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HomeMy WebLinkAbout0034 MERION WAY - Health r341 erL o 'A14 04 lie ' Barnsta ` a : r ] 3�S: �.r T .. n _ a - ° , „ n < n s t a , t , S �" .. - , � '� � F .Y � ., a p• -� � ., "'`., 3' - .. �� �` - - � ��` � .p. : .r • _ • x • °a k v. rwoo w s� v r, e y r , J � COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS d DEPARTMENT OF ENVIRONMENTAL PROTECTION YO 4 TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL_ SYSTEM FORM PART A CERTIFICATION Property Address: 34 Merion Way, Cummaquid-Barnstable,MA i Owner's Name: Estate of Helen Richards Owner's Address: Bruce Richards 1 ► ��'• 41 frontier Road,Cos Cob Ct.,06807 w Date of Inspection: 01/232008 3 5 L��S' �n a C)I Name of Inspector:Reid C.Ellis Company Name:Ellis Brothers Const.Co. Mailing Address:23 Enterprise Road r Yarmouth Port,MA 02675 __j rn Telephone Number.508-362-6237 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 d maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to ion 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: C� Date: —'� P gn 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. 1 el Form 6/15/2000 P� Title 5 inspection T _ . Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 34 Merion Way,Cummaquid,MA Owner: Estate of Helen Richards Date of Inspection:01/23/2008 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ��IJ Y 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 h i the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replace or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. 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 r tank failure is imminent.System will pass inspection,if the existing tank is replaced with a complying septic tank a s approved by the Board of Health. *A metal septic tank will pass inspection if it is structw ally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is avail ible. ND explain: Observation of sewage backup or break out or gh static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box:System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is rem ved distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the.Board of Healtl broken pipe(s)are placed obstruction is removed ND explain: ' 2 , 2 Title 5 inspection Form 6/15/2000 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 34 Merion Way,Cummaquid,MA Owner: Estate of Helen Richards Date of Inspection:01/23/2008 C. Further Evaluation is Required by the Board of ealth: Conditions exist which require further evaluatio by the Board of Health in order_to.determine if the system is failing to protect public health,safety or the environn ent I 1. System will pass unless Board of Health deter mines in accordance with 310 CMR 15.303(l)(b)that the system is not functioning in a manner which v rill protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surf ice water Cesspool or privy is within 50 feet of a bon lering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(al ld Public Water Supplier,if any)determines that the system is functioning in a manner that tprotects t public health,safety and environment: , The system has a septic tank and soil absoiT tion system(SAS)and the SAS is within 100 feet of a sur_face water supply or tributary to a surface w r supply. The system has a septic tank and SAS and t Le SAS is within a Zone 1 of a public water supply.. _ The system has a septic tank and SAS and t ie SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and a SAS is less than 100 feet but 50 feet or more from a . private water supply well**.Method used to detx rmine distance **This system passes if the well water analysis,1 erformed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicate that the well is free from pollution from that facility and ' the presence of ammonia nitrogen and nitrate gen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analyi is must be attached to this fdrm. 3. Other: 3 Title 5 Insoection Form 6/15/2000 IF Page 4 of 11 . OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A w CERTIFICATION(continued) Property Address: 34 Merion.Way,Cummaquid,µMA' Owner:Helen Richards Date of Inspection:Ol/23/2008 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes Vac lcupofsewage into facility or system component due to overloaded or clogged SAS or cesspool charge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or e spool uid depth in cesspool is less than 6"below invert or available volume is less than'/z day flow uired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped y portion of the SAS,cesspool or privy is below high ground water elevation. y portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface w er supply. _ portion of a cesspool or privy is within a Zone 1 of a public well. Z 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria ,�. are triggered.A copy of the analysis must be attached to this form.] (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 se e a facility with a design flow of 10,000 gpd to 15,000 gpd- You must indicate either"yes"or"no"to each of the f flowing: . (The following criteria apply to large systems in addition to the criteria above) yes no — — the system is within 400 feet of a surface.drir g 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 a ea(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 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, 4 Title 5 insnection Form 6/15/2000 Page 5 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 34 Merion Way,Cummaquid,Ma Owner: Estate of Helen Richards Date of Inspection:01/23t2008 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Ye No Ping 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? 