HomeMy WebLinkAbout0025 RYDER LANE - Health 25 Ryder Lane
Barnstable P
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III
TROY WILLIAMS P 3
SEPTIC INSPECTIONS
Certified by MA Department of Environmental Protection - 00
19 Hummel Drive _ ��� RE�El ED
South Dennis, MA 02660
�-\ COMMONWEALTH OF MASSACHUSE.M'S APR 2 7 2003
BARNSTABLE
EXECLITIVF, OFFICE OF ENVIRONMENTAL P` Or- H EPT
D .
DEPARTMENT OF FNVIRONMEN'rAL PROTECTION
"TITLE 5
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SVST'F.M FORM
PART.A
CERTIFICATION
ProperIN Address: 25 Ryder Lane
Cummaquid,MA .
Ossner's Name: Kevin Curtin&Susan Jeghelian
Owner's Address: P.O.)3ox 491
Cummaquid,MA 02637 0
Date of Inspection: April 15,2003 O
Name of Inspector: Troy M.Williams �.
Company Name: Troy Williams Septic Inspections
Mailing Address: 19 Hummel Drive
South Dennis,MA 02660
Telephone Number: (508)385-1300
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
appros ed system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The systenv
Passes
Conditionally Passes
Needs Further Evaluation by the Local npptoving Authorn)
Fails
Inspector's Signature: � � Date: Y/i s /o.3
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of I lealth 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
Although system meets the minimum requirements set forth by the Massachusetts Department of
Environmental Protection,certification is not to be construed as a guarantee of future working condition
of system,piping or components. This Inspection represents the conditions of the system on the Date of
Inepectlon noted above.
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. l his inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 pa PC I of II
I
Page 2 of I l
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
25 Ryder Lane
Owner: Cummaquid,MA
Date of Inspection: Kevin Curtin&Susan Jeghelian
April 15,2003
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 CNIR
13.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
i
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to b eplaced or
repaired. The system, upon completion of the replacement or repair,as approved by the Boar f Health,will pass.
Answer yes. no or not determined(Y,N,ND)in the_ for the following statement . f"not determined"please
explain.
The septic tank is metal and over 20 years old* or the septic tank(w ether metal or not)is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is ' minent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved b e Board of Health.
•A metal septic tank will pass inspection if it is structurally soun not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled uneven distribution box. System will pass inspection if(with
approval of Board of Health):
b en pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The syste equired pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspectio f(with approval of the Board of Health):
broken pipe(s)are teplaced
obstruction is removed
ND explain:
A
rR:f•t,.
2
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued) .
Property Address:
Owner:
25 Ryder Lane
Cummaquid,MA
Date of Inspection: Kevin Curtin&Susan Jeghelian
C. Further Evaluattohris Requred 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. Sy stem will pass unless Board of Health determines in accordance with 310 CMR 15.3030) that the
system is not functioning in a manner which will protect public health,safety and the env' onment:
_ 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 m
2. System will fail unless the Board of Health(and Public Water upplier,if any)determines that the
system is functioning in a manner that protects the public heal ,safety and environment:
The system has a septic tank and soil absorption sy em(SAS)and the SAS is within 100 feet of a
surface eater supply or tributary to a surface water s ply.
The system has a septic tank and SAS the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and S and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tan , and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". ethod used to determine distance
"This system passes ' he well water analysis, performed at a DEP certified laboratory, for coliform
bacteria and volati organic compounds indicates that the well is free from pollution from that facility and
the presence o monia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure crit are triggered.A copy of the analysis must be attached to this form.
3. Other:
y
E � t �
fy
3 ,
Page 4 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 25 Ryder Lane
Cummaquid,MA
Owner: Kevin Curtin&Susan Jeghelian
Date of Inspection: April 15,2003
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
Discharge 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
cesspool -
- a//i Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow
Required pumping more than 4 times in the last year N T 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.
— /um Any portion of a cesspool or privy is within 50 feet of a private water supply well.
-ti 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
nitrogea and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.)
No (Yes/No)The system fails. 1 have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303. therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a des' n now of 10,000 gpd to 15,000
gpd•
You must indicate either"'yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the trite above)
yes no
— _ the system is within 400 feet of a surface drink water supply
_ the system is within 200 feet of a.tribu to a surface drinking water supply
the system is located in a nitro sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone 11 of a public water s ly well
If you have answered."yes"t y question in Section E the system is considered a significant threat,or answered
"yes"In Section D 4 ove large system has failed.The owner or operator of any large system considered a
signtlCant threat uh¢e ection E or failed under Section D shall upgrade the system in accordance with 310 CN�R
15.304.The syste wner should contact the appropriate region# office of the Department. ..
