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HomeMy WebLinkAbout0349 SHOOTFLYING HILL RD - Health 349 SHOOTFLYING HILL, CENTERVILL A= 214 062 llll RE��Fo llll UPC 12543 NO.53LOR `�'srcoN�"j NAS?INGS.tin L I 7 I { I I I .y. No.f7 L� '� � Fee si� ` THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: es PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZIppiicatiou for -Mioogal *pgtem Congtructton 3permit • Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. S Owner's Name,Address and Tel.No. Assessor's Map/Parcel Z ��c/G'f�p�f�!i✓✓� //�s!'t"' �N/ /��l�i - Installer's Name,Address,and Tel.No. 3(o-2--jo 2-`j 7 Designer's Name,Address and Tel.No. 23 ma -e� a,, Type of Building. Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( I�V Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 2 5—'� G I�vw� o `� 5 Ai. v- ne_�o9 !' i 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 oard of Signed Dater��� Application Approved by; Date �� Application Disapproved for the following reasons Permit No. Date Issued 9F "� � M4I Ail No. "" Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: , es r'`F PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS -• x ZIppYication for Migogal *pgtem CCongtruction Permit • Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 7 S Owner's Name,Address and Tel.No. Assessor's Map/Parcel /!� �6 Z �� c_Y rlGD 0f n ,f A fl �� % �L/ ucv Installer's Name,Address,and Tel.No. .3(0 2— G 2,37 Designer's Name,Address and Tel.No. L C Lj s 3 rw s• 6-oj s , Type of Building: Dwelling No.of Bedrooms -3 Lot Size sq.ft. Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank -.t Type of S.A.S. Description of Soil G Nature of Repairs or Alterations(Answer when applicable)_ o`Z 5 f/pv►•t ejo `f Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenanee 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 Board of al - Signed l Date W ,� Application Approved by �" ���� ,,� • Date Application Disapproved for the following reasons Permit No. des Date Issued ----------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired ( )Upgraded( ) Abandoned( )by �_�-�-� ' 3n-a F• at LL has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit Np'92!A-7i 4'�dated_ 15�'- zfzs. Installer rt,u 1 - Coo N S f' Designer The issuance of tlu;s�p/er shallot be nstrued as a guarantee that the s mwill function as wdesign � Date (�=r Inspector 0 !�° ------,v-`-�------------------------------- No.� rani- ! Fee . a THE COMMONWEALTH OF MASSACHUSETTS G�� s PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS 3 S Mi5po5ar *p5tem CCon.5truction Permit Permission is hereby granted to Construct( )Repair( )Upgrade( )Abandon( ) System located at 34e S Z:Z2J %k A�ti' /t� 4f2,O 7,?, yi 1,e�6 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 thi t. Date: -_ �l A �- Approved ASSESSORS MAP NO 2/ PARCEL NO- 6 L' 1/6/99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) I, n �J hereby certify that the application for disposal works construction permit signed b me dated �/ '� � p g y , concerning the property located at 3 f� /�✓ /J/✓ meets all of the following criteria: 0 J� /`� • This failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. V• -The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. J� J• There are no wetlands within 100 feet of the proposed septic system There are no private wells within 150 feet of the proposed septic system. There is no increase in flow and/or change in use proposed JThere are no variances requested or needed. uThe bottom of the proposed leaching facility will not be located less thari'five,feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when /applicable] If the S.A.S.will be located with 250 feet of any vegetated wetlands,the bottom of the proposed leaching facility will not be located less than fourteen (14) feet above the maximum adjusted groundwater table elevation, Please complete the following: /v A) Top of Ground Surface Elevation(using GIS information) ✓ B) G.W.Elevation +the MAX.High G.W.Adjustment(v'14 ( ' DIFFERENCE BE WEEN A and B ~ r� 3 SIGNED : ` sv I DATE: [Please Sketch proposed plan of system on badk]. J NOTICE t Based upon the above information,a repair permit will be issued for `3 bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system plans. q:health folder:cert 1\� I � � w` 4 G:7 ! v t :7 v '4 44}. TOWN OF BARNSTABLE OCATION ��Gc �-��i ` � ��/ SEWAGE # �' LLAGE CY� rI/i 71 ASSESSOR'S MAP&LO INSTALLER'S NAME&PHONE NO. 1-I1! S are-774o-S' Cave 9ok SEPTIC TANK CAPACITY 1000 G 4 1 LEACHING FACILITY: (type) 279619 65 1 Jrl+yu," (size) 500 Cx4.L NO.OF BEDROOMS 3 BUILDER OR OWNER V , w► PERMTTDATE: W 119CO ® COMPLIANCE DATE: ! �� Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells_exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by. '� "�_ �,,.. � � � � � , p ��. � �� �� '�� o . � 0 r - TOWN OF BARNSTABLE C® LOCATION 341 SEWAGE #.2000 j VILLAGE C-r,7,�*tw, 7 I ASSESSOR'S MAP & LO (Nll INSTALLER'S NAME&PHONE NO. IS I h S 69p,kL. GO. SEPTIC TANK CAPACITY 1000 G a 1 LEACHING FACILITY: (type) 279 00 Gn I (size) 500 Cx, NO.OF BEDROOMS 3 BUILDER OR OWNER ►'�( W� ; PERMTTDATE: 141(11o ,000MPLIANCE DATE: V Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist i 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 O 6 O ' I I i i --- --- ---- - ................ THE O FLMA�SS^C T ETTS P'1I-'C f f�G/'1 TH i Appliratioo -for Dhipoiial Works Tows rortioo Pprutit Application is hereby made for a it to Constr t ) or Re air an Individual Sewage Disposal System at: ................... -•-•-- --•- ••------- - -- - ------•••- -- -- . --------- -•-- -----------------------------•.........•----- ocatio Address or Lot No. •........,� .. _._ ---- .... .._`........ . .....................................................--.................. --------------•-------------_Owner Address Installer Address U Type of Buildings Size Lot____________________ q. feet � --.._...S Dwelling No. of Bedrooms.............�_..._.....__ Expansion Attic ( ) Garbage Grinder ( ) ` Other.—Type e of Building ____________________________ No. of ersons.._____________________--___ Showers 0.4 YP g P S ( ) — Cafeteria ( ) P.' Other fixtures --------------- ---•--------.. . . W Design Flow...................... d_... Mons per person per day. Total daily. flow............5___------------ -------------gallons. WSeptic Tank 4-Liquid capacity, allons Length---------------- Width_._;------------- Diameter----------...... Depth.__.-_____._.... x Disposal Trench—No_____________________ Width-----------_ _ __. Total th.:.. ___._._. _ Total leaching area_.__.____._.-____._.sq. ft. _ be .__ Total leachiu� area Seepage Pit No.___:_./----------- Diameter._. ___ __. w t----_ __.___.._.sc. ft/.� Z Other Distribution box ( ) Dosing tank ( ) o� �� Percolation Test Results Performed by------ __ _________________________'_....._..._____ Date-_--.--•_____-_-__---__-_._-_______----. aTest Pit No. 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water.._-____._____-__._.__.- G14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water--_-----------------_- Ix -------------------------- Z------------ / ---- --------------- .................. Description of Soil-__-____-._"^ '- � -------- -•_c v � � ----------- U ---------------------- ---------- 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 Article NI of the State Sanitary Code—The unders. ned further agrees not to place the system in operation until a Certificate of Compliance has byo issued the bo d of health. gne ....... --- ------ --•--------•--- -••-----------------•------• ----•-----•-------------------•- Da Application Approved By............ __ %--- i--� 7ate Application Disapproved for the following reasons----------------------------------------------------------------------------------------------------------•------ ------------------------------------------------------------------------------------------------------------------------------------------------------- Date 24 Permit No......................................................... Issued........7 Dat .................... THE COMMONWEALTH OF MASSACHUSETTS BOARD F H EA Appliration -fur Uiipniittl Works Cnowitrurtion Prrmit Application is hereby mad r for it to Constr ct '- ) or Re air ( an Individual Sewage Disposal System at: r c ----------------- --•- .........-• -••• ------ -' K -- ------......----------•-•.._..-'-' --- ocatio -Address b or Lot No. ----'------•--•---------------------••------•----"......-•'--••••-•••-------- Owner Address W .�'................................................ � Installer Address UType-of Buildirw., Size Lot____________________________Sq. feet .1 Dwelling!—/'No. of Bedrooms........._.._ ________________________Expansion Attic ( ) Garbage Grinder ( ) aaq Other—Type of Building ____________________________ No. of persons-_____,_____________.___--__ Showers ( ) — )Cafeteria ( ) A' Other fixtures _______________ ----------------- w Design Flow____________________________)AZ ____ allons per person per day. Total daily flow---------..«�.+_..__._-----------------------gallons. WSeptic T ctnk Liquid capacitgallons Length________________ Width------.--------- Diameter---------------- Depth-------•-----.- x Disposal Trench No _._.__.___ Width_.�� tal th_ Total leaching area__-_________.______sq. ft. Seepage Pit No.- Diameter-_ 1� -------- 6w et_.... Total leachin area,,, P -- - ------sq. ft. z Other Distribution.-.box '( ) Dosing tank:( �C = / / '-� Percolation Test Results Performed by....."' Date Test Pit No. 1------------------nimutes per inch Depth of Test Pit____________________ Depth to ground water-..___-__._________. - CL, Test Pit No. 2.........:......minutes per inch Depth of Test Pit____________________ Depth to ground a J water__._ ___-___________ '•---==-•---------- --------- f----- ..-- .-.. �J - - �-- ---------•---_-•---- DxDescription of Soil----------'�---------------0-�--------•-` ...... - _-- -------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- w UNature of Repairs or Alterations—Answer when applicable.______________-____________________________________________________________.................. •-------•--•--•---•--___---•--------_-•-•-•------------••--••------ Agreement: , The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The under • ned further agrees not to place the system in operation until a Certificate of Compliance has issue the b d of health. igne - ( -- ---- -- --------------•-------------- ................ ............. Application Approved BY -•--- -'-• / •--7�!-y.... Date Application Disapproved for the following reasons:............................------•-----------•--------• ...................................................... Date PermitNo. - ................................ Issued........................................................ Date `THE COMMONWEALTH OF MASSACHUSETTS ` BOARD'"" HEALTH t r . ...OF...... .. .. .....:....::.:.. .:....:..............•--.-.-••-----..--.......... err#ifirate of Tompliaurr THIS TO ERTIFtl : the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by........ ----- : at............... .._ i insc �'f f+�fx _ � ► �!lA has been installed in accordance with the rovisionns of Articl iof he St e Sani y Co a des ibed in the application for Disposal Works Construction Permit No._.__._ __.._.._--f�-------------- dated-----------��-�i?_.-$............. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. • r DATE---............................................................................ Inspector----------------------••---••--•-----------•---•-------'--"-----'----'--------''-- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH " _..OF.........:. ,�-. ................................ No. > `Y.--• FEE. ................ Di vo or ii n, #rurtion Frrmif Permission h reby granted - ---=... �- --- --•--.__._. '° to Const t ( or epai . ) an In i ua,� Se e D po yste e at Street as shown on the application for Disposal Works Construct"ion t No:_"._ •____.__ _ Dated__. _ ____�j ________. ' ........ ...................... ~ Board of Health DATE- ----- .......I..............---------'_- i FORM 1255 HOBBS & WARREN. INC., PUBLISHERS ... -..__ ,-,.�__. _ ..�`. .._---� � _.- '•`y _ _ :'a r" �..mot;' i rear of lot II Ca"'9" north arrow t o E 1 °' _ ° o N N y distance to corner distance to corner ('b"feet if cornerlot) �! ('o feet if corner lot) lot lines frontage of lot -- street nameowl r Y w a • W a � � � '�� - -� � � - � - ;�a a ' c �u fr_-_ "' - e d.,. e,�; r � „ � ...� f w.,r - s v- !_� a ._ � � � ^' o F C y , n �: � - �: - e �K3 - �°; ' t .. � - YS 000* -L O C-A_T-1.O-N f SEW Q_ _P_E.R MIT IJ of FIE Ll — � - - - - - - - - - - alder - -1-t�1 D-AT-E—CO KA P-l_1-W A CE--1-SS-U ` ��t �� \ i / �. .. / .. _ _. ® ��� THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINALS) I M ^C&L DATA SUnAURYACF SEWAGE DISPOSAL SYSTEM INSPECTION FORM 1�S S ol: p1 .)Pr-'Vty Of ...Vs,P e -j- ri PART A C! ZCKLIST if Ai.fo --ion was request-4 o-i' the owner, occupant, and Jcard of - j*',,it:.