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HomeMy WebLinkAbout0046 SEA MARSH ROAD - Health 6 Sea Marsh Road ` Centerville P a 227 131 No. 4210 1/3 ORA ®mods : 1000 N 114-27 C Make application to local Fire Department. Fire Department retains original application and Issues duplicate as Permit. /,XT- Mae 6 rcxo O/A 0 ON and PERMIT APPLICATI""' for storage tank tamoval and transportation. to approved tank disposal yard in accordance with the provisions of M.G.L. Chapter 1,/,8, Section 38A, 527 CMR 9.00, application is hereby rrade by: Tank Owre,-N?rre(pleage print) Tc,:q_rr.f y Residence----_--_ x Address__i27.._fs uar�7 TraiI_L Delray �B �,. _riL 334P3 Company Name Enviro—Safe CorD. Co,Wndividual Print i _,4B. Jan Sebast.Jan Drive Address -- Sandwich, rifA Fdn�., U) 'igr.a re!ff applyin r of-ornit)G sigr.,htureTl apply errnit) CO 4 jI, I FC4 Certi-i, 6 Othqr.-- P !FCI*Car?. ed Q L tank Locatim 4t, See Mi'K$i'! RO,:Idf Centervill'ej 14A StOWAIdess Tank Capacity(gallons) 2 Q 0 Substance Last Storod __4.2 Yank Dimenslcn:.(diameter x length? c-/ Firn'ransporting waste_Ell x, ro—S at e. H az'ardous waste manifest# .1AAQ654243 E.P.A.# MAC300001617 Approved lank disposal yard V 2.8.A 1, 9 Tank yard YO. r.of Inert gag T ank yard address-. I t li A.... Cify or—own Qentervfll= FDID4 Date of issue Ap r j, 2 6, Date of cxplratlotj IS Din safe appmval nort-.ij)'6�: 20061601750 ','Iq Saf T U Free 1,Numbet- 9�--122-Q44 3�gnature I This of Officer gra7�1np per 1/ kJi After removal(s),"Consumptive Use"fuel oil tanka Pxemptpd)serld.Form FP-29OR sighed by Lccai Fire Inept, Clornplianoe Unit,Department of Fire Servioeb,P,O.Sox 102 ,State Road,$t;m,NIA 01775, InternatItmal Fire Code institute 1-24(revisso 41 Find MaplParcek 227131 ` Tovnfof Barnstable Fleaith De artment Health System r p 3 Jv i i _� r ' `3 a b ii Map/Parcel 227131 Tank�Nbr 01 ag Nbr: 00618 r r Installed 12/01/1980 Location B �> 7, a Date Test�Not�fication Date— �Sfatus sr �� `K oval�Notification Date„ € � ' z Il y Test 'P 05/O8/1991, 1115) JIF , < eino ate 1 04/26/2006 t is p FuelyStored �D Fuel Stora9e�RBaSOn a s i T Cap GJty Cnstru tion yea Detection Cath�od�c De ect o sS#orage ank Info 002000t Addttionalg�etaiks ; CONSTR UNKNWN NO TEST NEEDED si ti/10 - : 19 � aZ a y Add Change I �\ COMMON'WTALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMEN-T_AL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PmAP �D SEP 0 1 2004 PARCEL. TOWN OF BARNSTABLE HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: P R A r.1i Ur MA Owner's Name: Owner's Address: V Date of Inspection: Name of Inspector: lease riot) Company Name: a V MB oapedtv4s Mailing Address: Telephone Number: O 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 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority FAils ector's Si ��� :/ Date: LDS Iu p �ature: 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 Itow 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—'NOTFOR VOLUNTARY ASSESSMENTS" SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:A�L PS�` Owner. -7�;•,�,d 9� Date of Inspection• Inspection Summary: Check AAC,D or E/ALWAYS complete all of Section D A. System Passes: I have-not found any information which indicates that any of the failure criteria described in 310 CMR i 5.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section n to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by oard of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following ments.If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic (whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank as appro ed by the Board of Health. *A metal septic tank will pass inspection if it is structurally und,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is availab . ND explain: Observation of sewage backup or break or bigh static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled uneven distribution box.System will pass inspection if(with approval of Board of Health): b piPe(s an rqplaced strtxicm as removed distributim box is lewled or replaced ND explain: The system require pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with roval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of i I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE IDISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: -S� /P !r "v Owner: iga Date of Inspection: C. Further Evaluation is Required by the Board of Health: Conditions exist which.require further evaluation by the Board of Health in order to determ' 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 3 MR 15.303(I)(b)that the system is not functioning in a manner which will protect public healt afety and the environment: ` Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetate etland or a salt marsh 2. System will fail unless the Board of Health( d Public Water Supplier,if any)determines that the system is functioning in a manner that protec the public health,safety and environment: _ The system has a septic tank and so' absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a s ce water supply. The system has a