98 Title 5 Application/Permits, 1987, 2004, Report 2004 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Part A
Certification (continued)
Property Address: 98 Momingside Drive, Florence,Ma.01062
Owner: David Junno
Date of Inspection: August 25,2004
INSPECTION SUMMARY: CHECK A, B, C, D or E /ALWAYS complete all of Section D
A] SYSTEM PASSES:
I I have not found any information which indicates that any of the failure conditions described in 310 CMR
15.303 or in CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
COMMENTS:
B] SYSTEM CONDITIONALLY PASSES:
® One or more system components as described in the "Conditional Pass" section need to be replaced or
repaired. The system, upon completion of the replacement or repair, as approved by the Board of
Health, will pass.
Answer YES, NO, or Not Determined (Y,N, or ND). in the for the following statements.
If"not determined", please explain.
NO 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:
YES Observation of sewage backup or breakout or high static water level in the distribution box is due to
broken or obstructed pipe(s) or due to a broken, settled, or uneven distribution box. The system will
pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain: REPLACED
NO 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:
Title 5 Inspection Form 6/15/2000 Page 2
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5 INSPECTION FORM
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Part A
Certification
Property Address: 98 Momingside Drive, Florence, Name of Owner: David Junno
Ma. 01062
Date of
Inspection:
Name of
Inspector:
Company Name:
Company Phone:
August 25, 2004
Philip J. Pasiecnik
Greg's Wastewater Removal
239A Greenfield Road
S. Deerfield, MA 01373
(413) 665- 3989
Address of
Owner:
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 approved system inspector pursuant to Section 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:
AAte LLW DATE: r/a L/
The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or
DEP)within thirty (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: No failure criteria as described on page four of this inspection form was found at the time of
inspection of this system. System Distribution Box needs replacement due to the concrete is deteriorated and
cracked. The system upon completion of the replacement or repair, as approved by the Board of Health will pass.
***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
Title 5 Inspection Form 6/15/2000 Page 1
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Part A
Certification (continued)
Property Address: 98 Momingside Drive, Florence,Ma.01082
Owner: David Junno
Date of Inspection: August 25,2004
D] SYSTEM FAILURE CRITERIA applicable to all systems:
You must indicate either"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.
❑ Z Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day
flow.
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed
pipe(s).
Number of times pumped
❑ ® Any portion of the Soil Absorption System, cesspool, or privy is below the high groundwater
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 I of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a
private water supply well with no acceptable water quality analysis. [This system passes if the
well water analysis, performed at a DEP certified laboratory,for conform bacteria and volatile organic
compounds indicates that the well is free front 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.]
® The system fails. I have determined that one or more of the above failure criteria
exists as defined in 310 CMR 15.303, therefore the system fails. The system owner
should contact the Board of Health to determine what will be necessary to correct
the failure.
E] LARGE SYSTEMS:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd
to 15,000 gpd.
You must indicate either"Yes" or"No° to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
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 threat, or answered "yes" in
Section D above the large system has failed. The owner or operator or 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.
Title 5 Inspection Form 6/15/2000 Page 4
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Part A
Certification (continued)
Property Address: 98 Momingside Drive, Florence,Ma.01062
Owner: David Junno
Date of Inspection: August 25,2004
C1 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 the 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 THE PUBLIC HEALTH, SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS 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 THE ENVIRONMENT:
The system has a septic tank and soil absorption system (SAS) and the SAS is within 100
feet to 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.
LJ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply
well.
fl 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 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.
