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HomeMy WebLinkAbout0033 LAZARUS LOVELL ROAD - Health (3) ti 33 Lazarus Lovell Centerville A= 171 - 155 - __ Y.__._ . __, 3 No. ° �O� � � Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: \"'✓�1_i� PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ftphLotion for 11isposal *pstrm Const union V¢rmit Application for a Permit to Construct( ) Repair Q�j Upgrade( ) Abandon( ) []Complete System E/n"dividual Components Location Address or Lot No.33 (A2AR,�S U a((grn1 kb. Owner's Name,Address,and Tel.No. Assessor's Map/Parcel 1 I I SS d`�C)v� l Tv D`1 TO^ L Installer's Name,Address,and Tel.No 0S -y 1-1 " 2 V )-1 Designer's Name,Address,and Tel.No: (Zl,A�.r � ev2 Co 3(c 3 L-a h Jcj pa� Z o ZTO `A-YLv.oJt'1A 0 z.l(e'-t Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures P Design Flow(min.required) kj gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) �SsVr}II At-w bR3 H10 Box LA. ristr /A-N Co.m_. (, cfotiJ Grz&DE Date last inspected: Agreement: The undersigned agrees to ensure the construction maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Enviro de and not to lace a system in operation until a Certificate of Compliance has been issued by this Board o alth Signed Date o l 2 r 2 Application Approved by Date Application Disapproved by 01 Date for the following reasons Permit No. — 3 a I Date Issued 1" . ! AI 4 fir., -wpm !�f �..I..`�a .. ... •.� f l '"'' '''� No. Fee /J THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ✓ PUBLIC HEALTH DIVISION-TOWN OF BARNSTABLE, MASSACHUSETTS Yes 0[ppfication for 33isposaf tent Construction permit Application for a Permit to Construct( ) Repair N Upgrade( ) Abandon( ) ❑Complete System [Individual Components i. u � Location Address or Lot No.33 LAZAR,�S G-4-0 k kb. Owner's Name,Address,and Tel.No. + Assessor's Map/Parcel 1 I Ss "'i b S u b s ro'� L Installer's Name,Address,and Tel.No. SH _1-1"� ' '1 `1 Designer's,Name,Address,and Tel.No. Type of Building: ��5 Dwelling No.of Bedrooms �f� Lot Size sq.ft. Garbage Grinder( ) , a } Other Type of Building No.of Persons Showers( ) Cafeteria( ) ` Other Fixtures Design Flow(min.required) �}' gpd Design flow provided I,)) gpd Plan Date Number of sheets Revision Date '.T• i�, Title + Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) r_<,��1►1 Y1tw boa H10 evi is. rl(f%r lk►.4+> <o,`Ce. Jicicc.1 ` 6144DC' k � ' Date last inspected: Agreement: The undersigned agrees to ensure the construction an&maintenance of the afore described opi-site sewage disposal system in accordance with the provisions of Title 5 of the Envirom�tal ode and not to lace the system in operation until a Certificate.of Compliance has been issued by this Board I�Health Signed / � - Date �� ' 2 Application Approved by ram-If _ Date rL!r��'" Application Disapproved by Date for-thefollowing reasons Permit No. 0 ! Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed(I ) Repaired( ) Upgraded( ) Abandoned( )by / at r'j 'IC- 7 c.) (+ has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. ;109 1^ V dated Installer Designer #bedrooms N 1,4- Approved design flow Alf/¢' gpd The issuance of this permi"hall not be constru ed as a guarantee that the system will-function as designed Date r '�!"` Inspector No. '�d i 1 0 L/ Fee THE COMMONWEALTH OF MASSACHUSETTS our PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposaf *pstem Construction Permit Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon Systern located at L t? crv., L,� and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction most be cPmpleted within three years of the date of this permit. Date 1 t t l Approved by L t�V rr Y CO,-MI MONVYEAL;TH O:F MASSACHUSETTS s 'EXECUTIVE OFFICE OF ENVIRON1wIENTALAFFA>RS.9j = 1"EiAF�TI4IE2*TT OFNUIR'ONIVIENTAL PROTECTION V V TITLE 5 OFFICI_A:INSPECTION FORM—NOT,FOR VOLUNTARP ASSESSM>✓NTS SUBSURFACE SEWAGE.DISPOSAL SYSTEM FORM. PART A CERTIFICATION ' Property.:Address: ® A Owner's Name ' Owner's Address: Date Hof Inspections: . Name of Inspec# (p;eas�pint �) r�1 ` , Company Name - �� fi'Iailing Address: Telephone Numbe:: (� CERTIFI'CATI.ON STATEMENT � I.certify that I have per sonally`insp'ected the sewage disposal•s.ystem at this address and'that the 'nformat�on repcited below is true,accurate and complete as of the time of the inspection.The inspection was perfo ed basS-d=on nP) training and-experience.in the proper function and maintenance of onsite sewage disposal syRre' ns. I ani�D.Ef?t; -approved system inspector pursuant#.o Section X5:340 ofTitle.5=(3.YO CIIIR 15:000) The-slystem: ca "^ Passes. Conditionally Passes. .. N _i Needs Further Evaluation.by the.:L•ocal Approving_A thorityp w ails pti Insp:ector's Sigtatxt e:. Date:. A6 07 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board-of Health or DEP):within'0 days of completing this.inspection. If the system:is.a shared system or has a design flow of 10,000 gpd of greater,the inspector and the system owner shall submit the report to the appropriate regional office-of the DEP,'The orieinal shouldbe sent to the systern owner and copies sent to the busier, if applicable, and the approving authority. Notes and-Comments ****This report only describes.conditions at the time of inspection•and under.the coDditions:of use at that time.,This inspection does not address"how the system will perform in the future under the same or different conditions of use. Title:5'Inspection Form 6715l2000 page 1 Page:2.of I .OFFICIAL WP.ECTIO=MFO—RM:_NOT FOR VOLTJI",TARY ASSESSMENTS.- SUBSURFACE-SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A. CERTIFICATION (continued) )'roperty A ..ress: l & . Owner:. / Date of inspectio &?7WIC���•,.�..� � y� Irspection�Summary: .Check A,B',C,D or E/ALWAYS complete.all of Section.D A. System Passes: I have not found any information whi ch.indicates that any of the failure cnter.•a:described in 310:CMR l-5303"or in310 C141R 15.304 exist.Any failure criteria.not evaluated are indicated below. Comments: B. System Conditionally Passes: 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, Nill-pass. Answer yes,no or not determined(Y,N;NID)in the for.the following statements. if"not determined:'please explain. ; The septic,tank is metal'and.:o:ver,2..0 years:ol&%or.the septic tank(whether metal or.not)is structurally unsound,exhibits substantial.infiltration ot.exfiltratioii or.iank failure is imminent.System will pass inspection if the existing tank is replaced with-a.complying septic-tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is I;ess than 20.years old is available: ND explain: Observation of sewage..backup-or break out.or high static water level in the distribution box due to broken or: obstructed'pipe(s).or due to a broken,.settled or uneven distribution box. System will pass inspection if(with approval of Board..of Health): broken pipe(s).are replaced. T obstruction is-removed distribution:;box is leveled or replaced ND explain: The system required pumping more than:4 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 remo.yed ND explain: Fagg 3 of 11 OFFICIAL IN' SPE CTION FORM.-.N.OT F OR VOLUNTARY ASSESSMENTS SUBSURKkCE SE`WA.GE..DISPOS . SYSTEMJNSPECTION"Fb'RM PART'A.. CERTIFICATION,(continued) `Property dress; ..Owner: bate oflnspectio , C. Further.Fvaluation is Required by.the Board.of Health: Conditions exist which require fiu-ther evaluation by the.Board of Health'in order,to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15:303(1)(b)that the system is not functioning in a manner yyhich will'protect:pubiic health,safety and the environment: Cesspool or privy is within 50'feet of a'surface water Cesspool arpn .is within 50 feet of a bordering vegetated wetland or'a salvmarsh 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. rotects the public health,safety.and environment: _ The.system has a septic tank andsoil absorption system (SAS)and the SAS±is.within 100`feet of a. surface water supply.ortributar -to a surface wate'r:supply: The system has aseptic tank and SAS and the'SAS;is`.within°a.Zone 1­of.apublic.water supply. _ The system has a septic tank and SAS and the SAS i's..within 50.feet of a.private,water-supply well. _ Tlie system.has a septic tank:and SAS and the.SAS is.less than 100 feet but'50 feet or more from a private water supply well". Method used to determine,distance d *This system.passes if the well water,analysis;performed at a DEP certified-laboratory, 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 nitro.geri is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis:must be attached to this.form, 3. Other: - 3. Page 4.of.1 k O..FFIC�AL IId;SPEC:TION;FOR:[i�I-.,NOT"E:OIL: '�01��`J.T�d'�'A�:Y �.S�ESS�YIEN`�'S SUBSURFACE.SEWAGE I)ISPG'S .SYSTEM-I SPECTION.FORIM PART A CERTIFICATION(continued): Property.Address.,(.' Z)_ Dpj e, iJ- ,p 22 C owner: Date of Inspecti n•. D. System Failure-.Criteria applicable.to al1systems: You must indicate "yes"or"no"to each.of the-.fallowing for all inspections: Yes No/ _ t! Backup of;sewage into,facility,:or system component due to.overloaded:or clogged SAS or..cesspool Discbarae.or pondmg'of effluent to the.surface;4fthe ground.or surface waters-.due to an overloaded or clogged SAS or cesspool 1/ Static liquid 1'ev.eI Jn the distribution:box above..outlet.invert due to an-over]oaded: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. ' 1/ of-times pumped Any portion of the.SAS,cesspool or privy is..below high ground water elevation. Any:portion of cesspool'.or privy is.within.1,00�feetof a.surface,water supply or tributary to.a.surface water.supply:; _ Any portion of a cesspcol.or.privy,is withima Zone 1 of a:public well. _ Any portion of a:.cesspool.or privy is-within.50-feet oft:-private water supply well:: ' Any portion of a cesspool oriprivy feet but.greaterthan.50 feet from a private water supply well with:no acceptable.-water quality,analysis:.[This system passes-if:the,well water analysis, performed a.t:.a AEP certified laboratory;for coliform.ba.cteria and::volatile,arganic compounds indicates that the.weli is free from pollution from that.facility and the,`presence,of ammonia nitrogen andlnitr:a.te nifrogen.is equal.to or Jess than 5 ppm,provided that no:other failure criteria are triggered:,A.copy-of the analysi".must-be attached to:this form.l (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as. describe&in 3:10 CMR 15.303,therefore,the system fails.-The.system owner should contact the Board of Health to determine what-will be necessary to correctthe:failure. E. Large:Systems: To be considered a large;system the system must serve:a facility with a design flow of 10,000:gpd to.1.5,000 gpd You must indicate either"yes" or"no"to each of the following: (The following criteria.apply to large systems.in addition to the criteria above) yes no - the system is within.4.00 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. If.you have;answered".yes"to any question in.Section.E the system is considered a significant,threat, or answered-, "yes in Section D above the large systern has failed.The owner or operator of any large system considered a significant threat.:under Section E or failed under Section D shall upgrade the system•in accordance with 3.10 CMR 15.304.The system owner:,should contact.the appropriate:regional office of the Department. Page S of 1.1 OFFICIAL ENSPECTIO . 1- OR.M ' NQT FOR"�VOLiNTARY"ASSESSII ENTS SU 3SIIRF E'SE A E D SPOSIA- SYSTEM INSPECTION FOR:iVZ p'ARTB CIECMLIST Property dress: ' !d Own er: _ Date of Inspectio Check if the following have.b6en done..YYou.must indicate`yes""or"no"as.to each of the following: Yes. -o ` Pumping:information-was.provided by the owner,.occupant, or Board'of Health: /"Were any of the system components pumped out in the previous two weeks V Has the system received normal flows in the previous two week period? 