HomeMy WebLinkAbout0023 DUNASKIN ROAD - Health 23 DUNASKIN RD, CENTERVILLE
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ASSESSORS MAP N0:2
PARCELN
No................._...--- Fps$....3.�.�.��.....
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
TOWN OF BARNSTABLE
Appliration for Mitip Sal li orkii Tonmrnrtion tIrrmil
Application is hereby made for a Permit to Construct ( ) or Repair ZX� an Individual Sewage Disposal
System at:
.23....➢uaas-kixl...Zoad...�entervi11e
..................................................................................................
Location-Address or Lot No.
...........................
•-----------------------------------
•-----
-----------------------------------------
•----------------------------------------
-....
W J. P.Macomber Jr . Owner Address
Installer Address
Type of Building Size Lot............................Sq. feet
DwellingX—No. of Bedrooms---------------3--------------------------Expansion Attic ( X) Garbage Grinder fe�
per, Other—Type of Building -------YOU.......... No. of persons-------- .__--_____-_.--_. Showers ( ) — Cafeteria ( )
(1r Other fixtures ..
W Design Flow-------------5.5--------------------------gallons per person per day. Total daily flow..-_._.-33D-______-___-___-.---,____-.-gallons.
WSeptic TankX-XLiquid capacity-1-00OgalIons Length8_'_6"_..... Width4.�_1 ��_ Diameter---------------- Depth_.T.'..7......
x Disposal Trench-0-No. ------0............ Width-------- Total Length-.-_-.6__--------- Total leaching area....................sq. ft.
Seepage Pit No.-:-.2-..------..... Diameter-------6........... Depth below inlet-----i-�...._..... Total leaching area_.2.6.3.......sq. ft.
z Other Distribution box ( 1) Dosing tank ( )
aPercolation Test Results Performed by..g i-e-h-a r d---A r-Ba x t-e-r-�------------------------ Date._.1247--f 124748.1.................
Test Pit No. 1.2...mill_minutes per.inch Depth of Test Pit.-.13_.......... Depth to ground water-----N o water
rz. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water....._..................
9 ....------•------------------------••------------........._..---.........-•••---•--•-----...•-•-•----....------•--•------------ ......
.....
------------
0 Description of Soil...lte diu a...aaad---•--•-•---••------•-•------•••...-----•---••...................•----
U •••••••--••---•--------••-----••••-------------•-•--••-•-•-•••••---•---•-•-------•---•--•----•------------•-•--------••-......-•------•----•----
W
x .................. ----------------------------------------------•---------------------------------------------- --•-------------------------•-•-•-••---•---•-•--••....------••••--........_..._.
U Nature of Repairs or Alterations—Answer when applicable.-A.dd....an....a.d-di.t_i_o.A al.._1.Q.0-Q_..ga-1_l o n.....___-_.
-------------------i-eae-hi-n-g----pi-t----t-0---- �---e-x-ista.n•g....I-IOD...gallo.n.---taak. k-Q•x---and...60q.--P- t...........
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code —The undersigned further agrees not-to place the
system in operation until a Certificate of Compli a n ce has be n i ued y the bo d health.
Signed ----- — G..
ce
A lication Approved B
...................................................... Dace
Application Disapproved for the following rearons- -- --------------------- ----------------------
----------- -------------------------- ---..-----......--- --------.......------------------- -------------------------...._._.----------
Permit No. _.._... Issued
Dace
Fi$$.....
0.•00..... -
TH-E COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
AVVr iralilan for Di-npmial Vurlti Toustrnrttnn 11ami#
Application is hereby made for a Permit to Construct ( ) or Repair :(�X�. an Individual Sewage Disposal
System at:
23__Rumnksk-i.a...R.(). d__-Centerville
Location-Address or Lot No.
.1±n e-d.__.WhL:L-t
Owner �\ Address
a J.P.Macomber Jr.
