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HomeMy WebLinkAbout0073 ASHLEY DRIVE - Health 73 ASHLEY DR. , CENTERVILLE MAP-172 PAR-06 � Illl UPC 17534 No.2_ 1163�COR %wooso rASTINOS. MN ° TOWN OF.BARNSTABLE LOCATION 73 d-i L A SEWAGE# 07 �—YfR �I,LAGE �� - �� ASSESSOR'S MAP&LOTr 1INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) a y 61 c�VQ4 size) NO..OF BEDROOMS -' BUILDER OR OWNER p. PERMTTDATE: 7 COMPLIANCE DATE: 1���Z _ Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet, Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by t� t L�� l�2 .^ — TOWN OF BARNSTABLE + LOCATION 73 4A& GHQ SEWAGE # 7 J 128 VILLAGE C'66a`'-94.1` ASSESSOR'S MAP &LOT /1 17�- INSTALLER'S NAME&PHONE NO. & SEPTIC TANK CAPACITY � ® LEACHING FACILITY: ((type) ;Z 30U O(1C Q-PA size) 44"S-tD1 — NO.OF BEDROOMS / f. BUILDER OR OWNER Now-fiq�Bla PERMITDATE: _f q COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet,,,. Private Water'Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by U f � � �� r t �.* �. 9 r. 9 NO. a ! Fee =mil THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01pplication for Mtzpooal *potent Cow6tructiou Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) O Complete System El Individual Components Location Address or Lot No. 77 ,Qs�/ � Owner's Name,Address and Tel.No. )�G� <i /, d Assessor's Map/Parcel Installer's Name,Address,and Tel.No. ` vo— Z15qa Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow _Z761 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank ZoQQ Type of S.A.S. Description of Soil D(.-- 1_M a4 y 3 Fw a r ��/Iv Nature of Repairs or Alterations(Answer when applicable)G�/1�/I��C.. �509 U/_,f 46TI-1 CMA6 s A = fn Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the ' onm al Code and not to place the system in operation until a Certifi- cate of Compliance has been issued b boar ea Signed Date Application Approved by Date Application Disapproved for the following reasons Permit No. r ' Date Issued 9 r I —9'7 No. 97 �` e _ Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS TippYiratton for.Mt5poga1 *p!tem Con.5trurtton Vertu Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. /���LC%Q Owner's Name,Address and Tel.No. Assessor's Map/Parcel _ �()� /`/� / C Installer's Name,Address,and Tel.No. L1.20_ W((. Designer's Name,Address and Tel.No. / f� fL rQTkL7W C/A 1-4 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank ZO—O0 Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable)IM�//� eV t&ly G.6�_1 f1B0 ' � Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the onme al Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by ' Boar o ea Signed Date �� Application Approved by i Date Application Disapproved for the following reasons Permit No. (17 -1-116f Date Issued --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certiftrate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( krRepaired ( )Upgraded( ) f Abandoned( )by at / 6'01�4 h been constructed in accordance with the provisions of Title 5 and, a for Disposal System Construction Permit No5lr dated Installer f�/4 Designer The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date Inspector � _--h- ---✓J------------------------------------ No. Fee �:/ L.!• THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION BARNSTABLES MASSACHUSETTS x1i6pogal *pztem Congtrurtton Verna Permission is hereby granted to Con truct �Repair(v)Upgrade( )Aba5cjn( ) System located at & -a1 �'y ! -� ..•�',�J Y and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this it. Date:9��I " Approved b i CEILTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL NVORKS CONSTKUC ION PE101I T (WITHOUT DESIGNED PLANS) hereby certify that the application for disposal works construction permit signed by me dated `—lq---q- , concerning the property located at meets all of the following criteria: • There are no wetlands within 300 feet of the proposed septic system t/ • There arc no private wells within 150 feet of the proposed septic system �• The observed groundwater table is 14 feet or greater.below the bottom of the leaching facility • There is no increase in(low and/or change in use proposed • There are no variances requested or needed. SIGNED:— DATE: _�2 LICENSED SEPTIC SYSrMINMSTALLER IN THE TOWN OF BARNSTABLE NUMBER (Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submittedj. e GAuay T)Wk I� p 11 Box ool prr 272 . A� - Lo71 Commonwealth of Massachusetts l�Z r Executive Office of Envirolunental Affairs Dept. of Environmental Protection One winter Street,Boston,Ma. 02108 John rab G D.E.P. Title V epticILispector P.0.,B6aX 2119 Teati6ket,MA 02536 WILLIAM F.WELD (508) 564-6813 Governor ARGEO PAUL CELLUCCI SFP Lt.Governor .. 7 SUBSURFACE SEWAGE DISPORT ASYSTEM INSPECTION FORM TO;1 ov eq 199? CERTIFICATION �ITHp p�Tgg� N Property Address: 73 Ashley's Dr.Centerville Address of Owner: 1 Date of Inspection:9/9197 (If different) ti Name of Inspector: John Graci Hollenbach I am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000) Company Name,Address and Telephone Number: 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 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 This inspection is based on criteria defined in Title V _ CondFacopy es code 310 CMR 15,303.My findings are of how the system is Needluation B the Local A rovin Authori performing at the time of the inspection.My inspection does Y PP 9 ty not imply any warranty or guarantee of the longevity of the X Fails septic system and any of its components useful life. Inspector's Signature: Date: 919197 The System Inspector shall sof this inspection report to the Approving Authority within thirty(30)days of completing this inspections. 