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HomeMy WebLinkAbout0072 SCUDDER BAY CIRCLE - Health 72 Scudder Bay Circle Centerville A = 187 041 OPWIdef/mr :12 ® 1521/3 ORA 100/0 p2 No. 20'as-, Fee �/ / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 2pprication for Mi.5poear *p5tem Construction Permit Application for a Permit to Construct( , epair( )Upgrade( )Abandon( ) O Complete System KIndividual Components Location Address or Lot No. ,�� �,R� me— AP011, Owner''sNamme,Addresssand Tel.No. 5'O �,�—Assessor's Map/Parcel V i In- 0qt le= Installer's Name,Address,and Tel.Nao1/- ,(' f Designer's Name,Address and Tel.No. Type k Building: Q- 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 n.i Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature r Alterati (Answer when applic�ab�l Re ai �J LJ 0 n.ti+ gyp.�b/ i F ,I DWG . ` Cif J ia t6l?4 Date last inspected: Ld) 'in b4 � Agreement: 0 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 lace th stem in operation until a Certifi- cate of Compliance has been issued by this Board of Health. Signed Date Application Approved by Date Application Disapproved Yr the following reasons Permit No. CV Date Issued r=cl s— No. o$^ Jd Fee l/v THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: t Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE,, MASSACHUSETTS•--• 01pplication for Oisspo!6al 6pztem Construction Permit Application for a Permit to Construct( ) epair )Upgrade( )Abandon( ) El Complete System Individual Components Location Address or Lot No. � �r ,Owner's Name,Address and Tel.No. �— Assessor's Map/Parcel Ip- Installer's Name"119; Address and Tel No.) `J _ 4--501 Designer's Name,Address and Tel.No. aa. or �hU�fe AnniS nnvoy Type of Building: 0 U Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other 71�pe of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date r1 1 R Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil / Nature of Repai r lteratio s(A saver when applicabl 1Gt(;�LJ "1 U �J�1�1t lJ ' l W of R- 1 +01t W� ru _,e r� roe h~t- � � ►,n-s .n r --6 9 ar i ens vn a 1�Aek l l � l w i r, Date last inspected: UJ b?% 0, P l9 n l)� 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 s stem in operation until a Certifi- cate of Compliance has been issued by this Board of Health. _ Signed(-\ Date -D 4L Application Approved by r-1-- -f v Date Application Disapproved for the following reasons- Permit No. CV3 - Date Issued - --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIU,tat the On-site Sewage Disposal System Constructed( ) epaired )Upgraded( ) Abandoned( )by Uj Prl I 6JV d n at o: Cj k,\ (, el . . (Y)V4 has been constructed in accordance with the provisio ss.of Title 5 d the for Dis Qsal System Construction Permit No. ✓f% 3c dated �,l 0 �1 Installer t is, �l k6L6-,) - d U ! Designer n ft The issuance of this permit shall not be construed as a guarantee that the s.is will unction designed. Date = -03, Inspector- ---------------------------------------� -� No.�(_N}-- - Fee f 1�o THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE,, MASSACHUSETTS Migozal 6 tem Construction Permit Permission is herebyfanted to Construct Repai )U grade( )Abandon( ) System located at (V O ( y 4 ��°, ��' 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:Cons -ctio must be completed within three years of the date of this pe t. Date: J Approved by r TOWN OF BARNSTABLE LOCATION 'Ion SCUccle-h14.0 SEWAGE # VILLAGE Cc4eev✓, <L e_ ASSESSOR'S MAP & LOTS D'/ INSTALLER'S NAME&PHONE NO.Aar K 20SeG.G j SEPTIC TANK CAPACITY LEACHING FACILITY: (type) e� NO. OF BEDROOMS r �, *OR OWNER PERMITDATE: r' 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 i TOWN OF BARNSTABLE LiNfATION lla scUclde.h--8CL SEWAGE # VILLAG ASSESSOR'S MAP & LOTIM OZ -f `INSTALLER'S NAME&PHONE NO. gjar IC �aSeL.L �AS� SEPTIC TANK CAPACITY LEACHING FACILITY: (type) e) NO. OF BEDROOMS I�OR OWNER 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 COMMONWEALTH OF MASSACHUSETTS ` EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION lop TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A �� f7o� ^� �� o/CERTIFICATION Property Address: P• Q�y c l,;. Owner's Name: g 2 h/ 3 c r7i Owner's Address: 7J. Date of Inspection: co Name of Inspector:(pleaseprint) F Company Name: mil% 1 — EC Mailing Address: C d Telephone Number: Sb 7 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 