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HomeMy WebLinkAboutInspection Report 2020 Mar 15 IA L.16 �.�� . maz02,:: Pp_car.TO 9 V/1/ MAR 3 0 2020 . Commonwealth of Massachus�e tni.ve.T.R.e4te.4 Title 5 Official Inspection Form HEALTH DEPT _ . Subsurface Sewage Disposal System Form -Not for Voluntary Assessmen r t . r ( 5 ,,. t'.. 3 .4 A. Property Address L:74°0'--/- S ore_ LLC Owner Owner's Name information is 1 required for everyCl/ s .0144 1,44 "/4 V�t� /n 3 3/ichp page. City/Town State ZIp Code Date of i pectic Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. important:When A. Inspector inf tion filling out forms on the computer, l �j use only the tab a r I1'/ O �J ',11/ keyto move your Name of inspector y /� �I 0 -� 7 E C- cursor-do not �/,/// use the return key. Company Name g �/) / �Q ro /e / o v 111417Company Address ��S7f� �C,0-j /17./1 0oil 6 `T.2, City/Town S0 \ 01 0 'I / 90 State ` _O 4k Zip Code MeJ Pi N Telephonmber License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); i have personally inspected the sewage disposal system at the property address listed above;the information reported below is true,accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the s : 1. ' Passes • 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails /ri licideig. 3 Inspectors ignature Date //5/20 The system inspector shall submit a copy of this Inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: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. t5insp.doe-rev.7/26)2018 '2e 5 O"4a,;rspector.Form.S Osurface Sewage Disposal System•Paget of 18 • Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 0 C4'la Property Address 4E-5 i° Owner Owner's Name information is /� required for every -es 4(72,01.44 y.4 / i i4 03 6 '3 3 15 o page. CitylTown State Zip Code Date of lnspe on C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) Syste sses: 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: 2) System Conditionally Passes: E 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. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): tsinsp.coc•rev.7262018 ?me 5 Office inspection Form.Suosurtace Sewage Drsposa System•Page 2 of 18 • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments o Cc Property Address '---j Owner Owner's Name informationeis /�S AS N /,/ //9A 3 is 010required for every (� `r� . page. City/Town State Zip Code Date of In pection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ENE ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N E ND (Explain below): ❑ 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 ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) 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. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5fnsp.tloc•rev.7/26!2018 Title 5 Offidai.nspecnon Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts _* -P Title 5 Official Inspection Form ` * • Commonwealth of Massachusetts __ -14 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments (5--1- PropertyAddress, c Owner Owner's Name 6454. information is (4/Yl �A R'16*33 s //drequired for every Vo' CA page. City/Town State Zip Code Date of In pectton/ C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Li Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow rRequired pumping more than 4 times in the last year NOT due to clogged or 1.— l'Pobstructed pipe(s). Number of times pumped: D Any portion of the SAS, cesspool or privy is below high ground water elevation. E V" Any portion-of cesspool or privy is within 100 feet of a surface water supply or ributary to a surface water supply. Li Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. d ,J b Any portion of a cesspool or privy is within 50 feet of a private water supply well. E Lid' Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ The system is a cesspool serving a facility with a design flow of 2000 gpd- 0 000 gpd. 1—, The system fails. I have determined that one or more of the above failure —I 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. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or'no'to each of the following, in addition to the questions in Section C.4. Yes No ❑ D 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 • 7the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well 5insp clot•rev.7252015 -itte 5 Office lnspeGton Form.Subsurace Sewage Disposal System•Page 5 of 18 1 Commonwealth of Massachusetts F- �,FTitle 5 Official Inspectionection Form m S— Subsurface Sewage Disposal System Form -Not for Voluntary Assessments mentsa _ 1 . __ e ,0 C Ge vilta S 4- Property Address S Owner Owners Name information is "S =11?OLS i /T A Com. 6*3 3 /,S/�•b required for every page. City/Town State Zip Code Date of Insp tion C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section C.4 above the large system has failed.The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section C.4 shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No ❑ umping information was provided by the owner, occupant, or Board of Health ❑ re any of the system components pumped out in the previous two weeks? ❑ s the system received normal flows in the previous two week period? ❑ Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined? (if they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? Were all system components, excluding the SAS, located on site? E7.---- ❑ 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 een determined based on: ❑ Existing information. For example, a plan at the Board of Health. v.