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 to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B,C, or D: A] SYSTEM PASSES: _I have not found any information which indicates that the system violates any of the failure criteria defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: 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(Y, N,or ND). Describe basis of determination in all instances. If "not determined", explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal, Is cracked,stiucluially unsound, shows substantial irlfiltiation or exfilllation,of talik 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. (revised 04/27/97) One Winter Street e Boston,Massachusetts 02108 9 FAX(617)556-1049 • Telephone(617)292-5500 t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 73 Ashley's Dr.Centerville Owner: Hollenbach Date of Inspection:9g/97 _ 5ew.aae backup or.breakout.or. hiah.static water level observed.in.the distrihution b.ox is due to a broken. or obstructed pipe(s)or due to broken, settled or uneven distribution box.The system will pass inspection if (with approval of the Board of Health). Describe observations. broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed 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 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: The system has a septic tank and soil absorption system and is within 100 feet to a surface of water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply well. The system has a septic tank and soil absorption system and is within 50 feet of a private watersupply well. — The system has a septic tank and soil absorption system and the SAS 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 presense of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid) 3)Other D] SYSTEM FAILS: You must Indicate either"Yes"or"No"as to each of the following: 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. Yes No _ -x- Backup of sewage in facility or system component due to an overloaded or clogged SAS or cesspool. _X— Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged cesspool. x_ SAS is in hydraulic failure. (revised 04127197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 73Ashleys Dr.Centerville Owner: Hollenbach Date of Inspection:9/9/97 D] SYSTEM FAILS(continued) Yes No X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Numbers of times pumped X Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. --X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. _C Any portion of a cesspool or privy is within 50 feet of a private water supply well. X 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"as to each of the following: The following criteria apply to large systems in addition to the criteria: The system serves a facility with a design flow of 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: Yes No X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X 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. (revised 04/27/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: 73 Ashleys Dr.Centerville Owner: Hollenbach Date of Inspection:9/9197 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: _y_ — Pumping information was requested of the owner,occupant, and Board of Health. x None of the system components have been pumped for at least two weeks and the 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 part of this inspection. x As built plans have been obtained and examined. Note if they are not available with N/A. x — The facility or dwelling was inspected for signs of sewage back-up. x — The system does not receive non-sanitary or industrial waste flow. �— — The site was inspected for signs of breakout. x All system components,excluding the Soil Absorption System,have been located on the site.. x 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. x _ The size and location of the Soil Absorption System on the site has been determined based on The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal Systens. x Existing information. Ex. Plan at B.O.H. x Determined in the field(f any failure criteria related to Part C is at issue, approximation of distance is unacceptable)]15.302(3)(b)] (revised 04/27/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 73 Ashleys Dr.Centerville Owner: Hollenbach Date of Inspection:9/9/97 FLOW CONDITIONS RESIDENTIAL: Design flow: 330 U.P•d./bedroom for S.A.S. Number of bedrooms: 3 Number of current residents: 4 Garbage grinder(yes or no): No Laundry connected to system.(yes or no): Yes Seasonal use(yes or no): No Water meter readings, if available:(last two(2)year usage(gpd): n/a Sump Pump(yes or no): No Last date of occupancy: n/a COMMERCIAL/INDUSTRIAL: Type of establishment: nla Design flow:0 gallons/day Grease trap present:(yes or no) No Industrial Waste Holding Tank present: (yes or no) No Non-sanitary waste discharged to the Title 5 system: (yes or no) No Water meter readings,if available: n/a Last date of occupancy: n/a OTHER:(Describe) n/a Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System has been maintained yearly information from owner System pumped as part of inspection: (yes or no)No If yes,volume pumped: 0 gallons Reason for pumping: n/a TYPE OF SYSTEM X Septic tank/distribution box/soil absorptions system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes, attach previous inspection records,if any) I/A Technology etc. Copy of up to date contract? Other: APPROXIMATE AGE of all components,date installed(if known)and source information: 1985 Sewage odors detected