HomeMy WebLinkAbout0590 CRAIGVILLE BEACH ROAD - Health F'590 Craigville Beach Road
Centerville
A= 246-223
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S M E A D
No. 2.153LOR
UPC 12534
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET. BOSTON. MA 02108 617.292-5500
Vr7LL1AM F.WELD TRUDY COXE
Governor Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner
PART A
CERTIFICATION Cheryl Gray
Property Address: 590 Crai ville Beach Rd Address of Owner: Halcyon Drive - Unit 1 B
Date of Inspection: 11 -A7--9 � Hyannisport (If different) 300 Buck Island Rd
Name of Inspector: Wm E Robinson Sr W Yarmouth, MA 02673
1 am a DEP approved system inspector pursuant to Section 15.340 of Title 0 CMR 15.000)
Company Name: him E Robinson Septic Service
Mailing Address: PO Box 1089 Cent-Prvi 1 1 j- , HA 02632
Telephone Number;,508 779-8776
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that t formation reported b is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training an ex In t e 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: GtJ d I ' Date: `%n*-9-9
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 CMR 15.303.
v Any failure criteria not evaluated are indicated below.
COMMENTS:
B YSTEM CONDITIONALLY PASSES:
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.
IndiLte es, 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, structurally unsound, shows substantial infiltration or exfiltration, or tank
,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 04/25/97) Page 1 of 10
DEP on the World Wide Web: http:ltwww.magnet.state.ma.us/dep
eJ Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 590 Craigville Beach Rd, Hyannisport
Owner: Gray
Date of Inspection://F-129-717
B] SYSTEM CONDITIONALLY PASSES (continued)
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
will inspection if with approval of the
or due to a broken, settled or uneven distribution box. The system it pass p l pp
pipe(s)
Board of Health). Describe observations:
broken pipes) 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] FU THER 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 PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system (SAS) and the SAS 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 the SAS is within a Zone I of a public water supply well.
_ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply 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 presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method used to determine distance (approximation not valid).
3) OTHER
(reviasd 04/25/97) Page 2 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 590 Craigville Beach Rd, Hyannisport
Owner: Gray
Date of Inspection: //—V-9--q 17
DJ YSTEM FAILS:
You ust indicate ei;,,er "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 o
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 112 day flow.
_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped _.
Any portion of the 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.
EJ RGE SYSTEM FAILS:
Yo must indicate either "Yes" or "No" as to each of the following:
The 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 health and safety and the environment because one or more of the following conditions exist:
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area- IWPA) or a mapped Zone II of a
public water supply well)
Th owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
req irements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 04/25/97) Page 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 590 Craigville Beach Rd, Hyannisport
Owner: Gray
Date of Inspection: ?
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No
_ Pumping information was provided by the owner, occupant, or 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.
✓ As built 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.
1/ _ The 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.
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.
,V 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 System.
y _ Existing information. Ex. Plan at B.O.H.
_✓ _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) [15.302(3)(b)]
(revived 04/25/97) Page 4 of 10
,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 590 Craigville Beach Rd, Hyannisport
Owner: Gra
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow:'b3 0 g.p.d./bedroom for S.A.S.
Number of bedrooms: S—Z/
Number of current residents:l
Garbage grinder (yes or no): a
Laundry connected to system (yes or no)
Seasonal use (yes or no):
Water meter readings, if a ailable (last two (2) year usage (gpd): 1995 — 68, 000g
Sump Pump (yes or no): L-d 1996 - 27, 000g
Last date of occupancy: 9?
CO ERCIAUINDUSTRIAL:
Type establishment:
Design flow: gallons/day
Grease trap present: (yes or no)_
Industr a) Waste Holding Tank present: (yes or no)_
Non-s nitary waste discharged to the Title 5 system: (yes or no)_
Wate meter readings, if available:
Last date of occupancy:
OTH R: (Describe)
Last f occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
A-Of
Syste pumped as part of inspection: (yes or no) �a
If yes, volume pumped: gallons
Reason for pumping:
TYPE Of SYSTEM
(/ 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)
I/A Technology etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information: 1d ...2 s ✓��,��
Sewage odors detected when arriving at the site: (yes or no)[-0
(revised 04/25/97) Page 5 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 590 Craigville Beach Rd, Hyannisport
Owner: Gray
Date of Inspection: %/—;L F —1??
