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HomeMy WebLinkAbout0018 MILLSTONE WAY - Health 18 Millstone Way Centerville A=251 - 154 UPC 12534 2.13E 53LO . I No. ID30 b `" Fee L/9 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Rpplicattou for Migozal 6pgtemc Cou.5tructiou Permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components Location Address or Lot No. �—/^ /S�! Owner's Name Address,and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. R0 Type of Bu ding: Dwelling f No.of Bedrooms Z Lot Size ,-26, 33 sq. ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) -2.20 gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank in n n Type of S.A.S. QGIS(7 e 77 Description of Soil Nature of Repairyforv, r Alterations(Answer when applicable) Pao f 4(e b � el i if b ek PIE 40C 19_ r t Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmenta ode and not to place the system in operation until a Certificate of Compliance has been issued by this Board of He Signe Date -- Application Approved by Date Application Disapproved by: Date for the following reasons Permit No. (9 0 Date Issued `ry w.9.-Tw+--...+r...-.w..v+�,..,`.� _u'�i:r,�.�:>r...y„��;,�-a�.s-:r.v-...r-+-^. . .fir..,-,r,�-.�'r�'."`.""`"'�».,n:_.-y.::-.,,..,..ra:..:.�._„�: .,,r, _:.�.. ./. _-• ,. .: �- NO. Fee /d� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: r PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ZIppYtcatton for tgpoat fpp,5tem Cow5tructton Permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑ Complete System❑Individual Components Location Address or Lot No. —/_ /�—�/ Owner's Name,Address,and Tel.No. Assessor's Map/Parcel GL 4 Installer's Name,Address,and Tel.No. Designer's Name,Address and.Tel.No., Type of Building: Dwelling I No.of Bedrooms �'' Lot Size 76, 376 sq.ft. Garbage Grinder ( ) * Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. fWZ) 1pIT Description of Soil Nature of Repair rAlterations(Answ r when applicable) f9Ce f lom he, a 4h/C K Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environment ode and not to place the system in operation until a Certificate of 'Compliance has been issued by this Board of Hedlth, Signe Date t Application Approved by Date Application Disapproved by: Date for the following reasons Permit No. (9 Q Date Issued f) fty THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of Compliance THIS IS TO CERTIFY hat the On-site'Sewage Disposal System Constructed ( ) Repaired ( -') Upgraded ( ) '4 Abandoned( )by /7 S'/e at has been constructed in accordance with the provision of Title , d the for Disposal System Construction Permit No. 0�� �� � dated, �p Installerf7 I Designer #bedrooms Approved-des•ign flow gpd � \ ��. The issuance of this permit shall not be c�j ns rued as a guarantee that the syst\em will functi• n a eslgned. � Date O , . ) 1 Inspecto�rl ------y—,�-- j------------------------------ ---- No. ( ` I Q 0 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH ?DIVISION—BARNSTABLE, MASSACHUSETTS �Dt5 opal Stem Congtructton Permit � C� Permission is hereby granted to onsstruct ( ) Repair (t' ) Upgrade ( ) Abandon ( ) System located at /9" t��s�v�e 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 b completed within three years of the /ate of this p, i . Date 9 Approved`b TOWN OF BARNSTABLE LOCATION f I�lf�< J�� SEWAGE # BUD6 '` y VILLAGE efa oleef'lllP - ASSESSOR MAP & LOT INSTALLER'S NAME&PHONE NO. ' SEPTIC TANK CAPACITY �� GJ D 5 LEACHING FACILITY: (type) � (size) NO. OF BEDROOMS BUILDER OR OWNER PERMTT DATE: j 17L COMPLIANCE DATE: Separation.Distance Between the: Maximurii Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Prix to Water Supply Well and Leaching Facility (If any wells exist osiie or within 200 feet of leaching facility) -Feet Edge of Wetland and Leaching Facility(If any wetlands exist ,,Within 300 feet of leaching facility) Feet Fur1, "shed by ` r3 0 o � a 0 3 y - > COIN'BION'ATALTu - _ OF _ LS, �CHi;SE�TS _; EXECU!'I�-E OFFICE OF EN VZROYti!E�'T_� rEV i DEPARTMENT OF ENDIRONNTEN T_aL PROTECTIo-\� TITT OFFICI_AL INSPECTION FOR-1%7 NOT FOR VOLUNTARY ASSESS-AIENTS SUBSURFACE SEWAGE DISPOSAL. SYSTEM FORM PART A p CERTIFICATION Property Address: d /�/��S�ol�►e W�►� Geh e✓v!