HomeMy WebLinkAbout0054 ZENO CROCKER ROAD - Health (2) 15YZENO CROCKER RD. #54, Genterv.
A= 170-250
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UPC 17534
No.2 3COR �"tn
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TOWN OF BARN IT LE
.c-i" t . W E # 7- �7
LOCATION —'�� zGI'l/l Gl�'dG SE .AG
VILLAGE �PN1I^!//���ti ASSESSOR'S MAP& LOT /?e�`ZSO
INSTALLER'S NAME&PHONE NO. �Dl��LO % COr�57� 77/'�31� +
SEPTIC TANK CAPACITY 04 t
LEACHING FACILITY: (type) 65, .-J U (size)
NO:OF BEDROO
BUILDER OR
PERMUDATE: 7 �9`9 7 COMPLIANCE DATE: 7
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility s7� Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) ilk Feet
Edge of Wetland and Leaching Facility(If any wetlands exist � ;9
within 300 feet of leaching facility) Feet
Furnished:by
3�� p
r
'77
No. —-3 7 Fee
—
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
Zipp[ication for Mtgaal bpgtem Cougtruction permit
Application for a Permit to Construct( )Repair( )Upgrade Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. Owner's Name,Address and Tel.No.
Assessor's Map/Parcel Ge_w�ex11��e_ 1 �� pZ f�z z
Installer's Name,Address,and Tel.No. 45!274f7 Designer's Name,Address and Tel.No.
-� �
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder(_250
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow //� gallons per day. Calculated daily flow J gallons.
Plan Date Number of sheets Revision Date
Title _
Size of Septic Tank B r Type of S.A.S. /�!/Zer
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) 7-2 4Z Ll.�
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 y this d alth.
Signed Date
Application Approved by Date ^
Application Disapproved for t foll ing reasons
Permit No. Date Issued
No. � � � ' -------- -----_.-,._ _,� / / r� Fee 70
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
lDizpoga l *pgtem Conmrartton Permit
Permission is hereby granted to Construct( )Repair( )U grade( ✓)Abandon( )
System located`at
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 this permit.
Date: ,7 - 0/- 7 ? Approved by
7 7 cam >
No. _ ..�:• Fees .
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
01ppYicatiott,:for Digpool *pgtem (Cottgtruction Permit
Application for a Permit to Construct( )Repair( )Upgrade(/,Abandon( ) ❑Complete System O Individual Components
Location Address or Lot No. Own5f I Name,Address and Tel.No.
Assessor's Map/Parcel _ Ge� �d���/�
�7 /-j G�"-- �i r�Z-LIZ 173
Installer's Name,Address,and Tel.No. .,t� Designer's Name,Address and Tel.Nor
'77/
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 ��� ?,f,!t gallons per day.'Calculate' daily flow � � gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Ael eV 11r P _ Type of S.A.S. y �l'�'j�f/2�/� .L 4/
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) 7���1e- V
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 y th's d/ f
Signed Date
Application Approved by Date
Application Disapproved for the foll ing reasons
Permit No. Date Issued
---------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
(Certificate of (Compliance'
THIS IS TO CE TIFY,t t the On-site Sewa a Disposal System Constructed( )Repaired ( ) Upgraded(
Abandoned� )by �07�1 `lam
at J _/ Z :°h� G/OC E"/" r GCafr-611/1le- has ^b-e�en constructed in accordance
with the prov�i jiions of Title 5 and the for Disposal System Construction Permit No. / dated
Installer Designer
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
Date W /� 2 Inspector
0
1 C
�y
7.4
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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 PLAINS
hereby certify that the application for disposal works
construction permit signed by me dated /g/O concerning the
property located at meets ail of the
foilowina criteria:
are no wetlands within 300 feet of-:he or000sed seprc sv_ stem
• ere are no private wells within 1:0 feet of the or000sed septic system
ie observed aroundwater table is i- =eei or Treater beiow the conom of the ieacnin2 'aci;i
ere s no increase n Low andior _,�anQe m use or000sed
: ere art no var:ands recuested or::weed.
