HomeMy WebLinkAbout0031 MANNI CIRCLE - Health 31 MANNI CIRCLE, CENTERVILLE
A= 189124
No l 3'OR
HASTINGS.UN
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4
NOTICE: The Town of Barnstable
recommends that the applicant
seek legal:advice to prepare a
properly worded deed
restriction document.
DEED RESTRICTION
WHEREAS, -� �� r - of
(owner's name) / MA
—� (address)
\ /!' located
is the owner of 3 f h ( r �
_(address) '-Cl
at �o � fe � v, llP ,
f'^c%
MA (hereinafter referred to as �C 11�at4� r ,
and being shown on a plan entitled "SubdivisioA of Land in
C.9 h It MA, Property of 9 �-
et al, duly recorded in Barnstable County Registry
of
Deeds in Plan Book y , Page
Or on Land Court Plan Number
WHEREAS, — f < as the owner of said lot has
(owner's name)
agreed with the Town of Barnstable Board of Health to a restriction as to the
number of bedrooms which can be included in any home built on said lot as a
pre-condition to obtaining a disposal works construction permit in compliance
with 310 CMR 15.000 State Environmental Code, TTitle.V, Minimum
Requirements for the Subsurface Disposal of Sanitary Sewage;
WHEREAS, the Town of Barnstable Board of Health, as a pre-.condition to
granting a disposal works construction permit for a septic system in compiance
with 310 CMR 15.200, State Environmental Code, Title V, Minimum
Requirements for the Subsurface Disposal of Sanitary Sewage, and authorizing
the issuance of. a building permit for the construction of a single family home on
this property, is requiring that the agreement for the restriction on the number of
bedrooms in any house constructed on the lot be put.on record with the
Barnstable..County Registry of Deeds by recording this document,
deedr
l^ -
-��✓ does hereby place the
NOW, THEREFORE, koln/�C."
(owner's n e) j
• I
following restriction on his above-referenced land in accordance with his
agreement with the Town of Barnstable Board of Health, which restriction shall
run with the land and be binding upon all successors in title:
U I Ae may have constructed
(address)
upon the;lot a house containing no more than *irtc- (3) bedrooms.
agrees that this shall be permanent deed
(owners n e)
restriction.affecting 10 6�cl located on .fit Cii'dt MA, and
being shown on the plan recorded in Plan Book 3 , Paged ,26 .
Or on Land Court Plan
For title of see the following deed: Book , Page
_ ) 5?, . Or Land Court Certificate of Title Number .
Executed as a sealed instrument _day of UQr c
Owner's si tune
Ov_iner's signature
Owner's signature
COMMONWEALTH OF MASSACHUSETTS
20o
Then person Ily appear d t e above-named
/07
known tome to be the...perso . ho executed the foregoing instrument and
acknowled d
the same to be free act and deed, before me,
Notary
Public
S �� 'o.,,� My commission expires:
<
(date)
ELIZABETH S.CALLARAN
deedr C9 1! '\`�, NGTARY PUBUC
BARNSTABLE REGISTRY* DEEDS My Commission Expires Jan.7, 05.
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PATE:
TOWN OF BARNSTABLE l&;5� t ��
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LOCATION Mp�" I 0,00vq, SEWAGE # 8 649
VILLAGE ASSESSOR'S MAP & LOT 5
4
[�,N ..at
INSTALLER'S NAME & PHONE NO. \aQCSWW � "t
SEPTIC TANK CAPACITY 1010CD
I,
LEACHING FACILITY:(type) �� (size) l��
NO. OF BEDROOMS PRIVATE WELL OR UBLIC WATER
f�n
BUILDER OR OWNER
DATE PERMIT ISSUED: 2&
DATE COLIPLIANCE ISSUED: S)J71 PQ
VARIANCE GRANTED: Yes No
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THE COIWONWEALTH OF MASSACHUSETTS
A�pOAR® OF HEALTH
........OF...... ��._ -•-•s
A1141firFation for Uiopos al Works Towitrnrtion Ppruat
Application is hereby made for a Permit to Construct (V�or Repair ( ) an Individual Sewage Disposal
System at:
•-• ••- --_........ .... ..