I
3) Other
Title 5 Inspection Form 6/15/2000 Page 3
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Part C
SYSTEM INFORMATION
Property Address: 98 MomInnside Drive, Florence,Ma.01062
Owner: David Junno
Date of Inspection: August 25,2004
FLOW CONDITIONS
Residential:
Number of bedrooms (design): 3 Number of bedrooms (actual)_3
DESIGN Flow: 330 G.P.D. (based on 310 CMR 15.203-for example: 110 gpd x#of bedrooms)
Number of current residents: 4
Is Garbage Grinder present (yes or no) No
Is laundry on a separate sewage system (yes or no) No if yes separate inspection required
Laundry system inspected (yes or no)
Seasonal Use (yes or no) No
Water Meter readings - if available
(last two (2) year usage (gpd) 144,750 Gallons = 198 G.P.D.'
Sump Pump (yes or no) No
Last Date of Occupancy: Currently Occupied
Commercial/Industrial:
Type of establishment:
Design flow: (Based on 310 CMR 15.203) gallons per day
Basis of design flow (seats/persons/sqft,etc.)
Grease trap present (yes or no)
Industrial Waste Holding Tank present (yes or no)
Non-sanitary waste discharged to the Title 5 system
(yes or no)
Last Date of Occupancy/Use:
OTHER (describe):
PUMPING RECORDS
Source of information:
GENERAL INFORMATION
System was last pumped 2 years ago per owner.
Was system pumped as
part of the inspection: No, system will be pumped as part of the D-box repair
(yes or no)
If YES -enter volume gallons
pumped How was the quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM:
7 Septic Tank/ D Box/ Soil Absorption System ❑ Single Cesspool
Overflow Cesspool ❑ Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any) No
Innovative/Alternative technology. Attach a copy of up the current operation
and maintenance contract (to be obtained from system owner)
Tight Tank Attach a copy of DEP Approval
OTHER (describe):
Approximate age of all components, date installed Of known) and source of information:
17 Years Old / 1987 / Design Plan
Were sewage odors detected when arriving at site: (yes or no) No
Title 5 Inspection Form 6/15/2000 Page 6
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Part B
CHECKLIST
Properly Address: 98 Momingside Drive, Florence,Ma.01062
Owner: David Junno
Date of Inspection: August 25,2004
Check if the following have been done. You must indicate either "Yes" or "No"
as to each of the following:
Yes No
® ❑ Pumping information was requested of 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)
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 Soil Absorption System, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the
condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge
and depth of scum?
❑ Was the facility owner(and occupants if different from owner) provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has been
determined based on:
Existing information. For example, a plan at the Board of Health.
Determined in the field (if any of the failure criteria related to Part C is at issue approximation of
distance is unacceptable) [310 CMR 15.302 (3)(b)]
Title 5 Inspection Form 6/15/2000 Page 5
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Part C
SYSTEM INFORMATION (continued)
Property Address: 98 Momingside Drive, Florence,Ma.01062
Owner: David Junno
Date of Inspection: August 25,2004
TIGHT or HOLDING TANK: (Tank must be pumped at time of inspection) (locate on site plan)
Depth below grade:
Material of Construction: ❑ Concrete ❑ Metal ❑ Fiberglass ❑ Polyethylene Other(explain)
Dimensions:
Capacity in gallons
Design flow in gallons per day
Alarm present (Yes or No)
Alarm level Alarm in working order [Wes ❑ No
Date of last pumping
Comments: (condition of alarm and float switches, etc.)
DISTRIBUTION ® Yes ❑ No (If present MUST be opened -locate on site plan)
BOX
Depth of liquid level above outlet invert: Not Above
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.) The concrete distribution box is badly deteriorated and must
be replaced. Leakage out of the box was evident. No solids carryover was in the box when opened for
inspection. The cover to the distribution box is approx. 20" deep below grade.
PUMP CHAMBER: ❑ (located on site plan)
Pumps in working
order: (Yes or No)
Alarms in working order
(Yes or No)
Comments: (Note condition of pump chamber, condition of pumps and appurtenances, etc.)
