61 Title 5 Application/PErmits 1986, Inspections 2003, 2005 knporbnt
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Commonwealth of•Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
Inspection results must be submitted on this form or on previously published DEP forms.
Inspection forms may not be altered In any way.
A. Certification
1. Property Information:
(r/ /9%O-0..sr7Auu 5'-1• //area c•e
am_
OwnerSyne
»n7t
Owners Address
a-
Date of Inspection: /Q -//-oS
2. Inspector.
Ray Champagne
State Zlp Code
Date
Name of Inspector
Whiteley Septic Service
Company Nome
133 Middle Road
Company Address
Southampton
City/Town
413-527-1835
Telephone Number
MA 01073
State Lip Code
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�v5,//(310 CMR 15.000).The system:
tgPasses ❑ Conditionally Passes ❑ Fails
yrs Further Evaluation by the Local Approving Authority
InspectotSignature Date
The system Inspector shat 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 10,0W 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 buym,if applicable,and the approving au0wdty.
*"*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.
t5nsp.doc.doc•012003 The S Official hepedico Form:Subsurface Sewage Disposal System•
Page 1 of I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont.)
6/ meu.v14oi.0 Sf `
Property Address
FIB reg7Ge /PA • O/ o6Z
Citynown Stele
lROknt) Woad Zip Code
io- i/-os
Owner's Name
Dale of Inspection
Notes and Comments:
s S5e.s4.or P 1flns W Ie ire /o j Qiopr.dCf
sr Co-iisr.rfs c-j Se,,,,4 o 7071r.o t"ore fed
/.€A.t4 Pr+ . ad " si4.,diaswafiriv,l!/y37 "
t5insp.doc.doc•04/2003
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•
Page 2 of 2
Commonwealth of Massachusetts
Title 3 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont.)
(o I Yy1 O at,4 A,W
P rty Address
IDreute I VA • O/Olo 'L
Q frown State ➢p Code
Owners Name Date of Inspection
Inspection Summary Check A,B,C,D or E/always complete all of Section D
s4.
A) System Passes:
I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as des d in the"Conditional Pass"section need to be
replaced or repaired.The system,upon Mellon of the replacement or repair,as approved by
the Board of Health,will pass.
Answer yes, no or not determined(Y, N, °D)in the❑for the following statements.If"not
determined,"please explain.
❑ The septic tank is metal and ov= 20 years old*or the septic tank(whether metal or not)is
structurally unsound,exhibits bstantial infiltration or exfiltration or tank failure is imminent
System will pass inspection the existing tank is replaced with a complying septic tank as
approved by the Board of ealth.
•A metal septic tank II pass inspection if it is structurally sound, not leaking and if a Certificate
of Compliance indi -ling that the tank is less than 20 years old is available.
ND Explain:
t5insp.doc.doc•00/2003
The 5 Official Inspection Form:Subsurface Sewage Disposal System-
Page 3of3
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont.)
/o! 4 at,lfa..o s#
Proggity Address
en eU r K_
/ //14 -
Ciicifroovm , State
rYJhi 119619L Ao-fi oS
Owners Name Date of Inspection
B) System Conditionally Pass (cont):
❑ Observation of sewage b kup or break out or high static water level in the distribution box due
to broken or obstructed ipe(s)or due to a broken,settled or uneven distribution box.System will
pass inspection if(w' approval of Board of Health):
Q/0 /O%
Zip Code
❑ broken pi (s)are replaced
❑ obstruction is removed
❑ distrjdution box is leveled or replaced
ND Explain:
❑ The system required pumping more
system will pass inspection if(with a
❑ broken pipe(s)are replaced,
❑ obstruction is removed
ND Explain:
4 times a year due to broken or obstructed pipe(s).The
val of the Board of Health):
C) Further Evaluation is Required by the 8
of Health:
❑ Conditions exist which require further eve ation by the Board of Health in order to determine if
the system is failing to protect public he i ,safety or the environment
1. System will pass unless Board • Health determines in accordance with 310 CMR
15.303(1)(b)that the system is n• nctioning in a manner which will protect public health,
safety and the environment:
tSmsp.doc.doc•04/2003
❑ Cesspool or privy is w'i 50 feet of a surface water
❑ Cesspool or privy is in 50 feet of a bordering vegetated wetland or a salt marsh
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•
Page 4 of 4
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont.)
