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Home My WebLink About0090 PATRIOT WAY - Health 1 90 PATRIOT WAY, CENTERVILLE A= 192 134 No. 42101/3 ORA ESSELTE 10% (5 e o 0 0 8-k 26230 Ps 175 �19205 04-09-2012 a 11 _ 4.1ti DEED RESTRICTION WHEREAS, MELISSA JANE STOPYRA of 90 Patriot Way, Centerville, Massachusetts is the owner of 90 Patriot Way, Centerville, Massachusetts and being shown as Lot 8A on a plan entitled "Subdivision of Land in Centerville-Barnstable t ¢ Mass. Property of John E. Bernard, Jr." dated May 17, 1965, recorded at Barnstab Registry of Deeds in Plan Book 197,Page 127. le € X. Whereas MELISSA JANE STOPYRA, as the owner of said lot has agreed with . . � gr� the Town of Barnstable Board of Health to a restriction as to the number of bedrooms ' which can be included in any home built on said lot as a pre-condition to� obta'variance from the 310 CMR 15.214 mung a State Environmental. Code, Title V, Minimum Requirements for the Subsurface Disposal of Sanitary Sewage and to obtaining a building }. Permit for this lot. Whereas, the Town of Barnstable Board of Health the variance from 310 CMR 15.214, State Environmental CgodecTilelV_tM_nim_nm__ _ _- Requirements for the Subsurface Disposal of SanitarySewa a sand-authorizin issuance of a buildingg the permit for the construction o£.a single family home on this lot is � requiring that the agreement for the restriction on the number of bedrooms in any house constructed on the lot be put on record with the Barnstable County Registry of Deeds by recording this document. ` Now Therefore, MELISSA JANE STOP 1 restriction.on this above-referenced land in accordance with this, does herebylace the following agreement with the Town of Barnstable Board of Health, which restriction shall run with the land and be r. binding upon all successors in title: `is'_ t 1• 90 Patriot Way, Centerville, Massachusetts may have constructed upon the lot a house containing no more than four(4) bedrooms. MELISSA JANE STOPYRA agrees that this shall be a permanent Deed Restriction affecting Lot 8A located at 90 Patriot Way, Centreville, Massachusetts, and being shown on the plan recorded in Plan Book 197, Page 127. LOCUS: 90 Patriot Way, Centerville,Massachuetts For title of MELISSA JANE STOPYRA see Deed dated May 29, 2001, recorded at Book 13884, Page 294. Executed as a sealed instrument this 5"'day f A ril, 2012. e issa Ja Sttopyr COMMONWEALTH OF MASSAC TTS j Barnstable, ss On this 5 h day of April, 2012, before- me, the undersigned Notary Public, personally appeared Melissa Jane Stopyra, proved to me through satisfactory evidence of identification being: j other state or federal governmental document b a photograph image; or earin g [� Oath or affirmation of a credible witness known to me who knows the above signatory; or 0 My own personal knowledge of the identity of the signatory to be the person whose name is listed above and acknowledges to me that she signed the foregoing instrument voluntarily of her own free act and deed. g p / 7yy ,. t 5.oi►'ss'a�t-•"4�- Su E. Clark N ,�oe• �o,�4: ,Notary Public .► _ = My Commission Expires: f BA REGISTRY OF DEEDS B x '�. f i 6 001 BATH RESTORED TO SINGLE Fo FAMILY, SINK REMOVED AND PIPES CAPED BELOW BEDROOM HOME OFFICE FLOOR BEDROOM ABOVE GARAGE i STORAGE REPLACE EXISTING ROTTED SECOND FLOOR PLAN 6'SLIDING DOOR,WITH LIKE FOR LIKE DOOR �m za-y�al�,ay u j Dw L01 FAMILY BATH BEDROOM - GARAGE REPAIR ASPHALT SHINGLE ROOF ABOVE ENTRY WAY/REPLACE ROTTED PLYWOOD I I i I FROM ENTRY DOOR i MASTER BDRM DINING FITST FLOOR PLAN PROPERTY LOCATED @#90 PATRIOT WAY,BARNSTABLE FLOOR PLAN PROVIDED BY JAMES ELGIN UPTON 508 362 4440 i r �ivt�ive�z �iry�aa�-n•- y O01 -------------- BATH ® RESTORED TO SINGLE FAMILY, SINK REMOVED AND PIPES CAPED BELOW HOME OFFICE FLOOR BEDROOM ABOVE GARAGE BEDROOM STORAGE FO v 0 REPLACE EXISTING ROTTED SECOND FLOOR PLAN 6'SLIDING DOOR,WITH LIKE FOR LIKE DOOR NF �12! N�T1�131 l DW °0° 0GARAGE FAMILY BATWFJ BEDROOM REPAIR ASPHALT SHINGLE ROOF ABOVE ENTRY PLYWOOD WAY/REPLACE ROTTED PLYWOOD T FRONT ENTRY DOOR MASTER BDRM U DINING LL- FITST FLOOR PLAN PROPERTY LOCATED @#90 PATRIOT WAY,BARNSTABLE FLOOR PLAN PROVIDED BY JAMES ELGIN UPTON @ 508 362-4440 TOWN OF BARNSTABLE LOCATION ,�. � —� .