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Home My WebLink About0068 KENNESAW AVENUE - Health 68 KENNESAW AVENUE, CENTERVILLE A= 249 021 UPC 12534 No.2_OR HASTINGS, MN �� 'ry a. ,�k�i� � o � t �o� �r � �r�v`o�995 777777M777777777777777i TOWN OF-.,,�'.BARNS TABLE ' BAR-W Ordinance br Regulation WARNIMG.,.VOTICE '. Name of Offender/Manager I -,j Address of .Offender X 15-S A 1-,� A MV/MB; Reg.# Village/State/Zip �z Business Name , m on > 2 0, ., Business Address _ _...m -�-_ "_-"" -,.-.�.,._.,._ f f� — .. �'`� ��,..".�..� -.., Signature of Erif c"-6r in g Officer Village/State/Zip V —,xf fi)-'J Location of Offense A Ar Enforcing Dept/Division, �/A%, Of f ense A 4,1 1 Facts This will serve only as a warning. At this time no legal action has been taken. V It is the k"goal of Town agencies to achieve voluntary y compliance of *Town, Ordinances, Rules and Regulations., Education efforts and warning notices are attempts to gain voluntary compliance' Subsequent violations will .,res'u*lt in appropriate legal action by the Town. WHITE.-OFFENDER . CANARY-ORD./REG. PROG. PINK-ENFORCING OFFICER GOLD 7 ENFORCING DEPT., (4+: b'r✓7 rs{z,`:.t ^,+w ,_.Y sr ar8rcv ti t. ; :e s5.. ""!� hr -z':_S +, t ai'w i-�77777- 77 TOWN OF BARNSTABLE BAR-W k Ordinance or.:Regulationj' ' WARNING ,NOTICE Name of Offender/Manager dob ' {' Address Offender w C '�_1 rA js-,5A k-TV A\l+ - MV/MB Reg.# Village/State/Zip tw'. �,' ,, a tii I LC. �:,,.✓t/a. 6 21 ? SS# Business dam/pm) on f f Z. 5 20 0`'j Business Address Signature of Enforcing Officer Village/State/Zip .. d h.. / ,_� i _ •, 3 G. Location of Offense s �=-' s: �� t 1 ( '=� -•7 /y /� ' Enforcing Dept/Division Offense 1�/. ► G = f 'C, ,�1 , f/ y _ ;= t/ u }�' r.s,�,i: *'/ �v T q , Facts J ~f,J i «� 1 t j'�C l v «✓ A / .'F, /( ,d j/ /ei`(� J T✓�t' .r. .,i . 1y�.45:.....:,y �/;� l �-/ :iyf"},� ,� •.•\,/ ��''r� ,'.''.§,1 i�7 ;✓ .;�,'� � l t/I e�,/ � f4� i i�!`,�(.,:y,r <1 ? This will' serve only as a warning. At this time no legal action has/been taken. It is. the goal of Town agencies , to achieve voluntary compliance of Town Ordinances, Rules and Regulations. Education efforts and warning notices are attempts to gain voluntary compliance.', Subsequent violations will result in _ appropriate legal action by the Town: WHITE-OFFENDER CANARY-ORD./REG PROG. PINK-ENFORCING OFFICER ' GOLD ENFORCING DEPT. I TOWN OF BARNSTABLE BAR-W 5927 Ordin/ance or Regulation WARNING NOTICE / / Address of Offender t) ►' MV/MB Reg.# Village/State/Zip ( fPI R�� _ /h 0/0 3.,2_ Business Name am pm, on 7/ I S120,11 Business Address Signature of Enforcing Officer Village/State/Zip G Location of Offense ()/� er.1 F-(A 14.,- l 1�i.jrnvr_ �+°�c�.�+�fy 11,�4 �1411 Enfo=icing �ge,tt/Division Offense )OW04 4l gArll 51H9Q l i 353- 1 - (/t,!/lelf Facts IffPP/' k 4r_j Grh ✓'v rl� /h of P�' /Ari �l a #Y{r,.m / !!" �P C J oo.,,,0 �1/ <44-7 VVI 469 This jwEll serve only as a%warnir g. At' thifs time no slegal act�(bfi has been taken. It is the goal of Town agencies to achieve voluntary compliance of Town Ordinances, Rules and Regulations. Education efforts and warning notices are attempts to gain voluntary compliance. Subsequent violations will result in appropriate legal action by the Town. WHITE-OFFENDER CANARY-ORD./REG.-PROG. PINK-ENFORCING OFFICER GOLD-ENFORCING DEPT. Ij TOWN OF BARNSTABLE BAR-W 5927 Ordinance or Regulation WARNING NOTICE Name of Offender/ManagerG�l�{/ - jt�y�trt Address of Offender r rr� 'c'=..: , �. "n f MV/MB Reg.# Village/State/Zip ( r✓+"'r t,,,, //ram_ r;6.4 o1, 3 Business Name if J?a am pm, on 'f t ' S! 20l ,7 Business Address Signature of Enforcing Officer Village/State/Zip Location of Offense Enforcing ,Dept/Division Offense �,�+.� „ .r s,/ s t aT ,* •t v - r Facts Jerry A- c ef4',, ,., ' 0.. This will serve only as a7warning. At' thil's time no legal acticon has been taken. It is the goal of Town agencies to achieve voluntary compliance of Town Ordinances, Rules and Regulations. Education efforts and warning notices are attempts to gain voluntary compliance. Subsequent violations will result in appropriate legal action by the Town. WHITE-OFFENDER CANARY-ORD./REG.-PROG. PINK-ENFORCING OFFICER GOLD-ENFORCING DEPT. -. . _�.. ,.....f.. - .• _.... .: ten.,. TOWN OF BARNSTABLE BAR-Wfl2 Ordinance or Regulation WARNING NOTICE Name of Offender/Manager eAAC41 �., Peg _t1( Address of Offender /07 1t4, 4/ plAtf MV/MB Reg.# r'am Village/State/Zip C ' I±'�l� ,+' '+ (� ,rl� i �-- ' If/ Business Name ��: .�C1 pm; on r . 20,97 Business Address.,; Si gfature of Enforcing Officer Village/State/Zip �� Location of Offense (Cjtu ,r.�C �+ rf�.t1PTfza ,, ► r,.. �7- '�, /* Enforcing/tept/D3 ivi s ion Offense. Facts 34,o/vrC1' Im 41#,,rl rA, 1, tp i4f Lr 0^4441 l ` � y f <<nf ✓D hair p^d e/u f4r,! I'pr .. 1, qb0 07 tjr. 1'kh �(�+�+U This will serve only ad aawarning. At this time no legal action has been taken. It is the goal of Town agencies to achieve voluntary compliance of Town Ordinances, Rules and Regulations. Education efforts and warning notices are f attempts to gain voluntary compliance. Subsequent violations will result in appropriate legal action by the Town. WHITE-OFFENDER CANARY-ORD./REG.