HomeMy WebLinkAbout0084 BRIDGET'S PATH - Health 84 Bridgets Path,Centerville
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I/7/f/tU[lC
UPC 12534
No.2_ 153LOR � ro
HASTINGS.MN
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Commonwealth of Massachusetts
Executive Office of Environmental Affairs UP ? 4 1996
Department of HEALrHDCPT
Environmental Protection 70"'"oF ' "
BUEE
William F.Weld Trudy Coxe
GOMM" 8-asury
Aryeo Paul Celluccl David B.Struhs
ti Govemor
•
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Add rass: 84 Bridgetts Path Centerville,MassAddressofowner.. 9208 Bayard Place
Date of Inspection:9/9/9 6 • . (If different) Fair Fax Virginia
Name of Inspector.Joseph P.Macomber Jr. 22032
Company Name,Address and Telephone Number.
J.P.Macomber & Son Inc . Box 66 Centerville ,Mass . 02632 508-775-3338
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:
,
,prise,
_ Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
_ Fails
Inspector's Signature; ' yZ/, Date:
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 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 as defined in 310 CUR 15.303.
Any failure criteria not evaluated are ind+'cated below. ,
BJ SYSTEM CONDITIONALLY PASSES:
X116 One or more system components need to be replaced or repaired. The system,upon completion of tha 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,cracked,structurally unsound,shows substantial infiltration or exilltration,-or tank failure is
imminent, The system will pass inspection if the existing septic tank is replaced with a ponforming septic tank as approved
by the Board of Health.
(revised 11/03/95) 1
One Winter Street a Boston,Massachusetts 02108 a FAX(617)556-1049 a Telephone(617)292.550o
r. Prir ted.Recycled Paper
II-1CATION Wontinu )
Propperty Addroaa:
84 Bride etss Path Centerville ,Mass .
n Ower. Michael onovan
Date of Inepaction.9/9/96
B) SYSTEM CONDITIONALLY YASSfIS
AL0 Sewage backup or mreakOUL w I.:;. : a'—Lil waterse level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken, settle:) ur u:.:,,ii ii.,tribution box. The system will pass inspection if(with approval of the Board of
Health):
e) are replaced
ib removed
d�,r it,tiion 1x)x is levelled or replaced
jW The system requimd puinput� i:-:c u,:un four tin•.-s 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
on is removed
Cl FURTHER EVALUATION IS RIat'Ul1i!`.a ;.1tD OF 111:A1.TH:
NO Conditions exist which require fur:i.v: chr Board of Health in order to determine if the system is failing to protect the
public health, safety and the envirunr.,.,;,i
1) SYSTEM WILL PASS UNLESS BC-A-I(U OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A
MANNER WHICH WILL YROTEC l fi : 11'OBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
�C Cesspool or privy is within b0 i' iurface water
Cesspool or privy is withi:t `,O f .. .. .: 'wrdering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE 130AxD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE)
DETERMINES THAT THE SYSTEM I5 FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT:
�l The system has a septic u::. ,..... ..... .:(:�urption system and is within 100 feet to a surface water supply or tributary to a
surface water supply.
Ale The eystein hax a septic tariz system and is within a Zone I of a public water supply well.
The system has a septic tank and foil 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 ti-:e pn:sence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm.
3) OTHER
(revised 11/03/95) 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
PropertyAddrea•: 84 Bridgetts Path Centerville,Mass . f
Owner. Michael Donovan
Date of Inspection:9/9/9 6
D] SYSTEM FAILS: '
•
ItI,l)_ I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 16.303. 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.
�1 Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
i Discharge or ponding of effluent to the surface af"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-eesspool is less than 6"below invert or available volume is less than 1/2 day flow.
AAD Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
�i .v0 Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
d1 Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
�Q Any portion of a cesspool or privy is within a Zone I of a public well.
j ly well.
Any portion of a cesspool or privy is within 60 feet of a private water supp
Any portion of a cesspool or privy is less than 100 feet but greater than 60 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:
The following criteria apply to large systems in addition to the criteria above:
Xi'b The system serves a facility with a dasign 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:
the system is within 400 feet of a surface drialdng 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 Anther information..
