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HomeMy WebLinkAbout0869 PHINNEY'S LANE - Health E= 2 NEY'S LANE, CENTERVILLE 47 �JaRECVCIFdCp2m - lIII � ? UPC 12534 � No.2_153LOR � � HASTINGS, MN Town of Barnstable Inspectional Services Department 6ARN5CABL£. Public Health Division KAM 9�a 1639. � 200 Main Street, Hyannis MA 02601 rF4 MAC A Office: 508-862-4644 FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL#7021 0350 0000 1549 4171 September 17, 2021 MOYNIHAN, LAWRENCE J & JUDY A 869 PHINNEYS LANE -- CENTERVILLE, MA 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 869 Phinney's Lane, Centerville, MA was inspected on 09/06/2021 by Michael Sears, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system"Fails" under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: • Static liquid level in the distribution box is above the outlet invert due to an overloaded or clogged SAS or cesspool. You are ordered to repair or replace the septic system within one (1)year from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. You may be eligible for a waiver from replacing an`onsite sewage disposal system if your property will be connected to public sewer in the near future. You may seek an extension to the one (1) year deadline for a total of two (2) years, as Town Sewer may be available at this address in a year in a half. You would have to connect within six (6) months of Town Sewer becoming available, and there will be no extensions for new septic systems. For information regarding public sewer availability at your property, please go to https://www.townofbarnstable.us/Departments/Assessin /g Property Values/Property- Look-Up.asp or telephone the DPW Administration Office at(508) 790-6400. Any written request for a waiver or extension must be filed in writing to the Board of Health, 200 Main Street, Hyannis MA, 02601 ER OF THE OARD OF HEALTH as ean, HO, Agent of the Board of Health Q:\SEPTIC\Title V Inspection Report Letters Mailing\Failed or Needs Further Evaluation Letters\869 Phinneys Lane Centerville.doc 1.6. ..«{ r0 :MPLIETfF THIS SECTIOIT::': COMPLETE THIS SECTION ON DELIVERY $ : ■ Complete items 1, ,irfid A. Signature ❑Agent ■ Print your name ari ddrss on the reverse X so that we can retu -the card to you. El Addressee ■ Attach this card to the back of the mailpiece, B. Received by(Printed Name) C. Date of Delivery I or on the front if space permits. - "dress different from item 1? ❑Yes delivery address below: ❑No MOYNIHAN, LAWRENCE J& JUDY A 869 PHINNEYS LANE ENTERVILLE, MA 02632 II I IIIIII IIII III I II II I I II I I IIII I I I I I IIII II I III 1 sulSignature Type ❑Priority Mail Express® ❑Adult [I Registered MailrM dult Signature Restricted Delivery ❑R istered Mail Restricted: Certified Mail® is' 9590 9402 6702 1060 1008 23 ❑Certified Mail Restricted Delivery nature Confirmationm ❑Collect on Delivery ❑Signature Confirmation 2. Article Number(Transfer from service labeh_- ❑Collect on Delivery Restricted Delivery Restricted Delivery , ail 7021 0350 0000 1549 4171 'ail Restricted Delivery PS Form 38 053 Domestic Return Receipt 11,July 2020 PSN 7530 02-000 9 i:1 5E f I 7 p �Ygt5lff.7�9+�1871�'I�t9���t1�1��114��(�I�1I.8��.f1l �itPFF� .14�t� �§ I �"�.��''.,6z 9z— SVLL9_699-rV sezee re9ze ::)s :)Nn lLE ki QJ- 01 3 12VNF1 -1:3NR I. e.r w.a-vg. - %: y.i r y%,iH. V AUX W f H3N9"V-I `NVj-fjNAOW � c N� L ZOZ 'OZ 'd3S£b L U'C0000 }- t 2L2fi 6hS'L 0000 OSEO 'C20L ��+E�+ M6 ZO p it it 1�0 L 09ZO dIZ i�r'Z'0z,.cU -oz 09ZO VW SIaUEAH 1asnS areY OOZ " . ®e 0 y t 0 DJ =DN9G i�c'�C� uoTSIAKI gaiea or H [qT►d o S3MO8 A3N1ld<<3E)t;iS0d'S'(1 . alq�su zeU jo uAos . . t .� � _ _ _ r �. F � , � ,�. + �' ! ���t. �t. h �. —.-_ !-�.,,. �t -- ��^-6 `-1... c — --- � . ._.�_, _�,-.. �e_ .dW-���. _.__,.. . _w__ _ _— � _ , � �. TOWN OF BARNSTABLE LOCATION Uaq SEWAGE # 0 VILLAGE l_eowj 'I-Q, . ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY i 1000 Ci Gild) n LEACHING FACILITY: (type) 81"la) (size) NO. OF BEDROOMS —> M BUILDER OR OWNER �\' C �C'n-\" PERMTTDATE: 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 �e L 0o A iA A ��� Ag ` t 6A y9 LQ-CATI&N a SEWAGE PERMIT NO. VILLAGE ol INSTA LS�NA & ADDRESS l. B U It DE R OR OW N ERe DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED© 9 LO LOCH ION SEWA GE PERMIT NO. /f V L L A G E INSTA LLER'S NA i ADDRESS UL Atnal�c 3 UILDE R OR OWNER DATE PERMIT IS ED �lY DATE COMPLIANCE ISSUED a �r r TOWN OF BARNSTABLE r 1 LOCATION 'f G :RL�C�CZ ` +.f a SEWAGE # VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE +NO. SEPTIC TANK CAPACITY i y LEACHING FACILITY: (type) _ \, Ot t-Jjc o, (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: 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 1.6 SkelL M R A b 'fit 0 6A �3 ti �. ... . Commonwealth of Massachusetts - Executive Office of Environmental Affairs - John Grad - __ D.E.P. Title V Septic Inspector - Department of - P.O. -Box 2119 - .Environmental Protection Teaticket, MA 02536 William F.weld -(508) 564-6813 G"Mor - _ Trudy Coxe _- - 8ecntary,EOEA - ---- David B.Struhs- - Commissioner - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A � 1 e�CERTIFICATION -6uci "r`��4151�' ,s �• C-211'1 of Owner: Property Address: - `\ Date of Inspection: (If different) Name of Inspector: - Company Name, Address and Telephone Number: 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 experien r function and maintenance of on-site sewage disposal systems. The system: d� Conditionally Passes O ��pr a Needs Further Evaluation By the Local Approving Authority to -N V Fails a � S' •ae Inspector's Signature: It Date: � N The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty 30;day of co pet n his inspection If the system is a shared system or has a design floe of 10,000 gpd or greater, the inspector and th.e � tf,;H " shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to me \stem owner anti copte� sen; to the diner, if appiicatile and the appro.ing au',onty. i INSPECTION SUA"+ARY: Af B, C, or D: Chec AJ SYSTEM PASSES: shave not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. BJ 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 8/15/95) 1 One VAnter Street • Boston,Massachusetts 02108 Is FAX(617)656.1049 • Telephone(617)M-UM 0 Pnnied on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM _ PART A CERTIFICATION (continued) - - - Property Address: Owner:. Date of Inspection: e) SYSTEM CONDITIONALLY PASSES (continued) - _ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): - broken pipe(s) are replaced obstruction is removed LL distribution box.is-levelled 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 15 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 priv� 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 E'\VlRON�tENT: Ine sten, nd� a �eUUC tank aflu -sun dUDorpUon sysien. and Is it �vv fcci :G d iu�aCc '.'.c:C." i�f,r i.' v� .�� a:c- surface water supply. The s�ste ha, a septic tank and soil absorption system and is within a Zone I 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 s>stem has a sep:ic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is- free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. D] SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or dogged 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. (revised 8/15/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A. - CERTIFICATION (continued) Property Address: _ Owner: Date of Inspection: _ 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). Number 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 I 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 above: The design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safet% 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 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 8/15/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM -. PART B - __ CHECKLIST - - Property Address: Owner: - Date of Inspection:_� (qS Check if the following have been done: _Pumping information was requested of the owner, occupant, and Board of Health. G_<one of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. L--�As built plans have been obtained and examined. Note if they are not available with N/A. L—Tfie facility or dwelling was inspected for signs of sewage back-up. L The system does not receive non-sanitary or industrial waste flow l-,;Fhe site was inspected for signs of breakout. L.