Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
0221 RIVERVIEW LANE - Health
221 Riverview Lane Centerville A=228 189 S ME A D No. H163OR UPC 10259 smead.com • Made in USA �CYC� S Z TOWN OF BARNSTABLE ATION SEWAGE # LAGE ASSESS R'S MAP & LOT 9 /} NAME&PHONE NO. _ ydf- rSEPTIC TANK CAPACITY �OD� XLntY /�n���(( ,� ��{� &n' c LEACHING FACILITY: (type) (size) A000e NO. OF BEDR BUILDER R OWNER PERMITDATE: COMPL CE 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 I 6y I Vo 0 6 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION M � TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 221 RIVERVIEW LN �� CENTERVILLE Owners Name: SEELEY Owner's Address: Date of Inspection:8/26/06 Name of Inspector: (please print) Douglas A.Brown Company Name: Douglas A.Brown Septic Inspections Mailing Address:RO Box 145 s C3 Centerville,MA 02632z Telephone Number: 508-420-4534 - - 00 CERTIFICATION STATEMENT `' I certify that I have personally inspected the sewage disposal system at this address and that informon reported below is true,accurate and complete as of the time of the inspection. The inspection was perfo ed based on my training and experience in the proper function and maintenance of on site sewage disposal sy ems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: 14 Date: 8/26/06 The system inspector shall submit a c py of this inspection report to the Approving Authority(Board of Health or DEP)within.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 DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable, and the approving, authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different Conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Revised on 10/31/2000 Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 221 RIVERVIEW LN CENTERVILLE Owner's Name: SEELEY Owner's Address: Date of Inspection: 8/26/06 inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information winch indicates that any of the failure criteria described in 3 10 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: SYSTEM MEETS MINIMUM PASSING REQUIRMENTS AT THIS TIME. B. System Conditionally Passes: one or more system components as described in the"Conditional Pase' section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health, *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced The system required pumping more than 4 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 Page 2 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 221 RIVERVIEW LN CENTERVILLE Owner's Name: SEELEY Owner's Address: Date of Inspection: 8/26/06 inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information winch indicates that any of the failure criteria described in 3 10 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: SYSTEM MEETS MINIMUM PASSING REQUIIZMENTS AT THIS TRAE. B. System Conditionally Passes: one or more system components as described in the"Conditional Pase'section need to be replaced or repaired. The system,upon completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health, *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced The system required pumping more than 4 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 . Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 221 RIVERVIEW LN CENTERVILLE Owner's Name: SEEl EY Owner's Address: Date of Inspection: 8/26/06 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 public health, safety or the environment 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2.System will fail unless the Board of Health and Public Water Supplier, ( pp er,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ the system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 221 RIVERVIEW LN CENTERVILLE Owner's Name: SEELEY Owner's Address: Date of Inspection:8/26/06 D.System Failure Criteria applicable to all systems: You must indicate"yes or no to each of the following for all inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. _• X 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. (This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] NO (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 3 10 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure, E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or no to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no 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 If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered ye§'m Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 221 RIVERVIEW LN CENTERVILLE Owner: SEELEY Date of Inspection: 8/26/06 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No X Pumping information was provided by the owner, occupant, or Board of Health — X Were any of the system components pumped out in the previous two weeks ? X _ Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) X — Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out ? X _ Were all system components,excluding,the SAS,located on site? X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? X Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no X _ Existing information. For example, a plan at the Board of Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3 ))(b)] 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:221 RIVERVIEW IN CENTERVILLE Owner's Name: SEELEY Owner's Address: Date of Inspection. 