(revised.11/03/95) 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Add. 84 Bridgetts Path Centerville ,,Mass .
Owner. Michael Donovan
Date of Inspeotion:9/9/9 6 e
Check if the following have been done: `
,,,.0umping information was requested of the owner, upant,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 part of this inspection.
AOAs built plans have been obtained and examined. Note if they are not available with N/A
,ZThe facility or dwelling was inspected for signs of sewage back-up.
_ The system does not receive non-sanitary or industrial waste flow
,]/The site was inspected for signs of breakout.
IM
All system components,excluding the Soil Absorption System, have been located on the site.
i
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.
The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub.
Surface Disposal System.
(revised 11/03/95) 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
ProportyAddre6&: 84 Bridegets Path Centerville,Mass .
Owner. Michael Donovan
Date of Insp•ootiou: 9/9/96
FLOW CONDITIONS
RESIDENTLkLz
Design flowM�ons
Number of bedrooms:S
Number of current maidents:'o PWA4-7—
Garbage grinder(yes or no): 10
Laundry connected to system(yes or no):!GS
Seasonal use (yes or no): .l�� li
Water meter readings, if available: 6 C�(J 3
*s4aw741 o 1�' �� a d'.4> 114A a vy joer �4y
Last date of occupancy:.
COMMERCIAL NDUSTRIAL:
Type of establishment:
Design flow:-&&-gallons/day
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)4A
Water meter readings, if available:_
JVA _
Last date of occupancy: AA
OTHER. (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as part of inspection: (yes or no)&�5
If yes, volume pumped: P gallons
Reason for pumping: -VJ¢
TYPE 0y-.S'y3TEM
Septic tankldistribution bos/soU absorption system
dtZ Single spool
A11) Overflow cesspool
A.16 Pricy
/ Shared system(yes or no) (if yes, attach previous inspection records, if any)
Other(ezplrin)
APPW, )G ATE AGE of all componets date ' stalled (if known)and source of information: —�
Sewage odors detected when arriving at the site: (yes or no)
(revised 11/03/95) 6
-W INSPECTION FORM
PARI, C.
(continued)
Property Address: 84 Bridgets Path Centerville ,Mass .
Owner: Michael Donovan
Date of lnspection.9/9/96
SEPTIC TANK:,Wd
(locate on site plan)
Depth below grade:_A2
-Zconcrete metal FRP Umcf(u4j;(1)
Material of construction:
Dimensions:
Sludge depth:
Distance from top ofsl.udge to bottom Of Outlet Lee or
Scum thickness:-
Distance from top of scum to top of outlet tee or baffle:-Z44L-0 -
Distance from bottom of scum to bottom of outlet tee or baffle._
Comments:
(recommendation (or pumping, condition of inlei and outlet t"s or baffle-.
depth of 11 id 1pvel in relation to outlet invert, structural
�rity, evidence of leakage, etc.) Pump_ septic tank ery ,27Y years -
-,Inlet and
T
outlet re j q eA d level . is 5'J" - tout e . in'VPT��
—The P. -,a 1)t i r, tank i S_ _Q-t_11r_ally s o-t nd No-,q±,rU 'igns of leakage, No
i
repairs need-ed- at the---present time
GREASE TRAP.A)&AV-
(locate on site plan)
Depth below grade:','*A J
" -4
Material of constri-ii6n,4/Woncrete —Metal —FRi'
AA
Dimensions;
Scum thickness:
Distance from top ui scum to top of outlet tee or baWe: j#'
Distance from bottom ()( c(um i- botion, of owiet ice o, u5ii,r
Comments:
(recommendation for pumping, ccindil-fi of inlet zif'.0 ualfflcs, depth of liquid level in relation to outlet invert, structural
integ ity, evidence of
(revised 8/15/95)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
PropertyAdd,ess: 84 Bridgets Path Centerville ,Mass .
