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Home My WebLink About0046 DONEGAL CIRCLE - Health 46 DONEGAL CIRCLE, CENTERVILLE A=169-072 •'--fir--- -------------------- ----� -- � _ _ ____- --__---�r� ,��/ JJRECYCLfOCo'L UPC 12534 a No.21� HASTINGS,UN L DATE;_ 6/21 /00 - PROPERTY ADDRESS RECEIVED 46_Donegal Circle________ Centerville JUN 2 8 2000 ------------------------ TOWN OF BARNSTABLE HEALTH D PT. On the above date, I Inspeoted the eeptlo system at the a This system conslsts of the following; 1 . 1 -1000 gallon septic tank / 2. 1 -distribution box 17 3 . 1 -1000 gallon leaching pit Based on my inspection, I certify the following condltlons: 4 . This is a title five septic system. ( 78 Code ) 5. The septic system is in proper working order at the present time. 6. The leaching pit was dry at the time of inspection. SIGNATURE:„/ --1-=1A1 Name:_� ,_P �,1{9SsmtL4C �J�--_--.. Compahy; Joa.�h_P � Hacomber b Son , Inc . •. Address:— Box_66------------- • __Cencervi11eL Ha ._02632-0066 Phone;___ ------- THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY JOSEPH P, MACOMBER & SON, INC, Tink><•C@:><pools•t,@scMlslds Pumpod rw Instilled Town Sower Conneotlons P,O. 8ox 6775•3338erY1114.M 102632.0066 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 292.6600 TRUDY COXE Secretary ARCEO PAUL CELLUCCI DAVID B. STRUNS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTL9CATION Owrw Anne Wynne P'°Q'rtyA�r's"46 Donegal Circle AddressorNO rsa�r:790 Falmouth Rr3 H at,nis Apt 102 Dau of rtspKtcor,Centerville F P Name of rsspector:("1FAAWoseph P. Macomber Jr. I sin a DEP approved system Inspector pursuant to Section 15.340 of TWe 5(310 CMR 15.000) Dort,p y", : Joseph P. Macomber & Son Inc. lA,ang Address: o x 66 , Cen—F-erville, Fia, 02632-0066 Telephone Number: — C>RTIRCATION STATEMENT 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: n Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: Date: The System Inspect hall submit a copy of this Inspection report to the Approving Authority (Board of Health or DEP)w(tftln 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 stint submit the report to the appropriate regional offlcv of the Department vKrivironmeraad Protection. The original should be sent toV* system owner and copies sent to the buyer, If applicable, and the approving authority. NOTES AND COh1MENTS revised 9/2/98 Paeriortl 01 Primed on R"led Paper SV&SV"ACZ SEWAGE DI3►OSA-L SYSTVA 193► CnON FORM ►AXT A .r . C93"VICAMW (oond-u04 > '" Nop.rtyAdaea4: 46 Donegal Circle, Centerville Ow"'r' Anne Wynne Dww of Vwpoctk-: 6/21 /0 0 ►43►SCT10N $VhAMAAYt Ch ci A4, B, A, SYbToj ►A33ES: AS I hsvo not fovnd my Inform+don wNch Indicates that uty of the f+llwo ov4tlorts dosortbod In 310 CMR 14.303 oxlst Any N& crfteM not #v+Jvst#d uo Ind)catad below. COIIICEM3: It. SYSTDI CONDMONALLY MUM om w more system sompononu w de#ortbod In Ow 'Co"dwW Isa#' 000don mod to be ropleood w ropa)red. Tho syetam, %op complsdon of the repJesement a repOJr,ad apprOvod by the Sowel of H#sJth, wW pass. tn44eto yeast• no, or not determ)ned (Y, N, w ND). OwAbo baaJ#of dowminadon In ey WuAoes. If •not detormjr0od', oxpWn why not. �{�Jr The #epdc tank If metal, un)O## the owner w opuatw has prohrtded the oyetam tnapowtw whh s sopy of s Cer"cat• o ComptJenco (sttsched)Indlsedno that the tank was InaWlOd wIWA twenty(20)yea#prtw to th.o data or the Vupecvon ate ospdc tent, whether er not mete,Is OreOkOd,+Wwtw+lly vn+ovnd, ►how# sub#tandaJ LMWGt1on w 0x vVeldon. a 1 f#Jlvro is ImrNment. The eyotsm wW ps#e In+pOsdon If the OW40Rp sOpds tank Is "pissed whh a sompryM+p #Optic WA +pprovod by the loud of HoWth. $Owego beckvp or brs#kovt or Nph stado water level observed In the dlstrlbudon box Is due to brokon w obsvh,cua pip or dvo to s broken, settled or vnevon dJ#vibvtJon box, The ►y#tom wW ps#s In#pOotJon If(wM approval or the Soard or Mevthl, broken Ops(s) us ropl+ced obowcdon la removOd dJsvUwdon box Is Iovollod w repl+ced The syrtOm rOQuksd pvmphi7Trwry dan 1ota�+neo�yssrdue to broliwn w obsovotOd p1pO(0). ThO vYvwm ww-P mw-- Irupocdon If(wlth opp(ovd of the hoard of Health)t broken plpols) ue roplacid obswcdon Is rsmoved revised 9/2/98 Pigs IorIt I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORA PART A CERTIFICATION (contirxwed) PropertyAd&*": 46 Donegal Circle, Centerville Owner: Anne Wynne Dety of Inspection: 6/21 /0 0 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: �I I� Conditions exist