when arriving at the site:(yes or no) No (revised 04/27/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 73 Ashley's Dr.Centerville Owner: Hollenbach Date of Inspection:9/9/97 SEPTIC TANK: X (locate on site plan) Depth below grade: 12' Material of construction:X concreate_metal FRP_Polyethylene_other(explain) If tank is metal, list age D Is age confirmed_by Cert'Ificate of Compliance No (Yes/No) Dimensions: L B'6'H 5'7'W 4'10' Sludge depth:2" Distance from top of sludge to bottom of outlet tee or baffle: 25" Scum thickness:3" Distance from top of scum to top of outlet tee or baffle:over Distance form bottom of scum to bottom of outlet tee or baffle: 15" How dimensions were determined: Measured 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.) Septic tank and all components are structurally sound.Recommend pumping septic system every two years for maintenance. GREASE TRAP: (locate on site plan) Depth below grade: nra Material of construction: concrete metal FRP Polyethylene_other(explain) Dimensions: n/a Scum thickness:n/a Distance from top of scum to top of outlet tee or baffle:We Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping,/, 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.) n/a BUILDING SEWER: (Locate on site plan) Depth below grade: 2' Material of construction:_cast iron X 40 PVC_other(explain) Distance from private water supply well or suction lin0own Diameter: 4' C,vamments:(conditions of joints,venting,evidence of leakage,etc.) (revised D4/27/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 73 Ashleys Dr.Centerville Owner: Hollenbach Date of Inspection:9/9/97 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: We Material of construction: concrete_metal_FRP_Polyethylene_other(explain) Dimensions: n/a Capacity: n/a gallons Design flow: n/a gallons/day Alarm level:—n/a Alarm in working order?_Yes_No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches,etc.) n/a DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: n/a Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box etc.) n/a PUMP CHAMBER: (locate on site plan) Pumps in working order:(yes or no)No Alarms in working order(yes or no)_Yes Comments: (note condition of pump chamber,condition of pumps and appurtenances, etc.) n/a (revised 04/27/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 73Ashleys Dr.Centerville Owner: Hollenbach Date of Inspection:919197 SOIL ABSORPTION SYSTEM (SAS):X (locate on site plan,if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: n/a Type: leaching pits, number: 1,000 gallon leach pit leaching chambers,number:n/a leaching galleries,number: n/a leaching trenches,number,length: We leaching fields, number, dimensions:n/a overflow cesspool, number:n/a Alternate system: n/a Name of Technology:_n/a Comments:(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation,etc.) The leach pit is past the effective depth of leaching.The sas is in hydraulic failure.Pit was ponding. CESSPOOLS:_ (locate on site plan) Number and configuration: We Depth-top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater: n/a inflow(cesspool must be pumped as part of inspection) n/a Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.) n/a PRIVY:_ (locate on site plan) Materials of construction: n1a Dimensions: n/a Depth of solids: Na Comments:(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) n/a (revised 04/27/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 73 Ashley's Dr.Centerville Hollenbach 9/9/97 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references, landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) .mil pock JA o O� AC 3� (revised 04127/97) page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 73 Ashley's Dr.Centerville Hollenbach 9/9/97 Depth of groundwater 12, Please indicate all the methods used to determine High Groundwater Elevation: Obtained from design plans on record. Observation of Site(Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of Health Check FEMA Maps Check pumping records Check local excavators, installers X Use USGS Data Describe in your own words how you established the High Groundwater Elevation.(MUST be completed) USGS Maps and Charts (revised 0427/97) page 1Q of 10 Board of Health CC Town of Barnstable No.0..1�..-- P.O. Box 534 _- FRic s10.w............ _ 4 G� 1 TH �M1IfM1fgL �L�9'N�i7"'IOIA` HUSETT 'S BOARD OF HEALTH -•........................................OF.......................................................................................... Appliration for Diipniial Morkii Tnnitrnrtinn famit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: ..... ..... ;3 Sud Location Address P�_. Ins44=,AA & .1.1 - CA t er Address 14 Type of Building - Size Lot____________________ _____Sq. feet Dwelling—No. of Bedrooms.................3........._...__.........Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures ................................... --------•-------------------- W Design Flow............ ....................gallons per person per day. Total daily flow.__.._....._..�.�-�...�-....._._..._gallons. WSeptic Tank—Li uid�ca acit p q p yls..._�. _gallons Length--- ..__.__. Width..___l�t.._..... Diameter________________ Depth...��_.--------- x Disposal Trench—No..................... Width..._........______.. Total Length.................... Total leaching area....................sq. ft. Seepage Pit No....... Diameterlac.4..... Depth below inlet....�r .._LI._.. Total leaching area.. F�t_sq. ft. Z Other Distribution box (A--)-- Dosing tank ( ) �� 4�7/ '-' Percolation Test Results Performed b ._•4-�-�. Z_ aY •-- .L Date------------------------------�-----.. ,.a Test Pit No. ls5.:.:_.3_-minutes per inch Depth of Test Pit..