SIGNED : DATE: /
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
[Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan,
this plan should be submitted].
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q health folder cep
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OW 11
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TOWN OF BARNST�LE ,
SEWAGE #
LOCATION
V*�LAGE L '` ���� � ASSESSOR'S MAP &LOT / `CJ`Z
INSTALLER'S NAME&PHONE NO. t0� % C057`;
SEPTIC TANK CAPACITY —
LEACENG FACILITY:(type) U (size) &�XC?e X�NO.OF BEDROO. 3
BUILDER OR 1#'
PERMTTDATE: 7 V 9 7 COMPLIANCE DATE:
Separation Distance.Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility SY 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) la Feet
t
I Furnished:by
v _ .�. __ ..( _. . �_._..
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TOWN OF BARNST LE ,
LOCATIO Z G ev- rl/ , SEWAGE # _�7— 1-/7
t
VM,JAGE f?ij^I//'��t�i ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. Ceo 77/-����`
SEPTIC TANK CAPACITY a
LEACHING FACU rrY: (type) i6ba` --4 U (size) Id�X?d X�
NO..OF BEDROO 3
BUILDER OR 81A,7 e �
PERMUDATE: 7 7 COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility s� Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) IIJ14 Feet
Edge of Wetland and Leaching Facility(If any wetlands exist "' '
within 300 feet of leaching facility) la Feet
Furnished by "'
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Commonwealth of MOSSOChusettS ,John Grad
oil a Executive Office of Envlronmerria!Affoirs D.E.P. Title V Septic Inspector
Department of P.O. Box 2119
Environmental Protection Teaticket,ME102536
-6813
8
A ro
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION F �/
PART A R960
CERTIFICATION MAY 3 p 1997 ,
Property Address: 64 Zeno Crocker Rd.Centerville Address of owner: MWOF_H ,
Date of Inspection:5126197 (If different) AIJOEP7. N
Name of Inspector:JohnGracl Mazerolle:9 Windsor Way Wes
Company Name,Address and Telephone Number: S
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper,function and
maintenance of on-site sewage disposal systems. The system:
_ Passes This Inspection is based on criteria defined In Title V
Conditionally Passes code 310 CIVIR 15.303.My findings are of how the system is
performing at the time of the Inspection.My inspection does
_ Needs Further valuation By the Local Approving Authority not Imply any warranty or guarantee of the longevity of the
X Fails septic system and any of its components useful life.
Inspector's Signature: �(i4
Date: 5127197
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspections. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit
the report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
Check A, B,C,or D:
A] SYSTEM PASSES:
_I have not found any information which indicates that the system violates any of the failure criteria
defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below.
B] SYSTEM CONDITIONALLY PASSES:
_One or more system components need to be replaced or repaired. The system,upon completion
of the replacement or repair,passes inspection.
Indicate yes,no,or not determined(Y, N,or ND). Describe basis of determination in all instances. If "not determined", explain why not.)
_ The septic tank is metal, cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is
imminent. The system will pass Inspection if the existing septic tank is replaced with a conforming septic tank as approved
by the Board of Health.
(revised 11115195)
One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 9 Telephone(617)292-5500
1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 54 Zeno Crocker Rd.Centerville
Owner: Mazerolle:8 Windsor Way Westford Ma.
Date of Inspection:5126197
_ Sewage backup or breakout or high static water level observed in the distribution box is due to a broken,
settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
_The system required pumping more than four times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the
system is failing to protect the public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS
NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER, IF APPROPRIATE)DETERMINES
THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
_ The system has a septic tank and soil absorption system and is within 100 feet to a
surface of water supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and is within a Zone 1 of a public water
supply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water
supply well.
_ The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private
water supply well,unless a well water analysis for coliform bacteria volatile organic compounds indicates that the well is
free from pollution for that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm.
3) OTHER
D] SYSTEM FAILS:
_ I have determined that the system violates one or more of the following failure criteria as defined in
310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be
contacted to determine what will be necessary to correct the failure.
