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HomeMy WebLinkAbout0077 GLENEAGLE DRIVE - Health 77 GLEN EAGLE DRIVE, CENTERVILLE A = 191 138 I //// �, 2 UPC 12534 No. 2-1553LOR HASTINGS, MN = _= COMMON WENIA]I OF MASSAC lUSETTS _ = EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAI Q . DEPARTMENT OF ENVIRONMENTAL, PROTECT. IV ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500 31 99 S Jam F 350 MAIN STREET 1\� �N9VpFl ARGEO PAUL CELLUCCt WEST YARMOUTH, MA "guy 1 R. s is Governor 508-775-2800 Con i. i ner 1 s ti SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION MAP 191 PAR 138 PROPERTY ADDRESS: 77 GLEN EAGLE DRIVE, CENTERVILLE ADDRESS OF OWNER: DATE OF INSPECTION: MARCH 23, 1999 DAVE LAPHAM NAME OF INSPECTOR : JAMES D. SEARS I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 9310 CMR 15.000) COMPANY NAME: A&B Canco MAILING ADDRESS: 350 Main Street,West Yarmouth,MA 02673 TELEPHONE NUMBER: (508)775-2800 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: X PASSES CONDITIONALLY PASSES NEEDS FURTHER EVALUATION BY THE LOCAL APPROVING AUTHORITY FAILS INSPECTORS SIGNATURE: _ DATE: MARCH 25,1999 The system Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP) within thirty(30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. NOTES AND COMMENTS: SITE OVER ALL PASSES,INSPECTION OF SYSTEM IS BASED ON CONDITION OF SYSTEM AT THE TIME OF THE INSPECTION.THERE IS NO GUARANTEE ON THE LIFE OF THE SYSTEM. revised 9/2/98 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIVICATION(continued) Property Address: 77 GLEN EAGLE DRIVE, CENTERVILLE Owner: LAPHAM, DAVE Date of Inspection: MARCH 23, 1999 INSPECTION SUMMARY: Check A, 8, C, orD: A] SYSTEM PASSES: X I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B SYSTEM CONDITIONALLY PASSES: N/A One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The System,upon completion of the replacement or repair,as approved by the Board of Health will pass. Indicate yes,no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain why not) The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate Of Compliance(attached)indicating that the tank was installed within twenty(20) years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank is 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 pa pass inspection if(with approval of the Board of Health). broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed revised 9/2/98 2 / i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 77 GLEN EAGLE DRIVE, CENTERVILLE Owner: LAPHAM, DAVE Date of Inspection: MARCH 23, 1999 C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: N/A Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303 (1)(b)THT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet 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 1 of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen and is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER revised 9/2/98 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 77 GLEN EAGLE DRIVE, CENTERVILLE Owner: LAPHAM, DAVE Date of Inspection: MARCH 23, 1999 D]SYSTEM FAILS: NIA You must indicate either"Yes"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 16.303. 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 facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an over- loaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. _ Liquid depth in cesspool is less than 6"below invert or available volume is less than'%day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s) Number of times pumped Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater Elevation. Any portion of a cesspool or privy is within 100 feet of surface water supply or tributary to a Surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: N/A You must indicate either"Yes"or"No"as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or mapped Zone I I of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. d revised 9/2/98 4 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 77 GLEN EAGLE DRIVE, CENTERVILLE Owner: LAPHAM, DAVE Date of Inspection: MARCH 23, 1999 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No N/A Pumping information was provided by