Installer ` Address
Type of Building Size Lot............................Sq. feet
Dwelling.No. of Bedrooms---------------3--------------------------Expansion Attic ( X) Garbage Grinder IeJ
Other—Type of Building _---_NONE__--._-___ No. of persons-------2 Showers ( ) — Cafeteria ( )
d Other fixtures --------------------------
------------------------
DesignW Flow-------------5_'�--------------------------gallons per person per day. Total daily flow--------3 0.__...__._._..____.__.___•.gallons.
WSeptic TankY. .Liquid capacitv__1_UO(�gallons Length$__ ��_.__._ Width��-i ���-- Diameter................ Depth_5.�711...
x Disposal Trench$No- ------0........_... Width-____-.Q---------- Total Length------ Total leaching area................ -.sq. ft.
Seepage Pit No-----2_..-.- Diameter-_-----6........... Depth below inlet-----6_�__._.___ Total leaching area__163.......sq. ft.
z Other Distribution box ( 1) Dosing tank ( )
Percolation Test Results Performed by._n _e x ._•-_�-, r_e- --------------------------- Date-__1,_2 f_7_!R 1_-------_•-•_•---.
a Test Pit No. 1-2_-_in—in-minutes per inch Depth of Test Pit-__13�_____.___ Depth to ground water---------o water
f� Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
--••--•-•--------------•----•-----_....----•--•----•-------•-•-•----•-•-•-•-•-•-•------•----•-------..........................................................
D Description of Soil-- . ••--•••••-•-------••••-----••-•-••••----••--------------•--------•-•-----
U ---•--•-----------•---------------•------------•----•-----------------------------•------•---------------------------------------------
W
x = -------------------------------------------------------------------------------------
V Nature of Repairs or Alterations—Answer when applicable_-AAA---an...sd_(l�i-t-ton11---l:.RQ4.__g��Ion•-•••••--
...................1-eac lh-k -;--p--t-- It-c---�-n-- ^_!-1 S:tL*t. _..1f�(U_0 gsllon----tankfi tank - ��d-•-600. pig? -
Agreement:
The undersigned agrees, to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has been i ued y the bo'-rd. K health.
Signed - -- ----- - .... ............. ... 9.5...... -
Application.Approved By ------- ----------------------
Dare
Application.Disapproved for the following rearons: ------- -----------------
------------------------------------------------
- - ------.......
Issued .........
Permit No. .... _/ '✓... e
Dare
>--a >... >as ——-----——— .
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
✓ , 01je>r#tfYctt#E of Cimplianve
THIS IS�TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired XY )
bye* J.P.Macomber Jr. .,.
--- --- -------
------
at - ------ 23...Dunaskin Road Centerville,Mass.
has been Installed in accordance with the provisions of TITI. 5 o The tare Av onmental de as describ its.,.,_,_.
the application for Disposal Works Construction Permit No. -'
PP a P ..... . .�'�� ; dated ...
THE ISSUANCE OF THIS CERTIFICATE SHALL NO E CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. t
DATE - tNJ--------- :. _t--- _ .. ....... ........_... Inspector ........ -----------------------------------------
.....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD 1OF HEALTH
,. � TOWN OF BARNSTABLE
No. .....................
FEE$_._30.00
Uhip al Works �nn��r�tr#uan erntit
Permission is hereby-granted----3 -R.1—arar^-b-e-r---.J-'-a----------------------------------------------------------------------------
to Construct ( or Repair:}(g ) an Individual Sewage Disposal System
at No..........2;- una#l:€_in' Road Centery lle,Mass.
-.................................................................................
St r e _
as shown on the application for Disposal Works Construction Perm —------Q •�ated------ ^_'"""_ %!"
