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Home My WebLink About2755 MAIN ST./RTE 6A(BARN.) - Health 2755 Main Street 4 Barnstable A=258-035 "t rP o. w. a " S Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -N!ot for Voluntary Assessments SS Property Address I Owner Owners Name information is CAS�G le ��` �� required for State Zip Code Date f Inspection every page. City/Town Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms on the computer,use o to move your 1. Inspector: nly the tab key cursor-do not Name of Inspectors use the return key. Company Name �O 0 Q0 � x / Company Address Zip Code c7� rmm City/Town State� O'2 S- 77— &2�?) 0 Telephone tuber i,. License Number B. Certification 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 ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority o'. 9 /l 4spect Signature Date 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 thel DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****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 s the same or different conditions of use. I 15ins•09108 Title 5 Official inswuon Form:Subsq-gat System•Page t of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form. Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property Address Owner Owner's Name information is required for State Zip Code Date ofinsp4iction every page. Cityrrown B. Certification (cont.) 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 need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) 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. ❑ Y ❑ N ❑ ND (Explain below): t5ins•oeroa Tale 5 Official Inspection Form:Subsurface Sewage Disposal system-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address ^^// Owner Owner's Name Aq p� / information is G,,,��s�'�,� required for state Zip Code Date o Inspe on every page. CitylTown B. Certification (cost.) B) System Conditionally passes(cont.): ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 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 [Sins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a/- - Property Address Owner Owner s Name aev-o dainformation is required for State Zip Code Date of Insp chon every page. City/Town B. Certification (cont.) 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 yank 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: �► he well water analysis, performed at a DEP certified laboratory, for coliform This system passes If t i bacteria indicates absent 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: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No . ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or.cesspool ❑ Ell" Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool El Static liquid level in the distribution box above outlet invert due to an overloaded u or clogged SAS or cesspool El , ,// Liquid depth in cesspool is less than 5" below invert or available volume is less LLL�� than '/2 day flow t5,ns•09r08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Tithe 5 Official `Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments J Property Address Owner Owner ;Name information is 6 required for State Zip Code Da of specUon every page. Ciry/Town B. Certification (cont.) Yes No ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipes). 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 L� 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. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent 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 and chain of custody must be attached to this form.] ❑ The system is aicesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ 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 al large'system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. 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 II of a_public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D abovei 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. I&ns•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 official Insplection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M Property Address Owner Owner's Name �h /� 0 1.)6 � ) / information is I / i�/ (/ O� required for State Zip Code Date of Inspection every page. CitylTown C. Checklist 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 ❑ Q/Were any of the system components pumped out in the previous two weeks? �❑ Has the system received normal flows in the previous two week period? ❑ Have large volumes of water been introduced to the system recently or as part of this❑ asbuilt inspection?Were as built plans of the system obtained and examined? (If they were not available note as N/A) ❑ Was the facility or dwelling inspected 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: ❑ [� 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 CMR 15.302(5)] . D. System Information Residential Flow Conditions: 3 . Number of bedrooms (design): Number of bedrooms (actual): 330 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): t5ins•09/08 Title 5 Official Inspection Form:Subsurface sewage Disposal system-Page 6 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address / 2Pi Owner Owner s Name