549 Title 5 Application/Permits 1978, Soil Evalutation 1978, Septic Inspection 1995 .fi 9 1 M
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
I
CERTIFICATION (continued)Property Address: 599 do ns Sr "'s Rd. /1ei1ln.fla l
Owner. Len 50Korows C(
Date of Inspection: tl' 1 19s
el SYSTEM CONDITIONALLY PASSES(continued)
_ Sewage backup or breakout or high static water level observed 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):
Coder
_ broken pipe(s) are replaced
obstruction is removed
v distribution box is levelled or replaced
yap pleat
_ The system required pumping more than four times a year due to broken or obstructed pipets) The system will pass
inspection if(with approval of the Board of Health):
_ broken pipes)are replaced
obstruction is removed
CI 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 and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND 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 THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
_ l n. .v.wn. na, a semIC is( riled awl .,,'..p14•1• st Steil and Is .r 103 feet .c :. s'arfa.c water sapp . ...__ -, -
surface water supply.
_ The syslem has a septic tank and soil absorption system and is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
_ The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water
supply well, unless a well water analysis 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 S
ppm.
DI SYSTEM FAILS:
_ I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
_ Backup of sewage into facility or system component due to an overloaded or dogged SAS or cesspool.
_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or dogged SAS or
cesspool.
(revised B/15/951
2
WIWrn F.Weld
9s
Trudy y co Cox•
..•••1•.WH,
David
Co ht
Commonwealth of Massachusetts
Executtve Office of Environmental Affairs
Department of
Environmental Protection
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: $c/9 Aar th Farms Picot
Nart{aaP ior N% Address of Owner.
Date of Inspection: ///Z if S Of
different)
Name of Inspector: fired Fr tics
Company Name,Address and Telephone Number: F)s os Enfrp, ;set Inc
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reponed below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
."-Passes
_ Conditionally Passes
_ Needs Funher Evaluation By the Local Approving Authority
Fails
Inspector's Signature:
q�',"s�.( g („/_
The System Inspector shall submit a copy of this inspection report to the Approving Authority 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 Department of Environmental Protection.
The original should be sent m the system owner and copies sent to the buyer, if applicable and the appros ing authority.
Date:
rr/2' /p5
INSPECTION SUMMARY:
Check A. B,C,or D
A] SYSTEM PASSES:
r/TE 1 have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
B] SYSTEM CONDITIONALLY PASSES:
_
One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,
passes inspection.
Indicate yes, no, or not determined fY, N, or ND). Describe basis of determination in all instances. If not determined', explain why not)
_ The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfihration, or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as
approved by the Board of Health.
I revised 8/15/95)
1
On•*After Strait • Boston,Massachusetts 02108 • FAX(617)5561049 • T•aphe •(617)292-5500
0 Primed en Recycled Pape
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
_ PART A
A+vus Y." CERTIFICATION (continued)
Property Address: 599 4rdns Firms
Owner: Len 5eicaeowsCi
Dated Inspection: a t zi cis-
SYSTEM CONDmONALLY PASSES(continued) •
_ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipers) or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of the
Board of Health):
_ broken pipes)are replaced
—s/-y obstruction is removed
distribution box is levelled or replaced
1164.f64 Ate
Cover
c n tp(ereJ
_ The system required pumping more than four times a year due to broken or obstructed pipers).'The system will pass
inspection if(with approval of the Board of Health):
_ broken pipets)are replaced
obstruction is removed
CJ FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
_ Conditions exist which require further evaluation by the Board of Health in order to determine
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT
WHICH WILL PROTECT THE PUBLIC HEALTH AND 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.
if the system is failing to protect the
FUNCTIONING IN A MANNER
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATD DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
_ I n smem nes a aeuut 1.6111k di'u au a.v...opovi. s)=ten; and is ss;th■rl ICC feet to a s'-ia_c water supp. or...__ -, -
surface water supply.
_ The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well
_ The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
_ The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a p 'vale water
supply well, unless a well water analysis 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.
DI SYSTEM FAILS:
_ I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
_
Backup of sewage into facility or system componem due to an overloaded or 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 o
cesspool.
trevaeea 8/15/e5)
2
Property Address:
Owner:
Date of Inspection:
Di SYSTEM FAILS(continued):
hs
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Static liquid level in the distribution box above outlet imen due to an overloaded or dogged SAS or cesspool.
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 dogged or obstruaed pipelsl.
Number of times pumped
Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any potion of a cesspool or privy is within a Zone I of a public well.
Zty 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
J acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
conform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
El LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above:
The design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety
and the environment because one or more of the following conditions exist:
_ 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
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revived B/15/951
3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 6H 9 /IAL Frni/S
Owner: 1.241 e ta41 d WS
Date of Inspection: n/N/fr
Ed. Nert/fany
Check if the following have been done:
Pumping information was requested of the owner, occupant, and Board of Health.