/�� /� Oo163oZ Owner's Name: Owner's Address: Sa SNha hl, /�Gf /Gns--- L Ne.� 4 o15e6a - /-?-?3 Date of Inspection: Name of Inspector.-_(please,print) Companv Name:, yV� o— % C- 3 `'Mailing Address: o .t?o_)< € t;�XN Telephone\umber• P1 Lm CZ) rO CERTIFICATION STATE�-TENT -r) :ri I certify that I have personally inspected the sewage disposal system at this address and that the in o na=er're exx c below is true; accurate and complete as of the time of the inspection,the inspection-,,,:as perform e basedEc r, training and experience in the proper function and maintenance of on site sewage disposal s�stem.. I air, SI)LP r approved system inspector pursna=Passes .340 of Title S(310 C1R 15.000}, is e s�s e r,: rrt Conditionally Passes Needs Further Evaluation by the Local Appro-ving_!kuL'rcr Fails Inspector's Signature: Date: The system inspector shall submit a copy of this inspectior report to the A-pproving:l u-mo z-(Ecard e 1 e.at,cr DEP)within 30 days of completing this inspection.If the system is a shared system or has a deign iov gpd or greater; the inspector and the system owner shall submit the report to the appropriate region;o_"ce o=t e DEP.The original should be sent to the system owner and copies ser_i to the buyer; if a �licable. arm-he a-^ro: � _uT.11Orih'. _ _ _ Notes and Comments """"This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will conditions of use. perform in the future under the same or different Title 5 Inspection Form 61,512000 page 1 Pane 2 of 11 ` OFFICIAL INSPECTION FORM—NOT FOR VOLL- T_ARY ASSESSMENTS SUBSURFACE SENVAGE DISPOSAL SYSTEvI INSPECTION FORM CERTIFICATION(conti-:ued) Property Address: !� iIXs�-O y� Owner, Co h✓.Z c Date of Inspection: // /S' 0,6. Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Syste asses: I have not found any information-kvhich indicates that any of t e failure care-a dtscr=be 15.303 or in 310 CMR 15.3104 exist.Any failure criteria not evaluated are indicated belo Comments: B. Svst m Conditionally Passes: / 70ne or more system components as described in the"Conditional.Pass,:sec ion need-o be replaced o_ repaired. The system-upon completion of the replacement or repair,as approved by the Board of Health. will-ass. Answer yes; no or not determined(Y,N,ti�D)in the for the follo«ring statements.If" of dete,._wed"niease explain. The septic tank is metal and over 20 years old*or the septic tank{whether metal or no-)is sL_au ral'_ unsound; exhibits substantial infiltration or ekfiltration or tank failure is imI:nnent. System,v" m s i-- as . c .on f;ie 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 stracturaily sound,not Leaking and if a Certirca-e indicating that the tank is less than 20 years old is available. \"D explain: Observation of sewage backup or break out or h:gh static water level in the distribution box due tc b-oker:o- obstructed pipe(s) or due to a broken,settled or uneven distribution box. System v-il pass nspec=on if ._.- approval of Board of health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced \'D explain: The system required pumping more than 4 times a year due to broken or obstructed pass inspection if(with approval of the Board of Health',- broken pipes)are replaced obstruction is removed 'STD explain: Page 3 of 1 I OFFICIAL INSPECTION FORM-NOT FOR tiOLLTNT-A-R�' ASSESS-NIEITS SUBSURFACE SEWAGE DISPOSAL SYSTEM ItiSP-F_CTTOS FOR-! PART A �jCERTIFICATION(continued) Property Address: Owner: Cot, /< Date of Inspection: C,.