the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15340 of Title 5(310 CMR 15.000). The system: P ' [i'onditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: r� - Date: v The system inspector shall submit a copy 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 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: ,,` C- Owner: .P 6 Date of InspectI n: Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: V I have not found any information which indicates that any of the failure criteria described in 310 C11Rt 15.303 or in 310 CMR 15.304 exist Any failure criteria not evaluated are indicated below. Comments: B. System ditionally Passes: One or mor e system components as described in the"Conditional Pass"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 for 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 so indicating that the tank is less than 20 years old is available. und,not leaking and if a Certificate of Compliance 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): bro ipe(s)are replaced ` � h'on is removed distribution box is leveled or replaced ND explain: 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 ND explain: Titles G inenarlinn P^rrn All V7AAA 7 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 7aS c/,P C'r n 6V1 r 6 s` Owner: t� Date of Iuspec on• p 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 15303(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,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 tnbutary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 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 col form 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 pp provided provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: Titles G inennMinn Lnrn.[/1 GNnAn ; Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: o ti�p� Owner: e �aZ6 , Date of Ins on: D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No �T ckup of sewage into facili or stem co ,— Discharge h' Y mponent due to overloaded or.clogged.SAS or cesspool- - charge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or logged SAS or cesspool _/ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or ,..--cesspool — j4quid depth in cesspool is less than 6"below invert or available vohune is less than=day flow ✓ ° ,of times pumped Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number —�►ny portion of the SAS,cesspool or privy is below high ground water elevation. _✓Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. sty portion of a cesspool or privy is within a Zone 1 of a public well. �/ pordon 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.[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.] (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 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: (Tbe following criteria apply to large systems in addition to the criteria above) Y 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 Wellhe Zone H of a public water supply well ad Protection Area—IWPA)or a mapped If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in 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 15.304.The system owner should contact the appropriate regional office of the Department. T41. A Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 7 < d P /Ja (:�'/t., Owner: ewl Date of Inspec on• D Check if the following have been done.You must indicate"yes"or"no"as to each of the following. Yes �Pumping information was provided by the owner,occupark or Board of Health Were any of the system components pumped out in the previous two weeks? Has the system received normal flows in the previous two week period? _ -h=-�ve large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined?(If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? Were all system components,excluding the SAS,located on site? 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? _✓ 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 Sao Existing information.For example,a plan at the Board of Health. c/ _ 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)J T41a G 4/1 C/7AAA 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: e C�oZG?1 Owner: e Date of Inspection: lup OW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CM�L 15.203(for example: 110 gpd x#of bedrooms): � Number of current residents: c�.. Does residence have a garbage grinder(yes or no): .