Locatio r ss � '
. � .. !' 1---------------------•--. ------ ..° ram. `"�=................ . _..._... .... ---•- -•-� 3
Owner Address
W
Installer Address
Type of Building Size Lot... ....Sq. fee
UDwelling—No. of Bedrooms........... ...........................Expansion Attic ( ) Garbage Grinder
aOther—Type of Building -•__________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
a' Other fixtures ------------------------------
W Design Flow...........`5. ......................gallons per person per day. Total daily flow.......... .....................gallons.
t W -. -Septic Tank—Llquid capacity&Wgallons Length ..(P4.-.. Wldth.L/.1"0_'. Diameter................ Depth...`.:5 �.'.... .
x Disposal Trench—No. .................... Width.................. Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No.......I........... Diameter..... Depth below inlet.....(''..._..... Total leaching area.:�.....sq. ft.
Z Other Distribution box y4:'S Dosing tank (&
'" Percolation Test Results Performed by________________________----��_!A� ate.....
Test Pit No. 1.....Z-------minutes per inch Depth of Test Pit..../.Z......... Depth to ground water---A1/0---__-_-.-
f4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground
water.-_______--_---___-____.
----;----_- ----•----------------•---.---•--------•- -•---------• ••--••--- -----------------•--------------------------------------••---..----
w0 Description of Soil..........i0/_Z....
.....4 �.....:t' U �--...
._..
-.r a � •---
U - --------------------------------------------------------
-------------- -------- --------------------- '---....� .....----•-----------------------------------
U Nature of Repairs or Alterations—Answer when applicable-------------------------------------------------------------------------------------------
........................................................................................................................................................................................................
•---------•-••---------------------•------•------------•----•-------•----•-•-------•.....-••-----•--•---------.....••---------.............•---•-•••••...------•••-•--•-•-•---••--••-•-•--•----.....----
Agreement:
The undersigned agrees to install the aforedescribed I i dual Sewage Disposal System in accordance with
the provisions of:1'!Z- 5 of the State Sanitary Code ndersigned further agrees not to place the system in
operation until a Certificate of Compliance has been i the board of health.
igned-•--•-•-- ........... .............................................................
- at
Application Approved By...................•--••••---.............��.............................:...,....... 1--0.- .
Date
Application Disapproved for the following reasons-...............................................................................................................
.......--••---•---------------------------•-•--.....-----------•-----•-••------------•-----••---•--........_...............----------------•----------------------------------------------------.........
Date
Permit No.----7Z&-�.........&-'q ......... Issued------..Lol ±. � '
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
D. N...................OF.... ...��'.�.L�.........................
Trtif iratr of TompliFana
T�f�I I� TO CERTIFY, That the Individual Sewage Disposal System constructed (� or Repaired ( )
V ---- --- ��, ••---•-••••--e--•----------------------------------------------•--•-••--•--•-•-------..-------------------------------
by-••------------------------- i Installer
at ....................................................... y���------------------------------------------------------•-----------------------•----------------•--------------------
has been installed in accordance with the rovisions of TITIE 5 of The tate Sanitary s Cod . a de cribed in the
application for Disposal Works Construction Permit o......................................... dated--.:.-_..-f 2-( �-------.-..............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.................s .:._ . _:..67......-----•.................... Inspector------------. --- ------------------...-----•---------------•---•--•----
THE COMMONWEALTH OF MASSACHUSETTS
BOAR OF HEALTH
� r /qI ................pw►J..........OF................................N. . 1 .G.- •---....... -j �
No...................•..... FEE
t o orks Tonotrurtton Uprutit
Permission is hereby granted.......................................................
to Constrµct ( ) or Repair ( ) an I til u�,l, Sewage Disposal stem
t.r 1�Ck:-r-
-•-• • ...................... .-••---••-•••.......---••-..............I.....•••-••-•-
at No. D -Z� ��J`'� ` -'v
Street ''lltt
as shown on the application for Disposal Works Construction Permit N ..�y1 Dated...!�'l 2 4-�.................
...................... .-...-.G..Grti 1----.....................................
i Board of Health
1L/� l (/ 7�
DATE . ---- ......
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS .
i�
No......................... FEs ..��.. .
THE COM.AAMOI�i+"V1/EALT�Fu c HEALTH TS
RD OF
f�
ApplirFation for Uhipoii al Works Tnnitrnrtinn Vamit
Application is hereby made for a Permit to Construct (4'or Repair ( ) an Individual Sewage Disposal
System at: ,
............�-------------••---•----------•-•---.........................---•-•........--------- -• -
��� 7 (� �,. LocatiA /dress � {1 .— or
.-� - ) > �r � --'--��=��---------•----•--•-•----- -•--• '-� ...................-----.........?...........-•----------... ...... ..
Owner Address
W
Installer Address
U Type of Building Size Lot_.__ =.Z ' ____Sq. feet
Dwelling—No. of Bedrooms............:?............................Expansion Attic ( ) Garbage Grinder (,A//r
aOther—Type of Building ............................ No. of persons............................ Showers ( ) Cafeteria ( )
p' Other fixtures ........................:...