septic tank d SAS and the SAS is within a Zone 1 of a public water supply. . _ The system has a septic and SAS and the SAS is within 50 feet of a private water supply'well. _ The system has a Sept' tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply wel *.Method used to determine distance **This system passe f the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatil organic compounds indicates that the well is free from pollution from that facility and the presence of onia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria a triggered.A copy of the analysis must be attached to this form. 3. Othe 3 1 k Page 4 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DOMOSALMSTEM INSPECTION FORM PART A, CERT'IFICATWN'(continued) Property Address: 00� S;G C:gAIN ' Owner: o Date of Inspection- D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for ail inspections. Yes No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool of Liquid depth in cesspool is less than 6"below invert or available volume is less than''/z day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped AA Any 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. Any portion of a cesspool or privy is within a Zone l 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 ifl0 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.IThis system passes if the well water analysis, performed at a DEP certified laboratory;for arm bacteria and volatile organic.conqxmmds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is.egaat 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.] ),Q (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 ,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 ve) yes no the system is within 400 feet of a surface water supply the system is within 200 feet of a tri to a surface drinking water supply _ the system is located in a gen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone H of a public ly well If you have answered"y ' to any question in Section E the system is considered a significant threat,or answered "yes"in Section D ab a the large system has failed.The owner or operator of any large system considered a. significant threat der Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The em owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM[INSPECTION FORM PART B CHECKLIST Property Address: �b J' � ^ Owner: r. Date of Inspection: Check if the following have been done You must indicate`yes"or`�no"as to each of the following: Yes No Pumping information was provided by the owner,occupant,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? — Have 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? 1 _ Was the facility owner(and occupants if different from owner)provided with information on the proper m'amtenance 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 _ Existing information.For example,a plan at the Board of Health. _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15302(3)(b)J 5 Page 6 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:__Z 11 Owner: T� Date of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): SO Number of bedrooms(actual): ,,ma�yy DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): #TO Number of current residents: oZ Does residence have a garbage grinder(yes or no):AVSr'u'�3 Is laundry on a separate sewage system(yes or.no)- [if yes separate inspection required] Laundry system inspected(yes or no):ND Seasonal use:(yes or no): $* 03/ 7 TS Water meter readings,if available(last 2 years usage(gpd)): oat S6 I ``peP Sump pump(yes or no): Last date of occupancy: Gv/ COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CNIR 15.203): gpd Basis of design flow(seats/persons/sgft,e Grease trap present(yes or no): Industrial waste holding tank ent(yes or no): Non-sanitary waste disch wed to the Title 5 system(yes or no):u Water meter readings ' available: East date of occu cy/use: OTHER cribe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the uspection(yes or no):&)0 If yes,volume pumped:_____gallons—How was quantity pumped determined? Reason for pumping: TYPE 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/AIternative 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,4ate m lied i known)and source of information: 1.2 J-45!/n f 42 G2 Were sewage odors detected when arriving at the site(yes or no):No 6 r Page 7 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address- . 7 S49a (v-P t Owner: Date of Inspection: BUILDING SEWER(locate on site plan) . a Depth below grade: Materials of construction: cast iron Y40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: K (locate on site plan) Depth below grade: Material of construction: concrete metal,fiberglass`polyethylene _other(explain) If —metal tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of certificate) Dimensions: L pia _ Sludge depth: r !