which require further evaluation by the Board of Health In order to determine If the system Is falling to protect the public health. safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 ChER 15.303(1Kb)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH.WILL.PAO.TECT THE PUBLIC HMTH.AND SAFETY AND THE 8CZ8ONAAE>>ZL• �e Cesspool or privy Is within 60 feet of surface water Cesspool or privy is within 60 feet of a bordering vegetated watland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETOUAWES THAT THE SYSTEBA tS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALSii AND SAFETY AND THE ENt,/IRONMEWT: Aj The system has a septic tank and soil absorption system(SAS)and the SAS is wlthin 100 feet of 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 60 feet of a private water supply wall. The system has a septic tank and soil absorption system and the SAS Is less than 100 feet but 60 feet or more trom a private water supply well, unless a well water analysis for collform bacteria and volatile organic compounds Indicates that the well Is free from pollution from that facility and the presence of•mmonle nitrogen and nitrate nhrogen Is equal to w less than 5 ppm. Method used to determine distance d!4� (approxlmstion not valid).- 3) OTHER revised 9/2/98 Page 3orit f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART A CERTIFICATION(continued) Property Address: 46 Donegal Circle, Centerville owns: Anne Wynne Date of kupection: 6/21 /0 0 D. SYSTEM FAILS: You,rpust Indicate either "Yea' or "No" to each of the following: I have determined that one or more of the following failure conditions exist as described In 310 CMR 15.303. The basis for this determination is Identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure Yes No Backup of sewage into fecilltyer•n-to m cornponent•due cto an overiwdod orcbggedSflS-or-cees000l. •s--�' ' Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or dogged SAS or / cesspool. Static liquid level tn the,distribu ion bo ove outlet Invert due to an overloaded or clogged SAS or cesspool. Liquid depth in 'Is less than 6" below Invert or available volume is less than 112 day flow. Required pumping more th 4 times In the last year NOT due to clogged or obstructed pipets). Number of times pumped�. ZAny 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 60 feet of a private water supply wall. Any portion of a cesspool or privy Is less than 100 feet but greater then 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: You must Indicate either 'Yes" or "No" 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 put health and safety and the environment because one or more of the following conditions exist: Yes No _ l� the system is within 400 feet of a surface drinking water supply the system•le•witWo 200 reetof-9-404butery-404e4Arfa0"4nk4w9-waWe#u►Ply _ --- _ 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 upgrade the system in accordance with 310 CMR 16.304(2). Please consult the local region+ office of the Department for further Information. revised 9/2/98 Page 4orII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 46 Donegal Circle, Centerville own«: Anne Wynne Dau of kuq"ctl'on: 6/21 /0 0 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 systsmcon4saawas kak%bwn pwrrpedJ*Pmt•J•aat two•w*WW haabaaogNoW wq amemal floes 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 exemined. Note If they are not available with N/A. _ The facility or dwelling was Inspected for signs of sewage back-up. The system does not receive non-sanitary or Industrial waste flow. _ The she was Inspected for signs of breakout. _ All system components,�luding 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 baffle or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System orrthe site has been determined based on: ZExisting Information. For example, 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) 115.302(3)(b)) _ The facility owner(and.occupants,Jf dittuaut froauawaar).w&lr&4 raWd&d wUh 1-formatlomon rha proper m alwa wLac. ^f SubSurfece Disposal Systems. revised 9/2/98 page sortl SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION PropertyAddresa: 46 Donegal Circle, Centerville Owner: Anne Wynne Dow of kupection; 6/21 /0 0 FLOW CONDITIONS RES0EN IAL; Design flow:_jj. Q_g•p•d./bsdro Number of bedrooms(deslg Number of bedrooms(actual) 'Total DESIGN flow r Number of current resldents:ia Garbage grinder(yes or no): Laundry(separate