None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
during that period. Large volumes of water have not been introduced into the system recently or as pan of this inspection.
AIZ As built plans have been obtained and examined. Note if they are not available with N/A.
The facility or dwelling was inspected for signs of sewage back-up.
f /The system does not receive non-sanitary or industrial waste flow
Y The site was inspected for signs of breakout.
ZAll system components, excluding the Soil Absorption System, have been located on the site.
✓ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or
tees, material of construction, dimensions, depth of liquid,depth of sludge, depth of scum.
✓The size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
ZThe facility owner ;and occupants, if different from owner) were provided with information on the proper maintenance of Sub-
surface Disposal System.
(revised 6/15/95)
4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
�//'' carols INFORMATION (continued)
Property Address: it NO carols �Ci Nor 40,0/cm
Owner: Len Jrskapt 0W34 (
Date of Irtapection: f/ /z/ /q(
SEPTIC TANK: ✓ ,1000 9G/,
(locate on site plan)
Depth below grade: /33.
Material of construction:✓concrete_metal_FRP other(explain)
Dimensions: if X 7 X ff cide0
Sludge depth: /R 7 r(
Distance from top of sl dge to bottom of outlet tee or baffle:
Scum thickness: -
Distance from top of scum to top of outlet lee or baffle: y it
Distance from bottom of scum to bottom of outlet tee or baffle: If r
Comments:
(recommendation for pumping, condition of nlet and outlet tees or baffj�s, depth of liquid evel in relation to outlet invert, structural
integrity, evidence of leakage, etc.) Aso w free gala+ (Ss fir ellST-'I
GREASE TRAP:_
(locate on site plan)
Depth below grade._
Material of construction: _concrete metal _FRP_otherlexplain)
Dimensions.
Scum thickness
from top of scum to top of outlet tee or baffle.
D:G2"Ce tro^ bonN^ ^• `r: r., nonnm or Clonal tea e' Dania
Comments.
(recommendation for pumping condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc
revised e;s/esi
6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
� // 'S/YSTEM/INFORMATION
Property Address: 549 Aid. Firms Rd dort/Iamp fern
Owner: teN Jakute did f<r
Date of Inspection: // /21 /QS
RESIDENTIAL:
Design flow: 430 gallons
Number of bedrooms: 3
Number of current residents:4
Garbage grinder(yes or no):_g O
Laundry connected to system(yes or no): S,S
Seasonal use (yes or no):_Et 0
Water meter readings, if available: N/^
FLOW CONDITIONS
Last date of occupancy: j'(CS en T
COMMERCIAUINDUSTRIAL
Type of establishment:
Design flow: gallons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: ryes or no)_
Non-sanitary waste discharged to the Title 5 system: (yes or no)_
Water meter readings, if available:
Last date of occupancy_
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
Yuen peel /985
System pumped as pan of inspection (yes or no) S
If yes, volume pumped DQO allons
Reason for pumping o ill SP ec F(eT farr1003es
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)
— Other (explain)
APPROXIMATE AGE of all components, date installed (if known)and source of information:
/9 78
Sewage odors detected when arriving at the site: (yes or no),ad
(revised 6/15/951
5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C. .
.�
SYSTEM�INNFORMATION (continued)
red ro
Property Ado 54 f NO rhls ed No r At ostio
Owner: Len cTCIc la ecuskl
Date of Inspection // z/ 7fi
SEPTIC TANK:✓ /000 lilt
i. (locate on site plan)
r ,,/
Depth below grade: /3.
Material of construction: ✓'concrete_metal_FRP other(explain)
Dimensions: B x % ' x N p
'dee
Sludge depth: i.R _ / r!
Distance from top of sludge to bottom of outlet tee or baffle:_?
Scum thickness: r
Distance from top of scum scum top of bottom tee outlet baffle:_ ,r
Distance from bottom of scum to bottom of outlet tee or baffle: /'%
Comments:
(recommendation for pumping, condition of'nlet and outlet tees or ba�j , depth of liquid)evel in relation to outlet invert,structural
integrity, evidence of leakage, etc.) X4 to AA-ee/Cit T ✓ed.n ha 14 re-Ss.-7
GREASE TRAP:_
(locate on site plan)
Depth below grade:_
Material of construction: _concrete_metal _FRP other(explain)
Dimensions.
Scum thickness.
Distance from top of scum to top of outlet tee or baffle:
D!sta,ce nor, noncifn •r. In nonnm or rnmei tee of nai.nt.