�/ SEWAGE # VILLAGE��r-�e�',�I � ASSESSOR'S MAP & LOT--Y!!Sa� INSTALLER'S NAME&PHONE NO. � SEPTIC TANK CAPACITY LEACHING FACILITY: (type) a a (size) -7''`—,�. _ NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: 5:/aa —_COMPLIANCE DATE: 21- Separation Distance Between the: Maximum Adjusted Groundwater Table and 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) /A Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by r � r ' No. �L /� Q THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: es PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS ZippYtcatton for ;Dtopo.5al *potent Construction Vermtt Application for a Permit to Construct(X)Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.CYO (Fi h� Owner's Name,Address and Tel.No. Assessor's Map/Parcel Installer'sN"""amee,Address,and Tel.No. � 177V,C-6; -Designer's Name,Address and Tel.No. oo Type of Building: Dwelling No.of Bedrooms' ' Lot Size sq.ft. Garbage Grinder( ) Other Type of Building: No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow /AA CZ gallons per day. Calculated daily flow_ /�/ (� gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when ap li S'0,9 w.,6ecs Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of c ' -the a ore es ' e 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 issu d oarTIHe Signed - Date Application Approved b r Date "` Application Disapproved for the following reasons Permit No. �� Date Issued �� 67 No. 46/ %L/ Fee�� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: es PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSE S. 01ppCication for Oigozal 6potem Construction Permit Application for a Permit to Construct(X)Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 0�Pgp Owner's Name,Address and Tel.No. Assessor's Map/Parcel Installer's Name,4ddress, d Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( ) Other Type of Building _ No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when ap 1- ble --51AS r �,w,6Pf<, Date last inspected: / �€j6 Agreement: ---� The undersigned agrees to ensure the construction and maintenance of the afore escn a on-sife 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 issu d oar f He(t 1 Signed Date C7 Application Approved b Date Application Disapproved for the following reasons _ � n Permit No. Date Issued ————————————-——————————— ————— —— — t THE COMMONWEALTH OF MASSACHUSETTS wwd rad Kt S z-5 BARNSTABLE, MASSACHUSETTS .a-� Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded( ) Abandoned L )by / Ge im^ at WG has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Pe opf 7AP dated—/,- ''Z®1? Installer Designer The issuance of this p rnu'yshall not be construed as a guarantee that the/ syst tll fu =,sign �. (�� Date � z y/ Inspector �. g THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Mizpaal *pztem Construction Permit Permission is hereby g nted to C- struct( )Repair( )U grade( )Aban on( System located at e 'I ' �,s Log V, � 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'thti emit. Date: Approved A M I l/6/99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) I, `O , hereby certify that the application for disposal works construction permit signed by me dated /",� i � concerning the property located at ` ��- �e�\f -meets all of the following criteria: This failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. v The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. • . There are no wetlands within 100 feet of the proposed septic system v• 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.. v• The bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation..[Adjust the groundwater table using the Frimptor method when ,applicable] If the S.A.S.will be located with 250 feet of any vegetated wetlands, the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: r A) Top of.Ground Surface Elevation (using GIS information) B) G.W. Elevation >C1 +the MAX. High G.W. Adjustment . = �1 DIFFERENCE BETWEEN A and B '� SIGNE : �gT - DATE. [Please Sketch proposed plan of s m on b I ; NOTICc Based upon the above information, a repair permit will be issued for bedrooms maximum. No additional bedrooms are.authorized in the future without engineered septic system plans. q:health folder:cert �� SO ,vc- C r 6 v � •fit o Dom. � I { i .'7 1 V-o i f l p� �l bS i rn 4f> �5 i0 i A THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINALS) I M ^C&L DATA � f _ � } ,� �r, ;, P I � ra-A"� � (mow'' ^tln`'. 9 i-- 5'li'a TOWN OF BAkI�STABLE I LOCATION Y r-� U SEWAGE # . s. .. VILLAGE_ ASSESSOR'S MAP& LOT INSTALLER'S NAME&PHONE NO. ' SEPTIC TANK CAPACITY LEACHING FACILITY. (type) a G (size) X 1 NO.OFBEDROOMS BUILDER OR OWNER }>' PERIviIT DATE ``/1 _COMPLIANCE DATE.. �= 21.