� Is laundry on a separate sewage system(yes or no):A v (if yes separate inspection required] Laundry system inspected(yes or no): A/0 Seasonal use:(yes or no): *0 Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no): 0 Last date of occupancy: COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): and Basis of design flow(seats/persons/sgf4etc.): 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: oZ C>03 O w Y Was system pumped as part of the inspection(yes or If yes, volume pumped:_gallons.-How was quantity pumped determined? Reason for pumping: OF SYSTEM _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/Altemative 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: ISO// Were sewage odors detected when arriving at the site(yes or no): TWA ' Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: ..� .off � Ce 14�kv ` !r Owner: Date of Inspec 'on: p BUILDING SEWER(locate on site plan) Depth below grade: 'o Materials of construction._ ast 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) /01 Depth below grade: ( )- Material of construction:_c�_metal_ gas_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) 6 ✓ / O. Dimensions: /t Sludge depth: A� f Distance from top of sludge to bottom of outlet tee or baffle: oz 9 Scum thickness: / ,/ Distance from top of scum to top of outlet tee or baffle: �2!� Distance from bottom of scum to bottoms of outlet tee or affie: 7 How were dimensions determined: o c 4 vi c Comments(on pumping recommendations,inlet and outletlee or baffle condition,structural integrity,liquid levels a la7ted to outlet invert,evidence of le e,etc.): ss ANI�/ GjN IH CM I /O L-eAl�.s. GREASE TRAP:&.6ocate 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.): T41. C lncnal•tinn l:n.m. /1cYfnnA 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Q.e t " 3�, Date of inspection: 9 r TIGHT or HOLDING TANKA�(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. eallons Design Flow: uallom/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 resent must be o ened loca r ! )( to.n site plan) Depth of liquid level above outlet invert. 401-"a(� 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 .): ,,ol�ee /t-e c.—, X 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)M Property Address: / A G 41V �a r d Owner: t/ C32 Date of Inspecti : O SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type �� 'Teaching 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.):tg �h�� •� /f AC 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,Ievel ofponding,condition of vegetation,etc.): 0 Page 10 of 11 ' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 7 ✓C r+ JJ4 le 'A C� h �w ✓v 4 Owner: Date of Inspection: ©r' 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. AF' r ' /Y f f f f � l f a l 1 a —`ter l �/0 /Z , /)k V'-1- f} Titla G inaT pt;^n Rnrm 4/1 Si,)nnn 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: �D` the✓ . Owner. p Date of Inspection: p SITE EXAM Slope Surface water Check cellar l•f J Shallow wells ! 0 Estimated depth to ground water y '3feet 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: rved 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 c ' how you established the high ground water leyadon: �o 4- O o P U I < (9 `I © 00 0 V7 tAl � 3 Tifla,S Tnerar}in„ Fnrm�/1 Chnnn 1 1 o�►ti..�c=Z . f o yt +50�* GGO G•P p. sync. -rA-4VL-•44,0 x2oo .. &654> G.P C7. U gr v%S Po•SAt_ P IT U T 319 S.F. 3?75•�, �C 2-.s 947, G.PC;., i 90;rOAAF- 15.7 -6Ft- G.(=,lc;�;. i ToSat_ t�EStfewl 1099 6.Pn• It t o TAW o2 L. 457. �p`pk OF MAsf d+r HICHARD � b D C ID. yG� A. THULIN 1 %AXTI^R, c u No. 29976 fg ' Top -AZ y pE wu o4,f r ¢ 9 3 oic.:.: 4"Pp� ot�r. tNu SA.L.c :Y/7 ._. . . &A L• .. 1 WtTlb cro w ra. ' �! 3 P20 Ft 1..�-- l.v+carto►.� COSTE4!y tL.1,.E iYv yt/.dTN�: �.lo Sc.,�t„6a . : . . . : 5G_Q•� �" -..�Dt V A`T�3'Zi��`� � pt_al�i CZEFFJZCWC-t= t Ca><TI FY T"AT T► I-m P .O'i� Ft-lL-,>. µE2co1.4 - GoticP -YS wtrl-4 TciE ritTDF-t It- Mz. A&JD s�TC'BacK 1Z�?JIP.�M�t1T� OF 1"WE I TM4/f4 o f I31AQ t4 5T A.W lc> • IS t•40 T- l.oi�A,�T'C-3� 1Tt-1l f.! ' 64E: C7C-t70t::) PLAT W. DATA I BAXT@2 4 u`f� It•.1G. G tJ c am- %Z v5TQ MCC Lb.Wo 40ZVl2Wtr- -T414 PL&W ter UOT BASED OW AU t"4TWMEWT OtTE Vlt_tf�. M1LS��• SUe� ( 4 T6A G. oFFS@Tri -5WOUt.D UoT Yi6 USA gPPI.IG_AI•t'f 3� y7•�7 l t Jr 9-r r� \ oQ 7W F�oP i Tim! Ars PMOP n 19 7�4 PIT 99/ ARZ 100, �%lCHA9D J V"�✓ 1 BMA t ER •Zi! Pta 2^;;E9 `► <r lea V 4-1 ! Al No.. m THE COMMONWEALTH OF MASSACHU;5ETTS BOARD OF HEALTH ..........................................OF......................................................................................