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0426 NOTTINGHAM DRIVE - Health
426 NOTTINGHAM DR., CENTERVILLE A= 148 031 Nop215 LOR HASTINGS,MN TOWN OF BARNSTABLEJ� L0CA7.'ION /V0 y�l—e,04' d SEWAGE# t VILLAGE �i>° �vli�� ASSESSOR'S MAP& LOT INSTALLER'S NAME dt PHONE NO. SEPTIC TANK CAPACITY l.aoQ GAL LEACHING FACILITY: (type) 3,r4 Lnntti s (size) )0t9 Z,2 NO.OF BEDROOMS BUILDER OR(� 'Cr, HJ PERMIT DATE: 10"ZY—QS COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist . on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by f _ F�! ,� •�E t �+ a�'S•� . . No. Fee—\`` � THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Xes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS Zipprication for Dfgpogar *v5tem Construction Permit Application for a Permit to Construct( )Repair(✓)Upgrade( )Abandon( ) El Complete System "-dividual Components Location Address or Lot No. p , / ® � Owner's Name,Address and Tel. o. "[LQ /iW� ®�' " e�� Assessor's Map/Parcel �e)d# �/ / � Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 1y Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder(,A�p Other Type of Building e No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow d140, gallons per day. Calculated daily flow 3 3e gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank 1:16169 m 4WA.0 Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 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 Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued hy this Board of Health. Signed Date Application Approved by Date J Cj 5 f Application Disapproved fort follo ins reasons Permit No. Date Issued 19 No: G G Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE,, MASSACHUSETTS Zippr catfon'for M-4pogat *pgtem Construction Permit Application for a Permit to Construct( )Repair(v )Upgrade( )Abandon( ) O Complete System Individual Components Location Address or Lot No. �1 Z/ �D„[,� „/ .� D� Owns Name,Address and T�o. ode 6/P/ Assessor's Map/Parcel �'�v� ��'v, Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. BorfoGo�1 �0�/57` 7 71-93��Y Type of Building: 1 , Dwelling No.of Bedrooms Lot Size: sq.ft. Garbage Grinder( � Other Type of Building �°z,5/4: f//-eNorfiof�Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow llZ:-/ gallons,per day., Calculated daily flow 3�� gallons. Plan Date ']Gnb of{sheets " Revision Date Title Size of Septic Tank X/s ��% ����� - Type of S.A.S. -1wee Description of Soil t Nature of Repairs or Alterations(Answer when applicable) `W_ 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 Environmental Code and not to place the system in operation until&Certifi- cate of Compliance has been issued y tt Board of Health. Signed t ' Date Application Approved by Date /0-;k Application Disapproved for the folloxVing reasons Permit No. Date Issued --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the-On-site Sewage Disposal System Constructed( )Repaired ( )Upgraded( )\ Abandoned( )by &f OLo 11J CO�s7` - at �i 400 /r'9 e;7 r Cep fv1 - has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. �S-`S'G ,,dated„ ,, x " Installer Designer The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date - / q q� Inspector --------------------------------------- No. Fee \5 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE,, MASSACHUSETTS w1f 5 pogal *pgtem 'Congtruction Permit Permission is hereby granted to Construct( ) epair( Upgrade( )Abandon( ) System located at Y2-6 0�I', C 2� � and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date: rl _ �. y - �� Approved by t10 Oo[ q r �yv � K � r s� r 10/9/97 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT ENGINEERED PLANS) hereby certify that the application for disposal works construct p g Y ion permit signed b me dated ®! ��� , concerning the property located at e5�W,*'7/40kets all of the following criteria: There are no wetlands located within 100 feet of the proposed leaching facility There are no private wells within 150 feet of the proposed septic system There is no increase in flow and/or change in use proposed There are no variances requested or needed. }' If the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the proposed leaching facility will=be located less than fourteen(14.) feet above the maximum adjusted groundwater table elevation. Please complete the following: A)Top of Ground Elevation(according to the Engineering Division G.1.S.map) ° B)Observed Groundwater Table Elevation(according to Health Division well map) SIGNED : DATE: LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. q:health folder:cert 3 �� O TOWN OF BARNSTABLE LOCATION 071 l`ti�ti/?D�1 Ar• SEWAGE # VILLAGE 6-e-14/�� ASSESSOR'S MAP &LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 1,aaQ Gk LEACHING FACm=: (type) 3.rL L�r.,4 Gl�,�yi-s ( (size) NO.OF BEDROOMS BUILDER OR( N�F�B PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) /v Feet Furnished by i ! M BORTOLOTTI CONSTRUCTION, IPdC i Z 1998 765 WAKEBY•ROAD,MARSTONS MILLS,NIA.02648 raofPTge� 508-7714399 508-428-8926 .FAX: 508-42..8-9399 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION;FORM Of PART A CERTIFICATION r, R ,,q 1 *P q Property Address: Date of Inspection: / Inspector s Name: Owner's a an ddress: 44) R i 'Ns M1 .}k'4yW - CERTIFICATION CTATF.MFNT• I certify that1haye:.personally inspected the sewage disposal system at this address and that theInforma- tion reporteti,below is true,accurate and complete as of the time of inspection.The inspectlon�, p's formed based on my training and experience in the proper function and maintenadce of;on-sitersewage disposal stems. The System: .Conditionally Passes :, S Needs'Further Ev Lion y Local Aproving Authority ti.. ' ..... Fails Inspector's Signature: _Date: J 77 The System,Ins , yst Inspector shall submit a copy,of this inspection:rPport tooth p ,authoity within thu ,p ty,`(30)J4ays;oCcompleting this inspection, If, system is a sharedsystem,or,hasa:designaflow of.10;000;;; gpd,or greater, the inspector and the system owner shall submit the report to the;:. i . po appropriate regional . • : . offrcefof the,Department of Environmental Protection The<original should,be,sent tojthe system owner; and copies sent to the buyer, if applicable and the approving authority. t ISPECTION C TMMARY• A)1{SYS 'PASSES: r yI have not found any information which indicates that the system violates any&of the failure, . ii criteria as defined in 310 CMR 15.303. Any failure criteria not evaidatedtare indicated�"� ;.below �, v_ %HAP! '� �"�I�k.yjp• :.