= Sepia on.Distance 'Between the: Maximum Adjusted Or ater Table and Bottom of Leaching Facility; Private Water.Supply Well and Leaching Facility (If;any.wells exist on site or with kWQ feet"of.leaching facili 4 Edge of Wetland and Leaching Facility(If an y`wetlands exist w1thin.300 feet of leaching facility) Furnished b ,Fee 1.. 77 >' a , .r i l� i t P, V r, t' Commonwealth of MassachusettsJAL hr Executive Office of Environmental Affairs ° • .. Department of Environmental Protection ", I William F.Weld Governor Cd 1 ,c PU Trudy Coxe Secretary,EOF.4 - David B. Struhs Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: Tr%UTw'4` CE'`�rvYi(I� Address of Owner: ) . t4N? arm �-- P Y 90 ��,q � � Date of Inspection: `T— (If different) Name of Inspector1200 -C e� Company Name, Address andR�elephone N��jber:, CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-sitesage disposal systems. The system: Passes _ Conditionally Passes Needs further Evaluation By the Local Approving Authority _ Fails ,I Inspector's Sigrhature: ` Date: 7- The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (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 me system owner and copies sent to the buyer, if applicable and the apprm ing authority. INSPECTION SUMMARY: Check A, B, C, or D: A) S�YSTT PASSES: V 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 completion of the replacement or repair, passes inspection. Indicate yes, rip, 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 septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 8/15/95) One Winter Street • Boston,Massachusetts 02106 • FAX(617)556-1049 • Telephone(617)292-5500 10 Printed on Recycled Paper n SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION.(continued) Property Address: q0 Owner: A1t1 ,w-c•%.L Date of Inspection:, Z�'j-C-00 B] SYSTEM CONDITIONALLY PASSES (continued) , Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed A` pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are 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 Healthi: 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 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. �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 i ENVIRONMENJ: _ Ihp wsteni hati a septic tank ano 501i absorptiun sysient and 6 Within IOG fee,, tu.a su,a-c 'rYaici Su�Ni'j Or trlbutafj t0 a surface water supply. _ the system h& a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic 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 and volatile organic compounds indicates that the well is. free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 t.; ppm' D) 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 alth should be contacted to determine what will be necessary to correct for this determination is identified below. The Board of He the failure. _ Backup of sewage into 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 SAS or cesspool. (revised 6/15/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property A dress: 43V pe i rio?—t c.y CCtYT, Owner: I+M of►-R L-- Date of Inspection: D] SYSTEM FAILS (continued): Static liquid level in the distribution box above outlet invert due t6 an overloaded or clogged 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 pipe(s). Number 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 I of a public well. L 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 large systems in addition to the criteria above: The design flow of 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 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 suppiy 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 8/15/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 90 'O'l-r )U1 IL y/i Owner: Ivi<r�t(- Date of Inspection: 7-�y�� Check if the following have been done: ✓Pumping information was requested of the owner, occupant, and Board of Health. c/None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. —TF resystem does not receive non-sanitary or industrial.waste flow site was inspected for signs of breakout. _ II system components, excluding the Soil Absorption System, have been located on the site. C T e 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. 