HomeMy WebLinkAbout0098 ELIJAH CHILDS LANE - Health 98 ELIJA CHILDS LANE, CENTERVILLE LL
A= C
is
IN
UPC 12543No.53LOR WOW'
�a
HASTINGS, MN
i
COMMIDIW MALTH OF l.N ASSACHUSETTS 4 J u N 2 � 2000
EXECUTIVE OFFICE OF EAMROMAENTAL AFC RS TOKWOF
DEPARTMENT OF ENNUMNUENTAL PROTECT 6N
ONE MINTER STREET, BOSTON MA 02108 (617) 292.5500
TRUIr,CORE
30eveI
ARGEO PAUL CELLUCCI AVS:A:E,. 9TRUH.B
Governor Ca6.-BT-sIM.9
S19 URFACE SEWAGE DISPOSAL.STSTIN MISPECTIOM FOAM
PART A
p ftipwty Address: f rJ 6(a t OL �' Ak ka 04 Rarne of oei rw / Norms Ca Mole
Datae rof BttapaaSaia: G Pti�a✓1 v 1 0�t` tit Sy Q Aaldreaa of Owner. a I .��t i 1o�S �.,0.1q
!Mesas aeaf(rdepaoMi:S �P�irrRl��7 Z e ks@ t It C
arse a R9® arryaslwa ----
C161111115.340 of This i(310 Cat ti.000}
company Now: �� r1.
Sk�Aa ib® : ®Ono r � .C-ft or's
j g
TMepltsfela IMeYratrisr: 4?J�y _ '
AILUMM
I Canby that I haws personally Inspectr d the sewage aSspoeal system at this address and that the Information reported Wem,is'!Ius,sc+:urnts
rnaintenence on-aft oro/d he dm�e of Inspection, The inspection wait performed beued on my training and experience in qte proper!hum;tics arai
se" spoaail Systems. The system..
- - Passes
w Condldonamy Rpaae;
Needs Fui"w "vouation Sy the Local Approving Authority
FaNa
lea" aw's SWWIWQ.
) 00
The S I yetao" Pospa®edar shelf submit a a:aly of this inspection report to the Approving Authority
codn!alating"a l:taparctlon. H the ayetan Is a shared system or has a daeign flow of 10.000 (d ord of Health or DEP}w1>Ifain thir y l3;}I 1s�,s of
shell submit the repo"to the appropriate regional office of the
� grasltar,the inspector grad th eyetWi owner
systeom owner arxt 00009;sent to the k er,if he pp,,,,, of I'"ro"mewel Protection. The original should tw,as nt to Ito
y appliooble,and the approving wlBtority.
IMOTIM AND COMMeNTS
rr--
revj,Sed
Pair t or 11
511MURFACE SEWAGE DISPOSAL S1t$TEM MPECTWMI FORM
PAINT A
CE N TW"TIOBI Ioar tSra+adl
Prsfartl/ a .b q El
OMM:
l S/i pac,I=SIAIaMARY: d»ob Al, & C. or A
A. SYSTM PALM:
I have not found any information which Indleotes that any of the faiGairo conditions described in 310 CMR 16.303 exiist. Any hillum
oriterla not evaluated are h+dWated below.
COb1�17S:
S. SYBTM CONDITIONALLY PASSEII:
a_ One or more system components as described in the"Conditional Ps section need to be replaced or repaired. 'I'he sr,stern,upcn
completion of the replacemsmi or repair.as approved by the Soar 'Health, will pass.
Indicate yes,no, or not determined(Y.III, or RID). Describe basis of mminsdon in sfl instance*. If"not determined",explain n by riot..