8/26/06 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN How based on 3 10 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Number of current residents: Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): NA Seasonal use: (yes or no): NO o q.;2-7 fb G ?,D Water meter readings,if available(last 2 years usage(gpd)): O S— 2 l Sump pump(yes or no):_ Last date of occupancy: COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sqft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no): _ Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no): If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM X 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) _Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: UPGRADED 1995 OFF OLD INSPECTION REPORT Were sewage odors detected when arriving at the site (yes or no)? NO Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 221 RIVERVIEW LN CENTERVILLE Owner's Name: SEELEY Owner's Address: Date of Inspection: 8/26/06 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: cast iron _40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:_ (locate on site plan) Depth below grade: Material of construction: X concrete_metal_fiberglass _polyethylene other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no): _(attach a copy of certificate) Dimensions:.1000 gal Sludge depth: 18" Distance from top of sludge to bottom of outlet tee or baffle: 28" Scum thickness: 8" Distance from top of scum to top of outlet tee or baffle: 8" Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: TAPE Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.)- COULD USE PUMPING GREASE TRAP:_(locate on site plan) Depth below grade:_ Material of construction:_concrete metal_fiberglass—polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 221 RIVERVIEW IN CENTERVILLE Owner's Name: SEELEY Owner's Address: Date of Inspection: 8/26/06 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection) (locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 0 Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 221 RIVERVIEW LN CENTERVILLE Owner's Name: SEELEY Owner's Address: Date of Inspection: 8/26/06 SOIL ABSORPTION SYSTEM(SAS): _(locate on site plan,excavation not required) If SAS not located explain why: Type X leaching pits,number: leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): PROBED BESIDE PIT TO ABOUT 4'NO SIGNS OF HYDRAULIC FAILURE AT THIS TEME CESSPOOLS: (cesspool must be pumped as part of inspection)(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(yes or no): 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.): Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 221 RIVERVIEW LN CENTERVILLE Owner's Name: SEELEY Owner's Address: Date of Inspection: 8/26/06 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. D 1 �3�_ L4 o Page 11 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM ] INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 221 RIVERVIEW LN CENTERVILLE Owner's Name: SEELEY Owner's Address: Date of Inspection: 8/26/06 SITE EXAM Slope: Surface water: Check cellar: Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: TOWN OF BARNSTABLE LOCATION. / �Il/�!`llfl%�lrr• SEWAGE # ZeV,0-3�ZL VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. /7yl' LF� ��Di1✓�`. 77�f�f SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF DE BEDROOMS O MS BUILR lt;0—N R _5 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) Feet Furnished by lei A , �' 7 1 No. �' T 4 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: es PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01pprication for 30iopoml *pgtem Construction Vermtt Application for a Permit to C nstruct( pair(v)Upgrade( )Abandon( ) ❑Complete System F ndividual Components Location Address or Lot No. Owner's Name,Address and Tel.No. Ma / zz1 �l�z��/fez�ln, sa/ r� Assessq�'s P 8�j�� cel e,e.,t,,�f/)� Installer's Name,Address,and 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 Ge 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 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 by th's Board of alth. 6h��Signed Date Application Approved by - Date ' 4 ,� Application Disapproved for the following reasons ,r Permit No. Date Issued No. / { (� o r Fee t THE COMMONWEALTH OF MASSACHUSETTS _ Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS F' ` Z(ppYication for Zigpogar bpgtem Congtruct[on Permit Application for a Permit to C n s c ( pair(Upgrade( )Abandon( ) O Complete System ?]Individual Components Location Address or Lot No. �jfr Owner's Name,Address and Tel No. '. Assess�?Map Orel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: 1, Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( � Other