812 title 5 applications/permits 1984, 2005, Inspection Report 2005, eety 06 Zoitaast, ?114444chaaed
212 3 un Seteei
Waraciatfrean, Wed 01060
%C, 413-587-1214
lax 413-587-1221
Title V Certification of Compliance
TO BE FIT I FT) OUT BY THE SYSTEM INSTALLER
INSTALLER SIGN-OFF
Pursuant to 310.CMR 15.00 of the State Environmental Code:Title V, Minimum Requirements for the
Subsurface Disposal of Sanitary Sewage,Section 15.021 (3),the Installer of a system is required to sign
this form as a condition for issuance of a Board of Health Certificate of Compliance for the onsite septic
system
This is to certify that the onsite sewage disposal system that I installed as:
�" new censtmction
at t9(�7 ' -14 repair(existing system)
ry z on0 c4,200.‘" DWCP number 2c&
(Address) (Date `� �S
has been constructed m compliance with 310
original approved plans have been reflected on an
hw135. k Gw-y
5 y'evc. (T(H,'rz
(Print Installer's name)
C,MR 15.00, and all local requirements.Any changes to the
as-built plan that has been submitted to the Board of Health.
NOTE:This certification represents no warranty,expressed or implied as to the functioning or longevity of the on-site
subsurface disposal system. Rather,the plan and installation are in compliance with all applicable rules and regulations as are
in effect at the rime of plan submittal.
COMMONWEALTH OF MASSACHUSETTS-
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5:1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
woe t/ /BUG
Property Address:
Owner's Name:
• Owners Address:
Date of loepeetlon:
Name of ipipeetort
• 'Company Nome:
Mailing Address:
Telephone Number• j:-/z ,-S
CERTIFICATION STATEMENT
1
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 theinspettfon.The inspection was performed Mined on my
training and experience in the proper Madan and mammas ofon,site savage disposal systeins:I am•DEP
approved system inspector pursuant to Section 13,340 of Title S(310 CMR 15:000): The system,: '
lease print) .W/<-!....//9? l //f/1%2,/72/ .. Pi
s'lx,Ot •
/cz2
4 • ti1.
Conditionally Passes
. - .� Ne� Further valuation by the Local Approving Authority
Inspector's Signature: ! ! _ Date: //�/ors. ..
The system Spector shall submit a copy of this inspection to the Approving Authority(Board of Beall or
DEP)within 3.0 days of completing this Inspection.If the system is a shared system or has a design flow of 10,000
ad or greater,the inspector and the system owner shall submit the to the
DEP.The original should be sent to the system h eappropriate, f pl regional
bl ,onal nfeapprove..
auWari ystem owner and copies sent to the tiuycr,if applicable,and
ty .
Notes and Comments , /teeCiact /�/Qr� 12ptir 0"C-42
.!!-eCessQvy ,za ec /c-r u- .n/
c3/o ex-I< ✓rt a
f ••••T6h report oniy.describes conditions at the time of Inspection and under the conditions of use al that
time.This Inspection does not address how the system will perform In the future under the same ordiffereot
conditions of user -
Fade 2 of I1.
OFFICIAL.INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENT&
SUBSURFACE SEWAGE DISPOSAL SYSTEM I NSPEC ION TORM
PART A
CERTIFICATION(melmrd)
Property Address:
egia /45/07
Owaw: r5
I .
Date of hepatica: 54// 3/4 5
laspetdon Summary: Check A,B,C,D or B/ALWAYS complete all of Section D
A. System Posses:
I have'nal(bond any information which indicates that any of the allure 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 described in the"Conditional Pass"section need to be replaced or
repbed.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_Wrnenu If Ism determined"please
explain
•
kThe septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration aornflutbn or teak thaws afmminem.System will past fmpecion((the
existing tank is replaced with a complying septic tack 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
�yeears old k available. 1
ND explain: 77Mt /JeecJS J2+€/o1C fr .
Obsrvadon of sewn*backup or break our or high static wart loved in the distribution box due"'broken or
obstructed pipe(s)oi due toa broken,settled a onto di on box.System will pus inspectionif(with
.Approval ofBoand of Health):
_ broken ptpe(s)ammpboad
&stru sin novel
_
distribution box is leveled aemitted
ND explain:
_ The system required pumping more than 4 times a pa doe to broken or obstructed ninths).The system will
pass inspection if(with approval of the Board of Heaffik
broken pipe(s)are replaced
_
obstruction b removed
Page 3 of 11
OFFICIAL INSPECTION FORM•NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: Cy/a /1/0/07/ ,k/.0& S
4JO/IJl-/i9n g/?JKl 444
Owner: . ( LPL(.