to 1 Oleo,V44r0 C4-•
Pic Address
-F ln&v.vct n1 OiDGZ
O awn State bp Code
V Dk r.v 1.1)00.4 to— //—O.S�
Owners Name Date of Inspection
C) Further Evaluation is Required by the oard of Health(cont.):
t5lnsp.doc.doc•04/2003
2. System will fail unless the Board •f Health (and Public Water Supplier,If any)
detemtines that the system Is fun oning in a manner that protects the public health,
safety and environment:
❑ The system has a septic to and soil absorption system (SAS)and the MS is within
100 feet of a surface water-upply or tributary to a surface water supply.
❑ The system has a septic .nk and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a se tic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has . -ptic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a p ' - e water supply well`.
Method used to ,etennine distance:
"This system passes
coliform bacteria and
that facility and the
ppm,provided that
to this form.
3. Other
the well water analysis,performed at a DEP certified laboratory,for
lathe organic compounds indicates that the well is free from pollution from
sence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5
other failure criteria are triggered.A copy of the analysis must be attached
The 5 Offidal Inspection Form:Subsurface Sewage Disposal System•
Page 5 of 5
Commonwealth of Massachusetts
kitt:j Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface S Di
ewage Disposal System F orm
A. Certification (cont.)
4, ✓ Ja...,•-..:.,, s4 .
Properly Address
lore 0-ffic a-4 Ow&L.
State o iti GLiaa1 D-//-z9b zpcoae
Owners Name of Inspection
D)System Failure Criteria Applicable to All Systems:
You must Indicate"Yes"or"No" to each of the following for all inspections:
Yes No
❑ >ut Backup of sewage into facility or system component due to overloaded or
Y� dogged 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
❑ 14 Liquid depth in cesspool is less than 6°below invert or available volume is less
than Va day flow
❑ Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s).Number of times pumped:
❑ g Any portion of the SAS,cesspool or privy is below high ground water elevation.
❑ My portion of cesspool or privy is within 100 feet of a surface water supply or
t4 tributary to a surface water supply.
0 My portion of a cesspool or privy is within a Zone 1 of a public well.
❑ cl Any portion of a cesspool or privy is within 50 feet of a private water supply
well.
❑ My 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 coiNam 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.
tshsp.doc.dm•042003 Title 5 Official Irepemon Form:Subsurface Sewage Disposal System•
Page 6 of 6
Commonwealth of Massachusetts
Tithe 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont.)
(o/ /77ou,rrf.o,., Sf.
Property Address
NO re Ace_
Lp Code
ohm, "VDOQ• b- /1-a5-
Owner's Name Date of Inspection
E) Large Systems:.To be consider
design flow of 10,000 gpd to 15,
For large systems,you must indicat
questions in Section D.
YES NO
a large system the system must serve a facility with a
9Pd.
either yes"or"no'to each of the following, in addition to the
❑ ❑ the sys is within 400 feet of a surface drinking water supply
❑ ❑ the tern is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ th system is located in a nitrogen sensitive area(Interim Wellhead Protection
a—IW PA)or a mapped Zone I I of a public water supply well
If you have ans - -• -s'to any question in Section E the system is considered a significant threat,
or answered'yes" Section I)above the large system has failed.The owner or operator of any large
system considere a significant threat under Section E or failed under Section D shall upgrade the
system in actor ce with 310 CMR 15.304.The system owner should contact the appropriate
regional office •f the Department.
