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HomeMy WebLinkAbout0962 OLD STAGE ROAD - Health 962 Old Stage Road Centerville j° A= 172 — 158—004I S M EAD No.2-153LOR UPC 12534 smsed,com • Mad*In USA e �Y� 4 r TOWN OF BARNSTABLE cko LOCATION /0 9l0�R p0 -1C� �1 �G `-Z SEWAGE# 313 VILLAGE ASSESSOR'S MAP&PARCEL /7 a /5 g INSTALLERS NAME&PHONE NO. Ste SEPTIC TANK CAPACITY r LEACHING FACILITY.(type) (size) NO.OF BEDROOMS OWNER PERMIT DATE: �®C� 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) MIN Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) 04 Jor Feet FURNISHED BY off s►9 A (3 G 3 L+�3 Haig 3 X° 2y zs D40% y vevK No. o � �O.✓ Fee vv THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: -Z;/- PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes 2ppl.tation for Misposal *pstrm Construction permit Application for a Permit to Construct( ) Repair� Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No. (Q Q l��� S � Owner's Name,Address,and Tel.No. Assessor's Map/Parcel Ss Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms C Lot Size R5-)= �Ap sq.ft. Garbage Grinder(,AI/A, Other Type of Building /j/a No.of Persons ) Showers( Pf'Cafeteria(Imo' Other Fixtures LQS) A kR�A (r\Qj-�!4 �,(1k Design Flow(min.required) 3300,81wo gpd Design flow provided �� ,'aS gpd Plan Date 113 Number of sheets Revision Date Title v Size of Septic Tank 91f 1 1���� Type of S.A.S. Description of Soil r7�e-4 6 [� 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 Certificate of Compliance has been issued by this Board�q Health. Signed Wo ii-p �o Date Y,,>� Application Approved by Date Application Disapproved by Date for the following reasons Permit No. 1 3 Date Issued 1^t r -- - ---------- --- I�...,,.�°v a:-.-r-,*,4-'t.� �� �.. ... .�......,.-, ..-_-•.,i"`Nn^`r=+:.aV.«nsw.s..a+ � a�� r ra �� '"""-+.`�'-'-.."`�.,_ -_..... �;....�...d,-...... r ,r - .. - No. d400 1 VV Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes i. ftplitation for ]Disposal *pstrm ConstrUttion Permit Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) ❑Complete System C/Individual Components Location Address or Lot No. Q,�,` S Owner's Name,Address,and Tel.No. k# ` Assessor's Map/Parcel VIA S v t C) '�@�G I"�, �eS� Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. Type of Building: .. Dwelling No.of Bedrooms. Lot Size 1.5 �y[� sq.ft. Garbage Grinder Q�/A,19, Other Type of Building No.of Persons 3 Showers( K Cafeteria Other Fixtures L -Ion. Design Flow(min.required) gpd Design flow provided (E, gpd Plan Date 1 + �j �Q ! Number of sheets Revision Date j7 { Titlecxx Size of Septic Tank � �,^�— ��)�c,` Type of S.A.S. (n Description of Soil. � r. n\�,h �y ����r6 4 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 r, "accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of � Compliance has been issued by this Board f Health. Signed Date Application Approved by _ Date Application Disapproved by Date for the following reasons Permit No. 2-coot ` 3 83 Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliante THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( ) Abandoned( )by - at has been constructed in accordance f j with the provisions of Title 5 and the for,D,isposal System Construction Permit No. dated Installer AA.A �, �/`{'� `� Designer #bedrooms r �� Approved design flow gpd �l 5m The issuance of this permit shall ny t be construed as a guarantee that the system will fimet�o as designed. Date l/ -- /7� Inspectoir� No. p20'O '--3:- _---._ -_--�_- _-•-•-___r...�_._�:,.__._..__-_-- ---.�,_.�-,_-=-_ --__._,.._.-_._,._.,--._____ .Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION BARNSTABLE,MASSACHUSETTS bisposal 6pstem Construction Vermit Permission is hereby granted to Construct( )A Repair,( ) Up ade ) Abandon( ) System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit, '1 y Date D 1 Approved by f TRANS.NO.: P a CITY/TOWN: APPLICANT: Y C� ADDRESS: 9U DESIGN FLOW: ��JO gpd REVIEWED BY: DATE: N/A OK NO Legal boundaries denoted[310 CMR 15.220(4)(a)] Street,Lot,tax parcel number and lot number noted on plan[310 J CMR 15.220(4)(u)] V Locus Provided [310 CMR 15.2204(t)] Plan proper scale? (l"=40'for plot plans, 1"=20'or fewer for components) [310 CMR 15.220(4)] Easements shown[310 CMR 15.220(4)(b)] System located totally on lot served[310 CMR 15.405(1)(a)for upgrades]-if not, a variance is required [310 CMR 15.412(4)] Location of impervious surfaces(driveways,parking areas etc.) [310 CMR 15.220(4)(d)] Location all buildings existing and proposed 310 CMR 15.220(4)(c)] Location and dimensions of system components and reserve areas. [310 CMR 15.220(4)(e)] System Calculations[310 CMR 15.220(4)(0] daily flow septic taiik capacity(required and provided) soil absorption system(required and provided) whether system designed for garbage grinder North arrow [310 CMR 15.220(4)(g)] Existing and proposed contours [310 CMR 15.220(4)(g)] Location and log of deep observation holes(existing grade el. on each test) [310 CMR 15.220(4)(h)] Names of soil evaluator and BOH representative[310 CMR 15.220(4)(h)and(i)] V Location and date of percolation tests(performed at proper / elevation?) [310 CMR 15.220(4)(i)] V Percolation test results match loading rate? [310 CMR 15.242] Certification statement by Soil Evaluator[310 CMR 15.220(4)0)] Observed and Adjusted groundwater(method for adjustment given or indicated) [310 CMR 15.103(3)and 310 CMR 15.220(4)(n)] Address 9(026ecA Sheet 1 of 7 i N/A OK NO Location of every water supply,public and private, [310 CMR 15.220(4)(k)] within 400 feet of the proposed system location in the case of surface water supplies and gravel packed public water supply ✓ within 250 feet of the proposed system location in the case within 150 feet of the proposed system location in the case of private water supply wells Location of all surface waters and wetlands located up to 100 ft. beyond setbacks listed in 310 CMR 15.211 and any catch basins I� located within 50 ft. [310 CMR 15.220(4)(1)] Water lines and other subsurface utilities located[310 CMR ✓' 15.220(4)(m)] (if water line cross see 310 CMR 15.211(1)[1]) Profile of system showing invert elevations of all system components and the bottom of the SAS [310 CMR15.220(4)(o)] Stamp of designer[310 CMR 15.220(1)and 310 CMR 15.220(2)] Stamp of Registered Land Surveyor(required if construction V activities within 5 ft.of lot line) [310 CMR 15.220(3)] Test Holes adequate(two in each of the primary and reserve unless trenches as permitted in 310 CMR 15.102(2)or as approved for an upgrade under LUA at 310 CMR 15.405(1)(k)] Test hole adequate to demonstrate four feet of suitable material? ✓ [310 CMR 15.103(4)] Test Holes adequate to confirm adequate groundwater separation? [310 CMR 15.103(3)] Benclunark within 50-75'of system [310 CMR 15.220(4)(q)] Materials specifications noted? [various sections of 310 CMR 15.000] System components not>36"deep(unless Local Upgrade / Approval or LUA requested)[310 CMR 15.405(1(b)] V Address 9(Q a _` L )\ �1�� Sheet 2 of 7 ( �\VQ N/A OK NO `SEP^TIC� � AN �'`�`�� -�" � � _ ��'''• 1'� ' a ° " ��a�r��� �� � `, ���, �. „ Size OK? [310 CMR 15.223(1)] Inlet tee located ten inches below flow line[310 CMR 15.227(6)] Outlet tee 14"or 14"+5"per foot for increase ft depth[310 CMR 15.227(6)] Outlet tee with gas baffle or approved filter[310 CMR 15.227(4)] Note regarding installation on stable compacted base[310 CMR 15.228(1)] Separation between inlet and outlet tees(no less than liquid / depth)[310 CMR 15.227(2)] V bilet/Outlet elevations at least 12" above high groundwater (except as described 310 CMR 15.227(5))or permitted for ✓ upgrades under LUA[310 CMR 15.405(1)(k)] Minimum cover 9"(Tanks buried more than 9"must have risers on all openings and on the d-box) [310 CMR 15.2228(1)and 310 CMR 15.232(3)(f)] Three access covers(inlet and outlet must be 20"or greater)- middle access at least 8"(by 7/07) [310 CMR 15.228(2)] Access to within 6"of grade -one port for systems<I 000gpd, two for systems>1000 gpd[310 CMR 15.228(2)] All at-grade covers secured to unauthorized access? [310 CMR , 15.228(2)] V > 10 ft from building foundation[310 CMR 15.211(1)] Buoyancy calculation Required/Done[310 CMR 15.221(8)] ✓ H-20 Where appropriate? [310 CMR 15.226(3)] Setbacks from resources[310 CMR 15.211XA Required when other than single-family dwelling or flow>1000 gpd[310 CMR 15.223(1)(b)] First compartment 200%daily flow;Second compartment 100% 1/ daily flow[310 CMR 15.224(2)and(3)] "U"pipe through or over baffle,outlet of each compartment with gas baffle or approved filter[310 CMR 15.224(4)] Address Sheet 3 of 7 °�\\4Z , `� N/A OK NO - v.K', - 'G!