DATE-------- __•_• Board of Health />
-•----�-� ----
d ------------ 1
FORM 36508 HOBBS 6 WARREN,INC.,PUBLISHERS �>
TOWN OF BARNSTABLE
LOi A'i`iONs;l �t)►'tiG� v� SEWAGE # J g
VILLAGE (e ��� V��) _ ASSESSOR'S MAP & LOT
INSTALLER'S NAME F. PHONE NO.I--'P_�AIAQnM
SEPTIC TANK CAPACITY kO O O
LEACHING FACILITY:(tppe)a c '%4! 5 (size) �op®
4
NO. OF BEDROOMS_ -�_PRIVATE WE''LL OR PUBLIC WATER
BUILDER OR OWNER
DATE PERMIT ISSUED: ''
DATE COMPLIANCE ISSUED:
t
37 —
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px
� New
o1,a
` TOWN OF BARNSTABLE
I, t LOCATION ` 3 c sl- SEWAGE #
VILLAGE �'2 � � ASSESSOR'S MAP&LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:.
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
'1h � � r
�3 ov.v� S k Ile-
Existing 1000 pit .
New 1000 gallon piL 1-distribution box
'O Existing 1000 Tank .
23 dunaskin road centerville ,mass .
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS)
I,J o s e p h P,Macomber J r . , hereby certify that the application for disposal works
construction permit signed by me dated 7/31/9 5 , concerning the
property located at 63 D u n a s k i n Road Centerville ,Mass . meets all of the
following criteria:
• There are no wetlands within 300 feet of the proposed septic system
• There are no private wells within 150 feet of the proposed septic system
• The observed groundwater table is !4 feet or greater below the bottom of the leaching facility
• There is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
SIGNED DATE: 7/31/9 5
LICE SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER 2 5
[Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan,
this plan should be submitted].
PPP,
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ASSESSORS MAP NO. 2
PARCEL NO- f
DATE: 7/28/95
PROPERTY ADDRESS:_2,3 Dunaski,n' $Pad RECE 20
___..Ceutery lle ,Mass . AUG 7 1995
0 2 6 3 2 NFALTH D'=PT.
-- -- --- - ---- TOM OFI AMSTABLE
On the above date, I inspected the septic system at the above address.
This system consists of the following: _
1 . 1-1000 gallon tank. ��
2 . 1-distribution box.
3 . 1-1000 gallon leaching pit .
Based on my Ingoec-tion, I certify the following conditions:
1 . This is a title five septic system.. 78 Code )
2 . The septic system was filled to the covers .
3 . The system is in failure .
4. The system must be upgraded .
SIGNATUR! ._.
Name:_jyP,_da_c omb�x-fir
Company:_J_P.Mac6mber. & �ori_,Inc ,
Address:_31P_x _66______`______
ass_._ 02632 �•
i
Phone:-__ 5108_775_3338_______
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
s
JOSEPH P. MACOMBER & SON, INC.
Tanks-Cesspools-Lesohfieids
Pumped & Installed
Town Sewer Connections
P.O. Box 66 Centerville, MA 02632-0066
775-3338 775-6412
^E SrWAGE DISPOSAL SYSTEM 1148PE^'.
Address Of PropettS 23 Dunaskin Ave Centerville ,Mass . 02632
Owner ' s name Michael T. Munhall
Date of Inspection 7/25/95
PART A
CHECKLIST
Check if the following have been done:
_Z Pumping information was requested of the owner, occupant, and Board of
Health.
None of the system components have been pumped for at least two weeks
and the system has been receiving normal flow rates during that
period. Large volumes of water have not been introduced into the
system recently or as part of this inspection.
As built plans have been obtained and examined. Note if they are °not
available with N/A.
_Z The facility or dwelling was inspected for signs of sewage back—up.
The site was inspected for signs of breakout.
:ZAll system components, excluding the SAS, have been located on th
e
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.
The size and location of the SAS on the site has been dete
rmined based
on existing information or approximated by non-intrusive methods.
_Z The facility owner (and occupants, if different from owner) were
provided with information on the proper maintenance -.of SSDS.'