Design Flow...........`2 ......................gallons per person
. er day. Total daily flow...... .............gallons.ns-
�W .
01.
Se tic Tank—Liquid*ca aclt -�-r- gallons Len th.. meter________________ De th__",?._, . r . Width_ -- Dia
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area----------_---------sq. ft.
Seepage Pit No......./-........... Diameter.._...c�_......... Depth below inlet..... Total leaching area..:?��.._..sq. ft.
Z Other Distribution box )5 Dosing tank (4/0-
Percolation Test Results Performed by---------------------_--- ........../_...--!-- Date.....
aTest Pit No. 1.....?._._....minutes per inch Depth of Test Pit....!(=.......... Depth to ground water_.-,A--lr-------------
( Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water_-_-------------------
P4 .............................................-......;�.•......:..........................................................................I----•--------------
Description of Soil = _ --------------- _...
V L..' _. ? ' r L r r( -% �i1sl i�jcJ ..�•-•--• ,{ '----------------------••--------------•-•-------------
---•-•--------
.........
W itlC�
UNature of Repairs or Alterations—Answer when applicable................................................................................................
----------------------------•-------•------•-------•--------------------------------..............--•-•........-••-••-----•---•------•--•--••---•-•••--•-----•-•--•-••••••-•---••-•--•••..._--------•-•-
Agreement:
The undersigned agrees to install the aforedescribed Ind- id -al Sewage Disposal System in accordance with
the provisions of L i is
p 5 of the State Sanitary Code— rslgned further agrees not to place the system in
operation until a Certificate of Compliance has been issu t board of health.
�'".. Signed. ..... ------------
.--------------------------------
••------------Ir i at
ApplicationApproved By.................................................................................................. -------Z..-- --------- ------------
Date
Application Disapproved for the following reasons:-------•-----------•--•--------•------••------•----•--------------------------•------------------•-•----...._._
......................•-•--•.........-•••....••......--•---•...........---------------•----•------•--....------•---------•-•-----••-••-•••-••••-------••---•-----••••--•••----••--------•-•-----------•-
/� Date
Permit No.... 8...........L.r�._Lf ---------. Issued......�. 1-z`
Date
e,
075 f /DO 8%,
07.7
4`.
03
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MARYI Svc . � =�"I r✓ �1:�:r�C�/�C
M(4jZAN 9
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CERTIFIED SEPTIC SYSTEM REPORT
LOCATION
31 MANNI CIRCLE
CENTERVILLE , MA 02632
MAP 169 PARCEL 124 LOT 54
PREPARED FOR
SELLER
MR. JAMES MACURDY
29 MANNI CIRCLE
CENTERVILLE MA 02632
BUYER
MR. RON TAYLOR
31 MANNI CIRCLE
CENTERVILLE, MA 02632
PREPARED BY
HILLIARD HILLER, JR.
41 MAPLE AVE
CENTERVILLE, MA 02601
508-778-1.472
7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Address of property 3/ ,1r44V1 cl.PcGE
Owner 's name y
Date of Inspection
PART A
CHECKLIST
Check if the following have been done:
Pumping information was requested of the owner, occupant, and Board of
Health.
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.
As built plans have been obtained and examined. Note if they are not
available with N/A.
r The facility or dwelling was inspected for signs of sewage back-up.
_ V The site was inspected for signs of breakout.
v All system components, excluding the SAS , have been located on the
siLe'.
v 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 SAS on the site has been determined based
on existing information or approximated by non-intrusive methods.
__4,/" The facility owner (and occupants, if different from owner) were
provided with informati
on on the pro
per per maintenance of SSDS.