information is required for State Zip Code Date Inspection every page. City/Town D. System Information Description: / �oo6 �_e 7n__ A, 41, CA 41(o P1 0 A/ Number of current residents: Does residence have a garbage grinder? ❑ Yes L� 1VO Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes E—No Laundry system inspected? ❑ Yes ED'-No Seasonal use? 2—yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes No Last date of occupancy: Date Commercial/industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present?' El Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: isins•09toe Title 5 Official Inspection Form:Subsurface Sewage Disposal System-?age 7 of 17 Commonwealth of Massachusetts Title 5 Official I,ns:ec�tion Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments '( C'2 /S-S Gil > T Property Address Owner owners Name �� information is ��S7� Le /�Y required for State Zip Code Date Insp coon every page. City/Town D. System Information (cont.)j Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes o If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of S m: Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes of no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternativetechnology. Attach a copy of the current operation and maintenance contract,(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): i Title 5 Official Inspection Form:Subsurface Sewage oisposai system-Page 8 of 17 15ins•09/08 r ,<L Commonwealth of Massachusetts Title 5 official Insiction Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address ,6 I Owner Owner �'� 5^ �� information is ��f (�/� required for City/Town/Town State Zip Code Dat of In pection every page. tY D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: ; 61 f Were sewage odors detected when arriving atthe site? ❑ Yes No Building Sewer (locate on site plan): r E Depth below grade: feet Materi f construction: cast iron �40�PVC ❑ other (explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): I i Septic Tank (locate on site plan): / i Depth below grade: feet Mate of construction: concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) i t If tank is metal, list age: years i Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: a-s ��_ Sludge depth: t5ins•09/08 - _ Title 5 officiai inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 I Commonwealth of Massachusetts Title 5 official lno ction Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a - Property Address I Owner Owner's Name / information is rn/yl�c, 6le— t �� — required for S'Itate Zip Code Date of I spe on every page. City/Town D. System Information (cont.)! Septic Tank (coot.) Distance from top of sludge to bottom,of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle17 Distance from bottom of scum to bottom of outlet tee or baffle a�e cjVict How were dimensions determined? F Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,llevidence of leakage, etc.): (.1 N1 f kj ✓bo //' t�C J �of✓1 d/�10�/J � - A-T Grease Trap (locate on site plan): Depth below grade:, feet Material of construction: ' ❑'fiber lass ❑ polyethylene ❑ other(explain): ❑ concrete ❑ metal i 9 i _ 4 ; t Dimensions: { Scum thickness Distance from top of scum to top of outlet tee for baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Title$official Inspection form:Subsurface Sewage Disposal System-Page 10 of 17 15ins•09/08 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Fbrm •Not for Voluntary Assessments Property Address Owner Owner's Name information is GrN f`�R O / r required for I State Zip Code Date Ins ction every page. Cityrrown D. System Information (cont.)[ Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, vidence of leakage, etc.): i i i Tight or Holding Tank (tank must be{pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: i i ❑ concrete ❑ metal f ❑ fiberglass polyethylene other(explain): f Dimensions: I i Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): ' Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No ts,ns•09108 Title 5 Official inspecfion Form:Subsurface Sewage Disposal System•Page 11 of 17 i! I f i ' Commonwealth of Massachusetts Title 5 Official Ins0e.,ction Form Subsurface Sewage Disposal System Fiorm Not for Voluntary Assessments Property Address f� Owner Owner's Name information is ,c� a required for I State Zip Code Date f Inspection every page. City/Town D. System Information (cunt) ~ Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invest Comments (note if box is level and distributiofh to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): I I i o v� I 0 a I �e 9 Pump Chamber(locate on site plan): Pumps in working order: 1 El Yes ❑ No Alarms in working order: i ❑ Yes ❑ No Comments (note condition of pump c;amber, condition of pumps and appurtenances, etc.): i I f I f — 'I Soil Absorption System (SAS) (locate on sitae plan, excavation not required): 6 If SAS not located, explain why: j i i 12 Of 17 Isins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page I s ' Commonwealth of Massachusett Title 5 Official Inspection Form Subsurface Sewage Disposal System Porm - Not for Voluntary Assessments Property Address gee i Owner / Information is Owner's Name ref �Or)6,� -5 /!q/ ( l required for 6/ State Zip Code Date 6f Insp ction every page. Cityfrown D. System Information (cont.) coy lae.