Type of Building PSG z'Oe4? No.of Persons Showers( ) Cafeteria( Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title I Size of Septic Tank Type of S.A.S. �r " "" ,",'Description of Soil -Nature of Repairs or Alterations(Answer when applicable) Date last inspected: E� 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 by this yBr�oard of . alth. / Signed Date Application Approved by Date - z—;FCTotn� Application Disapproved for the following reasons ,t Permit Na,'' Date Issued THE COMMONWEALTH OF MASSACHUSETTS Z Z9 fS�9 i _4 }. BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERT, ,that a O,9-site Sewage Disposal System Constructed( )Repaired ( Upgraded( ) Abandoned( )by, d/" at ? Z w All, has been constru led in accordance .. with the provisions of Title 5 and the for Disposal System Construction Pe * dated l — -:`% �-- I Installer Designer A 4 !A U r 1. The issuance of this pe ' shall not be construed as a guarantee that the s}Mtrl will functi°n�as signed. Date Inspector A p v '� N® .r . , f .....�---------------� f�U _A ? --Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS N° ;Dfgpogal &paetu�Congtruction Permit ;x Permission is hereby granted to Construct( )Repair(4Upgrade( )Abandon( ) System located at Z / A)/0,�? " 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 rmit. Approved Cy -►�1' f � i i raa,� fl wee— WNOIPOly fo)DI r NOTICE: This Form Is To�BeVsed For the Repair Of Failed Seotic.Systems Only.` - CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUMON PERMIT(WITHOUT DESIGNED PLANS) I, ®�G/��` Al' hereby certify that the application for disposal works construction permit signed by me dated 6/Z z XV concerning the property located at _ Z z-/ R11wr ileW AY, cl- AM11/l meets all of the following criteria: i/ The failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. +� The sail is classified as CLASS I and the oe:cciation rate is less than or equal :o : minutes per inch. II/II/There are no wetlands within 100 feet of he aroD_osed smtic s✓stem There are no private wells within 150 fee:of the proposed septic system Y There is no incase in flow and/or change in use proposed +� There are no variances requested or needed. ✓ The bottom of the proposed leaching facility will not be located less than five fee:above the mwimum adjusted groundwater table elevation. (Adjust the groundwater table using the Frimptor /method when applicable] +� If the S.A.S. will be located with 250 fee:of any vegetated wetlands, the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the mammum adjusted groundwater table elevation, Please complete the following: G A) Top of Ground Surface Elevation(using GIS information) ( • B) G.W.Elevation / +the MAx High G.W.Adjustment. 3 = 1 3 r/ DIFFERENCE BETWEEN A and B SIGNED:_.. DATE: (Sketch proposed plan of system on bade]. q;h=M foldw am S , �fIV EO 2040 p °ftor lam; BORTOLOTTI CONSTRUCTION, INC. 45 INDUSTRY ROAD; MARSTONS MILLS, MA 02648 ' ` 508-771-9399 508-428-8926 FAY: 508-428-9399 4111 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: G2.2 , Date Of Inspection 6111oloo Inspe tor's Name: Owner's Name and Address: CERTIFICATION STATEMENT 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 perform- ed based on my Training and Experience in the Proper Function and Maintenance of On-Site Sewage Dis- posal Systems.T e system:' Passes Conditionally P s Needs Furt r alu y the Local Approving Authority Failure Inspector's Signature Date: � �GJ The System Inspector shall submit a copy of this Inspection Report to the Approving Authority with Thirty (30)Days of completing this Inspection. If the System is.a Shared System or has a Design.F,.low 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. SPE I N SUMMARY: A) SYST E PASSES: V I have not;found,any Information which indicates that the System violates any of the fail- ure criteria as defined in 310 CMR 15.303. Any Failure Criteria not evaluated are indi- cated 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,nor,or not determined (Y,N,OR ND). Describe bases of determination in all instances. If"not determined",explain why not. The Septic Tank is Metal,Cracked,Structurally Unsound,shows.Substantial Infiltration or exfil- tration,or Tank Failure is imminent. The System will Pass Inspection if Existing Septic Tank is Replaced with a conforming Septic Tank as Approved by the Board Of Health. Sewage Backup or Breakout or High Static Water Level observed in.the Distribution Box is due to broken or obstructed 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): -1 - 'e 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Broken pipe(s)replaced Obstruction is removed Distribution Box is leveled or replaced The System required pumping more than four times a year due to broken or obstructed pipe(s). The System will pass inspection if(with approval of The Board Of Health): Broken pipe(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 HELATH 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 