Backup of sewage in facility or system component due to an overloaded or clogged SAS or
cesspool.
_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged
cesspool.
SAS is in hydraulic failure.
(revised 11115195)
2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 54 Zeno Crocker Rd.Centerville
Owner: Mazerolle:8 Windsor Way Westford Ma.
Date of Inspection:5126197
D] SYSTEM FAILS(continued)
_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
_ Liquid depth in cesspool is less than 6°below invert or available volume is less than 1/2 day flow.
_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Numbers of times pumped
_ Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or.tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone 1 of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
_ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area (IWPA)or a mapped Zone II of a
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further Information.
(revised 11115195)
3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECLIST
Property Address: 54 Zeno Crocker Rd.Centerville
Owner: Mazerolle:9 Windsor Way Westford Me.
Date of Inspection:5126197
Check if the following have been done:
x Pumping information was requested of the owner,occupant, and Board of Health.
X None of the system components have been pumped for at least two weeks and the and the system has been receiving normal
flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
inspection.
Na As built plans have been obtained and examined. Note if they are not available with N/A.
X The facility or dwelling was inspected for signs of sewage back-up.
X The system does not receive non-sanitary or industrial waste flow.
X The site was inspected for signs of breakout.
X All system components,excluding the Soil Absorption System,have been located on the site.
X The septic tank manholes were uncovered,opened, and the interior of the septic tank was Inspected
for condition of baffles or tees,material of construction,dimensions,depth of liquid, depth of sludge, depth of scum.
X The size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 11115195)
4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 54 Zeno Crocker Rd.Centerville
Owner: Mazerolle:8 Windsor Way Westford Ma.
Date of Inspection:5120197
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 330 gallons
Number of bedrooms: 3
Number of current residents: 5
Garbage grinder(yes or no): No
Laundry connected to system(yes or no): Yes
Seasonal use(yes or no): No
Water meter readings,if available: n1a
Last date of occupancy: n1a
COMMERCIAL/INDUSTRIAL:
Type of establishment: n1a
Design flow:ll gallons/day
Grease trap present:(yes or no) No
Industrial Waste Holding Tank present:(yes or no) No
Non-sanitary waste discharged to the Title 5 system:(yes or no) No
Water meter readings,if available: n1a
'Last date of occupancy: rda
OTHER:(Describe) Na
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System has not been pumped In the last two years.
System pumped as part of inspection: (yes or no)No
If yes,volume pumped: o gallons
Reason for pumping: n1a
TYPE OF SYSTEM
x Septic tank/distribution box/soil absorptions system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) ( if yes,attach previous inspection records,if any)
Other(explain)
APPROXIMATE AGE of all components,date installed(if known)and source information:
198s
Sewage odors detected when arriving at the site: (yes or no) No
(revised 11115195)
5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 54 Zeno Crocker Rd.Centerville
Owner: Mazerolle:8 Windsor Way Westford Ms.
Date of Inspection:5126197
SEPTIC TANK: X
(locate on site plan)
Depth below grade: V
Material of construction:X concreate_metal_FRP_other(explain)
Dimensions: L 8'8'H 5'7"W 4'10-
Sludge depth:5'
Distance from top of sludge to bottom of outlet tee or baffle: 22'
Scum thickness:1'
Distance from top of scum to top of outlet tee or baffle:6'
Distance form bottom of scum to bottom of outlet tee or baffle: e'
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,
evidence of leakage,etc.)
Septic tank and all components are structurally sound.Recommend pumping system every year for maintenance.
GREASE TRAP:
(locate on site plan)
Depth below grade: n1a
Material of construction: _concrete_metal_FRP_other(explain)
Dimensions: nfa
Scum thickness:n1a
Distance from top of scum to top of outlet tee or baffle:nla
Distance from bottom of scum to bottom of outlet tee or baffle: n1a
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,
evidence of leakage,etc.)
n1a
(revised 11115195)
8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 54 Zeno Crocker Rd.Centerville
Owner: Mazerolle:8 Windsor Way Westford Ma.