the owner,occupant,or 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 that 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,including the Soil Absorption System,have been located on the site. X 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 Soil Absorption System on the site Has been determined based on: X Existing information.Ex.Plan at B.O.H. X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)11 5.302(3)(b)) X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal System. revised 9/2/98 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 77 GLEN EAGLE DRIVE, CENTERVILLE Owner: LAPHAM, DAVE Date of Inspection: MARCH 23, 1999 FLOW CONDITIONS RESIDENTIAL: Design flow: 330 g.p.d./bedroom for S.A.S. Number of bedrooms(design) NIA Number of bedrooms(actual): 3 Total DESIGN flow N/A Number of current residents: N/A Garbage grinder(yes or no): NO Laundry(separate system) (yes or no): N/A If yes,separate inspection required Laundry system inspected(yes or no): N/A Seasonal use(yes or no) NIA Water meter readings,if available(last two(2)year usage(gpd): 1997 78,000/1998 102,000 Sump Pump(yes or no): N/A Last date of occupancy: N/A COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: Gpd(Based on 15.203) Basis of design flow 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 PUMPING RECORDS and source of information: NIA System pumped as part of inspection:(yes or no) NO If yes,volume pumped: Gallons Reason for pumping TYPE OF SYSTEM X Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) I/A Technology etc.Attach copy of up to date operation and maintenance contract. Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed (if known)and source of information: DATE OF SYSTEM 1980, PERMIT#80-213. NEW PIT INSTALLED 1997, PERMIT#97-88 Sewage odors detected when arriving at the site:(yes or no) NO revised 9/2/98 6 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 77 GLEN EAGLE DRIVE, CENTERVILLE Owner: LAPHAM, DAVE Date of Inspection: MARCH 23, 1999 BUILDING SEWER: N/A (Locate on site plan) Depth below grade: Material of construction cast iron 40 PVC other(explain) Distance from private water supply well or suction line Diameter Comments:(condition of joints,venting,evidence of leakage,etc.) SEPTIC TANK: X (Locate on site plan) Depth below grade: "I, Material of construction X concrete _ metal _ Fiberglass _ Polyethylene _ other(explain) If tank is metal,list age Is age confirmed by Certificate of Compliance (Yes/No) Dimensions: 1,000 GALLON PRE CAST Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: N/A' Scum thickness: V, Distance from top of scum to top of outlet tee or baffle: N/A' Distance from bottom of scum to bottom of outlet tee or baffle: N/A` How dimensions were determined ASBUILT&TAPE NOTE:OUTLET COVER 44"BELOW GRADE,ROCK HARD GROUND. 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.) TANK AT WORKING LEVEL,INLET BAFFLE,INLET COVER 8"BELOW GRADE. GREASE TRAP: N/A (locate on site plan) Depth below grade: Material of construction — concrete _ metal _ Fiberglass _ Polyethylene _ other(explain) Dimensions: -- Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from,bottom of scum to bottom of outlet tee or baffle: Date of last pumping: 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.) revised 9/2/98 7 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 77 GLEN EAGLE DRIVE, CENTERVILLE Owner: LAPHAM, DAVE Date of Inspection: MARCH 23, 1999 TIGHT OR HOLDING TANK: NIA (Tank must be pumped prior to,or at time,of inspection) (Locate on site plan) Depth below grade: Material of construction _ Concrete _ metal _ Fiberglass _ Polyethylene _ other(explain) Dimensions: Capacity: Gallons Design flow: gallons/day Alarm present Alarm level: Alarm in working order Yes; No Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: X (locate on site plan) Depth of liquid level above outlet invert: 0 Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc,) D-BOX IS 16"X21",ONE IN,TWO OUT.BOX IS 54"BELOW GRADE,BOX COVER IS 3'BELOW GRADE,BOX IS CLEAN AND SOLID. PUMP CHAMBER: N/A (locate on site plan) Pumps in working order:(Yes or No) Alarms in working order(Yes or No) Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) _ revised 9/2/98 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 77 GLEN EAGLE DRIVE, CENTERVILLE Owner: LAPHAM, DAVE Date of Inspection: MARCH 23, 1999 SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not located, explain: Type: Leaching pits,number: 2 Leaching chambers,number: Leaching galleries,number: Leaching trenches,number,length: Leaching fields,number,dimensions: Overflow cesspool,number, Alternative system: Name of Technology: Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) OLD PIT IS 38"BELOW GRADE,COVER IS 22"BELOW GRADE,NEW PIT S BELOW GRADE,COVER 22"BELOW GRADE, _ OLD PIT IS 6'DEEP ENW PIT IS 4'DEEP,BOTH HAVE 18"WATER. CESSPOOLS: N/A (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: Indication of groundwater: 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.) PRIVY: N/A (locate on site plan) Materials of construction: Dimensions: _ Depth of.solids: _ Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) revised 9/2/98 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 77 GLEN EAGLE DRIVE, CENTERVILLE Owner: LAPHAM, DAVE Date of Inspection: MARCH 23, 1999 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100'(locate where public water supply comes into house) '3 6' 13' o 5° do revised 9/2/98 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 77 GLEN EAGLE DRIVE, CENTERVILLE Owner: LAPHAM, DAVE Date of Inspection: MARCH 23, 1999 NRCS Report name Soil Type Typical depth to groundwater USGS Date website visited Observation Wells checked Ground water depth: Shallow Moderate _ Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to no groundwater 12 Feet Please indicate all the methods used to determine High Groundwater Elevation: X Obtained from Design Plans on record Observation of Site(Abutting property,observation hole,basement sump etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators,installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation.(Must be completed) DEPTH TO NO GROUND WATER TAKEN OFF PLAN. revised 9/2/98 11 TOWN OF BARNSTABLE I `rLOCATION I t OeQ ^i1 tC l-e- Jib. SEWAGE # VILLAGE �'Pl. '�J! �� ASSESSOR'S MAP& LOT INSTALLER'S NAME&PHONE NO. A' C A M�G -7-7 S"'Z WD SEPTIC TANK CAPACrfYCfS'�i�'� <.LEACHING FACIL=: (type) L-f C (size) NO.OF BEDROOMS__ 'BUILDER OR OWNER PERMTTDATE: a- f a COMPLIANCE DATE: �/ 9 7 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 ° �19 ! 33 3� 66 ANk i Sox (7 .z) 3 LOCATION SEWAGE PERMIT NO. VILLAGE / =F fy 'i/ Vf G C /�'7 / 91 `j F INSTALLER'S, NAME i ADDRESS BUILDER OR OWNER Ave DATE PERMIT ISSUED DATE COMPLIANCE ISSUED � � � �=�v�7 a ,�: •�Yl�1F.f �� No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS Zlpp 'rats f r Oigool *p5tem Cow5truction Vermit Application for a Pert to Construct( )Repair( )Upgrade(--)/Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. of- 7 1e h eQ9 c Dr• o ner's Name,,Address and Tel.No. e Assessor's Map/Parcel ` MxTe-r` ',i ( e- bwvc ^AYnAm rn� Installer's Name,Addres Io tANCO signer's Name,Address and Tel.No. 350 Main Street , �f T�ylo r W. Yarmouth MA 02673 Type of Building: Dwelling No.of Bedrooms 19 Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( } Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date L( /9 S v Number of sheets a Revision Date A /J9 Title FI'-AA)K 14AA)i'F I f Size of Septic Tank 10 e " Type of S.A.S. b x cx cr 4ac4 n�� Sl4iyc.� Description of Soil Nature of Repairs or Alterations(Answer when applicable) T/JSfA // 49eS e i'44-e_ C /'P4- d_e r 1A-N AP Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Bo f alt . Signed Date D-A J Application Approved by ®► Date Application Disapproved for the following reasons Permit No. Date Issued +� r No. I Fee THE COMMONWIAL H OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Zippricat'on fir Migaar *p.5tern Construction Permit Application for a Perm to Construc@( )Repair( )Upgrade(./J'Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. ? /e A eGg l t Dr. Ojw�ner's Name,,Address and Tel.No. Assessor's Map/Parcyl e-✓��'e r I "A' hA��Ah T Installer's Name,Addres D�g signer's Name,Address and Tel.No, Ali W-eANCO C'roG/e//- ;r,4 y1a�'' 350 Main Street ! W. Yarmouth MA 02673 09 t l i I o 4- s Type of Building: ' k Dwelling No.of Bedrooms �11 Lot Size sq.ft. Garbage Grinder Other Type of Building .. No. of Persons Showers.