system) es or r o If yes, separatelnspactlon•requirod Laundry system Inspected ee or no) Seasonal use lye& or not: / r Water meter reading&,If av able (last two year's usage(gpd): � 6e" ll Sump Pump(Ye&or no): 7` /� f�•I Last date of oeeupaney:�'r'= COMSM1ERCtAL11NDUSTRLAI; Typo of a&tablishment: It 10 Design now:_ A god ( Besed on 16.203) Basis of design flow Grease trap present: (yes of no) Industrial Waste Molding Tank present:(yes or no)" Non sanitary waste discharged to the Title 6 system: yes or no)m Water meter readings,If av&ilab e. All Last date of occup&ncy:� OTHER:(Describe) 104 Last date of occupancy: ' GENERAL INFORMATION PLUMPING RECORDS and source of Information: System pumped as part of inspection: (yes or no) if yes, volume pumped: gallons Reason for pumping: — TYPE F SYSTEM Septic tank/distribution box/loll absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes, attach previous Inspection records,If any) I/A Technology et Attach copy of up to date operation and maintenance contract Tight Tank Wh Copy of DEP Approval Other APPROXIMATE AGE of all components, date Installediif kn'own)•and souroe ofJwformation: Sewage odors detected when arriving at the site: (yes or no)le� revised 9/2/98 Pser6ofII • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION!FORM PART C SYSTEM INFORMATION(corrtirwed) Property Address: 46 Donegal Circle, Centerville owner: Anne Wynne Data of Inspection: 6/21 /0 0 BUILDING SEWER: (Locate on site plan) N Dept below grade: Material of construction:cast iron 40 PVC,&other(explain) Distance from.private water supply well or suction line •t' Diameter40 Comments: (condition of joints,venting,evidence of leakage,-etc.)Joints ap PaT' t 1 ghi' No Clzi damna of leakage. -- 9EPTIC TANK: (locate on site plan) It Depth below grade-- Material of construction: l�concretey(&metaLdI)Fibergla334&Polyethyleneother(explain) VA If tank is(natal,list age AZg 13.ago.co�nfig^rmeed by Certificate of Complianc (Yes/No) Dimensions: Pis„h l Sludge depth, Distance from top 4i.Wudge to bottom of outlet tee or baffle Scum thickness: �,,,/ Distance from top of scum to top of outlet tee or baffle:. A Distance from bottom of scum to botto of outlet a or baffl :ti t How dimensions were determined: Comments: (recommendation for pumping,condition of inlet and outlet tees or-baffles, depth of liquid level in relation to outlet invert, structurel-integrity, b? �—ta__k ®uer 2 � Inlet & outlet evidence of leakage,etc.) PUI(l the 4P t i r• n ,__ �e&z8 tees are in 1 fifty nnP innhmcaanis s u ows ne—euideeee or a a GREASE TRAP: (locate on site plan) Depth below grade:�� Material of construction;(aconcret& metaWJ*iberglasstkPolyethylene,&other(explain) .424 Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baftle:,,elk Distance from bottom of scum to bottom of outlet tee or baffle:�9 Date of last pumping: 10 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.) rease trap is not present revised 9/2/98 Page 7of11 SUBSURFACI SEWAGE DISPOSAL SYSTEM WSPECTION FORM PART C '�. .. SY3T0A WFORMAT10N(cortdnuoQ) ProgerryAd&o": 46 Donegal Circle, Centerville °'rw: Anne Wynne Dow of In►p.�don. 6/21 0 0 T10MT OR MOLDING TANK:�t(Tank must be pumped prior to, or at time of, Inspection) (locate on site plan) Depth below grade:M Material of conewction:Concrete4Qmeta Flberpl►► Polyethylene other(ezpl►In) IM Olmenslons: Cspsclty: M g►llon& Design now: gallons/day Alarm present Alarm level: Alarm In o(king order:Yes&&Nor Oste of previous pumping: Comments: Icondloon of Inlet tee, condition of alarm and float switches, etc.) i nr hnl di zag tal41.s aEe net pr OLSTRIBUTION BOX: Ilocste on site plsnl Depth of liquid level above outlet Invert: Comments: Inote If level and distribution Is equal, evidenoe of olids carryove(, evidence of leakage Into or out of►ox, etc.) Dis one lateral.No evidence of c;n1jr1.q (-;4rrl7 over.No evidence of 1 Pakaga i ntiLOr flute e€ t1je 19ejf. PUMP CMMBER:All e Ilocate on site plan) `/�} Pumps In working order:(Yes or No) 4 Alarms In working order (yes or No) Iff Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) revised 9/2/98 Ps�e�orll SUBSURFACE SEWAGE DISPOSAL SYSTSA INSPECTION FORM PART C SYSTEM INFORMATION(contirx►ed) Pmp*MAd&*": 46 Donegal Circle, Centerville Owrw: Anne Wynne Dou of Inspection: 6/21 /0 0 SOIL ABSORPTION SYST84(SAS):_ (locate on slit plan, If possible; excavation not required,location may be approximated by non-Intrusive