-PROG. PINK-ENFORCING OFFICER GOLD-ENFORCING DEPT. TOWN OF BARNSTABLE BAR 'W ` Ordinance or Regulation WARNING NOTICE Name of Offender/Manager �14,-,d pera r,/ Address of Offender b? 1, 4C MV/MB Reg.# Village/State/Zip t i E t i'r x'`. ,'? f, Business Name /, ; fam pm, on r Business Address .°; � �:, - . .U,L' f Signature of Enfb.Ecing Officer Village/State/Zip Location of Offense ""it"s ke"'4.4 SS .,.+ f' • tJ' d�..,'1,' i�E. �, Enf'rcing•`Dept/Division . 1 Offense fr � , , lr' ` t�° t _ T .. Vra ,* 36 Facts � >`t. Ch !✓ttr./' fd#s .fI t �. t Fit Y��4 t'••r^f 1� a :�al '�/r,/?tdi � . i / d t:q; c rt ,.} l ei .�ff c< K { This will serve only as' a� warning. At this time no legal action has been taken. `r It is the goal of Town agencies to achieve voluntary compliance of Town Ordinances, Rules and Regulations. Education efforts and warning notices are attempts to gain voluntary compliance. Subsequent violations will result in appropriate legal action by the Town. WHITE-OFFENDER CANARY-ORD./REG.-PROG. PINK-ENFORCING OFFICER GOLD-ENFORCING DEPT. " �. }€ ._ _ ..... .. _"._- F Stones 11 Story _ Fuel Gas at on Poured Conc. Permit History t IlIssue Date I Purpose I Permit# I Amount Insp Date I Comments Visit History Date Who Purpose 10/28/2002 12:00:00 AM Paul Talbot Meas/Listed 10/25/2001 12:00:00 AM Paul Talbot Meas/Listed 10/1/1996 12:00:00 AM Lloyd Kurtz Meas/Listed - Sales History Line Sale Date Owner Book/Page Sale Price 1 4/5/2002 PEACOCK, RANDY S &ANN MARIE 15020/227 $190,000 2 4/11/2001 DRISCOLL, DAVID & LUMSDEN, KRISTIN 13717/234 $100 3 12/15/1995 DRISCOLL, DAVID A 9952/313 $93,500 4 2/15/1982 KADDY, MARSHA E 3437/303 $19,500 - Assessment His Save# Year Building Value XF Value OB Value Land Value Total Parcel Value 1 2007 $140,200 $0 $0 $118,000 $258,200 2 2006 $123,800 $0 $0 $115,800 $239,600 3 2005 $114,200 $0 $0 $108,600 $222,800 4 2004 $92,700 $0 $0 $86,900 $179,600 5 2003 $88,800 $2,400 $0 $67,100 $158,300 6 2002 $82,400 $2,400 $0 $67,100 $151,900 7 2001 $82,400 $2,400 $0 $67,100 $151,900 8 2000 $64,300 $2,300 $0 $37,500 $104,100 9 1999 $62,900 $2,300 $0 $37,500 $102,700 10 1998 $62,900 $2,300 $0 $37,500 $102,700 11 1997 $71,500 $0 $0 $30,000 $101,500 12 1996 $71,500 $0 $0 $30,000 $101,500 13 1995 $71,500 $0 $0 $30,000 $101,500 14 1994 $67,800 $0 $0 $33,700 $101,500 15 1993 $67,800 $0 $0 $33,700 $101,500 16 1992 $77,100 $0 $0 $37,500 $114,600 17 1991 $79,900 $0 $0 $67,500 $147,400 18 1990 $79,900 $0 $0 $67,500 $147,400 19 1989 $79,900 $0 $0 $67,500 $147,400 20 1988 $59,100 $0 $0 $38,500 $97,600 21 1987 $59,100 $0 $0 $38,500 $97,600 22 1986 $59,100 $0 $0 $38,500 $97,600 Photos i , 6 91trM F. Town of Barnstable t_i11:. 3 LL i..L. pd 3E3 Public Health Division `^ 200 Main Street Hyannis,MA 02601 "� ' YNEV B' 0 2 1 A $ 00.390 0004606238 APR19 2007 MAILED FROM ZIP CODE 02601 k e- Cev4rv1`l e� RETURN TO SENDER NOT ISELIVERADLE AS ADDRESSED UNABLE TO FORWARD BO.: .026C7.L t�O�®O 74' c -CJ53O Q-1E3-O9 UOr [IL ®O� ,l'IFFt�t,�r1sr,�lrrFFai.1fi1FF(/(F�F.�lrrrrr�Fj��FrrJlr.�rrjrlr, � . t It f: fi y.{ _{{ 1(( tF{ 4 i4 a{{{{.i t ti {i tiii 1 it li ii Ft {tt ti tit i I it Hi i TOWN OF BARNSTABLE BAR—W N2 . 3925 Ordinance or Regulation WARNING NOTICE / Name of Offender/Manager eAAd �A ee4,o k Address of Offender 0-7 Kl/�1A i MV/MB Reg.# Village/State/Zip Cei��`I/eT 1m4� (�oZ61 Business Name 2on20� Business Address S nature of En orcing Officer Village/State/Zip / Location of Offense j0 &j?V?'e5r1W �pfve l�P�►�@�Mll� aJ En rcing ept/Division Offense. 8u,yj o A✓lnJ P cc de S7iAfo II e. y 147 Facts jfa o6iervc r# 6�� (.i v' re-'I- ► ry e,/� my-I This will serve only as Alwarning. At thi time ho legal acti n h s been taken It is the goal of Town agencies to achieve voluntary compliance of Town OV- Ordinances, Rules and Regulations. Education efforts and warning notices are ` attempts to gain voluntary compliance. Subsequent violations will result in appropriate legal action by the Town. WHITE-OFFENDER CANARY-ORD./REG.-PROG. PINK-ENFORCING OFFICER GOLD-ENFORCING DEPT. s.. a fQ LOT 9 0.49 I DRISCOLL,DAVID A 101 68 KENNESHAW AVE 00 CENTERVILLE MA 02632tC4 00-0000-000 DRISCOLL, DAVID A 1295 9952/313 0.0 8ui 0.0 0.0 58 KENNESAW AVENUE 0833 0180 VW ®: 0000 0000 4 l 5 < y a t 4 � ' l � lfr RESIDENTIAL PROPERTY MAP NO. LOT NO. FIRE DISTRICT SUMMARY STREET 68 Kennesaw dve• Centerville 4LDGS 21j9 21 C-0 OWNER �� / c `� RECORD OF TRANSFER DATE E1FC PG I.R.S. REMARKS: LAND p G LD T BLDGS. /J 7,5 0 /S6 TOTAL a h2aS LAND F O G G-R - 5m ITu I< E U m BLDGS. a3-24 Xaddy, Robert J. & Marsha E. 4-9-74 2024 179 $36,900 TOTAL /S o (p till LAND BLDGS. P � TOTAL Iv r LAND BLDGS. TOTAL LAND at BLDGS. TOTAL LAND BLDGS. at TOTAL LAND ; BLDGS. INTERIOR INSPECTED: TOTAL �j DATE: 3//3 7y -L ( 2U/]S LAND ACREAGE COMPUTATIONS BLDGS. LAND TYPE # OF ACRES PRICE TOTAL DEPR. VALUE TOTAL HOUSE LOT ' o'j, 2 Q oLi O Q LAND CLEARED FRONT ?4 BLDGS. REAR TOTAL LAND WOODS&SPROUT FRONT REAR BLDGS. WASTE FRONT TOTAL REAR LAND BLDGS. m TOTAL LAND 7 BLDGS. LOT COMPUTATIONS LAND FACTORS TOTAL FRONT DEPTH STREET PRICE DEPTH% FRONT FT.PRICE TOTAL DEPR. COR. INF. VALUE HILLY TOWN SEWER LAND Po/ ROUGH TOWN WATER BLDGS. , HIGH GRAVEL RD. TOTAL LOW DIRT RD. . LAND SWAMPY NO RD. BLDGS. i TOTAL - nc. Blk.Walls Bsmt. Rec.Room St. Shower Bath Bsmt. PURCH. DATE nc. Slab• Bsmt.Garage St:Shower Ext. Walls 1.r PURCH. PRICE. ick Walls Attic Fl.