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Home My WebLink About4054 MAIN ST./RTE 6A(BARN.) - Health I054)Main;Street (Route 6A) Barnstable A = -,336 '048-. , , i I� �I i a Jul21 1511:37p p.18 �� 3310-DAB Commonwealth of Massachusetts MENEM Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4054 Main Street(Route 6A) a Properly Address Mike Ryan y Owner owners Name x. requir ation a �r�(�/�cS% J��i MA 02637 7-20-15 �required for every Cur1yFT quid � page. City own State Zip Code Date of Inspection pp� rT.1 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:When filling out forms A. General Information `�aHiuu it uurp,,� on the computer, �� VA OF 4,q use only the tab ` 11033 �• ....... ssq�,i . y , key to move your 1 Inspector. cursor-do not ,lames D_Sears ,!A M ES :�= use the return Name of Inspector key. CapewideEnterprises,LLC . �o.•�� Company Name 153 Commercial Street Company Address Wshpee MA 02649 i Ciitylrown State Zip Code 508-477-8877 S1623 Telephone Number 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 7-20-15 spector's 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 the 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 the same or different conditions of use. t5ins-3113 Tltle 5 Official Inspedon Form:SuDsu few Sewage Disposal system•Page/of 17 Jul21 1511:37p p,19 Commonwealth of Massachusetts Title 5 Official Inspection Form iy Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 4054 Main Street(Route GA) Property Address Mike Ryan Owner Owner's Name informationis required for every Cummaquld MA 02637 7-20-15 page. Citylrown Slate Zip Code Date of Inspection B. Certification (cons.) 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: The system is a old c. pool.and pit. 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. Q Y Q N ❑ Na(Explain below): 15ins-31'3 Title 5 Official Inspection Fom:Subsurface Sewage Dispose[System-Page 2 of 17 Jul21 1511:38p p.20 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 4054 Main Street(Route 6A) Property Address Mike Ryan Owner Owners Name information required for every CumnTaquid MA 02637 7-20-45 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. 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 below (Explain ❑ 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 t5iras•3113 Tide 5 Official Inspection Form Subsurface Sewage Dsposal System•Page 3 of 17 Jul21 15 11:38p p.21 Commonwealth of Massachusetts Title 5 Official Inspection Form 1= Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 4054 Main Street(Route 6A) Property Address Mike Ryan Owner Owner's Name information is Cummaquid MA 02637 7-20-16 required for every page. City/Town State Zip Code Date of Inspection 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 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. E] 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 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 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 i ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ti,4 ❑ ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y day flow t5ins-3113 rib 5 ORctaf t.s, pet'Uon Form:SAs.niaw Sevrage Disposal System-Page 4 of 17 Jul21 1511:38p p.22 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 4054 Main Street(Route 6A) Property Address Mike Ryan Owner Owner's Name information is required for every Cummaquid MA 02637 7-20-15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® 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 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 arnrnorria nitrogen and nitrate nitrogen is equal to or less than 3 pprn, 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 a cesspool 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 e)dst 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. i For large systems, you must indicate either`yes"or"no"to each of the following, in addition to the questions in Section D. i Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply i ❑ ❑ 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 I I 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. t5hs•3l13 Title 6 Official Inspedion Form:Subsurface sewage Disposal System•Page 5 a 17 Jul21 1511:39p p.23 commonwealth of Massachusetts Title 5 official Inspection Form a l� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments _4054 Main Street (Route 6A) Property Address Mike Ryan Owner Owner's Name information required for every Curr maquid MA 02637 7-20-15 page. Citylrown State Zip Code Date of Inspection 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 ❑ 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 inspection? N� ❑ ❑ Were as built plans of the system obtained and examined? (If they were not available note as NIA) ❑ 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? Q 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. i ❑ ® Determined in the field(if any of the failure criteria related to Part C is at issue 1 approximation of distance is unacceptable)131 D CMR 15.302(5)) D. System Information i Residential Flow Conditions: Number of bedrooms(design): NA Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 for example: 110 gpd x#of bedrooms): 440 t5ins•3113 Title 5 Official Inspection Form;Subsurface Sewage[Disposal System•Page 6 of 17 Jul21 1511:40p p.24 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4054 Main Street Route 6A Property Address Mike Ryan Owner owner's Name information required for ev every Cummauid MA 02637 7-20-16 page. Citylrown state Zip Code Date of Inspection D. System Information Description: The system is a old c. pool and pit I I i Number of current residents: 1 I i Does residence have a garbage grinder? ❑ Yes 0 No Is laundry on a separate sewage system?