(', ) Cafeteria( ) i Other Fixtures � ,i s Design Flow gallons per day. Calculated daily flow gallons. Plan Date L(- /9 bU Number of sheets a Revision Date A Title - - Fri/UX 14A,01,F I f, Size of Septic Tank I 000 C',<"5 .+ Type of S.A.S. to X (a &2a,rA ;+- Description of Soil A a�64AJ ti -f Nature of Repairs or Alterations(Answer when applicable) T/)J f A // Re S e e- r !J/,*A) E .\ A/3 /CO,, u d =2 S Date last inspected: i. 'Agreement: t The undersigned agrees to ensure the construction and maintenance of the afore described on-site*sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Boqrq qf altl Signed � Date S^- Application Approved by ® Date , Application Disapproved or the following reasons Permit No. - Date Issued 4 ———————————————————————-- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded( Abandoned( )by e"4/t/ec) at 7 -le constructed in accordance f with the provisions of Title 5 and the for Disposal System Construction Permit No. — dated Installer Designer mint .// TAfe,, 'The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date Iq - !:2 Inspector " i — — -- ----------------- ————————— —�"'-- No. ".° Fee y D THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS 1=i.5pogar *pztem Con!5truction Permit Permission is hereby granted to Construct( )Repair( )Up rade( "'}sAbandon( ) System located at 7 2 e5:7�s-7 en, and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction mu t be co lete within three years of the date of th s pe t. 'V I � p Date: 414, �// Approved byUL�( r / TOWN OF;-�BARNSTABLE LOCATION G�eu d�C�I� Jr. SEWAGE# !7 � VILLAGE C�,. �r�I I III ASSESSOR'S MAP & LOT_tZL--ZdS- INSTALLER'S NAME&PHONE NO.��� (wj(G -1-1 S' 2 D SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size)NO.OF BEDROOMS BUILDER OR OWNER 1-4121)Dnr, PERMIT DATE: 9 COMPLIANCE DATE: 3 — 19 - 9 7 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 &A V-09 AN�C i o3ox 70 I> Cj tj 4 IVO Zb NON., ?`c � �� ,� � � � �' v h► � r:, ' ;�+. �; � s� I� Z �• fir;, 7 lo �� L�7 7 -cc 40L � Zc y b � ebb �', I� _ b�a,;��� _ ,;. o a ve U n � � j o o � . o oirn � � y , ! � rnyo c � Z 'rN��� b�ult � � p � y k � m b`�f'y � y � �m tj CIS "41 rn U, (A m tj OWN ej 1A :U 1� Ors v b D I r 0 �t b No...._....2 3..... F$$... .......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF...... .!Y. .l..rf. 1 ................................ Applira#iott for Diripwml Worbi Tattritrnrtiott rrrntit Application is hereby made for a Permit to Construct (V/) or Repair ( �an� 'vidual Sewage Disposal System at: T.ocation-Address or Lot o. / A7Y.!� L7G[ •.............................. . ... .......•-------------------•--••--•-••--•. --- ....---........................................ ... ..- ._ ..... . ... Owner Address W ......................................................... ......... Installer Address I/53 QType of Building Size Lot............... ........Sq. feet Dwelling— No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder 04 Other—Type of Building ............................ No. of persons............................. Showers ( ) — Cafeteria ( ) p-t Other fixtures ---------------------------------- W Design Flow.............. 5.........................gallons per person per day. Total daily flow..........33.0......... ............gallons. W Septic Tank— Liquid capacity/TJ00—aalions Length.S-'L....... width.:4.1O_- .. Depth..S..x_..... x Disposal Trench--- No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No....._.._I.......... Diameter.......6.......... Depth helow inlet.....G 1.......... Total leaching area..ZPP....sq. ft. z Other Distribution box ( ( ) Dosing tank ( ) Percolation Test Results Performed by..__C.:..f .:.S_ Q '_T...................: `t" 2'L — 80 Date. ................................. aTest Pit No. 1..G._2-...minutes per inch Depth of Test Pit...... Depth to ground water..NO..N£....... CL, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water! 4;K 9 --------------------- ----------•--••-•--•-•---•--...................------------------...--•-.....---........