HomeMy WebLinkAbout0016 ELLAS LANE - Health 16 ELLA'S LANE, CENTERVILLE
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UPC 12534 S
No.2_ 153LOR
HASSTINGS,MN
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LOT 22 kode Fence
,07 SIF REFERENCES:
--
Assessors Map: • 189
35.92•CB/oH _ Parcel: 162
— — Fnd
-- - Lot 27 LCC 35548D
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/ of
LOT 28 '
�l 19,340f SF
z o ZONE:RC
o Setbacks:
Fron t: 20'
- Side: .10'
. , I
3 Rear: 10'
- � I
I Stone Wolk \ I o,
17.3' /
Wood
Deck \
❑
sty W/F I °' O LOT 29 f I of
0
19
o Iin
to
°#j 6 i Legend:o
19.5 ® Roilrood Spike Found
o 19 ^ Q PK Noil Found
C6 CB/DH
t wok it N 0 Guy
` ° W Utility Pole
4.4' 9Ss�� `�\ ° N Light .Post
12.3' 'n
10- OHW— Overhead Wires
F SaP�. I n ❑ Stockade Fence
loa` 2 o Post & Roil Fence
� I
LOT 27 1 I
I 1 I
1 j
1 I
oHw 1
NIF
Charles W./ & Janet 1
Haggerty 1 0
j 1 j
1 I
to C5 1
O 1 1 0
v O 1 a
M 1 I
Pove Drive 00' 0" E
PK RRSPK rI 79•
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38259'17'E m ��
110.66'
LOT 26 _
PLOT PLAN
At 16 Ella's Lane In
BARNSTABLE
NOTES: (Centerville)
1.) The 'structures shown were located on the ground
MASS.
by conventional survey methods on April 8,' 2008. DATE:23/APRI08 SCALE:. 1"--30'
0 15 30 45 60 FEET
2.) The property line information shown hereon was
compiled from avar,l k J:lltetcord n:,formation. PREPARED FOR:
3. This Ian is not for recording and is not to be Charles A. Wry
p g 16 Ella's Lane
used for construction laxout or: deed description Centerville MA 02632
purposes. C, :6 9V 1 Al $ 1iJ?
PREPARED BY: CapeSury
318 `t , 3 f
7 Parker Road
Osterville MA 02655
DWG #: C716gl L FIELD BY. MLL/DWB (508) 420-3994 / 420-3995fdx
� 75
66'
12'
Bath
Proposed Bedroom Dkvwtte Kitchen
Art
15' studio
Bath
Garage ' 26'
Uvtng Room
Bedroom
Bedroom
NEAL A. PRATT CHUCK WRY RESIDENCE DATE: 11,10.08 PAGE 1 of 1
BUILDER/DESIGNER I -16 ELLA'S LANE SCALE: None
42 CHASE ROADAl
E. SANDWICH MA. 02537 BY: NAP
PHONE: (508) 888-3206 Existing House Floor Plan
ATLANTIC ENVIRONMENTAL
P.O.BOX 2384
MASBPEE,MA 02649
Attn: Commonwealth of Massachusetts Date: 06/21/96
Town of Barnstable
Board of Health
367 Main Street a ,�
Barnstable, MA 02630
SUN 2 5 199 '
From : Mr Michael DeDecko
Po Box 2384 F
Mashpee MA 02630
kaA
Dear Board of Health Official;
I certify that I have personnally inspected th�sewag disposal systems at the following
address : 124 Megan Rd. Hyannis, Ma. & I6 Ella's-d". Centerville,Ma. .
The informations reported are true, accurate and complete as of the time of the
inspection.
If you have any questions regarding this inspection, please contact me at this number:
(508)477-14-20. Thank you.
Mficerely,
tf
Michael DeDecko
phone 508 477-1420
I
Commonwealth of Massachusetts
Executive of Environmental Affairs
DEP '
Department of
Environmental Protection
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 16 E lla's Lane. Centerville Ma.
Address of Owner: Sarah Kay B. Quelle_
(if different)
Date of Inspection: 06/13/96
Name of Inspector: Michael D eD ecko
Company Name, Address and Telephone number: Atlantic Environmental
P.o Box 2384 - M ashpee Ma 02649. Tel : (508) 4771420
CERTIFICATION STATEMENT
I 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
- Passes
---- Conditionally Passes
---- Needs further evaluation by the local Approving Authority
---- Fails
1
Inspector ' s S ignatuie: �{J"J ti,\, `Date: 06117196
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 or the Department
of Environmental Protection.
