HomeMy WebLinkAbout0067 CAPTAIN BELLAMY LANE - Health 67 CAPTAIN BELLAMY O D
Centerville
A = 230 - 180
-----------------
UPC 12534 '
No.2_ 15_ate
HASTINGS. MN
r '
S'
i
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Department of
Environmental Protection
William F.Weld Trudy Coxe
GwArnor asaot ry
Arpao Paul Cslluccl David B.Struhs
LL Governor 6amrrttNiorta
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A _
CA)0Tq,ld CERTIFICATION
Property Address: ? C 4 P /• 1:j ri��r L. d G�- I. Address of Owner.
Date of Inspection: ''/—/$—�T (If different)
Name of Inspector. W.E. Robinson SR
Company Name,Address and Telephone Number. ( 5 0 8 )7 7 5—8 7 7.6
W.E. Robinson Septic Service
P.O. Box 1089 Centerville MA
CERTIFICATION STATEMENT
I cartiig 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 is the proper function and
maintenance of on-site sewage disposal systems. The system:
_Passes
_ Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: Date: Gy/ 9 4,
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 seat 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) PASSES:
7ir ave not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 16.303.
Any failure criteria not evaluated are indicated below.
B) SYS CONDITIONALLY PASSES:
or more system components seed to be replaced or repaired. The system,upon completion of the replacement or repair.passes
Indicate 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 TNaphate(617)292.5500
40 Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL BY87EM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: ! cf}h�� kf) C_aW7!l(/!
Owner. M /-A/I gM
Date of InspecUm
1-/�-% L
BI CONDITIONALLY PASSES(continued)
Sewage backup or breakout or high static water level observed in the distri1xrtion box is due to broken or obstructed pipe(s)
or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is levelled 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) ER EVALUATION I8 REQUIRED BY THE BOARD OF HEALTH:
tions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
lic health,safety and the environment.
1) STEM 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.
Z) YSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)
ETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND
8 AND THE ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a .
surface water supply.
The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and is leas than 100 feet but 50 feet or more from a private water
supply well,unless a well water analysis for ooliform 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 lea than 5 ppm.
3) OTH
(revised 11/03/95) 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(oontinued)
Property Address; / oZlll m c/ 01,h ee1j;t'6/i
Owner.
Date of Inspection-
DI FAIL&
I determined that the system violater one or more of the following failure criteria as defined in 310 CHR 16.303. Ths basis for
determination is identified below. The Board of Health should be contacted to determine what will be necessary to oorred the
Backup of sewage into facility or system component due to an 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 1/2 day flow.
_ Required pumping more than 4 times in the last year NOT due to dogged or obstructed pipe(s).
Number of times pumped
Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
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.
El LARG SYSTEM FAILS:
following criteria apply to large systems in addition to the criteria above:
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
and safety and the environment because one or more of the following conditions exist:
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone II of a public
water supply well)
The owner or r of any such system shall bring the system and facility into Poll compliance with the groundwater treatment Program
requirements of 4 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information..
' I
(revised 11/ /95) 3
a
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Pngwt,Addresw & ,J �/r�'y kr)
Owner. *1 r4r 14 h19-PiA
Date of InVeotlon:
Cock if the following have been done:
_L/'Pumping information was requested of the owner,occupant,and Board of Health.
one 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.
✓A/s 't plans have been obtained and examined. Note if they are not available with N/A.
The facility or dwelling was inspected for signs of sewage back-up.
.
2mm system does not receive non-sanitary or industrial waste flow
/The site was inspected for signs of breakout.
(/All system components,excluding the Soil Absorption System, have been located on the site.
L.I�e 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.
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
Property Address: / c
owner.. n4,4r R A�
Date of Inspeotion:,!_/q_q Z,
FLOW CONDITIONS
RESIDENTIAI:
Design flow: 3�6 lions
Number of bedrooms: 3
Number of current residents:
Garbage grinder(yes or no):�i
Laundry Connected to system(yes or no):�[
Seasonal use(yes or no): /L-d
Water meter readings,if available:
Lest date of oocupancy:_y
COMMERCIALANDUSTRIAL:
Type of establishment:
Design flow:gallons/day
Grease trap present:(yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non4auitary waste discharged to the Title 5 system: (yes or no)_
Water meter readings,if available:
Last date of occupancy:
OTHER.(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as pik of inspection: (yes or no)_
If yes,volume pumped: ¢allons
Reason for pumping:
TYPE gr SYSTEM
L/ Septic tank/didributwn bar/soil absorption system
Single Cesspool
Overflow Cesspool
Privy
Shared system(yes or no) (if yes,attach previous inspection records,if any)
Other(explain)
APPROXIMATE AGE of all components,date installed(if known)and source of information: %°" 161,A S �-.p % A.,
Sewage odors detected when arriving at the site: (yes or no)Lt/
(revised 11/03/95) 5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: �Q //5t!/ lm
Owner. V k
Date of Inspectio/ (�
SEPTIC,TANK L
(locate on site plop)
Depth bebw grader /
Material of construction:_eeacrete_metal_FRP—other(explain) -�
-
Dimensions: l -tom$'
Sludge depth: (�
Distance fiiom top of sludge to bottom of outlet tee or baffle:
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 baffe:
Comments:
(recommendation for pumping,condition of inlet and outlet teen or baffles,de t of liquid level in relation to outlet invert,structural integrity,
evidence of leak
age,etc.)