(include laundry system inspection information in this report.) ED Yes ❑ No Laundry system inspected? ® Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): 2013-37,000Gals Detail: 2014-32,000Gals Sump pump? ❑ Yes ® No Last date of occupancy: Present Date CommerciaUlndustrial Flow Conditions: I Type of Establishment: i Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft, etc.): i Grease trap present? ❑ Yes ❑ No Industrial waste holding present?resent? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, If available: Kire 9/13 TIYe SMcial Inspedion Form:Subsurface Sewage Disposal system•page 7 ar1T Jul21 1511:40p p.25 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 4054 Main Street(Route 6A) Property Address Mike Ryan Owner Owner's Name information is required for every Cummaquid MA 02637 7-20-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: 2013 Was system pumped as part of the inspection? ® Yes ❑ No If yes,volume pumped: 800 Gal. _ gallons How was quantity pumped determined? Gage on pump truck Reason for pumping: Part of inspection on c. pool Type of System: ® soil absorption system ® Side 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)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): 151ns-3(13 Title 5 Official Inspection Faun:Subsurface Sewage Disposal System•Page 8 of 17 Jul21 1511:40p p.26 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 4054 Main Street(Route 6A) Property Address Mike Ryan Owner Owner's Name Is requir required every Carnma aid equired breve 4 MA 02637 7=20-95 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed(if known)and source of information: NA Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 3' feet Material of 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.): Pipeing is 4" PVC SCH 40 and orange burge. Septic Tank(locate on site plan): Depth below grade: feet Material of construction:. ❑ concrete ❑metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 0117 Jul 21 1511:41 p p.27 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 4054 Main Street(Route 6A) Property Address Mike Ryan Owner Owners Name information is Cummaquid MA 02&37 7-20-15 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) 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 baffle -- Distance from bottom of scum to bottom of outlet tee or baffle --- How were dimensions determined? — Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.).- Grease Trap(locate on site plan): Depth below grade: feet Material of construction: 0 concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness --- i i 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: Date ` F (Sins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Pape 10 cf 17 i i Ii i I i Jul21 15 11:41p p.28 Commonwealth of Massachusetts Title 5 Official Inspection Form 0 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4054 Main Street(Route 6A) Property Address _Mike Ryan Owner Owner's Name informationisequired for every Cumma ufd MA 02637 7-20-95 page. City/Town State Zip Code Date of Inspection D. System Information (cons.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc_): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: i Material of construction: ❑ concrete ❑ metal J ❑fiberglass ❑ polyethylene ❑ other(explain): � I f Dimensions: Capacity: gallons i Design Flow: j gallons per day Alarm present: ❑ Yes ❑ No ,f . i Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: gate Comments (condition of alarm and float switches, etc.): I 1 t i i "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No l5ins•3113 rifle 5 DrBe7al Inspection Fam:Subsurface Sewage(Disposal System.Page 11 of 17 i l Jul 21 1511:41 p p.29 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4054 Main Street(Route 6A) Property Address Mike Ryan Owner owner's Name information is Cumma uiaf required for every q AAA 02637 7-20-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert --- Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): i j 7 i i i Pump Chamber(locate on site plan): i Pumps in working order: ❑ Yes ❑ No* i Alarms in working order. ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): i -- I i i l i * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: 1 i t5ins-3013 Title 5 Official Inspection Form:Subsurfsoe Sewage Disposal System-Page 12 of 17 Jul 21 1511:42p p.30 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4054 Main Street(Route 6A) Property Address Mike Ryan Owner Owner's Name _ information is required for every Cummaquid MA 02637 7-20-15 page. City1 76wwn state Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number. 