FUNCTION- ING IN A MANNER THAT PROTECTS 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. The System has a Septic Tank and Soil Absorption System and is with a Zone 1 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 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: I have determined that the System violates one or more of the following Failure Criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overload 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. Static liquid level in the distribution box above outlet invert due to an overloaded or clog- ged 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 - 2 - 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 1 of a Public Well. Any portion of a cesspool or privy is within 50 Feet of a private water supply well. Any portion of a cesspool or privy:is less.--than 100 Feet but greater than 50 Feet from a private water supply well with no 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 now of a system is 10,000 ggd 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 es located in a nitrogen.:sensitive area Interim Wellhead Protection.Area (IWPA)or.a mapped Zone 11 o.f 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 315 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: _JZPumping 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. v 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. The system does not receive,non-sanitary or industrial waste flow. The site was inspected for signs of breakout. All system components,excluding the Soil Absorption System,have been located on site. The 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, 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 - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST(continued) 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 RESIDENTIAL:v Design Flow: Q rgallons Number of Bedrooms:Number of Current Residents: Garbage Grinder: Laundry Connected To System: Seasonal Use:_- j-= Water Meter Readi s,if ilable: Last Date of Oceupancyc -- COMMERCIAL/INDUSTRIAL: /ram 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 MeterRea:dings,If Available: Last Date of Occupancy: OTHER: (Describe) Last Date of Occupancy: GENERAL INFORMATION PUMPING RECORDS any source of information: . System Pumped as part of inspection;,!� l I yes,volume pum d:' C017 gallons Reason for Pumping: TYPE + SYSTEM: Septic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow.Cesspool Privy Shared System(If yes,attach previous inspection records,if any) Other(explain): PPROXIMATE AGE of all mpo ts,date installed (if known) and source of information: Al— Sep a odors detected when arriving at the site:�J /� -4- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C / GENERAL INFORMATION (continued) SEPTIC TANK: Depth below grade: /� Material of Construction: concrete metal FRP Other P g �_ _ (explain) r Dimensions: tRS .6' )((,o')f 5-" Sludge Depth:. Scum Thickness: j Distance from top of sludge to bottom of outlet tee or baffle:. Z q Distance from bottom of scum to bottom of outlet tee or baffle: y �/ Comments: (recommendation for pumping,conditioin of inlet and outlet tees or baffles;depth of liquid level in relation to ou t invert,structural integrity,ev' ence of leakage, tc.) jai, & q 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:' 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: V Depth of liquid 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: '� Pump is in working rder: Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) - 5 - 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 approximately by non-intrusive- methods) If not determined to be present,explain: Type: Leaching pits,.number:_L—Leaching chambers,number: Leaching galleries,number: Leacahing trenches,number,length: Leaching fields,number,dimensions: Overflow cesspool,number: Comments: (noteconidtion of yoil,signs of hydraulic fail re level of po ding,condition of veget do ,etc..) � . `. All /r - - CESSPOOLS: 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 Materials of construction: Dimensions: Depth of Solids: Comments: (note condition of soil,signs of hyddraulic failure,level of ponding,condition of vegetation, etc.) - G - ' I 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. Locate all wells within 100 Feet. c�3 'v: S r DEPTH ,TO GROUNDWATER: / Depth to groundwater: .I q Feet nn Method of Determinateggn or Ap roximation: . D - - 7 - TOWN OF BARNSTABLE LOCATiON��` rye�`U� �f� K=��� SEWAGE # VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME PHONE SEPTIC TANK CAPACITY LEACHING FACILITY:(type) . �L i/ (size) NO. OF BEDROOMS "-3 PRIVATE WELL R PUBLIC WATER BUILDER R OWNER � DATE PERMIT ISSUED: 1 DATE COMPLIANCE ISSUED: -3 VARIANCE GRANTED: Yes No i _ , :��.. ��. i� � �� P3 ,� �y �� l _ _ ______ 189 [�/ No...... ................ Fmc.. p..-•....... . THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Applira#inn for UhnVatittl Works Tunutrnr#iun ramit Application is hereby made for a Permit to Construct ( ) or Repair (D< an Individual Sewage Disposal ` System at: .... �-i r M Location-Address or Lot No. ..Le s-►.. �S Y ..