327 Title 5 Application/Permits 1976, Report 2007 Owner
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
327 North Farms Road, Florence, MA 01062(Northampton, MA)
Property Address
CIO Bob Cook POB 73,Whately, MA 01093
Owner's Name
Northampton, MA(Florence)
City/Town
MA 01062 09.07.2007
State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.
A. General Information
Inspector:
Alan E.Weiss
Name of Inspector
Cold Spring Environmental Consultants Inc.
0
Company Name
350 Old Enfield Road
a
Company Address
Belchertown
City/Town
411323.5957
MA 01007
State Zip Code
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
9.7.2007
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.
WN6eao7pmYeIem.0ee6
Tine 5 gfld Inspection Form:S&fse Sewage D system•Page 1 of 15
•
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
327 North Farms Road, FLorence, MA 01062(Northampton, MA)
Property Address
CIO Bob Cook POB 73 , whately, MA 01093
Owner owners Name
information is Northampton, MA Florence MA 01062 09.07.2007
everyrequired for P (Florence)
every page. City/Town State >-0 Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. My failure criteria not evaluated are
indicated bebw.
Comments:
S,Tank level proper.Tank& Field are 30+years old. 1500 gal.S Tank was pumped, Inlet&Outlet
baffles were in place. D. box levels&stains were proper(New cover installed). No wet stained or
ponded areas. Disposal not Recommended.System not used since March 07.
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.
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 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.
ND Explain:
❑ 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
❑ obstruction is removed
Ntle5new07rwurreNaroh O&M
True 5 Mani c edion Fam.Subsist ace 5emp D 53Lan'Par 2 of 15
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
327 North Farms Road, FLorence, MA 01062(Northampton MA)
Property Address
CIO Bob Cook POB 73 ,Whatety, MA 01093
Owners Name
Northampton, MA(Florence) MA 01062 09.07.2007
City/rown State Zip Code Date of Inspection
B. Certification (cunt.)
B) System Conditionally Passes (cont.):
❑ 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 Health):
❑ broken pipe(s)are replaced
❑ obstruction is removed
ND Explain:
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:
tifeSr.0)f m1•OW05
❑ 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
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.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
Title 5 Official f ,Form.Sb.fg Sewage Disposal System•Page 3 0115
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
327 North Farms Road, FLorence, MA 01062(Northampton, MA)
Property Address
C/O Bob Cook POB 73, whately, MA 01093
Owner's Name
Northampton, MA(Florence) MA 01062 09.07.2007
City/Town State Zip Code Date of Inspection
B. Certification (cunt)
C) Further Evaluation is Required by the Board of Health(cont.):
❑ 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 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
Liar x07pas(eYlnm•06./06
❑ ® 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
❑ ® 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 NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® My 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.
The somas MryecMo Fpm'.S irla2 Sewage OtSPoW system•Page 4 f 15
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
327 North Farms Road, FLorence, MA 01062(Northampton, MA)
Property Address
C/O Bob Cook POB 73 ,Whately, MA 01093
Owner's Name
Northampton, MA(Florence) MA 01062 09.07.2007
CityfTown State Zip Code Date of Inspection
B. Certification (cant.)
D) System Failure Criteria Applicable to All Systems(cunt.):
Yes No
❑ Z Any portion of a cesspool or privy is within a Zone 1 of a public well
❑ Z Any portion of a cesspool or privy is within 50 feet of a private water supply well
❑ Z 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 conform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.)
❑ The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000g pd.
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.
r.
❑ Z
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.
For large systems, you must indicate either yes or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes°to any question in Section E the system is considered a significant threat,
or answered"yes"in Section D 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.
bte&'e.orpesrxeam•00106
Me 5 0?0'Iispemai Wow ststip Sewage Disposal System•Page 5 of 15
Owner
information is
required for
every Page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
327 North Farms Road, FLorence, MA 01062(Northampton, MA)
Property Address
C/O Bob Cook POB 73,Whately, MA 01093
Ownefs Name
Northampton, MA(Florence) MA 01062 09 072007
City/rovm State Zip Code Date of Inspeuion
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?
❑ Z 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 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 om
® ❑ Existing information. For example,a plan at the Board of Health.
® ❑
Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)[310 CMR 15.302(5)]
lille5new07passf sdaci-666 The 5 Official hagsliar Fenn Subsurface Sewage Disposal System Page 6 ot 15
Owner
information is
required for
every Page
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Fonn-Not for Voluntary Assessments
327 North Farms Road, FLorence, MA 01062(Northampton, MA)
Property Address
C/O Bob Cook POB 73,Whatety, MA 01093
Owner's Name
Northampton, MA(Florence) MA 01062 09.072007
City/Tovm State Zip Code Date of Inspection
D. System Information
Residential Flow Conditions:
Number of bedrooms(design):
5
Number of bedrooms(actual).