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields _ number,dimensions: ❑ overflow cesspool number: ❑ innovativetalternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is a 1000 gal. precast pit. Pit and cover at 29"below grade T water in pit i i i i . i i t i i Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): i Number and configuration Laundry 1 1 ' 8" 5' Depth—top of liquid to inlet invert i Depth of solids layer . 4" 2" i Depth of scum layer 2" 0 Dimensions of cesspool 5' Deep 7' Deep Materials of construction Block Block Indication of groundwater inflow ❑ Yes ® No 15ins-M3 Title 5 Offfdal Inspection Form:Subsurface Sewage(Disposal System-Pege 13 of 17 Jul21 1511:42p p.31 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4054 Main Street(Route 6A) Property Address Mike Ryan Owner Owner's Name informationeicedfor every Cumma uid required for eve 4 lb4A 02637 7-20-15 page. Cily/Town state Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Main Pool 5'Deep block w/cover at 2'.One line in one line out water level at outlet Privy(locate on site plan): Materials of construction: — - -- Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): i i Y i i t k �I t51ns•W13 Tille 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Jul21 1511:42p p.32 Commonwealth of Massachusetts U Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 4054 Main Street(Route 6A) _ Property Address Mike Ryan Owner Owner's Name rcrreron is Cumma uidrequired for every NIA 02637 7-20-15 page. City/Town state Zlp Code Date of Inspection 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 or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below ® hand-sketch in the area below Q drawing attached separately [A,1�i I ' I l - = y3� s . f - i I 1 i i 15ins•3I13 Me 5 Oftal hVedon form-SuDwfaw 5ewep Disposal Sg510rn Page 15 Of 17 i I Jul21 15 11:43p p.33 Commonwealth of Massachusetts uTitle 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 4054 Main Street(Route 6A) Property Address Mike Ryan Owner Owner's Name information required for every Cummaguid MA 02637 7-20-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Ive Estimated depth t high ground water. 46 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ 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: Well SDW 252 You must describe how you established the high ground water elevation: U.S.G.S. WeILSDW 252 @ 47'w/1'adj Bottom of pit at 8'-6"Below Grade. i i I I i I I I i i Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ns.W13 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 i i Jul21 1511:43p p.34 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 4054 Main Street(Route 6A) Property Address Mike Ryan Owner Owners Name information is required forevery Cummaguid r1/iA 02637 7-20-15 page. City/rown Stale Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D,or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file i i I i i t51ns•113 TIAe 5 Official Inspection Form:Subsudace Sewage Disposal System•Page 17 of,7 No...... = _ U FRla..... .. o .................... �w fj rJ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH __. ..._ . . ... ............OF..........................I.,........ .................... - ... App iratinaa -fair itipma l Marko C utuitrurtioaa Vanift Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: 4� r __��a_-' .................................................. ................................................................................................. ............................... ---a •- -- ® �! M��•1 � ca�ti�n.Add t � .......... S\ c W Ow e Address .......... �'s......::................... .................................................................................................. ----------------------------------- Installer Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons-_.-------_-._....------- Showers ( ) — Cafeteria ( ) Otherfixtures --------------------•-••--------------------------------------------------------------------------------•--------------------------------•----------- W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons. P4 Septic Tank—Liquid capacity------------gallons Length................ Width................ Diameter-------.-------- Depth................ xDisposal Trench—No. .................... Width-------------------- Total Length....__-_----_------ Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter-------------------- Depth below inlet.................... Total leaching area-------------------sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.-------------------------------------------------------------------------- Date--------------------------------------- Test Pit No. 1----------------minutes per inch Depth of Test Pit.................--. Depth to ground water...._.-..--_...._-...-.. (_, Test Pit No. 2................minutes per inch Depth of Test Pit...-_-..--.._-_--_- Depth to ground water.................._.--.. 9 --------..------------------------------------------------------------------------------------------ --------------------------------------------------------- ODescription of Soil-----------------------------------------------------•---•-•-------------------------------------------------------------1-------------------------------------------- -------------------------------------------------------------------------------------------------------------- < ....... --------.