G1REA8 _
(locate on s plan)
Depth below
Material of nstrution•_concrete_metal_FRP other(eaplain)
Dimensions:
Scum
Distance top of scum to top of outlet tee or baffle:
Distance bottom of scum to bottom of outlet tee or ba'M
Comments:
(recommendatio for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,
evidence of ,etc.)
(revised 11/03/95) 6
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMMATION(oontinuueed,),
Property Address: W
Owner. ✓�/� /� ,��
Date of Inapeodo L✓
TIGHT OR HOLDING TANK:_
(locate on ' plan)
Depth grade:
Material of n:_concrete_metal_FRP_other(ezplain)
Dimensions
Capacity: ons
Design flo Gallons/day
Alarm 1 1:
Comments
(condition of inlet tee,condition of alarm and float switches,etc.)
DISTRIBUTION BOX: 0"
(locate on site plan) ��ll
Depth of liquid level above outlet invert: V
Comments:
(note if level and distribution is equal, evidence of solids carryover,evince of leakage into or out of box,etc.) !rs✓C c,I�;t�i1 C 1�i z�Z�
9
PUMP C BER_
(locate on plan)
Pumps in rking order:(yes or no)
Commen
(note condi ' n of pump chamber, condition of pumps and appurtenances,etc.
(revised 11/03/95) 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address
owner. / n� fit,- iiL
Date of Inspeotiono/V rKy�
.(/-/ g-4 4
SOIL ABSORPTION SYSTEM(SAS):
(locate an site plak if possible;excavation not required,but may be approximated by non-intrusive methods)
If not determined to be present,explain:
Type:
leaching pits,number-
lesebing chambers,number._
leeching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
over1low cesspool,number:
Comments:(note co 'on of soil,signs of hydraulic failure,level o!.ponding,condition of vegetation,etc.)26
C. =C 0-0 t
t f
CESS LS:_
(locate on plan)
Number configuration:
Depth-top of to inlet invert:
Depth of so' layer.
Depth of layer:
Dimensions cesspool:
Material construction:
Indira ' of groundwater:
(cesspool must be pumped as part of inspection)
Comments:( condition of soil,sigma of hydraulic failure, level of ponding,condition of vegetation,etc.)
PRIVY._
(locate on • plan)
Material of Dimensions•
Depth of solids:
Comments:( condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
(revised 11/03/95) g
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
,, SYSTEM INFORMATION(continued)
Address: le
Owner-
Date of Inspeotion.1" "9t \/&17
8I0=11 OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all welt within 100'
P.u �
L
66
3
e
0, (fox
kAj
DEPTH TO GROUNDWATER
D%Ah to goundwater:jfeet
method of determination or approximation: 1,&5 1 146 1 1- �-�-- 1 �r 6e
(revised 11/03/95) 9
fe(9
No._ �*�' �� y Fee t/_� C/
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
Application for Mi5pogal *p-5tem Cotittruction Permit
Application is hereby made for a Permit to Construct( )or Repair(Afan On-site Sewage Disposal System at:
Location Address or Lot No. Owner's Name,Address and Tel.No.
4P '7 6MY- . y /-/I M Cur Aly)
Installer's Name,Address,and Tel.No. 7 —,?7 76 Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No. of Bedrooms t 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
Description of Soil 1/14
Nature of Repairs or Alterations(Answer when applicable) Via d ,7` coi- ✓'� S��1 „�e.�k i�.
irn 2.
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 Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this and o ealth-
Signed Date /v/C
Application Approved by
Application Disapproved for the following reasons
Permit No. �� e '7 Date Issued, �'�
Fee0.
' THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
appItration fot Migoot *p6teMl Cott!5truCtiou veim t
Application is hereby made for a Permit to Construct( )or Repair(,k-fan On-site SewagO Disposal System,at:'
Location Address or Lot No. Owner's Name,Addkss and Tel.No. '
9
Installer's Name,Address,and Tel.No. 7 7 s Designer's Name,Address and Tel.No.
t /Ltd�bi✓JScrJ Se,ohc.
s
Type of Building:
Dwelling No.of Bedrooms L Garbage Grinder
Other 5 Type of Building No. of Persons Showers( ) Cafeteria( )
Other Xll
tures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
w'Title
Description of Soil
r "
Nature of Repairs or Alterations(Answer when applicable) 01 q d cc 7`_ ol- ,Y'2. - S�rl�_ .LP.��i�✓i f
t" ; j
r ile, l �
Y
Date last inspected: I
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 Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this and o ealth-
Signed Date !�
R N
Application Approved by
Application Disapproved for the following reasons
Permit No. _ J 7 7 Date Issued
lk '
. - THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
' Certtftcate of Compliance - -
THIS IS TO CERTIFY,that the On-site S.ewa a Disposal System installed( )or repaired/replaced(X )on
for 6 .�C . cal/ l /YI y n'I� '/1 h<J
-as f I n has been constructed ' accordance
with the provisions of Title 5 and th for Disposal System Construction Permit No G`�y� dated !n
Use of this system is conditioned on compliance with the provisions s,qefo below: '
.L
101
No. / W Fee�4.eil
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
1=igpoga1 *pMem Construction Vertuit
Permission is hereby granted tok C kdimi7e7 lye/Y/
to construct( )repair(It")an On-site Sewage System located at 7 /y/ .17
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.
All construction must a co pleted within two years of the date below.
Date: 7 �6��6 Approved by AO
• � EG
I L'�
yuy_� ns ►�
Vo
14
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fi'y yti ?tZ 20 .y
7
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A6 ROBE
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MOMSE
LEGEND
sseea<,
t EXISTINS SPOT ELEVATION OAO CERTIFIED PLOT PLAN
EXISTING CONTOUR ——— 0
FINISHED SPOT ELEVATION i L �� ,t ��<=r• �t [ 1 �y L�± N�
FINISHED CONTOUR 0
NOTE: The location of airy existing underground sewerage, IN
wells, or other utilities shown on t} is plan is approx- i
imate only as determined from records and/or verbal •�'� ,
information. The contractor is responsible for the Nr +,is. 9 3' S5-
Verification of the existing locations in the field. SCALEI DATE$
DREDGE ENGINEERING COf�1jP/c
:, . CLIENT. i CERTIFY THAT THE PROPOSED
EOISTERE REGISTERED JOB NO. S3 t Z/ BUILDING SHOWN ON THIS PLAN
6CIVIL LAND DR.BY� CONFORMS TO THE ZONING LAWS
NQIN.49R R OF BARNSTABLE , MASS. i
712 MAIN STREET. CH. By
kE
HYANNISt MASS. SHEET� OF A REG. LAND SURVEYOR
�67 TOWN OFBARNSTABLE
LOCATION e^4/7-0,9 V,14 GE SEWAGE # _
VILLAGE `T/����/� 1,Y 'Z - All ASSESSOR'S MAP &LOT,?;7d A90
INSTALLER'S NAME&PHONE NO. . ,f, /P o e 1 i1/,r 77s 7 7�
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) ize)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMI TDATE: V[J� fo z COMPLIANCE DATE: fi /7 Z gZ
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
G�RMA
i
o
B
I _
A EAC, � _B
t
Ivo. r�. ��/ - Y FEBO:.ob...
s
�J j THE COMMONWEALTH OF MASSACHUSETTS
o�/ BOAR® OF HEALTH
o..cv�u----------------------OF....... ���.
Appliration for DiipnsFal Works Tungtrnrtion Permit
Application is bg y made for a Permit to Construct ( ✓) or Repair ( ) an Individual Sewage Disposal
System at:
l��
.._...�oT#g....... i�T414,!,1........................... ........e_/ lq�----�---�[�"�=�!�1� ................................................
. -� Location_Address or Lot No.
t2sz.t.�2................ ................. ••........ .
Owner. Address
a ---------------—). A�5.. CZ� S,�... ............ ----....-------- ...............................................................
Installer Address
PQ
Q Type of Building Size Lot__ .....Sq. feet
Dwelling—No. of Bedrooms......>....................................Expansion Attic (,vo) Garbage Grinder (a.a)
pa,, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Other fixtures ..............__ ________________
W Design Flow.........--`J._Z...........................gallons per person per day. Total daily flow.........3.30......................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width-----------_--- Diameter................ Depth................
x Disposal Trench—No--------------------- Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box (✓S Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
,aa Test Pit No. 1_ _ -.....minutes per inch Depth of Test Pit.....LZ........ Depth to ground water..!�a"! ..........
(i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a ---•---------------------------..............................................................................................................................
Description of Soil ...sLUn__ANC...Ss� ol�----------------------- -------------------------------------------------•----------
(xj .�-. .... 1 L?. i_t�l __ at�lV1? �� �- -...............................................................
W .....:?yAl?,d�,res?�t -
VNature 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 TITI1, 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed---. .. G/2 7. 5..
