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HomeMy WebLinkAbout0042 MONOMOY CIRCLE - Health 42 MONOMOY CIRCLE Centerville A = 190 - 199 5MEA,D KEEPING YOU ORGANIZED No. 12534 2-153LOR SUSTAINABLE FORESTRY MIN.RECYCLED AfnkINITIATIVE CONTENT IA W CoNfied Fiber Sourcing POST-CONSUMER venvsriproa.p SFF012p0 MADE W USA GET ORGANIZED AT WEAD.COM �2 :*'Y a � ' � �=� _ t sue_ zap Ilk NO - x ano DT? file D(_jl P.O. Box 2119 En �ornena 'p_ f6 �On-: - _ ;Teat' MA 02536 , ' -�v+. �-4.:.w-i.. �'�z� ,:1°'.'i'�i 4-. Ya.��-ie.��z. 7.i•'.�'�T ..� {-•...i.•..^'m�cx^�':S— SUBSt712FACESEWAGE DISPOSAL SYSTEM INSPECTION FORM CERTIFICATION i Property Address 42 Monomoy Clrcfe Ceatervllle � `'�} W. � Date of inspection:101V9s Address of Owner. t Name of Inspector:John tract (if different) 021 Walsh 14 Porter Rd.Waltham Ma. 54 Company Name;Address and Telephone Number: CERTIFICATION STATEMENT I certify that Lhave personallyinspected the sewage disposal system at this address'and ttia and oomplete as of'tl e'time 9`ins ction" The.mspection was performed based on.my train nthand-experience reportedon the mope is true, accurate P 9 P p per function and maintenance�`of on site se'wa a disposal s stems The system: x_,:Passes Conditionally Passes Needs Further Eyaluation By the Local Approving Authority _ Fails inspector's Signature: 1 ,(wy Date: 10117196. The System Inspector shall su mit a copy of this inspection report to the Approving.Authority within thirty(30)days of completing this inspections. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional,office of the Department of Environmental Protection. .The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. INSPECTION SUMMARY: Check A, B.C, or D: A] SYSTEM PASSES: X I have not found any information which indicates that the system violates any of the failure criteria defined as in 310 CMR 15.303. .Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no,or not determined(Y, N, or NO). Describe basis of determination in all instances. If "not determined", explain why not.) The septic tank is metal, cracked,structurally unsound, shows substantial infiltration or exfiltration,or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 11115195) One Winter Street • Boston,Massachusetts 02108 . FAX(617)556-1049 • Telephone(617)292-5500 1 A 'K4s3-- -- -.3a",s��s.fix" , - ^�i,. '�.r •'tse' .,saS3. t c s - i a ..+M Aig— SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - - _- - PAF1� A _ _ = E - eERI7oC- cgkl[ uie - d' _ p rty Addiess :42"Manomoy Ctrcle Centerville= _ `. a ; Owner Walsh 14 Porter Rd Waltham Ma 42154 Date offngsipeotlon 1'lliff/96 _ x'�--. �- rs .�.� ��!8ErQ1[F'o�hrPA�2.71`ttt A11 htJll=-e�lfl� `�— •'�'• '_' ^,-^}:-"s- ." .- �c.�s.^ `-c. --=.,�- �:=-'`. broken pipers)ace:r-eplaced - •�w4ti'Rz � L _-_ i. + -f - -o-bstr_uctlot is emaved distribution boz is leveled or replaced The system required pumping more than-four times a year due to broken or obstructed pipe(s).. The system will pass inspection if(with approval of the Board of Health): broken pipe(sj are replaced obstruction is removed C] FURTHER.EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: ` _ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the:publip-health;,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF1 HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER'WHICH WILL PROTEC T THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of'a surface water Cesspool or privy is.within 5d feet of a bordering vegetated wetland or a salt marsh.;_. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER, IF APPROPRIATE)DETERMINES, THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has aseptic tank and soil absorption system and is within 100 feet to a . surface of water supply or tributary to a surface water supply. _ The system has a septic tank and soil absorption system and is within a Zone 1 of a public water supply well. The system has aseptic tank and soil absorption system and is within 50 feet of a private water supply Well.The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria volatile organic compounds.indicates that the well is . free from,pollution for that facility and the presence of ammonia nitrogen and nitrate nitrogen,is equal or less than 5 ppm. 3) OTHER 0] SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage in facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged. cesspool. SAS is in hydraulic failure. (revised 11115195) 2 �` r�-_.; 'ta���3s�rasn `-r--� �-_��+�-�.