BU ING SEWER:
(Locate on site plan)
Depth low grade:
Materi of construction: _cast iron _40 PVC_other (explain)
Dist ce from private water supply well or suction line
Diam er
Com nts: (condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK:_✓
(locate on Site plan)
e •
Depth below grader
Material of construction: Zncrete _metal _Fiberglass _Polyethylene _other(explain)
If tank is metal, list age — Is age confirmed by Certificate of Compliance —(Yes/No)
Dimensions: ' ``L tS `� Ca
Sludge depth:
Distance from top of sludgg to bottom of outlet tee or baffle:3
Scum thickness: 0^/ * a
Distance from top of scum to top of outlet tee or baffle: '?-
Distance from bottom of scum to bottom of outlet tee or baffle: / 3
How dimensions were determined: 0 'ems--
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.) f c 4>
GRE SE TRAP:
(locat on site plan)
Depth elow grade:
Materi of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain)
Dime sions:
Scu thickness:
Dis nce from top of scum to top of outlet tee or baffle:
Dis ce from bottom of scum to bottom of outlet tee or baffle:
Date f last pumping:
Corn ents:
(reco mendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integ rty, evidence of leakage, etc.)
(revised 04/25/97) Page 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 590 Craigville Beach Rd, Hyannisport
Owner: Gray
Date of Inspection: 9
TI T OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection)
(loca a on site plan)
Depth below grade:
Mated I of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain)
Dimen ions:
Capac ty: gallons
Desi flow: gallons/day
Alar level: Alarm in working order _ Yes; _ No
Date o previous pumping:
Comme ts:
(conditi n of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)
A, 6 yC
PUM CHAMBER:_
(locat on site plan)
Pum s in working order: (Yes or No)
Alan s in working order (Yes or No)
Com nts:
(note ondition of pump chamber, condition of pumps and appurtenances, etc.)
AA-
(revised 04/25/97) Page 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 590 Craigville Beach Rd, Hyannisport
Owner: Gray
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS):
(locate on site plan, if possible; 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:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure,,�vel of ponding, conditigq of ve a. g c
l� ram' ,
0 E- W, 17t_ rZ
SPOOLS: _
(loc to on site plan)
Num er and configuration:
Depth top of liquid to inlet invert:
Depth of solids layer:
Depth f scum layer:
Dime ions of cesspool:
Mater' Is of construction:
Indi tion of groundwater:
inflow (cesspool must be pumped as part of inspection)
Com nts:
(note ndition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PR _
(lo to on site plan)
Mat ials of construction: Dimensions:
Dep of solids-_—
Co ments:
(no condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised 04/25/97) - Page 8 of 10
1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 590 Craigville Beach Rd, Hyannisport
Owner: Gray
Date of Inspection: jl--2.9^0a ,
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)
o �
31 �
G '
(revised 04/25/97) Page 9 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 590 Craigville Beach Rd, Hyannisport
Owner: Gray
Date of Inspection: — $--g 7
Depth to Groundwater jo Feet
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
Use USGS Data
Describe in your own words how you established the High Groundwater Elevation. (Must be completed)
y
(revised 04/25/97) Page 10 of 10
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD PF HEALTH
- � ...-... OF....... �c�dLl.1 !A .................
Appliratinn for Diapniittl Warkii Tatuarnr#inn Frrutit
Application is hereby made for a Permit to Construct ( ) or Repair (Individual Sewage Disposal
System at
... mac . ........... ..... . ......... ........ ............
a io - dd ss or t No.
..?if
....... ... '` _......... ..............
Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............................................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—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
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 b ---•-•••-•-•-••-•••••••••-••-•-•-•---•-••-••--..._•---••----••••--•-•-••-• Date........................................
aTest Pit No. ]________________minutes per inch Depth of Test Pit.................... Depth to ground water........................
rX4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a •••-•-•----•--•-•••••••••••----
O Description of Soil ._ ..:-•_7..•-•-
----•---------------------------•----------------
qxavr ----------------------------------------------------
U -----------------------------------------------------
_---------------------------------------------------------------------------
•--•-------------------
.._...--------
___--•---•--------
---•------------
W •-•-••----------------------••----••••••-•---•••-•-••-••-•----------••-••-•-•--•--•----••••-----••-•-••-•--••---•--- -
VNature of Repairs or Alterations—Answer when applicable............. __— ....f1_�_._A __.__P.�_ .....___-___-._______________-
-••-•---••••--•------••-----•-•••--......-••-•-•-••••-•-----•••-••---•---•-•---•....................•-•-••••••-•-•••------••----••••--•-•-•......••••---•••--••••-•-•-•-•------•----•---...-•-------•-•-
Agreement
The undersigned agrees to install the aforedescribed. Individual Sewage Disposal System in accordance with
the provisions of TITLL 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been ssued by the b rd health.
Application Approved B .. v�
Date
Application Disapproved for th;,, 110 ng reasons:---•----------------•-------....------••--------------••-------------------- .... -
-------------------------------------•---...._.......__.c................................................................................................................................................
Date
PermitNo....................................................... Issued........................................................