*H system components, excluding the Soil Absorption System, have been located on the site. Lthe 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. L.Ihe size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods L.r ` a;,,. i, 4 n ,,,n,.,ic r dif;P.A­ ire- o"nP-' were orovided with information on the proper maintenance of Sub- Surface Disposal System. (revised 8/15/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Q ; Property Address: Owner: Date of Inspection: N C 5 __ I _ - FLOW CONDITIONS RESIDENTIAL: Design flow: 3 3o stalons _ Number of bedrooms: _ Number of current residents: Garbage grinder (yes or no): n� Laundry connected to system (yes or no): lam. Seasonal use (yes or no):� - - Water-meter.readings, if available: Last date of occupancy: COMMERCIAUINDUSTRIAL: Type of establishment: Design flow: gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING orrORDS and source of information: System pumped as part of inspection: (yes or no If yes, %,ctTTK'& pumped gallons Reason for pumping: TYPE OF SY TEM 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) Other (explain) APPROXkMATE AGE of all components, date installed (if known) and source of information: __ ���� �C� \(�• 1Ct"fig Sewage odors detected when arriving at the site: (yes or no) (revised 8/15/95) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C r, SMEM INFORMATION (_continued) Property Address: lJ Owner: Date of Inspection: SEPTIC TANK:_✓ - (locate on site plan) Depth below grader Material of construction: <6-n-crete _metal _FRP —Other(explain) Dimensions: 1, R'h`t 1A 1-1 t l0`t _ Sludge depth: `t Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: C) - t� Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: C� Comments: (recommendation for pumping, condition f inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) vC,AD 2- KfJtk"N cir c. 2 2 CLCf fi(. (\L GREASE TRAP:\ (locate on site plant Depth belov`, grade: Material of construction: _concrete _metal _FRP _other(explain) Dimensions: Scum thlckne_,. Distance from top of scum to top of outlet tee or baffle: distance from botto— /" —i—i t, hnttorn of outie! tee or baffle: Comments: (recommendajjpg�-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.j (revised 8/;5/95) 6 ,7 — a., SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C. -SYSTEM INFORMATION (continued) - Property Address: �� ��N���S Owner. Date of Inspection: TIGHT OR HOLDING-TANI - — _ (locate on-site plan) Depth below grade. Material of construction: concrete _metal _FRP —Other(explain) - Dimensions: Capacity: eallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:i_i' ;locate on site plans Depth of liquid level above outlet invert: Comments: incite If le et and dutriuuuu;. cUuai. l'��uc�l�c �O�ii:_ �c:�.,l(c�, c`. C:c:��c I2dnaF,2 I.1,0 0' out Ot DcX ': e 2JEF s CoEks, AEiEi, PUMP_CHAMBER:L�-C (locate on site plan) Pumps in working order.(yes or no) Comments: (note condition oFpump chamber, condition of pumps and appurtenances, etc.) (revised 8/15/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C C�, - SYSTEM INFORMATION (continued) - Property Address: C�oC� �snn�' Owner: ��C,�t1 C <'o Lin G „. Date of Inspection: '. 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: i vpe: - leaching pits, number: leaching chambers, number:_ - leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: _. overflow cesspool, number: Co m�nm (note condition of soil, signs of hydraulic fa�ure, level of ponding, conditio�,of vegetation,etc-)- GCn QiT 1 CESSPOOLS: C 'r aocate on site plan) `umbe, and configuration- Depth-top of liquid to inlet invert: Depth of solids laver: Depth of scum layer: Dimensions or cesspool: �,atenals or construction: inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.; PRIVY:;locate an site plan) :Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 8/15/95) 8 �v ?aY . SUBSURFACE_SEWAGE DISPOSAL SYSTEM INSPECTION FORM _ PART C-... — h— SYSTEM INFORMATION (continued) Property Address Owner: ar(�oc _ Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: _- include ties to at least two permanent references landmarks or benchmarks _ locate all wells within 100' c Ge4 (r DEPTH TO GROUNDWATER Depth to groundwater: feet method of determination or approximation: k)e�G.S (revised 8/15/95) 9 L ' LO-C AT ION SEWAGE PERMIT NO. VILLAGE INST�A„LLER'S NAB E & ADDRESS eJ B U I'L D E R OR OWN ER, D A T E PERMIT ISSUED - - � 5 DAT E COMPLIANCE ISSUED p c10 `i G U LOCA ION SEWAGE PERMIT 'NO. V LLAGE INSTA LLER'S NAMI R ADDRESS 8 U I L D E R OR OWNER DATE PERMIT IS E D DATE COMPLIANCE ISSUED �� --3 � � - -+ ����~_ �: ��' ' .,� ... �' �� • � � .. i� �,� S� No................ Fxs..�7. ................ THE COMMONWEALTH OF MASSACHUSETTS BOAR® OE HEALTH .-._..-. . *f-W. .....------.....OF...... rt�`x � .......................................... Appliration for Bi_qpnia1 Works Cnnnitrurthut Prrutit Application is hereby made for a Permit to, Construct (X) or Repair ( ) an Individual Sewage Disposal System at: ........................... R,B(/ c� C� ... _ rf E�.._..._..._.._.... .� I__......__..............._..._......__._._...__.._...... Loc lion-Address a or Lot No. ............. x?enko:i.61 ... ........... .. O ner Ad res a ............*Al is ....... ........................................ ............ !5.--------........._._..-----.........._... Installer Address 14 Type of Building, Size Lot....,6, .....Sq. feet' U Dwelling No. of Bedrooms-__-_..ji l..�........................Expansion Attic ( ) Garbage Grinder ( ) P4 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) P4Other fixtures .-----------•----•-----•-------. ------------•-••-------------------- W Design Flow..............................�__% ____gallons per person per day. Total daily flow.................. .� ?_........__._gallons. WSeptic Tank—Liquid capacityij�✓_gallons Length................ Width-----------_--- Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area_._._..____.._______sq. ft. Seepage Pit No..l�_gvnr-.___. Diameter...... ......... Depth below inlet..... ........... Total leaching area..................sq. ft. Z Other Distribution box ( Dosing t,,ik '~ Percolation Test Results Performed by__...._IR!___ c ._-.._ � ______________ Date....,c_�� ...7 '......... I Test Pit No. 1 ......minutes per inch Depth of Test Pit____________________ Depth to ground water.................... Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water----------------:;,_'_ .................. ...................................................._......_.._.._.----.---__.._................................ __....._..-----•I--•-_-- O Description of Soil. - ._ _ _���� �ir,�.� i� - � ..... -P F'het'R=�...� ------------------------ ----------------------------------•---------------•--------------------•--•-•-------•-----------•-------•••-•-----.....-•-•-----•---•---------------••---••------•---•................................. VNature 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 iITi iE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has }fin issued by-the board ofhealth. Sig ed.�. 9or � '7� � j y_ ........ ..................._.._...___ l.___.......�'. Date Application Approved By-- Date Application Disapproved for the following reasons:.... ----------------••----••--------------•------•---------------------------•----•-•-••-----_----- i ---•-----•--......---•------••---------------•-----•--------.......--•---•-••----•--.._......---•----------••------------------•-•-------•------....-----------•--------•---- ---------------------•--- Date 7 PermitNo--------------------------------------------------------- Issued.-- . ---- �_ I Date No......... ....... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH � . lc.ay. l..................oF...... �r,rrsrs" .................................. Appliration for Di"ag al Works Tonstrur#iuu ramit Application is hereby made for a Permit to Construct X) or Repair ( ) an Individual Sewage Disposal System at: ............. ......... -------------- ..... ............ :-- ---- ----------------.--_----- . -------. ----- Locati5n-Address +` or Lot No. .. ........... l r to*.x ki-i....--....