Date of Inspection:5126197
TIGHT OR HOLDING TANK:
(locate on site plan)
Depth below grade: Na
Material of construction:_concrete_metal_FRP_other(explain)
Dimensions: n1a
Capacity: n1a gallons
Design flow: n1a gallons/day
Alarm level: Na
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
n1a
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert: n1a
Comments:
(note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box etc.)
Na
PUMP CHAMBER:
(locate on site plan)
Pumps in working order:(yes or no)
Comments:
(note condition of pump chamber,condition of pumps and appurtenances,etc.)
Na
(revised 11115195)
I 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 54 Zeno Crocker Rd.Centerville
Owner: Mazerolle:8 Windsor Way Westford Ma
Date of Inspection:5126197
SOIL ABSORPTION SYSTEM (SAS):x
(locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods)
If not determined to be present,explain:
n1a
Type:
leaching pits,number: 1,o00 gallon leach ptt
leaching chambers,number:nfa
leaching galleries,number: nfa
leaching trenches,number,length: nfa
leaching fields,number,dimensions:nfa
overflow cesspool,number:nfa
Comments:(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
The leach ptt is past the effective depth of leaching The sas Is in hydraulic failure.The pit was full.
CESSPOOLS:
(locate on site plan)
Number and configuration: nfa
Depth-top of liquid to inlet invert: nfa
Depth of solids layer: nfa
Depth of scum layer: nfa
Dimensions of cesspool: nfa
Materials of construction: nfa
Indication of groundwater: nfa
inflow(cesspool must be pumped as part of inspection)
nla
Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.)
nfa
PRIVY:
(locate on site plan)
Materials of construction: nfa Dimensions: nfa
Depth of solids: nfa
Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
nfa
(revised 11115195)
8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 54 Zeno Crocker Rd.Centerville
Owner: Mazerolle:8 Windsor Way Westford Ma.
Date of Inspection:5126197
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
IA rc l G a �
ask
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DEPTH TO GROUNDWATER
Depth to groundwater:12 feet
method of determination or approximation:
USGS Maps and Charts
(revised 11115195)
9
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 134 Cap'n Lijah's Rd.Centerville
Owner: Robert Elliot
Date of Inspection:5126197
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
4 v 1 0
A B
A9 4°�
As
gA
BB N6�
DEPTH TO GROUNDWATER
Depth to groundwater:12 feet
method of determination or approximation:
USGS Maps and Charts
(revised 11115195)
9
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ASSESSOR'S MAP•N0 A CEL
LOCATION SLfS SWAGE PERMIT N0.
VILLLAG-E �t ►
log
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-INST A LLER'S NAME a ADDRESS
U I L D E R OR OWNER
DATE PERMIT 1SSUEV- � 1C L
DATE COMPLIANCE 15SUED
wo- -rimy
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
w. ...............OF..... * L� k .l._ '_/
Appl nithin for Bhipasal Works Tanotrudiun Permit
Application is hereby made for a Permit to Construct ") or Repair ( ). an Individual Sewage Disposal
System at:
- ((( ��` ��
................_-I ::. .... .... .o..ca?-f. ... : �1 ....................
oc
......................
.:.1..! ation:A es.. ....
......
l. Co Lot No«........................«....«.«...
a .................. ... ........ .... Owner ......— ... .. ._ Address —............ ................
Installer .-••---..
Address
Type of Building Size Lot._ _-1 r11_. ._ Sq. feet
4 Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbdge Grinder,(YP
aOther—Type of Building .........:.................. No. of persons............................ Showers ( ) — Cafeteria�( )
d Other �xtes .... {Jf� tF�+�{ ............. .............................Design Flow........... . ....... _. .. gallons peL.�e�eerr r day. Total d�il ow......... �„� .............. lons k
W Septic-Tank—Liquid ca actt ._ lions Len h Width:_.. . Diameter:._ D th.. _ ..
P. q P y.I= T � ..... .._. ep ).0..
x Disposal Trench—No. .................... Width................... Total Length.............. Total leaching area -_.__ .... ..sq. ft.