-S."' ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Of5cai inspection Form:Su0sL.rface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts --T-17IF Title 5 Official Inspection Form L,--_-_---17-r-- Subsurface Sewage Disposal System Form -N for Voluntary Assessments 2o ci 7 54-- Property Address S Owner Owner's Name information is required for every dray P 44 ()x643 3/5A0 page. City/Town State Zip Code Date of Ins D. System Information Pm, + .* 9S, 61/ -/1/1., .1. Residential Flow Conditions: (74 tf Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Description: 0 /COO / i /' C 14lv / S_ 0 Number of current residents: Does residence have a garbage grinder? ❑ Yes lEr.1o Does residence have a water treatment unit? ❑ Yes No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes No information in this report.) Laundry system inspected? ❑ Yes No Seasonal use? ❑ Yes No Water meter readings, if available (last 2 years usage (gpd)): Detail: ❑ Ye No Sump pump? ` Last date of occupancy: C to ?i;ie 5 Cftclai.nspecaon Form.Suosurface Sewage Disposal System•Page 7 of 18 t5insp.doc•rev.7128,2018 • Commonwealth of Massachusetts ,> Title 5 Official Inspection Form __ t_,_— Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ---,- 20 Ceid'i- Property Address E--%.r / Owner Owner's Name information is / . UA____ , �//j 0a. �3 spz) equired for every (il/ //page. City/TownState Zip Code Date of inspe on D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? D Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: / v /d----- Source of information: --- Was system pumped as part of the inspection? ❑ Yes e-'f�o If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.tloc•rev.71252018 Title 5 Offiaa,!nai specr.Form.$Lbs.mace Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts * >, F Title 5 Official Inspection Form " Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,........;..0 `� Property Address Owner Owners Name6k/ea /�information is ��1 - I a c23 3 /s' A7 required for every �/l page. City/Town State Zip Code Date of Insp �on D. System Information (cont.) 4. Type of Sys . 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)and a copy of latest inspection of the 1/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): �s- 6// Approximate age of all components, date installed (if known)) d sone of informs i Taw pg.51 4 o,1— • , 7 ' S ��/Lc Were sewage odors detected when arriving at the site? E] Yes lao _ 5. Building Sewer(locate on site plan): " Depth below grade: feet Materi of construction: cast iron ❑40 PVC ❑ other(explain): /0 ( 7L Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): C4"5 4- -------- - (4.e... 4.10 4 (-44 (A...It /91/16- if L.--__--. .56 _ibe 5.^`cal Inspection Po'm.5uc5uface Sewage Disposes System•Page 9 of 18 t6insp.dac•rev.7126/2018 Commonwealth of Massachusetts Title 5 Official Inspection Form b Subsurface Sewage Disposal System Form -Not for Voluntary Assessments CG1 .5" Property Address /52S Owner Owner's Name / information is u S �a frA .-� /73 ,y/s-/do do required for every / J(/' (�((� page. City/Town State Zip Code Date of inspe 'on D. System Information (cont.) 6. Septic Tank(locate on site plan): /2 „ Depth below grade: feet Materia construction: concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 5 >4 8 / r c ii Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle /42 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 gie How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): girri 00 j Qek I (316b d (.0., e ,t7c, zee. t5insp-da•rev.7/2612018 -ate 5 Ctfica,Inspection Form.Sucsuriace Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts >l, Title 5 Official Inspection Form _� A Subsurface Sewage Dis osal System Form - of for Voluntary Assessments 0 4 efig SY-- Property Address z_--...s P Owner Owner's Name /� n information is �3'� de/0.A ! ' co ` /� x c. �0 required for every / !! page. City/Town State Zip Code Date of ins ction D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete E metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. 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 per day t5insp.doc•rev.7126/2018 'ige 5 OOffoa..nspecuon Form.Suosurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Dis °sal System Form -Not for Voluntary Assessments 4 CA 0111 Property Address Owner Owner's Name L a oU' o c 9.7 /' 4vinformaon is /. Mef required for every page. Cityrrown State Zip Code Date of In ectio D. System Information (cont.) 8. Tight or Holding Tank (cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box (if present must be opened) (locate on site plan): ,G Depth of liquid level above outlet invert L_.► //�G 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.): ape LSinsp.tloc•rev.7/26E2018 Trtie 5 Qifica:nspecoon Form.Suosurtace Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts -? Title 5 Official Inspection Form V-----t-7,1=:,,,, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments If) CG rty cf Property Address Z--..-- s, Owner Owner's Name /� information is (4./ a4 IMO(4 14 ! //i- eal-- -,3 �!