Date of Inspection:
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 I5.303(1)(b)that the
system is not functioning in a manner which will protect 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 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.
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 coliforn
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.
3. Other:
3
Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 8/° ,10012, 41 F9ti�o ,!T
,7m,oJ�J M0 SS
rouisl�
V/3/or
Owner:
Date of Inspection:
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"n0"to each of the following for all inspections:
Yes No
x
— %(
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 ih 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 SAS,cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy is within 100 feet of asurface water supply or tributary to a surface
water supply.
Any portion of a cesspool or privy is within a Zone 1 of a public well.
Any pomon of a cesspool or privy is within 50 feet of a private water supply well.
Any pomon of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
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.)
A/6 (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.
,vee clod '24C4ir5 CC)/CC. 6t: '.E 'tt #0
E. Large Systems: O it 4
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 significant threat,or answered
"yes"in Section])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.
4
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 94' 'WOW 4/ZIG 51
4)012.1 ' --r,%S4esc/ /WA/
Owner: /2 Z.m5.radi s
Date of Inspection: ro /3/0 Jt-
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
X Were any of the system components pumped out in the previous two weeks?
X _ Has the system received normal flows in the previous two week period?
X Have large volumes of water been introduced to the system recently or as part of this inspection?
LO AU4yL19Wereeaas built plans of the system obtained and examined?(If they were not available note as N/A)
J( _ Was the facility or dwelling inspected for signs of sewage back up?
V _ Was the site inspected for signs of break out
_ Were all system components,excluding the SAS,located on site?
y _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid, depth of sludge and depth of scum?
>( _ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on
Yes n4o
t Existing information.For example,a plan at the Board of Health. /(X, 47j14<G/4S
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))
5
Page 6 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: enri 4/D j%% k/, DY,L '7
r2%061/ f"Vh/QZT
Owner: / /},5.77)a-/sef5,
Date of Inspection: (L1)7/O C
FLOW O IT[ S
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual): .j
DESIGN flow based on 370 CMR 15203(for example: 110 gpd x q of bedrooms):
Number of current residents: /
Does residence have a garbage grinder(yes or no):N<'
Is laundry on a separate sewage system(yes or no):( j[if yes separate inspection required)
Laundry system inspected(yes or no):AZO
Seasonal use:(yes or no):iii
Water meter readings,if available(last 2 years usage(gpd)): J G4/c /'c C
Sump pump(yes or no):_A.10 3;:/rip ,J 6x4/05
Last date of occupancy: —
COMMERCIAIJINDUSTRIAL -mvri
Type of establishment:
Design flow(based on 3.10 CMR 15.203): gpd
Basis of design flow(smWpersonstsgft,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):_
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: 19 t 9 Pt_-1,)F cf Per crAcJ w1 fC
Was system pumped as part of the inspection(yes or no):
If yes,volume pumped: /C z,tgallons—How was quanti�ped determined?
Reason for pumping: // '.91 C et
TYPE OF SYSTEM
j Septic tank,distribution box,soil absorption system
Single cesspool
Overflow cesspool
Privy
_Shared system(yes or no)(if yes,attach previous inspection records,if any)
_Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
_Tight tank _Attach a copy of the DEP approval
_Other(describe):
Approximate age of all components,date installed Of known)and source of information:
j7.)-/JvtflO //c/o(/' (5j''rs/Y7 0 -5 lsr' 66.0
Were sewage odors detected when arriving at the site(yes or no 5eanc.77/A/ /s 061-/A.//GO r
G CO.uo/7704)
N
Page 7,111
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner:
Date of Inspection:
0/417' ,/.v6 BTx ecT c�
t/77 A04_, h/i%t15J
BUILDING SEWER(locate on site plan)
rI 36 it
Depth below grade: ZV t
Materials of construction:_cast iron 40 PVC other
Distance from private water supply well or suction line: P
Comments(on condition of joints,venting,evidence of leakage,
%'Z�4)M fn AF
� r•
explain): fan 35
U.BUC Nett
etc.):
a`1li, if •
SEPTIC TANK:_(locate on site plan)
r.
Depth below grade: �
Material of construction:!�concrete_meal fiberglass polyethylene
otbe(explain) . —.ea) irs eta tow, ,c eeds 4 %e / .tp/a cod
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of.
certificate).