8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION
FLOW CONDITIONS
If residential
number of bedrooms
number of current residents
Al - garbage grinder, yes or no
14S laundry connected to system, yes or no
&12 seasonal use, yes or no
If nonresidential , calculated flow:
Water meter readings, if available: , ,� o
e2
last date of occupancy /` !y a7, 4e-
GENERAL INFORMATION
Pumping records and source of information:
---N�_/�"cU '�5 ___._—.�a�ti�`ic r1;�•�, /�fl,�i'i7•�°'G,�' CJ.�4i
N� System pumped as part of inspection, yes or no
if yes, volume pumped
for pumping :
Type of system
_!/ Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
------ Privy
Shared system (yes or no) (if yes, attach previous inspection
records, if any)
Other (explain)
Approximate age of all components. Date installed, if known. Source of
information:
/vsT��c�'o /v -G��a= c�/yT' Go.•i�G/%.vG.c" /5 .Q%
/1✓/I/�i�/Sl J'7i�L� /? o C/
- Al Sewage odors detected when arriving at the site, yes or no
9
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION Continued
SEPTIC TANK: &,-"
(locate on site plan)
depth below grade:
material of construction: L/concrete metal FRP other(explain)
di.mensions:_
V sludge depth
as„ distance from top of sludge to bottom of outlet tee or baffle
P� 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
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, recommendations for repairs, etc. )
DISTRIBUTION BOX:--
( locate on site plan)
---_Q 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, recommendation for repairs, etc. )
L d4,,2C L /, Z-Xr /�F /� `" 13�Goc.� UriTG .i �1.�.� i9
-- 1011'��r L -
_— 1017 r,115 sflo�rid_o�c/ Tit /y5%�GG�'/CS d/�9G%�9/r J, T/�is pig' arcs
PUMP CHAMBER:
(locate on .site plan)
pumps in working order, yes or no
Comments:
(note condition of pump chamber, condition of pumps and appurtenances,
recommendations for maintenance or repairs, etc. )
i
10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
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:
/3e-,
Type
leaching pits and number
leaching chambers and number
leaching galleries and number
leaching trenches, number, length
leaching fields, number, dimensions
overflow cesspool , number
Comments :
(note condition of soil , signs of hydraulic failure, level of ponding,
condition of vegetation, recommendations for maintenance or repairs, etc. )
CI`SSPOOLS ( locate on site plan) :
number ,ind 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, recommendations for maintenance or repairs, etc. )
' 1'I21VY :
( 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, recommendations for maintenance or repairs,etc. )
11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100 '
3/
I'
a. , 5
M �
DEPTH TO GROUNDWATER
G depth to groundwater
method of determination or approximation:
NEXT
i
WATER TABLE DETERMINATION FOR: 31 MANNI CIRCLE
CENTERVILLE
The Barnstable drawing entitled "Observed Water Table
June 1992" shows a water table contour of 25 ' running through
the site . The Barnstable GIS shows a 31 ' contour running
through the location of the leaching pit .
The engineered drawing showing the test pit (dug on June
13 , 1988) shows that the test pit was dug 2 ' down gradient
from the actual pit and went down 12 ' without finding
groundwater . This puts the actual groundwater down below
17 ' ( 31-14=17) in the same month as the interpolated lines on
the ''Observed Water Table June 1992" drawing which shows 25 ' .
Applying the USGS correction (MIW-19 ZONE D) 4 .4 ' to the
17 ' gives a maximum groundwater elevation of 21 .4 ' . The
bottom of the pit is nine feet deep (per the engineer 's
drawing) . Subtracting 21 .4 ' from the 31 ' gives 0 . 6 feet . the
bottom of the pit is not in the maximum high water table .
12
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
FAILURE CRITERIA
Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of
determination in all instances. If "not determined" , explain why not)
Backup of sewage into facility?
Discharge or ponding of effluent to the surface of the ground or
surface waters?
Static liquid level in the distribution box above outlet invert?
A/R Liquid depth in cesspool <6" below invert or available volume< 1/2 day
flow?
_ lJ Required pumping 4 times or more in the last year?
number of times pumped _
Septic tank is metal? cracked? structurally unsound? substantial
infiltration? substantial exfiltration? tank failure imminent?
Is any portion of the SAS, cesspool or privy:
_ below the high groundwater elevation?
..IV within 50 feet of a surface water?
__ k/ within. 100 feet of a surface water supply or tributary to a surface
water supply?
_4/ within a lone I of a public well?
I/ within 50 feet of a borderin
g vegetated wet g g land or salt marsh
(cesspools and privies only, not the SAS) ?
Al_ wiithin 50 feet of a private water supply well?
/V 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 analysi
for coliform bacteria , volatile organic compounds, ammonia nitrogen
and nitrate nitrogen.
y
13
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART D
CERTIFICATION
r
Name of Inspector
Company Name
Company Address
Certification Statement
I certify that I have personally inspected the sewage disposal system at
this address and that the information reported is true, accurate and
complete as of the time of inspection. The inspection was performed and
any recommendations regarding upgrade, maintenance and repair are
consistent with my training and experience in the proper function and
manitenance of on-site sewage disposal systems.
Check one:
I have not found any information which indicates that the system fails
to adequately protect public health or the environment as defined in
310 CMR 15. 303 . Any failure criteria not evaluated are as stated in
the FAILURE CRITERIA section of this form.