- required for every page. City/Town State Zip Code Date of insp 'on D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No; Alarms in working order: E Yes 0 No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: OS .2:14T/llf 0 leaching pits number: 0 • leaching chambers number: O teaching galleries number: ❑ leaching trenches number, length: O leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovativeialtemative system Type/name of technology: -me 5 Offoai:nsoeovon=orm.Suosunace Sewage Disposal System•Page 13 of 18 tainap.doc•rev.7/26/2018 • Commonwealth of Massachusetts Title 5 Official Inspection Form ISubsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Ca,vtlio s� Property Address E"-- if') Owner Owners Name information is r, / (11 /� 1required for everyCN e' N ( ' ,/ (/� (3 G�Q page. Cityrrown State Zip Code Date of Insp ction D. System Inform ion (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): S"-1© .. av1 � ; i (kc14/6 a od „cyvi 5 014497 b---4a tea 4— "LC 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.tloc•rev.7262018 'me 5 3/ rx `ca�Inspeon Form.SLCs dace Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts -.-=----11-- ,� _er Title 5 Official Inspection Form o' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments k„....,_, 70 C-G)ty 657— Property Property Address 5, Owner Owner's Name information is required for every 6/es-i- y.,4,t,,,(4 /t/A. Od�/ 3 S page. City/Town State Zip Code Date of Inspe 'on D. System Information (cont.) 13. 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.): t5insp.tloc•rev.7/262018 True 5 Official,nsoecnon=orro.6 osvrface Sewage disposal System.Page 15 of 18 Commonwealth of Massachusetts l4 Title 5 Official Inspection Form --Ei. T. ''' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 2oVa Sri Property Address ' S Owner Owner's Name information is /W!e) �� OffN f✓ /47A �A 0.16e .3 �//c/J —,required every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landma r benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the b • ing. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately scr041 c- �"✓I 4� MO 0 (Tdn//oh Gl0 ., - . et,i '----- ------Frt'-v ________. v.)? •. Na .411fiz40eS 5 A- ._. /0.1. -off A.c,, - 1'7 4- d-5? /13 - 3--S' 43 -2s Lt/i- - 3 ) ay- 3 t5insp.tloc•rev.7/26/2018 `ne 5 O i ei,rspection Form.Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts n -F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 70 cis Property Address - Z.:::' 5 Owner Owner's Name information is l ! n required for every A es - , � (f�%_7 3 .n a n page. City/Town ., State Zip Code Date of[ns ctio D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar E Shallow wells /1- ,57 Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 1SQ feet of SAS) ❑ Checked with local Board of Health - explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe you establishegi the hi ground water el�tion: g.K4- — 4%vw c...9 ñiwL3O Am ., - zn-Ki/1.ft. . 4,6 S' / • . /a.CLc. d✓� Cl ' f S � - • •S IS et AL ii.Q_k_L;:- 4 I (4 0 bi C/._A_A 11: Before filing this Inspection Report, please see Report Completeness Checklist on next page. 5insp.doe•rev.7/26/2018 -itis 6 10ca.rspFoy-:Fo :Suos::dace Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Form -Not for V Disposal System FoColuntary Assessments CA el, s� Property Address E OwnerOwner'sS I" hame (,,,,,,i reformation is 4required for every page. City/Town State Zip Code Date of In E. Report Comp eteness Checklist Complete all applicable sections of this form inclusive of: A. Inspector Information: Complete all fields in this section. B. Certification: Signed & Dated and 1, 2, 3, or 4 checked C. inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (F •ure Criteria)and 6 (Checklist)completed D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.tloc-rev.7126/2018 True 5 Offiaa:nspealon For .Suosurrace Sewage Disposal System-?age 18 of 18 l "-) `'1 E� ••+. CA 3. No.?.S—tvlI 1 ( S THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF YARMOUTH , Appliratinn for Disposal lig arks Cnnn,strnrtinn Prmit Application is hereby made for a Permit to Construct ( ) or Repair (1G) an Individual Sewage Disposal System at: T ocation-Ad7 resTi'l'fr u t-1 '4.4.1.r i `l (>=Y .. e4 Le i C r P 'N 1/l _ or Lot No. tjV E' S �/t: !vv., i Z1AtAi.1 % Owner :1 'V-- T. i Addr/es Installer / e7 � �'t Type of Building Address Dwelling—No. of Bedrooms Size Lot Sq. feet Other n Type of B dr Expansion Attic ( ) Garbage Grinder (NO g No. of persons Showers Other fixtures ( ) — Cafeteria ( ) Design Flow 5 5 gallons per person per.day. Total_y flow �Yr Septic Tank---Liquid capacity/' O gallons Length.___] Width.. Diameter gallons. Disposal Trench—No.._.. .'-.� r Depth Width Cf Total Length-:.3- ! Total leaching area sq. ft. Seepage Pit No Diameter Depth below inlet q Other Distribution box p Total leaching area sq. ft. ( ) Dosing tank ( ) Percolation Test Results Performed by Test Pit No. 1 minutes per inch Depth of Test Pit De th to Date Test Pit No. 2 minutes per inch Depth of Test Pit p ground water Depth to ground water Description of Soil Nature of Rwairs or Alterations—Answer when a licable f` ,%% Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLI 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been]std by/ bgar-51 of health. Signe. __=-„ 1_ P'✓.('' `j �2`'j_ r Application Approved By__. j ` ---- 6 ate cis— Application Disapproved for the following reasons: / «IGGG Date Permit No Issue 1 S — i Date Issued_ — YS� Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH • TOWN of YARMOUTH trrtif iratt of elomplittnrg THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (- ) s by at Installer has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as describ application for Disposal Works Construction Permit No ed in the ' dated ' THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE T SYSTEM WILL FUNCTION SATISFACTORY. HAT THE