— The septic tank Is mirtal,unbsss the owner or star has provided the system inspector with a copy of a tI.rb ifiawt*of
Compliance latteched►indicating that the It was Installed within twenty (201 years prior to the data of the i; sp*rtlon;or
the septic tank, wholher or not metal, eraeked.structurally unsound,shows substantial Infiltration or oxflltri tion, cr tank
failure Is Imminant. rho system will as$Inspection If the oxisting septic tank is replaced with a complying at tdc tank re
approved by the Board of Health
Sewage backup or bra out or high static water level observed In the distribution box Is due to broken or of it uctod hlprls)
or due to a broken, or uneven distribution box. The system will pass Inspection if(with approval of the. Board of
Health).
broken pipo(s)we espleved
Obstruction Is remaved
distribution box Is levdlad or replaced
7The m required pumping more than four times a year due to broken or obstructed pipet*), The system xr,ll pass
if(with aR proval of the Board of Health):
Woken PIWS)are replaced
o»tructlon Is removed
revised 9/2/98 pop 2of11
laMURFACE SEWAGE DM OM SV'STEEII MSSPECTWN FOM
PART A
CE#IVICATiQMO foa!vilinu l
11,01"aft Address: 9 E 1r j 4 cal US /,G r.4
Dass sf CA/h l't
�o /®0
C. FURTHER EYALUATM M IS MG M=MY THE BOARD OF HEALT4l_
�..o._ Condition*exist which nags Ourther evaluation by the Board of Health In order to termine if the system is faEin fi 1:ci!:u oteet+?ie
pubRt heath, @slaty and Ow environment.
11 SYSTEM tfnLL PASS LRAM BOARD OF HEALTH DEZ MI ES Mi/t WITH 310 CMR 16.302 I101-ntA►'!THE 6.1/O 1'®li
E NOT FUNCTi0MQ ills A EOI~R WHICH WILL fMOTECT THE FML HEALTH AND SAFETY AND THE RMNORIViNT:
Cesspool or privy is Nrithin 60 feet at surface wetw
a.. Cesspool or privy is nrthin 60 feet o4 a bordering v N wetisnd or s salt marsh.
31 SYSTEM ML FAIL UMLESS 11 BOARD OF HEALTH(ARID PUBLIC WATER SUPPL9M.V ANY1 DETOMM U THI\1'in IE S't'S iuki a
/The,
I A MAW T PROTECTS THE PUKM MALT14 ARID SAFETY AND THE E!!INEIOR WFXT:
stem so;,tic tank old sol absorption system(SA&)and 0►e SAS is within 100 feet of a swfene w,;ter auptr{p or
ry to rate water suPPly.
s has a s ptit:tank and soil absorption system and the SAS Is within a Zone I of a public waterr mvpi:ly well.
e leas a ssgdc tank and soil absorption system and the SAS Is within 60 het of a private water saga; y V4,0
term has a saycMc tank and son absorption @yaterte and cite SAS is ices thon 100 feet but t50 feet er Horn! from l
water eupply sap, unieea a weE water analysis foe ci>wiform baeterla and valatps orpenie cenv!poun+is i +!icae+ns the+:the
frw franc poE!,tbn from that fatipty artd tlfe pKeeonce of ammoNa etibopen end rtlt►ate rdteogen is sq�uu to or ineai
ppm. Moth" used to determine distant@ (appoxknodon rot vaidl.
3
reprised 9/2/96 Polio 3 of-li
SUMURFACE SEWAGE OWKN AI SYSTM NSPWTWN FORM
PART A
elm I N ICATM leeeAMfasdh
be er e
O. Sylil lh PASS:
You anust w4cata eMher"Yes'or"No' to each of the following:
I have determined that one at 1ttors of the following failure conditions exist as described in 310 CMR 16,303, The teas f for this
determination Is Identified below. The lased of NeoM should be coiv-mcted to determine what will be necessary to der uct th•fe burs,
Yen No
backup of eewege Otto facility or system.ompopwM due to on overloaded or clogged SAS or cesspool,
01schergs or ponding of oflluent to the a of the ground or surface waters due to an overloaded or clapti+1 SAS or
cesspool.
_ Static liquid level in the distributi box above outiot Invert due to an overloaded or clogged SAS or cosupoa"l.
Liquid depth In cesspool is a then S" below invert W available volume is Isss than 112 day flow.
Required pumping nn?r then 4 times in the last year JW flue to clogged or obstructed pipets),
Number of ulnas _
.r ,, Any portion of Still Absorption System,cesspool or priory is below the high groundwstor elevation.
Any of a cesspool or privy is within 100 foot of a suurfac*water supply or tributary to surface water uuppiy,
Any on of a ceuipool or p?Ivy is within a Zone I of s purtunc well.
portion of a asef.pool at privy 4 within 50'beet of a private water supply wall.