- . : --3 . _ ';e.;. .., ��� �� T ��� B)SYS CONDITIONALLY-PASSES; i $,_J One or more system components need,to be replaced or repaired.The system'upon comple- lion of the replacement or repair,passes inspection. MM Indicate yes,�nor`N;or not determined(Y,N,OR ND).Describe basis,of deterod amion m all.instances If not deter ni ed;:,explaui Why not.The '• a, s .f,}a<tl f S.°t- t ,:s"t ` +G,a ci}"b rc,:°' septic tank is metal,cracked,structurally unsound,shows,substanda1;in6ltra49n or c , ,, exfiltration,orunk failure is:imminent:4The;systemwiff paw inspagdon if the existingfsep- tic tank is replaced with a conforming septic tank as approved.41 ThGr�ard of Hea1W: L -Sewage backkup or breakout or high.static-water.level obsecverhlt,fhe;diatdhutionbox is due Ito broken or obstructed pipe(s)or due to a broken,,settled or,uneven dittribµoon box. The ;system will pass inspection if(with approval of The Board of Health): • - 1- • ow r F o d: r v tst r. �s F rtV¢f, i s • st i' t SUBSURFACE SEWAGE DISPOSA .SYSTEM INS1 t&.1 iN FORM �. PART'A CERTIFICATION (continued) + }" k Broken pipe(s)replaced tJbstiuciion is removed ` Distribution Box is levelled or replaced The System required pumping more than four times a year due to broken or obstructed pipe(s). The;system will pass inspection if(with approval of The Board of Heath): , 7 'Broken pipe(s)are replaced i i ' Obstruction ds removed C)FURTSER EVALUATION IS REQUIRED BY THE BOARD'Op'IIIm .'[H• VIA Conditions exist which require further evaluation by The Board,of Health in order to determine>f: the system is failing to protect the public health,safety and the envttonrnent:' `1)SYSTEM�WIL.L PASS UNLESS BOARD OF HEALTH DETEI?'.NIL1gS WHAT THE ak'F ��Gii '"SYSTEWIS NOT FUNCTIONING IN'A`MANNER WHICH WI LI..'j4RO'IECT'THE 6l6 14 PUBI:IC HEALTH AND SAFETY AND THE ENVIRONMENT Cesspool or privy is within SO Feet of:a surface water Cesspool or privy is within 50 Feet of a bordering vegetates+ v 6davd or a salt marsh: ,. 2)SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (h I)1��lB1t.�C'WATEIL SUPPLIER,IF.APPROPRiATE')DETERMINES.THAT TH,i.fly,'SI Er IS°FUNCTION lING IN A MAN) ER THAT PROTECT THE PUBLIC HEAL",,. llct S,AFE'I'Y AND . ENVI1tONMENT• The.system.'has a septic tank-and soil absorption system and is wlfa�i 100 Feet to a surface . r ,, 'u tiu` ail°.. water supply.or tributary to a surface water supply The stem has a tic tank and soil absorption system and rs;v 04li'Zone I ofapublic water supply well The system has a septic tank and soil absorption system'and is withini50 Feet �of a`pri atf t water supply well. The system has a septic tank and soil absorption system and is,less Chan 100 Feet but SO Feet or more from a private,*pater supply well,unless a well water at9alysis for ooltfoim ' bacteria and volatile organic compounds indicates that the well Jr.tree from polltltio�t from r rwte�Eentis equalrto� s°less` , r the facility and the presence of ammonia nitrogen and ni�relt oii a r _,v>•q +^ `, ate. . tj xrr i than S ppm. Dj'SYSTEM•FAILS: �. I have determined that the system violates one or more of the foliour►..rg i,a lure criteria as de&bd in 310 CMIt 15.303: The basis for this determination is identili(A i`)eluw: The Board of Health r " should be contacted to determine what will be necessary to wrrec(the �tv litre { Backup of sewage into facility or system component due I cps wk o,erloaded or`clogged SAS.- or cesspool. Discharge or ponding of efluent to the surface of the gro and ar r uu face waters due to an i3l „± "`overloaded or clogged SAS or cesspool` Static liquid level in the distribution box above outlet invert glue tR att overloaded or flog t i god SAS or cesspool.' Liquid ft(b:in cesspool is less than 6"below invert or available volume is less than 11/2 day flow: i z,, i ! . r• � k Required, more than 4 times in the last year N(1 I duh'n cl®gged or obstructor pipe(s).,, Number of times pumped .2- In '#a µ, fl i a` 4 ."SitBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) . `Any portion'of the Soil Absorption System,cesspool or privy is below,the'high groundwater elevation. = " Any portion of a cesspool or privy is within 100 Feet of a surface water supply or tributary to a surface-water supply. portion of a cesspool or privy is within'a Zone I of a public well'. Any portion of a cesspool or privy is within 50 Feet of a private water supply well. Any portion of a cesspool or privy is"less than"100 Feet but greater than Xpeet from alp water supply well with no acceptable water quality analysis. if the well has been analyzed' to,be acceptable,attach copy of well water analysis for colifornt bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E)LAR�G}E SYSTEM FAE S: The(l{.ollowing`cdtedtaapply to a large system In addition to the criteria abov2s s E ' ft The design flow of a system is 10,000 gpd or greater(Large System)and,the system is aasigoifica)nt t4reat td*ibhc healtH•and safety and the environment because one or,,more.ot,,the followings �: ' conditions exist-' x a. I Tlie s�stem is within 400 Feet of a surface dsnking The.:system is.within'200 Feet of a.tributary to a surface drinking water,;supplyl ' The isystem is located in a nitrogen sensidve'area Interim Wellhead Protection'AreaRv #1 (IWPA)'orba mapped Zone II,of-a public `a '4 � ? 4The owner or-operator of any such system shall bring•the�system and facility into:fullticoinplrauoea ►itbt,the <�oundwater,treatmenCprogram.requirements of 314 CMR 5.00 and 6.00 ;Pleate,oonsult the regional office of the Department for further information. Al. 