� sysl:eTn components '�,.ve bi'.t��n pumpod. :for at least two weeks e. bee-n rece ; , .*­q nor��ial flOw rases during that p ".targe vo,j.umes of !,,ave been ilitroduced into the tax: ear, -�)art h-ive obtz n�!vl a examir.- Note if they are FiatNI*A, signs of sewage back-up. f ij. or was in��-f,ented for q:,4: i)-i.-e,!akout. S y 5 t eXciuding the SAS, have been located on the " he sopt :: es we uncover,,,d, opened, and the interior of k-,, p e e!1 for condition of baffles or t e es, r-1 1 6';.:f.ens ions, depth of liquid, depth of on the site has been determined kkized "Tf.I,.'oximated by non-intrusive methods. (ofid occupants, if different from owner) were - wi'i-,h on �_'.he propel xi.aintenance of SSD!Fo, 41 KJ <0 X49 A* 6' Nt SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B ` SYSTEM INFORMATION FLOW CONDITIONS If residential number of bedrooms / number of current residents !'-J garbage grinder, yes or no laundry connected to system, yes or no W seasonal use, yes or no ca cu a e -flow: ct q i -� 73, Water meter readings, if available: Q`Gu ,Q Last date of occupancy GENERAL INFORMATION Pumping records and source—0f information: Jul J r�i V System pumped as part of inspection, yes or no if yes, volume pumped Reason for pumping: Type of system Septic tank/d L--- _� '-ox/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Other (explain) Approximate age of all components. Date installed, if known. Source of information: Ald Sewage odors detected when arriving at the site, yes or no J SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTER INFORMATION continued SEPTIC TANK: .(locate on site plan) depth below grade: material of construction: L-----C-oncrete metal FRP other(explain) dimensions: � - n C� sludge depth 22" distance from top of sludge to bottom of outlet tee or baffle O scum thickness distance from top of scum to top of outlet tee or baffle distance from bottom of scum to bottom of outleL 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, recomm nd tions for repairs, etc. ) DISTRIBUTION BOX:. (locate on site p' n) depth of li`q id level above outlet Comments: (note if level and dis ion is a 1 , evidence of solids carryover, evidence of lea g into or out of box, mmendation for repairs, etc. ) PUMP CHAMBER: (locate on site plan) pumps in working orde yes or no Comments: (note condition of pump q�L er, con ition of pumps and appurtenances, recommendations for fitenance or rep irs,etc. ) 1( SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ) PART B SYSTEM INFORMATION continued SOIL ABSORPTION SYSTEM (SAS) : `—� (locate on site plan, if possible ; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type. leaching pits and number leaching chambers and number leaching galleries and number leaching trenches, number, length leaching fields, number, dimensions overflow cesspool ; number Comments: (note condition of soil , signs of hydraulic failure, level of ponding, cond`ition_c vegetation, commendations or aint ance �r, repa r,etc. ) CESSPOOLS locate on site plan) : ( P ) number ano configuration depth-top liquid to inlet invert depth of soli layer depth of scum lay dimensions of cesspool materials of construct ' indication of gr water inflow (ce of must be pumped as part o�spection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs,etc. ) PRIVY: (locate on site 1 materials of construction dimensions depth of solids Comments: (note condi ion of soil , signs of hydraulic 'lure, level of ponding, condition of vegetation, recommendations for maintenance or repairs,etc. ) S-- SUBSURFACE SEWAGE' DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE SPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100 ' �sz•412 A 3 3 - c 2�— 13 5�- DEPTH TO GROUNDWATER -- depth to groundwater me d of determination or appro imation: SUBSURFACE SVWAGE DISPOSAL SYSTEM INSPECTION FORM PART C FAILURE CRITERIA Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of determination in all instances. If "not determined" , explain why not) �ackup of sewage into facility? � T _ A- Discharge or ponding of effluent to the surface of the ground or surface waters? 