Owner. Michael Donovan
Date of Inspection: 9/9/9 6
TIGHT OR HOLDING TANK:A j J,
(locate on site plan) / s
Depth below grade:
Material of construction:q�4oncrets_metal_FRP--other(explain)
PR
Dimensions: AA
Capacity: ons
Design flow: ous/day
Alarm level:
Comments:
(conditionRRf inlet tee,condition of alarm and float switches,etc.)
ko
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert:_
Comments:
(note if level and distribution is equal, evidence of solids over,evidence of leakage into or out of box,etc.)
Box is level with equal flow-No evidence of solids carry over;
No evidence of leakaae in or out of the box, No repairs needed at
PUMP CHAMBER.-A!0 `'
(locate on site plan)
Pumps in worldng order:(yes or no) /f
Comments:
(note conditio of pump chamber, condition of pumps and appurtenances,etc.)
(revised 11/03/95) 7
.;"SURFACE SEWAGE DISPOSAL SYSTEM INSPECTION VOIL-
PART C
SYSTEM INFORMATION (continued)
84 Bridgets Path Centerville,Mass
Owner. Michael Donovan •.
Date of Inalzwuo�: 9/9/9 6
SOIL ABSORPTION SYSTEM(SAS):-��09 �.' '�
(locate on site plan,if posw'ble;excavation not required,but may be approximated by non-intrusive methods)
If not determined to be present,explain:
Type: leaching pits,number:
leaching chambers,number.
leaching galleries,number. 715
leaching trenches,number,length: 0
leaching fields,number, nsio r.
overflow cesspool,number:,
Comments: (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
Pit is empty. House has been vacant :'or 10 months ;No sins oy ran is
failure or ponding; Vegetation is normal. No repairs needed at the
=oon+' time,
CESSPOOLS:
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert: IV#
Depth of solids layer- i19,4
Depth of scum layer:
Dimensions of ccaapool: AM
Materials of couatruction: 49A
Indication of groundwater: A).4
inflow(coaspool must be pumped as part of inspection)
til4'
Co nts:( condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
PRIVYc
(locate on site plan)
Materials of construction: Dimensions: 44 1
Depth of solids:/
Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,-etc.)
71Jd �.n�rJslil��Y-_s
(revised 11/03/95)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FO RM
�. PART B
SYSTEM INFORMATION continued ..
� SKETCH OF SEWAGE L=SPOSAL SYSTEM:
include ties to at least two permanent references landmarks• or benchmarks
locate all wells within 100 '
• Centerville Osterville Marstons Mills
t Water, Company
1 .
DEPTH T 7k* DWATER
+ � Ah dep h to groundwater
rRthod of. determinzilicii or aj:proxiination:
,see
i
_ I
I
i
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N
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�L1H or \ p�18OFM
RICHARD
JAMES ` . �� RICHARD ti
o �,, o JAMES
as O'HEARN -. O'HEARN p No.21�71 O H W. 694 O N
I T l r\1 cLEGEND vy FOIST E�`��c j l �CIST EPA
...� -.-..n.r: t-.3:Rntsy?,ws:..ic:'v�... :•-ear.:=:._.... -...,..,.. .... :.�. i,...., . _ ... . i -
SOIL TEST INVERT ELEVATIONS NOTES:
DATE OF SOIL TEST - INVERT AT BUILDING s3 FT ALL WORKA
WITNESSED BY_,,,0," INLET SEPTIC TANK
PERCOLATION RATE—- -?- FT. SHALL TO
O
MIN./INCH OUTLET SEPTIC TANK � FT. AND THEE T
ERVATION : .HOLE - I OBSERVATION HOLE. Z INLET DISTRIBUTION BOX FT AND REGULAT
ELEVAAT10N= 9s.9 ELEVATION= OUTLET DISTRIBUTION BOX 9-0-2 FT. DISPOSAL OF
wooe�s� INLET LEACHING PIT FT.
BOTTOM LEACHING PIT o FT.
DESIGN CALCULATIONS
NUMBER OF BEDROOMS . ?