'SOBSURFACE SEWAGE DISPOSAL SYSTEM 1NS?E(MON FORM ;.. PART B h ,` CHECKLIST Cl}ocdc iff t�e following have been done: 714 r w t/ ing information was requested.of the owner,occupant,,and-Bq d:uf Health.,, :� one of ft system components have been pumped for atleast two wee ;and the�system,w j,been receiving normal flow rates during that•period:4 Large volumes of waterhavenotboen I ' uced�into the system recently or as part of this_inspection'. , cp �, � a k"itil't plans have been obtained and examined. Note if they'ae mot&*ailable•with N/A„ e facility or dwelling was inspected for signs of sewage backupK - E The; ystem does'not-taceive nottsanitary or industrial wasteflowY� wad ins�iected for'sips of breakout x _,; ' ; A <'> M _z/All systein;cobipouents,excluding the Soil Absorption System9 have been located on site. ��'fhe.septic.tank manholes were uncovered,opened,and the inteNott of�t#aey c�tank w,as '.�spected for condition of baflies or tees,material`of construction,dunensionr�„ � I th of sludge,depth of scum. to n< f.~. � , size°an'd location of the'Soil Absorption System on the site haq beck determined based on existing information or approximated by non-intrusive method;.. —3- O r;p h Z Pf +E y-.: j �9 { a t ; arlm,� �n v" ��,�,7 +. � r;�'�. ,:7�'" - ,z •a' r •x( '•1 a� � } I r. SUBSURFACE SEWAGE DISPOSAL SYSTEIII INSPECTION FORM PART B CHECKLIST(continued) j4 '^ a facility owner(and occupants,if different from owner)were provided with,nformation on. ':.the proper maintenance of Subsurface Disposal System SUBSURFACE SEWAGE DISPOSAL SYSTEM INSY19CTIQN,FORM i 7 SYSTEM INFORMATION FLOW CONDITIONS Design glow: ons Number of Bedrooms:_2, Nu ber of Current Residents ,s Garbage Grinder: Laundry Connected To System: Seasonal Use' =Water;Meter Readings if 'lable: LasuDate�of Occupancy: , . COMMUIRCIAT Type of Establishu►ent € - . Desigtt'Flow. r:' gallons/day Grease Trap Present: (yes or no) *a Industrial'Waste Holding Tank Present: !Non.SanitaryiWaste-Discharged To The Title V System: ` Water Meter'Readings;If Available: Last Date of OccupanTf 'kN ri ,. OTHER:.j Describe) Last Date of Occupancy: s , l5 GENERAL INFORMYO ATION LIMPING RECORDS°m:d source of inform :on: ay System Pumped as part of inspection: v if ye ,volume pumped:? ' �r• * � �1�11bns `{ F . IF Reason for I• - 1 I fYh h�•Y } 'F ii Septic�TanktDistributionBox/Soil'Absorption System ,Su gle I y Overflow Cesspool 3, ,� . # t Privy LL a.1 Stared System(if ,attach previous inspecti n record any) Other AP ROXIIVIATE of all wm neN^„uKts date installed(if known)and sburwoftinformat_ioa t y Mrt 9w� y 4,*R xTR{aK $ x e odors detecteti when arriving at the site. `` i R f, f t: ' ^!� r r' ('gy,•€Rr} k�c ", 1�1 .`�s J' • s4 °»,r.�. H £ S1�B,SURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C : . i GENERAL,INFORMATION (continued) SEPTIC TANK:, Depth beloyw.grade /Material of Construction: ✓oncrete metal FRP Otherg�, Dimisions. 'XcS Sludge Dep0h: Scum Tluckkkr�fss:_ 0-2 Distance from top of sludge4o bottom of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baMe:� Velf e— � Comments?(recommendation for pumping,condition,of.inlet.and outlet tees or, es,d th of llqutd `{ ...F AeAinrel on too et invert,structural integrity, 14 01 GREASE TRAP: Depth Below Grade: Material of Construction:_concrete metal FRP 6di rr— Dimensions: ` > Scum Thickness: .Dlstence from top of scum to top of outlet tee or baffle: tommentsa(recommendation for pumping,condition of inlet and outlet tees or;bafffiys,depth of,,alquid'; level in rel tion5to outlet lnvert,structural integrity,evidence of.leakage. etc) I is ,•�_ •_ I _ ... .. 3;5+ 1. Y'F TIGHT;O HOPING TANK: Depth 13elo*Grade: Material of Construction: concrete metal FRP Other(explain) A imension Capacity; gallons Design Floe,: �__gallo Wday A unt Level: C6)nmcnts::(condition bf inlet tee condition of alarm and float switches,et^ pA DISTk1BUfnON-BOX:Ab f Depth 4,11c uid level above outlet invert: Comments:(note if level and distribution is equal,evidence of solids carryover,evidence'of leakage into , or out of box,etc.) PUMP CHAMBER t Pump is in working order: Comments:(note•condthon bf pump chamber,condition of pumps and`'appmUnanr ,etc.) �' i, rto � dd SUBSURFACE SEWAGE DISPOSAL SYSTEM414SPFCTION FORM A PART C SYSTEM INFORMATION(continued) SQIQ.AB$0A.MON SYSTEM(SAS): yr t (L.ocate on;slto plan,if possible;excavation not required,but may be approximated by non intrusi%e q,, methods) 'If not determined to be presept,explain: ' _ t rw " Leas lWng pits,'number Leaching chambers,number. Leaching gaUerr es,numbec ;Leachingtrenches,number,length: 77 tIeschingfields,number,dimensions: Overtlow�cesspool,':number: Comments,.(note condition of soil igns of h draul' failure 1 el of pon!yg vea'cxlad�tion of etaticn lie x �n-xi.►. i K a' .Cnii0'I L►7: 1` - -y f .a> i ga'' Pkt r ' "+7 S'14+1�s Number a W configuration: Depth-top of liquid to'inlet invert: DePth.of solds_layer: Depth of scum layer: Dimensions of p�l:T. - Materials of construction; Indication of grourfilfN terY Inflow(cesspool must be`pumped as part of inspection) Comments: (note condition of sonic,signs of hydraulic failure, level of pondi,, ca rnd ition tof ta* etc) , . Y a rtels of construction: _ Dimensions: eptkof Coitment¢.(note condition of soil,signs of hydraulic failure,level of ponding,conditionof vegetatiop," etc.) NOV I -6 rk ,1 SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) SKETCH;OF SEWAGE DISPOSAL SYSTEM: , Include ties to atleast two permanent references, landmarks or benchmarks. o cia to all wells within 100 Feet. . y . a `A i DEPTH TO GROUNDWATER: i Depth togm-updwater, /'d Feet ,/ Method-of D&rml 'on or Approximation: 01 X1 c�� �'�Dr� 5 -7 • Lox itF,Mc';d . S•s}'"'x:t_ Yr RQ v-4i0 .1"• F t' h 44 'b BORTOLOTTI CONSTRUCTION,INC. 765 WAKEBY ROAD,MARSTONS MILLS,MA 02648 A,,, 01 ; 508-771-9399 508428-8926 FAX: 508428-9399 Cs SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORMS` PART A CERTIFICATION Property Address: 11_X) Date of Inspection: nspector's Name: CERTIFICATION�TATFMFNT• I certify that I have personally inspected the sewage disposal system at this address and that the informa- tion reported below is true,accurate and complete as of the time of inspection.The inspection was per- formed based on my training and experience in the proper function and maintenance of on-site sewage disposal terns. The System: Passes Conditionally Passes Needs Further E luation B 1 the Local Aproving Authority Fails Inspector's Signature: q— �i✓t,.,�y 12j w Date: The System Inspector shall submit a copy of this inspection report to the Approving authority within thir- ty(30)days of completing this inspection. 