� Further Evaluation is Required by the Board of Health: /v Conditions exist which require further evaluation by the Board of Health ?orde_-o deter =_ne ff is failing to protect public health,safety-or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CAIR 15.303(1)(b)that the System is not functioning in a manner which will protect public health: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 sal:rnarsh 2. System will fail unless the Board of Health(and Public Water Supplier.. if any) determines that the system is functioning in a manner that protects the public health.safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is s.-ithin 100 et of a surface water supply-or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is vahir.a Zone i of a �biic w`a-.-s::nnly. _ The system has a septic tank and SAS and the SAS is within 50 feet of a privates The system has aseptic tank and SAS and the SAS is less than 130 feet but 5.0 feet or mere private ,vater supply well**. Method used to determine distance "This system passes if the well water analysis.performed at a DEP certi ed laboratort-, for Col',* bacteria and volatile organic compounds indicates that the a-ell is free from-00"bution=am that facility a-u the presence of ammonia nitrogen and nitrate nitrogen is equal to or less Iran 5 nnm o :.de -� �" _i_q: .. oghe` failure cri'ter a are triggered.A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FOR-JNZ—NOT FOR V"OLUI-T- RY"ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL, SYSTEIII I\�SPECTION FORM . PART PK CERTIFICATION(continued) Property Address: 1�1- k"cl evr rl/i f� 6z O«-ner: CO H o Date of Inspection: 1510 D. Svstem Failure Criteria applicable to all systems: You must indicate "yes"or"no"to each of the following for all inspections: Yes NO cicup of sewage into facility or system component due to overloaded or clogged S.kS or cesspool Discharge or ponding of effluent to the surface of the ground or ss--face v aters true,e an C-;e-!c_dec� c. Coed SAS or cesspool _✓ Static liquid level in the distribution boy above outlet invert due to an overloa or clogCe S_�S o- cesspool _ �/I uid depth in cesspool:is less than 6"below invert or available volume is '_ess tr�an day �/Required pumping more than 4 times in the last year\'pT due to clogged or obs- ,e^p_ipef s i.NUr,^e- c/ times pumped yv Anv portion of the SAS,cesspool or privy is below high around water elevation. 11-1�kny portion of cesspool or prii y is within 100 feet of a surface water supply or t__bu,ary to a s -;:ace ater supply. y portion of a cesspool or privy is y thin a Zone 1 of a public�-el'_. v portion of a cesspool or privy is vttithin 50 feet of a private water sup:,lv„-:17. portion of a cesspool or privy is less than 100 feet but g eater than 50 feet irony a pr;ate ;;a.,er supply well Ninth no acceptable water quality analysis. [This system passes if the well Rater 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 nitrogen is equal to or less than 5 ppm.pro«ded that no other failure criteria are triggered.A copy of the analysis must be attached to this form) / O (Ye s/,o) The system fails.I have determined that one or more of the above fail r,e crtena ez s`a; described in 310 CMR 15.30'.therefore the system fails.The system ow,zer s'i' u1G the ccntac, Bca-d c Health to determine;what will be necessary to correct the 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 15.000 gp d You must indicate either,"yes"or"no"to each of the following: *, hewing criteria apply to large systems in addition to the criteria above; 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 ti ellhead P-ozenon Area Zone II of a public water supply well ` if you have ansNvered"yes"to any question in Section E the system is considered as' "yes"in Section D above the large system has failed.The owner or operator of any large s.