-r' k Type: { W l 1 5�"e leaching pits I number: / ❑ leaching chambers j number: ❑ leaching galleries i number: i ❑ leaching trenches I number, length: ❑ leaching fields I number, di mensions: I ❑ 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.): 0� f� 01T; o�� i i i II Cesspools (cesspool must be pumpdd 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 j Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No 15ins•09108 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Owner's Name ll information is required for State Zip Code Date of nspe on every page. City/Town D. System Information (cunt.) Comments (note condition of soil, sign, of hyd�aulic failure, level of ponding, condition of vegetation, etc.): I i I Privy (locate on site plan): Materials of construction: i Dimensions I , Depth of solids Comments (note condition of soil, sign of hydraulic failure, level of ponding, condition of vegetation, etc.): i i i i i I i i [Sins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments C-�2 � i�� y SS � � S Property Address / c Owner owner's Name information is 9c-,required for f✓t every page. City/Town Slate Zip Code Dak of I pection D. System Information (cont.)! Sketch Of Sewage Disposal System: provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks & benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the duilding.!Check one of the boxes below: 01hand-sketch in the area below ❑ drawing attached separately a3 43 3a Ffoh 6-e/ol,/ 'J t i i / ' )alvl + 15ins•09/08 Title 5 Offiaal Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 I Commonwealth of Massachusetts ipOfficial 5 �Tit 0 ho. Ins ection Form Subsurface Sewage Disposal System Form • Not for Voluntary Assessments Property Address Owner Owner's Name information is required for r Gi/✓1� a o� � every page. Cityfrown State Zip Code Date of nspe lion D. System Information (cons.); Site Exam: ❑ Check Slope ; ❑ Surface water ❑ Check cellar j a— r { ❑ Shallow wells Estimated depth to high ground water:; feet 1 Please indicate all methods used to determineithe high ground water elevation: ❑ Obtained from system design plan on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) Ly' 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: I r C; OG✓ &A W�— i I Before filing this Inspection Report, ollease'see Report Completeness Checklist on next page. 15ins•M08 rue 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 I W Commonwealth of Massachusetts Title 5 Official Insoe-ction Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments C � Property Address Owner Owner's Name information is 5 / required for 01 r — every page. Cityfrown State Zip Code Date of Inspe6tion E. Report Completeness Checklist inspection Summary: A, B, C, D, or E checked 2'inspection Summary D (System Failure Criteria Applicable to All Systems)completed Q'System Information — Estimated depth to High groundwater Sketch of Sewage Disposal System either!drawn on page 15 or attached in separate file t i y i r isms-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•page 17 of 17 rJ ' TOWN OF BARNSTABLE B LOCATION SEWAGE # ?9-,5-7S— VILLAGE ASSESSOR'S MAP & LOTS INSTALLER'S NAME & PHONE NO,.,A?a/,no -ey7 C',51A) ? 77/-9&3�q SEPTIC TANK CAPACITY /ODD C LEACHING FACILITY:(type) (size) /6CY NO. OF BEDROOMS PRIVATE WELL O PUBLIC WATER_ BUILDER OR OWNER "FYIofAj DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: f VARIANCE GRANT : '.Yes I ' N m I o ' ,AZ -Zoe 7 Fss . Cl� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............................................. Appliratinn for Disposal Works Clunstrurtinn rrrmit Application is hereby made for a Permit to Construct ( ) or Repair (ao an Individual Sewage Disposal System. .................................. 4:�V ----------------------------------------................._.... Location-Address d or Lot No. --•..............................._............ Owner Address a ...... .......... . ...L . .. - Z7--..----- .. ---... Installer Address — Type of Building Size Lou400- ...Sq. feet aDwelling—No. of Bedrooms...... vim........................Expansion Attic ( ) Garbage Grinder ( ) p, Other—Type of Building ..... --4�.......... No. of persons............................ Showers ( ) — Cafeteria ( ) 04 Other fixtures .----•--•.................................•.._..._._............a ............ ................ •----------- W Design Flow................ 52 ............... per person per day. Total daily flow...............� �1_...............gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench-No..................... Width.................... Total Length-------------------- Total leaching area....................sq. ft. 3 Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area.................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) 0-4 Percolation Test Results Performed by•••••-••••••••••••-•-•-•-•-...-•••---••................................. Date........................................ aTest 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 -•-•....