7 Have large volumes of water been introduced to the system recently or-as. art of this insPpection.? 7— P. Were as built plans ofthe system obtained and examined? (1f they were'not available*note as N/A) V/_ Was the facility or dwelling inspected for signs of sewage back up Was the site inspected for signs of break out? y Were all system components, excluding-the SAS,.located on site V_ Were the septic tank.manholes uncovered, opened, and the interior-of the tank inspected for the condition of thhe baffles ortees, material of construction, dimensions, depth-of liquid,.depth of sludgella_nd.depth of-scum`;) . G/ Was the facility owner(and occupants if different from owner)'provided with information.on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil_Absorpfion System'(SAS) on the-site has been'determined based on: Yes- no Existing information.For example, a plan at the Board of Health.. _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance Unacceptable) [3 10 CMfi 15 302 Page 6 of I 1. OF I�ZAL.INSPECTIONFO:�S �NOT'FoR VOLUNTARY.ASSESSMENTS, BSURk+'AGEEWA SGE;�ZSP.OS.t L SIT SXSTEM I�d.SPI1C'fd0N FORIM PART:C SYSTEMT INFORMATIOi`d WProperty`�'ddYessr '-�Owner:Date,of nspecti7DITIONS RESIDENTIAL Number of bedrooms{design): Number of bedrooms.(actuaI).:. DESIGN flow:based on`310 5.20 ample: 11;0 gpd x M of bedrooms): Number.of current resid'ents:. Does residence have a car•bage grinder(yes or no):/+<("a Is laundry on.a se a arate!sewae p system..( or no):_/�[if yes:separate inspection required] Laundry system inspected(ye .or no):. . .. Seasonal:use: (yes orna): N _ ( y (-P )) ®D®© Water meter.readings if a.v Table -last 2 ears.usaQe: d .:.(�✓` _ �� is Sump-pump (yes or no) y /�� � / Last date of occupancy; Q, / ,. ��fY� . J y/ COMNIERCIAL/INDUSTRIAL Type of.establishment:, •rid �� Design flow(based on 110 CMRA5.203): apd' Basis of-design flow(seats/persons/sgft,etc.):.- 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 readin.2s. if available:- Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: r Was system pumped as part ofthe.i specfion(ye r no): t) If yes, volume pumped:_ gallons--How was quantity pumped determined? Reason.for pumping: TY OF SYSTEM Sepiic Tank,distribution box,soil absorption,system _Sinale cesspool —Overflow cesspool Privy - _Shared system.(yes.or no)(if yes, attach previous inspection records,.if airy) _Innovative/Alternative technology:Attach a copy of the.current operation and maintenance contract(to be obtained from system'owner) —Tight tank: _A:ttach.a copy`of the DEP.approval _.Other(describe): Approximate age of all components, date installed(if known) and source of information: Were sewage odors,-detected when.arriving at the.site(.yes or no);,� Page 7 of 17 OFFICIAL INSP CTI'ON FORM-NOT FOR�V'OLU.NTARY ASSESS1v1ElvTS SUBSTJRFAcF SF'4VAGE DISP6SAL:8 -STEM-IM PECTrON F.6RM: I'ART:.0 SYSTENI.I-NFORM-,kTTON(continued) Property Address: ,j ld?06-61 44 Owner: Date of 7nspectio BUILDING SEWER(locate on site plan)_1/0 Depth below grade: Materials of construction:_cast iron _40 PVC_other(explain): Distance-from private water supply well or suction line: .. Comments(on condition`ofjoin#s;venting, evidence of leakage, etc.): SEP I IC TANK: ocate'on site plan) 101 Depth below_wade: , Material of constniction:. /concrete metal_fiberglass .Aolyethylene _oth er(exp l ain) If tank is metal list age:_ .Is aaezconfirmed by a Certificate of Compliance(yes or hb)._(attach..a copy of certificate) Dimensions: �.��' (�O` x Sludge depth:, '2 >/ Distance from top of sludge to bottom of outlet tee or baffle:. Scum thi'ckhess:r 2, Distance from top of scum,to top:of outlet tee or baffle'.. Z Distance from bottom of scum to bottom of outlet tree-or baffle: How were dimensions.deterr,7ined:QAzdV.Ae Q �Q� .l1/h e Comments (on pumping recomme dation , inlet and,outlet tee or baffle condition, structural integrity, liquid levels elated to outlet invert, evidence of leakage, etc.): J jf Aj GREASE TRAP(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 oflast.pumping: Comments (on'.pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet.invert,-evidence of leakage, etc.): 7 , Page 8 of 1.1 OFFICIAI.INSPECTiO i.FORM NOT;`FOR.V, *t' �; '' SSESSI TE T 5 SUBSURFACE-SEWAGE DISPOSAL' SYSTEM INSPECTION FORM PART C.