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):
Number of current residents:
Does residence have a garbage grinder? ® Yes ❑ No
Is laundry on a separate sewage system?of yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage
N/A
9 ( Y 9 (9pd)Y
5
500
0
Sump pump? ❑ Yes ® No
Last date of occupancy: Mar. 07
Date
Commerciaglndustrial Flow Conditions:
Type of Establishment: N/A
Design flow(based on 310 CMR 15.203): N/A
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft.,etc.): N/A
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
N/A
Last date of occupancy/use:
Other(describe): N/A
meseaorpavrremn,•mros
N/A
Date
TNe 5 Official tiSpecton Fan.Y4&a(a»%weir DtsPosal System P
7 au
• Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
327 North Farms Road, FLorence, MA 01062(Northampton, MA)
Property Address
CIO Bob Cook POB 73,Whately, MA 01093
Owner Owners Name
information fns Northampton, MA(Florence) MA 01062 09.07.2007
everrequired for P ( )
every Page. City/Town State Zip Code Date of Inspection
D. System Information (cunt.)
General Information
Pumping Records:
Source of information: Unknown
Was system pumped as part of the inspection?
If yes, volume pumped: 1500 g
gallons
How was quantity pumped determined? meas.
Reason for pumping: T-5
Z Yes ❑ No
Type of System:
Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) Of yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components,date installed(if known)and source of information:
30+Years
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Stle5new07 •BBAB
lag S Ot®I Hp@an Form'.Sumnax Sewage D¢Pm'Syelan•Page B d 15
• Commonwealth of Massachusetts
Owner
information is
required for
every page.
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
327 North Farms Road, Florence, MA 01062(Northampton, MA)
Property Address
C/O Bob Cook P08 73 ,Whately, MA 01093
Owners Name
Northampton, MA(Florence) MA 01062 09.07.2007
City/Town State at Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan):
Depth below grade:
Material of construction:
❑cast iron
® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line:
1.3'+
feet
10'
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade:
Material of construction:
®concrete
1.5'
❑ 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:
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?
titlaysa]P.area.m.0606
10.5'X4.5'X4.5'
6"
11"
Measured
'fide 5 01lom Inspection Fpm:subset Swage Diw I Sy9em-Page 9 615
• Commonwealth of Massachusetts
Title 5 Official Inspection Form
Owner
information a
required for
every page-
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
327 North Farms Road, FLorence, MA 01062 (Northampton, MA)
Property Address
C/O Bob Cook POB 73,Whately, MA 01093
Owners Name
Northampton, MA(Florence) MA 01062 09.072007
City/Town State Zip Code Dale of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert,evidence of leakage, etc.):
Tank levels g od were. Structural integrity appeared good at time of inspection. (baffles in place),
Grease Trap(locate on site plan):
Depth below grade.
Material of construction:
❑ concrete ❑ metal
N/A
feet
❑ fiberglass ❑ polyethylene ❑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 tee or baffle
N/A
N/A
N/A
N/A
N/A
Date of last pumping:
Date
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
WA
Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
N/A
Depth below grade:
Material of construction:
❑ concrete
N/A
❑ metal
❑fiberglass ❑ polyethylene ❑ other(explain):
tilInneFe]pRNepaen•00/06
ine 5 navel Fan Sa,lax Sange Minn!system•Page 10 a 15
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
327 North Farms Road, FLorence, MA 01062(Northampton, MA)
Property Address
C/O Bob Cook POB 73 ,Whately, MA 01093
Owners Name
Northampton, MA(Florence) MA 01062 09.07.2007
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Tight or Holding Tank(cont.)
Dimensions: N/A
Capacity: N/A
gallons
Design Flow: N/A
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: N/A Alarm in working order ❑ Yes ❑ No
Date of last pumping: N/A
Date
Comments(condition of alarm and float switches,etc.):
N/A
'Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert
2 inv.
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.):
Box was in good condition. Levels of liquid are at invert and even. New cover on box 24"down
Pump Chamber(locate on site plan):
Pumps in working order:
Alarms in working order:
INe5nei.O]rme(wla t•0806
❑ Yes
❑ Yes
❑ No
❑ No
rae5°RUa Inspecbon Form:SItSNace Sewage(wens Systm,•Page II 615
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
327 North Farms Road, FLorence, MA 01062(Northampton, MA)
Property Address
C/O Bob Cook POB 73 ,Whately, MA 01093
Owners Name
Northampton, MA(Florence) MA 01062 09.072007
City/Town State Zip Code Date of Inspection
D. System Information (cunt.)
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
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: 420 SF(3 line)
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of
vegetation, etc.):
No Evidence of hydraulic failure, (No Standing liquid in stone noted or past ground staining or
ponding.)