Title 5 Inspection Form 6/15/2000 Page 8
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Part A
Certification (continued)
Property Address: 98 Momingside Drive, Florence,Ma.01062
Owner: David Junno
Date of Inspection: August 26,2004
BUILDING SEWER(Locate on site plan):
Depth below grade: 2Z
Material of construction: cast iron XXX 40 PVC other(explain)
Distance from private water supply well or suction line Town Water
Diameter 4"
Comments: (condition of joints, venting, evidence of leakage etc) Joints were in good condition. Venting was visible
outside the dwelling. No leakage was evident.
SEPTIC TANK (locate on site plan):
Depth below grade: 16"
Material of Construction: ® Concrete ❑ Metal ❑ Fiberglass ❑ Polyethylene Other (explain)
If tank is metal, list age Is age confirmed by Certificate of Compliance
(Yes/No) (If"Y", attach copy of Certificate of Compliance)
10'6"Lx5'6"Wx5'4"D Dimensions:
8" Sludge Depth
23" Distance from top of sludge to bottom of outlet tee or baffle
6" Scum thickness
6" Distance from top of scum to top of outlet tee or baffle
11" Distance from bottom of scum to bottom of outlet tee or baffle
Measured How dimensions were determined:
Comments: (On pumping recommendations, inlet& outlet tee or baffle condition, structural integrity, liquid levels as
related to outlet invert, evidence of leakage, etc.) The septic tank should be pumped every two to three years. Cast
in place concrete inlet tee was in good condition and extends 15" below the flow line. Cast in place concrete outlet
tee was in good condition and extends 17" below the flow line. The liquid level was at the outlet invert. Structural
integrity of the septic tank was good. No leakage was evident at this time. Concrete riser on the center cleanout is 4"
below grade. .
GREASE TRAP (locate on site plan): n
Depth below grade:
Material of Construction: ❑ Concrete ❑ Metal ❑ Fiberglass ❑ Polyethylene ❑ Other (explain)
Dimensions
Scum thickness
Distance from top of scum to top of outlet tee/ baffle
Distance from bottom of scum to bottom of outlet tee/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.):
Title 5 Inspection Form 6/15/2000 Page 7
{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.
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Part C
SYSTEM INFORMATION
Property Address: 98 Momingside Drive, Florence,Ma.01062
Owner: David Junno
Date of Inspection: August 25,2004
SKETCH OF SEWAGE DISPOSAL SYSTEM:
**** { SEE EXHIBIT A) ****
Title 5 Inspection Form 6/15/2000 Page 10
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Part C
SYSTEM INFORMATION (continued)
Property Address: 98 Momingside Drive, Florence,Ma.01082
Owner: David Junno
Date of Inspection: August 25,2004
SOIL ABSORPTION SYSTEM
(SAS):
(locate on site plan, if possible; excavation not required.)
If SAS is not located explain why:
TYPE:
Leaching pits& number 2 - 1000 Gallon Leach Pits ( per design plan )
Leaching chambers & number
Leaching galleries & number
Leaching trenches, number, length
Leaching fields, number,
dimensions
Overflow cesspool, number
Innovative/Alternative system:
Name of Technology:
Comments: (Note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation etc.) The soil was
sandy with no clogging evident. No signs of hydraulic failure or ponding. The soil wasn't damp over the
area of the leach pits. Vegetation was mowed grass and plantings which were uniform in growth over the
areas of the leach pits. Liqiud was heard dropping into the pits which indicates the liquid level was well
below the inlet inverts. .
CESSPOOLS ❑ (Cesspool must be pumped as part of inspection-locate on site plan)
Number&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 hydraulic 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 pending,condition of vegetation etc.) _
Title 5 Inspection Form 6/15/2000 Page 9
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Part C
SYSTEM INFORMATION (continued)
Property Address: 98 Momingside Drive, Florence,Ma.01082
Owner: David Junno
Date of Inspection: August 25,2004
SITE EXAM Z Slope
® Surface water
Z Check cellar
❑ Shallow wells
Estimated Depth to Groundwater > 7 Feet
Please indicate (check) all the methods used to determine High Groundwater
Elevation:
Z Obtained from system design plans on record - If checked, date of design
plan reviewed: 1987
Z Observed site (Abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health - explain:
❑ Checked with local excavators, installers - (attach documentation)
❑ Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
No sump pump in the basement which was dry at 7 feet below grade. No
surface water nearby to the system. No groundwater coming from sloped areas
on the property. No infiltration of groundwater into the septic tank after pumping.
