•------•---••._.......-••---•••••--------------•--•-•-•••-•-•-•--------••-•••------•-•---•-----••--•-----•---•--•-••-----•-••••.
W
. --------------------------------
\V Nature of Repairs or Alterations—Answer when applicable V�:-- .............�T��.....� � .. .... �..
--------..•-----------------•-------------------...-----•--•-------------------•----........----------------....--------------------------•---------------------------------------------•--........•••--
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
l•1T Rl-F^
the provisions of 1 i t,.i- 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has be issued by the board of health.
Date
Application Approved By......... —fate
.
i Date
Application Disapproved for the follow `reasons:..............................I.......................................................
..............-........... ....................................................-.....................
G Date
PermitNo....... ................. Issued_..................-----------------•••••-•••---•---•-
Date
=1
�— �
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF FUMMING ENGINEER MUST SUPERVISE
IN #rTION AND CERTIFY IN WRITING
G csL.........oF......./ e-,.. i TEM•WASANSTtALLED IN STRICT
err ifirtt#r ofT9MPJfW9V TO PLAN.
THIS IS TO CERTIFY That-the Individual Sewage Disposal System constructed ( ) or Repaired C/A
by.........................-----------------.... r ---/"-/
1 1 Installer
...........-...........--------.........................-......................................................................................
has been installed in accordance with the provisions of TIT E 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No...._�7_.-__5_.V.ek..... dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector........................-...........................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............. ..........................OF.......................................-•-
Appliration for Diaposal Works Towitrnrtiun umit
Application is hereby made for a Permit to Construct ( ) or Repair (r✓') an Individual Sewage Disposal
System at
02 -� D �1..r c�, ate✓ ��,ra
__.-___---•--_________--•-----•---------•-•- - .........•----------------------------------------------------------------------------------------
ddx
T!l / /iA �'.;t ' /.ems ,rs� C or Lot Ivo.
......................--.......................................................................... ••------••-------------•...--•---------......-----•-------•-••-------•-------•------------•----...
Owner Address
-----------
Installer Address
Type of Building --f Size Lot....._......................Sq. feet
Dwelling—No. of Bedrooms......... _____________________________Expansion Attic ( ) Garbage Grinder ( }
Other—Type T e of Building No. of ersons____________________________ Showers
(� YP g ---------------------------- P ( ) — Cafeteria ( )
Q' Other fixtures __________________________________
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter__-__-_______.__ Depth................
x Disposal Trench—NTo_____________________ Wid1th.................... 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........................................
,.a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water_____---_-____.______--.
fi Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a •-•-•-•-••-•••-•-----•---•••-•...............••••••-•-••-------......_•-•-----------•-•-•-•------••-..............................................
•----_-----
0 Description of Soil.....................................................................................................-•---------------•--•---------------------------------------•••---
x
U
W -----------------------------•-••-•-•-•••••-•••--•----•---••---•-•._.....-•----•------•---•-••-----
U Nature of Repairs or Alterations—Answer when applicable��' .'`........:. 7-6 �..jF � A.5 ....
----------------------------------------•--•---------------•------••-----------------•---•-•-_----•-•-•--------•-----------------•---•---••-----••-------•-----•-•-•-•••••-••--•••-•--•--------.....----
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of'TT 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b € ,issue -by the b and of lth.
Signe z ' - -/ f
Date
Application Approved BY = •;---•---•------------------ --•- ' r---
Date
Application Disapproved for the following reasons:--•---------•----------------------------------•--•-•----------------------------------........................
...._._..-•---------•---....-----•-----------------------•--•-------------••--•--•---•---._._..._...----•._......_....---•-------•-----------•--------------------------------------------------------•-
�i Date
Permit No......15.2_--.2!5 Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
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Corrtif iratr oaf Tompfianrr
THIS IS TO CERTIF ?That t` Individual Sewage Disposal System constructed ( ) or Repaired
bY------------------------------------------------------------------------... ...............--•--•--•-•----------...-•----•-••-...--•--....................-•-----._...._.........----...•-••------
r I Installer
at.....................................................................................................................................................................................................
has been installed in accordance with the provisions of Tim,�'rr� j 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 YHiE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector....................................................................................
3 THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
No...U7 D Q< r Cw!............OF........e`c�::��::'........'................. t.--.............................
._._...s:� /FEE.._... .....
Biopnsa1 Works Tnnirudian permit
Permission is hereby granted - fir'"e /7,
--- -----------------------------------•-•-�-----------------------------...._...--•-•-------------._...--•--------......__..........._._..
to Construct ( r) or Repair an Individual ewage Disposal System
at NO. ,✓ C�,4,'� l
.............................. •-••------••••---•--._...--•-•--••-------._...-•-•••---•--•••--•----•-•---••----...--•--
Street ��ry
as shown on the application for Disposal Works Construction Permit No.�____/____________�(____ Dated..........................................
Board of Health
DATE................................................................................
FORM 1255_ HOBBS & WARREN, INC., PUBLISHERS
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ELLIS & THULIN INC.
. ;.E-F-r- ;" 7eST >,T -7� LAND SURVEYORS AND CIVIL ENGINEERS
�s Mr-.��u�� ��r�o � ;� yT _ EAST SANDWICH MASS.
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