&Stairs Toilet Room Roof RENT ine Walls Fin.Attic Two Fixt. Bath Floors ' :rs INTERIOR FINISH Lavatory Extra wD mt.' �/ '1: 2 3 Sink ' Lam. -?- q70 - Attic r/2 r/4 Plaster - Water Clo. Extra JQ EXTERIOR WALLS Knotty Pine Water Only uble Siding Plywood No Plumbing Bsmt. in. . igle Siding Plasterboard Int.Fin. 418 Shingles TILING nc. Blk. G F P Bath Fl. Heat ce Brk.On Int.Layout ,�/ Bath &Wains; Auto Ht.Unit .� c,LC 03 Int.Cond.. Bath Fl.&Walls � . Veneer Fireplace m. Brk.On HEATING Toilet Rm. Fl. Plumbing lid Com.Brk. Hot Air '�. Toilet Rm.Fl.&Wains. 3 o Tiling -f ,5-60 Steam Toilet Rm. Fl.&Walls anket Ins. Hot Water St.Shower of Ins. Air Cond. Tub Area Total Floor Furn. ROOFING COMPUTATIONS ph. Shingle j/ Pipeless Furn. S.F. god Shingle No Heat /6 0 S.F. s0 5D ,bs. Shingle Oil Burner S.F. '- ate Coal Stoker S.F. e Gas S F OUTBUILDINGS ROOF, TYPE Electric ble Flat S.F. 1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 819 10 MEASURED p Mansard FIREPLACES S.F• Pier Found. Floor imbrel Fireplace Stack i Wall Found. 0. H. Door LISTED FLOORS Fireplace Sgle.Sdg. Roll Roofing nc. LIGHTING Dble.$dg. Shingle Roof 5 DATE rth No Elect. — Shingle Walls Plumbing �,,e 3�13 rdwood ROOMS SOU Cement Blk. Electri 7 z1 c ph.Tile Bsmt. 1st TOTAL Brick Int. Finish PRICED ngle 2nd 3rd FACTOR -- MV REPLACEMENT OCCUPANCY CONSTRUCTION SIZE AREA CLASS AGE REMOD. COO-ND. REPL. VAL. Phy.Dep. PHYS. VALUE Fun�ct.yDep. ACTUAL VAL. a yso o 2 3 2 3750 2 3 4 5 6 7 8 9 ,1 O TOTAL Property Location: 68 KENNESAW AVENUE MAP ID: 249/021/// '�F' Vision ID:17906 Other ID: Bldg#: 1 Card 1 of 1 Print Date: 03/13/2001 Element Cd. Ch. Description Commercial Data Elements Style ype H RanchElement Cd. Ch. Description Model 1 Residential Heat Grade C Average Grade Frame Type Baths/Plumbing Stories 1 1 Story Occupancy 0Ceiling/Wall ooms/Prtns 12 1 Exterior Wall 1 5 Vinyl Siding /o Common Wall 2 Wall Height Roof Structure 3 able/Hip Roof Cover 3 sph/F Gls/Cmp Interior Wall 1 5 Drywall _. �.a .. ..�. � CUAD 2 Element Gode Description tactor " Interior Floor 1 14 Carpet Complex 2 5Vinyl/Asphalt Floor Adj Unit Location Heating Fuel 3 as Heating Type 1 None Number of Units BAS C Type 1 None Number of Levels g BMT 2 %Ownership Bedrooms 3 3 Bedrooms Bathrooms 1 1 Bathroom S%" � M " 10 1 Full unadj.Base Kate 0.00 Total Rooms Rooms ize Adj.Factor 1.08701 ath Type Grade(Q)Index .90 YP Adj.Base Rate 8.70 Kitchen Style Bldg.Value New 5,798 Year Built 960 48 ff.Year Built A)1981 rml Physcl Dep 19 uncnl Obslnc con Obslnc ML-Xblu USA, t pecl.Cond.Code Ja X , pecl Cond% Code Description iulu Singleam en ercti:e �e Overall%Cond. 36 eprec.Bldg Value l2,400 VT Code Description nits Unit rice Yr. Lip Rt %C;nd Apr. Yalue f FFLI Fireplace , , SUMM . . .i, . o e Description LivingArea ross Area Eff. \Area Unit Cost Undeprec. value BAS First Floor789893 BMT Basement Area 0 19344 269 11.75 15,790 WDK Wood Deck 0 192 19 5.81 19115 TtL Gross LivlLease Area i,toizi Rla—g-Va7z- , Property Location: 68 KENNESAW AVENUE MAP ID: 249/021/// Vision ID: 17906 Other ID: Bldg#: 1 Card 1 of 1 Print Date:03/13/2001 -. r; � �� escreption Gode Appraised Value ssesse Value 8 ICENNESHAW AVE 801 SIDNTL 1010 84,800 84, ENTERVILLE,MA 02632 800 IVE DATA-Barn.,MA ccoun an Ret. Tax Dist. 300 Land Ct# er.Prop. #SR VISION Life Estate DL 1 LOT 9 Notes: DL 2 GIS ID: Totatill 51,9001 1519900 wdv1tw1X"1F _ , ~: u- v; MOM AE v <N Uo Assessed Value Yr. Code Assessed value Yr. Loae ASSeSSea value KADDY,MARSHA E 3437/303 02/15/1982 Q I 19,500 , , , 2000 1010 66,6001999 1010 6592001998 1010 65,200 r—Total., IU4,IUU102,7001 Totar-1— 10297U Ulm is signature acknowledges a visitby a ata CoUector or Assessor Year lypelvescription Amount Code Description Number Amount Comm.Int Appraised Bldg.Value(Card) 82,400 Appraised XF(B)Value(Bldg) 2,400 ota: Appraised OB(L)Value(Bldg) 0 pP (Bldg)Appraised Land Value Bl 679100 Special Land Value Total Appraised Card Value 151,900 Total Appraised Parcel Value 151,900 Valuation Method: Cost/Market Valuation etTotal AppraisedParcel a ue , ,• % '01 .T E. e Permit 7D Issue Date lype Description Amount Insp.Date o Gomp. Date Conip. Comments Date 7V Ca. Purposelicesult eas es e a_ .ram �._. ur:, -., __. ,-_ ..` e. .., ....,� r.n •- z 3� ,.,. sin,.. Use Code Description Zone D Frontage Depth nets net rue 1.Pactor actor otes-AdjlSpecia ruing �. net nce an a ue mg a am o es:IU IBLDG 137,U2U.50 67,IUU Total Card an nets ---Parcel Total an rea: —Y.4� Tot-a-n and Value , to o No.0 W' 'I ! Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZIpprication for Mtgogaf *pgtem Congtruction 3permit Application for a Permit to Construct( )Repair(X/Upgrade( )Abandon( ) El Complete System Itdividual Components Location Address or Lot No.I06 Owner's Name,Add re and Tel.No. Assessor's Map/Parcel �p (�A" S�U�� Inst N e,Address,and T Np. �"' Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms 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 lS % gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank S!(�� Type of S.A.S. �.G t T Description of Soil Nature of Repairs or Alte ations(Answer when applicable) �`�7�y7s OLA qi Z EL l `Z Date last inspected: ��/ y- 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 Environment Code an�not place the system in operation until a Certifi- cate of Compliance has b y is o Signed Date 0 Application Approved by Wl"P b4 Date "3 G Application Disapproved for the following reasons Permit.No. o2m) Date Issued Lo o 4 fi No. Fee Entered in computer:_ THE COMMONWEALTH OF MASSACHUSETTS p Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Zipphratton for Miopozar *p!tem Construction Verna Application for a Permit to Construct( )Repair( Apgrade( )Abandon( ) ❑Complete System LNdividual Components Location Address or Lot No. K �Qcw�C Owner's Name,Addres and Tel.No. WV Assessor's Map/Parcel ` , �-� G Install N e,Add�ss,�T�Ne� � Designer's:Name,Address and Tel.No. ✓ ,,.( Type of Building: Dwelling No.of Bedrooms :�3 Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures t Design Flow , X� gallons per day. Calculated daily flow `) gallons. Plan Date r Number of sheets Revision Date Title Size of Septic Tank �eQ. So �Jc Type of S.A.S. A+ �a c t?1 - •i Description of Soil Nature of Repairs or Alterations(Answer when applicable) ' r&t C,-T /d..k i A 5�Io V7S lam.. W � t t 0 ( ,r' -fir-6 XZ „Date last inspected: �e �� i�d/�-Gt 1�7 f 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 Environmenta Code and not to place the system in operation until a Certifi- cate of Compliance has been!•issedbytt his Signed Border e .: Date 1�1 1''o Application Approved by V, ,C�ti.j 4_A'P lJ Date AlG Application Disapproved for the following reasons F Permit No. -9 cc Date Issued .�I)Cp l o --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO C t the On-site Sewa {Disposal System Constructed( )Repaired( ) Upgraded Abandoned( )by �r rr n;A �. t at --has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 9QQ) "Ao/ dated 2 Installer Designer The issuance of this permit shall not be construed as a guarantee that the system will function as designed. a Date l f 9 n Inspector CLi _7z l �i , LA io)_I --------------------------------------- No. �QU I'j Lp / Fee SD THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Migponl 6potem construction Vermit Permission is hereby granted to Construct( )Repair( )Upgrade( Abandon( ) System located at 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 must be completed within three years of the date of this permit._. Date: Approved by,_ V,6v(,, PH % P 1/6/9g i .r NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL V WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) hereby certify that the application for disposal work Pp p s construction permit signed by me dated �j" �—O) , concerning the property located atY�,N2a go,uJ A.(,e—, meets all of the following criteria: —• This failed system is connected to a residential dwelling only. There are no commercial or business / uses associated with the dwelling. v• The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. There are no wetlands within 100 feet of the proposed septic system There are no private wells within 150 feet of the proposed septic system _*-""There is no increase in flow and/or change in use proposed There are no variances requested or needed. �'T'he bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation..[Adjust the groundwater table using the Frimptor method when applicable] / I the S.A.S.will be located with 250 feet of any vegetated wetlands,the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation (using GIS information) r B) G.W. Elevation �206oJ+the MAX. High G.W.Adjustment.,?, DIFFERENCE BETWEEN A and B SIGNED : DATE: Q [Please Sketch pr o .d plan of system ]. 'NOTICE Based upon the above information, a repair permit will be issued for bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system plans. q:health folder:cert f ow [r w 17 7 SFr w �4 140 I ELL �oGA�'bf� 4 TOWN OF BARNSTABLE j LOCATION SEWAGE # - VILLAGE n ASSESSO MAP & LOT INSTALLER'S NAME&PHONE NO. d�. ✓ s j SEPTIC TANK CAPACITY ) i s7"✓n-:�— ((lIJO�r'.i(� L-j LEACHING FACILITY: (type) _��'S J��i��t!ili T r C,( (size) ��1� T NO. OF BEDROOMS_ \ BUILDER OR OWNER r\S(f o 1 PERMITDATE: 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);` eet Furnished by ir�;Ttn� a 13A, : I $ ! No...... r Il E Ftms...,,..�......... L. Ala r i1 LTHI ;COMMONWEALTH OF MASSACHUSETTS �;BOARD OF HEALTH ..