6 Static liqu ' level in the distribution box above outlet invert? V/Liquid depth in cesspool <6" below invert or available volume< 1/2 de flow? Required pumping 4 times or more in the /last year? number of times pumped Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank failure imminent? Is any portion of the SAS , cesspool or privy: _ below the high groundwater elevation?—Az within 50 feet of a surface water? within 100 feet of a surface water supply or tributary to a surface water supply? lvr"L. At ' V within a Zone I of a public well? IV within 50 feet of a bordering vegetated wetland or salt marsh (cesspools and privies only, not the SAS) ? within 50 feet of a private water supply well? 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 anr ' . for coliform bacteria, volatil ganic compounds, ammonia nitrog and nitrate nitrogen. ��„���� TOWN OF BOARD OF HEALTH - SUBSURFACF. SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D - CERTIFICATION -TYPE OR PRINT CLEARLY- PROPERTY INSPECTED STREET ADDRESS ASSESSORS MAP, BLOCK AND PARCEL # OWNER' s NAME PART D - CERTIFICATION NAME OF INSPECTOR COMPANY NAME ? /�fs�k- 0 COMPANY ADDRESS -7 i:T Street Town or City State ZIP COMPANY TELEPHONE (5 S) `3��- � FAX CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true, accurate , and complete as of the time of inspection . The inspection was performed and any recommendations regarding upgrade , maintenance ; and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one: &----System PASSED The inspection which I have conducted has not found any information which ' indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15 .303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. System FAILED* The inspection which I have conducted has found that the system fails to protect the public health and the environment in accordance with Title 5., 310 CMR 15 . 303 , and as specifically noted on PART C - , FAILURE CRITERIA of this in tion form . Inspector Signature Date P g !' One copy of this certification must be provided to the OWNER, the BUYER ( where applicable ) and the BOARD OF HEALTH. * If. the inspection FAILED, the owner or operator shall upgrade the system within one year of the date of the inspection, unless allowed or required otherwise as provided, in 310 CMR 15 . 305 . partd.doe 130. VN LOCATION S SEWAGE PERMIT NO. '� VILLAGE INSkA LLER'SS AME j ADDRESS } �sr , S UIL R OR OWNS GATE PERMIT ISSUED DATE COMPLIANCE ISSUED 11,5; Nab:� .... ©.T �� 7 Fss.....1..... = THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH YO.4.1 ..................OF............._/ A. ii/� -.................. AVVftration for Blip iial Workii Tomitrurtiun Vamit Application is hereby made for a Permit Construct ( ) or Repair ( ) an Individual Sewage Disposal System t:_ ton�Add�ess � Lot No. //�/YI/A .._... W a rei no / Address , C,. C ��....c..... 1.n......__. .P.�........./lrig(.vic.y:. ...--••-•.... Installer Address UType of Building 2 Size Lot�yl..4* .4.Sq. feet Dwelling—No. of Bedrooms........................ _._..Expansion Attic Garbage Grinder ', 0 Other—Type T e of Buildiii yp g CeV,�.............. No. of persons_._._A.................. Showers/,Qt,Gy — Cafeteria") dOther fixtures ......_�O�t:G--•----••-----....---••-•-•-.-----•--------------•........................................................................ W Design Flow.........2.. ................... ......gallons per person gPr duty. Total daily flow.....3_ ..�... .._._..._.........gallonsh C4 Septic Tank—Liquid capacit fit~ gallons ength._..._�....__. Width.11_�G Diameter._._ _. ... De th....!„4%�d' W Disposal Trench—No...F ...... Width.N.A_...... Total Length.. /�._... Total leach' g area.P 3V...sq. ft. x Seepage Pit No..../------------ Diameter.._./.a_..... Depth below inlet............. Total leaching area........ ...sq. ft. z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by......................................................0.......--•......... Date......................................... a Test Pit No. L.2.4_...minutes per inch Depth of Test Pit.................... Depth to ground water........................ 444 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water......................... a .......-................................................. . 0 Description of Soil..........G...-..3i..........C2 !!!... 0,4;;0"Z,_W-...... ......... ................................ �., W ----•----------- - - ----------------�!'u•----•-- c.�o..... ...... ......................... •-••--•---•-•--=--------•------••-•-------•-------.............. V Nature of Repairs or Alterations—Answer when applicable............................................................................................... ---- --•--•-------••........................................................................•---............. Agreeen Thm Il dersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with *ppla usof iI`r E 5 of e State Sanitary Code—The undersigned further agrees not to place the system in a ompliance ha n is ed by the bo of health. Signed �.... . �� ..... /0 /3 pproved By-•••----------••-••..................••---- Date sapproved for the following reasons:-•-•---•--•-----•--------------•--------•---•---....---...-•--•-•--•-•-•-•--•--•-----•-----....----------.------ ................:........................................................................................................................................................................................ Date PermitNo......................................................... Issued....................................................... Date ,� nn Fim THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH .-----......_...........................OF Appliration for M-4po,ial orkii Tomitrnr#inn rrntit Application is hereby made for a Permit;to Construct �C6 ) or Repair ( ) an Individual Sewage Disposal System at: t' --•---•-----••-----•-••--•---•--•..............................•-•-•-'-•'---.............-----.... .......•'••••----••---'--•••••-----•-•---•-•-------•--•---------•----•-•----•---••--------•-••..-- Location.Address or Lot No. ................................................................................................. .......•..•.....•.....••--......_.._....___...._........................._........................ W Owner Address Installer Address UType of Building Size Lot............................Sq. feet r 'a Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures .......................... .............. -- ---••--- ----------------------- -------------------------••------••----•-•------._.-----•-•-• W Design Flow................... ... j'4i9,..__�allons per per day. Total daily flow......................................... WSeptic Tank—Liquld capacity._._____....galloris 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........................................ a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ G� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water____-----_--.-_.----_--- .--••--•••-----------------------•----------------•---------•-.....--•--•........-•-•--•---._....•.......................................................... 0 Description of Soil........................................................................................................................................................................ c ---------------------------------------••••--------------------........----•-----••---........------......•-----•----------.._..--------•'------•-•-----•----••--------•--------•-•-•-••-•••--.......... W VNature of Repairs or Alterations—Answer when applicable.................. •-------•-------------------•--••••---•---•----••------------------•-•••--•----•------•._....••-•-•-••-•••'-••-•-•------•-------•--•-••---••••....••......._...........•••.........-•-•••----•-•----- Agreement The a dersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the prdvis' us of TITa 5 of t e State Sanitary Code—The undersigned further agrees not to place the system in ope I do u r ' d t ompliance has been issued by the board of Health. fSigned...................................................................................... •--•---••---•-�� 1°� -- Date Applicaon pproved BY.................................................................................................. ........................................ Date Ap li tion Disapproved for the following reasons-............................................................................................................. ......--•-••-------•---•---••--...•-••-••••---...----•••--•--•-------'•--•------••• Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF EALTH .........v /^ .