-. e...,�.tt..;. .Y4b+rs.h2i+ xm�:r..� Ft ..�? Ef- ��;''• Located at least ten feet from any water line?[310 CMR 15.222(2)] Disposal piping at least 18"below water line(when water and sewer cross,see 310 CMR 15.211(1)[1]) V Cleanouts required/provided? [310 CMR 15.222(8)] Thrust blocks specified in force mains?310 CMR 15.221(6)(c)] Slope of sewer line not less than 0.01 (1/8"/ft) 0.02 preferable / [310 CMR 15.222(6)] Proper pitch on all runs? (.005 within gravity-distributed trenches and beds) [310 CMR 15.251(9)and 310 CMR 15.252(2)(c)] Siphon problem/(leachfield below pump chamber) Endcaps or vent manifold specified? Size and orientation of discharge holes specified?(not smaller than 3/8"not larger than 5/8") [310 CMR 15.251(8)and 310 CMR 15.252(2)(h)] Materials specified (310 CMR 15.251(5)specifies various pipe types allowed) DISTRIBUTIONBOX �t � a 1 srr r Stable compacted base[310 CMR 15.221(2)and 310 CMR 15.232(2)(a)] Splash plate or baffle tee required on inlet/provided?(when pressure sewer to d-box or steep pitch of gravity sewer) [310 ✓ CMR 15.323(3)(a)] Riser if deeper than 9" [310 CMR 15.232(3)(0] Inside minimum dimension 12" [310 CMR 15.232(2)(b)] Minimum sump 6" [310 CMR15.232(3)(e)] Watertight cover if QOOOgpd);waterproof manhole if>2000gpd [310 CMR 15.232(3)(d)] Capacity(emergency storage above working=design flow)? [310 CMR 231(2)] Proper setbacks[310 CMR 15.211 (same as septic tanks)] Watertight 20-in minium access manhole at least 20"MUST BE TO GRADE[310 CMR 15.231(5)] Service components accessible(not too deep with piping, disconnects accessible) Alarm floats-alarm on circuit separate from pumps specified? Exceeds two units must have two pumps operating in lead-lag mode. [310 CMR 15.231(6)and(8)] Stable Compacted Base[310 CMR 15.221(2)] Buoyancy calculations needed?Provided? [310 CMR 15.221(8)] Address�� _ \ Sheet 4 of 7 N/A OK NO SOIL%ABSORPTTONSSITE'11IS0PSETOEN,ERAxL Calculations correct? 4 feet of naturally occurring material demonstrated? [310 CMR 15.240(1)] Required separation to groundwater? [310 CMR 15.212)] s Aggregate specified as double washed[310 CMR 15.247(2)] ASS �d System Venting required/provided?(system under driveway or >36"deep)[310 CMR 15.241] Inspection ports specified and within 3"final grade? [310 CMR 15.240(13)] Breakout requirements met?(No violation of breakout elevation within 15 ft of SAS unless barrier) [310 CMR 15.211(1)[4] and Guidance Document] Chambers and Gal. in trench configuration supplied with inlet every 20 ft. [310 CMR 15.253(6)] Each structure with one inspection manhole(if>2000 gpd must be to grade) [310 CMR 15.253(2)] Aggregate I'minimum-4'maximum. [310 CMR 15.253(1)(b)] 2'sidewall credit maximum[310 CMR 15.253(1)(a)] In bed configuration,inlet every 40 sq.ft. [310 CMR 1.5.253(6)] TRENCHES 31;Q,C1VI A'I" Y_9 ' BE m �a` `.s.� ; #.�f s' tad Width 2'minimum 3'maximum[310 CMR 15.251(1)(b)] 1/ 100 feet-maximum length[310 CMR 15.251(1)(a)] 1/ Minimum separation 2x effective depth or width whichever greater(3x if reserve between trenches) [310 CMR 251(1)(d)] Situated along contours[310 CMR 15.251(2)] Breakout OK? [310 CMR 15.211(1)[4] and Guidance Document] minimum 2 distribution lines [310 CMR 15.252(2)(a)] Maximum separation between lines 6'[310 CM R15.252(2)(d)] Maximum separation between lines and outside of bed 4'[310 CMR 15.252(2)(e)] Aggregate depth below discharge pipes 6"minimum, 12" maximum. [310 CMR 15.252(2)(g)] Ids Separation between beds 10'minimum. [310 CMR 15.252(2)(0] Bottom area used in calculations only[310 CMR 15.252(2)(i)] Address �p p` ®� � �� Sheet 5 of 7 N/A OK NO D;IFD aliE PLAN INVO ;vE '' a kt fI } w vNr� �;, rxy. F� Pressure Dosed System ? Provided pump and piping calculations as required[310 CMR 15.220(4)(r)] Pressure dosing required on all systems>2000gpd or alternative systems under remedial approval[310 CMR 15.254(2)and I/A Remedial Use Approvals] If used in gravelless system-make sure jet is directed as not to scour soil interface[Guidance Document] Inspections once per year(systems<2000 gpd)or quarterly (>2000gpd)good to note on plan[310 CMR 15.254(2)(d)] Construction in fill -Did the plan specify that the fill shall meet the specification of 310 CMR 15.255(3)? Impervious barrier and/or retaining wall? [Guidance Document] Impervious barrier installation must be supervised by designer[310 CMR 15.255(2)(b)] Retaining wall must be designed by Registered Professional Engineer[310 CMR 15.255(2)(a)] Side slope not exceed 3:1 ?