IiWYs O7[affie4d Tip-nSVG Tim 5 Mad Fmn:SbJ/xe Savage 0.rym9 System•Page 12 of 15
Owner
information is
required for
every page_
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
327 North Farms Road, FLorence, MA 01062(Northampton, MA)
Property Address
C/O Bob Cook POB 73,Whately, MA 01093
Owners Name
Northampton, MA(Florence) MA 01062 09.072007
City/rown State Zip Code Date of Inspection
D. System Information (cant.)
Cesspools(cesspool must be pumped as part of inspection) (locate on site plan).
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction: N/A
Dimensions N/A
Depth of solids NIA
Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,
etc.):
N/A
swsowonaseeadme 08/05
Tine 5 ghdal l aped ion Fenn.SLMeR Sewage Deposal l System•Page 13 o115
• Commonwealth of Massachusetts
Title 5 Official Inspection Form
Owner
information is
required for
every page,
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
327 North Farms Road, FLorence, MA 01062 (Northampton, MA)
Property Address
C/O Bob Cook POB 73 , Whately, MA 01093
Owner's Name
Northampton, MA(Florence) MA 01062 09072007
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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_
rue5ne..mra.u1d rt•35/05
92
50i
Tie 5 Official hspecha,Form.Subsuleme Se✓up Disposal SyNm,•Page 14 N15
Owner
information is
required for
every Page_
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
327 North Farms Road, FLorence, MA 01062(Northampton, MA)
Property Address
C/O Bob Cook POB 73 ,Whately, MA 01093
Owner's Name
Northampton, MA(Florence) MA 01062 09.07.2007
CM/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
❑ Surface water
® Check cellar
❑ Shallow wells
Estimated depth to ground water:
8.0'(1973 records)
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: 1973
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-explaih:
You must describe how you established the high ground water elevation:
See existing records and no Sump in basement reported
west a)pass etivrn.08/05
Ti165 Mad ho erdi Form'.SW Vaface Sewwe Disposal System-Page 15 of 15
1:113/21/Ala/ U:4b
PUG- t-4 et" 09:47, FftCIK & PEPS-4
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/HE COMI-1-0Werig•LTI4 OF MASSAi.PIU9rotS.
SOAR° OF HEALIII
a cr v Coar H a Ms--•0 kJ
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Application if hereby ;Pile to. a Venni: :u Construct
r%):-/C7 nI V A no A 0
rla
1 613 52? 591e P.01/n.
&ittgritrttutt Jrriuit
) Pepair ) bolisidcal Sewage Deposal
tar co. /0
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int.11,4 Mgr e: ZS,54 Z.
pe of Snarling 6' Szt
E welling—No. ef Beil ran is,,,,.......... .... ...............Espannon Attic ( ) Garbage (dinner (
Other--Type of Ilisitding No ef persons . Showers ( ) — Cafeteria ( )
Other lunatic ... . .. r..3'..c.a C.)
ceign Flow_ ,"--- tant3 parses per personsseratay. l'ut4Syrailentow . 41'444•
eptir Tank--linoid eepacity...„. .. ;i303% Length V;ithl:-.. Diannier .. rispth
Lingual Trsoch—ME wth.i....... . . Total Isengt1:,. t.L&$ Total leathlin; RTY...412.0. ... sq.ft.
tepee- l'it h4o. Dionseter Depth below inlet. . ..Total leachieg are; zq It
Ihtr Distribution ban ( ) Dee Si.ffer(e)Es cal EA?-e4lip'e uJine:( Ssil la -7.3
ereolation Thu Reep1t 5 Performed br - . Date kii34.1e...
Test Pit No. I. ntntutts per nor), Depth of Test l'it.4.4:a.,a4P-te DePth to greed entw. 10-1^2-Nblesn'
Test PA No. 7 minutes per innt Depth of Test Pit. Depth to ground water
(in" Tir2SJ.I.i , 0 2ilwer'tstsaereat: 4,..-MCPIPISINV---5A-hrltay ..-1?--nea
Arlfrfindn: rage:LIS'i-aratre-SAN)=11-
'• ' .. .
.. .._ ,,
attne of Repairs Cr Alterations—AllSw V when SppIitable ..