-----....OF..........J.X.... ............... tiri illy' flan BiiiVaoal orko Towitrurtiun Prrmi# Application is hereby,imade for a'Permit to Construct (�or Repair ( ) an Individual Sewage Disposal System a Ili -•.. ... . ._. .. z ` . L tion• ddress . �'//d4e-4 � or Lo._.......f.. ` -- --f!.!:...naare55 - - --- ------.... . Wq L Q Type g , `Installer I' C�j _ .�' —Address I , Size Lot...a�f__ .............Sq. feet U ��'`. . e o Butldii} Dwelling No. of Bedrooms..::.................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Buildin No. of persons............................ Showers — Cafeteria Pk g P ( ) ( ) i,. Other fixtures .... . .:. - W Design Flow................ �. allons allons per person per day. Total dailyflow.-. �� ..gallons. W Septic Tank -Li uid ca acity� Length................ Width.... Diameter..___._...._.... Depth................ P q P x . Disposal Trench—No. .....:1..............jWid _.___.___. _ Total Length._______..___.-___ Total leaching area.................... ft. T ..._ 3 Seepage Pit No.�_..........`1._L �r: :._. ..!..L... Depth below inlet_.��r__._.___.._. Total leaching areas 0 q7- ft. Diamete z Other Percolation r1bution boxTest Results ;> Performed' Dosing1tank ( ) bY-----•_• ----•-•---••--•---- Date--•----•--•----•------------•--•-------- HTest Pit No.1......_..-::1...minutes,per inch Depth of Test Pit.................... Depth to ground water------------------------ rZ4 Test Pit No. 2..........___ .minutes per inch Depth of Test Pit.................... Depth to ground water-___.___.__-___--____._. a ... ...... -- - ------------- D Description of Soil------------------ .-- + U Nature of Repairs or ....Alterations—'Answer when applicable.-------------------•--_---------•_--_-________-___-___-____-________.__-__..____:___________--- �.: •------•--•--•---•----------------------------------------------------•--•-------------------------- �r: If Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI 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 bo d of health. l+:k; 11:, tgned.li� ( 3j7. •--------- ti• .I I Date Application Approved BY - J.=� �`V ----- - - •-- • .................................................... -------- Date----- Application Disapproved r f or the.f ollowznq reasons:............................................ ------ ----------- ----------- ! Date PermitN.............�:,,; -------•----------------- Issued-- ---._��- ..-- ----•--------------•---- F D e I:`T -COMMONWEALTH,OF MASSACHU.SErTS ,I BOARD OF HEALTH .. F. ........ .... ........... II i O, THIS IS TO CE FY' hats e Individual Se Disposal Syst constructed ( or Repaired by.-----. v- I, S r&! "' staller ............................................................. , y� "Foi/ has been installed in accordance wiff the provisions of Article XI of The t to Sanitary Cod as d cribed in the 1 application for Disposal Works ont'truction Permit No.............................1. _ __ dated.__, �e =_: �: .._........._.. l; THE ISSUANCE O ?THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARA EE THAT THE , ;.I SYSTEM W L UNCT N SATISFACTORY. . ..., DATE a Q f�`t Inspector -----� i�............. ...... , , 3 Im"i '' THE COMMONWEALTH OF MASSACHUSETTS t s J* ` '!` BOARD F HEALTH �� F � pit, ;.....:.. -------- •----t�•.. ...... ....... ........ •---...... u ................. FEE. ..... ...... °rs r 1 'd` O' •• ��ttl_ rk� Cnita� .fr�tCtilt i Permission t hereby granteds t� 3:.___ ___ _. .--...._.. to Consgttor Rep i (' )fan Individual S age Dispo Syst n I} 1 at No.: -- = I {.-, Street r - I I 4 �t I. as shown on the a hcatio :for Dis sal Works Corisfruction P it"N1 ;._ Dated:--'.- A5_ _..___ .�.. PP p ! `"�"/� h ttrtBoard of Health I f I it y DATE .. ............ i 111 l FORM' 1255. HOBBS & WARREN aINC., !11LSHERS'r. -fir OfTHETo�♦ TOWN' OF BARNSTABLE • HAHd9TADLE, i NAM i639 .� INSPECT MPYa� BUILDINGOR APPLICATION �- LIGATION FOR PERMIT TO 0 .. -; TYPE OF CONSTRUCTION r.:.................. ......................................................................... ....... • gyp .. TO THE INSPECTOR OF BUILDINGS: =The undersigned hereby applies for a permit according to the following information: Location ... '��:.!Z. ..'�: Q Proposed Use 4... `� Zoning District .......... Fire District .... �-/:"t?:.. i .n..Vl /•G ......................... Name of Owner 4 ...I�A... ............Address f Nameof Builder ....................................................................Address ......................... .. ..................................................... Nameof Architect ................ .................................................Address ....................................................... Number of Rooms ........6 ....................................................... AI P .. . Foundation ..�d. ...:r.c�a—1 1.s...................... ExteriorQ.l1. „�j, , Q:4V:.h.....t............ ? ..................Roofing {?. ! FloorsGi.t�. { . ......................................................... Interior .. �. ,h ...r.d..�,...5.......... Heating ,r` .a �I.. .�/ .I�.r... .. ..... .. ...CP. .!' ..`.:1.. 4..`� Plumbing ..... .?':'... ."