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 af07fles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? of _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal,systems? a The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Y 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(3)(b)] 5 5 Title 5 Inspection Form 6/15/2000 r Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 34 Merion Way,Cummaquid,Ma Owner: Estate of Helen Richards Date of Inspection: 01/23/2008 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 33*0 Number of current residents: V , Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(y or no).:V yes separate inspection required) Laundry system inspected(ye r no) Seasonal use:(yes or no): ©s -s ('�'K 01- p-' 30 Water meter readings,if avP' able(last 2 years usage(gpd)). Sump pump(yes or no):W0 Last date of occupancy:.a O 4 t / Y COMMERCIAL/INDUSTRIAL ,v Type of establishment: Design flow(based on 310 CMR 15.203): d Basis of design flow(seats/persons/sgf3 etc.): _ Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yejono): Water meter readings,.if available: Last date of occupancy/use:OTHER(describe): � GENERAL INFORMATION " Pumping Records Source of information: /s✓ ' Was system pumped as part oe inspection(yes or no): / If yes,volume pumped:_,? gallons--How w uantity pumped determined? Reason for pumping: T 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) ' 4 _Tight tank _Attach a copy of the DEP approval —Other(describe): Approx' age o�All components; to installed(if known)and.so of inPo, ort`o V406R£1 Cti/(�/ — Were sewage odors detected when arriving at the site(yes or no): g . 6 6. , Title S insnection Form 6/15/2000 i Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 34 Merion Way,Cummaquid,MA Owner: Estate of Helen Richards Date of Inspection: 01/23/2008 BUILDING SEWER(locate on site plan) Depth below grade: 7 Materials of construction:_cast iron V 40 PVC!other(ex lain)a Distance from private water supply well or suction line: �' P Comments(on coji ition f joints,venting,evidence of leak ale,etc.): /1 t ,Y { SEPTIC TANK: Qi ocate on site plan) j t�� G fl Depth below grade: .1 Material of construdd7o_n. 1J 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: Sludge depth: 0 Distance from top of sludge to bottom of outlet tee or baffle: (7 Scum thickness: 0 Distance from top of scum to top of outlet tee or baffle: C7 Distance from bottom of scum to bottom of utletee or baffle How were dimensions determined: Comments(on pumping recommenaons,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.). _ �Ae.e Vjz s j , site GREASE TRAP: (locate on plan) Depth below grade: Material of construction:_concrete_metal_ erglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or ba e: Distance from bottom of scum to bottom of outlet t or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 34 Merion Way,Cummaquid,MA Owner:Estate of Helen Richards Date of Inspection: 01/23/2008' tank must be um of' ction ocate on site plan) TIGHT or HOLDING TANK: ( us p p inspe �1 p ) Depth below grade: Material of construction: concrete metal fiber lass polyethylene other(explain): Dimensions: " Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.):. A'000V �c 490"V 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.): { CHAMBER: ocate on site plan) PUMP (1 P � Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pi mps and appurtenances,etc.): �i. 8 Title S IncnPCtinn Form 6/15/2000 • - .. 8 - - Page 9 of 11 OFFICIAL INSPECTION,FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:34 Merion Way, Cummaquid,MA Owner:Estate of Helen Richards Date of Inspection:OWU2008 ! ✓� SOIL ABSORPTION SYSTEM SAS( ) (locate on site plan,excavation not required) If SAS not located explain why: T Pe - Y i✓� leaching pits,number. ~ �1eZ.J�✓�./✓} ?,x� leaching chambers,number: dorms �l~ ;J Gr leaching galleries,number: ` ��� a, leaching trenches,number,length: Q leaching fields,number,dimensions: . overflow cesspool,number: A7 innovative/alternative system Type/nameJ of technology: °� _ t.0 Comments(note condition of soil,signs of hydraulic fail leyel of pontling,damp soil concUtion of vegetation, A.&%`.sue -r ree, XA1 j A.'rqW�+ o p CESSPOOLS: (cesspool must be pumped 1part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraul c failure,level of ponding,condition of vegetation,etc.): 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.): 9 9 Title 5 Inspection Form 6/15/2000 - Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 34 Merion Way,Cummaquid,MA Owner: Estate of Helen Richards ` Date of Inspection: 01/23/2008 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. lot IV 1 , ftov , ----------------- aV . y �- Lh p 10 1 �d 10 Tit1YP S Imnection Form 6/15/2000 i Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . SYSTEM INFORMATION(continued) Property Address: 34 Merion Way,Cummaquid,MA 1 Owner. Estate of Helen Richards Date of Inspection: 01/23/2008 SITE EXAM Slope Surface water Check cellarfi� ✓ /,�/'�' Shallow wells Estimated depth to ground waw4ff—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: Observed site(abutting property/observation hole within 150 feet of SAS) C ecked with local Board of Health-explain: hecked with local excavators,installers-(attach documentation) Accessed USGS database-explain You mast describe how you established the high ground water elevation: r9 IF - � Ole/Ag _.._ �, =9 ....... - 11 Title 5 Incnechon Form 6/15/2000 11 I Town of Barnstable OF THE Tp� y�P`• ti� Regulatory.Services BARNSTABM 1 Thomas F.Geiler, Director. 