4
Page 5 of I 1
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
25 Ryder Lane
Owner: Cummaquid,MA
Date of Inspection: Kevin Curtin&Susan Jeghelian
April 15,2003
Check if the following have been done.You must indicate"yes"or"no"as to each of the followine•
Yes No
P..;nI;ing information was provided by the owner. occupant, or Buard 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)
_�Z _ Was the facility or dwelling inspected for signs of sewage back up?
Was the site inspected for signs of break out?
✓ Were all system components,excluding the SAS, located on site?
Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
_ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems ?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
✓ _ Existing information. Fur 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)]
j
' ,Kra ";t u•
Page 6 of l l
OFFICIAL INSPECTION.FO
RM RM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
25 Ryder Lane
Owner: Cummaquid,MA
Date of inspection: Kevin Curtin&Susan Jeghelian
April 15,2003 FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): `/ Number of bedrooms(actual): y
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x k of bedrooms): 99a
Number of current residents: 3
Does residence have a garbage grinder(yes or no):nio
Is laundn on a separate sewage system (yes or no)'wa separate inspection required]
Laundry system inspected(yes or no); AM
Seasonal use: (yes or no):
Water meter readings, if available(last 2 years usage(gpd)): 0 1-o�= y, , ��,�s a Z-'; = 7'7
Sump pump(yes or no): N ov f '
Last date of occupancy: i
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): _gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):—
Industrial waste holding tank present(yes or no): _
Non-sanitary waste discharged to the Title 5 system es or no):_
Water meter readings, if available: _
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Scnirceofinformation-. t—,k
Was system pumped as pan of the inspection(yes or no): nio
If yes, volume pumped: gallons-- Now was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
✓Septic tank,distribution box,soil absorption system
_Single cesspool
_Overflow cesspool
_Privy
—Shared system(yes or no)(if yes,attach previous inspection records, if any)
_Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
i
_Tight tank _Attach a copy of the DEP approval
Other(describe):.
2roximate age of all components. date installed(if known)and source of information:
Were sewage odors detected when arriving at the site(yes or no): ,vo
Page 7 of 1 I
OFFICIAL INSPECTION FORM.—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
25 Ryder Lane
Owner: Cummaquid,MA
Date of Inspection: Kevin Curtin&Susan Jeghelian
April 15,2003
BUILDING SEWER(locate on site plan)
Depth belu�s grade: 18"4
Materials of construction: _cast iron Z40 PVC___other(explain):
Dktancr fron. private water supply well or suction line: ,c//�
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: (locate on site plan)
Depth below grade: I '
Material of construction:/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: _ S ' 9 'k 4 ' /eou 5
Sludge depth: _ S" _
Distance from top of sludge to bottom of outlet tee or baffle: —9
Scum thickness: --T—A I Ny
Distance from top of scum to top of outlet tee or baffle: (°
Distance from bottom of scum to bottom of outlet tee or baffle:
blow were dimensions determined: O,.fl 6 _
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
/as related to outlet invert,evidence of leakage,etc.): / -
l..�L✓^_'.t.�__u J_ t w. .'+"t i�+�. �'V C� yh�'L.'.r- Tt.i R�4 r i "`� t✓" _ i l�J
t. / �g�ti c..a O /_' C H 1 t G.>1t- r N.c�✓h.._c,. .._�1L_—1 �.s`.a. !-+� .. I� ,...i of 1 h u f n y1.c��
6 Ile,
GREASE TRAP:_(locate on site plan)
Depth below grade:_
Material of construction:_concrete_metal_fiberglass—p ethylene_other
(explain): _
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet to or baffle:
Date of last pumping:
Comments(on pumping recommendations,in and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leak ,etc.):
7
Page 8 of 1 I
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
25 Ryder Lane
Owner: Cummaquid,MA
Date of Inspection:Kevin Curtin&Susan Jeghelian
April 15,2003
TIGHT or HOLDING TANK: (tank must be pumped at time of' spection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal_fiber ss_polyethylene other(exptain):
Dimensions:
Capacity: gallons.