°ste~ significant threat under Section E or failed under Section D shall upg ad:the s�'ste__�;l a cer are i 5.304- The system owner should contact the appropriate regional office ofthe Depa_-rrner . Tito � T-�cr�ortinn T,nm� �;rv�nnn a Page-;� of 11 OFFICIAL INSPECTION FOR-M—'NOT FOR VOLL-"T:-Ik—RY ASSESS-MENTS SUBSURFACE SENVAGE DISPOSAL SYSTEM I-SPECTIOI FORM PART B p CHECI-MIST Property-Address: Owner: Co N a Date of Inspection: / d- Check if the following have been done.You must indicate"yes"or"no"as to each o:`the fo o,imrg: Pumping information was provided by the owner,occupant. or Board of Heah.h Wereny of the system components pumped out in the previous two�zeeks �a Has the system received normal flows in the previous two week period Have larae volumes of water been introduced to the system recently or as pa_t of this insnec_ion Were as built plans of the system obtained and examined?(If then were not available note- as 1:A f ✓ Was the facility or dwelling inspected for signs of sewage back up? — Was the site inspected for signs of break out? v — Were all system components; excluding the SAS; located on site? Were the septic tank manholes uncovered.opened.and the interior of fr_e tare i,sn-CI for h- ce~ditior of the baffles or tees, material of construction.dissensions,depth of liquid; depth of sludge and depth of scum ✓ _ Was the facility owner(and occupants if different from owner)ner)pro-'ided'vk` f Irma;on, e th-�-o^e- maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been dete-^_ned based n--,: Yes Existing information.For example,a plan at the Board of Health. Determined to the field(if any of the failure criteria related to Part C is at issue an^ro; .i nn e is unacceptable) f310 CNR 15.302(3)(b)] T Page6ofil OFFICIAL INSPECTION FORIM—NOT FOR VOLUT=-RY ASSES SNIENTS SUBSURFACE SE`VAGE DISPOSAL SYSTFAI ENSPECTION FORAI PART C SYSTEM IN FOR.NIATIOIti Property Address: wG L2 Owner: 640-1 / o Date of Inspection: /S O FL W CONDITION'S / RESIDE.\TIA.L q� \umber of bedrooms(design): c- Number of bedrooms(actual): oZ D=SIG\flow based on 310 CN R 15.203 (for example: 110 gpd x-of bedroom ): - a O 1 \"umber of current residents: D — ��P✓`�'l Does residence have a garbage grinder(yes or no): Q � Is laundry on a separate sewage system(yes or no):/-0 Fif yes separate inspect on recuire•' Laundry system inspected(yes or no): 4- Seasonal use: (yes or no):/ Water meter readings, if available(last 2 years usage.(gpd)): Sump pump (yes or no): Last date of occupancy: CO LIIERCIAL/IND STRIAL Type of establish-Went: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(sea ts/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):_ Gti-ater meter readings. if avaiiabld: Last date of occupancy/use: OTHER(describe): GENERAL I\TORMATION Pumping Records Source of information: c>7 wLet- -- Was system pumped as part of the inspectio (yes or no /L-C' If yes; volume pumped: gallons--How was quantity pumped determined':' Reason for pumping: TI F SYSTEM _Septic tank, distribution box, soil absorption system _Single cesspool _Overflow cesspool _Priv— Shared system(yes or no) (if yes, attach previous inspection records;if any-) Innovative,,'A.itematiye technology.Attach a copy of the C'M nt operation and - obtained from system oNvner) —Tight tank _Attach a copy-of the DEP approval —Other(describe): Approximate age of all components; date EiristalIe (ifkno-;-;n)and source of info--na on: Were sewage odors detected when arriving at the site(yes or no): �/� -1 irfo G Tn cno�tinn L'�.-.,., LIi ZP)nnn G Pa-,- 7 of 11 OFFICIAL. INSPECTION FORM—NOT FOR VOL;!��IARY ASSESS1iENTS SUBSURFACE SENVAGE DISPOSAL SYSTEM INSPECTION FOR-f PART C SYSTEM INFORMATION(cont'mued) ' Property Address: Owner: �H Roc, Date of Inspection: BLTILIDING SEVER(locate on site plan) Depth below grade: C� Materials of construction:_ oIl _ PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of Joints;venting,evidence of leakage,etc.): SEPTIC T _\AK:_(" locat,- site plan) Depth below grade: / Material of construction:_concrete__petal_fiberglass_polyetlivlene other(explain) if tank is metal list age:_ Is age confirmed bv_ a Ce-icate of CornFliance(ye= or no): _ a7, ach a cod.. �= Dimensions: Sludge deptL: Distance from ton of sludge to bottom of outlet tee or baffle: Scum thickness:;4,es1 /l� <i Distance from top of scum to top of outlet tee or baffle: 41. Distance from bottom of scum to botto0 outlet tee.Sr baffle: o How were dimensions determined: / /e k5 Q�ie — Comments (on pumping recommendations,inlet and outlet tee or baffle condition. Sm-,Criral as lated to outlet inve evidence of leakaJge,e`c.): / 1✓� s/JO `eB C'Ci or ;Ahl r 7G 7 sue'!p GREASE TRAP: //(locate on site plan) Depth bellow grade: _ Material of consTlction:_concrete_metal_f be-glass polvethylene 07,ver (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 o-baffe:_ Date of last pumping: Comments (on pumping recommendations; inlet and outlet tee or baffle condition. sz=ctu-a'_ r-`, -:. as related to outlet invert; evidence of leakage, etc.): Page 8 of 11 OFFICIAL, INSPECTION FORM—NOT FOR VOLUlT_•�LRY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTE-11 I\SPECTION FORM P AY23' C SYSTEM INFORMATION(continued) Property Address: �l��l�✓Jg (,fQ� N ri,,—Ile- Owner: o Date of Inspection: / �5 TIGHT or HOLDII\G 'T_4-N K/t (tank must be pumped at time of impection)(ioca.te on site n Depth below grade: Material of construction: concrete metal fiberglass_poh ethylene ^Le "e r.lainl: 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: Comments (condition of alarm and float switches, etc. - DISTRIBUTION BOX: (it/ f present must be opened)(locate on site plan) Depth of liquid level above outlet invert: �Dld"�� L Comments (note if box is level and distribution to outlets equal,any evidence of solids car-n:over, a e::dance or leakage i ±o or out of box. etc.): PLNIP CHAIZBER: 6l/ (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.?: T;rl. TncncntinY �nrm (I1 S/^nnn g Paze 9 of 11 OFFICIAL INSPECTION FORA-- OT FORVOI.L=IT--'VRY ASSESS--NIENTS SUBSURFACE SEWAGE DISPOSAL, SYSTEM INSPECTION FORM Y AR'r C SYSTEM INFORMATION(continued) Property Address: Owner: Qo Date of inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan, excavation not required) If SAS not located explain why: T`pel leaching pits; number: leachin_a chambers;number: leachinz Qalieries, number: W leaching trenches, number, length: s7�Oh� leaching fields;number, dimensions: overflow cesspool. nuriber: innovative/alternative system Type/name of technology: Comments(note condition of1soil, signs of hydraulic/failure;level ofponding. darn soil. cond:n n CESSPOOLS: /r/ (cesspool must be pumped as pan of inspection)(locate on site plan) Number and cor�iguration: Depth—top of liquid to inlet invert: Depth of solids laver: Depth of scum laver: 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. con-itcn C. •e_eta-io^. e:c. : PRIVY: (locate on site plan) Materials of consuuction: Dimensions: Depth of solids: Comments(note condition of soil.signs of hydraulic failure.level of pon-ding, coro-� o i 41. : Pave 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLL NTARY"ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR7-4 Y_a12T C SYSTEM INFOR_NIATION(continued) Proper-ty Address: Z /Yi//-<-A Owner: Co h d o Date of Inspection: /,S' D,6 SKETCH OF SEWAGE DISPOSAL SYSTENI Provide a sketch of the sewage disposal system including ties to at least iandr-arras or benchmarks. Locate all % ells within 100 feet. Locate where public vaater supply-enters the hui_di-g. / / 0 Li � III 41 20 1 � w oZ I(' O 143 i T;*lo Page i 1 of 11 OFFICIAL, I.lSPECTIO'i'FORii-I—-OT FOR YOLUNT—ARI` ASSESS:�IENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Y?�RT C ,p SYSTEM I\FORMATION(conrnuedl Property Address: �p /�i��f7 u N.e Owner: lq—e, Date of Inspection: SITE E_X kM Slope Surface water Check cellar / Shallow.yells Estimated depth to ground water cz] feet Please indicate(check)all methods used to determine fae high guound water elevation: Obtained from system design plans on record-If checked,date of design plan Ob�n ed site (abutting prop erty/observation hole} hin 150 feet of SAS) —, Checked-with local Board of Health-explain: f",Ns Checked with local excavators;installers-(attach documentation) Accessed-?SGS database-explain: You must esc_ibbe how you established the hi h around waterr elevation: Tcl�l /^S_)o ��e ��•.