methods) If not located, explain: Type: leaching pits, number: leaching chambers, number: leaching galleries,number:- leaching trenches,number, length: leaching fields, number, dim• Ions: overflow cesspool,number: Alternative system: Name of Technology: —72 Comments: (note condition of soil, signs of hydraulic failure, level of pondin damp soil, condition of vegetation, etc.) Loam sandI�o si ns or ponainq.Soiis are is rma . CESSPOOLS:ALWIZ (locate on site plan) Number and configuration: Depth top of liquid to Inlet Invert: JFJA Depth of solids layer: Depth of scum Isyer: AIN Dimensions of cesspool; Materials of construction: Indication of groundwater: Inflow (cesspool must be pumped as part of Inspection) Cesspool are not ,prPSnnA-. Commems: (note condition of soil, signs of hydraulic failure,level of pending,condition of.vegetation, etc.) Cesspools are not present- PRIVY: (locate on site plan) Materials of construction: �A Dimensions: Depth of solid&:-" Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation;etc.) Privy -is revised 9/2/98 Page 9of11 SV93VRFACE SEWAGE Ot3POSA1 VYiTVA NN3PCCTION FORM PART CSYSTEM WFORIAATION(odrtdnwQ).• ftop.MAd&*": 46 Donegal Circle, Centerville 0~: Anne Wynne Dfu of V•`°"d«: 6/21 /0 0 SKETCH OF SEWAGE DISPOSAL SYSTEM: Inc:udo dot to C I4641 two p#rm#nont r9lorinc•Iandmuki or bttnchm rks loc•t� ►II wails within 100' (Lcc•t•whirs publlc water supply comes Into hours) egal cZr of St N INN j / t revised 9/2/98 ► tf loot 11 SUBSURFACE SEWAGE DLSP93AL SYSTEM INSPECTION FORM PART C SYSTEMy4FORMATWN(cor*wW) PropertyAddresa: 46 Donegal Circle, Centerville owner: Anne Wynne Dew of tn`p'ctsoru 6/21 /0 0 NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep _ SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to GroundwateW Feet Please Indicate all the methods used to determine High Groundwater Elevation: Ll Obtained from Design Plans on record 0 served Site �conftlon. observation hole, basemeat sump etc.) Datarmined from lo Checked with local Board of health _Checked FEMA Maps Checked pumping records Al Checked local excavators. Installers Used USGS Date Describe how you established the High Groundwater Elevation. (M3LO be completed) Used water contours Map. Gahrety & Miller Model 12/16/94 revised 9/2/98 Page 11of11 •w.mr..-n��••-�r• rwranr•ne.wrr•+..+a�.rrnwn�.++�.►r�w*�.w.n ner�ti*wr�n�n i-n e-..err-r��-r+r ...r•-} TOWN OF RARNSTART.F LIOARD OF HEALTH Tom^ • SU(1SU((FACF 9EWAGF DISPOSAL�SY�9TFM INSPECTION FORM - PART D •- CEIZTfF1CATI0NrA - -TYPE OA PAINT CLEAALY- PROPERTY INSPECTED STREET ADDRESS 46 Donegal Circle, Centerville ASSESSORS HAP, BLOCK AND PARCEL OWNER' s NAME Anne Wynne PART D - CERTIFICATION NAME OF INSPECTOR Joseph P. Macomber Jr, COMPANY NAME Joseph P. Macomber S" Son, Inc. COMPANY ADDRESS Box 66 Centerville MA. 02632-0066 str•.t To►m or city Stat• EIP COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX ( ) - w. w CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this nddress and that the information reported is true , accurate , and omplete as of the time of •inspection . 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 : ; System PASSED ' The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public healLh or the environment as defined in 310 CMR 15 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. System FAILED* The inspection which I have con acted has found that the system fails, to protect the }-itlblic health and the environment in accordance with Title 5 , 310 CMR 15 .303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . Inspector Signatur Date v�l-d� ne copy of this er tificati�on must be provided to the OWNER, the BUYER R( where applicable ) and the DOARD OF HEAL'I'It. • If the inspection FAILED, the owner or operator shall upgrade ' the system within one year or the date of the inspection, unless allowed or required otherwise as provided in 3.10 CMR 16 . 306 . partd .doc No........ ........ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF H A - -H 14/w, ............0 02 � ) _';.; F.../ .. .