Any portion of a casnpool or privy Is lose-than 100 feet but grater than 60 feet from a private wets?supply vi ali vvith nt
aaceptable water qutdity analysis. if the wall has been analyzed to be scaeptabia, attach copy of won wetor 41:1slygis Ra,
r:oWorm becteris,veletib organic compounds,ammonia nitrogen and nitrate nitrogen.
i
L LARGE SYSM FALL:
You must Wildleaa either'Yee' or "No' to sesch of the no;
The following arkads apply to Jerg,eyetama addition to the oriterls above:
^„ The system servos a facility with a des flow of 10.000 gpd or granter Marge System)and the system is a signi1icnnt threat to lrubMe
health end safety and the onviionm because one or more of the feMowing conditions exist:
Yes No
.,, the system Is n 400 fast of a surface drinking water supply
the s within 200 feet of a tributary to s surface drinking water supply
the a tom Is locataru in a nitrogen sensitive ore*Unterim Wellhead Protection Area 1WPA)or a mapped tons it of a puillic
w supply wsln
The yawner or star of any such system shall upgrade the system In aaaordenee with 310 CMR 1 S.304(2). Please consult taws oeol re-gianal
off le of the for furthar Info ynation.
evised 9 8 r /2/9 h+ye4oftt
IRMSuNFACE SEWAGE DISPOSAIL SYSTEfM MIISPECTION FOAM
PART a
CHECKLIST
Chech if the fonowing hew been done:1'eu must Indicate either"Yes"or"No"as to each of the following:
No
►umplrtp Information was provided by the owner, occupant,or board of Mseith.
_ None of the system components have been pumped for at Mast two weeks and the system has been recalyringl nitrmel floe
rose during that period. Lorga volumes of water hove not Moen introduced Into the system racentiy or sit pact;if this
Inspection.
1 As built plants hove biwm obtained and examined. Note if they are not available with N/A.
The facility o►dwelling was Inspeoted for signs of$*wage bisck•up.
_. The system does not rsoeive non-sankery or industrial wasto flow.
1[ _ The eke was Inspeetsti for signs of breakout.
AN system components,excluding the Sall Absorption System. have been located on the alb.
�[ The septlo tank manhcias were uncovered,opened,and the interior of the soptic tank was Inspected for condAtiun of bsffkfs
"T or toed, material of cointruotion,dimensions,depth of pgeid„ depth of sludge,depth of scum.
The site and location of the Soil Absorption System on the site has been determined based on:
_ Existing Information. Isar example.Plan at III.O.M.
_ Determined in the flebd (if any of the failure criteris related to Port C Is at issue,approximation of distance is unii;ceptobM)
116.302431(b))
The focillty owner Iand occupants,if different from ownerl mare provided with information on the proper,main•t,:r►ar.ra of
Subsurface Disposal 5 ystoms.
revised 9/2/96 of it
StJMSURFACE BEWAGE DISPOSAL SYSTIEM NSPECTX)N FORM
PART C
SV=TW WF4DRFAATWN
Cam 0, `` nn
Date et esOflaatlaro: �/oz�(.t�v
( PLOW CONIDCTltIIIIIS
DssApn Now- JI.P.d•/bedroom.