3 Seepage Pit No......k-...._._.... Diameter....... ........... Depth below inlet...........____ Total leaching area. �.r.-sq. ft.
Z 'Other Distribution box Dos' )
.." r•.. y. J�,� Date.....L.
Percolation Test Result erformed.b �. _
Test Pit No. 1... nutes per inch Depth of Test Pit.. . ... Depth to ground wa er... .. � �
44 Test Pit No. 2................minutes per i h Depth of Test Pit.................... Depth to ground water.. .....................
1� •�
Description of Soil...... l.:�TT. •-- -•- C � b!u�ii_•_Ly1 / .�
.............................•--••-----.............-----•------••--------•-----------....--------••--------.......------......------.....-•---••---......-----....._............................_......
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
______----•--••-•--------•-- --•-•-••• ...............
Agreement: �jWy.
The ttndersiignagrees to install the aforeddescritfd Individual ewa a Disposal
g p System to accordance with
the provisions of TI':L; 5 of the State Sanitary Co ' h under • ne f ther agrees not to lace the system in
operation until a e titi Com a has bee is e b th rd ealth.
Signed...... ........ ..... . ... ... -•-•...-•••••-•.................. .....��J.. .�_'....
Application Approved By.. �...(.,, ..... ...................:.........
..___....._�.._./-..ate..............
Date
Application Disapproved for the following reasons:................................................................................................................
---------•......................•-------...................................................___-.----.........:...........---........ ._...----_____•_-......._..._..._....--•--•----..-_-_..........._
Date
Permit No.......� --•-----•_ ssued......_••-- ......--•--••••••-
--•• .
-
''r,..�.� I Issued. ........ ......
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...........................................OF.... J—P! ),P...................
..... ..................
Tprtifiratp of Toutpliana
THIS IS-TO CERTIFY, That the.Andividual Sewage Disposal System constructed (C-)-bir Repaired
by............ ...... tz����....... ...........................................
I Installer
y �-
za d,,)eQ el,�i 4, 7--
at............... ...... ....... .........................--------------t=T ...... ..........................
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as descriped in the
application for Disposal Works Construction Permit No.....:7 . ...-...1'4-11.... ................... dated..........v�A.tj(2.../.6
.... ..........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL TUNCTION SATISFACTORY. I
� /--, I \?r"-, f, -1
DATE.......................................... Inspector..... .A,............
-----17....................... ���...........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF
9 —HEALTH- (V
.......................................... /0!Pfi... ..P ..............
No....
FEE....
Disposal., Works Tonatrudivit frrutit
4 1<�- c--ex,;;
Permission is hereby granted..... 0&:- - I...... ........................................................................................
to Construct (4,)-'or Repair an Individual-S. ...
Sewage Disposal System,/
at No.....................'A 774" —V-P4—
.......7..........=��' .................. ...i�r'eet----------------------.................�=-- ................................
as shown on the application for Disposal Works Construction Permit No..�.� Dated......
...........
.......................................................ww� . .......................................
DATE..................f..2 h-d 9S Board of Health
...................................
No Y: -12 20
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...................O F............-................._..... ..........--.------......---.........._...........
Appliratinn fur Disposal lVorks TonstrWiun Vrrutit
Application is hereby madelfor a Permit to CoristructN(k),or�Repair ( ) an Individual Sewage Disposal
System at: �. �, `. 'r.� 1. a�' ?®cZ` yt t)` 1 n1
Location Address ; //`�It rA t No. �� .....
pOwner l� •� •�,r-^^---' Address ....................»........
!�_"1'i(Z mac^! a A r !n11�- ...................................... .