_..............--•...........--•.......--...... O Description of Soil....n-- L w M__•£_`S�! �C?!.L----•-. _ .................. Lzl �t ..................... ....................................... --------•---........-----•------......--.................... ................................................................... V Nature of Repairs or Alterations—Answer when applicable............................................................................................... Agreement: The undersigned agrees to install the aforedescribed Tndividual Sewage Disposal System in accordance with the provisions of:i p 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 bole- of healtlk Sig , t � ---------•---• 1 Da e Application Approved By Hate Application Disapproved for the following reasons: .......................................................................................... --•........................................................................•--••-•--•-----•--...................._...._...._..----•-------•-••-------....---•-•--•-•-•--•---•-•.....--•--•---••..._--••-- �-7 v)Permit No......................................................... Issued..._l: ��Z 7 . � "......D Date ate ...... Date ' I No. -2�-3.... • . _ Fes$:..J�d............ THE COMMONWEALTH OF MASSACHUSETTS --�7�� �_/BOAR® 0�' - HEALTH .........f.�.W./V................OF......4 '!�1....1 .L ..........................------ , pplirFatinn for Dhgpvii ai Workii Tiamitrnr#inn Vantit Application is hereby made for a Permit to Construct (✓) or Repair. ( ) an Individual Sewage Disposal System at: Location-Address or Lot No. ---------- ------------------------------- Address J753 Q © Type of Building Size Lot_______________............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( 0) Other—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Q' Other fixtures ............................ W Design Flow.....__._... 5........................gallons per person per day. Total daily�flow_.._.......4 ......................gallons. WSeptic Tank—Liquid capacity_ _..0gallons Length.9'6a_`.____ Width.4_.1d_.._ Diameter................ Depth.5._.9_ ... x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter--------6-4-------- Depth below inlet.....6........... Total leaching area.. ©®....sq. ft. Z Other Distribution box Dosing tank' ( ) Percolation Test Results Performed by.... _c__ -_5 ¢ T_______________________________ Date.__¢-. ._'_ .... ____.. aTest Pit No. 1... __Z___minutes per inch Depth of Test Pit-----/ ........ Depth to ground water../0 ........ fT Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water!�k�v? n£D a ....................---....................... .............................................................................................................. O Description of Soil.... - -'_..L _______ t 4 --------------------------------- �z` ^� �!�?^ Car-?,Zs s D b< .g-A ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ 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 i T i p 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 bar of health Sig d. .. - --•••... Date Application Approved By........ r � �� %' :'_ " .._.__.... Date Application Disapproved for the following reasons-----------------------------•-------•---------------------------------------•------------------•-----------•-••- ....--•---•----------------••-----•---------•------------------=•---------------------.......----------------•----•------------------...---•-----------------------------------------•------------------ Date Permit No.............•--•-•---..._........_ `•� �`-c' Issued -----==1----- ------------------------- Date No.........2.�3.... - Fxs.... d............ Yi9 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH - j.il...............OF...-.. ..a!V:.0 r.L. 4-1........................-- ---- Appliration for Disposal Works Tonstru.rtton Frrutit Application is hereby made for a Permit to Construct (1/) or Repair ( ) an Individual Sewage Disposal System at: ' --......--.....- ...................................... ........•----••----•----••---•---•------ ...-•------------------.... ........•. �y,, Location-Address or Lot No: ............/..... !