&re:merit:
The a:We:signed ogre/. to install th: oft:tech:scribed Individual Sewage Di%posat system in -soeurdanee with
he()rani:ions A Artick XI the State En liury code—Tlx undersigned further agrees not to nice the 3V:01 in
cation until a Certificate of Compliance has been issued by the bread of health.
Sigr yd.
..
Dos
Appinon Appro./4 By - . — - - . . .
Os,
AppikaiOTIDISZPIPTOVed Igo the folfrOng reasons ...... ............. ....- .,..„_„...... ....,... ......._,...... .____
Os.. •-
Issued
Permit No.
D..
08/21/2807 88:45 4135496115
PAS 1-2807 09:44 FINCK & PEI3R6S INS
KARLS EXCAVATING
1 413 52? 597
4) 44 #, pjes _
TO*p. P.02
td
No...7./--
THE COMMONWEALTH OF MASSACHUSETTS
OARD OF HEALTH
LL OF "51-7:6- z-77
Appliratiuu fn f3- iupuuttl Nark (RUiiutrurtiuu �frrinit
Application is hereby'rnade for a Permit to Construct
Loutli
..X .24
..0 un MJeaes n
or Repair ( ) an India ideal Sewage Disposal
tIV e �p Address
]lana:kr Address
Type of Building Size Lot Sq. feet
Dwelling—No. of Bedrooms 'Expansion Attic ( ) Garbage Grinder ( )
Other--Type of Building .. No of put suns Showers ( ) -- Cafeteria ( )
Otl ter fixtures _
Design Flow gallons per person per day. Total daily flow grill on-.
S t Tank—Liquid capacit010..agiillons Length Width Dfnmeter Depth.
Disposal Trench —No / AVidth_cxQ Total Length -3 0 I otal leaching arc. 60Q sq. fl
Seepage Pit No Diameter Depth below inlet Total badbing area. _..
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by Date
Test Pit No. I minutes per inch Depth of Test Pit Depth to ground 'vier -
Test Pit No. 2 minutes per inch Depth of Test 1'it. Depth to ground waur
Description of Soil
Nature of Repairs or Alterations—Answer when applicable
Agrement:
The undersigned agrees to install the aforedescrihed Individual Sewage Disposal System in accordance with
the provisions of Article N 1 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued b the board of health.
Signer
Application Approved By _
PZov, /7 /i7‘
]).arc
Application Disapproved for the following reasons'
Permit No 7y7
Issued.jZrv.._.l 7..ff7.4
CHECK OR FILL IN WHERE APPLICABLE
r
r
No._..._ ...t
FEE_/S! ' ✓ O
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF ,HEALTH
OF i ': fdl! r %'
Appliratinn -fare flhs}maal Narks Cnatwtrurtian lrrntit
Application is hereby'made for a Permit to Construct ( ") or Repair ( ) an Individual Sewage
System at:
Disposal
or Lot No.
Address
Type of Building
Dwelling—No. of Bedrooms
Other—Type of Building
Other fixtures
Adores=
Size Lot Sq. feet
Expansion Attic ( ) Garbage Grinder ( )
No. of persone Showers ( ) — Cafeteria ( )
Design Flow gallons per person per day. Total daily
Septic Tank—Liquid capacit OD_ eal Ions Length Width
Disposal Trench— No. .1 width_ ",:ti Total Length_.. -a
Seepage Pit No Diameter Depth below inlet
Other Distribution box
Percolation Test Results
Test Pit No. 1
Test Pit No. 2
Description of Soil
Dosing tank ( )
Performed by
minutes per inch Depth of Test Pit
minutes per inch Depth of Test Pit
now gallon:'.
Diameter Deptlt
Total leaching area iC'.d..sq. ft.
Total leaching area sq. ft
Date
Depth to ground water
Depth to ground water
Nature of Repairs or Alterations—Answer when applicable
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to
operation until a Certificate of Compliance has bee issued b I board of health.
Signed. ifh4.-2-
Application Approved By 2/, -"!% -c4
Application Disapproved for the following reasons'
in accordance with
place the system hi
Date
Permit No.._
f
Date
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF.
(nrrtifiratr of ftomplitturr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
Installer
at -has been installed in accordance with the provisions of Article RI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE Inspector
No Pi
(
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Marko «onotrurtion lrrmit
Permission ts.k(ereby granted If '/ 4 7 fs " - '/
to Construct )) or lair ( ) an. Individual .Sewage Disposal $ystd 1
at No ;71.Q s>r.t Al. Tom. L ..?n.L__.i /
Strtet
as shown on the application for Disposal Works Construction Permit No�,�� Dated fl-(✓
fl7/i
Board of H.me,J
FEE
DATE
FORM 1255 HousS & WARR EN. INC.. PUBLISHERS