�`��z:`��-3 r*�i+��s•� �- �a��t �• �.��`�Gs� �r � .. ¢ ::. •. '"' �—..; _< _.-.,:.- .,i�ram:: --.. c '; r �.. I,'. - - SUBSURFACE°SEWAGE DISPOSAL SYSTEM INSPECTION FORM` - r PAR ;A PloPerty} dress'#2 IVtd�om071C[cfe Centerville- _ Owner. Walsh 14 Portet Rd Waltham Ma 02758 Dade of Inspection 40/&98 - - — - t _ Static liquid level m the distribution box_abo!ce_outtetAMe0-due-to an-overioaded°or clogged-Sa56r cesspool: Liquid depth in cesspool is less than6"below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). :r Numbers of times pumped Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of`a surface water supply or tributary to a surface water supply _ Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any.portion of a cesspool or privy is less than 100 feet'but greater than 50 feet from a private water supply well with no r acceptable water quality analysis.,.If the well has.been analyzed.to be acceptable, attach copy of.well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a.significant threat to public health and safety and the environment.because one or more of the following conditions exist: the system is within 400 feet of a surface drinking water supply the system is within 200'feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area (IWPA):or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 11115195) 3 a _ i a r � k.- � M "'`"=" SUBSURFACE 3EYICAGE;DISPOSAL:-SYS.T.EM INSPECTION.FORM.' e ; taK Zi r Pf6perty7�cCdTess�fi2MOffftdVCtrere_Ce`ntervffle r = ;. OW ref Walsh 1aPortecRtl WalthamMiiLt215� _ =Data oflnspectFon ie18/96• � H: .��-_tea---��"� - ,--•�=- �- t. Check-if the_following,-have been-done. X Pumping information was requested of the owner,'occupant, and Board of Health. X None.of the system components.have been pumped for atieasftwo:weeks and the and the system has been receiving normal. flow rates during that period. Large volumes of water have not been introduced into the.system recently or as part of this inspection: X As,buiIt plans have been obtained and examined. -.Note if they are not available with N/A. X` The facility or dwelling was inspected for signs of sewage back-up; x The system does not receive non-sanitary or industrial.waste flow. X. The site was inspected for signs of breakout. X All system components,excluding the Soil Absorption System,have been located on the site. X The septic tank manholes were uncovered,opened, and the Interior of the septic tank was inspected,. for condition of baffles'or tees;material of construction,dimensions, depth of liquid, depth of sludge;depth of scum. X. The size and location of the Soil Absorption System on the site.has been determined based on existing information or approximated,by non-intrusive methods. ,y x The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub- Surf ace Disposal System. - xl (revised 11/15/95) 4 qq SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION'FORM. PART.C, Property Address 42MortamoyClrNeCentervllle~ - -- - - _ — �OWne� Walsh 14PorterRd Waltham Ma02154 - -�- Date:ofins�ection ilN8t96 - �' Destgn ftvvrr yaRons - w - Number of current residents:. 