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. INSPECTIONSUMMARY: A)SYST94PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B)SYSTEM CONDITIONALLY PASSES; One or more system components need to be replaced or repaired. The system,upon comple- tion of the replacement or repair,passes inspection. Indicate yes, nor,or not determined(Y,N,OR ND). Describe basis of determination in all instances. If not determined",explain why not. The septic tank is metal,cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent. The system will pass inspection if the existing sep- tic tank is replaced with a conforming septic tank as approved by The Board of Health. Sewage backkup or breakout or high static water level observed in the distribution box is due to broken or obstructedpipe(s)or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of The Board of Health): ; - 1 - a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Broken pipe(s)replaced Obstruction is removed Distribution Box is levelled or replaced The System required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of The Board of Health): Broken pipe(s)are replaced Obstruction is removed C)FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by The Board of Health in order to determine if t� the system is failing to protect the public health,safety and the environment. 1)SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 Feet of a surface water Cesspool or privy is within 50 Feet of a bordering vegetated wetland or a salt marsh. d 2)SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)DETERMINES THAT THE SYSTEM.IS FUNCTION- ING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 Feet to a surface water supply or tributary to a surface water supply. xb The system has a septic tank and soil absorption system and is with a Zone I of a public a water supply well. The system has a septic tank and soil absorption system and is within 50 Feet of a private water supply well. y� The system has a septic tank and soil absorption system and is less than 100 Feet but 50 Feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. D)SYSTEM FAILS: Y} 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. aT Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of efluent to the surface of the ground or surface waters due to an .' overloaded or clogged SAS or cesspool. : } Static liquid level in the distribution box above outlet invert due to an overloaded or clog god SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 ^ day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed r" pipe(s). Number of times pumped -2- t, Z}1 rr. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 Feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 Feet of a private water supply well. Any portion of a cesspool or privy is less than 100 Feet but greater than 50 Feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E)LARGE SYSTEM FAILS: The following criteria apply to a large system in addition to the criteria above: The design flow of a system is 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following zt 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 11 of a public water supply well. The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Check if the following have been done: Pumping information was requested of the owner,occupant,and Board of Health. _None of the system components have been pumped for atleast two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. yAs-built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. LThe system does not receive non-sanitary or industrial waste flow. vThe site was inspected for signs of breakout. k-All system components,excluding the Soil Absorption System,have been located on site. yThe septic tank manholes were uncovered,opened,and the interior of the septic tank was in- spected for condition of baffles or tees, material of construction,dimensions,depth of liquid, U depth of sludge,depth of scum. The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. -3 .t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST(continued) y The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Subsurface Disposal System SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION FLOW CONDITIONS RF.SIDENTLAS: Design Flow: f3D gallons Nurnber of Bedrooms: of _ Nun)Jbcr of Current Residents. � Garbage Grinder: 0 Laundry Connected To Syste►n: YCtiS Seasonal Use:,/ 6 Water Meter Readings,if a ailable: Last Date of Occupancy: ��lyel"-2 COMMERCLAL/INDUSTRLAL• NU Type of Establishment: Design Flow: gallons/day Grease Trap Present: (yes or no) Industrial Waste Holding Tank Present: Non-Sanitary Waste Discharged To The Title V System: Water Meter Readings,If Available: Last Date of Occupancy: a OTHER: Describe) t Last Date of Occupancy: GENERAL INFORMATION PUMPING RECORDS and source of informat' System Pumped as part of inspection: If yes,volume pumped` gallons Reason for pumping: TYPE OF SYSTEM: __,Xeptic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy Shared System(If yes,attach previous inspection records, if any) Other(explain): PRO TE AGE of all components,date installed(if known)and source of information: Sew a odors detected when arriving at the site: i11C -4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C GENERAL INFORMATION (continued) SEPTIC TANK: Depth below grade: Material of Construction: concrete metal FRP Other (explain) Dimisions:_X s'XLo "Sl S Sludge Depth:A16 n e Scum Thickness: Albn e Distance from top of sludge to bottom of outlet tee or bailie: 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 relatio to outlet invert, structural in' e rity,evidence of`1 akage,etc.)