Comments:
(recommendation for pumping. condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert,structural
integrity, evidence of leakage, e!c.i
(revised a/:s/ssi
6
Property Address:
Owner Lsn
Date of Inspection:
SOIL ABSORPTION
(locate on site plan,
If not determined to
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)•
5'17 Ale FrMS �e( X.4e A4Mfine
AIM o6(0
SekanowsL a6E
SYSTEM(SAS): ✓
if possible; excavation not required, but may be approximated by non-intrusive methods)
be p • Srncin: tar'IL a. LT atie
Type
leaching pits, number:_
leaching chambers, number:
leaching galleries, number:_
leaching fields, number,nbmbegmensi:�_B60 p� -ix
leaching fields, number, dimensions OO
overflow cesspool, number:_
Comments: (note condition of soil, signs of hydraulic failure, level of pending, condition of vegetation etc.)
CESSPOOLS:
(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 (cesspool must be pumped as part of inspection)
Comments: (note condition of sod, signs of hydraulic failure, level of pending, condition of vegetation, etc.)
PRIVY:
(locate on site plan)
Materials of construction:
Depth of solids:_
Comments: (note condition of soil,signs of hydraulic failure, level of potding, condition of vegetation etc)
Dimension:
(revised S/15/95)
S
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (cootinuet
Property Address: 599 N . Farms Tfza nip/ow
Owner: Len cTe k an o w s k i
Date of Inspection: At /cc
TIGHT OR HOLDING TANK:_
(locate on site plan)
Depth below grade:_
Material of construction: _concrete_metal _FRP_other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm level:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:_V
(locate on site plan)
Depth of liquid level above outlet invert O
Comments:
(note it level and distribution is equal, et iaence of solids carryover, evidence of leakage into or out of bop, etc.)
D SO ✓idfetls Sat realer nuntbe/ o !.'as.- e (M)
PUMP CHAMBER:
(locate on site plan) -
Pumps in working order:(yes or no)_
Comments:
(note condition of pump chamber, condition of pumps and appurtenances etc.)
trevised 0/15/95)
7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
/
SYSTEM INFORMATION (continued)
Property Address: ST17 AL 'Cron ,Pi 4r/444 kv AM: G/a Co
Owner: lan Sekcanogoskr
Date of Isspectiora
SOIL ABSORPTION SYSTEM(SAS):✓
(locate on site plan, if possible;excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, esplain:
X' Sex L✓' %� t Q4'l�
Type
leaching pits, number:_
leaching chambers, number:_
leaching galleries, number:_
leaching trenches,number, d,length:_r-B6o nir f/ •
leaching fields, number, dimensions: J Y
overflow cesspool, number:_
Comments: (note condition of soil, signs of hydraulic failure, level of pondin& condition of vegetation etc.)
CESSPOOLS: _
(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(cesspool must be pumped as pan of inspection)
Comments: Inge condition of soil, signs of hydraulic failure, level of pondin& condition of vegetation, etc.)
PRIVY:
(locate on site plan)
Materials of construction:
Depth of solids.__
Comments: (note condition of soil,signs of hydraulic failure, level of pending, condition of vegetation,etc.)
Dimensions:
(revised 9/15/95)
8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFjTION (rakinued)
Property p �ts: Je4Arow firms Rd. Nnt%a 1110 MA.
Date of Inspection: s(/Q( /lc
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
Leah field .Bed
800 .37 . FY.
[ n I
I�
No Farms Rd.
SPfio Ter Ai
rIDUSE
Tanksa t
Lcaolx 106' i
DEPTH TO GROUNDWATER
Depth to groundwater: to fi feet ,( /�n p /
method of determination or approximation: Acif e r 3 -4 T f l ye// a l
ea/!7 eat
(revaeetl 6/15/95)
9
.mod ?9
7.1.a. %alit
7. 1# l
v£ :/ , Z, 2 ;S
0� / £F ;/ � __CZ •/ „ %/ ;s
,�, „£ ; / EZ ., (o°M 1,4'.Pi2ms6'3`✓ 3W1
1/G1(�3a'nsN7(/ 34.cz
1s� XO9 enoy Sz _..970/1 'Q
S3'd'OOXJOd� l •d1 ,%/2617071W 'rr
r j`°2' I
(Aess.827/J/ 1.M4-d'3,0 awls
1_97 '/✓/J!✓/N'/ AS- 07779 d vgI d�9,Y)
(gz) 1s e a'nod ysn ' o�-
42 ; 7
fNeJ /15. 1 anc7i Y//O
�. qv r r7lorv /pi /4 ,G/ dole.., 'Z
7
/// tz7a Z/ 970/,/ 77/'
77/441 745, / .270y _1 St.L
od s �1 :jd6'x9odg.z
n3iv1 �ld9o7 74�e/6 .tzz6'¢'
oO Oo eon f_vp'
° srs g .1,0"1/ r // a/Xzrop yd
9979 %4 rid i
i?i •ocy SWagtyltioty 1��d1S
'L a wag/ / o�ssveHt a'a/v ://t11
/7.22.72/S' 9/16'.7
1s22 A7/1U7o•7d c
•
.-1caC. _*Y/ 7'7/7 ✓/ r
--',=,-do SrEG eY: IL/At 74- ✓AGEC
L oc.a 7/04. oA;. 9/772
47eXeccv Ffi,?/ns e13. ogjeA'vfV ✓. HiAPT
Na.e7tiiJ.a1P41t/v_-
F
sLeo
/
7o fixes
Oe6A✓i�
✓•TP ems,'61
07C f
Ca447-0
-1_
620 UNG
6s AC,Ac
7/t-L
¢ ev
I4 7E<- ^«ONC c:G.i:j
6.Fo 4..:2 s4A rce GROU,vc, N1.7
ALMER HIJNTLEY, JR. a ASSOCIATES , INC.