---------•---?--� ..'?` / .rr rev - --------20L- Ow er dress W `�t�/�—r ac... ;;7 i,.,�s ., r��.�' °7fo� c�.�� tij __✓_ v___I___.___- ___�__L__L_ 5 Installer Address 2 Q Type of Building Size Lot............................Sq. feet U Dwelling— No. of Bedrooms... Garbage Grinder................_____________ Ea ansion Attic ( ) aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) dOther fixtures ..._---------------------•----------•-------•-•--•-••----------------------------------- -----•--------------.---------•---•---•-------•-•--••-------- w Design Flow....................5,$ ...........gallons per person per day. Total daily flow................?ZO...............gallons. WSeptic Tank—Liquid capacitv_lNo.._gallons Length---------------- Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area________-..-_-------sq. ft. Seepage Pit No.............�----- Diameter......1A__.____- Depth below inlet-----6........... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.................................................................... -•--• Date........................................ a 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........._.............. a ••----••-•---••--------------------•----••--------••---••--••••----•--•-•--••---••--•-•----•._............................................................... 0 Description of Soil........................................................................................................................................................................ w U Nature of Repairs or.Alterations—Answer when ap licable___ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance; as een issued y board of health. Signed ---- ! ......s . ................. --------------- 0 Date Application Approved B - Dace Application Disapproved for the following reafonf: .. .................. ............. ......................... .............. ............... .................... --................. .............----------.....q ..............r..... �'---D...................... ----- ..................................ace ----- ....... Permit No. ------- - ------------ Issued --------- 3/ 2Z� /89 No. ; _.. -•- Fas..:� ............... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliratiun for Uij-pu3ttl Workii Towitrnrtiun ramit Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposals' System at: .... ••-••-•....................---• •- __-•- -•--•-----------------_----- .----- ----•---•-----------•-•-•-----------. --•- •--...---...-•----•-•-•-....-.....--•----- --- Locatiou Address or Lot No. ` mot �i9 S 0, Aj.A ..�t ..........._...... -----------------•----------------- .....-..................................................................7......................... _ Owner dress a � r Ci us r I C CAN S J/Gv�___/&-j '76-5- W,;,1 KW 1J "6 ✓til , /0 1 l k__, •••. . Installer Address Type of Building Size Lot............................Sq. feet ., Dwelling—No. of Bedrooms..................... ------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) dOther fixtures --------------- ---------•------------._...-•--------------•---------------•-----•-•-- ---••--•--•-••------•-----------•-----•---•-••--....------... W Design Flow.................... ______._____gallons per person per day. Total daily flow_.-_._-_____..____2-;,0.._.__.___.__.._gallons. WSeptic Tank—Liquid capacity.Z�u?a---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 ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ _ ,.a Test Pit No. 1................minutes per inch Depth of Test Pit____________________ Depth to ground water__-___--_________ --__. (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 9 ---•----------------------------•--•--•--•-••-•••--•------------•-•-----------••-•--......---•------......................................................... 0 Description of Soil.......................................................................................................................................................---------....----- U --•-•-------------------••-•••••------•--•-••---•••-•--•-•-•---••---•-•---•----------•--•-•-•-•----•••--••--------•--•-••-••-•-•----------•--•-•-•-----------•--•-•••......-----••.. W ,} ------------------------------------- --•-•-----------•---•---------•.._.....------------..._....•-----••----------------.........-•-•• ••-•-••••-•••-•-----•••--------•-•---•••--•--•--•-----•- U P PP s C Nature of Repairs or Alterations—Answer when applicable �c�Ut.�.7` '7� l� ...�-X�1 j?�.J-L.__.__�:�-A��_.... / _._. Ge t! l/GUa t� �-- z1-:t1 �� fi /C�3--.5—� t.x l� G i I -,f 6 J1_- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued y 'aboard of health. Slgned ...... .; ./... ....., n.. a.Cn ................