Dimensions: B k 5 ".S Cie /`/oA.J 1, 4_19
Sludge depth: /2
Distance from top of sludge to bottom of outlet tee or baffle:AS -
Scum thickness: 3 i
Distance from top of scum to top of outlet tee or baffle: 3 3 ii
Distance from bottom of sewn to bottom of outlet tee or baffle: 20
How were dimensions determined: /24-1 fS 021 d
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outletinvert,evidence ofjeakage ):
PUn-roe xvlyt /D /it-' ere / /w%.0.--/ate
ou/4 •
GREASE TRAP: (locate on site plan)
Depth below grade:
Material of construction:_concrete_metal_fiberglass polyethylene_other
(explain).
Dimensions:
Scum thickness: •
Distance from top of scut[to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or 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.):
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 8/.2 *//06 5
Owner: 22 L-Ji$%-z 9SA7L
Date of Inspection: ‘1/3/05—
,0,079
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: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):_
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX:-(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: U
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.): "" )
,» 57 tc:.f ,c-e ) /.0 Ccozy Ga c/c/ T7e/,ft
0W/
PUMP CHAMBER:_(locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
8
Page 9 of l l
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: (949 4/0/2/71
/B k4c4 Sr
/72,0Al2 /✓J/5i
Owner: - ,Q { , S
$/
Date of Inspection: %/. o'.i
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Type /COutVO 2e4 u-e & ,t&aw c,*o }e-ti
leaching pits,number. Z �%ae or a4..//y ✓�. '-emu J `� cc-.0
leaching chambers,number:_ �'/-. r-
_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.): LOU/se.. C,64fm Xi ,- /5 4e,x/c "OOo4tZ2
<•>i r'1 cttv'.c/3'C <c'-RTC/2_ fro
5/.9 6 true re-c/o 4 .
CESSPOOLS:��spool 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 laver:
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.):
/ON19
PRIVY:_(locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
Page 10 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: C9162 /vo,wV 4416 5-7
Owner: G/%5/-IG[/ s-
u, �4
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.
SiCfl/%t %Mac-
J' ,i 78
$c: 36.8
r- /joie
AD 3
so '{A,b
etc,
A6 /tz,o
,Vtx f2P k) �' ,9t kr
7a B£ A
/�rmd /7-
09 rut.°/r=
F
/vo i //a z, 1° S ✓
Page 11 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
M 'V6 `sr
Property Address: eJ 1/a �D2'i�
.t/Dfltlittn✓slog./ Nl�I
Owner: a t 95rotisle- C..
Date of Inspection:
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
sysl
Estimated depth to ground water ' feet GAt/cy [`--5-feals ocD
Please indicate(check)all methods used to determine the high ground water elevation:
_Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
)C Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
NO girl/v..5 1c004/19 />/¢rZ
You must describe how yyu established the high ground water elevation:
/4T Soil
Chit;/01 .el' / u//14
lYJ%rav v'I �'/ be z4n 4'per/ 1 y9WP/,J,q o CIVU
Or CA'Ynndcr 5 s✓co/t/&
II
S
FEE naI)
CO' MONIW{A'JIl Of MASSACHUSETTS tut t- ng
(
54
3351
Board a Health, 4/0/2/71/9/17,41; MA. $99 -Ib} y(_w�?
CATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
'ice G./(-
)cation P, 4,95% it/5/6„L
Owners Name a G7/�7ea./f lG,
ap/Parcel#B/2 4/0/Z 771 *1V6 ST
sbldres /&3 Soflj p/rz
tt beirgrkJ3/V7'/aa(' /WQ55 i i
tstaller's Name r a
A., L- I _.tear.
Designers Name /. /FE-4
Address C//%
:kb ress / _�Amgen
elcphone# •_4///g^Cle --• sg3=1b / 0/S
aephone# 6'5-02S
—.CZ
of Building __/2-.E351/9/etiff r / e- /14.129E
ring-No.of Bedrooms O�.VOI4 ,t,b 4075,0615416
054
er-Type of Building r^// Z/_t
JP/%%/ C �
Lot She
ri'JS%` sq.ft.
Garbage grinder(4/0
No.of persons 4, Showers(/).Cafeteria µyea
cr Fixuires ' ��p
ign Flow (min. required/7D le 3 X/r57igpd Calculated design flow T at-it- Design flow provided gpd
n Date /P2/e-a 4 >a:21Rumber of sheets I Revision Date
5EEP77( s rJr /y/ gdfloani E P 143/a is,
rripuon of Soil(s) /0 A./4'
Evaluator Form No. /911.1J_ Name of Soil Evaluator Date of Evaluation��/
iCRIPTION OF REPAIRS ORAITERATIONS J2/FAL-4-c Ea-/sJ7-t 5'EA/7C T».r/L
a ve._ 77JLE S cemV/rn-L/cf
•undersigned age es to install th above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
her agrees to toplayetlhe em in ope ation until a Certificate of CCompliance has been issued by the Board of Health.
r e.bi e- .7/ Date (///05--
led X
v,
Decuors
COMMONWEAIIIqq➢ OF MASSACIIUSFTTS
Board of Health. %C (7.i 17 7,7:21 MA.