RECOMMENDATIONS
1 . Must install new 1000 gallon leaching pit packed in stone.
2 . The present system is in failure .
3 . Soil intrusion in distribution box. Must have new one .
4. New lines from the septic tank to the distribution box
and existing leaching pit .
SUBS4 :FACE SEWAGE DISPOSAL SYSTEM IXSPECT•ION FORM
PART B
SYSTEM INFORMATION }
. J
FLOW CONDITIONS.
If residential
number of bedrooms
number of current residents
garbage grinder, yes or no
laundry connected tc system, yes or no
,..�Q seasonal use, yes or no
If nonresidential , calculated flow:
Water meter readings, if available:
1 93=120, 000 gallons=GPD=328 . 76 1994=109 , 000 Gallons =GPD=298,63
Last date of occupancy
GENERAL INFORMATION
Pumping 1988co�rds and&srg?e of information:
J. P.Macomber & Son Mc .
System pumped as part of inspection, yes or no
if yes, .volume pumped
Reason for pumping:
Pumped system folling inspection.
,_Swgtam was filled to capacity .
Type of system
XXXXSeptic tank/distribution box/soil -absorption system
No Single cesspool
No Overflow cesspool
Nn Privy
Mn Shared system (yes or no) (if yes, attach previous inspection
records, if any)
Un other (explain)
Approximate age of all components. Date installed, if known. Source of
information:_
15 Years Baxter'--&-.-N""e --E-r inee-rin - -
s e .
NO Sewage odors detected when arriving at the site, yes or no
l
9
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SEPTIC TANK: 1000 gallon tank. .
(locate on site plan)
depth below grade: 10" _-
material of construction: xxxx concrete metal FRP other(explain)
dimensions: g ' h" T V 10" W 517" H
2" sludge depth
23" distance from top of sludge to bottom of outlet tee or baffle
Tracescum thickness
0 distance from top of scum to top of outlet tee or baffle
n _ distance from bottom of scum to bottom of .outlet tee or baffle
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, recommendations for repairs, etc. )
annuall . Garbage disposal present . 5 ' 3." over tees .
Tank must be pumped Presently filled to capacity .
l DISTRIBUTION BOX: XXX
(locate on site plan)
NO 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, recommeSdation .for repairs, etc.)
Box is level ;No solid's :being carried over ;There soil intrusion in the
box Box must be replaced ; New lines installed from the tank to the
distribution box to the existing leaching pit .
PUMP CHAMBER: NONR
(locate on site plan)
N0NE pumps in working order, . yes or no
Comments:
(note condition of pump chamber, condition of- pumps and appurtenances,
recommendations for maintenance or repairs,etc. )
NONF
1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION TORN .
PART B
SYSTEM INYORKATION Coatinued
SOIL ABSORPTION SYSTEM (SAS) : XXXX
(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 and ,number 1-6 ' x7 ' 1000 gallon .,, ,-
leaching chambers and number -NONE -
leaching galleries and number -NONE
leaching trenches, number, length _ONF
leaching fields, number, dimensions mnNF
overflow cesspool ,, number _N nNF
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding,
condition of vegetation, recom nation .f tenpance �r re airs etc.
Sand & Gravel ; Leachining in fa.11ure .ions,i e� � ca acit p !
1.e.as.h.incy pit m„st be pumped . New . allon leach pit ins a e
CESSPOOLS (locate on site plan) :
number and configuration NON ,
depth-top of liquid to inlet invert -NONF —i
depth of solids layer NnNF
depth of scum layer _NnrjF
dimensions of cesspool , QN'F
materials of construction _ rrnrrF
indication of groundwater
inflow (cesspool must be pumped as
part of inspection) _MONK
m
Comments:
.(note condition of soil, signs of hydraulic failure, level 'of ponding,
condition of vegetation, recommendations for maintenance or repairs,etc.)