9� ' 9 g AjED3.iA Public Health .Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable.Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system in'the future nor does this Division agree with any technical observation s and interpretations contained within this report. - In addition, by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual ` number of bedrooms approved at a particular property would-be listed on the"Disposal Work Construction Permit". If you should have any questions regarding this report, please contact the certified Septic System Inspector who conducted the inspection. } TOWN OF BARNSTABLE LOCATION 3 I"4 m /ir4'1 wc ,, SEWAGE# VILLAGE ASSESSOR'S MAP&PARCEL INS N E&PHONE NO. ��►S�i�l�+ ���5 � �� ��°i f�O� SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) NO.OF BEDROOMS OWNER PLATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching.facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY gv i7o3 I' j , 9 •�` _.d.D•:! - 3:��.'(^'i3�' �'•r + r JI�,rF.'J.^t!`! � 'yam F r z,,V lo a I A"Of 61L _ - - - --- - - - -- - r C 32 0. � y v �4 y� -�- -- ------- - - -- ---/_ 47ti i �� — _ J —.■- — — �� -J, __ _� . . __ —__�..__..��^i - __ ..� __._. , �.. i � /r.n��� � 1 '} 7 _. i t 71 No..----eF��.. ................. . 2V.0 � � THE COMMONWEALTH OF MASSACHUSETTS U N BOARD OF HEALTH _.:... _ UL. ........OF............ ....... -.-..... tration -fur Ui_q vital Workii Cnl nstrurtiou Vrruift pplication is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal Syst at ----- tion- dd ess orVJ Own A Installer Address d Type of Buildiin Size Lot..�_.�L>� __Iq. feet U Dwelling No. of Bedrooms---------�--- -_--.-_.Expansion Attic ( ) Garbage Grinder ( ) Other—Type T e of Building ---------------------------- No. of ersons...___._._._._.._...._..._- p�., YP g p Showers ( ) — Cafeteria ( ) W Other fixtures ----- . --•-•-•-• W Design Flow_ ______________......t ._.__.�-----_gallons per person per day. Total daily flow....._ ....�..gallonti. WSeptic "hank -Liquid capacity/V-1_1gallons Length................ Width------------.-.. Diameter------.----.-_-- Depth-----------.---- x Disposal Trench—No_____________________ Width. _____ ___ t 1 th_: TWtoW4einrea_:� -- N� Seepage Pit No_______ ___________ Diameter_ .. p �- ---•-•-- e t ow m t--- --------._ trea------ --- ---- c�-rr.�W Z Other Distribution box ( ) Dosing tank ( ) _ , C _ Percolation Test Results Performed by------ - -----------------------•------------------------••--------------- Date-------------------------- ------------- Test Pit No. 1________________minutes per inch Depth of Test Pit.................... Depth to ground water........................ f� Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water--.----..-------_-.____- ------- ------ •• -- . Description of Soil-- - ----------- - A... .....- _'_Y/---- --- --------- .... ... x - = ------------------------ ---- U Nature of Repairs or Alterations—Answer when applicable----------------------------------------------------------------------------------------------_ -------------------------------------------------•----------•--•-----------------------------_---•-•-•-----•---------------_-----•• --•-------------------•----•---•--••-•-----------------------_------ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI 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 Ward of heap / z3 Date / Application Approved BY•- ------ ---•- . ------. --••---• - -----. T e Application Disapproved for the following reasons:................................................................................................................ -----•----------------•---------•---------._...---•-••-----------••-•--------•----•••--••----I-•-------------------------•-••-------•--•-----------•------------•------------•--••-••---•-----------•--- Date PermitNo......................................................... Issued........................................................ Date No. !" Fps............................ _ I ` THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH , Apjilirtttion -for Mtipu�ttl Works C owitrurtion Vrrutit Application is hereby made for a Permit to Construct (/-*)"`or Repair ( ) an Individual Sewage Disposal Syst t , -- ---- ----- � • Lo ion- d ss '�+- �/or t�/N�. /✓K�� '/� Own Address iInstaller Address �''✓ Q Type"of Buildi Size Lot_-� �S _.5q. feet Dwelling No. of Bedrooms-'," -------- Attic ( ) Garb ge Grinder '( ) aOther—Type of Building ......................... No. of persons-------_:.................... Showers ( ) — Cafeteria I. Other,fixtures -------------------------------------------------- ------------------------ Q W Design Flow_ .__:___1____ -_-allons per person per day. Total daily flow------- . . .