l�iwr er Of bedr *mg 1 ):_., Numbw of bedroom#(actuaf):-_j
Total DtsOa Now_„ l
Number of ewrrerrt redde ts:,,�
S■taegs OWN (yes or no).—No � L
Laandry lawarsto system) (yes or ncl:.,o if yes,$*Wale inepootlon"I red
Laundry system Wopected t or no)
fe.sanai use tyes at no)s,
Wrw meter readings.If oweAmble hest two yeses usage(gpd):
swap Pump dyes or no):
Lest date of ooewy:JCJj�y '-
TO*of establilshment:
D"W Now: cad (®ased an 16.2021
Basle of design Raw _
Orome"W Present:(Tat or no)_ _--
WA,MW yiWsots Balding Tank presem Or nOF
loon-sanitary waste dhuhare"to
ter 1'h10 E system:tyes or no)—
Water one readings,M
LerM:data of occupancy:
S lo=1 :(Dote
�.an.dote of aney:—,
28111AAL NSa0S1r41 rM
plslWMQ Reemm and sou a 0 f+r>ntttttion: 1
tiyatem pwrrtped as Part N umpecton:tyes or no)�
If Yee.vokorna pumped: ._gaWens
Reason tea pumping:— -�
t Gd<MVS I
sapfle tankldlttrlbutlon box/scyl absorption syetam
Uwe 4ettpod
ems, Ovwftw CeOapeed
.r...- Prh►y
-� Shared systems(yss Or nOl Of Yes,attach previous)nspectlon records. If aryl
1/A Technology oft, Attach cozy of up to data operatdon and malntenanoe contract
Tight T&* Copy of C111P Approval
tltlm
APMATE AGE of ON a0ntponsrtts,date lnsts8sd(if known)and sotros Of 6nforrreati0n:
___._L
!€+swaps Odes detected when wAvkV at the sit®:(yes or no) �
revised 9f2/198 aetafl
>II Mi.NIFACE SEWAGE DISPOSAL SIFSaT 3A NSPECTIM FORM
PART C
OYSTM twMtf»ATNM 4*WVWNedl
mly,Iwdre 98 CA jIL C lee(06s C,a
omits of laapst ltnr: 'r �a81 Q
�Ieo.00la
(Lee@%on else Pktn)
r
Oepth bell,kA- rob:
MnwW of construction:—oast kon_K40 PVC—ettw(explain)
MMOOtas troT'Ovato water supply woll ar suation Ikw
Cam►rmerrts:(eenditlon of joint@, venting, evidence of leakage,etc.)
(locate on oft plan)
P
Ono*6 Im»grade;A
Matirrial of aonstructlon:_ffeonerete,metal_fibsralses .Potysthylene..ctherisxpleini
It tattle is metal,flat op_ is so*confirmed by Certificate of Compliance __ tYss/Mol
Dlmtmtlonw: /0®Q 412.
swp 4Wth:
atrnee from top of r�edae to bottom ed`*404 tea or bafAe:�,,,,r o Dl
fioum ft%knose: [�_, [�
Disunca tram top of scum to top of outl,+t tes or baffler !/
DWiwwe from bottom of scum to bottori of outlet t or baMe:--LL
'Io+r.dlrrefgioRe were detetmirred:•���
Cortr'ttrents:
(recommendation for pumping, tior of Inl4p end outlet tees or b Cy_s,depth oi�lqu3�Inv Iin relation�tp outlet Invent,structurr.l I tear. r
e�nt�q of 1s age,ee*.) u/ats S •,,.._.�i._ CXt (hZ4'j'v4
I�idE TIIAh
flocete on she phn)
Deptlu below arede:_
Meterial of construction:_eorwoto,rrnwW_„19barglass --.Polyethyl ,yiatlwr(explain)
Dimensions:
scum tftickrrass:
Dletance from top of scum to top of ouffiet too or bafAs:
Otnenee from bottom of scum to botton; of outlet r baffle:
Data of last purnping:
CrontrMorrta:
(recoaivrnendation for pumping,co of inlet end outlet tees or baffles, depth of ilquid level In relation to outlet invert,stnao+tur.p I int•sarty,
evidence of leakage.etc.)
revised 9/2/98 PW7of11
SUSSNltd<ACE SEWAGE OMPOSAL SYSTU4 MPECTION FORM
PART C
..... SYSI NWORMATMi
n.smw Address: r �� �- G k%�s
o.eor: C(X fh j6w 4
°'► : -)/a660a
IMI"r ON HOLDON TANK. Monk must be pumped prior to, or a of, Inspection)
(iocarts on*0 plats)
Oaplh bslsar grafo;...o
memiai of conallualion:_**now* ;nsotaf ,Fib —Polyethylene -othar(explaln)
Ob ienaiorla: _
Capacity:__0010-18
Design flow: Sellonalday
Al s+rn prooant
Alarrfl Tavel: Alonn in w P;order:Yea No
Oohs of prWous pumpwq. ._._
Comments:
(corK9tipn of Inist too, co of slarm and float switches,otc.)