� �S !�O l�L�" �S � S�o y w c�crd T+tic fncncrtirn �nrm r/1 l i :/')nnn THE COMMONWEALTH OF MASSACHUSETTS BOAR® HEALTH --------------oF........ .. ....x.................................................. Alipiira#ion for Di ipasaj Works Tonstrnrtion Vrrmft Application is hereby made for a Permit to Construct ( } or Repair ( ) an Individual Sewage Disposal System at: 1-o- .3 I c__t-,5T'6 p C lj p,`� G C ti - • - -------------_•------•----------------------------------------------- tz V 1 L_L� --------j Location-Address --_-'___'__...---•_-...___-_•__••_....._=-----------------—....—....... •---- 1CQ�j wzpkky or Lot No. -- h ------------ ----- --------------- - ..../ M- W Owner Address - - -------------------- (1� Installer Address Type of Building Size Lot_aOL_3TO------Sq. feet Dwelling L No. of Bedrooms___.._______________________________Expansion Attic (ice Garbage Grinder (NC)) Other—Type of Building ___' {•____-_:_-_ No. of persons-_______-3________________ Showers ( L) — Cafeteria ( ) Other fixtures w Design Flow----------------- - ?---- ----------gallons per person per day. Total daily flow_..._.----.�_�y=s_--_---_-_____-_--gallons. USeptic Tank—Liquid capacityLaq..__.gallons Length________________ Width__________.____ Diameter..._ _ T ---------- Depth----------------Disposal Trench—No. ________�___._____. Width_ -?-. Total Len --�-- ----------------- Total leaching area--_--_-- -----sq. ft. Z Seepage Pit No ution___o_.._________ Diameter........�_L�__.... Depth below ' et__ _._41 .______ Total leaching ar;A. ...sq. ft. z Other Distribution box ( Dosing tap,�c ( ) - e • d� - 0-2>- ?,�' Percolation Test Results Performed by....:._ __ __ !�g' Test Pit No. i __ - --------------------------- =--------------------- - Date--- ___minutes per inch Depth of Test it____________________ Depth to ground,water:.___ S _' u. Test Pit No. 2----------------minutes per inch Depth of Test Pit................... Depth to ground water-_--______-_____.---___- r4------- 1 ® �� f .,�. x Desc�ri n of Soil `.._ . �.. - _ '°a ` ,1 LSD r . --------------- ,� -- --------------------------------------- U attire of Repairs or Alterations—Answer when applicable----------------- ---------- ________________________________ Agreement: --------------------------------------------- ---------•-- The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE; 5 of the State Sanitary Code= The undersigned further agrees not to place the system in operation until a Certificate of Compliance has is tied by the board of health _..-- igned - __- -- ---- = - ----- /0 - l " �.7 - --- Application Approved By--------- e Date x- ---- -------------- Application Disapproved for the following reasons:----------------- Date ------------------------------------------------------------------------------ -------------------------------------------• ------------- ----------------------------- ;. Date Permit No--------------------------------------------- Issued =- ` = -_ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD HEALTH ........OF...... .-�- Tafffiratr of (gAnt�Ilt�tYtrl' TH ITOC RT That e Individual Sewage Disposal System constructed ( ) or Repaired ( ) by~--_. . _.... ff p at- oz77 F - .: has been installed in accordance with the prow' c TI - -- --------/-0 ns of The State San as described in the ------ - - 5 f itary C4 e application for Disposal Works Construction Permit No.___ �"' l ...........