The original should be sent to the system owner and copy sent to the buyer, if ap( able
and the approving authority. `
t
t ..
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 16 E lla's Lane. Centerville M a.
Owners : Kay B. Q uelle
Date of Inspection : 06/13/96
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 CM 15.303. Any failure criteria not evaluated are
indicated below
B) SYSTEM CONDITIONALLY PASSES:
---- One or more system components need to be replaced or repaired. The system, upon
completion of the replacement or repair, passes inspection.
Indicate yes, no, or not determinate (Y,N, or ND). Describe basis of determination in all
instances. If "not determinated", explain why not.
---- The septic tank is metal, 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.
---- Sewage backup or breakout or high static water level observed in the distribution
box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven
distribution box. The system will pass inspection if (with approval of the Board of
Health).,
..... broken pipe(s) are replaced
----- obstruction is removed
---- distrkution box is levelled or replaced
---- The system required pub g more than four times a year due to broken or obstructed
pipe(s). The system w; ss inspection if (with approval of the Board of Health):
----- broken pipe(s) are replaced
----- obstru6on is removed
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address : 16 E Ila's Lane. Centerville M a.
Owner : Kay B. Q uelle
Date of Inspection : 06/13196
C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
---- Conditions exist which require further evaluation by the Board of Health in order to de-
termine if the system is failing to protect the public health , safety and the environ-
ment.
11 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 of water
---- Cesspool or privy is within 50 feet of a bordering vegetated wetland or a small
marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER
SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNC-
TIONING INAMANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY
AND THE ENVIRONMENT.
---- The system has a septic tank and soil absorption system and is within 100 feet to a
. surface water supply or tributary to a surface water supply.
---- The system has a septic tank and soil absorption system and is within a Zone I
of a public water supply well.
---- The system has a septic tank and soil absorption system and is within 50 feet
of a private water supply well.
---- The system has a septic tank and soil absorption system and is less than 100
feet but 50 feet or more from a private water supply well, unless a well water analy-
sis 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 notrogen is equal to or less than 5 ppm.
D) SYSTEM FAILS:
-- I have determined that the system violates one or more of the following failure criteria
as defined in 310 CM 15.303. The basis for this determination is identified below.
The Board of Health should be contacted to determine what will be necessary to cor-
rect the failure.
--- Backup of sewage into facility or system component due to an overloaded or
or clogged SAS or cesspool
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 16 E lla's Lane. Centerville, M a
Owner: Kay B. Quelle
Date of Inspection : 06/13/96
D) SYSTEM FAILS (continued)
-- 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 over-
loaded or clogged SAS or cesspool.
--- Liquid depth in cesspool is less than 6" below invert or available volume is
less than 1/2 day flow.
--- Required pumping more than 4 times in the last year NOT due to 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 cesspool or privy is within 100 feet of a surface water supply
ortributary 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 ana-
lysis. 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.
I
/7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 16 EIla's Lane. Centerville, Ma.
Owner: Kay B. Q uelle
Date of Inspection : 06/13/96
E) LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above :
The design flow of system is 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 :
--- 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 I I of a public water supply well.
The owner or operator of any such system shall bring the system and facility into full compli-
ance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00.
Please, consult the local regional office of the Department for further information.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B
CHECKLIST
Property Address: 16 EIla's Lane. Centerville, Ma.
Owner: Kay B. Q uelle
Date of Inspection: 06/13/96
Check if the following have been done :
-x Pumping information was requested of the owner , occupant and Board of
Health.
--x None of the system components have been pumped for at least two weeks
and the system has been receiving normal flow rates during the period. Large
volumes of water have not been introduced into the system recently or as part
of this inspection.
--x As built plans have been obtained and examined. Note if they are not available
with N/A.
--x The facility or dwelling was inspected for signs of sewage back-up.
--x The system does not receive non-sanitary or industrial waste flow.
--x The site was inspected for signs of breakout.
--x All system components,excluding the Soil Absorption System, have been
located on the site.
---x The septic tank manholes were uncovered, opened and the interior of the sep-
tic tank was inspected for conditions of baffles or tees, material of construe-
tion, dimensions, depth of liquid, depth of sludge, depth of scum.
---x The size and location of the Soil Absorption System on the site has been deter-
mined based on existing information or approximated by non-intrusive methods
---x The facility owners and occupants if different from owner were provided with
information on the proper maintenance of Subsurface Disposal System.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION .
Property Address: 16 E lla's Lane. Centerville, Ma.
Owner: Kay B. Q uelle
Date of Inspection: 00 3/96
RESIDENTIAL:
Design flow : 33o gallons
Number of bedrooms : a-_-,,
Number of current residents: c:> 1
Garbage grinder (yes or no) : N
Laundry connected to system (yes or no):u
Seasonal use (yes or no) : r�U
Water meter readings, if available: rj
Last date of occupancy :
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow : gallons/day
Grease trap present: (yes or no)
Industrial waste holding tank present (yes or no) :
Non-sanitary waste discharged to the Title 5 system (yes or no) :
Water meter readings, if available :
Last date of occupancy :
Other: (Describe) ..........................................................................:.................................
Last date of occupancy:
GENERAL INFORMATION
PUM^P^I\\N(G(�� RE ORDS and source of information :
System pumped as part of inspection(yes or no) :..... ........
if yes, volume pomped: .................... gallons
Reasonfor pumping :............................................................................................................
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 16 EIla's Lane. Centerville, Ma.
Owner: Kay B. Q uelle
Date of inspection: 00 3/96
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)
--- Other (explain)...........................................................................................
APPROXIMATE AGE of all components, date installed (if known) and source of information
.................................................................................................
................................................................................................................................................
................................
Sewage odors detected when arriving at the site: (yes or no)......N.Q.
SEPTIC TANK :
(locate on site plan)
r�
Depth below grade: ... Z.
Material of construction: ..&. concrete ......... metal ........ FRP ........ other (explain)
. ................................................................................................................................................
Dimensions:'S.4.�.,'�.?i-.1- x
Sludge depth :..7``......
Distance from top of sludge to bottom of outlet tee or baffle:.......... ................
Scum thickness :....A.::............
Distance from top of scum to top of outlet tee or baffle: ..............!.b.....................
Distance from bottom of scum to bottom of outlet tee or baffle :.....`.5.`............
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.)......................
')......................... ..i.... ..........�......: ..:y.\.'..... ..........................................................0 ..- '� r , t........
,�. L..... � .tc...................... ... . ....... a ......
SUBSURFACE SELVAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 16 E lla's Lane. Centerville M a.
Owner: Kay B. Quelle
Date of inspection: 06/13/96
GREASE TRAP : ........ �...
(locate on site plan)
Depth below grade: ...............
Material of construction: ........concrete.........metal........FR P........other(explain)....
..........................................................................................................................................
Dimensions:...............................
Scum thickness:........................
Distance from top of scum to top of outlet tee or baffle.........................................
Distance from bottom 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, etc.)........................
................................................................................................................................................
................................................................................................................................................
TIGHT OR HOLDING TANKS:.......
(locate on site plan)
Depth below grade:...............
Material of construction:........concrete........metal.........FR P..........other (explain)..........
...................................................................................................................................
Dimensions:............................
Capacity:....................gallons
Design flow:...............gallons/day
Alarm level:.............................
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
................................................................................................................................................
................................................................................................................................................
i
1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 16 EIla's Lane. Centerville Ma.
Owner: Kay B. Q uelle
Date of inspection: 00 3/96
DISTRIBUTION BOX:_*5
(locate on site plan)
Depth of liquid level above outlet invert:...
Comment:
(note if level and distribution equal evidence of solids carryover,evidence of leakage into
or out of box, ekc.).':� : Y ..`"1:. :.. c:: ...:`..: , .. :.::.!:::....................
.r:.'.!..r.................. .
................................................................................................................................................ .
PUMP CHAMBER:......
(locate on the site)
Pumps in working order: (yes or no)...............
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)....................
................................................................................................................................................
................................................................................................................................................
SOILABSORPTION SYSTEM (SAS):.....M5.....
(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: ... tom.
leaching chambers, number:........
leaching galleries, number:...........
leaching trenches, number , length:.....................
leaching fields, number, dimensions:...................
overflow cesspool,number:..........
Comments:
((note condition of soil , signs ,�^of.h draulic failure, level of ponding, condition of vegetation \\
etc �'.. t�A,�)�::' �a:.. : . *�.... .......... ..�.. t ............`..::r -._k_....
J
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
I'
Property address: 16 Ella s Lane. Centerville Ma.
Owner: Kay B. Q uelle j
Date of inspection: 06/13/96
0
CESSPOOLS:....N.......