CERTIFICATE Of COMPLIAN'CF
cription of Work: W'Individual Component(s) U Complete System
tdersigned h rpb miry that the Sewage:Disposal System: Constructed () Repaired( ).Upgraded (1,Abandon ( )
els",ti l „ � r I art yin! % ,v "tick. 'etc<i /2I Ft -'/L jS yr9.Syj-S
been installed in accordance_ with+1 e p os�slo t of 310 CY[R 15.00 (Title 5) and tl rove i design plans/as-built plans relating to
hafon No. G' 5 / dated rt o i, ? Design Flow yr5(gpd)
taller kft t24 S & ,1K0 “44 Tia-6 r i a�j ��yy�
g1C l✓/64/ -T! :/ h)Ii TA /I, Inspector:
�J .y(GLG�': ' Date: �f/t .` �`Lr -r
e issuance of this permit shall not be construed as a guarantee that the tem will function as designed.
COMMONIWLALTI} OF MASSACIIIISFTTS
/foam of Health, '!t F 1 r1,71'
DISPOSAL SY'STF 'CONSTRUCTION PERMIT
emission is hereby granted« Construct( ) Repair VI-Upgrade p1 khan on( ) an indisidual sewage disposal system
l5 t I M 444, as described in the application for
sposal System Construction Permit No. '.S` S_,dated 3°° 23, ZefiC
ovided: Construction shall be completed wit m hree years of the date of this permit. I local conditiot must he met.
n 125 Rev.5,96 AM Wain CD BO9oeMA Date US 14/6,S Board of Health 74 ILL/1 t rY
FF 5—Ctvv
THE COMMONWEALTH OF MASSACHUSETTS
OARD 0:1 H ALTH
.Appliratiun fur Disposal marks Tuff traction Permit
Application is hereby made for a Permit to Construct ( ) or Repair (X) an Individual Sewage Disposal
System at: �I'' \\
tmn Ad
__... ...°.T"l_ vert
a2 a.
Installer
Type of Building
Dwelling—No. of Bedrooms
Other—Type of Building
Other fixtures
Design Flow
Sgptic Tank—Liquid capacity
Disposal Trench—
Pit No r� Diameter
Other Distribution box ( ) Dosing
Percolation Test Results Performed by
Test Pit No. 1 minutes per inch
minutes per inch
Addre
Size Lo Sq. feet
Expansion Attic ( ) Garbage Grinder ( )
No. of persons Showers ( ) — Cafeteria ( )
gallons
gallons
Width
per person per day. Total daily
Length Width
Total Length r..
Depth below inlet a'""'
Test Pit No. 2
Description of Soil
(� c
tank ( )
flow gallons.
Diameter Depth
..Total leaching area_ sq. ft.
Total leaching area_ b sq. ft.
Date.
Depth of Test Pit 7 9 `r Depth to ground water '74
Depth of Test Pit Depth to ground water
Nature of Repairs or Alterations,—Answer whdrn applicable
w-kC . a, SO 1•ee4x2c-.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code, he undersigned further s not to place the system in
board oyheal'
4-1,s-eat Asec-iiie
operation until a Certificate of Compliance has been iss
Signed
Application Approved By
Application Disapproved for the following reasons'
Permit No
Date
Date
Issued
Date
by
at
has been installed in accordant(yid, the provisions of TITLE 5 of�'he State Sanitary Code as d ed in the
application for Disposal Works Construction Permit No 232 —°y` N dated /�
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE AS A GUARANTEE THAT THE
SYSTEM WILL FUlj�fjTION SATISFACTORY. (1
DATE "
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF H•LTH
Cf r, • /rY
airrtifiratr at fanmpliturr
THIS IS T ERTI Y, hatch Disposal System constructed ( ) or Repaired (P
71 kJ ' f5
Installer
No
3
Permission is
to Construct (,1
at No
as shown on the a
DATE
Inspector s titt'
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH i
i
//
OF FEE c
Tispnsttl
hereby granted
oc Repair ((:_).an Individual Sewage Disposal System
`V /� i Street
pplication for Disposal Works Construction Permit,.No
II
',rho fannStrurtinn 1�ermit
FORM 1255 A. M. SULKIN, INC.. BOSTON
Dated—_..._f le/Y117
Board of Health