Design Flu%s. gallons/day
Alarm present(yes or no):
Alarm level: Alarm in work' order(yes or no):
Date of last pumping:
Comments(condition of alarm float switches,etc.):
DISTRIBUTION BOX: IV/ (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.):
PUMP CHAMBER: (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condi ' n of pumps and appurtenances,etc.):
n
gr
- +'a<
Page 9 of I 1
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
25 Ryder Lane
Owner: Cummaquid,MA
Date of Inspection: Kevin Curtin&Susan Jeghelian
April 15,2003
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why,
Type
leaching pits, number:_
_�✓ leaching chambers, number:
leaching galleries,number:
leaching trenches,number, length: _
leaching fields,number, dimensions: _
overflow cesspool,number:
innovative/altemative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure, level of ponding, damp soil,condition of vegetation,
etc_.): // IA
ln� '►-.._ �.e.ice / 1
(LF ti Sic<_�t�; _ �-1�,�. � -fU ..ti .� .�.J. r„7 1,r!✓..,-,/ l: c_ � �✓rs, i�- ��...1�/.t-•,.� .ti 7�. /!Jc�;.f=1r .f1 I �+.,..� � J
�•_� : )•-. t�/ 1::. ,,,,�.�:-j �.- � .J�r'a. . I�r� :.,r ..�[�_✓✓u�,.f.`_ �,� .�y � � �` /^� r/j �;yf�p�—fip!•N:_.
CESSPOOLS: (cesspool must be pumped as part of inspection)(lo to on site plan) o
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 ydraulic 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 ure, level of ponding,condition of vegetation,etc.):
f W.
9 A
Page 10 of I l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 25 Ryder Lane
Cummaquid,MA
Owner: Kevin Curtin&Susan Jeghelian
Date of Inspection: April 15,2003
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.
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Page I 1 of 1
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
25 Ryder Lane
Owner: Cummaquid,MA
Date of lnspection: Kevin Curtin&Susan Jeghelian
April 15,2003
SITE EXAM
Slope
Surface water
Check cellar ✓
Shallow wells
Estimated depth to ground water I'7_I feet Adjustcd high ground water elevation — feet
Please indicate(check)all methods used to determine the high ground %kater 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)
Checked with local Board of Health-explain: __
Checked with local excavators, installers-(attach do cutnentation)
_Accessed USGSdatagase-explain: 414
You must describe how you established the high ground water elevation:`
----- - - --..--_..._.�',✓ ►-.�.n t /.Ju-✓a -lam 6 1.� ,.,,
4
iZ. s i7. Y '
r�N -0vwL —
l.y ,
This report has been prepared and the system inspected as of the date of inspection. This report is not a
warranty or guarantee that the system will function properly in the future. There have been no warranties or
guarantees, either expressed,written or implied,relating to the system,the inspection and/or this report.
11
v
No.-A...._...._.....:. Fps...... s.. ......
THE COMMONWEALTH OF MASSACHUSETTS
-BOAR® OF HEALT
Appliration for Uiopusttl Works Tongtrurtinn truti#
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at• j
...................... ....... ............................................................. -•--...---...---•-------'....-'-'-------'... .........................................
t I- dss of N �
..!.1 _...................... ............................................. .............
a -
� A,•
7._.._ _.._C31 5......�L.r � _ f'-_ /d/�r "r•- _ ..-_ // ....................
S Address n .....I ...-.. W�1/V
Installer Address a(d�
UType of Building `W Size Lot....................... feet
Dwelling—No. of Bedrooms...........................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
dOther fixtures -------------------------------------------•---------------•••-----•--•-••-••----•---•-•-----•-•----•......----•--------••••-•. .:._..
W Design Flow..............................,,,,-,,,--gallons per person per day. Total daily flow...................................'..._.___gallons.
Septi Taank�� i i€Lec�pacity_.___._.___.gallons Length................ Width................ Diameter._._____.___._._ Depth................
lowx —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 ( )
a -Percolation Test Results Performed by.......................................=.................................. Date.....................
...................
Test Pit No. ]................minutes per inch Depth of Test Pit.................... Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
04 ••-----•------••••---••-•-•••••--•---•------•---....-•.............................."-'•-'---------..........................................................
0 Description of Soil.............................. . .
u-- -------------
�i ..LiGLeI- J'7/!c /C -- _ �=GOw /F�-JS e`�S
------------------------•--•-- Gifu!r!---•---•---•--•-`--------r ---•--•C�dG�li-----------�--............---•,G -......---�GG............................
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 iITI,r 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 1he board of health.