9: - Garbage ghnder:(-yes or no)° Yes Laundry connected to system(yes or no): Yes Seasonal use(yes or no):No _ Water meter readings,if available: nla Last date of occupancy: June 1996 COMMERCIAL/INDUSTRIAL: Type of establishment: rda Design flow:o gallons/day Grease trap present;(yes or no) No Industrial Waste Holding T-Ank present: (yes or no) No Non-sanitary waste discharged to the Title 5 system:(yes,or no) No Water meter readings, if available: .n1a Last date of occupancy: n1a OTHER: (Describe) nla Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System has not been pumped since new system installed in 1995. System pumped as part of inspection: (yes or no)No If.yes,volume pumped. U gallons Reason for pumping: n1a TYPE OF SYSTEM X Septic tank/distribution box/soil absorptions 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)and source information: 7113195 Sewage odors detected when arriving at the site:(yes or no) No (revised 11115195) A _r a Mal yNR se .aa.`r-o-�' a'"Q•� xt fo-•�f�;-'i'�_r:,-a,..ta««�..+.ass-.. ''y" '".+ae^ Tr'kk+t'4"ik'sY�m '. _ SUSSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM'. . ... P -PART C ._ . ;r - - .f.. Property Address 42 MonomoyCirele Centervt Ile: _ — Owner: Walsh:14 Porter Rd.-Waltham M&02154 Date of Inspection 101V96 VAF k -Material'of construction:X concreate metal=FRP_other(explain) - = Dimensions: L a'e•H 5'7'w 4-10' — Sludge depth:2' - Distance from top of sludge to-bottom of outlet tee or baffle:25' Scum thickness:1' Distance from.to P of scum to to of'outlet tee or baffle:_6' P Distance form,bottom of scum to bottom of outlet tee or baffle:14' Comments.; _ (recommendation for pumping, conditi=of inlet and outlet tees,or baffles, depth of liquid level in relation to outlet invert,structural integrity, evidence.of leakage, etc.) Septic tank and all components are structurally sound.Recommend pumping system every two years for maintenance. GREASE TRAP: (locate on site plan) . Depth below grade: nla Material of construction: concrete metal_FRP other(explain) Dimensions: n1a Scum thickness:rda Distance from top of scum to top of outlet tee or baffle:n1a Distance from bottom of scum to bottom of outlet tee or baffle: n1a Comments: (recommendation for pumping, condition of inlet and outlet fees or baffles,.depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) n1a (revised 11115195) 6 . ._ - rz 7. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM R - PARtC - T { Pr , Ti,Fuati�� Property Address 42 Monomoy Circle Centerville OWner _ Walsh 14PorierRd Waltham Ma 02154 . Depth below grade:.n/a Material of construction: concrete_metal_FRP_other(explain) Dimensions:'Na Capacity: n1a gallons Design flow: nda gallons/day' Alarm level: n1a - comments: (condition of inlet tee condltlon.of alarm and float switches etc.). DISTRIBUTION BOX: (locate on site plan) Depth of liquid uid level above ouet invert: n1a. - Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box etc.) Na PUMP CHAMBER: (locate on site plan) Pumps in working'order:(yes or no) Comments: (note condition of pump chamber;condition of pumps and appurtenances, etc.) Na (revised 11115195) 7 y � , ..g ,,;, -.�.. '"a-" -z",ra.. "'�'cs*�^-- •r'',. ems-_" "ate,,. x. .F'"'�xa� <<-. -.. -- ...' •w .._r-, -�„r .-+.*�' `�e,. s-i+-�z �r m. s"'_`" z_ '�-es-T wy: "" � S�78t3t1RFACE SEUUi0.GE DISPOSALSYSTEMINSPEGTION FORM > ` — �F0 / TlON cssntlrrue_d-h fil)1 -. :-J�r4per>y/Xcidres2 Monomey_Circle Centervule r' 'r --� � --iNa(sh-'Y+LPoi'tec Itd-WalMairrMa«�2.154 �-� _ _ r. r•a ..?.. `-'�'+:tom ter• -.F.-? -re _ ��ur�y-' -�-+s-+.�--v-.aac i (locate on srfe plan ifpossible;excavation roof required but may appr oximated'by non-i'nfii'siv methods) = • not.determined _:. _n1a Type Type: - 'leaching pits,number.: n1a 'leaching chambers,number:nia leaching gallerias,.number: n1a leaching trenches,number; length: 2.38'x2'x2'leach trenches leaching fields,number;dimensions:n1a overflow cesspool, number:n1a Comments:(note condition of soil; signs of hydraulic failure, level of ponding, condition of vegetation, etc.) -Fhe sas is functioning propery :CESSPOOLS: (locate on site plan) Number and configuration: We' Depth-top of liquid to inlet invert: n1a Depth of solids layer: n1a Depth of scum layer. ` nia _ Dimensions of cesspool: n1a Materials of construction- n1a Indication of groundwater: nia - inspection) inflow(cesspool must be pumped as part of mspe ) n1a Comments: (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.) Na . PRIVY: (locate on site plan) Materials of construction: nla Dimensions: n/a Depth of solids: Na Comments:(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,etc.) PrivyComments (revised 11115195) 8 _ . .ram- .