_. Application for Disposal Works Construction jlrrmi# Application is hereby made for a Permit to Constru (4 or Repair ( ) an Individual Sewage Disposal System at Location-Ad esa Owner Adanaa ' ...............--.................._.._ ..........-.........._...............__...................... ............. Installer Addreaa Type of Building Size LOL.............._......_--Sq, feet aDwelling—No, of Bedrooms......�_..............................Expansion Attic ( ) Garbage Grinder (.� 6 Other—Type of Building __ u?n........... p ( ) Cafeteria ( ) . No. of arsons.............................Showers•._._--- ... .-.-.---_........... .._ Other fixtures .._..!)' .�_.. WW Design Fiow................ . .. _ gallons per person er�a y. Total ilyv.......fa.�_Q_......_.._.._.._..__..... ns. Septic Tank—Liquid'ca ci ..........gallons�ength. _..i....Width-.�.-.)....Diameter----------------D_e .Length.................... 3 Seepage Pit No..................... Diameter.................... Depth below inlet........._.........Total leaching area.................sq.ft. Z Other Distribution box ( ) I. . Dosing tank ( ) Percolation Test Results Performed by.............................................................._.......... Date-................_...................... a MTest Pit No. 1................minutes per inch Depth of Test Pit--------------------Depth to ground water......................... w Test Pit No.2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Ri ................................_........_.._.::-.-.-.............. ........... ._....- _....:......_._.._.._........................:_..._.. Description of Soil..............................._... ...:......._....._..: ._.................................. ................. ...-........................... ....................................................................................................................................................................................................... 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 TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a CertificatKCom nce hasb ' ued by the board of health. Signe .. e^.. .. 'r +-............ -.-_---- . ....... ... . .Application Approv y .... ..................................... ..... yl.. ......................... ..._........ Application Disapprov fing reasons:-............................................................................................................. ........................................................................................_...................._..--•---......._....-•---•--•-•-•-------••-•------........................_............._ Date PermitNo....................-----7......---_......._...._.._ Issued.................._....._--•---••--••......_ -— Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF.....................................I........................................... 9rrtifiratr of Tomplittnrr Ff CERTIFY, T at tt Individual Se age Dis System constructed (/) orRepaired ( ) by... :..fir .._..... ........................................................ ...... ...._. .... . ...I . at............ f ......... - r U . •.._........u� .. i1 1.................................................................... has been installed in accordance with the provisions of.TIT ��yy of Th S$�te Sanitary Code as described in the application for Disposal Works Construction Permit N ._._.__ __.13.._`�.__.; ..- dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL OT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WI FU)ICTION SATISFACTORY. DAT E....�rC.`.:Yf....a..�� .............. Inspector.-:. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH y, �13 OF.............................................................. v FEE...)................... 3�is�r it k Tnns#rudion rrrn it Permission is r y granted:-::(('_:'::::.. ... ............ ........ ............. _........_............._................... ......................... to Construct ( ( ) atb Individ}�,�ewages osal ern at No..............;:�-._..._...._ ..... Jt' e'.flFlC._.... p t �Y Street as shown on the application for Disposal Works Constru Permit IJ ... .. Dated._... � ............................ .........•----------...................._. / Board of Health DATE.........................................................................._..... FORM 1255 A.M.SULKIN•INC..BOSTON 4 I ate , . _ ..,.....�...�.............. ,T • d f THE COMMONWEALTH OF MASSACHUe>ETTS° F• BOARD OF HEALTH ...........................................O F..........I...................I..,...... Apphration for lliipnsttl Works Tnnitrnrtion ramit I Application is hereby made for a Permit to Construq (e-) or Repair ( ) an Individual Sewage Disposal `1 ystem at: '°-`.�..�.-............... f-.Y..z3................... ' ...... - "'` •-- Location-Ad ess Lot a -� Owner •. •---.-•Address �••..... ......................4......-•-•.......•-•-••....-----••-----......--- ----•-•---•...--••••......•-•-• ------------•....-••_......-•-------•--•--- Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms.......................................Expansion Attic ( ) Garbage Grinder (� a Other—Type of Building __ ............. No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures ..... _,_... ---------------------------------------------------•--------------------.............. W Design Flow..............: --gallons per person er eay. Total d ily v___..-_ _�_ --------•---------...--•-- llons. WSeptic Tank—Liquid ca acit ...__...gallons ength_ ._.__.____ Width._ ..---- Diameter________________ Depth. x Disposal Trench—No. ........ Width.... .............. Total Length.................... Total leaching area___ t. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) `-� Percolation Test Results Performed b .......................................................................... Date........................................ a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ f4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ .................................................. .......................................................................................................... ODescription of Soil........................................................................................................................................................................ 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 TITI.1 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Com ' nce has beef sued by the board of health. Signer. .J--..... � . -a..`'.^-••------------- - ------ ----•• •-•--------- Application Approv y_.__ - ---------•• ----------------------- y� •--•-. ......../� ............... Application Disapprov f the following reasons---------------•---------------------------------------------------------------------------------............••. .. .......... .... ...•-•••••--•-•-••-...---••----•-..........--••--............••-- --------------------------------------------- Date PermitNo......................................................... Issued_....................................................... Date ---- --- - -- --------------- - - �_�__ __--------- -- THE COMMONWEALTH OF MASSACHUSETTS• • BOARD OF HEALTH ............ ..........................OF..................................... Appliration for Disposal Works Tonitrn.rtion ramit Application is hereby made for a Permit to Construct (Gu) or Repair ( } an Individual Sewage Disposal System at --•-'7 = ... ..:..... ..C ......---.------ ...... . -----------------------. .....--------.....------................. Location-A ess' I t No. ......................•---•----------•---•---------- �fSl �iaQ..tA� ...,o�;& .:.. _:...._...... ..... Owner Address ............................................................. Pq Installer Address UType of Building Size Lot............................Sq. feet I—I Dwelling—No. of Bedrooms.......9.................................Expansion Attic ( ) Garbage Grinder (e_-) `4 e of Building a Other—T yp g �------------ No. of persons____________________________ Showers ( ) — Cafeteria ( ) Other fixtures ....f1 is w Design Flow...............64P ...gallons per person per flay. Total daily v---_-- _,!.. .........................dons. 04 Septic Tank—Liquid*ca acity.�.-_.-...gallons Length ..- a........._.. Width._. .. _... Diameter---------------- De,P�th... o. _..