REGISTERED LAND S VEVOHS 8 L'VJL ENGINEERS
238 BRIDGE'
CHECK OR FILL IN WHERE APPLICABLE
No
Fax..
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.Appliratinn fur finpnnat
nrkn alutu trurtinn iirratit
Application is hereby made for a Permit to Construct ((-1-'or Repair
System at:
Lg<v..�'....Fnice rs
3-¢2 t ,r,,,AL. Nok
an Individual Sewage Disposal
Address
9G.t7.Q.
Owner
Installer
Address
Type of Building
Dwelling—No. of Bedrooms 3 Expansion Attic
Other—Type of Building No. of persons
Other fixtures
Design Flow 3-0 gallons per person per day. Total daily flow 3e`'C gallons.
Septic Tank—Liquid capacityLFGQ..gallons Length_LCG" Width4 " Diameter Depth 41E 70"
Disposal Trench—No....# Width..?"°"' Total Length.L4 ' Total leaching area _¢.C....sq. ft. a'e
Seepage Pit No Diameter Depth below inlet Total leaching area sq. ft. 7� 5'E
Other Distribution box ( ) Dosing tank ( ) of 8e`D
Percolation Test Results Performed by.26'%?7/ftle/fl-CV 'S>e'' Date_..5L%7-2-
Test Pit No. 1 rs minutes per inch Depth of Test Pit e `Z' Depth to ground water 4/6-
Test Pit No. 2 % minutes per inch Depth of Test Pit -Cr: G , Depth to ground water • o.✓E
Description of Soil_6" n2e6 el Y'C 7G°SR<4....[i_.C'-Aij.6M t /“a" Sit? Ce et9/6"r Ce'-'O
Address
Size Lot Sq. feet
Garbage Grinder (N"
Showers ( ) — Cafeteria ( )
Nature of Repairs or Alterations—Answer when applicable
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed
Application Approved By
Application Disapproved for the following reasons
Date
Dale
Data
Permit No Issued.
Date
CHECK OR FILL IN WHERE APPLICABLE
No...J:2.7
THE COMMONWEALTH OF MASSACHUSETTS
_BOARD ,OF HEALTH
__ OFt
Applirtttiun fur Qiupusttl Utunntrurtiun lrrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
Aires
A imp- •Yr , Address
ediTL-6T¢ i .dcAW
FES.4J.!.. ..4
or Lot No.
l..
jr 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
Seepage Pit No Diameter Depth below inlet Total leaching area sq. ft.
Dosing tank ( )
Performed by Date
minutes per inch Depth of Test Pit Depth to ground water
minutes per inch Depth of Test Pit Depth to ground water
Other Distribution box
Percolation Test Results
Test Pit No. 1
Test Pit No. 2
Description of Soil
Nature of Repairs or Alterations—Answ when ap icab
„.LA. (z.
Agreement:
The undersigned agrees to install the aforedescribed individual Sewage Disposal System in accordance with
the provisions of TIT s 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.
Signed ' .LLLL(a 4...;,/tIC k.&`1 7T L
Yl [^12^, ... . Lied L, " e
( .-�YS'4.44
Application Approved By L� ..
/trhl, rt / 7e-
Date
Application Disapproved for the following reasons
Permit No 6)I'12
Issued... .a' 7..f.f,7
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
cy, OF
Crrtifirutr of Qtaih{Ilianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (V)
InstaBer:.
has been installed in accordance with the provisions of Ti',.. 5 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 jJ' l .>. i.....:_ Inspector
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
FEE
3lis.prwal
K8
arks Qinnzlrurtion rrmit
Permission is hereby granted
to Construct (_) or Repair ( ') an Individual Sewage Disposal 4stem
at No
Scrct
as shown on the application for Disposal Works Construction Permit No Dated
Board of Health
DATE
FORM 1255 HOBBS Or WARREN. INC.. PUBLISHERS