• . . S.YSTEM-INFORMATION(continued), Property dress Owner: Date o nspectio '7" �'/ TIGHT or HOLDING TANK: (tank must-be pumped at time ofinspection)(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.(yes.or no):. Alarm level: Alarm in working order(yes'or no): Date of last pumping: Commerim(condition of alarm and float.switches, etc.): DISTRIBUTION-BOX: (ifpresent must.beopened)(lo.cate on-site.p.lan). Depth of liquid Ievel above outlet invert:M�T." ' Comments (note if box is`.level and distributionto outlet qual,.any evidence of solids carryover, any evidence of. 1. ale into or out of box;ete. • - •� PUMP CHAiMBER:: (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.): Page 9 of I 1 OFFICIAL INSPECTION YORM.—NOT.FOR'VOLUNTARY ASSES' SUBSURFACE-SEV/AGE`DISpOSAL SYSTEM INSPECTTON FORS PART'C SYSTEM INFO'PMATION(continued) Property Address: � � Owne Date o Inspec n: SOIL ABSORPTION SYSTEM (SAS): i/ {locate on site plan,excavation not required') If SAS'not located explain why: TYP j. . leaching pits,number:, , leaching chambers,number: 1eaching.galleries, number: leaching trenches,number; len_ath: leaching fields,:number, dimensions: overflow cesspool; number: inn ovative/alternati.ve system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure,Ivel of ponding; damp-soil condition of vegetation. tc.): CESSPOOLS: (cesspool must be pumped.of inspection)(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.(yes or.no): . Comments (note condition•of soil, signs of hydraulic failure,:level of.ponding, condition of vegetation, etc:): PRIVY: /`� Iocate or.site Tan ( plan) Materials of constriction: Dimensions: Depth of'solids: Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc,)-.. Page 10 of t 1;. OFFICIAL.INS-PECTI03N--T,ORtYI:...N.0TPQRN-OLUINTARY ASSESSMENTS . 'SUBSURFACE SEWAGE'BISPOSAL SYS`IENLINSPECTION FOR PANT: SYSTEM ZI'Z:FORMATI:ON(continued), Property Address: az Owner: tAA Date of Inspection:. CX)77 C� SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the;sewage disposal system including ties to at least two permanent reference landmarks or tz benchmarks. Locate all:wells:within 100.feet.Locatz.where public water supply enters the bailding. o/ )00® [I a : Page l l of 1 l OFFIC.IAI1 INSPIICTION FORM —NOT FOR`*VOLUNTARY ASSESSMENTS SUBSURFACE+ SEWAGE DISPOSAL SYSTEM:INSPECTTON . RIM PAST C -SYSTEM-INFORMATION(continued) Property Address: 'Owner a-th,111 Date Inspec io 00 7 SITE E"AM Slope Surface water Check cellar Shallow wells Estimated.depth to ground water feet Please.indicate(check):all methods used tb determine the high.ground water elevation: Obtained from-systern design plans on record -If checked, date of design plan•reviewed: Observed site(abuttirig property/observation hole within 150 feet of SAS)' Checked with local Board of Health-explain: Checked with.local excavators, installers-(attach-documentation) _7Accessed USGS database-explain: You must describe how you established the high ground wa.ter.elevation: R ® r16. 1`0 1 ek Gc/. ,I i 11 • ri,., ¢,f Permit Number: Date: Completed by: — � HIGH GROUND-WATER LEVEL COMPUTATION Site Location: Lot No. Owner: Address: Contractor:__ Address:—. y Notes: zn" �l�s STEP 1 Measure depth to water table / q tonearest 1/10 ft. .............................................................................. .Date 5 month/day/year STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: AO Appropriate index well................... .. � rZ Water-level range zone ..................................................... C STEP 3 Using monthly report"Current Water Resources Conditions" determine current depth to water level for index well........................... 1�1 y6. month/year STEP 4 Using Table.of Water-level Adjustments for index well (STEP 2A), current depth to water level for index well (STEP 3), and water-level zone (STEP 213) determine water-level adjustment ................ ........................................................................... STEP 5 Estimate depth to high water by subtracting the water- level adjustment (STEP 4) from measured depth to water , level at site(STEP 1) ............. Id r Figure 13.--Repr0ducible computation form. f5 f n � � • �.L d 1 n l ,V ® A ti r D-7f �- TH BOARDALTH OFHEA,C�,T�.., TS OF............. ..:........ ......------------------------- Appliratiou for Ili-spnsaal Workii Tonstrurtiott Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal systeC. �----?` ....... ........... ocation-Addr s ,o t No. ....... ''. .. ..... .... .... ... ......................._...... ............. --............ .... ..................•.... W rl0wner Address Installer Address ��-- U Typed uilding Size Lot_ �t-- ___.Sq. feet Dwelling—No. of Bedrooms............. .........................Expansion Attic ( ) Garbage Grinder ( Alp— Other—Type e of Building ........ No. of persons............................ Showers 0., yP g .............•-•---• P ( ) — Cafeteria ( ) Q' Other xture .........-•-•--•-------•-----•••-•-••--••••••••. ....- d ,.. W Design Flow......:...................... .. ..: .gallons per person per day. Total daily flow.............................................�...._..•.....gallons. WSeptic Tank—Liquid capacity .gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .......... ........ Width... ............... Total Length........ ........ Total leaching area....................sq. ft. Seepage Pit No1..../� --.. Diameter.......+....... Depth below 'nlet.... . .......... Total leaching area..�0.4.sq. ft. Z Other Distribution box ( ) Dosing nkM�. C /'�-/y- 7� a Percolation Test Results Performed by--.. � ........... Date----- z-/ 7 CI.... Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ rL, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water..--................--.. J �....... ............. ... ....................... O Description of Soil••--- =�- 2= ' ... / '.-... c, ...........------------------------------------------------------------------------------------------- ._.....----------------------- ------ w 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 TIT`-.,. 5 of the State Sanitary Code—The undersigned urther agrees not to place the system in operation until a Certificate of Compliance has been .Isd the,board of ,ealth. . /Date Application Approved By...... - � -� -.r. ...�......_.. , suer 1 / Date Application Disapproved for the following reasons-------------•----•-------------------------------------•--------------------•------------ ...................... ----•-•.....--•-•••----•-•-•--••-•-•--••••--•-•••--•••-•----••-••--••--•-•-••---•••-....---•-••----•••---•••--••••--•-••---••---•-•----••--•••-••••--------••••-••••-----------•••••----••--•.......... ate Permit No. / / 7 r D Issued f G (/Q ------/--j•------------ Date f� C) ........... ................. ' revs THE COMMONWEALTH OF MASSACHUSETTS BOARD A HE 1@ ..........OF....... r Appftrtaffvt 'iur Disposal Works Tonotrttrtiun Daum Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individ�al Sewage Disposal Ss t ..y. °. oca,n Addrps zor t No. ... Owner A d d ress ...................... ........................ Installer Address N, Type of uilding Size Lot/5.7e�-P----Sq. feet I—I � Dwelling—No. of Bedrooms.............. --.._-. -----.------.__-Expansion Attic ( ) Garbage Grinder aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) d Other fixtures W Design Flow---"- " " gallons per person per day. Total daily flow--------•---- -------------"-dons. WSeptic Tank—Liquid capacity.........gallons Length................ Width................ Diameter................ Depth................ x Disposal Trenchj—No.................... Width.................... Total Length......... ......... Total leaching area_....._...__.__....sq. ft. Seepage Pit Nq+-._., r .... Diameter.......qC.--..... Depth below inlet__. ........... Total leaching area. /..sq. ft. z Other Distribution box ( ) Dosing ank ( �,��/ Percolation Test Results Performed by... Date..... Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ fasl Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ -----" ...................................... ................................. 0 a %'Descri tion of Soil .."'""" Do- P • •� "".......... t _ r V "-" ----"•... -------"------••-•-•-------•------....--"--• --• --•.... ........................................................... W UNature of Repairs or Alterations—Answer when applicable...........:................................................................................... fir ... .... ................................................................... Agreement The undersigned agrees to install the aforedescribed`'Individual Sewage Disposal System in accordance with the provisions of T i= 5 of the State Sanitary Code-The undersigned urther agrees not to place the system in operation until a Certificate of Compliance has bee s >3ed by the board of ealth. J S KI ag � Application Approved By...... �. -•_- Date ..__r►...... Date Application Disapproved for the following reasons:-------•----------------- -------------------------••------------------•--------........---"------.•-•-- ..............."----".......---•--....--•---------...------...------.....------"----•-•--....--••---•"••---"--.._.."-----"--"---•----•--"-•-"-------••-. -"--•-••------"---------...------"--------••--- Date PermitNo..............................•--•---........------...... Issued....................................................... Date THE. COMMONWEALTH OF MASSACHUSETTS BOARD QF HEALTH OF.......)6.4 ! 01rdifiratr of Tuutpliatta THI I O CE TIF t Individual Sewage Disposal System constructed (� or Repaired ( ) .......... ` ..... F_......... f Insta has been installed in accordanc ith the provisions of j of The State Sanitary Coe as described in the application for Disposal Works Construction Permit N __..__ .......... dated....= _, -t THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GBJAIYANTEE THATTE SYSTEM WILL FUNCTION SATISFACTORY. DATE.........fS_...�1�p :. _ .:............... •................ ' Inspector. ..... �'l. ........ THE COMMONWEALTH OF MASSACHUSETTS -BOARD OF HEALTH .. No ........................ - FEE. + .......:.... Permission Ohereby grante .----=". _. ..................."-. to Constr t f ) or Repair' ) an Indivi ual Se ge bi stern atat N '' ----------"0.. . .............. Street .7 as shown on the application for > posal Works Construction Pe > No..... ..... ...... D ted Ilk DATE---- _. .�C1. Board of Ilealth FORM 1255 HOBBS & WARREN, INC., PUBLISHERS "" r• � ra > _ rot �, .� . . r «✓, '' N D= r' rod L C it a • 0 .L - _;> �' c w . .�,.m.. ♦•r rI ` _ •�• n ..1 f " T ..: _-._._._"._.... -j.i w :• ^. . ..,���Ju��J• (' L. r�. +. + 1, t ,`� i TJ I P. n..1 '� t R P' -1 r F7 c9��i' N p _ 1. ?� 1 (f' � y J1 ?• � r �-- � .� I1• :�➢ r ____I__ r' n ri d _ 1 _ i tl ur\ tA o e min p • fill • ; ' ' , tr• �j �(• f� � �•�a��,•..-;, .�. :Y•��� off. -'.._ ^��' - � Z - c" �, � � -fit.; r� I1w c � .... � � 1'('� ., u r,:_ , 1 �-.�._:.«1.1 .O - y_ .—. i �--t.- •,. .' f i � �, 'L-2_ ._..; '. 'l ,_ /� ,�� /� (v' { ,•.wL f r .,f 0 • ;. t a,�- -�_ ..,t r r +� ...�.. ,„_,•.♦ar-.tip.---c { }� •`z .' - Y� _ i�/�. ,- � OT.�. � _ .i :w � F 1 �„r' t .t •_ _ `Y-1 . ...` �;..3 �J .. � - . '_••_ .Yt. L O CA T ON f r�- Z 7 SEWAGE PERMIT NO. VILLAGE I N S T A LLER'S NAME i ADDRESS B U I L D E R OR OWN ER DATE PERMIT ISSUED D TE,--,COMPLIANCE ISSUED �� 7� _� � � �- ` �- \ �� _ _ ��-'� U� �p o �MO � ` J t 3 I a� u-o 03