GARBAGE DISPOSAL
TOTAL ESTIMATED FLOW ( GAL/BR./DAY x.-T- BR.).., _-?s
REQUIRED SEPTIC TANK CAPACITY. ... . . . . . .. . . . . . . . . ... 49:
ACTUAL SIZE OF SEPTIC TANK TO BE INSTALLED....
sA. .f LEACHING AREA REQUIREMENTS
SIDE WALL AREA��GAL./S.F.
W9TEc'. rNCG: it'r�•FE� ) BOTTOM AREA /D GAL./S.F.
LEACHING CAPACITY ( BOTTOM
RESERVE LEACHING CAPACITY. . S4J
OF
D.
CONCRETE 4" SCH. 40 CLEAN SAND
COVERS PVC PIPE
�--- MIN, PITCH CONCRETE
1/8 PER. FT. COVER
1211 MAX. 2% MIN. PITCH
FLOW LINE Lj 2" LAYER OF 1/8'= 1/?-
r WASHED STONE o
4" CAST IRON ��� '� � e � 3/4�= 1 1/2 �
PIPE - MIN. PITCH
e 9
w r'n WASHED STONE
I/4 PER FT. � .=
DIST. o �_- PRECAST LEACHING
BOX oD" ti v.4; o v BASIN OR EQUIV.
LL_ b b
/aoo GAL ° w o inT
SEPTIC
TANK �o `f `„T. R. J. 0�
r
PROFILE OF GROUND WATER TABLE EA
SEWAGE DISPOSAL SYSTEM JOB NO.7:._
S ,
f
1 fir' -
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W
THE COMMONWEALTH OF MASSACHUSETTS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BE IT KNOWN THAT
Joseph P. Macomber, Jr.
satisfied the Department's qualifications as required and is hereby
Hass
authorized to use the title
CERTIFIED TITLE 5 SYSTEM INSPECTOR
as provided in 310 CMR 15.340 and Section 13 of Chapter 21A of the
General Laws. Issued by The Department of Environmental Protection.
June 8, 1995
Acting Director of the ' ' -ion of Water Pollution Control
TOWN OF Barnstable BOARD OF HEALTH
SM131JRFACE SEWA(;E DISPOSAL SYSTEM INSPECTION FORM - PART D .- CERTIFICATION
...... ..
-TYPE OR PRINT CLEARLY-
PROPERTY INSPECTED
STREET ADDRESS 84 Bridegets Path Centerville,Mass .
ASSESSORS MAP , BLOCK AND PARCEL #
OWNER' s NAME Michael Donovan
PART D - CERTIFICATION
NAME OF INSPECTOR Joseph P.Macomber Jr.
COMPANY NAME J.P.Macomber & Son- INc.
COMPANY ADDRESS Box 66 Centerville ,Mass . 02632
Street Town or City State LIP
COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX ( 508 790 1578
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposaj system at
this address and that the information reported is true , accurate , and
complete as . of the time of .iinspection . The inspection was performed and any
recommendations regarding Upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems ,
Check one :
XXXXXXXXX System: PASSED
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
health or the environment as defined in 310 CHR 16 , 303 . Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form .
Sys teal FAILED*
The inspecti6n which I have conducted has found that the system fails to
protect the public health and the environment in accordance with Title
5 , 310 CHR 15 - 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form ,
Inspector 8ig atu Koo�".4
Date 9,Z.12/96�
One copy of this certification must be provided to the OWNER, the BUYER
( where applicable ) and the 130ARD OF 11RAL1'll.
If the inspection FAILED, the owner or.".o,perator shall upgrade the system
within one year of the date of the inspection, unless allowed or required
otherwise as provided in 310 CNR 15 . 305 ,
LO`CAT10 - SEWAGE PERMIT NO.
VILLAGE
INSTA L ER'S NAME i ADDRESAJ
d UILDE OR OWNER .
A,
DA T E PERMIT ISSUED Z91 �T
DAT E COMPLIANCE ISSUED
,���. ,
H��+'c'� ��.