' t5insp.doe.dac•04/2003
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•
Page 7 of 7
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
B. Checklist
Aticikinv
P Address
efl •C PC 444 ' D/D G L
crown State Zp Code
ob;'o U1ood. /D-�/-D S
Owner's Name Date of aps on
Check if the following have been done.You must indicate"yes"or'no'as to each of the following:
YES NO
❑ Pumping infomatiionwaspsa-tbythe 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?
❑ gHave large volumes of water been introduced to the system recently or as part of
g this inspection?
❑ ❑AM Were as built plans of the system obtained and examined?(If they were not
available note as WA)
Was the facility or dwelling inspected for signs of sewage back up?
c
sr
ti
El
t5msp:doc.dot•04/2003
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:
Existing information.Fqr example, n at the Board of Health.
Def�ed'fn the field(if arty yooif the falure criteria related to Part C is at issue Won
approximation of distance is unacceptable)[310 CMR 15.302(3)(b)1
Tale 5 Official Inspection Form:Subsurface Sewage Disposal System•
Page 8 of 8
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information
to l Tflaotrba 9•v 5$.
P Address
iertaLe- mR .
a /Town State
;.is G9sa AO-/AS
Zp Code
Ow nets Name Date of Inspection
Residential Flow Conditions:
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN Now based on 310 CMR 15.203(for example: 110 gpd x it of bedrooms):
Number of current residents:
Does residence have a garbage grinder?
Is laundry on a separate sewage system? [if yes separate inspection required]
Laundry system inspected?
Seasonal use?
Water meter readings, if available (last 2 years usage(gpd)):
Sump pump?
Last date of occupancy.
Commercial/Industrial Flow Co •itions:
Type of Establishment
Design Now(based on 310 C R 15203):
Basis of design flow(seats -rsons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holdin tank present? ❑ Yes ❑ No
Non-sanitary waste •ischarged to the Title 5 system? ❑ Yes ❑ No
❑ Yes X No
❑ Yes X No
❑ Yes ❑ No
❑ Yes 0. hi6
?reseal 2.0211:40
❑ Yes No
preseeihr
Date
Water meter rea
Last date of
Other(des
t5insp.doc.doc•09/2003
):
' gs, if available:
pancy/use:
Date
Title 5 Official Inspection Fonn:Subsurface Sewage Disposal System•
Paae 9 of 9
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information jp/fikeweidest Si--
Property Address
FMrtote. flip . geftzlbZ
Cit frown • State Zip Code
R�0bnu wood iD-//-OS-
Owner's Name Dated lospeceon
General Information
Pumping Records: '
Source of information:
Was system pumped as part of the inspection? Yes ❑ No
If yes,volume pumped: ODD
gallons
How was quantity pumped determined? %llL�'1K d oa, Tra c�+...
Reason for pumping: /1 'W i-e J*n,c L
Type of System:
Septic tank,diatribtittacbox.sal absorption system k.4c 4 P 4
Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no)(if yes,attach previous inspection records, if any)
❑ Innovative/Altemative 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:
to t Sahnsa c.
Were sewage odors detected when arriving at the site? ❑ Yes'No
t5insp.doc.doc•04/2003
TNe 5 Official Inspection ramp:Subsurface Sewage Disposal System•
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cant.)
6/ Mou uf&a,.._e sl-
Address
la re Arc e_
!town State
io Woo4 f0—//-0.6-'
Owner's Name Date of inspection
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:
Zip Code
/-s
feet
C799 lit404r
feet
Comments(on condition of joints,venting,evidence of leakage,etc.):
JOs eat aft JOCK. a' /11%4.4.456e— o bssweal
Septic Tank(locate on site plan):
Depth below grade:
Material of construction:
concrete ❑ metal
/
feet
❑fiberglass ❑polyethylene ❑other(explain)
If tank is metal,list age:
years
Is age confirmed by a Certificate of Compliance?(attach a copy of
certificate)
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?
tSinsp.doc.dnc•04/2003
❑ Yes ❑ No
3 -
35
y
.,
n
/Z
This 5 Official Inspection Form.Subsurface Sewage Disposal System•
Page 11 of l i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cunt)
6/ Moo 04arn_, _SIC
Property Address
P lerE.uG+- /1%p• 01041
City/Town • ��p State C.