-.'= rUSFACESE:WAGE`QISeOSAt SYSTEM INSPECTION FORM_ k ' PART C — = _ - z� F92F.�11 ttJFQLt1VtALON�continued� r� Date oflnspect4on-1U18J9B- � .� "`"� _ - `5-�tt�,rz �...:7 _,�•--,. ,� -` -g.,...�".4, .::--�-`- :^-= Na t tp- - .v. ,;r --+' s2. - _ —=_�a,i�c„Fe,`G��I�RCi~S-A��3�5-�E�VE Y ti:. s- _ s =�,� — z.. - u�, •--�'�, � �.- - ,^.--�;.�? - x _ "Iota e-alf�xe(�v'�t q�''.�)�� -�-- � � �4- _ �.�..e4_ sL - �- - - •- a uAt DEPTH TO GROUNDWATER Depth to.groundwater:15 feet . method of determination or approximation: As-built (revised 1111519% 9 ASSESSORS MAP B THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH TOWN OF BARNSTABLE Appliratinn for Diipu3Ml Vork.6 Towitrur#iun Frrutit Application is hereby made for a Permit to Construct ( ) or Repair ( Individual Sewage Disposal System at: ------------------------ Locati or Lot No. .r4 2 _ --------•-------_----- •---------....................................................................................... Oner W ddr ,.a -•-�•..I..------..&.V.4.1� w------------------------------------------------ -------------------------------.....................................S�/� ,Eon----------------------------------- Installer Address UType of Building Size Lot............................Sq. feet Dwelling— No. of Bedrooms.-------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) 04 Other fixtures ................................ 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. 3 Seepage Pit No...__/............ Diameter-------C._._.... Depth below inlet.................... Total leaching area................„sq. ft. Z Other Distribution box ( ) Dosing tank ( ) � Percolation Test Results Performed by......... ............................................ ................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit_----.--____.-.-__- Depth to ground water........:.............. . 44 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water....... ............. OIx •---•------•------------•-•-••-•--••••-----•-----••••-----•••••••---•••-•-----•----••-•-----••--••--•-----••......-••••....••. -----••-•---•-- Description of Soil-----------------------•--------------------------------------•------------------------------------------------------------------------------ - - x x -- ---------------- Nature of Repairsr Alterations�ns hen appl• ble._.--..G�,+� __U = I•• = -----------------------------------------------•--..... .......................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environ Code —The undersigned further agrees not to place the system in operation until a Certificate of Complia e has ee issued e bo f health. Signed --------- ----- - - - ----- ----0 ........... ................. .. .............. Dare r Application.Approved ....... -- ----- ......................................... ... ........ Dare Disapproved for the following reasons: ................................._......- ------- Application. ............... .......................... ......... ......... ........ --------------------------------------------------- PermitN .....-- .. . .. ..... Issued .......� � .-........I-- - � ...........-.......... ................ ......--------------... .------ � a.t-e----.-.-.-.--. ...... ...... Dare THE COMMONWEALTH OF MASSACHUSE175 BOARD OF HEALTH,' TOWN OF BARNSTABLE Certificate of CITompliance THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired,( �,..)__ i by .......... ....__T._ .....Ife->R.I4,_ -._--------------------------------------.....-------------------------------------------------------.._...----------------------------------------- In r 11 i has been installed in accordance with the provisions of T T p51of.The State Environmental Code as described in the application for Disposal Works Construction Permit No. dated ;,1 -"''. , - THE ISSUANCE OF THIS CERTIFICATE SHALL NO BE CONSTRUE AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY DATE ���._ ../... ...... �� Inspec�f... . ....