- - f y/�; .................... Application Approved By ----PZ61-74'LA -----" t; `-' -:f'7T.... ........... ....................ate.................. �y -- Dace Application Disapproved for the following reasons: f................................................... ----------------------------------------- --------------------------- ---------- ------.;-------- -)... !1 ....1.,11).... Date.................. Permit No. ....... �... _ >> ... Issued ............."�� 4.'_ . . ate / l y ----------------------------- -------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE (9Ertifi.ratt of v((��TT IIiltyliance THIS IS TO CERTIFY-7-That the Individual Sewage Disposal System constructed ( ) or Repaired ( \) Gr r,LU71 /1 / by ---------------------- ---------------------------- ---------- �----------------------------.._------Fi .� .).. -------------- ---------------------------------------- ------------------- Instal has been installed in accordance with the provisions of TITLE�,-s�' o he State Environmental Code as described in the application for Disposal Works Construction Per No. ` -5--- _1---- ------... dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCT�ION,SATISF CTORY. l�, � ./ �/�,/ DATE - J....."... -----//- 1 - Inspector ...- ---------- <_ --- - �pp --------- --- --- -Lee —--------------------------------------- ------------ /S� THE COMMONWEALTH OF MASSACHUSETTS G� BOARD OF HEALTH No.--(A ,,. 13 TOWN OF BARNSTABLE --..(.�-.......4.. FEE........................ Rapustt1 Worb Tunutrnrtiun "unfit Permission is hereby granted ----------�/1%Zil---�'--- ------- ---- r ' --------------------------•••..._....... to Construct ( ) or Repair (<) an Individual Sewage Disposal System at No------------------------------------------- /..------ �-IV6LU?E�.__... --.--�'�_��__....__. ...................................................... G-,vT p J street �Jam-/•") as shown on the application for Disposal Works Construction Fermrt No.-r�_/_.__II%.-,_1S___. Dated........................ .......... Board of`Health DATE----------------------------....•-•--�-�-�--I-•--=-.-------------------------- FORM 36500 HOBBS h WARREN.INC..PUBLISHERS 379 .LOCATLON : 5EWAC4E PERMIT 1JO. !tilST LLER--S-U&ME-4 ADDRESS. -- --- �- I-LLB.-�y 5-�_ - ------_-- -- -------- -- DC.TE-PERMIT-ISSUED D AT-E- -COMPLI-W,ACE. .LSSUED -- �_' 7 -- -----Y r1 . . , . '� % ��� r��� i� '''"� � �`d � f �� !� D i No........ .... Fus y ... ......... THE COMMONWEALTH OF MASSACHUSETTS BOARD QF HEA T _. _. .. OF....... ...---- -- Applirativa -fur J%gpoutt1 Workii Tonstrurtion Perutit Application is hereby made for a Permit to Construct O') or Repair ( ) an Individual Sewage Disposal System at 11r 4 =- ��- �. :... - ............................................................. cation-Address or Lot No. •--•------- `-y..Lib ---------------------•------ Owner Address a ----------------------------------------- Building Of B Installer Address U Type of Buildin Size Lot..._� _r�--�.-Sq. feet DwellingBedrooms ...... .............................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building -------------------•-_-_-- No. of persons............................ Showers ( ) — Cafeteria ( ) � Othg fixtures ---------.--•-•=-------•---------•-•-----------•--•------------------------------------------------------------------------------------------------- W Design glow:___... Q...........................gallons per person per day. Total daily flow............ .....................gallons. WSeptic Tank Liquid capacity__t_ gallons Length................ Width................ Diameter-_.---..--.----_ Depth---_--_---_--- x Disposal Trench—No. .................... Width------------ __. _Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No..........1--------- Diameter___i epth below inlet.................. To) leaching area......._-.--___-_sq. ft. z Other Distribution box ( ) Dosing tank ( ) ah- ( %�+ Z J_ aPercolation Test Results Performed by---------------- ......................................................... Date------.-----•-------------------------- Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water-----------_--.-_---. - I:lq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------ a+ ••-----••---------------------------- - p d--------------------------------------------------------------------------------------------- O Description of Soil------ ........® _._.��-•_-----`�T.11 z.,., U --•-- x ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- U Nature of Repairs or Alterations—Answer when applicable------------------------------------------------------------------------------------------------ -----------------------•-•--•-- ----•--------------•---•------------•----.---_.-.-.---•----•--------------------------------.-----•--------------------•------------------------•---------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article NI of the State Sanitary Code— The undersi d further agrees not to place the system in operation until a Certificate of Compliance has be issued by the boar f heal . . t a Signed.. = �-` x---- " L1- - - -�- --�'•1--- --- - Date Application Approved By•--•-..._..