Zip Code
.013iw WOaa /D-//-off
Owner's Name Date of Inspection
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,
liquid levels as related to outlet invert,evidence of leakage,etc.):
edaricAst d...+j e.r! use
Grease Trap(locate on/site plan):
Depth below grade:
Material of contra
❑ concrete I ❑ metal ❑fiberglass ❑polyethylene ❑other(explain):
/-� a yt,a
feet
Dimensions:
Scum thickness
Distance from top of scum to top of get tee or baffle
Distance from bottom of scum to ttom of outlet tee or baffle
Date of last pumping:
Date
Comments(on pumping reco mendations, inlet and outlet tee or baffle condition,structural integrity,
liquid levels as related too t invert, evidence of leakage,etc.):
Tight or Holding Tank(tank musfbe pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete [/7 metal ❑fiberglass ❑polyethylene ❑other(explain):
t5insp.doc.doc•042003
The 5 Official Inspection Form:Subsurface Sewage Disposal System•
Page 12 of 12
Commonwealth of Massachusetts
uTitle 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
!v/ /new 10744.4; S#.
Property Address
Plo re Ott
C' crown
Owner's Nang
Tight or Holding Tarjk(cont.)
Dimensions:
Capacity:
gads
State ZIP Code
/o—/.os
Dated Inspection
Design Flow:
gallons per day
Alarm presen ❑ Yes ❑ No
Alarm level: Alarm in working order. ❑ Yes❑ No
Date of la pumping: Date
Comments(condition of alarm and float switches,etc.):
Distribution Box(if present must be ybened)(locate on site plan):
Depth of liquid level above outlet i ert
Comments (note if box is level a distribution to outlets equal,any evidence of solids carryover,any
evidence of leakage into or box, etc.);
Pump Chamber(locate site plan):
Pumps in working o r:
Alarms in world order:
t5l sp.doc.dec•0972003
❑ Yes
❑ Yes
❑ No
❑ No
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•
Pane 13nf13
1 Commonwealth of Massachusetts
uTitle 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
G! nkm.r foi.r.J
Properly Address
Pkrevice - 0/042-
City/Town • State Tip Code
Rok no Wood. ID-//-05-
(Timers Name Date of Inspection
Comments(note condition of pump 9liamber,condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS)(locate on site plan,excavation not required):
If SAS not located,explain why:
/QAck p r
Type:
6 - 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.): •
_443vlens 743 .he SA4.944.. So./ -
,vo £ ,de.oc aw. o do +rot Zc vayLt-.• o'Seioc'
t5insp.doc.doc•04/2003
Tele 6 Official Inspection Form:Subaurfece Sewage Disposal System•
Page 14 of 14
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
40/ 717oa.ri44;AM/:
Property Address
re.oc.e
Ci own
/.
4t. Wool
Owners Name
Cesspools (cesspool must be
Number and configuration
Depth—top of liquid to inl
Depth of solids layer
Depth of scum layer
Dimensions of ces
Materials of con
ool
ction
/Pa .
State
Jo /�0.5
Date of Inspection
OC
Zip Code
umped as part of inspection)(locate on site plan):
invert
Indication of , oundwater inflow ❑ Yes ❑ No
Comments ote 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
etc.):
ndition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,
t5insp.doc.doc•04/2003
Tolle 5 Official Inspection Perm:Subsurface Sewage Disposal System•
Page 15 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cord.)
L/ gegyza1441.0 54..
P Properiyiddress
/ Ornic e
Clalown .