4- he size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. _ 111e facility accupants, if differen,. fro•n owner? were provided \vith information on the proper maintenance of Sub- Surface Disposal System. (revised 8/15/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEMANSPECTION FORM PART C SYSTEM INFORMATION Property Ad ress: furl e) Owner: 140161 v".t Date of Inspection: /,•'ate��, FLOW CONDITIONS . RESIDENTIAL- h Design flow: l✓ all s Number of bedrooms: Number of current residents: Garbage grinder (yes or no): Laundry connected to system (yes or no): Seasonal use (yes or no)::s �� Water meter readings, if available: r Last date of occupancy, ✓Y°-STk7-/tuc— COMMERCIAUINDUSTRIAL• Type of establishment: Design flow: gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no), Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: ~ � � � j '�f Vk-�. �' .-L �S mac•%!0�J System pumped as part of inspection:.(yes or n ) [ If yes, volume pOmned. gallons Reason for pumping: YLG,'C TYPE OF PSTEM Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Other (explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site: (yes or no/Y/ (revised 8/15/95) 5 Al SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ` SYSTEM INFORMATION (continued) „`- Property Address: Owner: R-�Vv\>rttrctf`„ Date of Inspection: SEPTIC TANK: (locate on site plan) G( Depth below grade: Material of construction: concrete _metal _FRP—other(explain) Dimensions: Sludge depth: Distance from top of sedge to bottom of outlet tee or baffle: Scum thickness:' Vi l Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle:1_ Comments: (recommendation for pumping, condition of inlet and outlet tee or baffles, de th of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) 1 V t GREASE TRAP: (locate on site plan) ' t Depth below grade: k?.y Material of construction; _concrete _metal _FRP —other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom ro riv t- hottom of ou!ie! tee o• bailie- 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.) ' x ,a (revised 8/:5/95) 6 4: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: 4014 v"ct e-- Date of Inspection: TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP—other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: (Locate on site plan) Depth of liquid level above outlet invert: Comments: mote ti ievei ano distributic,i- ryu8i, evidence of sulid., evidence of leakage into or out of box, etc.) 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.) (revised 8/15/95) 7 +�a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM J 4 PART C SYSTEM INFORMATION (continued) Property Ad ress: Q/ TI'/U%cc,l��/ �',��✓ 3'h Owner: Date of Inspectio77_\ "q 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: overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) ,p CESSPOOLS: (locate on site plan) Number and configuration: - Depth-top of liquid to inlet.invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater. inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 8/15/95) 8 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Adjress: Owner: /4411a r-h C_r Date of Inspection: 7- SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' 47 1 dcc.� S,i i 1 0 L DEPTH TO GROUNDWATER Depth to groundwater:_Z�ffeet method of determination or approximation: �Z ME n. (revised 6/15/95) 9 L0, . AT ION �S E WAGE PERMIT NO. OS_ Ll VILLLAGE - 1 I N S T LE 'S NA;ME & ADDRESS B UtLDE R OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED 1 � � �� y _ , " �� -a N0.... ...�a....... 13� FRs....l.Jr-................ THE COMMONWEALTH OF MASSACHUSETTS BOARD O EALTI-! P ' 1( ......----OF..c :�(I,S.. .eft � .................................... Appliration -for Uiivooat Works Tontrnrtion Vrrniit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at, i r 11 1.L, d ss % ...... roc ��.-e1 . J.Jf Lot o. 11 caner /' Address t Installer Address Type of Building ��'�p- Size Lot... .�t '.____Sq. feet Dwelling—No. of Bedrooms-----1.�?.: ............................Expansion Attic ( ) Garage Grinder ( ) Other—Type of Building .q�ls �o_wt ... No. of persons..... ..............•....._ Showers ( ) — Cafeteria ( ) Q' Other fixtures - -------------------------------- d W Design Flow..........................-5.0........gallons per person per day. Total daily flow__... ---______---____.-..----..gallons. WSeptic Tank—Liquid capacity-I/t.%V-gallons Length-----_-------- Width................ Diameter_----..._-..___ Depth._.----.-_.-.... x Disposal Trench—No..................... Width-------------------- Total Length-------------------- Total leaching area..............------sq. ft. Seepage Pit No.. 1? ...... Diameter.................... Depth belo inle ._.. ..•_.._ Total leachiu area_..__._..__.___.sq. ft. Z Other Distribution box ( ) Dosing tank ( ) tJ . ��'t/- 7 aPercolation Test Results Performed bY----------------- ........................................................ Date---------------------------------------- .� Test Pit No. I---_------------minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ 41 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water...--- .--.---.-.--. -- ......... ----------------- ...... . ------------------ Description of Soil---- x 4t -•----------- -------------------- ---------- - --------------------------------------------- V 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 YI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee sued by the board of healtl r� Signed - --------------------- / `, Date Application Approved BY .... . ---------------- -- ....4 ^--;�- Date Application Disapproved for the following reasons:.......... ...................... ••..............................................•-•-----.. -----------•-- Date PermitNo......................................................... Issued........................................................ Date ��._- -------- --------------�� No. � FEs.....f F.................. THE COMMONWEALTH OF MASSACHUSETTS a BOARD OF=H, ,,EALTH y -� 'r ....... �. .O ..... ,,..................................... a, Applirtttion -fur Btgpagad larks Totm urtiall rrtttit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ----.. 'Location-Add�As or Lot 4o. a s P' wner ' Address ' Installer ' .Y;. Address Q Type of Building Size Lot---- -,�`:Y!x .-°:Sq. feet Dwelling—No. of Bedrooms------/ -L4=_________________________Expansion ttic ( ) Garbage Grinder ( ) Other—Type of Building _e- fJh v __ No. of persons------ --•------_-_ Showers ( ) — Cafeteria ( ) Q Other fixtures ..............................................-------- W Design Flow............................................gallons per person per day. Total daily,flow__---------: ---------_---------------gallons. R. Septic Tank—Liquid capacitv__,!:c gallons Length________________ Width_.............. Diametei---------------- Depth..-________---- W Disposal Trench—No_____________________ Width.................... Total Length.................... Total leaching area.......-__-_.-____-_sq. ft. x Seepage Pit No.__fry -____ Diameter____________________ Depth belo in le _ Total leachin area----_.._.........sq. ft. Z Other Distribution box ( ) Dosing tank ( ) 4 /.-�c,►, 7' aPercolation Test Results Performed by-------------------------------------------------------------------------- Date........................................ .a Test Pit No. 1................minutes per inch Depth of "Pest Pit-------------------- Depth to ground water...-_-__-_____.__-_-.-. �14 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water__.__.___-_-____-___.--. a ( - • O Description i f Soil----- w -------------- - ----3 '`--- -------- -- ---- - - - 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 bee"sued by the board of health Signed f -1. ___�_ -� �G - ----------------- af Date Application Approved B Date Application Disapproved for the following reasons_____________ ..•--•--•••--•-•-•-•----------------------••-•----•-•----------••--••-•-------•----••-••-••••------•---•....•---•---------------••••-•-•--------•--•--------_...-------•-----•----------•---...--••••••- v - ;Date PermitNo------------------- =------••••--•----•---•--••-•----- Issued---------------------- •-. ........................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ' -� s ?..........O a-4~.14101e..014..................... nfifirttte of Tomphaurr ,09 , . THIS O CE FY t the Individual Sewage Disposal System constructed ( or Repaired ( ') by -- .__._..--• + nstalle has been installed in accordance with the pr visions of A cl XI of The State Sanitary Code as desc. "bed in the application for Disposal Works Construction Permit No_'77 _......_ __0_r__.....__. dated_..'y�.-+�:,t�..t THE'ASSUANCE OF THIS CERTIFICATE SHA NOT BE CONSTRUED AS A GUARANTE ETHAT THE SYSTEM WILL FUNCTION SA FACTORY. DATE---------------------------------•........................-----------------..... Ins pector,-=--=................--=-------------------...................................... THA COM ONWEALTH OF MASSACHUSETTS OAR F LTH . o 2 ... No.4 FEE__ "'_:---�-� �ilh�>a,�ttl k� n Isar � it Permission by gran ed____._____ ,� f j «_..__. .. r- to Const ) or air "' ) Indiv•dual Se vb Dispos System j Street as shown on the application for Disposal'tWor Construction Permi "'�„$' !� DATE r **" Board of ea It FORM 1255 HOBBS & WARREN. 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