(locate on site plan)
Number and configuration: ....................................
Depth-top of liquid to inlet invert: ...........................
Depth of solids layer: ...............................................
Depth of scum layer: ...............................................
Dimensions of cesspool: ......................
Materials of construction: .....................
Indicator of ground water: ....................
inflow (cesspool must be pumped as part of inspection)
.................................................................................................
.................................................................................................
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.)
................................................................................................................................................
................................................................................................................................................
PR IVY : ..... ?. ....
(locate on the site)
Material of construction: ............:......................
Dimensions: ......................
Depth of solids: ................
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.) .
................................................................................................................................................
................................................................................................................................................
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address : 16 E Ila's Lane. Centerville M a
Owner: Kay B. Quelle
Date of inspection: 06/13/96
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks locate at
wells within 100'.
Ell
1�2 rs� �
DEPTH TO GROUNDWATER:
Depth to groundwater: :..`. :feet
Method of determination;lr approximative: t. _ G . .�c-�
... ......... ........... ... ........:� ... ,.. ......................... ..............
2 - _
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r
No.q. ::.7 K4 F.Rs........��..�.............
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
Ol ±1............O F................. .--•--
ApplirFatinn for Dispoti al Works Tonstrnrtinn ramit
Application is hereby made for a Permit to Construct (C,-Yor Repair ( ) an Individual Sewage Disposal
System. at
......... - --------.�Y-JI/1-�-�--•-------•-W�-----•---- -•--•-•------•--�•--�•------ D. ----------------------------------•-------
A- -•--------
. Location- ddress or L__ot� o.�
_._.. ....... -•--•-•-- ----••-•--------------------
owner Addre
t (1Si �--
a ---•......•--. ........ ---------------- ------------------------------ .....................................
Installer Address
Type of Building Size Lotq, �.�-__-�_.__...Sq. feet
U Dwelling—No. of Bedrooms..........�............................Expansion Attic WQ Garbage Grinder 00
aOther—Type of Building ------------------_------. No.- of persons---..................------. Showers ( ) — Cafeteria ( )
a' Other fixtures ............................... . .
d -------------------......---------------
W Design Flow...........!A.®.....................gallons per person per day. Total daily flow............... �.3-30
............................
WSeptic Tank—Liquid capacitylQQ ..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........ -a- �.�.....�....._ ._._!":_ "...... Date..........'
,_� Test Pit No. 1................minutes per inch Depth of Test Pit..--------_0...... Depth to ground water........................
Gi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water..--....................
P4 •-•••---• --•------- -- -•-----•------•-••---.-------•------ -•---------------------•--•----------------------------------------------------------
�- sue. �,
Description of Soil..........0.- --
--------•-••----•...Or.-----•....... 1.......................................................
W ----------------------------------- S. -A--�------------:Ml.-A--------------.... -A.
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 TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliani7F
d by the board of health.
atApplication Approved BY rl
Date
Application Disapproved r e following reasons--------------------------------•--------------------------------------------•--•---------------------........---
........................................................ ••-•------------•...•---------•••-•--•---------•-•-•••---••----•-•.----•-------...----•---•-•••••---------------------••-------------•--•-----
Date
PermitNo......................................................... Issued.......................................................
Date
T
a
No..-...•--.-•....r- ' Fins........ ............
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
J ...----:....OF....................... L -- . .:
.................................
.Apure#ion for M-4posal Vorkg Tontitrurtion amit
Application is hereby made for a Permit to Construct ( C,),'or Repair ( ) an Individual Sewage Disposal
System at
........ --------- :. -------------�An�------------- ----------------`,'`------•------------- -•----------------------------------------
Location-Address "' t( t or Lot Igo.
Fj
r r,.e_o -- �`-.. �'---- --------------•------ -----•-----_••..`.'�...� .. --•------.... s-.--•--.��........................._..
V e (� Owner Q_S J7 a� n1� �-AdC.`JLU t e_
....................... .................................................. ...._................._............... ...............-•-•--•..............•--•..........-----
Installer Address `� j
dType of Building Size Lot.............................Sq. feet
Dwelling—No. of Bedrooms.......... .............................Expansion Attic Garbage Grinder
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
QI Other fixtures ............................ _
W Design Flow............�...._�.....................gallons per person per day. Total daily flow--------------- ...............gallons.
WSeptic Tank—Liquid capacity.kg9 '..gallons Length................ Width................ Diameter................ Depth................
Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
3 Seepage Pit No--------------------- Diameter.................... Depth below inlet..................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank
'-' Percolation Test Results Performed by............ .............` .....::�....��... c..... Date........... ..........................
aTest Pit No. I................minutes per inch Depth of Test Pit....__........___...IDepth to ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water--------_...............
••--------------------------------------•-•--..........----•---...........-••.......•--•..........-•........................................................
D Description of Soil '-----
- ------------------ n_O .....................j >.,.'C 7' ..........................................
U ••••-•-•---•-•••-••-•--•-•••....••--......•-- -- -------------------------•. ---- . .....I.....-------------•-.I . ----------------•-----•--------------••--------
------------------
U Nature 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 TITIZ 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed,-- I 1...........•-- ---------------
Application Approved By...... � }�
� Date,/
jD =
Application Disapproved f or the following reasons---------------•------------------•----------------------------•----------------•-----------•--•---•--..._------
-•-•-----•-------••--•-•----••-•••-........•-•-•.....----•---•---•-•---•••••----•--•......................-••---•-•---••-•-••---- •-•---•••••••-••--••-•-•------•-•------•------•----••-••-•--------•----
Date
PermitNo......................................................... Issued-.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
4 i`...Q�0� ' ...�
.........�..............................OF.............................:...-............................... ................
Tnrtifiratr of TompliFanrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (L-�or Repaired ( )
by ' --.------------ -------------------------------------•-•-----.............----------..........----•-
I..
y ,
(,I Iynst Iler 1 �1- -, A,L- -__
at -------------•----------------------•---•-----•- -••.......---• -•••--••-•------•---•--••-•••••-•-•••......-•---•--- .........................................
has been installed in accordance with the provisions of TITLE 5 of,The State Sanitary Code as/d"escribed in the
application for Disposal Works Construction Permit No........f ......_.�U__`............. dated___.:___..j� .........___.._...
i
THE ISSU NC OF THIS CERTIFICATE SHALT. NOT BE CONSTRU A GUARANTEE THAT THE
SYSTEM V
YI CTION SATISFACTORY.
DATE... .. ... -----------------------------------------------------
Inspector....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEALTH
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No.!.�........`. /
.._...... FEE../ ................
11iipos al Vorkg Tuonotrnrtion, rani
Permissionis hereby granted..............------==--•------••�--�----------•--------------------•------------------------==-............---•----.._._._.....--------
to Construct ( L-1or Repai ( ) an Individual Sewage Disposal System -
e � 11 cam' ' ` 1. f�= en c. C"':� .-�_t1- k'k :`�.,._
at No. =--..••----••-•----•••---•--------------------•......_.. .... ...........---.---------------- --- -••••••• ••-•-•--....--
Street 11
as shown on the application for Disposal Works Construction Permit No-------------. Dated..........................................
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DATE_ Z � ..� .r �'" Board of Health
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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• ►.J - t_c�'r I..INU_ APPLIGA►`IT' TAMS
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LOCATION S E W A G I PERMIT NO.
VILLAGE
I N S T A LLER'S NAME i ADDRESS
� E7-Di24l,D &C
SUIEDEIt OR OWNER
5m T
DATE . , PERMIT ISSUED _� _ v�
OAT COM-PLIA,NCE IS-SITED 47///,I/IX
J
r?y`�ft
•l,=q
BATH DEN
- —Clos. — Clos.
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HALL
CIOS.
MASTER B/R
i
BEDROOM
22"x48" top w/ sink
and cab. under by owner
(contractor to install)
appr. 62 —
exist. deck
to remain
A. A exist. deck to
q-5 STUDIO ADDITION I ,} A_5 be removed
(pine flr.) O exist. fence
3 N to remain
1�®.e+4�
Q- RED qRC,4a
S. Gp9'y,>,;
ea 2 5' wind. ,ill ht. — — — — — f�SQ. O i
E ��� Z ►
. 3e63e N a
BOSTON,
N. i MASS.
! 5-O" fram. dim. •��q� 1 OF MP55P��
v
DATE:
LARRY GORDON ARCHITECTURAL DESIGN r� Residence REV.: . . 17/10/08
EII �'ROPOS. FLOOR PLAN rev. date: SCALE: AMPA y
Centerville, MA 02G32 508-790- 1 246 16 a s Lane, Centerville, IVIA 1 4 -1 -0 ® J
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