Date
�.�.......... ----- ............. ---------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD rQF HEALTH
t_✓1.v OF....... -�/ � ..• y.�/ ---------------------------•----
AVVIiration for Uiipn.>ial Workii Tomtrnr#ion ramit
Application is hereby made for a Permit to Construct ( ) or Repair (--�Individual Sewage Disposal
System at�-, 1
�.� 7/-. � '... ` t�_ 1..... .. ........... ... ---- -------•-- ----------------------------------------------------------
1 Locafior,-Address t or jot No
` �� ,,,,Owner, /f 1 ° class
Installer Address
U Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ........................... No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures .....----------------------------......................................................................................................................
w Design Flow............................................gallons per person per day. Total daily flow-----------................................gallons.
W Septic 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 ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
1-4 Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P4 ...--.-••-----------------------•terra....................I...........
ODescription of Soil............................................��,,:�' ?r _{ -........_ _ - - -----•--••--•----------•--------•--•------------------------
x
w
U Nature of Repairs or Alterations—Answer when applicable.....-...--. ._ h '.._., `. ..........................
---•_-.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLL 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee ssued by the b rdf health.
Syr ate
Application Approved By.... ----•-_•. � ... -----------------••---•-•--------•----•-•---•--- ... . . . .,... .............
Date
Application Disapproved for the to 'ng reasons-------------•------------------•----•-•.................------•----•----•-•-----•--------- ••-•--.........
-•-•----•------------•----------------------•------•-----------------•----•------•--....---•--------.....•---•---•--•......••--_•••---••-----•-•-----••-_-•-_•-••••-•---••-_••-•••••-----•--•-•••-•-•---
Date
PermitNo......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
- _ BOARD OF HEALTH 1
... ....... t ... .�......OF.....9. ........: V.�.,�........................
Trrttifiratr of Tonvi ttnrr
THIS-IS.X,O CERTIFY, That the Individual Sewage Disposal_S;stem.constructed- (- ) or Repaired ( =z
by-• .....:. _" r fir, ` �`�/ 1 _ %... y , i�C
j 3 "t J-s Installer j/t 1 P �✓�
d. f t �f `, d�.f�~ .A°f_._%ly ` `ar �2
------------------•-•-•-•..�? ` .
has been installed in accordance with the provisions of TITLE 5 of Th eta-te Sanitary Cod as cribed in the
application for Disposal Works Construction Permit No... .7.r.4.,,7��.............. dated... .s9. .. .f+. ...................
THE ISSUA ICE F THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A UARANTEE THAT THE
SYSTEM WIL FFU TION SATISFACTORY.
DATE._...�..11? .. ,1�..........................•-•-----...-------•---- Inspector... ...... l•---•................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Ow ..............OF.......�Y�'�� � ..........:
No......................... FEE._.....: '. 't ..
�io�ronFti 1 k� �on� nr#inn err .
yy
Permission is hereby granted...`"� f ........... 0 of •-t-�.�' 5_ .!).c.........................................
to ConstrueV
) �e ,Repair ( n In 'dual Se ag'� iposal ys em
L.
Street -
as shown on h application for Disposal Works Construction Permit No..................... Dated..........................................
.................•.............................-------------------------
................................
Board of Health
DATE..............`...................................................................
_
FORM 1255 A. M.•SULKIN, INC., BOSTON
` TOWN OF BARNSTABLE �
LOCATION,r4�_�j�t� �;ll�e-A) ggl SEWAGE #
VILLAGE _ ASSESSOR'S MAP & LOTo�,/—/Z
INSTALLER'S NAME PHONE NO.���G�.�
SEPTIC TANK CAPACITY.
LEACHING FACILITY:(type) (size)_
/
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC W A TTER IG1
BUILDER OR OWNER
DATE PERMIT ISSUED:
GATT? COLIPL'IANCE ISSUED:
VARIANCE GRANTED: Yes _ No r __
L
i
o
C761 0
rya. .....................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF H Thy
_.T_0_U)rq.....OF..... .c..............................
AVpfiration for Dispsal Works Tanstrurtion Frrmit
Application is hereby made for a Permit to Construct or Repair ,( A--)-an Individual Sewage Disposal
System at:
T.Yvj)?Q..five...................................... ..................................................................................................
Y-) jOLocation-Address or Lot No
P. ...................................... ...................
dress
.) OW.hop_
L e" );7 _14C. ..............................................
Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder (
Other—Type of Building ............................ No. of persons_._._.___.._._.._.__...____. Showers Cafeteria (
Otherfixtures ......................................................................................................................................................
< Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
1:4 Septic Tank—Liquid capacity............gallons Length________________ Width.._......__...__ Diameter__-_.-__.__._.__ Depth___...__.___....
Disposal Trench—No_.................... Width_.__....._._.._.____ Total Length._._..______._..____ Total leaching area....................sq. f t.
> Seepage Pit No_____________________•Diameter__._._._____.___._._ Depth below inlet_____.____________.. Total leaching area..................sq. f t.