Y � Installer �
� Address {{ --� •.��
Type of Building 1 .1* 1 1
YP g Size Lot.-.,....1.. .,,....Sq. feet
jV Dwelling No. of Bedrooms..........::=.. ....:Ex Expansion Attic
g— , ,. ----�---�-•-•---•--- �P . ( ) Garbage Grinder
Other—Type of Buildin
p, yp.a r g ......-•----------.�_..`__. No. of persons........................... Showers ( ) — Cafeteria ( )
a Other...fixtures................................UA:.e ate Air .A
Q
W Design Flow...:......�.10 ._ ...............gallons pe�person•Jper day. 'Total daily tflow..........>, `4 ...............gallons y
WSeptic Tank—Liquid capacity j�, �dlonsr Length9! .:` Width. Diameter................ Depth p:.1_O..
x Disposal Trench-No............. ...... Width.f�........_ Total Length......... t ...Total leaching area.........-:.........sq. ft.
Seepage Pit No: '_:.._� .'. Diameter Depth below inlet...... �* .... Total leaching area. ...._.sq. ft.
3 eP� -- . P
Other Distribution box ( � l Dosing tank ()
Percolation ` ''Test'Results Performed by...`...fR._�"�1. �,m._ ............ Date....��..
� Test P # *.....� lr y •-•-----....---•-----..
Pit No. 1...nr.— mmutes-per Inch Depth of Test Pit-J ..._. Depth to ground water...( E
G4 Test Pit No. 2................minutes pe n h Depth of Test Pit._.........�._..... Depth to ground water..:---............---.-_
a " r�t y t 1 a
�J .
Description of Soil 11 �`�._: y —-C��� ?-••. ` �.1 f
U .....................•-.....................................•-•----•--•------............•• ---••••-•--- • .........----•---•-•-•........................•--_.... ...............••........
---•-----•-•-----•---------•-----•-•..•---•.._..-----••-------------------•••--•-----•.................----•-•------------•••-:.......---•----.....................----........................-•-•••--
U Nature of Repairs or Alterations—Answer when applicable................-.. ..x___.._..........__....._..__..._...._...........__....:............. '
Agreement:
'a�� -" .........................................................' ---•----------•-•--- ....---•----•-•--...--•-•.........................
The undersigned agrees to install the-afore_described Individual ,Sewage Disposal System in accordance with
P Y
the provisions of TITL; 5 of the State Sanitary Code`: Th"undersigned further agrees not to place the system in
operation until a Certificat,f�Compliance has been iss edAby he-boaid,of�iealth.
Signed... �� Ay7
�' ..C7. v
f 1 i /Dae Application Approved B _.. .:.�!?.
Date
Application Disapproved for the following reasons:..............................................................................................................
---......•......................••------.............................................----...........-....._..---.-------------•---......--•------........-----.........--••••......•-•................._
DatePermit No...... �'>..: �?�� (-------------. Issued-----•---------.............-----......._. ......
Date
.t P16
SECTION - SEWAGE ! V "A�k
!� —SEPTIC TANK— rj _ ..p,.BOX — �I — LEACH. f
TOP OF FDN 1 �/, C�' , l
^/� �y� j/ � O
-✓_6�!t{IJ.IIMSL)i► � ••2•1 OF 1/8T0 Vi"
' WASHED STONE
+
IN• / OUT• 0
` IN- OUT-
SEPTIC
6f,701 TANK 52t 171 Sl i 1
ELEV. ELEV. ELEV. ELEV. \fit
52, 07
ELEV. ELEV. 1 �i I 52
! OF i4^
-18z" 1
WA�SHEDSTONtr \K �1! /. 7 2-2
TEST HOLE LOGS.
c c>tl L o�l 3
TEST BY
T DATE (� :? WITNESS
TES BEDROOM HOUSE
DESIGN
T.H: Ir1 T.H. s2 ZUi ' Z (
ELEV. ELEV.
NO
LD 5116 I PERC RATE MIN/IN.
'I G2 DISPOSER DISPOSE Z f /
S FLOWN RATE (GAL.IPAY)
G 17 SEPTIC TANK
RECI'D-SEPTIC TANK SIZE
LEACH 'FACILITY �- 5
SIDE WALL =/SD,�j (2 S) �77, .G/D. LOT , (o 3(o I
LoT- - ;
BOTTOM �3Z) TT^'��3 Z3
144 �'f I TOTAL . ZO/I ( SF
, r
of
• USE: LEACHING '�'/T �,' ✓�,.