[310 CMR 15.255(2)] Breakout requirements met? [310 CMR 15.252(2)and / Guidance Document] At least 5 ft. from impervious barrier to edge of SAS (10 ft. recommended) [310 CMR 15.255 (2)(e)] Check DEP Approval letters for credits and design conditions If used with pressure dosing do not allow pressure discharge to scour soil interface Allternattve Sepfzc System[UA Approval Letters] + �} r s ' �Was DEP Approval Letter provided and/or have you reviewed the letter for conditions? Is the technology being properly applied and does it meet all DEP Approval Conditions? Is there a note on the plan regarding the requirement for perpetual maintenance agreement? Any alarms involved on separate circuits Did the applicant submit an operation and maintenance manual? Has applicant submitted a copy of a maintenance Are thevariances listed on the plan? [310 CMR 15.220 1 (4)(q)] RLS Stamp necessary on plan if a component is within five feet of property line[310 CMR 15.412(4)] New construction or increased flow proposed-[Refer to 310 CMR 15.414] g Address oo Sheet 6 of 7 N/A OK NO Is the system in a Designated Nitrogen Sensitive Area(Zone H for a public supply well)? [310 CMR 15.214,310 CMR 15.215 and 310 CMR 15.216-also refer to Policy regarding upgrades of such existing systems] Is the system proposed on the same lot as served by private well? / [310 CMR 15.214(2)] Are the nitrogen loads proposed in compliance? [310 CMR 15.216(1)] Pumping to septic tank? [310 CMR 15.229] Shared System[310 CMR 15.2901 Address ���,� a Sheet 7 of 7 I Town of Barnstable °ft"E r°w Regulatory Services Thomas F. Geiler, Director * BARNSTABLE, 9�A MASS. � Public Health Division Thomas McKean, Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: Designer: Shay Environmental Services, Inc. Installer: (��, u 'y�1•`CU�S Address: P.O. Box 627 Address: East Falmouth, MA 02536 Ot sgaJ—A, On nk-N � _ was issued a permit to install a (da^e)) (i alter) septic system at 51 CM based on a design drawn by (address) '-KN-\'Z�-\\ _ Shay Environmental Services Inc. dated tc( (designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. N OF S\`er (Installer's Signature) o U S No. 11 1 crsTS (Designer's Signature) (Affix Desi p Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q: Health/Septic/Designer Certification Form r, Town of Barnstable P# i l'/ ]� F Department of Regulatory Services Public Health Division Date 0 •63p. 200 Main Street,Hyannis MA 02601 lED MA't� Date Scheduled (J Time 4P1 Fee Pd. ZO Soil 'tability Assessment for Sewage isposal Performed By: Witnessed By: L1/ LOCATION& GENERAL INFORMATIONLocation Address Owner's Name Address Assessor's Map/Parcel: -7 Engineer's Name NEW CONSTRUCTION REPAIR 11 Telephone# 5'C8 539--4 9(e(. Land Use Slop es '% p ( ) o Surface Stones NON Distances from: Open Water Body �J f'\' ft Possible Wet Area 1� IA_ft Drinking Water Well �ft 1 - I Drainage Way �V a` ft Property Line ZZ) _ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands 3n proximity to holes) I�( 97 (Rocs L6'k L4.j (wr Parent material(geologic) l.�G Depth to Bedrock. , J/A Depth to Groundwater. Standing Water in Hole: NCY-4- LbS Weeping from Pit Face /V OLIQ. lJ CSI(p G X t( Estimated Seasonal High Groundwater ( DETERARNATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: in. Depth to soil mottles: in. Depth to weeping-from side of obs.hole: in, Groundwater Adjustment ft. Index Well# Reading Date: Index Well level Adj.factor- Adj.Groundwater Level PERCOLATION TEST bate I I T mt 11:ov Observation RM Hole# 'q� � Time at 4" Depth of Perc A--- Time at 6" Start Pre-soak Time @ 'I°1©-..,_ Time(9"•6") End Pre-soak Rate Min./Inch Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the Barnstable Conservation Division at least one (1) week prior to beginning. Q:\SEPTICIPERCFORM.DOC 6 DEEP.OBSERVATION HOLE LOG Hole#�I _ Depth from Soil Horizon Soil Texture .Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. Consistency,% ravel ia- © -P. 1 c C, w1 a. sY�- sti7 DEEP OBSERVATION HOLE LOG Hole# a Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. C nsis en % ravel A ta' � L5 1n Y2 sl 3(P - Mta 1 2,Sy q Uose sr'� DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Cnito c 1% Gravel) I DEEP OBSERVATION HOLE LOG. Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. onsi ten ° Flood Insurance Rate Man: q / Above 500 year flood boundary No_ Yes Within 500 year boundary No , Yes Within 100 year flood boundary Now Death of Naturally occurring Pervious Material Does at least four feet of naturally occurring pervious aerial exist in all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth of naturally occurring pervious material? Certification I certify that on (date)I have passed the soil evaluator examination approved by the Department of Environ %ent Pr ction and that the above analysis was performed by me consistent with the required training x tis a d x ience described in 310 CMR 15.017. Signature Date Q:\SEp rlCIPERCFORM-DOC �O 4v, .'. .+sue � '•A No.. .........`... F ... ....... ............... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF H. A T I-I _ --- ------------------- OF.........f*41r.. App iration for Di-qvnFai Wor "amitrnrtiun ramit Application is hereby made for a Permit to Construct ( ) or Rep"it ( ) a Individual Sewage Disposal System at .... _........ :.:.. G -------- --- - - --------------------------•-................-- ocati dyes or Lot No. ............................... .................................................................................................. Own Address W -• .. .................................. ....•---•----•-•••----------•--•-.............--------••----------•......._......_._.............. Installer Address Q Type of Building Size Lot............................Sq. fee U Dwelling—No. of Bedrooms........... .....Expansion Attic ( ) Garbage Grinder p`�, Other—Type of Building ............................ No. of persons..........CX............ Showers ( ) — Cafeteria ( ) Q' Other fixtures ...___._ Q ----------------•---------------------------------------------------------------------•--------------•------------------- W Design Flow...... .......gallons per person per day. Total daily flow------P.Z.&.......................gallons. WSeptic Tank�—Liquid capacity/.00.gallons Length... ..__.... Width.....46-------- Diameter________________ Depth................ x Disposal Trench—N . .................... Width Total Total Length....._.._,,_rr Total leaching area........... ...sq. ft. Seepage Pit No_______ _________ Diameter.__...._C�"...._ Depth below inlet.____ .......... TotalVcin area._ .d_j._.sq. ft. z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.__.... lA d- ...:................................... Date.... % ............... W Test Pit No. 1................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........................ P4 ................... ----•--- --•-• ---- - ............. J_t.. .,�! Description of Soil---------- ------------ --------- rP -- t`'-- ------s r �1/ W U Nature of Repairs or Alterations—Answer when applicable----------------------------------------------.....------....................................... ------------------------------------------------•----------•------•-----• ----------........-------•---•----••-•------------------------------------------------------------------------•••-•--•---•-•-- Agreement: The undersigned agrees to install the aforedescribed Individual Sew ge Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Cod The n ersig f .er agrees not to place the system in operation until a Certificate of Compliance has been ' su d t bo o th. igne _ Date Application Approved By......... -,... . ....--- -------- - --- ,........._.. -•--` `� . Application Disapproved for the following reasons:............. ....................................... ..... .Date .... ................................................................