Dr'f11�t nm box!`
(locoee on oft pion)
�Deplh of Ygwid Wral above oudet invort:
Canlnmonts:
Inmo it level and AWbud ip a7, mAdence of solid cart ov r,ovidon off i�sl: o or CO of box, etc.l
{z max. _� ����1 ?" i c� ses s� aim
M
MW
flocafa on oita phny
ftwn;ao in wortsinp order:(Yes or No)__
Akswrse In wodit order IYes or No)—_
Comlw ts:
(moo eondidon of pump chernbsr.c"ll �of pumps and appurtonaness,atc,p
revised 9/2/98 hraofaa
IVIONSUIPIPACE SEWAGE MOPOaAL SYSTEM(VMPECTIOIM FORM
PART C
BYST)(M MWORM U M( la oona* "
.+caws)►nd�aluaw 98 1G C I i I A G 4(S5 1,4-q
Points on db plea,if possible eacavet-m not squired,location may be appaoximatad by non-intrusfiw methods)
Of not►ocaasd,eaapfabn:
MOO&E slnanahen,numbw-,_
Nast">umhoe,murnt r,loalith:.
iawelakeo f)slde,number,dhnantlons:
overflow assoPool,
Allsmathm system:_
fllarrae at Tocbnalow
C OMMOnts:
(sets oenditlon of sail,elgry,o 4�ydrenille fallurss,level of p nE, damp soll,condition of vepstotion.etc..
' g`a5'�slR1 &A of t,[s�?��( 12 C-C g�oe
CaaaP'OOIa:�, .
floeats an Nte Owl
MurrAw end eanSVvwlI*n:_,
_%pth4m of Now is him Invert ..__
epth of so0de leryor:
631p0 of roan
Obnonatens of oosepaol:
Mewwa at aonowme"":
bafiew(cesspool wtust be pump ad as f Inspootion)
Connnaraw: --
(note aenMw of soN,signs ofIx
ZOUIIC
faRws,level of pending,condition of wagetot)on, ate.)
PFAVV:_
asica t an alto p)en)
lllomie a of Owwwcsallon: DMneneiens:_._..._.,..
Oap o'of so&b:
Conm»nts:
(nano eondlflor►of sell,signs of hYdr c follwo.Orval of poradNag,condition of vagetellon, oft.)
i
revised 9/2/98 Pagrfottl
i
AMURFACE UWAGE OISPOS"Si/STEM PAPECT!®Ill FOAM
PART C
SYSTM IMPORLM1T941(oontln uad)
C4 ,1
1
Own a11MePo8tiaNt
Offfm OF&MAGI OWOM$TSTEM:
(no&i0e toes to at Isatt two penr►erent reference landmarks or benchmarks
locste all waft wfthin 100' (locate where pubk water supply cameo,into house)
\tt1 lb �
t
�r
revised 9/2/98 Pge10of11
SUBS IVACE SEWAGS DOMSAL SYSTW INSPECTION FORM
'ART C
SYSTEM offam"TIOM tearMirtsrsdN
OaNea►: to
Dow to ae�e�a►:�-sue`.�
XRCS Row some `- -- —
iled Two_
Ty*at depth to groundwoter_
USGS Dow weltoltrr visited
Observation !Walls chocked
Groundwater depth: Shallow Modwats
SITE EXAM 1110"
Surface water
Ch"k Collar
ShoPow wofia
pstirmtood Depth to GreandweW Fe.It
Mosse indieate rM the methods used to 6ttormino Mgh Groundwater Devotion:
Obtained from Design Plane on rocoord
Observed Sine(Abutting property,46servation hole.basement sump ate.!
Dootermined from local conditions
Checked with gaol Board of health
w� ';;hacked FE'MA Maps
.� :hocked pumping vecords
„:hocked towel excavators,insaffers
F)sad US*$Data
Descrl'ba hew you esSWIshed the High C roundwotor Elevation. (MM be completed)
9-A PQ `f r.K� -'1 C)cl IN,
revised 9/2/98 pop itofit
i
TOWN OF BARNSTABLE t
�*-AIION \ i ail � tr WJ4 SEWAGE #
GS ASSESSOR'S MAP & LOT5 V
INSTALLER'S NAME&PHONE NO. j
SEPTIC TANK CAPACITY
3A LEACHING FACILITY: (type) (size)
k7
NO.OF BEDROOMS
BUILDER OR OWNER Ci M�`@,"r
PERMUDATE: COMPLIANCE DATE: �
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the 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
a'
��'� ..