�Z., ...................................... Appliration for Bhipviial Marko Tonotrurtion Prrutit Application is hereby made for a Permit to Construct or Repair (�an Individual Sewage Disposal System at, . . ........d............azz, 1"�414...................................................................................... - i Location-Address or Lot No. - -- ------ - ----- --- - ---------*---------------------------------------- ---------------------------------------- ----------- .............0 r Address .......... .. .. .... .............................. . .................................................................................................. Installer Address U ype of Buildin Size Lot............................Sq. feet Dwelling No. of Bedrooms............................................Expansion Attic Garbage Grinder ( ) Other—Type of Building ............................ No. of persons............................ Showers Cafeteria ( ) PL4Other fixtures ...................................................................................................................................................... Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 04 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. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.__._............... Depth to ground water...._...._...........__. 44 Test Pit No. 2................minutes per c h Depth of Test Pit.__............._._. Depth to ground water.....___................ 94 e ---------------- ............................................................................................................................. 0 Description of Soil--------------44� ---------------------6-------------------------------------------------------------------------------------------------------------- W U ............................................................................................................................................... ....... ............................................................................................................................... ---------------------------- '2 .. 7 U Nature of Repairs or Alterations—Answer when applicable.......... i ........K 'e - ............................ ....................................................................................................................................................................................................... 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 been issued by he))O and ol health.j health. Signed... ....... ........... .. ..t......... ..... IV";wk 14 .... ......... .... ApplicationApproved By.............................................. ......�b..e.. ................... ....................Da-te.............. Date I . r Application Disapproved for the following reasons:. .. ........................................................................................................... ...................................................................................................-------------------------------------------------------------*--------------------"------------ Date PermitNo......................................................... Issued....................................................... Date ---------------------------- No......................... Fzz THE COMMONWEALTH OF MASSACHUSETTS BOARD OF H AJLTH ............ ............. .. ....................................... Appliration for Disposal Works Tottstrwtiott rtrutit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: /,j 'p ... ........ . ..................................................................................... at Location-Address or Lot No. ............ ............ ............................ . ................................................................................................. Ow°er Address Z21 ................................. . ............................................................................................ Installers Address ype of Building,,... Size Lot.... Sq. feet Dwelling-L*`N' o. of Bedrooms............................................Expansion Attic Garbage Grinder 04 Other—Type of Building ........................... No. of persons............................ Showers Cafeteria 04 Other fixtures ...................................................................................................................................................... Design Flow............................................gallons per person per day. Total daily flow............................................gallons. Septic Tank—Liquid capacity............gallons Length................ Width.........._..... Diameter................ Depth............_... Disposal Trench—No..................... Width.................... Total Length................._.. Total leaching area....................sq. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ 0.4 Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water....................._.. f4 Test Pit No. 2................minutes per inch Depth of Test Pit.....................Depth to ground water........................ ..............'..4..................................................................................................................................... .... ..............I............................................................................................................... 0 Description of Soil........... ............**--------------------------------------"........... ---------- ---------------*----------------*---------------------*.......*-----------......................................................................................................................................................................../............................. U Nature of Repairs or Alterations—Answer when applicable....,, ......... ....................... ....................................................................................................................................................................7........"....... ........... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE U 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 bythe board of health. V.. ..�0........... .... Date Application Approved By............................................. ................................. ....................................... Date Application Disapproved for the following reasons:... ....................................................................................................... ......................................................................................................................................................................................................... Date PermitNo................................ .................. Issued..................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH. ......OF...... ................................. ...................ram.. ......... ........... ,I ................... Grfifirate of Toutplianu TMISA;,OICERTIFY.I�that theIndividual Sewage Disposal System constructed or Repaired by.. .................................... ...........7. ............................................................................. VInstalli�r, at............... ..... 14�4114 4141 ............ . ............................................................... 1 14--- -----------.. .......installed has been if in a cordance with the provisions of TITLE 5 of The State Sanitary Co k ;�rdescribed in the application for Disposal Works Construction Permit No...........a.�.... dated....... -.2.-r'4Z_.............. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNC,/TION 4::;;� S ATISFACTORY. DATE................. LZ;�. �............................... - Inspector.........�/)'%................................................................ ... . THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ................OF ..................................................................................... ........................... No..... .................. FEE........ ............. Disposal Works Tonstrurtion Prrutit Permission is hereby granted...._.....K...................... e f I .............................................................................................. to Construct or Repair an Individual Sewage Disposal System atNo........................................................................................................... ................................................................................. Street as shown on the application for Disposal Works Construction Permit No....... _I...._.--- Da -----------A... .............. — Board T 0 Health DATE........................... ......... ...................................... FORM 1255 A. M. SULK N. INC.. BOSTON ASSE,SSOR'S MAP NO. , PARCEL 4 LOCATION �, SEWAGE PERMIT NO. H Ian I �QT VIUAGE , aakeNld�v I N S T A R'S� NAME i ADDRESS e UILDER OR OW DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED L— 1 Anne Wynne ' 46 Donegal Circle Centerville,Mass. G System consists of. 1 -1000 gallon septic tank. 1 -Distribution box. 1 -1000 gallon precast leaching pit. Leaching pit is 17 ' off the water table. J.P.MacoVbe & on I car D� oast .