- �, �C ' .. I4),:! t / � ,J Date Application Disapproved for the following reasons:._.. �.--------------------------------------------------------:-------------------------------- ---------------------------------------------•---.......---------------------------------------------------------------------------------------- Date / j PermitNo...., ....................................... Issued..../ -------------------------------------------- Date No.-••--•--•-•--_-•--• • Fmc...,t..................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEATH.,T ............OF....... ... ........ ............... ...................... Apphrtttiun -fur Bispuiitt1 Works Tonstrurtiun Prrmit Application is hereby made for a Permit to Construct ( Y,) or Repair ( ) an Individual Sewage Disposal System at .............................. .....t A, .......................................... J.ocation-Address or Lot No. �v �. © �•--•- ----- - ------ LA � W +Owner Address Installer Address G UType of Building Size Lot--.--_7`_.:_.�..�-Sq. feet .-� Dwelling A No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) per, Other—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) QOthe_ fixtures ----------------------------------------------------------..........---...... ..................................................................... W Design Flow..._..._ ..�..........................gallons per person per day. Total daily flow............. .....................gallons. WSeptic Tank—' Liquid capacity..1- allons Length................ Width_------.------- Diameter_-.--...-..----- Depth..-..-_-----_. x Disposal Trench—No. .................... Width------------ ___ �otal Length----------------_... Total leaching arca....................sq. ft. Seepage Pit No...........1--------- Diameter..__.._ '*�.Depth below inlet................... Tota�leachiti area.---.--.--.--__--sq. ft. z Other Distribution box ( ) Dosing tank 0,h/6(,0 `w a - /' r J— W Percolation Test Results Performed by------- ----------------•----•-............••••••.........------•-----_.. Date--------------------------------------- a Test Pit No. 1________________minutes per inch Depth of Test Pit-_------_-_--___--- Depth to ground water_-----..-----.--.-.---. LT, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P; ------•------------ -------•---- --- - - .r Description of Soil-------............... ` ,.._ x ------- ••• •. --------------------------------------------- ---------------------------------------------- U --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- W 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 undersiggfffurther agrees not to place the system in operation until a Certificate of Compliance has bt sued by the boar of health. Signed---- q ",-tic_ 1__•_r --- I �• \ ? Date Applic4on Approved By-------------- ---1� l i a�!.�t,�-.�------------------------ ----- � L -- `-- r.._. -�^,.----`----- -Date ..l•---- Applieation Disapproved for the following reasons: /.-----•--•-------•-------------------------------------•--.-. -------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ;^ Date Permit No.._.. _.KA. ---------------------------•-----------. Issued.----��-�=- - Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH It OF.......... ...................................... .............. ,.....���:� (9rrtifirtttr of Tumphattrr .Y THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by......................... .------ 5 "' eQ. Jc�cJ`/OGc.- GZtaller ��J�' .c' at �l 11�.' oO��' ''� G/tau. I has been installed in accordance with the provisions of: rticle XI,o The State Sanitary Code as described in the ..:. application for Disposal Works,`G4.nstruction Permit NO ,-:_: . PP P �-� •------••••-•-•-• dated........�'� _:_� .� 7 ......••- THE ISSUANCE OF THIS CERTIRCATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. .,_ DATE_ f V ..! y`S� I A� / nspector . r� �r tJ a!Giil� — D Jf — _ d P idle --15 c '. .. �A.- x-.0 ` THE COMMONWEALTH 0,FtMASSACHUSETTS $ BOARD OF HEALTH T� ...OF ��1s..6h1.« �i v FEE_�G: OGi .. �i� u tt1Trurk,i Qlunitrnrtiun Vrrm t Permission is hereby granted-_ �>1'/� ' ��' — •-•---- -------- --- ----•--- ....---- ----- -- to Construct ( ) or Repair ( ) an IndividuaalSewagDissp�osaI Sys terpL.��. at No..........-' 1. '----._ 1.0->r...� f"......................... . CC s :L1CL . • "•.'S;'. ink.' as shown on the application for Disposal Works Construction Permit'" 3 7... Dated---._._�_ ---- --_-_� -- .................... •---- o f -•. C Board of H i DATE... --•- -------- - --------------------------- FORM 1255 HOBBS &,WARREN. INC.. PUBLISHERS 4 � _� �► Clt N� u\s, 76 f � \S} all 2 900 117 , V C��e r F� PLo r P�Aw SCALE /'=30' DH`TE cerva z /7✓97.5 PLC e6; - I3ErniG L07' #i3 SAI,,w^/ oN T-,9CA:r T, $e S ye Vi 9 A-f, Fc��-jA�✓ .tea Q��+o eaED ..Z" CENT/,cy 7Nl)-T 77/E oni TWis Pl�A�l /.5 Loe,97Efl ani 771E GZ-O.Ll vD .75 Sh�WAI r;''r �/ER�/✓ gND T�i+T /T CO�/.eae/`1S 1; 4 To THE 7Wr 7oo Wti of 8shews14BtE' x� GCTc�E.e /7 /9 r , 24AL12> Lei/