�i`S a— /6eo % Gn .Pl77 Pn4LOVere ff, S' CCcf� Q. i/h %l7,S �cJ GREASE TRAP: Depth Below Grade: Material of Construction:_concrete_metal_FRP_Other (explain) .. Dimensions: Scum Thickness: Distance from top of scum to top of outlet tee or baffle: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,etc.) TIGHT OR HOLDING TANK: A16 4 , Depth Below Grade: Material of Construction:_concrete_metal_FRP_Other(explain) Dimensions: Capacity: gallons Design Flow: �allons/day Alarm Level: ;^ Comments: (condition of inlet tee,condition of alarm and float switches,etc.) A; DISTRIBUTION BOX: Depth of liquid level above outlet invert: lZ'od Comments: (note if level and distribution is-equal,evidence of solids carryover,evidence of leakagejnto or o of box,etc.) 4.Ur�1-4) bye Ot PUMP CHAMBER: Pump is in working order: Comments: (note condition of pump-chamber,condition of pumps and appurtenances,etc.) -5- c ti SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SOIL ABSORPTION SYSTEM(SAS):�� (Locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: Leaching pits,number:Leaching chambers, number: Leaching galleries,number: Leaching trenches, number, length: Leaching fields,number,dimensions: .r Overflow cesspool, number: ``{ Comments: (note condition of soil, signs of hydraulic failure level of po ing,con ' 'on of vege tion, etc.) _ O/'e Q_ v Q E? ald z; t ,a CESSPOOLS: Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of Cesspool: z Materials of construction: Indication of groundwater: Inflow(cesspool must be pumped as part of inspection) Comments: (note condition of soilk, signs of hydraulic failure, level of ponding,condition of vegetation, etc.) PRIVY: Materials of construction: Dimensions: Depth of Solids:' Comments: (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.) !S 4 }f'1 —6 . A ��k d SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent references, landmarks or benchmarks. _ 'L Locate all wells within 100 Feet. — — ' i . b O �/ 1-? C-N) DEPTH TO GROUNDWATER: Depth to groundwater: _Feet Method of Det rmination or Approximatio /� vV40/e Aelv �T� -7 Gv * 3 TOWN OF BARNSTABLE LOC`�.TION q2 6 /1,�(7�i i il!t SEWAGE # - 1 VILLAGE � E'�'pei'I "ASSESSOR'S MAP & LOT INSTALLER'S NAME SY PHONE NO. P h'/Q'o b,:i 6 acl.SO hT r SEPTIC TANK CAPACITY 60 6 LEACHING FACILITY:(type) (size) ®IV NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER— BUILDER OR O„=NER (' ri F f d'1 DATE PERMIT ISSUED: / �y DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No �� © �CZ _ .�, � 'Zx /I -� , �Z���� � ��h � . 9� ,f� .. /� •�9� �� eVG� �: t . . . / �Fti � ��� F J ASSESSORS MAP NO: ,-11Y,-. . ..,..., —� PARCEL NO: 4321 F�s.. ....20.:00'... No..�------------------- THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ................TOO Di...............o F............Barnstable--------------------------------------------- Appliratillu for Ui_qpusal 10ork,5 Tuuitruriiuu Pprutit Application is hereby made for a Permit to Construct ( ) or Repair (X) an Individual Sewage Disposal System at: ._426 1,0t t i1102al._kr.ixe__ eal arxllle--- --------------•---•---------------------------- �+ Location'-Address or Lot No. .....................................•-••---------........____......_._.... ..........--...................................................................................... Owner Address a Z._P.M'aombei�?............................................................ Installer Address Q Type of Building Size Lot............................Sq. feet DwellingYv—No. of Bedrooms.__..._.`3.................................Expansion Attic ( ) Garbage Grinder ( ) 04 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures ............................... .. w Design Flow............................................gallons per person per day. Total daily flow............................................gallons. fY4 Septic Tank—Liquid capacity------------gallons Length................ Width................ Diameter................ Depth............... Disposal Trench—No. .................... Width.................... Total Length.......,............ Total leaching area....................sq. ft. 3 Seepage Pit No._-______-_----_-_-- Diameter____________________ Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Gz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water....-................... a ----------------------------------••----..................--------------.....--•............._..._...._...-----------------••--------------------------_..... O Description of Soil....J5.&G-d... ... Iti.aV Q ------------------------------------•--------•------•--••-----•----------------•---•--••-----------•-----------••-•--•-•----- x U .----------------------------•--•--•---•-••-------------------•---•------------------------------•----------------------------------•--•-•.............................................................. -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 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'TTY-E 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance hasAbbeissue y tlygboard of health. Sign ���a� Pate. Application Approved By......... ...... . .. -L --- --------------•-...------•....----.......... -----------�-��u.��... Date Application Disapproved for the f ollo - reasons-------------•-••----....--------------------------------------•----------------------------------••--.._.__..... .....................•---------------••-•••----•...----------------------••-•-•----------------•---------------------------------•--•------------------------------------------•---------••------------ Date PermitNo.......52 ..... -°� ------------------------ Issued-........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..... i71: .-. .... .....OF...........�.s'•? !1 .: ' Appliratiou for Diipusti1 Works Tonstrurtiuu Vamit Application is hereby made for a Permit to Construct ( ) or Repair ( � ) an Individual Sewage Disposal System at: 4 r.6 �iG�r i!31jY'•.�(?r e j-'^.E ............................................. _..._....---._._..................______.._............__..____._..........._.__._................ Location-Address or Lot No. ....j: :°.fit_?_---------------------- ....-----....•..............-- ......--- -----•----------...------------------...------. ..........................-----------••--•---- Owner Address Installer Address. UType of Building Size Lot............................Sq. feet + Dwellin jF3 No. of Bedrooms.................................•...__.__..Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ____________________________ No. of persons.,........................... Showers ( ) — Cafeteria ( ) a' Other fixtures .............................d •----------------------------------------------•-------•---------------•----•-•--••--------------------:- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area--------------------sq. ft. 3 Seepage Pit No----------_--------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) a Percolation Test Results Performed by............................................... -....... ................ Date......................................... Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water-__---_____-___-_-___._. fT Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 O Description of Soil...? ?=z?_._ .. s •-••-••t_ x -••••-•--•-•-•-•...----•-••-----•••-----••••-•-••-•••---•••--•--•••-----•--•••- V ---•--•-••------•-•----••---•-••-•-•-•....•••••. .....-•••._..._. ------------------------- ---------•--------------------------------....-----------------------.......... -•---- - --------------•--------- V Nature of Repairs or Alterations—Answer when applicable._4:"2`-E! _'1...'rx'.:_ _?l._- _` ��. ? .................... --------------------------------------•------------•-----------........--------------....-•-------------------------------------------•------•---•-----------------...•--••-----••• Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE p J of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued,by the board of health. ,� .,. Signgd . ................... � = r a r f Date Application Approved By....... 4, 6 v -••---•....................... •--•--•••- Date Application Disapproved for the f ollo i g reasons:................................................................................................................ ---•----- -•-•-----••-------------•---•-----=------.....-----------...-------••-•-----.......•••••-•-•••--••-•--•-•••-•-•---•••••••-•----•--•--•-•--•-••-•----•......-•••--------. Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH A C�7F. i OF. :.;,, ; . r,1 YY c, .. Trr#ifiratr of Tuutpliatta THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired J;, } ",r�,{A�i .4J�iJ L, C" J m. ----- --p Lt"� r _ Installer • at. .-•------------------------------------------•-•-••••••--••••-•••••-•••-•-•--•••---••-•-•-•--•-••-••-•••......•- has been installed in accordance with the provisions of TrL 112 _� - T}1e-State Sanitary Code as descri m the application for Disposal Works Construction Permit No... _ ~T�S...___._._.. datedlQ...`_-------___.._._-_---..........._.___..•-_. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT YHE SYSTEM WILL FUNCTION SATISFACTORY. DATE....................�.:'1(t ' 1..?.............................. Inspector-•---- --- .......................... 14' V J I THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 9-U i�a..a .OF.. te r., .. U1e No N oJ....................... �i��r�a��t1 urk� �,�atu#ruau rruti# Permission is hereby granted-`o-'.. _-if)C ..c -r-•----......-----------•--•-------•----•------------------------------------•-----................---...... to Constrt ct ( ) or Repair'( ). an Individual Sewage Disposal System at 1\TO........ � a,:f- ttlovr,,,:n :,rive CEnte: v111_c ......•...._......._.__.._.:................................................................................._.............................................._......................... Street 7 as shown on the application for Disposal Works Construction Permit No _ .��. Dated.... ...__w_...................................... Board of Health DATE ..... ...... •-• ... FORM 1255 HOBBS & WARREN. INC., PUBLISHERS ASSESSORS MAP N0: 'l No.17�..D,/ PARCEL NO: I Fps. ®. ® cam THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ...........................................0 F.---...................................................................................... Appliratinn for Dhipo,sal Works Tomitrnrtiun ramit i Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at �, �o.r���s ����.: ................................................................ 1.�..._ -c.Qd................•_ -_..- .........------•....._.............. ......a. ......... Location-Address l� or t 130. .... ------ --------- -------- Owner Owner Address ti ._.. ...... .......... .......... jqf�:........ Instalier Address d Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) P4 Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) A4 Other fixtures ---------------------------•---. - W Design Flow............................................gallons per person per day. Total daily flow-------_....................................gallons. 1:4 Septic Tank—Liquid'capacity_._.__.__-_.gallons Length................ Width................ Diameter---------------- Depth................ W Disposal Trench—No_ ____________________ Width..................... Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ( Test Pit No. 2..._............minutes per inch Depth of Test Pit.................... Depth to ground water........................ . :.......... Description of Soil x ................................- ---------- ----•----- ---••---•-------•-•-•---•-----------------.._......._... W x ------------------------------------------------------------------------- ------------•-------------------------- .............................................. Nature of Repairs or Alterations—Answ when applicable__.-_._---- �\ ------------ -- �� .a.0 � a-- -------------------------------------------------------------------•-•-----•••--------••••-----------------•--------------• Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of i T T I ;of the State Sanit y ode— The undersigned further agrees not to place the system in operation until a Certificate of Compliance h e issue by the ko d of health. 37 Signed .--•-•_ .................. Application Approved By............... � s.c�+ ..... ........•-•---...----------- ........................................ t • Date Application Disapproved for'the following reasons________________________________________________............................................................... ....--••--•---•--------------•-----•-•--...