�..i.�.��J:�...9`..1�.�.�•. Fireplace ...... ..` . 5.... ......./...........................................Approximate Cost 6' Definitive Plan Approved by Planning Board -----------—_--_-__--------- Diagram of Lot and Building with Dimensibns SUBJECT TO APPROVAL OF BOARD OF HEALTH 1/ SEPTIC SYSTEM MUST BE INSTALLED IN COMPLIANCE 'WITH ARTICLE II STATE SANITARY CODE AND TOWN REGULATIONS. O Ll V A. I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the a ove construction. �� Name ..7(�..��:. Johnson, V$lliam i-": one story., : No .. Permit for ..................... ... .single family dwelling .... .. .................................. ° Kennesaw Ave* : +<1 ry � Location ...........................:.................................... 4. V <-� u e Centervi - _ -------_ Owner ........... 1118?!► .................... ..... frame Type of Construction .......................... ... .... ..... ...... .. ... .' �' I >. .•aj ry Plot ........................... Lot ................................ March ^ 19 73 �rm' Granted ............ .. ... a o nspection f. [ -- Date Completed . ,...................19 - s f; �3yy PERMIT REFUSED'' ............. 19 ......................................... yet:...................... � .......... ..................... .......... F f - .......................................................... ....`.. % .................................. .................... .� 1. f,\1 F - .r.J.•r .- _ n k1 _ Approved ..... ............. ....... 19 "� 1.. �:�' ✓ .................... ......... • .. .. S^;"..�, ..�'� •� \ _' Gam- / V 1Q 9 BORTOLOTTI CONSTRUCTION,INC. /VO 765 WAKEBY ROAD,MARSTONS MILLS,MA 02648 508-771-9399 508-428-8926 FAX: 508428-9399 'v SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM "'468 WLa PART A CERTIFICATION S+ Property Address: A U Date of Inspection: - - u'— Inspector's Nanie: Owner's Name an Address: ��7 CERTIFICATION STATEMENT• I certify that I have personally inspected the sewage disposal system at this address and that the informa- tion reported below is true,accurate and complete as of the time of inspection.The inspection was per- formed based on my training and experience in the proper function and maintenance of on-site sewage disposal tems. The System: •�5 ; Passes Conditionally Passes Needs Further Ev uation By tl e L cal Aproving Authority Ins Fails NO fC��FQ Inspector's Signature: �— g Date: // a7 c The System Inspector 8 1,99d y shall submit a copy of this inspection report to the Approving authority within f' P4. Pl? g ty ,... r ` ty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10, 011 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional 4 ` 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. INSPECTION MMARV• A)SYST"PASSES: 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. B)SYSTEM CONDITIONALLY PASSES; One or more system components need to be replaced or repaired. The system,upon comple- tion of the replacement or repair,passes inspection. Indicate yes, nor,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,cracked,structurally unsound,shows substantial infiltration or exfrltration,or tank failure is imminent. The system will pass inspection if the existing sep- tic tank is replaced with a conforming septic tank as approved by The Board of Health. Sewage backkup 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): - 1 - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Broken pipe(s)replaced Obstruction is removed Distribution Box is levelled or replaced '!. The System required pumping more than four times a year due to broken or obstructed pipe(s). The stem will ass inspection if with approval of The Board of Health): system P Pe ( pP Broken pipe(s)are replaced Obstruction is removed C)FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: 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 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 water Cesspool or privy is within 50 Feet of a bordering vegetated wetland or a salt marsh. 2 SYSTEM Y TEM WILL FAIL UNLESS THE BOARD OF HEALTH .(AND PUBLIC WATER ; ti SUPPLIER,IF APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTION- ING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY ANWTHE 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 with 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 analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal'to.or less than 5 ppm. xG.. D)SYSTEM FAILS: } I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool Discharge or ponding of efluent 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 overloaded or clog- ged 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 -2- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) 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 a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 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: The following criteria apply to a large system in addition to the criteria above: The design flow of a 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 II of a public water supply well. The owner or operator of any such system shall bring the system and facility into full compliance 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 Check if the following have been done: Pumping information was requested of the owner,occupant,and Board of Health. P"None of the system components have been pumped for atleast 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. r/As-built plans have been obtained and examined. Note if they are not available with N/A. -The facility or dwelling was inspected for signs of sewage back-up. _e-The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. -'All system components,excluding the Soil Absorption System,have been located on site. !