Signed..... ..............Cp �o7�i
•-•.........---.--
Date
ApplicationApproved BY I� = --------•-----•----------•--•----•------------------•--------- ............... --• —---�--
Date
Application Disapproved for the following reasons---------------------•-••---••---•-------•-------------------••--------------=-------- •---•............_
.............•------..................---•-------•-'•---------------------...----.....--------'•----•---••----•-•--••••---•-•-••----•-...-••-------••-•--•••-•----•----•----•--••-••------••---....•----
Permit No...P y: J 6 Issued---------------------------
Date
Date
L 0 C;A_T ION SEWAGE PERMIT NO.
VILLAGE
(,,,v w-
INSTALLER'S NAME a ADDRESS
Lett Co 57
R UILDER 0 OWNER
TsprV 11� ® 4Ze1 QNs.
i
DA T E PERMIT I S S U E D
DATE . r° COMPLIANCE ISSUED
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THE COMMONWEALTH OF MASSACHUSETTS
Lj
-
.------BOARD OF !—MEALY
.......... _V/,.t/2V............OF............. ,Q ,. _._.....
:;� lint i�an fur Disvaaal Works Tonstrurtuan jhrmff
Application''is hereby made for a Permit to Construct { ) or Repair ( ) an Individuah`Sewag eDisposal
System at: ,
.......................... •-
i Location-Address
--� or Lot No
Adar ess
/
Installer v
• (� Address
Type of Building Size Lot......................!_...Sq. feet
..� � Dwelling No. of Bedrooms.........••-.........................Expansion Attic
( ) Garbage Grinder ( )
04, Other—Type of Building •---_-.•-__-_---•.-.---••_ No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures _.........................................................................
Design Flow....................... .............gallons per person per day. Total daily flow............................................gallons.
g Septic Tank—Liquid cjtpacit .d...G.gallons . Length................ Width...... Diameter---------------- Depth................
: . FFl
x D — o. ..__....__41.... Width.................... Total Length.................... Total leaching area....................sq. ft.
` Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area................ ft.
Z Other Distribution box ( ; ) Dosing tank ( )
~' Percolation Test Results Performed by--..., --=•-•••--••-•---••-----••••------------------- Date---------- :.
►-7.'
:.� Test Pit No. I...........:....minutes per inch Depth of Test Pit..................... Depth to ground water.........................
G=I ,Test Pit, No. 2.................minutes per, Inch, Depth of. Test Pit.. e1.-_-------- Depth to ground water........................ '
F
x ••••
O Descriprion of Soil r �,
II}!7¢ �lGGGt __l..Cr. -/G ' d� rGG[u .___ .. /!^G�J_� •G- _.. y
V ............. ....... S
r�It ..!'P1&GG...�---•-- r :-- r - ....
r-V Nature of Repairs or Alterations—Answer when.applica
Agreement
The undersigned agree& to install 'the aforedescribed Individual Sewage Disposal System in accordance with.
the provisions of TITLE .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 board of health:_,
;.
f _ : ..a.._ . ----__ y
--
--
Date
Application Approved By........... �� =•/t - .. _: =----=------• = 7' •!P`�/ .
i. Date
Application Disapproved for the wing reasons------------------------••--•••--•-•-•-••••--:..........--••-
Date
Permit No...7u:t... ------- Issued_......................................................
Date
THE`'dOMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH /-4�+u,,� Cy/ X4�_Irt
Tlr'.r�. r .........OF.. fig. .
%rrtifiratr of Tomplianrr.......................................
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( : r
by.......... .ram!fkX;.... .6k4lZI-----•....................•-••--------•---------------.......................................................
Installer _ _
at...................
- 4'k ................
s '--
has been installed in accordance. with the provisions of TITLE 5 of The State Sanitary Code asYdescribed in;the '
application for Disposal WorksJConstruction Permit N _.?............. dated` _�._S,Tli1a "._1.�T.- 9�
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT`TWE
SYSTEM WI FU CTION SATISFACTORY.
DATE... ,/ :: :: ;< ` Inspector....
= ...
THE COMMONWEALTH OF MASSACHUSETTS
BOARD �tO+F `I-rEALTH
o ............... �'.L`...... ...OF......._... .R.!`f tk'bt C b
...................... r
No.....r ��. ~
-•----••- FEE...e�,el.•3*X"---- i
Permission is hereby granted............1,. '!1 k ( •-------••L'GG/J
...........................•_•••
to Construct ( ) or.Repair ( ?) an Individual Sewage Disposal System
atNo.... . . .. ........... ` .........
Street
as shown on the application foryD,isposal Works CoiistrpctioW, Pierihit No.._A'_n! (Dated.....__ .�" ..............
Board of Health
DATE.............
�' Rl
FORM 1255 A. M. SULKIN, INC., BOSTON