•/•.•.-.OF..... ..... ......,............................... - -........................... (Irrtifiratr of Tontplittnre THISJ,V TO C RTI Y, Th t the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by...... rs_-.4._ .-•• .•-• ........................................ ........................................zaa ----------••------•-------------------•---- �I Inst at....... / .. --f _.. -. has been installed in accordance with the provi ons of TITLE j of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......73�7 _ v............. dated---------LC.-.�3-r1�,............. THE ISSUANC OF THIS CERTIFICATE SHALL NOT BE CONST AS A GUARANTEE THAT THE SYSTEM WIJeCI'�F CTION SATISFACTORY. DATE.11r../�t Inspector-. ---- --•---•-------------------•---------•-----•------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD QF HEALTH OF................r ...... ..................................... .-s FEE....No... . ......�......--•••-• .... ........... trWinn rrntit g� Permission is herebygranted....... -•-----------------------------------------------•--....--•••••--.................... to Constr t ( � r Repair ( ) a " In ivi ual' Sewa.�f� Disposal.Syst ,J Street pp qq �^� as shown on the application for Disposal Works Construction Permit oA3_-_l.97 Dated..........16_-12.-:G4.7........ •-••-••••• .. •. •• -•----• = � Board of Health DATE................ FORM 1255 A. M. SULKIN, INC., BOSTON No—re /F EITt/tmR TX� SEPT/O TAN.iC DR ?o FT, l°///V• —� �_.EAGtllivG P/T �7 AE MORE TH.9:•! /2"�9ELO n/ i !'� �,4A DE, � 24 'A/.4 M E TES' CO/yC•��TC- CO YE•� /o Pr. M/ SNA4L B.F 9.re0uGN7' TO GT.4OE. Cp/yCRL•T� 4�Pi�C' Pf.PC tiEAVy CA 5.7- ,",eO/Y C S.'>A L 3= : SEA i �"L�v. i ��.s co��s /t•PF.� fT. � %RtOd1E Pl�� �O D U �� - s • �� : b b �• • s • nee � •o�s eft Sh'c'D STuNE �_ od��1 D/SP. • • • o • e e e • o a • t l r • e������:. $�E�T/tom Ti4/Vi� ®DX o b t � � r r s n • � s a m v s lCAtftl M[. DrT LuR'¢T TO f a, — I ;- w Ae of servo ee -, •♦ t r bEFFfC3'lVr� , j a D� ® a a e. • l�ASJtED STD.Y�' Tovsor�; � • o l •r PT�9 • c+ a �' � s o , ' • • • eb • s � sole' ti� �f r r.. I o • PRECA.S T SEZPAaZ ' y - • .•- • lb I' i • • J'e 9 p • I 2S.. 3—i-i61D - i®•+®• , et • • • meea t • o P/TORZVU/Y. 111/V�' E.��Y��/ � I i.3 x'I o I t 3 (� . • • s EL = 94.1 '} -V r yZR T'AT B///�/ !� I oo.5 PrT cA Pnc,-r 490 G/D y 3' �;L , 31 51A Al �r�uta77o�w, I. JW .T#ICsa '. R� "..•.+.J 1° ...Y. •YSi. f r Y:-. i s ., .f".e:' - V u ou-n-Er sz /C a �IJTlGl4 60 `del t g$��may► }�a ym ,✓ � i t .;f ,,� 4 r », 1 . d S Tied! t�t� �.q` I . f �T�lt iJ t.. i' 'Y .3y 'q q ,f fi3 T3.dIG/'.�j�!7. ,> IJ is/Q'1d fiFT m .S®IL L..®� l c„Jq,ttA6g,psPo3•4J- vV/r SOIL 7..19 / ToTAt E3T//�trsTEe FLON/ 33 `� G.4,L�Qi4Y SO/L TES.T f S1?/L TFSTs0G IYJMBFR (MI6 Lr CXfNre P/T� 1 !^E�LCri/ /O2• , >A7'� Opg SO/L TZST A f d ec�t3�'� �Al S/QF LA--'4CH/N6 PEI$PIT 150,8_5�a fT. D 2✓ Y RESULTS wlrlvz sz4o BY ,.1A PEVCCLArr,'ON AA7'Ac,*t LCSS /�7IN�/NCN 9GTT01�4 Na PAR P/T 113•�So. AT' o . .�AnFD Y •.w !f/t n/ NCid I ► � N TOTAL LEA.CN/NG A,RL=t9 'L6 . SQ fT. .. Tap 2io3.9 54. F T_ :.a FSFRVE LEftCNING ARF� . 1 G F. m '"D l l i'� n - �, S N d 0 7 4 w of S A mv:r-'3 V % L 1 RT Jam MORSE y #. { ca -L DRE0GE Fi1�G/NCR/iYts Co � p�No.10951�0 E./ V_ O, I 712 MA/N 57- , /+/YFati'viS, M4SJ. c fl hi _ Cq��isq� -►o fsStpN,ai NO G,10UN`7 i�{/Ar- ENCOUNTL��.-O CZI�NT:,yC)� //vcr PATE : FS SUR4� P] GRG UV 0 kVATE.Q �47- EL.ffV. JOB ND.- 8'3 v G 6 St1E�T Z'OF Z l i v L---o sir " 3 / 0 ' — --s -li�T f f r OF MAS �. s9 � goGN / r BE t 1 q y W =7a H suR��'� Ln T. T, s 6� N 7�a Z I­6 S,r ' 44 ArcAAE_-_"T b 1 10 19 s 1 _oi0ti�/ 1 n i r✓ <'i �T O u MASS / N'� / J < 0 ORSE 1`ZS V i No.10951 O Q =� 'r- '`�� ,• c;1 • Gl o SSIONA\_ c` T IS-�� ✓_ Q\ LEGEND �-,.a-�� CERTIFIED PLOT PLAN EXISTING SPOT .ELEVATION Ox0 EXISTING CONTOUR ——— 0 — „ Z_ 0 -7 • �SHUOTFL'//NCy f4/«L r<e�. FINISHED SPOT ELEVATION �. FINISHED CONTOUR 0 —��-- y4 IN APPROVED , BOARD OF HEALTH OAT E I A OEN SCALE, ;/ "= 4 O DATE , L DREDGE ENGINEERING CO CLIENT I CERTIFY THAT THE PROPOSED r EGISTERE REGISTERED JO®''NOs g`3,.�.__.._. BUILDING SHORN ON THIS PLANCIVIL LAND - CONFORMS TO THE ZONING LAWS ENGINEER R EYO OF SARNSTABI. MASS. 712 MAIN STREET ' CH.; ®yl 'cl _ 3 HYANN I S, MASS.- 2 9 2 83 _ { SNEET r OF 4 DATE RE LAND SURVEYOR •