/`The septic tank manholes were uncovered,opened,and the interior of the septic tank was in- spected for condition of baffles or tees,material of construction,dimensions,depth ofliquid, depth of sludge,depth of scum. The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. -3- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST(continued) V The facility owner(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 / FLOW CONDITIONS RESIDENTIAL v Design Flow: 3'30 gallons Number of Bedrooms: 3 Number of Current Residents: Garbage Grinder: Laundry Connected To System: Seasonal Use: Water Meter Readings, if available: Last Date of Occupancy: $19.5- COMMERCIAL D 1ST IA 1/Q Type of Establishment: Design Flow: gallons/day Grease Trap Present: (yes or no) Industrial Waste Holding Tank Present: Non-Sanitary Waste Discharged To The Title V System: Water Meter Readings,If Available: Last Date of Occupancy: OTHER: Describe) Last Date of Occupancy: GENERAL INFORMATION PUMPING RECORDS and source of infornrati n > System Pumped as part of inspection:_ If yes,volume umped: gallons Reason for pumping: TYPE OF SYSTEM: Septic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy Shared System(If es,attach previous inspection records, if any) Other(explain):,, y,-,. AP OXIMATE AGE of all components,date installed(if known)and source of information: Sewage odors detected when arriving at the site: -4- i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C GENERAL INFORMATION (continued) SEPTIC TANK: Depth below grade: Material of Construction: concrete metal FRP Other (explain) — Dimisions:$,5'X(� , V�i Sludge Depth: 4 7 Scum Th#kness: Distance from top of sludge to bottom of outlet tee or baffle: 3 L/ Distance from bottom of scum to bottom of outlet tee o_r baffle: N10�te Comments: (recommendation for pumping,'condition of inlet and outlet tees or baffles,d�UZliquid level in relatio to outlet invert,structural inte rity evidence of leakage etc.) per, G GREASE TRAP: M Depth Below Grade: Material of Construction:—concrete—metal—FRP Other (explain) — Dimensions: Scum Thickness: Distance from top of scum to top 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 TANK: Depth Below Grade: Material of Construction:—concrete—metal—FRP Other(explain) Dimensions: Capacity: gallons Design Flow: gallons/day Alarm Level: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX:Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) PUMP CHAMBER:_ Pump is in working order: Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) -5- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) SOIL ABSORPTION SYSTEM(SAS): (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: J Leaching chambers, number: Leaching galleries,number: Leaching trenches, number, length: Leaching fields,number,dimensions: Overflow cesspool,number: Comments: (note condition of soil igns of hydraulic failure level of pw4ing,condition of vegetation, / 6jtgs %� _ /7o s s. p j �.POPM CESSPOOLS: 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 soilk,signs of hydraulic failure, level of ponding,condition of vegetation, etc.) d a PRIVY•,L�1�(_f s Materials of construction: Dimensions: Depth of Solids: Comments: (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, ' etc.) -6- I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent references,landmarks or benchmarks. Locate all wells within 100 Feet. a' DEPTH TO GROUNDWATER: Depth to groundwater: Feet Method of Determination or Approximation: -7- 7 �en o e-sa� . 0 a . • � o 6 A o cp v , * o t wn 't No.----- .......... FicE..., .. ........ THE COMMONWEALTH OF MASSACHUSETTS BOARD OFF HEALTH �I� -----�j"'V , ................OF...............1v... --- -- -41---- ---..'.-... Appliration for Disposal Works Tnni#rnrtion Prrutit Application is hereby�jxnaoe for a Permit to Cons uct (41 or Repair ( ) an Individual Sewage Disposal System PM ,_ 6'......2 � ==! ---------------- Lo tion- ddress or Lot • = ----------ys Z� .....,. Address W Installer ddress Q Type of Building/ Size Lot__ f._��___Sq. feet U Dwelling No. of Bedrooms---------- _Expansion Attic ( ) Garbage Grinder ( ) p-, Other—Type of Building ____________________________ No. of persons..................._-------- Showers ( ) — Cafeteria ( ) P. Other fixtures ...................................................... W Design Flow..................... __ _ allons per person per day. Total dailyflow.