Hob.NJ Woad
Owners Name
0404,
State Zip Code
/O- //-OS
Date of Inspection
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.
t5ousp.docdoc•04/2003
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-
Page 16 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
Property Address
Flop-edict in •
Citygown • State
Kob, j Wood /o- //- os
Owner's Name Date of Inspection
Site Exam:
Slope
..c.dasv-.-
Surface water
ei/O&,2
Zip Code
Check cellar �~y
,t4107/
Shallow wells
6F
Estimated depth to ground water. f
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: Data
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 groundd water elevation.
ClOS6h//Cp 5-'',/e 1 . /Q'da�lisnp f/ha/J 9• ,
ZQS/ 03
t5insp.docdoc•04/2003
The 5 Official Inspection Faro:Subsurface Sewage Disposal System•
Page 17 of 11
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Owaaor
JANE SWIFT
In--..Governor
COM$ONWEALTH OF MASSACRUSETIS
EXECUTIVE OFFICE OF E Nvuto a sTTimLAFFADIS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET, BOSTON,MA 02108 817-292.6600
SUBSURFACE SEWAGE INSPOSA{.8y87Er INSPECTION FORM
PART A
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PART C
MIENIRpORMATIONlartl1
eoo nne
i rn1.4;v V. -Pore As cap_ MA .
PncidY Coast _ Wald
Date dbsPeetwc 1.4.03
BUILDING SEWER:
neon)on ate Otto
Depth below grade: 14
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NtffTCH of tEWACE DISPOSAL SYSTEM
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so-6 G -19 a» na+%f 19N, n'r "O( �9
a
O
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Appiiratian far 19ispusai Cu-tar
Application is hereby made for a Permit to Construct ( ) or Repair
System at:
Type of Budding
Dwelling—No. of Bedrooms
Other—Type of Building
Other fixtures
Design Flow ga
g
Septic Tank—Liquid capacity
Wr
a l
Disposal Trench--No.
Seepage Pit No Diameter
Other Distribution box ( )
Percolation Test Results Performed
Test Pit No. I minutes per
Test Pit No. 2 minutes per
FEB?/.�./.............
It j rrmit
an Individual Sewage Disposal
or Lot
Address
Address
Size Lot Sq. feet
Expansion Attic ( ) Garbage Grinder ( )
Showers ( ) — Cafeteria ( )
No. of persons
lions per person per day. Total daily flow gallons.
Ions Length Width Diameter Depth
dth Total Length Total leaching area sq. ft.
Depth below inlet Total leaching area
Dosing tank ( ) Date
by
inch Depth of Test Pit Depth to ground water
inch Depth of Test Pit Depth to ground water
Description of Soil
Nature o epairs or Ansvyer when applicable_
a t r / I QZ ° J. ._. l
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of:IThr. 5 of the State Sanitary Code by t. board of further agrees of to place t��ysteV�
issuld
operation until a Certificate of Compliance has
Application Approved By
Application Disapproved for the follow
g reaso
Permit No
Issued. q2/ kpate
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
(dtrtiftratt of itantt or Repaired THIS IS TO �ER7TFY Tat the ndividual Sewage Disposal System constructed ( ) � ( Z4-
at. �O/fd[�%t4 �7 m,leltu
hk
has been installed in accordance with the provisions of TITLE� rj of1%te State Sanitary C_ot�e�s���ribed in the
application for Disposal Works Construction Permit No / ¥b i/
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL EU��G7�'I/QN/SATISFACTORY.
DATE `�/1.f �'` Inspector
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
No
Binpusatilorito
Permission is hereby granted.-._f L
to Construpt ( )or Reoair ( f aanAmdlvydual
at-Np , '!
as shown on the application for Disposal Works Construction P
fr
f _ 1r-1.1.4
C�ttctian jtrmit
e Disposal System
DATE
FORM 5255
KIN. INC.. BOSTON