`5.L------ Depth Depth to ground water.�?'"��-____--. Gi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water--_--_..._----_----__-_. 9 •-•------•-••----•---••----....................................................... ...................................................................... O Description of Soil..... c ------------------ --.---•-•------ ;00 V .-..--•-------------------•------.-------------------.-------------•------------•--------•----------- ---- ----------------------------------------------- •-------------- •-------•-..... W V 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 iITL U 5 of the State Sanitary Code—T undersi ed further agrees not to plac the system in operation until a Certificate of Compliance has been issued the boaam of health. igned . ............................................ Application Approved BY Z_ a .. ....----•-•..................•--- Da Application Disapproved f the following reasons---------- ----•-•-••-••--•---•--•--------•---•-----•---------•-•-•------•------•--•----- -----•••.._._.._._ ...............................•----•---......------------.....-----------...------.......-•----.....---•.....-----------------------------•----------------------------------------------------•-....... Date PermitNo......................................................... Issued-----------------------............................... Date ----------- ----------- - -- Noiy._.....�_....._ �._- Fps�.... ................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .............------...........--....OF................................... Appliratiun for Disposal Works Tonstrur#ion Prrmit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: ..... ;1 ,�'/C `;...�........ ..................... ----- /C l / /Z.G� �.J%% //mac.C k tST A9 Z Location.-Address , ""'"" """"' -•_._�. .........._.. . / .. .P. ------------- W : ::::--- .:: ° r 1 C .._.. ........... .. Inst ler Address UType of Building /ttt�wC. Size Lot............................Sq. feet Dwelling—No. of Bedrooms______________- ___... ....___.__Expansion Attic ( ) Garbage Grinder_ ( ) Other—Type T e of Building a p '`�` �" t y ( ' )F Cafeteriax( ) a yP g �'Shoveers are rOther fixtures .......................... ••--• ----••••• ••• ................................. W Design Flow.............>.............................gallons per person per day. Total daily,flow........................ ..............gallons. W Septic Tank—Liquid capacityZPP93gallons Length._L a........ Width__.� _......._ Diameter_____ __________ De th_.,;o......... r x Disposal Trench—No. .................... Width.................... Total Length..........._........ Total leaching area--------------------sq. ft. Seepage Pit No._____E_____________ Diameter:_� c.:�...... Depth below inlet_�._..A._......... Total leaching area.. �..sq. ft. Z Other Distribution box (.r) Dosing tank a Percolation Test Results Performed by..................... ... Date........................................ � Z Test Pit No. 1 �-" .. -:minutes per inch Depth of Test Pit_�,' __�__r Depth to ground water.:v '...... G4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Ix --••-••-••--••-•-------------•----•--------••--•••-------•-••--•-•---•--••-•-------•.....------......-------••--•---•-•-•----•-•-------•-----••------•------- D Description of Soil____ -:'7 UNature 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 TITIE 5 of the State Sanitary Code— e unders• ned further agrees not tAplathhe system in operation until a Certificate of Compliance has been issued y the bo of health. igned....... ..... - ••• • ------------------------•--•-••--••.....---••. :_4_ a �. Application Approved B?/-c -- :. --•.................. ----•---•-D eApplication Disapprove following reasons:--..-------••••----=-----------•--••------•---------••-----•••----------•-•-•--•......-- .......................................................................... A.a Date PermitNo......................................................... Issued-----------------------------------------.. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... Tnrtifiratr of Tontplinttrr TH TO&TIF , That!the !provisions al Sewage Disposal System constructed orRepairedby-------- -•-•-- ...f . --- ----------------- - --- -- - - -- - --- - has been installed in accordan h of TLPE ` oVhe State Sanitary Code as described in the application for Disposal Works Construction Permit No " .............. dated--_.__.__.______..._______...-.._._.__..._._... THE ISSUANCre OF THIS CERTIFICATE SHALT. NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM 1dll F TION SATISFACTORY. DATE......... ....... �........_..._......----•..........--------••------ Inspector ------- -----•----•-•---------•------•----•-------..----------------_-•--- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...................................... .....OF...---..................--•-••--•••..........--•-•--•--...._.............-••-••---_-• �} FEE... tu�rou I urkn nub :r� . tt antic Permission is hereby granted-- � ' _-,� to Construct avid evvag posal System at No..... •_. .. Street as shown on the application for Disposal W r Construction Pert it-N ................. Dated...................._..................... -------....=..... ----- •....•••------•--•-•-------•••--•-•••-••••••---••---••...-------••-----.--- DATE............... - _k .............................. Board of Health -------------------•--- � FORM 1255 A. M. 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