-•-•--•••-•---•---•....-•-•--•-••...-•-.....••-••----•----•-••--•••-•.......................:......................... U Desc�npc> on of Soil....... ..... ... ..................... ...... ` - f ... .................. ....-- - ... ...............•------------•--------------------------------••---••----•---------------•--........-----.......--------------------.......--------....................................._.....-----.--... U Nature of Repairs or Alterations—Answer when applicabl ......... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of ilT:.i� 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been ' sued by the b rd health. Signed.... .... y1a.tApplication Approved By.... _-...... Application Disapproved for the following reasons:............................ ........................................................•--•......--•-•-........_. ......---•--....---•-----•---•--••-----------------•---------------.....---•----------------........................-•-----••---••---••---•....... ..---•---•-•------........-•---------...----------- Daft Q ; Permit No....�1. ''.__`�..�..�._..............._.._ Issued._...��. � Y No. IPW , v _ TH'E COMMONWEALTH OF MASSACHUSETTS r " BOARD OF HEALTH .....OF- _}. x-....-..................:........ .................••---..................._..... Apl ratiurt for Disposal Works Tonstrur#iun f rrutit s Application is hereby made for a Permit to Construct ( ) or-Repair ( ) an Individual Sewage Disposal System at: .•......... _................... _..... ._... - . .........._..................................... _.... Location-Address _or Lot No. ` ...:......... -----...----........... ??�5" -_..: � cR.-.._.?'`......I. _ _.._. - Owner. -•Address _ -----........••.._.....-•---.. ...�% --........_ .4:5. . ....--- �� rr. � . �� - -- ,.. Installer Address Type of Building Size Lot ...Sq. feet Dwelling—No. of Bedrooms.................3.........._.............Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ......�5.1-d .......... No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures . -•--•---------•-----------•---------•------------- W Design Flow................: z ...........--..gallons per person per day. Total daily flow....._.........! 12................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. x Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by----•------------------------------•----------• Date........................................ 0.4 Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground-water........................ Z4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground 'water........................ x - .---•--•. -- .......................•---...-• -••_.. ..........-•••---•-•............................ -- •-•-•-•-••••--- O Description of Soil....... ----- ....`... ----------------------------------------------------------------------------------------------------------------------------- --=------------•-••--•----••---......--•------•••-...... ••....•••--••-•-•••-----•-----------•--•-•------.._..------------........----•----•-••-•-•--•--••-------•-••----•-•--•---••---......••........ x - U Nature of Repairs or Alterations—Answer when applicabl .!?rcta[J P... ► ..� A �......... 24 Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T I T 1E 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the b -rd of�health. Signed.... ! J` i .... .... Date V2e✓ . Application Approved By----io.------ .....---- . ....._..�... ........-•--._..... •. Application Disapproved for the following reasons-------------------- •.......------•...---------------•---•-•----•-----•---••--•---.....--•---•...........---- .....................•---•---------........p...---....----••--------......---...------------•-----..........-----.........---.....-•-•--........--•-•--•--------•----------•-------•----------••----•••-•-- Permit No.... _,�`:. ! _.__ Issued.._.l�/ .�.....Date.•- - Date l THE COMMONWEALTH"OF MASSACHUSETTS BOARD OF HEALTH . ............OF.. ._.. ..................................... Taftf irtar of fanutoliaurr M THIS IS TO CERTIFY, That the Individual Sewage Dispos System constructed ( ) or Repaired,( ) by................. ...............•.......--•--•---------•--....... ....--•------•- Installer / _ at................... ........... :.. -ePP ...... � r✓�-.� i . has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as desc ibed in the application for Disposal Works Construction Permit No.... - dated.... _ ._.N.. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARAN EE TAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.... ...........................:........ Inspector. ..V........ , i ...... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........OF....2= ...................... .......-.................. ...... No... � .... FEE........................ 3��s�ns�tl ,arks �uttsfrttt#uau �rruti# Permission is hereby granted........ - -��:...................._.... to Construct ( ) or Repair an Individual-Sewage DJi steal System at No...._..... . .7� `---... !��&.. 2 .(�_a �.. ................. •`' Street 44 � as shown on the application for Disposal Works Construction Per i� Nd�=�"� Dated..,I_.._._._ `��.......... � - Board of Health DATE