-----------------•--------------•----------•---•------------•.•--------------•--......-----------••-----------------•--------------•--•••--•----•------•--•-- Date PermitNo.---- .. ..... .7.?.--------------------•-.... Issued....................................................... Date �..........�1 Fps...:.......................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ................... -- ..............OF............................._............... - ------------------------------ A;ip ira ion for Biipoiia1 Workii Tonstrurtion Prrutit Application is hereby made for a Permit to Construct ( ) or Repair �an Individual Sewage Disposal System at• ....... .•----••-•--------•-----•--------•----•--• h...._. Location-Address 1 or+ t No. .. _. .................... ............ Owner {� Address r Installer Address Type of Building Size Lot............................Sq. feet �-, Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) per, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) QI 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. Seepage Pit No-_-_-------------- Diameter.................... 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 water........................ P� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ... Description of Soil.. mar ' .............-------------------------------------- - - - - - - U ...................................................•••-•-...-------••-----------••-------------•-•-------------•-•-----------------•-••-------•------•---•--•---•--•---............----...----------•-- W U Nature of Repairs or Alterations—Ans hen applidable.______---- ?__ •:� _______________ _.*- ?............. -- ........................................................................................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with •'1T t'1�^ the provisions of I ;of the State Sanita ode—The undersigned further agrees not to place the system in operation until a Certificate of Compliance h bee issued by the board of health. n Signed •....................... ---- --....---7 Date Application Approved By...............S'1 --1... _,-,-,:_.. Mom, N Date Application Disapproved for the following reasons:................................................................................................................ -------••---•-•-•---•--•------•-••---•----•-----•-------•---•-•------------••------------------------••-.---------...._......---•--....----••-------•-------------•--•--•-------•-•----•----------_._... `ter Date Permit No.----e£•�-- .7-.-Y31--------------•-------..... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..................................... (Inr#ifiratr of Tontpliana THIS IS TO CP.RTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired) b �- ----•--------•-•---•------------------------------------------------•----..........-----------•--------- -_-Installer at--------------1-6,'----..�- �" •---•-�'--• = .< ------------M.-�--�!f............................................................................. has been installed in accordance with the provisions of Ti T iE 5 of The State Sanitary Code as-described in the application for Disposal Works Construction Permit No--- ........... dated-__._-_.-__--.-._--__-_----------------------- TFIE ISSUANCE OF THIS CERTIFICATE SMALL NOT BE CONSTRUED AS A GUARANTEE THAT YHE SYSTEM WILL FUNCTION SATISFACTORY. DATE----------_------7• 7................................. Inspector..•-- .......................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH A J� o r"L r OF........ _ 1 ?*`:..crP !7::.• ............................ �j .-- _.. FEE..- -•--...---•-•--•--• Disposal Workiiion r ion rruti# Permission is hereby granted-------- ..... ----------------------------•---...........---------.................... to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at No--------....Ll_ _ •-- ........ --..M......0?.<.-71 c�---------------------•-------•------------------------------------------•----------•-• ------ ------ Street as shown on the application for Disposal Works Construction Permit No..................... Dated.......................................... Board of Health DATE................................................................................ FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS LOCATION SEWAGE PERMIT NO. VILLAGE INSTA LLER'S NAME i ADDRESS UILDER/ OR OWNER DATE PERMIT ISSUED 12_&. DAT E COMPLIANCE ISSUED �_ r � a:, r� t s C -1 a a� i / - Fmc No......... ...... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH Application is hereby made'for a Permit to Construct ( �) or Repair ( ) an Individual Sewage Disposal System at: --.... ®7�f fir`.. ?/91'. ..................... -._ s '• - cation-Address ' ....... W .-•-.•.___- ----------------•-------------'•--------- Installer Address - Q Type Building v Size Lot.. 0.39..Sq. feet Dwelling—No. of Bedrooms......................................Expansion Attic ( ) Garbage Grinder (/'17) Other—Type of Building ..........:................. No. of persons--_--__.-___-___--_-.__-___- Showers ( ) — Cafeteria ( ) Q' Other fixtures ............................ W Design Flow..........�r� .......................gallons per person per day. Total daily flow........... > o......................gallons. WSeptic Tank—Liquid capacity_6o0.0galIons Length...lz ". Width...."e�©".Diameter._.S 'K Depth... .. _. x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No....../............ Diameter..... ............ Depth below inlet.... ........ Total leaching area.._ rK_.sq. ft. z Other Distribution box (4�1) Dosing tank ( ) '~ Percolation Test Results Performed by-------------�'/.f'�/P......XIII217.................... Date...... AW.�___..___.._. aTest Pit No. L.�.a-----minutes per inch Depth of Test Pit------ ....___.. Depth to ground water.....Yv'VF__. (i, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 9 --------------------------------------------------------------------------..._.........•----------------------------------•---------------•--------•---.----- ODescription of Soil.................... .-. e1.4 .9//.-----------------------------•---------------------------------------•--•---------- U ............................................. ..........