-----• dated-----f�----'`-�-�-��--------•--.. THE ISSUANCE OF THIS CERTIFICATE SHALL I�®T BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION..SATISFACTORY. i DATE.................. > t r J - Inspector n F' � 11 � � . L0� ATION SEWAGE PERMIT NO. � e / 4c t- &: Ae, VILLAGE N S T A L L E R'S NAME & A D D R E S SJ. CRAIG MEDEIROS Truchme 14.2 Corporation Street B U 1'L D E R 4R OWNER �s, > ass° -0828 DATE PERMIT ISSUED DATE COMPLIANCE ISSUED 9 a • s NO G , 0.J7 7 45-1 Fim......V' N .. THE COMMONWEALTH OF MASSACHUSETTS BOARD 9f HEALTH ;;7 k..............OF......../. ................................................. 57- Appliration for Uhipoiial Work.5 Tomitrurtion rumit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: 1-o-r 3 --*/k "miL-t-srope- Lo P a C- �J-Vtf(Z V1 LL E5 .................................................................................................. .................................................................................................. Location-Address or Lot No. Y ..................................................... ............... ........................... Owner Address .................................................... .................................................................................................. Installer Address U Type of Building Size Lot___.�_...ofj,...a..17'.C..........Sq. feet Dwelling I-No. of Bedrooms------ ..............................Expansion Attic (L-1- Garbage Grinder (00) Other—Type of Building ........... No. of persons---------%3................ Showers ( 2-) — Cafeteria aOther fixtures ........................................................................................................................ f---------------------------- Design Flow............................................gallons per person per day. Total daily flow............Q.V ..................gallons. 1:4 Septic Tank—Liquid capacity/PP O..gallons Length________________ Width ------------- Diameter..__...._.__..__ Depth.............. Disposal Trench—No........j.......... Width_*.�_.. Total Length---- ..... Total leaching area....... -----&6 Sq. f t. ------ Seepage Pit No-------J------------ Diameter........Z1Z------ Depth below Wet- 6 Total leachinga arediPL-.. ...sq. f t. Z Other Distribution box (1,-� Dosing taAk 7zi 0-;Z/- )7 Percolation Test Results Performed by.___:_. ............................ Date...... -,2 ......................;�......... Test Pit No. I ---minutes per inch Depth of Tes5?it ------------------- Depth to ground water_____.. (Zq Test Pit No. 2................minutes per inch Depth of Test Pit...._...-._.____--__ Depth to ground water..._.__..._._._.._.____. P4 --­--------------------- ......14........( ....... T.... 0 .... ...... esgript' D ion of Soil....... --- ---- U ............ ................ ----------------------------------------------------------------------------------------------------------------------------------------------------------------------.............. U Nature of Repairs or Alterations—Answer when applicable--------------------------------------------------------------------------------------------_. ...........I.................................................................................................................................................--------­----------�................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TL I Ti LE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b is ued,by the board of health ,-�lgned ... .. ....... ........U= A. ............................... .... Date Application Approved By--------- ......... ........ ................ .. ............. --------- ...... Date Application Disapproved for the following reasons:................................................................................................................ ........................................................................................................................................................................................................ Date Permit No. Issued_---= ................. Date No FEB...... THE COMMONWEALTH OF MASSACHUSETTS BOARD HEALTH .. oF....:.. --- -------------------------------------------------- App iration for Bhiposal Works Tonstrurtion ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ........._..