__�.gallons. WSeptic Tank Liquid capacity, gallons'- Length------------_- Width..___... ------ Diameter................ Depth_--.--_--...: x Disposal Trench—Igo....----- Wi�,i�-c-.-�---.-,------ = h_ � #t &nl ea.)}Seepage Pit No-__.�___ ____________ Diameter_ _y-�!:�'._:_' epth ow m t___ _� re. -zOther Distribution box ( ) Dosing tank � """ • aPercolation Test Results Performed by-------------------------------------------------------------------------- Date----- ------------------------------ - ,� Test Pit No. 1_-_•__________minutes per inch Depth;of Test_Pit.................... Depth to ground water.- .-.-__-.-_.._ Test.Pit No. 2__________......minutes per inch-•-.Depth` of,,.Test-Pit...__...._.____...._ Depth to round water------ - --- _-- --- - O Desc iption of Soil--- - ••-•-.... •--- -- • • -.-- -• • - ------ ° �- --------j-------------------•----••---•--•---•-----•--- --------------------------------------� �. -------------------------------------------- V Nature of Repairs or Alterations—Answer when applicable______________________________________________________________________________________________ ------------------------=--------------------------------•---------------------------------------------------.------------------------------------------------------------------------- = ........... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the systern in operation until a Certificate of Compliance has been issue by the b and o healt �3- gned-- ---• -• ......... . ., --------•-•------/-•-•-•----•'Date.............. Application Approved By_'.'- _:,... --_-•- _----• - i--• - //z 7 D e Application Disapproved for the following reasons:................................................................................................................. Date PermitNo.....................................•------------------- Issued•-•-._....--------------------::........................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF ALTH .. ..:.. OF_................ �,d./L�'"+?.^^�-........�:...... 011rrtifiratr of (11implittitrr •THIS I TT E TI ge Disposal System constructed ) or Repaired ( ) by---•---- --- -•------ •----F711 - -•-•-- ------------•------------------------------••--•----••-----••--••- • t er. at...... •• ....... .• .. . •----- :. has been installed in accordance with the pr isions of Article XI of The State Sanitary Code as descr'bed i the application for-Disposal Works Construction Permit No_________________2" .__.___.._•_. dated.... _.- . t _____ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONS RUED-AS A G�9ARANTEE TH AT AT THE Y SYSTEM W L U , CTION SATISFACTORY. F� � - f DATE. •---------------------- Inspector L ---" ------ THE COMMONWEALTH OF MASSACHUSETTS BOARD- Of HEAL TF ... O F....:.....4� �:...-.... i No.. 7 - � ^ /f FEE..../V........... 21 1 i rr it Permissio s ereby granted____....__. o - --------------- ......------ to Constru ( or/;.:_epair ( an Individual ewage ]his S tem at No: f r ----- . 'G ' %'V' Street / as shown''on the application for Disposal Works Constructio P rmi ; ' '.__ Dated,_� s7_�,f•___.____ y ` 1 DATE....... -- 1._ *..----i---•----..... ••..--•------••-•.... Boar r f d of FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS O L0CA.,,TION ` ' SEWAGE PERMIT NO. PILLAGE - e ALL ERi'S nNAMnE ADDRESS 414 4711 Q U I L D E R OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED_ r ����y� � � ` - _ - _ 6�` a, , , _� � � � � � ! � v / � t � 1 �3_ �. � � �`� / ' � `1 � ,� .r ...-- . � • ' Y`~ No.... Fini :.):-r-��.� THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ...........7cv ...............OF..... `?� t/ce�L..�. ............................................. Appliratinn for Mqvniial lVarkii Tonstrur#inn amit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: 3y /J9drroH ��y c�, � •� --.--•------ f ocati A dress�e y or Lot No - --- �. ._................ � r...........f� -- Owner /Add a ----•------------------T0 r_:a..---..R.,2r,�f. ................................... ..�S o. '��7 7 . ..... /1.................................... Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms.........5..............................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons__-.____-__-__-_-_--___-__- Showers ( ) — Cafeteria ( ) a 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. Seepage Pit No--_---------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ aTest 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........................ �+ ----------------------------------------------------------- ----------------------------------------- ------------ -.... .------------- -..... -•............. ..... 0 Description of Soil.............................................................---...----•-------.......-----------------•----•--•-------------------------------•--•-----------------•--- ....................................................... ---------------------------------•---------------------------------------------------------- ----------------------------- ._.............. U Nature of Repairs or Alterations—Answer when applicable__._ y.f �._._oLi?r- Ow ---•---••-----•- --------••-•--••---•-•----••-•••-•---•-----•--••••-•-•......------•---------------•---••------•-•-•-----••---•--•------•--------------•-•---•.._....-------•--••------........---...... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System.in accordance with the provisions of iITLU 5 of the State Sanitary Code The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be issu by the board of he4lth. Signed..... -------•--••---�-4% - 3 of XF- .. +� Date Application Approved By................. - F7 ' ,`.��"a..�'-:- ................ Date Application Disapproved for the following reasons:.............................................................................................................. ....................•-----------•........................._........---........---------................--............................•......•.....•--•-•------------------------.... ...----------- Date PermitNo. ..................--.... Issued........................................................ Date f(. THE COMMONWEALTH OF MASSACHUSETTS r BOA RD��rrOF HEALTH ---........A _.:?..............OF.....2v-: st.4[. ........------...._.._.._._...................----- Appliratiun for Bispuutt1 Works Tonsteurtiun Frrniit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ................_.......» ... _ t�GV..... :Gvt;� ............................-•--------- .................. - - ............---.......... /L,/ Locatipo�� Address or Lot No. .................[.I_d�I y.... :.._1.1.. .:!_ !f! f..._........._.._......_.... . ....... y_ y(1-/t?b? ...... ow er /Addre W .......................�Q.7.rt......J?:.: l.!.l!u........................._..._...... _../._5!7 ll�y�7-n T S T....!f � Installer Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms........._ee...........:....................Expansion Attic ( ) Garbage Grinder ( ) Other—Type T e of Building No, of persons............................ Showers A.1 YP g --------•---------------•-•• P ( ) — Cafeteria ( ) a, 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........................................ aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water.._.................._.. f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ �+ ................-............................................................................................................................................ 0 Description of Soil...................................................................................................................................................•........---......... W U --...-••---•-•.................................................•---•-------••-.._...•--........-----•---•--•••.......---•--•-----......•--•... --............_..-•-----•--.....-------•....._...... W U Nature of Repairs or Alterations—Answer when applicable_.....ry. `_.........o�.F''.���w ..--- •-•-•---•----••••-------------•----------••----•--•----•••-•--•--•--•-•.....--•-------••--------...-----•-------•-••----------•-•-------------•-••-----------------•----•-...•----•---.................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System.in accordance with the provisions of T IT LE 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bFissu by the board of h lth. /,"/Signed.... Y...... ... ......•---•......--•---...........---. ..�.....-•-•--......--..._.... Date Application Approved By................. r .... :.w-e - -:`t Date Application Disapproved for the following reasons:..........................................................................................................--- ................•-••--••••---•-•--••--••-•-•----•••-•--•••-•...•-•-----•••------.._..•-•-----•-•-•-•---•.I---•-•--..._.......----•••-----•••-••-•-.....-------•-•-----............---......•---........_ Date n Permit No.......6.$ ..3 .<�..JK..............••----...._ Issued......................................................» Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............/..•f"LG.t. ............OF....... ......................... ............ (Inrtif utttr of faunipliatta THIS IS TO CERITIFY, That th tndividual Sewage Disposal System constructed ( ) or Repaired ( ) by......... -=,.jj�,:=z........ .. ..::.......•-•-••-•--------•-•---•--------------.....----•-------•---------•-.....--•-------.........------•............._ Installer at..................Z--�........ .............1,.�.�c. r-a 'r-•----••-------•-----------•---•-------••----__-_---•------•-••--- has been installed in accordance with th4rovisions of TITIF 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.......?.2�.:_�._j....._. dated.............. .............................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE... ..-....1. .. . --- ,......... Inspector---•----------------�.:. ............................................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No.... Disposal Works Tunstrudiun ran it Permission is hereby granted.............. .......»»... to Construct ( ) or Repair ( an Individual Sewage Disposal System at No.................. - t�i .. �� r .. ....... ..�C:_:Lc-ya......... c1................. d::.......____.r..._•___.........._..............._.._................_..................... Street �o as shown on the application for Disposal Wor s Construction Permit No._ ,k,Jj ? Dated.......................................... ................................... .._.....---•-•-•-••---............-----•_..-•---. C � DATE.................... = = .............................. Board of Health FORM 1255 A. M. SULKIN, INC., BOSTON