--. ----- � •. U Nature of Repairs or Alterations—Answer when applicable._.tk�. ...e �1l ... �cC�1 O� E�._.... 4C-k!- --------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee issued by the board of health.A . R Signed ----------•- " u" ----•------- ------------------- -------- Date Application Approved B Date Application Disapproved for the following reasons--------------•---••---.........-•----------•--...------•-------...........-----------._........-•------------••- ----••--•-•--•-------------•--------•-------••---•- -----------------------------------------------------.--------------------------------------------------------------------------------------------- Date PermitNo......................................................... Issued.... ................... ate No........ i`EE..... ................ ` THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......... _. .._..... ----.OF..................................... ................... ` ,��firtt$in� -fix � �,��u��ti �ar�� Cn>a�t�#r�sti�r� �(rr�i� • Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal �y stem at t r . a 1� .CV �� Lv`ti�n-Ad ss 4 �01 J�� 1 .........................................................No. . .. ...�Q P Ow Address at 1 r �•�w i S --------------------- p Installer Address d Type of Building Size Lot____________________________Sq. feet U Dwelling—No. of Bedrooms______________________________ _____________Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ---------------------------- No. of persons............................ Showers ( ) — 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—No_____________________ Width-------------------- Total Length....................- Total leaching area-._-._--__.-.--___-_sq. ft. 3 Seepage Pit No..................... Diameter.................... Depth below inlet____.;_____-_.-_--- Total leaching area------------------sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by-------------------------------------------------------------------------- Date---------------------------------- ,� Test Pit No. 1----------------mmutes per inch Depth.,wof "Pest Pit.................... Depth to ground water------------------------ (� Test Pit No. 2----------------minutes per inch Depthof Test Pit.................... Depth to ground water------------------------ ....................................................--....---•-•--•--------------•-----•------------.......................................................... Description of Soil............................................................ ---------------------------------------------------------------------------------------------------------- x W ------------------------------------- ----------------------- .................................................. V Nature of Repairs or Alterations-Answer when applicable.-__�_�_---- - ----- .�3;d �'�`�L bt u - ._ _... S ------------------------------------- ---------------------- ------------------------ ----- :....._ t................... d �.._ '6.. .�_ -------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has "issu the board of health e, Signed. :„ Y�t ------------------------- Date ApplicationApproved BY-----------------------............................................................................ Application Disapproved for the following reasons: ________________________ .............................••.... Date__._..._ ......-•-•-•-•------------------------------------=------------------------------------------...................... .................................................................................... Date PermitNo---------------------------- --•---------------------- Issued.------------......' ------•--........................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD QF HEALTH ............OF........ .. +fl..r............... rr. ifira#r gf f��am littnrr TVS RTIFY, the Indiv?du Sewage Disposal System constructed ( ) or Repaired by • � Installer ' wiY .. W. at. -------------------- ...........................=...........................----------- has been installed in accordance the provisions of Article XI of The State Sanitary Code a de ribed in the application for Disposal Works Construction Permit No.____.: ._ .. ........... dated..._ �/.�.___----.---•- THE'•�,ISSUANCE OF THIS CERTIFICATE SHALL. NOT BE,CONSTRUED AS GIJ RANTEE THAT THE SYSTEM WI L� NCTI N SATISFACTORY."" DATE - --- -------7--- --------------- .......... Inspector.---- y .......... THE COMMONWEALTH OF MASSACHUSETTS BOARD O . EALTH III OF..... ..... . !" ►�.. - .................... ... No---------- ------------ FEE... ............... �il��ttl rk Permission is hereby grante - --•--•• - -------- ------ to Constru ) or Re r'( n Individual Sewage-Disposal System. .. atNo. f ---_ ------ i� --------•--- ----------- ------------------------------ s Stre as shown on the application for Dispo 1 Works Construction Pe it `o---- ___ ------- __._..... ...... ' -- .ems"-- . . ---- Board of Health DATE... :. --- ---------- ----- Z FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS 3 . x 3 T„