- 40/ ..Cqf'e sm......1v LTV.. /.6�'y7..jCmZ 1119.G------- -------------------------- ----•-------•-•-••-•..r_'/_9..-...... i. l��lll�1. _��_3�1 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�i p 5 of the State Sanitary Code—The nde signed further agrees not to place the syst m in operation until a Certificate of Compliance has b sue b e bard of health. Sig .. .. . .... ...................•........................................ ...-;7 ...... -------------- ate Application Approved By-•---- ......................... ................. 7 Date Application Disapproved for the following reasons: ------------------------------------------'----------------------•---•----------------........-- --•--•--•---------••-••--•--•------••------•••-•-•-••.......---------•----•----•---------••----------•--•--------••••-----•---•------•-----•-•---....---•-------•-•--•--••-••-•-•------•--•----------. Date r PermitNo......................................................... Issued_.---------��'------------------------------------ � Date f , No.......... ... s Fims ....... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH AOF...... .._............................................:................................. Appliratiun for Diipuiial Work.5 Tiamitrurtiun rruttt` Application is hereby made for a Permit to Construct (J ) or Repair ( ) an Individual Sewage Disposal System at: �,cai;n.-� essw' - ---- --/ Aaa ................ 1L,Y,P ' . ---- ------ -- - ----------•---------............-- ,.a Installer Address _,.- Typ Building Size Lot_ '_ 3S'n Sq. feet U Dwelling ...__.__..__ Eapanslon Atdc ( ) Garbage-'Grinder 010) a ng—No. of, Bedrooms----•--•-`,-�--•-----•----- p, Other—Type -of Building............................. No. of persons. ` !...................Showers "( ) = Cafeteria ( ) ' . Other fixtur'es ...................................................... ............. .. ---< ...... -•-----•---•---------------------- WDesign Flow..........3v� .......................gallons per person per day. Total daily flow....... _: _._............_........_gallons. WSeptic Tank—Liquid"capacity:j��gallons Length.. . 6.j�__ Width._!: -/�"Diameter._.w '. Depth..._ .`:__.. x Disposal,Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepages Pit No....../------------ Diameter.....4 ........... Depth below inlet__- >a ....... Total leaching area.../:�87sq. ft. Z Other Distribution box (� Dosing tank ( ) Percolation Test Results Performed by.................���I�...._5��`t! ' ....................... Date........_ Test Pit No. l._ .....minutes per inch Depth of Test Pit------ K_-.______ Depth to ground water-___ fT Test Pit No. 2................minutes per inch Depth of Test Pit-----_.............. Depth to ground water........................ ....................................................--....................................................................................................... Descriptionof Soil--------•------•----=-••--- -- X = .......................................-.......................................... ......... .� '-.--- 7 1../G!/jz_.....f.;!.._.. _Sr�l,!.......-«!/s h:--��cS'N� !�` h/1�='f"......--- U --••---•---•---•-------•......----•--------•----•-L , _ W •----•------------------- ------------------------- ------- ........................................ UNature of Repairs or Alterations—Answer when a"pplicable............................................................:.................................. ----------------------------------------------------------•---------------------------------------------------------------------------------------------------------------------------------•-.....••-- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T_7=," 5 of the.State Sanitary Code—The nd igned further agrees not to place the syst m in operation until a:Certificate of Compliance has b sue b e oard of health. T Sig - _ _ . Application Approved By--- _ .• [�- ter......................... ......... Ppa?.... .'__. �. Date Application Disapproved for the following reasons:---...----•---•-=-••--------------------•--•-----•--•--•-•--------•-•---------------•-------- ............. -••-•-•---------------------••----•-•--------•---------•------------•-----------•------•---•---------------•--•-------------•---•------•--.............-••----•----....-•-...••--`............•.....---- /1`�� Date Permit No. Issued ----------------1---------.......---•------------ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......T .............OF.....� / !!L S r!~ �� " r....................... Trrtgfaratr of Tuutpltanrr THIS IS TO CERT hat the I 'ivid a Se e,,Disposal System constructed ( or Repaired ( ) t 5, ,Disposal -•------------•-•-----------•----•-•-------- --. --...... �`I ^ .r..... :-•________________________________________________P_--••-•------------ ��i:�i---h/✓- 1Z7• •Inst er at ---t---•-.... has been installed in accordance w• h the provisions of T •- 5 of The State Sanitary Code as-described in the application for Disposal Works Construction`Permit No. �.-------------------------- dated-.-.' t '_rs _ ...._e._..--------. THE ISSUANCE OF.THIS CERTIFICATE-SHALL NOT BE CONSTRUE® AS,,A GUAR .NTEE THAT THE SYSTEM PILL FUNCT ON SATISFACTORY DATE--• /- :.. Inspector �; ---- ` .` THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 0.0 Map or u iun proof Permission is he bygranted---- . --- -----�to Construct*( or R pa ( an Indi idual Sew Disposal System -- Jo ..:.._._ Street as shown on the application for Disposal `Forks Construction Per o..____ _ _ Dya�tyed_.._cA." _•`_/_____________ 1.: �• �___'_L'. . ................................. oard of Health DATE. -.�j'. ,.)ja ...........................................' FORM 1255 HOBBS & WARREN, INC., PUBLISHERS - ` Itc Nx�3 x6 Yj yy £r i w"G1.,,r F" . � > ; �f 4- /goo /V o 7-IQ 9 - .Z,a, 47 _ Q, Orr ` ' ;j to sue? i 01) Y. x j3 u'/� SEP7-I4' S y5 TE:M CoN5'T2 U-4; .T/QN ' I SHALL CONFI?12,M TO MASS • D S/ /�! !�1. ow ���, G�.1D.�+ y " COL76 '7"i t /20. /� + 3 /N /MCA/ _OF? OF - t � . _ K . ;,4Ou%JZ>A770 0 � �t , iV f-10LE �CO✓E� 'TO EX:,TE&I.j� TO .r �: WN/ T- _/A/. 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