__. Disposal Trench—N . ......... Width---.........._ Total Length.................... Total leaching area... t�.._....Sq: ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ' ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water......................1-4 . rZ4 Test Pit No. 2................minutes per,inch Depth of Test Pit.................... Depth to ground water........................ Oa .......... --------------------••=-•••-•-•-................................-.......................................................-................. Description of Soil..............................................................................-.----•---------------•-------....------.-.---------------•-------------..._.._........... x w V Nature of Repairs or Alterations—Answer when applicable.......................................................................................0....... ...........................................-.................................................................................................0............. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be issued by the board of health. Signed. `d'' Z ....._.... Application Approv BV -•-_•--•--•--•.. ... .- Applieation Disapproved � the following reasons:................................................ .«� Date ---•-•••..........•-•--••-----•••--•---••........-•-•-••......---••--•-•---•--•••--•-------._...••••-•----•••-••••......-•••••-•--•••••............................................................................................... Date PermitNo........•.............................------------------ Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF.............................................................. �_ grrtifiratr of f�nrntphaurr TTT '!z-$'.C. CERTIFY, gat e Individual Sewage Dispos+dt`System constructed (X) or Repaired ( ) aller�...` ..F _ has been installed in accordance with the provisions of(TI T Ii: of Th 4t to Sanitary Code as described in the application for Disposal Works Construction Permit NB......... `�__'-'=-�.,�-• dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL WOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WI FU)ICTION SATISFACTORY. DATE....1 ,1 vY` a --------------- Inspector... _ ... -•--------------------------------------•--......----------.......----•- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH y' ?� ...........................................OF................••••-••--••-•••--•-•......................................-••........ t ,-v No.................•...... FEE.. ? Permission >s�her y granted : ..:' ----------------•-. ,....................-_•...................................................................... to Construct ( '�.o ep ' ( ) an Individwage 'sposal y-steam` �.� Street as shown on the application for Disposal Works Construc Permit No. .: f__.____.. Dated..........-.............................. Board of Health DATE----------- ....................................................... FORM 1255 A. M. SULKIN, INC., BOSTON , I t� 17IA l L1�( 'l-O`w/ • 11 Olaf �i p Go G.P v�SPoSAt_ Pt7 t,;E 2 - toA� �b•� vt�-Z 5��.1c ; 13 1'1 5.F. 37 7 5,F. x .�.-s 9 AFL 60, ., �.P Tay A2eA► 7 .s. F. 15.7 sFr � t •o . � �5� G•r?'r,>. ToTat_ �EStCw�, ' �t0'9 G.RS7r . . . . !T4>ML-.p.AfLY Ft0� `�-WX 1Ste% =GGO G.PD- pEYot.A-r(c)W, t 1 u 2 MjW o2 LF45+ . . j ol ��4 p ✓�P�ZN OF Mqs� j &, MCHARD "�. � DAC. yGs A. THULI AXT�R, a l�c� N.. 299 ce r 9 et,I Cis FSS/ON ' I r �• P- .3OGG _ 00.S a� i oP F,.ro •/a •PPE .d wu• 98.3 , .; ._„ • Ioao 9�3 tom,,. . . TAUVL . . , . . ,{• Gc �/ FITWtTO � I ! GTo 14 . . 9/ 3 r � CEt2 T 1 F t �17 Pl.-oT pt_.A u i t �Z � .3 L�qG bT"l O t..1 O S"T"E•�!V t t,..1..•tom_ 1 ( F-:,z c_ .tc.I-- I 1 C¢c'trY • TNAT peoQ).+�!c> FtL-;). St.1a�u►,J 7 2. 1-{E CO AA L-YS Wtrt-4 'r"C. rilt>E7U_11-4tE3. LC T AWt> St�''BP•GK R6=QJie�.M6�t.1"1"aj OF 1'lJE I . TOVdk t - 1 S. ti.IOT' lTl-1l W ` gr= �IAOC� PLA1U. DATA- ( 5 A-A i G `�c TL.rtSTt.. MET> LAun eOZVE�PVN. •T1414 PL&W (lti UOT 845ED OW Au 1tY,T OAAE►•1T OS.TEaz./tu..G. MAZE;• SUe�cl �, rNr- OFFSQ.T; -5WGU l> UOT Y.,6 U'.P.j:> APPL.IGAuT • .3� 97 7 i I oQ TN. P,r 9�'S PacePIT �. 7 Par � � EfCHARD 99•/ ye•6 F !J A. .' HAXTE.R •c;; fla VLily r�1 COCA.TION "Ir" 7oti SEWAGE PERNfIT NO. Z,=j l'-� SC<t JC' oLP fi' . T Ct-Lc-l2 V-1LLAGE C(2-n4P,rU( Ile INSTA LLER'S NAME i ADDRESS 'yN n AAi.tb B,ACKWOE SERVICE 150 Walnut Street Rarnstable, Mass-02668 I U I L D E R OR OWNER /wonre ynn-,o s. DATE PERMIT ISSUED DATE COMPLIANCE ISSUED ��, � r , e V�9 ,