__--..---------- - r THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN-OF BARNSTABLE /( FEE ,c!.� Permission is hereby granted/ ---- --. .... ------------------------------ ................................................ to Construct ( ) or Repair (C-r)—an Individual Sewag Disposal System / at No..........1�......---- /4/ --------......C'.'-.. G / <<2!// �tp ------ ---------------------------------------------- street — as shown on the application for Disposal Works Construction Pe it � � ated..-. ' ."'_fd_--_.-��-..------ ' a ------------ �, �r� Board of Health DATE------------------��..------,� ----------------------- FORM 36508 HOBBS 6 WARREN.INC.,PUBLISHERS M 190 _ No..l_._....:_..._...w.. f F�s.. ...... ......... THE COMMONWEALTH OF'MASSACHUSETTS ' BOARD OF HEALTH s TOWN OF BARNSTABLE 4 , Aplitiration for Binpngtt1 Wnrk,i Tilt itxttr#iuit rautit Application is hereby made for a Permit to Construct ( ) or Repair (Individual Sewage Disposal System at // . ..................... ..... -----••---...------•-----•----••-•------------••••--•--...._..-•-_- Locati i-rA44fe . or Lot No. Owner _ ddr ----------------------------------------- ---------- Iustaller ••- Type of Building- - t SizerLot............................Sq. feet �-, Dwelling—No. of Bedrooms--------------------•----------.__.____..._.Expansion Attic ( ) Garbage Grinder ( ) I aOther—Type of Building ---------------------------- No. of persons------------------------...._Showers ( ) — Cafeteria ( ) 1 } d Other fixtures = W Design Flow............................................gallons per person per day. Total daily flow---------------_............................gallons. 1:4 Septic Tank—Liquid capacity/OaQgallons Length---------------- Width---------------- Diameter.....----------- Depth................ W. Disposal Trench—No. .................... Width-------------------- Total Length._____...___._...... Total leaching area.................... ft. x 7 Seepage Pit No----,f`..---------- Diameter..._._s_�........ Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank Percolation Test Results Performed by.----------- ••------------------ Date... -= � ......•--•-•---•-•-•---- Test .Pit No. 1................minutes per inch Depth of Test Pit._.___--_-_--.--.-__ Depth to ground wader...._...._............. 91 Test Pit No. 2.........i------minutes per inch Depth of Test Pit.................... Depth to ground wate ....................... •-----••---------:--..........•.......................•-•---•--•-•---•---•--••--------•--- '� Description of Soil-------------•-_--. -----------------------------------------------------------------•---------.-•--- V ...................................•-•----•-----•--.....-•-----•-•------•--•----............---....-•---.....--------•-•---••---•--...--•---••--•---.....-----•-•-•-•-----...------••-•••-•-•••---...... .............. --•----------••-----------------------------•---••--•-----------•-------•--•-------••..... 41� V- Nature of Repairs or r Alterations,- ns v=vOhen appl� able.-•----------.......---------------------------------------------------- •-------•--------------•. Agreement: ; The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmen-ta1,.Code—The undersigned further agrees not to place the system in operation until a Certificate of CompliaA e has bee issued e bo� f health. • Signed . - ._ ----------- ° �S.... / y'- Daze Application.Approved - Y �,✓rd °�L� ..... Dace Application Disapproved for the following rearons: ............................................ _.... - _.... -------- �-----------------------------------------_ ...........------------------ ---.....-.............. ...... _......----------.-------- ------- ... —Hate - - Permit No. _. .._. �� -........._ Issued '���'� --------------- Dare TOWN OF BARNSTABLE LOCATION ` 1- G e SEWAGE # O - VILLAGE V ( l �P ASSESSOR'S f &LOT� �f INSTALLER'S NAME&PHONE NO. o -L f. C SEPTIC TANK CAPACITY �v o / LEACHING FACILITY: (type) �` 32 . size 4- NO.OF BEDROOMS BUILDER OR OWNER �fl Ta?iC!