NONE
PRIVY:
(locate on site plan) _--- — - _...- _......... _........... - - _._....
materials of construction NONE
dimensions NONE
depth of solids NONE
----------------
Comments:
(note condition of soil, signs of hydraulic failure, - level of .ponding,
condition of vegetation, recommendations for maintenance or repairs,v
N-NE
• •' ' • 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION •FORM
PART B
SYSTEM INFORMATION continued
SKETCH OF SEWAGE L=SPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100 ' Town Water
14 �r
� 3 ,!� v.vsi S� / ,4 �a •
DEPTH TO GROUNDWATER
20 ' + depth to groundwater
method 'of determination or approximation:
n talled System across the s*treet . It No water . Also insta e ca c
hac, n. , n 4 reet 14 ' No water . T p Marnmhar & Son Inc
12
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM .....
PART C I
FAILURE CRITERIA
Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of
determination in all instances. If "not determined", explain why not)
Backup of sewage into facility?
_,& Discharge or ponding of effluent to the surface. of the ground or
surface waters?
Static liquid level, in the distribution box above outlet invert?
. Liquid depth in �ycesspnn', <6" below invert or available volume< 1/2 day
flow?
Required pumping 4 times or- more in the last year7
number of times pumped /, Y r Q�
Ayd Septic tank is metal? cracked? structurally unsound? substantial
infiltration? substantial exfiltration? tank failure imminent?
Is any portion of the SAS, cesspool or privy:
below the high groundwater elevation?
within 50 feet of a surface water?
within 100 feet of a surface water supply or tributary to a surface
water supply?
LAO within a Zone I of a public well?
_ P within 50 feet of a bordering vegetated wetland or salt marsh-
(cesspools and .privies only, "o the SAS) ?
within 50 feet of a private water supply well?
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 anal,
.for coliform bacteria, volatile organic compounds, ammonia nitrogen
and nitrate nitrogen.
...���.. ....--�L.��-T..'�TT«�..T'-�� :�'.... T'..� .TiZ�..S�T�ESL- ._-_ ._.._ _ ._..-.._- .�..-« .-�« _ -. ....-_.--.....- .. .•�T��- _
TOWN OF B a r n s t a b l e BOARD OF HEALTH
SOBSl1RFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION
............
.__.--
-TYPE OR PRINT C1.EARLY-
PROPERTY INSPECTED
STREET ADDRESS 23 Dunaskin Ave Centerville ,Mass . 02632
ASSESSORS MAP, BLOCK AND PARCEL * 288-19
OWNER' s NAME Fred White
PART D - CERTIFICATION I
NAME OF INSPECTOR Joseph P. Macomber Jr ...
COMPANY NAME J.P.Macomber & Son Inc .
COMPANY ADDRESS Box 66 Centerville ,Mass . 02632
Street Town or City State ZIP
COMPANY TELEPHONE (508 1 775 - 3338 FAX (790 508 - 1578
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposaY system at
this address and that the information reported is true , accurate , and
complete 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
health 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.
XXXX System FAILED*
The inspection which I have conducted has found that the system fails to
protect the public health and the environment in accordance with Title
5 , 3.10 CMR 15 . 3031 and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form.
Inspector Signature Date 7/28/95
One copy of this ce tification must be provided to the OWNER, the BUYER
(where applicable) and the BOARD OF HEALTH.
* If the inspection FAILED, the owner or""I6 erator shall u d
within one year of the date of the inspection, unless allowed ort required
m
otherwise as provided in 310 CMR 15 . 305 .
partd.doc
C:,M,�^cnweacn c., Massccn::scrs
ExeculNe Gf lce cr Envlrcnl mEmC. a.s
Department of
Kim
ki Environmental Protection
Water Pollution Ccnrrol Tecnncci Assocnce ana Training Secnons
wiuiaM F.wow
cQ.~
Trudy Cox•
s«a.wy,roo►
Thomas& Powers
�arq cormr..on.