G /
Application Approved BY 2= -G---------
Date
Application Disapproved for the following reasons----------------------------------•-----•----------------------•------- ----------------•------------•.........
------•---•---...••....-•-••----------•-....•----.....---•...............•-•••---.._..-----••------------I---------------•-••---...•----------•----------------------------••-•---•---------••-----------
Date
PermitNo......................................................... Issued-.......................................................
Date
� 4
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
+rur*l......................OF....... A..,)V sP:A.F.
Appliration for Disposal Works Tonstrnrtion frrmit
Application is hereby made for a Permit to Construct ( 1') or Repair ( ) an Individual Sewage Disposal
System at:
.....412 I... CAP +�.?1�?.... L Ce v.......4 ..A>\i = .................................................
Location-Address or Lot No.
.......... .,.:.ram & __............�'--,.s�z .................... --------------
Owner Address
(� �tis\�.f. ._.•." �'"a"" ':"`? "S.".............................. Yd�'.4.�....................
Installer Address
d Type of Building Size ------Sq. feet
U Dwelling—No. of Bedrooms___: ....................................Ex anion Attic Garbage Grinder
aOther—Type of Building ............................ No. of persons...=........................ Showers ( ) — Cafeteria ( )
QI Other fixtures ..................................................
---------••••• ••---•--••--••• . .
W Design Flow......... ...........................gallons per person per day. Total daily flow--_-___--_r.. ...._.__.__...._.._......___gallons.
WSeptic Tank—Liquid capacity------------gallons Length................ Width................ Diameter--__--_--__._-_- Depth................
x Disposal Trench—No. ....................Width.................... Total Length......._............ Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box (,✓) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1.7`-.. .._..minutes per inch Depth of Test Pit..../. ....... Depth to ground water.!*fr: ...........
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
-----------------------------------------------------.. ------------
--------------
•-•--------------------------------------
--------------------------
Description of Soil '- _�....°.. >: =`� =-= ..------------------------------------------------------------------------------••-•-
x -- w. _.
U '.1. 'S-r= =:�t_ .. 4a�.'-t ' ,.a . � . k-----------------------------------------------------------------
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 TITIL 5 of the State Sanitary Code—The undersigned further agrees not to place the system.in
operation until a Certificate of Compliance has been issued by the board of health.
Date
ApplicationApproved By.................................................................................................. ------ '=a 5�----------
Date
Application Disapproved for the following reasons--------------------------------------------------------------------- ------------------------------------••----
--...._.....•-•--••--••••-•-••---••••--••---••--•••-••••.._...••-•••-•-•----•-•----•------...-•-••••-••--
Date
PermitNo------------------------------------------------------- Issued-.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
'+;;., ...: ................OF.......w�, `9 ..........................................
Tntifiratr of Tout rlianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (/) or Repaired ( )
_<<
r Installer
at ._.. "`a. !?.t . .-- = 5 �EaL s Goa•. '-�
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No...._.5_5>S-.-. ,_1f ------------- dated_-_.._-�-7-:Y-2S.................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CO STRUED A GU RANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.............. --..•---••-•....................•-•-----..--_. Inspector. =
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
NO......................... FEE...: .....: c! ...
Disposal Works Tnn#rndinn Uvrrmit
Permission is hereby granted------- --••--•• ==-...............................................................................
to Construct (/) or%Repair ( ) an Individual Sewage Disposal System
at No.... <?r_.'s`�------
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Street
as shown on the application for Disposal Works Construction Permit No.___..:__.P. ------ Dated _/_ _._
�S Board of Health
DATE ..........................................
FORM 1255 A. M. SULKIN, INC., BOSTON -
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LEGEND p
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5EX13TINe SPOT' ELEVATION OxO r'
s{ EXIDTINa CONTOUR — 0 - -- CERTIFIED PLOT PLAN
TrI8NED .SPOT ELEVATION (� 6.�
'.FINIXMED CONTOUR., 0
xf 1�1gTE. :The`location of airy existing u�nd_errou_d sewerage,
'wQilS, or-other utilities shown on t} is plan% is approx IN
E mate''only as determined from. records and/or verbal a.
1 9prruation. .The .contractor is responsible for the �� � � 740.lr,��,�J
3 Fry
Vfification of the existing locations in the field. SCALE, "- `/o DATES
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REDGE ENGINEERING Co"'No 1 CERTIFY THAT THE PROPOSED
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EOISTERE RE4ISTERED J08 NO. BUILDING SHOWN ON THIS PLAN
CIVIL LAND CONFORMS TO THE 20NIN0 LAWS
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{ ER RV OF BARNSTABLE , MASS. i
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B U I L D E R OR OWNER
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DATE PERMIT ISSUED
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DATE COMPLIANCE ISSUED Cf
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