•-•-•---------•-......-•---------••••-------------------....-----------------•---•-----•-------------------••--------•--••-------_... Date J PermitNo......................................................... Issued.--��---=-`�------7-�-:......-------------• , Date i .61� No..........�:3� $..2. ...��....... THE COMMONWEALTH OF MASSACHUSETTS BOARD F �-1 �A JET E-1 OW .... ....................OF......... .?.. C.j7 ..........._(Q .................................... Appliratiou for Mopuoal Vorkti Tonstrartion ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) ap Individual Sewage Disposal System at: di --....t !� ...(�Yt'�!. .••�- / �Locati -tY`ddres� _ or Lot No. Own r Address a .. .. ,�.... .. ................•-•-•-----------•• •-------•-•••------------------•--...•--••----•-------•---..._...............••------....._._..... Installer Address d Type of Building Size Lot............................Sq. fe t U Dwelling—No. of Bedrooms.... a Expansion Attic ( ) Garbage Grinder (( ) `A Other—Type T e of Building ............................ No. of ersons.....__.. Showers — Cafeteria PA YP aag P ( ) ( ) Q' Other fixtures ..__..}...�................... . W Design Flow..... .....s1 ._........gallons per person per day. Total daily flow______ ?..cZ__U...................:....gallons. WSeptic Tanker Liquid capacity/P.gallons Length..4`�........ Width.....A........ Diameter---------------- Depth................ x Disposal Trench—No..................... Width_.. Total Length..... ._____._. Total leaching area.....__..._...__.__sq. ft. _-_-- Diameter-__---__ De th belo inlet._... Seepage Pit No....... p Total 1 c >n area..;?.').......sq. ft. Z Other Distribution box ( ) Dosing to 2� � ~' Percolation Test Results Performed by....... J. ...:................................... Date....2:.5__...7j..........._.. a, a Test 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_--___-__-_--__----__-_- 0 Description of Soil----- = •�. �`_ L 1� � f - - f ..............•---•--- W UNature 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 TITL L 5 of the State Sanitary Co Th dersi :er agrees not to place the system in operation until a Certificate of Compliance has bee sst�ed. tYie b th. igne ._ deLr2% v" f��c C ' Date 7 Application Approved BY-------- -{= ,-----• ---� -------------------•- � y- Date Application Disapproved for the following reasons: ---------------------------------------•----------......---------------.._.............-- -------••••--••---•--•---------•............................................................•-----............--•-._......._...._....--•---....._..------.......................... ••------•-•--- Date PermitNo......................................................... Issued_..................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .....OF......... . ...:............................................. CCrdifiratr of Tootplitturr THI S TO CERTIFY hat the n ivi ual Sewage Disposal System constructed or Repaired ( ) by .C.... `, -- ----- •----- �/ � Installer has been installed in accoi nce with the provisions of fm IR 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No 7 _.___.._/_•.�. ;............ d-ated...3__-:2__{.—7-f.............. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE..................................._............._............-••.....-•------_. Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD HEALTH r C��—..J. 1.....oF........ . r�� ...........................................•.N . �.FEE4. Disposal loorks T uoIr ion ranti# _ .. Permis 'o i ereby granted--- I f j� ; ---........ i f r..._.._ =..j .................. , to Cons or �,2 �a i- ( iiTnc ivf'dual� a�jPo alU ` at No U lj •-•••--•-•-•••...._...._ 'IR Str I T r as shown on the application for struction Per 1,�0.rf t-'✓f/i /�✓ �. . , y Ji. Board of Health '55 HOBBS & WARREN. �- LOCATION SEWAGE PERMIT NO. L O'T 4 "o 1-`7 sFk4, Z 7 3 6 VILLAGE e �w a-rty l I-l � INSTA LLER'S NAME & ADDRESS 1C`�V it rc /c�� B U UL D E R ORE��R c tA✓i rc vt LL L � ❑ DATE PERMIT ISSUED �L � y DAT E COMPLIANCE ISSUED .� � o ,/ �� � . �� .. .�, r �I �b z?, �� 3�, f . . f Iln �� \ m