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9
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e 171
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Ficz.. . ................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F MTH
40AzlmOF. ..r ..................................... . ...........*... I
Aliptiration for Dhipogal Workii Ton,5trurtion ramit
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
S
stem at: 74zt- Z__6
7 -tZ11' - �....+���w-----•..C'�`�. t 4a
-7— ( 11 9'. �.. ................. . ... . . ...................................................... ..........................................
k�ocpjon-Address U N
LA,
.......................................................... ............................................... ......
Owner dr
Ad _ _t�.
•
................................................................................................. .............................
Installer 4,"', .5difess
- ----------------------------------------------A
Type of Building Size Lot.Z�9!nP.........Sq. feet
U
Dwelling—No. of Bedrooms.__..._._ ....Expansion Attic Garbage Grinder W9_
W,------ * ----------
04 Other—Type of Building4�_._-?k.....tit.16,1yo. ,�b'f persons............................ Showers Cafeteria
Otherfixtures ............................................ .....................................................................................................
Design Flow........S. .........................gallons per persqn per day. Total daily flow.....3u3.®........_....._............gallons.
04 Septic Tank—Liquid capacit/vigp.-gallons Lengtlit................Width................ Diameter._._-__..._..... Depth.............._.
Z
Disposal Trench . .................... ---No Width..:_..........._..._
,Total Total Length.................... Total leaching area....................sq. f t.
Seepage Pit No.................... Diameter.__.....-_,!__-_-__ Depth below inlet.... ........ , Total leaching area.2;�.......sq. ft.
Z Other Distribution box Dosing tank 7
Percolation Test Results Performed by.......T.--a6m......................................... Date..1A.—../k.::7.t...........
Test Pit No. 1.... 2---_minutes per inch-, Depth bf Test Pit.................... Depth to ground water........................
Test Pit No. 2................minutes per inch, Depth(of Test Pit.___._......__._._.. Depth to ground water.__....__._.........___.
...................
................
0 Description of Soil.......0.1. . .....................
........................................... ........................
.............................................................................
-----------------------------------*----------
............................................................................................. .........................................................................................................
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
....................................................................................... -----------------------------------------------------------------------------------------------------------
Agreement:
The undersigned agrees to install the afored6cribed Individual Sewage Disposal System in accordance with
the provisions of LIT?LE 5 of the State Sanitary Cd e—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance 4 ha>-bn-issued by the board of health.6_7�d " Le, 7.C/ne�----- 31........................................................ .... ....
Date
--f- ---—----------------------- ------- .7—.74-
..Application Approved By..... .4,v!... .... . .....114.0 ....
Date
Application Disapproved for the following reasons:................................................................................................................
......................................................I....................................................................................................................................*------------
Date
f
PermitNo......................................................... Issued_--.-_ ................Z-f.......................
Date
&74
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® F HEA TH
......... ...........OF.... .... *_
Appl rFation for Digpos al Workii Tnnstrnr#iun 11trutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal,
ZsWi
--- ---------
........................... ... -•-- ........
Loywg Address It. ! or Lot No
.. ..__.... ... ..--••---•------•---_---• ............................................
W � i �tl�w tj Owner aiR� C W y4; �r r77. Addr
.... ....... ................•---------............-•_......._...._.......•--••-••.
Installer r.i Address
Type of Building Size Lot./S�.Agtq.........Sq. feet
Dwelling—No. of Bedrooms.___ .::___.._.Expansion Attic (+VO) Garbage Grinder ,.
aOther-7 ype of Buildings!!"37 �v� 11ko 'of persons :_, Showers ( ) — Cafeteria ( )
Other fixtures --_----------------------- ------- --••--- -------- ----- --- ---................
---------------------
t W Design<;Flow...:.13" .........................gallons per person per day. Total daily flow... Q...........................gallons.
WSeptic Tank—' Liquid capacitA..W.gallons Length,............... Width................ Diameter__.___ --•- Depth................
x Disposal Trench r—No........... ... Width _Total Length............:....... Total leaching area....................sq. ft.
Seepage Pit No.I__________________ Diameter.___.4!`4 Depth below inlet-."; ............ Total leaching areaA44......sq: ft.