Title 5 Inspection Form 6/15/2000 Page 11
Sewage Disposal System at
98 Morningside Drive
Florence, Ma.
EXHIBIT "A"
Driveway
1500 Gallon Se.ticTank
46'
Drawing Not To Scale
1000 Gallon Leach Tanks
CARMEN C. JDV7VO
DAVID JUNNO
98%011NEVOSDIC ON. &19584.848
FLONRFI:.HA 01082
PAY
TO THE :' ( LI J',< I J
ORDER OF_ :.. ( rc �' �. _l�
�^ I
FOR / k IAi. U A� I ._
L:OLL0001381: 00042 962570 1622
1A.EET BANK
64956 NORTHAMPTON CENTER OFFICE
NORTHAMPTON,MAS$ACHV5ETT50/066
w fleet corn
5-13/110
hf
DOLLARS
1622
.k17'py5c ino/ 3b
-aa404., sanros
s�
yi
`�/.�
536 tnwal — ol-
.. dot 0QQI#
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Moil ssoaD
cRtiS
via
I/5 r 7,11 11!5 i
ar
a Nt>ay.3L
THE COMMONWEALTH OF MASSACHUSETTS
BOARD, /O// HE
OF HEALTH
C!r N of .VD/�'/° i/,//'//
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Fe ✓'�/ Dc)
Application for a Permit to Construct ( ) Repair (VUpgrade ( ) Abandon ( ) - ❑Complete System El Individual Components
93 trita de5/0eD/livf
DP‘..; v�
•,.,e.,
Lomnon
(IrVmLiVwtv-kSVLrt 0rlugOauce (
LIL:;—S S` Admr.3
xmplvarta,,
Sat/W W M."' 6 " 5
al (-5Wf
elephone,
In,islliiv SZme
1
N
*.Fame
AddrL
or.. .• ,.
IJ /l
_ _ 307
Aldrens
Telephone,,
Type of Building:
Dwelling—No.of Bedrooms
Other—Type of Building
Other fixtures
Lot Size � � yy.S,q.feet
Garbage Grinder V`W
Showers ( ). Cafeteria ( )
No-of persons
Design Flow
Plan: Date
Title
e
:red)
Cis
aW4 gpd Calculated design flow Design flow provided gpd
Number of sheets
Revision Date
Lp-Teo2 e,P NgicJ D-6o/
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersign agree
1RIF 5 and Furth
Signed
Ins
ecnon
to install the above described IndividuaTSewage Disposal System in accordance with the provisions of
to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
FAQ iJ(JArthefieR DatcX P"/ i 021Y
I i Ni%At _4I EW I / L3�1 . F L• "..1 J La a eit
L -
FORM I - APPLICATION FOR DSCP
DEP APPROVED FORM 5/96
No
Description of Work:
THE COMMONWEALTH OF MASSACHUSETTS
-,{P)/-1.7 OARD OF HEALTH
CERTIFICATE OF COMPLIANCE
❑ Individual Component(s) ❑Complete System
The undersigned hereby certify that the Sewage Disposal System:Constructed( ),Repaired( ),Upgraded X.Abandoned 1 )
I
a /
at ' 1�,//'u4' taut,i•.�-r{{2 L.4% 2{ c . — Ili.? IA./ /' t/: '
has been installed in accordancd with the provisions of 310 CMR 1 .00 (Title 5F end the approved design I /as-built
plans relating to application No._ dated/ _.'� . Approved Design Flow (gpd)
Installer l i�s. i. ( / ;ji<'LV,y
/ y
Designer /✓/A Inspector .P./1-7.1- "'✓°°"`ei Date e/7'"
Thef issuance of this certificate shall not be construed as a guarantee that the system will function as designed.