__._ •--- -- ...ij a....... ................. .. .•--•- _.. ..------••-------------......--•------ 6 Location Address or Lot No owner Address Installer Address as U Type of Buildinyg � Size Lot_ P ________ _ _______ G______S feet �., Dwelling No. of Bedrooms__.___.2..______________________________Expansion Attic (owl' Garbage Grinder (�dj per, Other—Type of Building ---------- No. of persons________............... Showers Cafeteria ( ) a' Other fixtures - ----•---..._•--••-------- W Design Flow.................. ` _ gallons per person per day. Total. daily,flow_-_________�l �______.________gallons. WSeptic Tank—Liquid capacity q.O gallons Le 'th _______________ Width_. _ Diameter................ Depth................ x Disposal Trench—No.........1......... Width Total Length- ----- Total leaching area � sq. ft. 3 Seepage Pit No.......I........... Diameter........III...... Depth below ' let__ .__ Total lea hi gg��area� ___sq. ft. Z Other Distribution box (Y Dosing to ( ) _� Ic Percolation Test Results Date__. ____-Zl, 7 7 Performed by._--`-- --- _. Y Test Pit No. 1 _:t_:.minutes per inch Depth of Test it___________________ Depth to ground water___._1 ___.*? _:. G>~ Test Pit No. 2............_...minutes per inch Depth of Test Pit.................... Depth.'to ground water............_........... + h Des9ri t;on of Soil .F9 " .. , ' .'" G UA. ' UW ---------------------------------------- --------------------------------------------•-•_---• - 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 TIME 5 of the State Sanitary Code.-The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b is ued by the boaarddjof health g' " igne -•..... board {-1�....!........ ............•------••-- •--�� --................_.._ Date r Application Approved By... �- ....................... •----•-•---•-- .......... -- ' Date, Application Disapproved for the following •reasons__________________c_ ..............•-----•----......_....-----.....__....-----------•-•---•--....---------...--•-•-------••-•------------------•------.------•----------------------•------------.•------------------••-•--- Date Permit No.........................:............................... Issued..... ` '"' W Date THE COMMONWEALTH OF MASSACHUSETTS BOARD O. HEALTH �...........oF........., f ' ` ' ....... .................................... (Inrfgfirate of Tontpltnnre TH I 0'C RTC That e Individual Sewage Disposal System constructed ( ) or Repaired ( ) by' `. .. ........ or Insta e has been installed in accordance with the prov�i ions of TI �� f The State Sanitary C de as described in the application for Disposal Works Construction Permit No._.: � r___-______. -• dated..... `"✓ls.''.? _____________ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY DATE.................... Inspector_... e L - . -•- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH /- �"' ?�°',y7..........OF.: ...............................:.............. No......... &�.Sr� FEE--- ............. �r�,ion �ernti� Permissio i here " ranted_____:_E.._!'? g -. ---• to Constr ct ep,"'� ( ) dlvld evtf Is os ys atNo._`__ki ............................................... / Street p 'as shown on the application for Disposal Works Construction Per No Dated./_ ..................................- ;. oard of Health DATE:.-••--••---`o`Z—/ . FORM 1255 HOBBS-& WARREN, INC.; PUBLISHERS r TO/� OF FoV.ti'OAT/O^/ /'I S L t @ El_ 56. o 54 - �D BoX /coo *qt }�- - _ \ . 5/ - 53.44 53.6 y so 49 .__ - . _ __ _ .S�•82 w 46.82 48- - 47 - - - - - - - GXiStir' yr0ur7o/ prof; /G 5 C / / O i d./ ' -o—o-o-a= proPosGel 9roci�� prof;/e. l/ E- �eT. SGAL B : /' _ / o 5C.HEO. EQvAL To SEPT/C - - - A�l - — i 3 Got 56 8 ti I000 c3GAG. SE�r�t Ti9N,� 4AJ6t5f7CCV Stone /( \ G.EAGH P/ T 90 �' \ 1 AJ ? /'4'-7/ O e_ e! 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