{ ��
�� �.
c�� � ��
��-
h
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
/.. .:. ..f .".to..:.........OF........ ...........................
Appliration for Uhipasal Vxirks Tonstrnrtinn Vamit
Application is hereby made for a Permit to Construct ( ) or Repair ( )fan Individu ,Sewage Disposal
4
System-.. at: ............ .- --....---•----•.......................... � . ---�----.................... --- .__.. . .....
ocation-Ad 642i��14; P,
Lot No.
... ................................................ •.......... -- ... .............I.................
Owner Address
--....... .. ------------------------------•------•-- ...............•... . . ....................................................
►-a Installer AddressPq
14 Type of Building Size Lot./I, _ �..Sq. feet
V 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................
x Disposal Trench—Yo. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No... ..0 . 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..--...................
f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
-----------------------------------------•-----••----------------------.............-•-•-------.............--------------...-------•-•--........----......•.
0 Description of Soil....................................................................................................................................................................
x
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 i1TL IT. 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been ' su d by th and of h Ith.
ned•. ------
�7
Application Approved By..... .... �1! W
�. Z Da
Date
Application Disapproved for the following reasons:-------• -------------------------------------------------------------------=----------------•-•---....------
.........................................................................................................................................................................................................
Date
PermitNo......................................................... Issued.......................................................
Date
s
Fizz..-r-.'.. ........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........................ .................OF.....................-------•--........"..."...............---------.._...................
Appliration for lliiposal Vorkii Tonitrurtion rjermit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
................__.............................................................................. ......._......---•----..............-----------••-------..........----•--•••--------........---••-
Location-Address or Lot No.
......................—.......................................................................... ..............•---------.................•----••-----.......•----------.......................----
Owner Address
W
Installer Address
U Type of Building Size Lot............................S q. feet
Dwelling—No. of Bedrooms.............._.............................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
P4 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..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.........................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a -••-•-•---•----------•------•-•-•--•---------•------------------------•------------------•---•.•----.........................................
-.-------•------
0 Description of Soil........................................................................................................................................................................
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V Nature of Repairs or Alterations—Answer when applicable...............................................................................................
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Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT. 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Sined......................................................................................
Application Approved By---- at Vr� -----------------•-----• / �'�
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......•.
Application Disapproved for the following reasons----------------•------------•---------------------------------------------------------------------.........•....
................•--••------------------......._.....-----------------------------•--.........-------•---------•......-••--•--•-------••-----------------------•-----•--•-•-----•••--•----•--••-•-••-----
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....... .........OF...... ................................
Trr#ifiratr of Tontplianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed l ) or Repaired ( )
by.............: - ------4--_---------------------------------.------•--••--•--.------------------••----•----.-------------•--•--•-----------------
Q
Installer
CJ i----�i _
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 �'o.___ � :__.,7.5 ....... dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE........................... ....................... Inspector.........I /� .. ...................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
No.�.�..---•--..__..__.� FEE..... ....:.........
�i��o�nl ork� �on��rttr�ion rruti�
Permission is hereby.granted_-.4=�_.Z....---•-- ...--•..........................................................
to Construct ( 4<c r Repair ( ,•,r -an�I_ndiv.idual,-. Lspos System
l �� 'at No ✓
Street
as shown on the application for Disposal Works Construction Permit No................ DZa .d_..___..._..____...____........__.._._....
J
f,
B d of Health
DATE..................................................�i
FORM 1255 HOBBS,. WARREN, INC.. PUBLISHERS
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LO•CATION C"` SEWAGE PERMIT NO.
lot 60 Elijah Childs Lane 81-757
VILLAGE
± Centerville, .PIA. l
I N S T A LLER'S NAME S ADDRESS
Robert Our Co.
Harwich, .MA. 02645 .
8 U I L D E R OR OWNER
Alan E. Small, Inc.
Box 536 Centerville, 14A.
I` DATE PERMIT ISSUED 1.2 22 81
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DAT E COMPLIANCE ISSUED
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