__ �� allons. WSeptic Tank�Liquid capacity ____ allons Len-th................ Width---------------- Diameter................ Depth......_......... x Disposal Trench—No_____________________ NA`id �_____.__._T. ........ Total Length_______............ Total leaching area....................sq. ft. Seepage Pit No,/---------------- Diameter_ !_.F.�_. Depth below inlet__4____-________ Total leaching area_ 62-n.sq. ft. z Other Distribution box ( ) Dosingltank ( ) aPercolation Test Results Performed bY........�:---------- --•-•-••--••-------------•---------------•--••-•---•-- Date-------------------------------------- a Test Pit No- 1________________minutes per inch Depth of Test Pit.................... Depth to ground water....-................... G=, Test Pit No. 2................minutes per inch Depth of Test Pit____________________ Depth to ground water------------------------ ODescription of Soil................... �+.�,,�11--- ---- + ----------___.---___._----------------------------------------------------- x W x -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 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 Article XI 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 bo rd of health. igned- --•- ----------•--•• '3-- ---------- �iDate Application Approved By........•- 7-3-------- Date Application Disapproved for the following reasons: ---------- -••••-•••••-----------••----••-•-•--------•-•- ----------------------------------------------------------------------------------------------------------- ••••--------- ----------------------------- Date Permit No........................................................ Issued--�f'----��-...... ----�"--'-------------- D e No.-----I -........... Fmrc... .................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .-..........O F.......... ---------- Apphration for Uhipooal Wore Tomlrurtillu Vrrtnit Application is hereby made for a Permit to Construct ( or Repair ( ) an- "Individual Sewage Disposal System a,, ,, " 6 Z !+t�y��y Lo ation ddress p� , fa or Lot, B � ca..--- ----- :.. ' -----_-----�= �1aZ.r_ t f` •��"y�'=�'ly ---Address nstaller Address Q Type of Building Size Lot_..�_�__ t � -- --- feet U Dwelling'. No. of Bedrooms____ _____ ___ _______ ___________Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............................. No. of persons............................ Showers ( ) — Cafeteria ( ) Q Other fixtures W Design0Flow••__________________L _ tllons er erson er d a . Total dai] t3ow___ � gallons. WSeptic Tank I—Liquid capacity/ Z2 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_•2 __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---..___--_____-----.-.. 44 Test Pit No. 2................minutes per inch Depth of Test Pit..................... Depth to ground water________________________ W --•••---••- ---- ------------I--------• ---------- ODescription of Soil------------------- � I.,.. z"( `Z -- ---------------------------------------------------------------------------- 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 Article XI 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. N 3' igned l G, _ ta.i =---------------------------- '�''�"., --------- Date Application Approved BY ;..- 01� . ... ---------- Date Application Disapproved for the following reasons:................................................................................................................ -•-•------•-•----•------••-••---•------------•--•-•-_...-•---•----•••••-•-•--•-----------------•-•----------•---•--••-•------._._._.__-•-•---•---------------.__......--- / - Date PermitNo..................::_..................................... Issued-_-----_---_---- ................................. Date' THE-COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ' ea...............OF.............. ...... �rrfif irab of Tontplitturr THIS IS TO CE IFY, hat e Individual Se Disposal Syst constructed ( or Repaired ( ) A.=� . 9 mr{J97_ staller A �... has been installed in accordance with the provisions of Article XI of The St4te Sanitary Code✓as described in the application for Disposal Works Construction Permit No '11_ ....--- dated--- ........... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARA EE THAT THE SYSTEM . L UNCT N SATISFACTORY. DATE.... Q y� ..................................... Inspector•- THE COMMONWEALTH OF MASSACHUSETTS BOARD 9F HEALTH ' � ;. . ....OF...... ..-i �4"` .......................•- No.....1� ...... FEE- - _..._. io �al ork Cott trnxtott rrntt antePermission ishereby gr ;x d € a-` ____ .. to Consttxklt or Rep ( ') an Individual Swage Dispo , Syst ��" at No. ...-• ` X j e s.� fj/ / �6 3 °- f s ---- ------ �< Street as shown on the application for Disposal Works Construction P it N� � D ited ,. ..... r._._..._-- - Board of Health DATE................ ........... :...........................•....... FORM 1255 HOBBS & WARREN. INC., PUBLISHERS