/ Distance from top of sludge to bottom of outlet tee or baffle: e?46 Scum thickness- Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee of baffle:13 How were dimensions determined: �j�'�Gf"/"& Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to utlet in ert,evidence of leakage,etc : Cv . GREASE TRAP:_(locate on site plan) Depth below grade:_ Material of construction:_concrete_metal glass polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to to outlet tee or baffle: Distance from bottom of sc to bottom of outlet tee or baffle.- Date of last pumping: Continents(on pum g recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outl vert,evidence of leakage,etc.): 7 Page 8 of I 1 OFFICIAL INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: e Owner:_ - Date of Inspection: TIGHT or HOLDING TANK: (tank must Zpu:a of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metalpolyethylene other(explain): Dimensions: Capacity: galio Design Flow: ons/day Alarm present(yes or no): Alarm level: Al in working order(yes or no): Date of last pumping: Comments(conditio of alarm and float switches,etc.): DISTRIBUTION BOX: X (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:_!ey� Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakaqinto or out of box,etc.): i/�(c_..5 .l P�/��Gc `�t('l►.-�-tt/�7� /t0 S' /t dt� rT�1' CO����(. PUMP CHAMBER: (locate on site pl Pumps in working order(yes or no):. Alarms in working order(yes or Comments(note condition ump chamber,condition of pumps and appurtenances,etc.): 9 f Page 9 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL. SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: CC- r t( Owner -b�O&c ` Date of Inspection: Q _ SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not Iocated explain why: Type 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.): is sutmu"t r %n ref ihv-a CESSPOOLS: (cesspool must be pumped as part of' tion)(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 groundwate nflow(yes or no): Comments(note con ' on 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 il,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' a PART C SYSTEM INFORMATION(continued) Property Address: ri G� Owner Znsp: O l Date of tion- 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. t' t� f Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM!INFORMATION(continued) Property Address: 1-Cc i r Owner:�Q Date of Inspection: SITE EXAM Slope,i4Y, Surface water AV Check cellar YMS Shallow wells /tb Estimated depth.to ground water I o17 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: _k Observed site(abutting propertylobservation 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 levation: ccseS�rrlX `�t� /off DC 11 AJ4 La, cc p,+ L O'C'A T 10N SEWAGE PERMIT NO. Lo 3l Seea• � (�� �'l -�S� VILLAGE INSTA LLER'S NAME i ADDRESS to 1 s 64 frock kd (3+ft !-Utt ot* OR OWNER --o o m e N DATE PERMIT ISSUED fv�� DAT E COMPLIANCE ISSUED 'p 3� r ♦ti R� rU -� �� �� �� ��' �e�ti P,t :����� THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ..........................................O F.......................................................................................... Appliration for Uigposal Works Towitrn.rtion Vamit Application is hereby made for./a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Systemat: 1............... ....'.1�. -. '�\:- = .-----.....-------............ --------------•--••.. . ..... ------ a..T....3 r . . ..... ..cation-Address ..............•...........................or Lot No. �J Owner ................................Address Installer Address Type of Building Size Lot----------------------------Sq. feet aDwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) p, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures .................................. W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid*capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ . 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_..................... a' ----•-------------------------------------------------------------------------------------------•--.......................................................... 0 Description of Soil...................................................................•--------------•-------------•---------------...------............................................. W U .............•---------•--•---------•-•--•---•-----------...-----•---••------------------------------------------•----•._...--------------..._....----------........_... ............................. x ----------- :.......................... ----- ..... .......... U - - ---- - U Nature Repair or Alterations—Answer when applicable.. ___________________ ..... ........._.. ._. .... ......... .............( ..---•--•---------------•------._......_...---------............._ ------•----- ------....._..-- ' Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of AITLa: 5 of the State Sanitar ode—The undersigned further agrees not to place the system .n operation until a Certificate of Compliance has een iss ed b the bo of health. � �./ Application Approv .... L Date Application DisapZ#ed ,-___I-O- lwing reasons---------------••-•--------------------------------------------•-----------------•-----..._...--•-----.....