WATER ENCOUNTERED
i tv
NES� (UNLESS OTHERWISE NOTED) f �?
ZONING
OT
=- D_AM l TylutSlJ�-_TAKEN FR�O�MJ if/l G�- 'QUADRANGLE MAP - : r F ICU N T - -20/ t_
2.MUNICIPAL WATER �'T oVAIUABL'E ----- OF _
PITCH:-11�!!P_ER.FOOZ-----=- .;-
4:DESIGN LOADING FOR ALL PRE-CAST.UNITS.AASHO- -44
S.MIN..GAOUNO COVER OVER ALL SEWAGE FACILITIES:(1)FT. -
6.PIPE-JOINTS SHALL BE MADE WATERTIGHT___. _ - -- _� f R:�H-R
/a.
7.CONSTRUCTION DETAILS TO BE ACCORDANCE WITH COMM..OF MASS.
STATE ENVIRONMENTAL CODE TITLES
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r
SECTION - SEWAGE e��' c M
141 -SEPTIC TANK- _..D.,BOX - ��- I -LEACH. �I-r
TOP O//F��FD��Nyy�� 1 �/ �� EL�CtI• }�, C
IMSL')'v ••2••OF'IS TO th"
WASHED STONE
IF
Op
IN- OUT.
OUT• .. INS .
JL.70' ✓ SEF
TAN K G 52t 17 t S l r�O
ELEV. ELEV. ELEV. ( ELEV. �1 \
ELEV. ELEV.
W/uOF'N••-13h"
HEO STONE
,0 7-T l of -T4_� 40 T 3
TEST HOLE LOG S
a
TESTBY
WITNESS
TEST DATE . �O 2� .� DESIGN ' . BEDROOM HOUSE �; -�� L U T 2- 1
T.H: • 1 T.H. +� 2
--bC ELEV.53,E ELEV. 2 0 �.. il ': h¢)
II G.Z DISPOSER -DISPOSE - .. '
�. LOAMSLit3 PERC'RATE MIWIN. o $' r'�
S I, FLOW RATE.�3c�(GAL✓PAY) 330
G p SEPTIC TANK 33c�' (14- S
t� REQ'D SEPTIC TANK SIZE
ck I ;: �� /
G ,& L, LEACH FACILITY. f O�
/SD,�j &2,61 _ -3'77r 52 .G/D. � L U
SIDE WALL/�/
Lo -
80TTOM =��) Tr=�r3 ILO1 �.3 GID. T. Z3
TOTAL ZOI� � 5F g27r �fp ±; h,'�o5r �51 �a GUTZ
o _
USE: -LEACHING LEACHING T O,i>,
WATER ENCOUNTERED
,
NOTES:• (UNLESS OTHERWISE NOTED) -ZONING
r
1.-DATUM_(MSL)+-TAKEN FROM G OVADRANGLE MAP a F R O N T -.o l ,:. . .
AVAILABLE* - - --- . .
2.MUNICIPAL WATER _
3,:FIPEPITCH:-SI:'PER_FOOT __ .
•4.DESIGN LOADING FOR ALL PRECAST:.UNITS:..AASHO• -' .44 —
ARNE H.. -
• S.MIN-GROUND COVER OVERALL SEWAGE FACILITIES:(1)FT.. - "- � , � � ,,,, Gt p '•� {�:R /Q� . . ,,,., -" _ -
6:PIPE JOINTS SHALL BE MADE WATERTIGHT U. •�A _.
-- -- c�
R�
7:CONSTRUCTION DETAILS TO BE ACCORDANCE WITH COMM OF MASS: - - - -
- --_ SITE PLAN
STATE ENVIRONMENTAL CODE TITLE 5 '..__ _,r �.. :^- of -- ._ w,
:Pt�H ------ - - L-b Z-3 ZLG/V 0._.�,,-�I',A,.-r •�,::..�.
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REG.PROFESf _. ENGINEER c
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