I have determined that the system fails to protect public health and
the environment as defined in 310 CMR 15. 303 . The basis for this
determination is provided in the FAILURE CRITERIA section of this
form.
Inspector' s Signature � �
Date
Original to system owner
Copies to:
Buyer ( if applicable)
Approving authority
I
C
TOWN OF BARNSTABLE .
LOCATION ��� t%, SEWAGE # . -,G Aca
VILLAG'(tl, U\Ll�, ASSESSOR'S MAP & LOT
INSTALLER'S NAME PHONE NO. � `�
SEPTIC TANK CAPACITY
r •�
2
LEACHING FACILITY:(type) ,- (size) __
NO. OF BEDROOMS _PRIVATE WELL OR BLIC WATE 6..f
BUILDER OR OWNER
DATE PERMIT ISSUED: "�Q
DATE ' COLIPLIANCE ISSUED;L_� - -�
VARIANCE GRANTED: Yes No
q i
�21
o z as
36
61� _ IF-
y, � I
KEY NUMBER <10173 >
NAME <MAC URDY, JAMES K > B-C 1 B-C 2
B-C 3 B-C 4
STREET 29 MANNI CIR
CITY CENTERVILLE ST MA ZIP 02632-2708 REF 1 REF 2
PHONE ( ) - REF 3 REF 4
METER NO. < 10477> DATE READING CONS
STREET <MANNI C-IR-,) NO. 31> 12/31/94 27 27
CITY CEN J (L54..' ST LOC 06/30/94 0 0
PHONE ( ) - 0 0
0 0
ROUTE NUMBER 32 0 0
SERVICE DATE 09/15/89 0 0
METER DATE 06/27/94 0 0
CAPACITY 7 0 0
STYLE T10
SIZE 1 RATE SCHEDULE
KEY PIT PLASTIC X
NOTE RR FRT RS ADDITIONAL CONS 0
ALTERNATE MIN 0
• t
THE COMMONWEALTH OF MASSACHUSETTS
O A R D OF HEALTH
.................OF.....!-�..... !"1 7`'' ..........................
Appliratinn for Dii.punu1 lVadw Tonlitrnr#inn Unmi#
Application is hereby made for a Permit to Construct (v5'-or Repair ( ) an Individual Sewage Disposal
System at:
........... ........•-----............--------.........-------•------------- •-----•-------... ` ..� /---- t2..----------......
"Locati!o � .. or
v .... . ` Loram . � V �..... .... . -.... .. ......
_ .........
Owner Address
W .................. ..................................................................................................
--a................................................... .. ... ......................
Installer Address
Type of Building Size Lot...ZZ7 ....Sq. fee
U Dwelling—No. of Bedrooms.............?_---------------------------Expansion Attic ( ) Garbage Grinder (
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
a4Other fixtures .--•--•-----------------•-••-------•-•--.....-•-----•-.•--•...-•••-••-••••..............._
w Design Flow............ ......................gallons per person per d4 y. Total daily flow...........-.--� _......... gallons.
WSeptic Tank—Liquid capacity/6XX.gallons Length._�..�P...... Width../..Q.-�.. Diameter................ Depth..�7...�a
x Disposal Trench-- No. .................... Width....I............... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No-------/............. Diameter--.---e........- Depth below inlet.....(e......... Total leaching area.� .....sq. ft.
Z Other Distribution box yQ,S Dosing tank Wb
Percolation Test Results Performed by..........................f.''1. ..F�'' ►"� Date.--.- ?--�3-� ...........
Test Pit No. I.....,Z.......minutes per inch Depth of Test Pit..../.Z......... Depth to ground water...A1/Q.........
.
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
p; ...................••--•............................-•-........................................._.................--......
O Description of Soil..:... Q./.- ......... ; �.....'h.....�?.. 3---��"'
. .. .. .....
v �...-�Z. ...... -`S ,r��.....M'�:72fV. 'd............ .. ...r�........................................................
......
UNature of Repairs or Alterations—Answer when applicable...............................................................................................
.......................................•--.....---•---•--•••-----..........-•-•••---...............•••••-•••-••................-••....................................-•--•••...........................
Agreement:
The undersigned agrees to install the aforedescribed f li dual Sewage Disposal System in accordance with
the provisions of`:I,i.;, 5 of the State Sanitary Codeeffic
ndersigned further agrees not to place the system in
operation until a Certificate of Compliance has been i., board of health.
igned......... ...... •-•-••-•-----................._......••...............
at
ApplicationApproved By............................................................................. ................... .......L.,.l?v.R.� .. .
Date
Application Disapproved for the following reasons:..............................................................................................................
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Date
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