06/12/95
ATTN: Joseph P. Macomber, Jr.
Joseph Macomber and Son
PO Box 66
Centerville, MA 02632-
Dear Joseph P. Macomber, Jr. ,
I am pleased to inform you that you have attended training, met
the experience qualifications, and have passed the Title 5 System
Inspector exam, pursuant to 310 CMR. 15 . 340. The passing grade for
the exam was 39/52 or 75% .
This is an official notification that you are a Certified Department
of Environmental Protection System Inspector pursuant to 310 CMR 15 . 340.
You will receive a System Inspector certificate at a later date.
If you have any futher questions, please write to me at the following
address :
Kimball Simpson
D. E. P. Training Center
`.30 Route 20
Millbury, MA 01527
Thank you very much for .,"oar time and consideration in this matter.
Sincerely,
Kimball Smp��n
DEP T.raini::y Ce: er Direcco.-
f2405) "
Route20 . .1bury, MA 01'.'? • FAX 503-755-92;1 0 To;,. ono 508-756-7-1
t •
Water
Con' s'ervation
SAVE Tips • • .
ME! , .
CHECK FOR LEAKS
Water Loss in Gallons Due to Leaks
Leak
this Loss Per Day . Loss Per Month
Size
120 3,600
• 360 10,800
• 693 ' 20,790
• 1,200 36,000
• 1,920 57,600
3,096• 92,880
0 41,296 128,980
® 6,640 199.200
6,9.84 '• 200,520
8,424 252,720
9,888 296,640
® 11,324 339,720
12,720 381,600
® 14,952 448.560
• r
69
THE COMMONWEALTH OF MASSACHUSETTS
BOAR ........ �,F A TH
r
I --- OF... �.d.. ..... D...
Appliration for Uiipnsal Work�or
nnstrn.riinn . rAft
Application is hereby made for a Permit to Construct ) Repair ( ) an Individual Sewage Disposal
S stem at
u
.E......... .................. ................................. .............................................................cation,Add
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R �.` •• Address � /
W ...... •_ — ®v "........-R..G�............... �_�.Ll:. A C .L. `
a Installer Address L�
dType of Building Size Lot... ...Sq. feet
U Dwelling—No. of Bedrooms.......... ................ .Expansion Attic ( ) Garbage Grinder (1e(
a —Type g .............. No. of persons....................... Showers (,� — Cafeteria ( )
Other—T e of Building ______________
a' Other fixtures ..................................
W Design Flow..•...............5..5......_.._..__..gallons per person per day. Total daily flow__._.........�..a..34................gallons.
R: Septic Tank—Liquid ca.pacityI•M_..gallons Length...t0....... Width...... Diameter................ De��lC.............
.
Disposal Trench—No. .... ............. Width-••--__---_----_-_-- Total Length.................... Total leaching area....._Z....._.......sq. ft.
o
Seepage Pit N ...............�iameter.___._......_....... Depth below inlet.................... Total leaching area................. q.
_s ft.
Z Other Distribution box Dosing k ( � d , 4r
aPercolation Test Res lt� Performed by........ .&................. ....!-V_ Date. .�._............
a Test Pit No. 1—.............minutes per inch Depth of Test Pit....... . ........ Depth to ground water....
PLO Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P4 - ._ . _t .......... 1
O Description of Soil----•- - ; 1�!�3.........a..�. .... ----�i................. ------ - - -
U .--- --- .._...........
W --------•- -----------•------------- -------•-•---------•••-••--------------------•---------------••••-•••---••-------•-------•----------•----••••--•----•--------•...._---------•--•-•--••--•----
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 TITS E 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has n issued by t boar o ealth 9 ¢
Signed' =-�............... .. .............. 1�---..
ppat
Application Approved BY `��/��Z
---- --
Date
Application Disapproved for the following reasons:________________________________________________________________________________________________________________
..............•----------.....---•---•--•••--•--........_.........---•--....-•---••............._....--••--------------•-•••----.......-•---•------•---------------••••--•--•••--...._------••-••--_....