/.x.'�... .-- .....fin........-•............................... Address ........................................ �fi Owner `..................... Installer Address QType of Building Size Lot---z5: ........Sq. feet U Dwelling—No. of Bedrooms.............3............................Expansion Attic ( ) Garbage Grinder &d Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) p' Other fixtures ................................. . W Design Flow............-55........................gallons per person per day. Total daily ..,flow........... 3-12......................gallons. WSeptic Tank—Liquid capacity/000gallons Length.9'6°_.___ Width.4'1 .-.. Diameter_4.' -___ Depth-...,►"'.-..8_.._.. x Disposal Trench—No-------------- ----- Width.................... Total Length.................... Total leaching area--------------------sq. ft. y Seepage Pit No.-_._.----_--___-.- Diameter...... .......... Depth below inlet.....?........... Total leaching area..Z0 ....sq. ft. Z Other Distribution box ( f ), Dosing tank ( ) Percolation Test Results Performed by.....<�. 7Z _�` ?. A� .erg r.._.......�_......_..•__........ Date_._'�':'.2—gb._..__.._.. aTest Pit No. 1__ .. _._minutes per inch Depth of Test Pit-__--� ........ Depth to ground water---A10A A--__--. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-+_1r- _—7:*�_ ED ....................................................................... ......................................................................... O Description of Soil....q ,...1 Ca 192.44 K.6Cq$Sa 'z. W -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- VNature 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 21:-.Dt� 5 of the State Sanitary Code- The undersigned further agrees not to place the system in operation until a Certifica e';of. Compliance has been issued by the bEo rd of healtk. �j` 6""' *� I Si 10, ed _ .......---- ----•------.••--- ............................... Application Approved-BR ••---- - •• t ...................... "`." /._ d2t r,yam... J •,, ....................................................................................Date -----------------------------------------•--------------------------..............................--•--•-•-----•••----•---•-•••-•--------•---•--•-•---••---------------•----••--•----•--•-•---•--•-•-- Date PermitNo......................................................... Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS X b '" BOARD OF HEALTH f _ra_&/n/ , ............................`......oF.........�� ............................. .:r "'3.n+.Sr��G . TrrtifirFatr of Toutpliatta T-H IS V6CflT Y, That the Individual Sewage Disposal System constructed ( or Repairedby t - ------- ------------------------- --------- --------'..//--- � ��>PInstaller /� y� •............................•--••-- has been installed in accordance with the provisions of 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit N . ......�•�............................ dated-.. Dr . /K.. ----.............. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.......... ' ...... ----••---- Inspector `L THE COMMONWEALTH OF MASSACHUSETTS BOARD OF .HEALTH TpGt/N oF....... 7�}`I'l NSAG ............................ o�... FEE. .a............ Elispos I Works o trur$ion amit `. Permission is liereby granted................/ `---..-• .-- -.. . \. to Con o/ an s r pair ( ) �dividual w ge Dis osal yst ''` N / i( 1 ^ at No.. J� ......` h.A ': .� - l"� = Street as shown on the application for Disposal Works Construction Permit No... ..... _ Dated.._.". -.'. ------------- Boa 77 rd of Health DATE......1-..................................................................... FORM 1255 HOBBS & WARREN, INC., PUBLISHERS - Ta p STD 4 U/ Prra�Qs`ra 2�2,✓ vy So, L: 1 N' s .?c9 71 c— 'lE.IJT S C,q L E Q._ FT.:�'?t'✓T �, = T'2E4 Tom' , 2 0o SED 3 SEPT/c_ 5.Y57—,--M• ,%UCT/OnJ. BED2Qos DES G iV 'A"L O tit/. 'GAL/D,4 Y C/vv/,�a�/n�En.lr,4L �vo�,•.T/rL� Y • . ' L_L.A G Al- J2 A TE �EQU/,E'C-1� LE,4GNf GAX�E1> # . yE�1�•T1v r��c=�C.lL,4 OtVS . P20po5 L� L EPIC/-t' r /`' AAIkIOZ E �CC7V6,2 7-0, E•X7-EnlL> TO /M.�C2✓/OCIS GOt/E� ,VV, .'Ts!/,Aj !' 'DF Ia2E�/�.VT D/5T. 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