Z Other Distribution box ( ) Dosing tank ( ) 0
`" Percolation Test Resu�2,__.inutes
Performed by ---•---------------••. .._...... Date._ldR".�,�':'"-fw_- .....•._....
a �...
Test Pit No. 1.... per inch Depth of Test Pit.................... Depth to ground water........................
f=, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth'to ground water........................
O t�-....., t �3 jf � r�
Description of Soil-----:...."...-••1---�- ..............r�.. t_ ..mac(_.... _'~._ ; /"`�•��}
x
W --......--•• •..•---•----••---••-----•-••-•------...•-•--•-•---•-••-•-••---•--••---••-•••-------•--
•-•-...--•------------------•--------------••--••••----------------......----------••-• -•--•------------•• ----------------------------------------
U Nature of Repairs or Alterations—Answer when applicable...__.._
..............................................-..............................................•....................................................................................•....................
Agreement:
The undersigned agrees to install the aforede�scribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in -
operation until a Certificate of Compliance ha ` issued b�,/the board o health
igned .` .... .. .. "
. ----..W..__ ... to
f Date �+
Application Approved By-••--- 7. ••• •...t- � .............
•---------
....... DateT.`
Application Disapproved for the following reasons: ...---••------••---------------------------------------•--•--------------------------------
..........................................................................._...._....__._......_._..Y............................._....................._.._.....------
Date
PermitNo.......................................................... Issuer ---_...
Date- .-
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF. HEALT
........OF....... ...................
TrrtiftrFatle of ampti anrp
I IS T CERTIFY, That the Individual Sewage Disposal System constructed ( or Repaired ( )
by -fps+"- t�.. .4 ..... -• � ......-•-----------------
Install l
-- -- •• - - 4 - --- -•• - - •�.....................................................
has•been installed in accordance with the provisions of 5 of The State Sanitary Code as described in the
.~application for Disposal Works Construction Permit N '' .......... __� _±______._.__ dated___.4 '�7. __7. .....................
THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUED AS A GUARANTErTHAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE........... ^.3 - L .................................. Inspector--.. ---..... ... ---- ----- -- .._ .. .
THE COMMONWEALTH OF MASSACHUSETTS
,.-- BOARD, F: 'HEALTH
w' ¢"�'Aw ...... ......�✓�''��' T 4...OF..... w .r............................................... ^*
No..........
FEE.......................
.:: Eltoprr 1 or . Tonotr ion amit
+'1.�R_
Permission > hereby granted.-- -------- •-----... --------•..........................•---•--------------.....--------...:-••---•---•-•--- �.
to°Constru j ( or Re it ( ) a divid S ge spos Syst
at / I
No.• •G "` �t Y I-
Street
as shown on the application for Disposal Works Construction P i No__ ______________ ated.4..._1_ .___ '
P1 Cj�'�j. t Board
DATE---... °�•- of Hem6
---
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS -
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L09 OF �tN'Qi.,�jq�
RICHARD �`'.; � RICHARQ yG
JAMES DAMES
O'HEARN =y r 1 O'HEARN
40
27871 ,p No.694 O W
i6TE��OG� E FG/ST�P�
LEGEND sURv�i/ san�ITAW
EXISTING SPOT ELEVATIONS O,A.
EXISTING CONTOUR— — - 0 — —
FINISHED SPOT ELEVATIONS 0.0
FINISHED CONTOUR 0 — PIROPOSED PLOT PLAN
APPROVED: BOARD OF HEALTH MASS.
his
.
DATE AGENT ' ` ��` , 4^c> =7-75 7t/
I CERTIFY THAT THE PROPOSED R. a OWEARN, INC., RLS, RS
BUILDING SHOWN ON THIS PLAN 1348 ROUTE 134
CONFORMS TO THE ZONING LAWS EAST DENNIS , MASS.
OF , !ti1 A Slz
.,. DATE SCALE:
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BUILDING ALL WORKMANSHIIP��- AND MATERIALS
INVERT AT 93 FT ,
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DATE OF - TEST.;.—
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REQUIRES SEPTIC CAPAC
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