------ -------------------•------.... --•------- -----------•--------...._--------....._---- Date PermitNo......................................................... Issued-....................................................... Date NoA..l: FEs..i....... ... THE COMMONWEALTH OF MASSACHUSETTS , BOARD OF HEALTH .............................._...---.....OF.......................................-----------------------..................__..._.... Appliration for Disposal Murks Tons rnrtion Vanfit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: .............. . .......... . _.� ..................... ........................................... ---'-----...................._........._. .. - � ocation-Address .or Lot No. ....r... ....G...:.-! ..................•..._........ ---^--......................... ._ Owner ____________________________Address ................................................... _............... ........•.................................. Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) y Garbage Grinder ( ) '4 Other—T e of Building No. of persons............................ Showers — Cafeteria PaOther fixtures --------------------------------------•--•-......----------------•------. --------------------=�--------••-•----------------..................------ d W Design Flow............................................gallons per person per day. Total daily flow__�:......_......................._.._....gallons. WSeptic Tank—Liquid capacity............gallons Length............... Width................ Diameter---------------- Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area.-:...............sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ aTest Pit No. I...............minutes per inch Depth of Test Pit.................... Depth to ground water......................... fi Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 ••••••-••...--------•-----••-•-•••••...............•-•-••••••-••-••.............••••__._.__...'-•"•-'-"--------............................................ 0 Description of Soil........................................................................................................................................................................ x U W ....... ---------------------------------------------------------------•. ---- ----------- Zxj Nature Repa>, or Alterations—Answer when applicable )_ ._.. ham' __. t� � „.._..._.. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitar� -Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has keen issued b the board of health. o Signed } ..:. >(�-•.. -- ! ' �' "" ,. :_. X., ..j Y ... ...` 4ate Application Approved By, _��%�� ................ _._..........._.__.._. ._ ' ........................... .....f Date ........... Application Disapp ove for the following reasons:-----•--------------•-------•-------------------------------•-••----------------------------------._............. ... ----------------------------•------•---..•..---------••...'-'-----•---------.-------•----------------..............................--...Date----------•••. PermitNo......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... C9rdifiratr of Tontpfianrr 1 CERTIFY, That the Individual Sewa e Disposal System constructed ( ) or Repaired ✓) . a............ ¢. �" ---------..by tI -- a - �-- '` �" �� -------J--- taller ................................................... as been installed in accordance with the provisions of 'ITILE j of The State Sanitary Code 0 deAribed in the application for Disposal Works Construction Permit ................. dated_.4114- .11........._._.__..... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE...I�..._ �� Inspector__ --• ----------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH " � j ..........................................OF..................................................................................... ��,,• No.. ..... FEE.........•.............. �io�r � I a r onn�rnr�ion anti# Permission is hereby granted -------j---------------- 60--------- .......a. .... ......................... to Constr t �,,..,) or Repair`( Indivldu rage sposal'. em t. Street as shown on the application for Disposal Works Construction Permit No..................... Dated.......................................... •................•---•-•-.--•-•--------------------------------------------------•••••......•........... Board of Health DATE............................................................................... FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS �o © \ Q�t T :a :fix ks-ranr C. prro - 1 �-- -$'�epr �- .•s'�tSr/t � - \ % Leriv�!/M+F prrf 1 �►` >'a T3�' z..� n 2? �-o far 3 c i .Lar 3,Z o e.�,.c/e v fir': D rlo,STg•t"T"�Frx, U t \ 4 I 1 t S owW� 7�Y �DWfiI� `7rjoME�.Y E.T UX NoRMAIJ gPOSSMAKI r'15C�ISITE—AE Y t 1. 0'CAT, 107N SEWAGE PERMIT NO. VILL GE` INSTA IIER'S NAME i ADDRESS Apo r QA-dflu el BUILDER OR OWNER DA T E P ERM11T ISSY E D DATE COMPLIANCE ISSUED �� ZdAl f r- ,r 4 Y� e (V No....27 1 ....... �'� F�s.,l��. .............. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF FEALTH - ................._O F....... .Q ., - L 6 Appliration for Diipuaal orki C�nnitrnrtinn ranfit Application is hereby made for a Permit to Construct (V/) or Repair ( ) an Individual Sewage Disposal System at: yy� / Q ........�..---_.:�......��f✓:.....-1��--la .......0 v??T---------------- Location_Address or,I of No. 1 > kstF',[ � 11??s° .... .�1.9�1 �U= .� .eL_3J:.......fo..•-- Ow er !f Address Installer Address Q Type of Building Size Lot..4 13)_.........Sq. feet U Dwelling—No. of Bedrooms._...3..................................Expansion Attic (V Garbage Grinder (wo) aOther—Type of Building ............................ No. of persons___-_____-_--------••-_-____ Showers ( ) — Cafeteria ( ) P4Other fixtures .--•-...------. •-•--........-•-•-•-----------••••---•-•------•-•......-•------------- --------- W Design Flow_...._..�_`19.77....................gallons per person per day. Total daily flow.._..?�.9....._....................gallons. Septic Tank—Liquid capacity.440...gallons Length-------_........ Width................ Diameter---------------- Depth................ �141W Disposal Trench—No. .................... Width.................... Total Length..___.............. Total leaching area....................sq. ft. / 3 Seepage Pit No.___---_1----.-__-__ Diameter....__-_........ Depth below inlet...... _........... Total leaching area.-:LQ®__....sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed b �1 ___ ►^__ _a ►� Y �l._�. 'l.�i = ------------------ Date y....... a Test Pit No. 1. __ __-minutes er inch Depth of Test Pit---�_L.......__. Depth to roun wa er...._-p--__W!_ e:_t- P P P g N- - =- 444 Test Pit No. 2.<..1L,-'__._mmutes per inch Depth of Test Pit---1.X...______.. Depth to ground water ................... ai a --•---• ...--- ................................................... Description of Soil_...IQ-+...... .. _- ----5�1... W ►a v -- sin ............ O ' P V .........-•--•-•••-•-•--•••-•---••----------•--••--•-•----•-•--••...--•----•--•---•--••-•••-•-----•--••-•---------••-••-•--•---•-•-•-•--•-••---•-••-•--•----•-••-•-•-•----•-•---•--•---•••••......----- W ------------------- ............................................................................................................................................................. ------•-- U Nature of Repairs or Alterations—Answer when applicable.---------------------------------------------------------------------------------.-____•-----__. -------------------------------------............-........................................................................................................ ............................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of i i L p of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issue by e rd of health. ` ------------- Signed-- -------•----•------•-• `! Date ApplicationApproved BY----- ............................-........................................................ --- 11_.__g° /........ Date Application Disapproved for the following reasons---------------------------------------------------------------------------------•-----------------------------•. .................................. .............................................................................................................................. -••--•------s-`--�--•--•---------••-•------- ���. �fir.r Date Permit No..._....... Issued �----- ( --`�' -----•----•------- j Date I � 4 f No................._....... FEs.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH I ' l-llvurJ_........... ........OF......- r .s2'c Appliratiun for Dhqpuuaf Workfi Tow3trnrtiun Vrrutit Application is hereby made for a Permit to Construct (V) or Repair ( ) an Individual Sewage Disposal System at ---------------- ------- ------ ..-•---•----• ------......---......---- ---•--.. .......----.......--------• /� nn - ocation-Address r t-oyM ...................................... ...... I d J!. :... or��t=/u W--=----90n;. _o_I_J..pb. Owner I-Address / -----------------------------------------------•-----------------.... Installer Address UType of Building Size Lot_47.17)..........Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder (40) aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) A Other fixtures . W Design Flow....... .....................gallons per person per day. Total daily flow........ :TQ....__...._..........__...gallons. R: Septic Tank—Liquid capacitylk?....gallons Length................ Width.........._----- Diameter---------------- Depth................ Disposal Trench—No..................... Width.................... Total Length..................:.. Total leaching area....................sq. ft. Seepage Pit No--------t------------ Diameter.....19........... Depth below inlet..... :........... Total leaching area..�®IO......sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed b ..._..__- P(�:I & ....6✓�fpi! t � � a - - -- - •- - - -- -•-•---------------- Date_--------. "�-�'1-------------...-. Y n 14 Test Pit No. 1_{. _...minutes per inch Depth of Test Pit_____11z..____.. Depth to ground water._N_u. ..A _C�et°r'�_. (S., Test Pit No. 2..