FORM:3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96
by'
f _
No -�'/. " t 3 . THE COMMONWEALTH OF MASSACHUSETTS FER;7
)'h%1/ %� >`80ARD OF HEALTH
DISPOSAL SYSTIWOUCTION PERMIT l�
Permission is hereby,gra9ted to Construct ( ) Repair ilpgr e ( ) Abandon I, ) an individual sewage
disposal system at ' (J /i''. 4/`'it/,L4 ,� 4421 �K' t'c - / /'+-ai --wt*1� as described 7
in the application for Disposal System Construction Permit No. /
/ T(.t7%I� fl` 7 dated .-}:aJ'- a 7�..
Provided: Construction shall be completed within three years of the date of this permit.All local conditions must be met.
- f�
Date "/ / ' adig I Board of Health
FORM 2 - DSCP DEP APPROVED FORM 5/96
FORM 1255 IREV 5/961
Ha HOBB6a WARREN TM
PUBLISHERS- BOSTON
IN WHERE APPLICABLE
O
U
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
''TY OFNORTHQMPPT^4
Appliratiun fur 3liupu,aI
Application is hereby made for a Permit to Construct
System at:
�.I
FEZ i V
urkE Cnunutrurtinu 1rrmit
AAI) or Repair
Y
an Individual Sewage Disposal
g',cQE4!LNGS/1ebr. � ..... . , ..
Locann .naaa..
237s Addren
Installer
Address
Type of Building Size Lot Sq. feet
Dwelling— No. of Bedrooms Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No. of persons Showers ( ) — Cafeteria ( )
Other fixtures
Design Flow gallons per person per day. Total daily flow gallons.
Septic Tank—Liquid capacity gallons Length Width Diameter Depth
Disposal Trench-- No. Width Total Length Total leaching area sq. ft.
Total leaching area sq. ft.
Seepage Pit No Diameter Depth below inlet
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by Date
Test Pit No. 1 minutes per inch Depth of Test Pit Depth to ground water
Test Pit No. 2 minute s per inch Depth of Test Pit Depth to ground water
Description of Soil 5..i.l.4 J�.Cf E SAN 1
Natu of R ns or Alterations—An wer when ap I ble
lu
kep/A e fri67Ls /efch 118/6/
0 U p
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary .de—The undersigned further agrees not to place the system in
operation until a Certificate of CompliancMs I issued y e b6ard of health. , /
Alent
Application Approved By
Application Disapproved for the following reasons
Permit No
Date
Issued
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
orNOP I HAI,I PT"
Olrrtifirair of aluminium
by THIS IS,�0 CERRLFY,.That the Individual Sewage Disposal System constructed ( ) or Repaired (4).
„✓ lodee 'I.....d..ldl!Y.. S
at
has been installed in accordance with the provisions of TIT{° 5 of The State Sanitary Cod as in the
/application for Disposal Works Construction Permit No '1'2 dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE NSTRJI£�D AS A G
SYSTEM WILL FU CTI9N SATISF CTORY.
DATE
/5— r? Inspector
No
7-i7
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
is OFNORTH MPTC
Dispusat rrurkp tQuristrnctinn lrrmit
Permission is hereby granted _2 i
an
to Construct ( ) or, Repair ( Individual Sewage Disposal System
at No 1 i
Fax
THAT E
p , 2l: 4 . T, G i-
�..� snar
as shown on the application for Disposal Works Construction Permit,,No._ .L:i' Dated(52.4:,
./
f- ' Board i
1'; � V7
` of Health
DATE
FORM 1255 A. M. dULKIN, INC.. BOSTON