/t PERMITDATE: -7 - to S COMPLIANCE DATE: -7 13-_ P, Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility I/S Feet Private Water Supply Well and Leaching Facility (If any wells exist / on site or within 200 feet of leaching facility) / `' Feet ? Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) . y� Feet Furnished by f. 1 Rai- r ;lq' _I LOCQT10 '' ENNJO C,E PERMIT UO, VILLAGE WS'TA E .5 ► 66ME ADDRESS BUILDER ' 1.1 A DDRE SS DNTE PERNA T ISSUED D b.TE COMPLI &KiCE ISSUED : — — — C2 00 No.. ••••--•--- Flnc........t.0.......... THE COMMONWEALTH OF MASSACHUSETTS BOARD HEAL ^A p ......OF.......... ' Wes• (..�... ... .. .. ............ ........ .............................. Appliration -fear Dhip vial Vv&a Tutuarurtion Prritit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ..•. ....... ------- -•-.••........... ....• ..........• ......•.• .......................................... Locatio -Addres or ...... -•- • .................. - .................................................... ......................• ..... --.............• ........................ ner ddress W Installer ess UType of Building Lot____________________________Sq. feet «-� Dwelling—No. of Bedrooms.......... _____________________Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures - ------------------------------------------------•-----.----_-----------------------------•--•---------•---------------••-•---------------------- W Design Flow...........................................gallons per person per day. Total daily flow............................................___-__-_.__.gallons. WSeptic Tank—Liquid capacity�� allons Length................ Width................ Diameter-__--....-.-___ Depth-__._-.__.__--- x Disposal Trench—No. ................ Width-----------------.__ Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit Diameter.................... Depth below nlet____._;._.......... Total.leaching area_.___..-__-___-___sq. ft. z Other Distribution box ( ) Dosing tank ( ) O, /`a��'� °- l G ' ?— 7 J Percolation Test Results Performed by-------------------------------------------------------------------------- Date-----.----._-_-.-----------------------. Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water........................ f14 Test Pit No. 2................minutes per inchD"ee th of Test Pit.................... Depth to ground water............___._____--- O Description of ....... a. l ��• ---- - '— � ....U � ` ..... x ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- U Nature of Repairs or Alterations—Answer when applicable...___________________________________________________________........_------------------------- --------------------------------------------=-•-•---•-------•--•---.-------•------------•------.---------------------------------------.------•---•---------•--•-------•-•------•---------------------.. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been ' e by the r p f health. Si --------------------------------•-.• Date Application Approved BY --- • . - • .../L=1.."..7 - Date Application Disapproved for the following reasons:.- ---------------------•.______.._......._._____-----...._._....._.......___.__......... --------------------- -----------------------------------------------------------------------------------•--•--•---••--••--------------------------------------------------------------------------..... Date PermitNo......................................................... Issued........................................................ Date No..Wr........... 1�...(.�r.F�a...... ......... THE COMMONWEALTH OF MASSACHUSETTS BOARD HEAL _OF.......... ....... .............................. Appliratinn -for 43Wli iial Workii Tonfitrnrttnn Vantit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at .......................................... ocatio Addre or' .. ... ...... ............................................ ....................... .....: -- • ....................... W wner Address ----------------- Installer Ad ess UType of Building Lot-_--__-. -___Sq. feet «-� Dwelling—No. of Bedrooms--------- _____________________Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures W Design Flow...._.____.....:__- ....................gallons per person per day. Total daily flow................ -------------gallons. WSeptic Tank—Liquid capacity/, allons Length---------------- Width................ Diameter................ Depth..-_____._.---- x Disposal Trench—No. -,4................. Width-------------------- Total Length-------------------- Total leaching area--------------------sq. ft. Seepage Pit No.;- . Diameter____________________ Depth below let.... Total leaching area...---.-_-._-___sq. ft. z Other Distribution box ( ) Dosing tank '~ Percolation Test Results Performed b - = ................................ Date.............._.____._.__._-_--.----.. Test Pit No. 1................minutes per-inch Depth of Test'Pit...._._._:__.-____-. Depth to ground water:...----__-_.__._-.-. (4 Test Pit No. 2________________minutes per inch De th of Test Pit.................... Depth to ground water.._..._:__-__-.---_---- P4 ...� . A =.. . ----- O Description of ,�1 W w � _ I " " yr (� '----------------------- .__._.-_ _______ .. - .----' -- ------.._._.. _----------._.. .......- � - vc----------- --------- W U Nature of Repairs or Alterations—Answer when applica.ble................................................................................................ •-------•----------•------------------:--------•-••----------------------•-•-....--------•-------•------------------------------------•----------•------------------------------------ ...... Agreement: he agrees - thee, r`ovisionseoftArta le �I of o 'Install the theState'Sanitary The vidual Sewage further Disposal System-i,�i,n accordance with ' p y g not ,to place the system in operation until a Certificate of Compliance has been by the r f health. Si . . ............................. -•-•--••-•--•-•------ ------------------ ---------•-- � Date Application Approved BY---fir .:--- �- ---�"�`�''t. .;:.. �----------------------------- ---A�".��/---"� �~-��-------. Date Application Disapproved for the following reasons':..... -------•-------------------------------•-...•----------------......---•--._...------... .......................................................:-------------------------------•---------------------------------------------------------------------------------------------------------------- Date PermitNo. •_---------•-----•-••-•----•--... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD HET ........¢' ........ OF:... .. r' %rrtif iratr of- f"nmplittnrr THIS IS4TJEY, T t Jhe Individual Sewage Disposal System constructed ( ) or Repaired'` ) --------- - - by r nstller (at. a ---�/., has een .._....__ installed in accordance witrWe provisions of : t 'e XI of The State Sanitary Code as descri ed in the application for Disposal Works Construction Permit , ,�..�, :'_ __ _ __u� ....._..__. dated _ .......... THE ISSUANCE OF THIS CERTIFICATE SHALL. NOT BE CONSTRUED AS A GUARANTEE'THAT THE SYSTEM WILL FUNCTION SATTIISFACTORY., DATI // -------- &'-----------------------•-----.-. Tospector-_oZ ! ....................... THE"COMMONWEALTH OF MASSACHUSETTS F BOARD HEALTH FE iri ntitt rh r Lin tin mtt Permission is e y granted...... ,.. t to Construe ( ) or Re ( „�)`an Individ S'�wa Dtspo s at No. III I A 4 as shown on the application for Dispos orks Construction P i o....... _ __.�,:._ - ........ / -- ' - ----- ------- - ---------_... / Boar of H Ith t' DATE F . ..,�� _ FORM 1255 O S & WARREN. INC.. PUBLISHERS } i r1O � or-AC) cI ;zc- E l O�,3�C:)C)� �QRA be, ` LoT --0 t . P c (T a 2 s \ 3 IA W , `r f<t •• i��ri o� CERTWIE© ROT t'"L.AN 47 i FLAN ?,E F a Fl e R C E - Zcai,.rJr�✓G ..Ph K7.�" '• 7"" 'AY V <: PLAN R.F'G. 3,Z-f Z 58 S -YTF c D/17W /V47 V 2! j''S'7,,,,,s&— LAsXD SURV 5yo;45 t � MASS. _QTd,.igTCQ I�iJta 2 0 e.,. PET IT t OR§.�P,