�_�...minutes per inch Depth of Test Pit-----!"........ Depth to ground water___'`.-_--.--�I---____- I -• ;o I ----- •---•-----------•............... Description of Soil-•--------1-9`.....Srth v _S�! ----...-•-----f�------...c0a��------5�"°� U ---•--------------------------------------•--------------------•----•-•---------••----.......----------••----------------------------------------................................................ W x •-----------•------------------------------•--•-•--•-----------------------•-•--•---•--••-•----••-••--------•-••----------------------•---•-•-••......-•••--•---....................................... V Nature of Repairs or Alterations—Answer when applicable................................................................................................ •-•-----------------------------------------------------------------------------------------------•---......----...-----------------------------------------------...--------------------...---•--..... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has beer d-by t e b health. g Signed. ... ........ ...•...:------•-----•--•-•.....--••••....------•-•-----•••---••--• � Date ApplicationApproved BY.................................................................................................. Date Application Disapproved for the following reasons:-------•-------•--------------------•-----------------------------------------------------------------•--------- ----•-•.............•----------------•-•-----••--•••---•--•-•••-------•---•••••----------•-••-•-----•••-----•-•--•---------------------•--------•-•----------•--•-----•-------••---------••------------ Date PermitNo......................................................... Issued....................................................... Date 1:; I Yg THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...................OF....... c.......... -........ ............ ..... Trrtifiratr of Bunt rfiana THIS IS TO CERTIFY, That the.Individual Sewage Disposal System constructed or Repaired ( ) bY............................................................................................... ....................................................................................................... Installer at....�1.6...... _ &.S.1----••---R.D-_- CCti E2v�tE. .v.. _31 has been installed in accordance with the provisions of TITLE j of-The State Sanitary Code as described in the application for Disposal Works Construction`Permit No---------- .. �=-c-________________ dated I.-r-tj'-_7��--_..:..._.______... THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY ' ✓ 1 ) DATE "! .1:- Inspector +� ♦ ,u. , �,. s. .n... ..?3 c:.�;�..� -. .``x 's`�,.."Y','�` .. �;��erg 4:�j�a�3��"=" ' 1. €i THE COMMONWEALTH OF MASSACHUSETTS 11 tt�,� HH ' L C �� N BQARC�n'�/VE/ _ .. ..........................................OF..........................................................:......................... No......................... r` ; FEE........................ iuruu�tf Turku Cunutrnrtiun Trrntit Permission hereby granted.........................------------L...................................." --------------------...... = to Construct ( r R n Indva13$evcrage Di/p�sal S3�st /`� R s H E A6.�Ar ��j at No. •• ••...... Str e �- �,, -. .._. .... as shown on the application for Disposal Works Construction Pe i o e ._ :. --- .--------------- r ^) �/ � Board of Health DATE...................................... =....................................... j FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS F7.A, rI" 4 F.FL. ELEV.= 3afac> FINISH GRADE = t'E' FINISH GRADE FINISH GRADE TOP OF FOUND. ELEV. = d l OVER TANK = T746 OVER PIT = Z-1416 _ 4�� C.I. '" , CHIMNEY BLOCKZZT7x( DWELLING - 4�i V.C, _ _ WHERE NEEDED BACKF ILL 3" PEAS TONE - 2 a V.cJ . .o .. ' 22�by 21t? o a o O Q O t v D b 0 CELLAR FLOOR 15OU 21f , , a c c q ' GALLON a o .� o , o O O p o 3/4" TO !2" 1- ELEV. = 22+oa REINFORCED GONG. /r d o O ` P _a O O o ° CRUSHED ST01t�' v ' p ° ° O O O . .. � " � O o 0 DIST. BOX ° O U O e-Qa�rc SEPTIC TANK >- (TO BE LEVEL17 o BOTTOM Of PlT --t. v � ' O o O o D . v: .AND STABLE) d ° O O O o e �. 4. /�� ELEV. c-�- " SYSTEM PROFILE ICE`--d„ ( NOT*TO SCALE) -- LEACHING PIT DESIGN CRITERIA AWMBER OF BEDROOMS ' 3 _ GARBAGE GRINDER = LIC7�F,. _ t C TOTAL DAILY FLOW = �_� � � Q 'lZ LEACHING AREA PROVIDED = S I I�Ewe.�c. asr .r, �► z�xsx h x Z.�,� 4 7 i.Z �c?p 41 � /" "';,�„��` _ M� � foAlma ''•,-.-. � 3 � ' \� d ! s �4,,_, . 3 SOILS LOG a -�-, , �� O° ELEV. - �2�Fo � - X0,0*0 r ri. .� PROPOSED SEIWAGE- 144" seAx. . : t" ' `.: ' DISPOSAL . . SYSTEM ,` , INSPECTED BYE PROPOSEDDWEL LING DATE { 91e YI IL� MASS. PERCOLATION RATE o +'� MIN./INCH SCALE AS NOTED DATE 7.9 l tt }Y AM OF higg .OWruEJ7 Br, F_0\11A CID -T"ca t5mf—:, 1r + i't', Sp or trli.`tfJ"++"� i€,) a t— ti � IL NORMAN '�.� 9ex,.,4, ��'�t'°ta,ra r..T't.,�tZiC�f► ` GROc { " i 127 . N 0 R M A N GROSSMAN PE, .R.LS c, . , .3-T.C3 t?p- 226 HOLLY POINT ROAD �SQh�+t CF<NTERVILLE MASS; ;� f�f'd'Gz�,a�e i Lt~.!',r,.-r,I.^�►� f�t' �-+t�, r."lrr�"7"s U a'.) �''!7' �', 4-'�."I'.'�t ��` ,p- , °",.