Other Distribution box ( ) .Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date________..__.............._..-________...
Test Pit No. I................minutesperinch Depth of 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........................................................................................................................................................................
U .........................................................................................................................................................................................................
.................... .............................................................................. ----
---------------- ------------ -----------
U Nature of Repairs or Alterations—Answer when applicable- -). A
.............................................................................................................................................................. .........................................
Agreeinent:
The undersigned agrees to install the aforedescribed 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 has bee issued by tht boar f Health.
Signed... - -------
Date
ApplicationApproved By................................................................................................. ........................................
Date
Application Disapproved for the followingreasons:...........................................................................................
. ....................
.........................................................................................................................................................................................................
Date
PermitNo......................................................... IssuedL................................................
Date
—-----------------------------------------------------------------------
LOCATION S AGE PERMIT NO. .
�- �3- L3�
VI AG E
1,4
111 T LLEI I 11S NAME i ADDRESS
R UILDE R . OR NE
DATE PERMIT ISSUED '
DATE COMPLIANCE ISSUED . � �
` _
.�
� .
�1 �` �cT
� � '� � 1
,� ���
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_ _ � r, .. _ _ - _ _� .�
No`�j....... �... Fss :.r� ..
THE COMMONWEALTH OF MASSACHUSETTS
_ BOARD OF HEALTH
.......... -----OF......
Appliration for Diiivwial Works Tomitrurtion F.rrutit
Application is hereby made for a Permit to Construct ( ) or Repair Individual Sewage Disposal
System ate*�
s �
...................................... ...................................................................................................
F ocation-AddressN
�:. 1� ,r
.......1 .--•-�.. 11.,k' ' .�.. _..._................................. rl. `-------------------
dress
�- Ownet �/' r
J'� ...............................................
Installer Address
UType of Building Size Lot.................... .....Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ____._......•............... No. of ersons........___....._._....._ Showers
a g P --- ( ) — Cafeteria ( )
d Other fixtures --------------------------------------------------•--.
-----------------------------
•---......
W Design Flow.............................................gallons per person per day. Total daily flow............................................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...............x::: 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................minutes per inch Depth of Test Pit.................... Depth to ground water........................
f14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P4 ............................. -•-•••-----•••-••••--••--••••--•-•-••-•-•••--••••--------••-•.............••-•-•--•-••-••---......--••••---.._.................
0 Description of Soil........................................................................................................................................................................
VNature QRe'paitcSr,Alterations—Answer when applicable...___.:_ :._ , --- 0 � ...--•�C.,�; ,._-.
..............................•-------------------------------------------------......................--••-••••-
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE; 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee issued by 7thboardygf health.Signed.._�'/. .......: 6 ' �#%-. `
Date
ApplicationApproved By..-•••••-•••••-----•---••••••••f-•-••••••••••••---•••••-•-------••..............••....._..•..... ........................................
Date
Application Disapproved for the following reasons:................................................................................................................
----------------------•-----•--------------------------------------------.....------------------....-------•••••••-•-•-••••-----••••-••-••--••••--•---•-•••••••••---•--••-•••••••---••••--•-•••••---•---
Date
PermitNo......................................................... Issued-.......................................................
Date
THE COMMONWEALTH'OF MASSACHUSETTS
BOARD OF HEALTH,
�./ e 1 ' ..Y 71 e Y
J . .e ........OF...�1. .a.. /. ✓. x.. ............................
Trrtif iratr of Tontplianrr
TH1S_IS0 CERTIFY, TIOLat the Individual Sewagl~„piRosal System constructed ( ) or Repaired
Installer -�
has been install o/d in accordance with the provision..of TIT 5 of T State Sanitary a r' ed in the
application for Disposal Works Construction Permit No...d�."'"...... •--...._.. dated-- . --- .................
THE ISSUA CE THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL UN ION SATISFACTORY.
DATE__...--2--... .... Inspector ...-- -•-•-•-
i ..
THE COMMONWEALTH OF MASSACHUSETTS
BOARD HEALTH
No.........................
......... .C2.�r4.r ........OF.....--- (ifs /.1. ...>�.. ....................................
FEs._........1 ..
`t } ork� �on�tr ton rrnti�
Permission is herebyranted.._....✓.. :..- 1 �11JT' _ _ Z
g .. .....................................
to Construct �._) or Repair L-�aii Inc)ivi ual Swage Dis osal System
/ f j ,.
at No.---- ,. 1.�� ��.., 1. ----- 1 ' Y ��
Street
as shown on the,application for Disposal Works Construction Permit No..................... Dated..........................................
...---•------•--•--------------------•-------•--------------------------------------------••••-•••-••_.�
DATE................................................................................
Board of Health
FORM 1255 A.'M. SULKIN, INC., BOSTON -