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSEETTS
6
r1l
ApplirFation for Uhiponaal orko Tomitrurtion ami#
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at
t--
--..............Av ....-. ........... ......... .....--
Lo,ation•Ad&4 or
Owner - : 1h Address --•-
Installer Address
d Type of Building Size Lot......_______?...---._____..Sq. feet
Dwelling—No. of Bedrooms...........______...........................Expansion ttic ( ) Garbage Grinder (!V)D
..IOther—T e of BuildingNo. of ersons.........�______________ Showers — Cafeteria
a
� Other fixtures -.........................
...
............ .....................................................................- --------.._.............._.'.
W Design Flow.................. __+_....._..____gallons per person per day. Total daily flow..............�3.....6...............gallons.
GG f Septic Tank—Liquid capacity.) _gallons Length.....Q.____ `�lidth________ ______ Diameter................ De th_..............
' Disposal Trench—No_ _____ ____________ Width.................... Total Length.................... Total leaching area__........".....sq. ft.
Seepage Pit No____________________ iameter.____.__.__..____._. Depth below inlet.................... Total leaching area..................sq. ft-
Z Other Distribution box W ) Dosing tank ( . )
a Percolation Test Results,,. Performed b .____._.��� ��
Y ••-••• r--- ....---•----- Date---`=----';'�-•-......_..
Test Pit No. 1_14----------- per inch Depth of Test Pit.......J......____ Depth to ground water......�'..... ...__.
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
x f j.
O Description of Soil........ ._..�.-- _!!�`. ........... `�� - -' - . -- - --- -- - .............
15
V .--------------•------..............................-. -�=r------...........i v r.•:--._._...------ •--------•---•=-----------------._._....-------------•----.....-•-----------•
W -•--••••--------------••-•-----------------•----•-•-•-----•-----•---••--•---•---•---••••---•--••••----••------------------------------•-------=------------•-•----•---- ----•--•-••••••-------------••-
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 TIT LE 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 e boar of ealth.
� s •-
Signed-•-• ..:All t-.d r+l�- ,/� c d ,f�
r
, ate
Application Approved BY ,. !• ............................. ----••--.7'--
Date
Application Disapproved for the following reasons:-•-•---•----•---•-••-----------••---------•-----••-•...............•------------•--...._•-••-------•-------•----
............................•-------_.._......__.....•---••-•_-_..._._.._........-------•--•---_....._......--------••-•-•---------•-------_-_-•-•••------------•--••••••-••--•--....--•---•-•--•••--•---
Date
PermitNo......................................................... Issued_.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
---- BOAR OF HE L- H
................. '`-::..............OF.....�. ....�.t`N.....5.....A....._....L"
I.
Tnrtif iratr of Toanph anrr
THI TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by......... ...--0YAa....... t_:"'..............•-----•--------------........ ........................._....--•-•-...........----...-----•--....-•---•---
Instal
at.._......--.2_!: -------------. --
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 _________________ dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
0
DATE..................................................A � L Inspector_.. _!1§ .._.._...
THE COMMONWEALTH OF MASSACHUSETTS
�'''''�'"� BOARD OF HEA TH
••t• •............................OF...-.......C`°a. : ...._....:�..` -- .10
_r,.•.
FEE....
Uiipoii al Workii Tonntr ion unfit
Permission is-hereby granted---... .......... - a-----------------------------------------------------------------------------
to Construct ( or epair ( ) In Individual Sewage isposal System
atNo.........;X-2 ...--••--. , ". --� -----------------------------------------•----•--•--•-------•------------•----------.........
Street
as shown on the application for Disposal Works Construction Per it No................. Date -,_______________-______________-___-_____
- + + ____________ ______________ __
G Board a th
DATE............... ................................... ,.
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS
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