-•............................................ Owner ` C � yAcLdr/es a ry` �''°="-= ---••-•X �•�i -' .............. - ,f +[7'- +�,v 4 e'$�'=T'S` ��,Fd ei ' .......................................... .._ lh Installer Address UType of Buildin,g`` Size Lot....4,-d! .....Sq. feet Dwelling- o. of Bedrooms.__.'" �:�'�________________________Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) A4 Other fixtures ---------------------------------------•-•......•..... W Design Flow.............................!�.&7......gallons per person per day. Total daily flow.................• T40.............gallons. WSeptic Tank—Liquid capacityrx4-9>:.gallons Length................ Width................ Diameter--------------... Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching ar sq. ft. See a e`Pit No..I. - p g i�' _.__.. Diameter______ __________ Depth below inlet___..'`._..._..... Total leaching a sq. ft. Z Othe%r Distribution box Dosing to '-' Percolation_Test Results ,`''-Performed by...... _ _°"'..4f `......_....., Date.....1 I.`!jG� �'• Test Pit No. 1~'._ ......minutes per inch Depth o Test Pit.................... Depth to ground atex.:...................... �Tq Test P:it No. 2.........`-....minutes per inch Depth of Test Pit.................... Depth to gro. n� water........................ •• ---- •--• -•---- -•--•-._......•--• •-- .. --•--........ D Description of Soil. rh(f� � � / � u� � �` /wg' + ,�' --------- ......................................................................................................................................................................................................... V Nature of Repairs or Alterations—Answer when applicable. 6= ................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in. accordance with the provisions of TITI.;,,. 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has J�ge�n� issued by the board of:health. J11 /,w a-- - (+ �j ign d�' A��J 6 r . .. rk!.... .1 r-- �'...- T! Application Approved BY -- • ••. .�•.•... - ;/ -- - •-----. ~-..... ...............� Date Application Disapproved for the;,f ollowing reasons_________________________________________ ............................................-.................................................................................................................................................. Date F,. Permit No----------------------------------- Issued......................................... Date ' n THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............. ......oF..........: .:.. ..... :..... ........................ TrrfifirFatr of ToutpliFaurr THIS 60�t R . at the Individual Sewage Disposal System constructed ( ) or Repaired... - ............................. .......... .............................................................. 4rnstall has been installed in ac o dance with the p:if6visions of TI' r' > of The St to Sanitary Co as describe in the application for Disposal Works Construction Permit No... _ _..____ -5 ' •- dated------- ��_...._..... THE'IS'SUANCE OF THIS CERTIFICATE SHALL NOT RE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILLL"FUNCTION SATISFACTORY. P a DATE------i �._.__ __ 7 ........................................ Ins ector-- ............................................ �M1 THE COMMONWEALTH OF MASSACHUSETTS BOARD.-V HEAL �vV •.-� &-W­ 14 r``J7�.oF........................................................•-----.................._.... .3lJ NO.........:... ......... FEE........................ .�k Disposal n1 n rrutit Permissioni reby grant d.....-----•.... ...... ........................... .......................�4....... ...... to Constrict or; an Indi % -�4........ vid �> > r !/�VLF �� Street i./ � ' ...... as shown on the application for Disposal Works.Construction 0�o. ated ....._. y Board of Health DATE--------= ..-- FORM 1258 HOBBS & WARREN, INC., PUBLISHERS - - " P.D, Cr I { 1 S;7 a -Z. _ kky 1 SCE 5 ► .a = SO G.ev, TOTAL T?SSIGW = •425 G..Pl=>. le,v ?.�"t"�L 'G.d.{f✓�{ Fuji _ 2^ t-�s-� �, I PSf�GD1.dT10t.1C�"f E : 1��tU �L.ht►►J' 02 Tor i�.� �. crn► 7JJ �/i�/�Tt TlJ7�'C + i vT=i �'.. ♦�.i�.� Q, . wA.y s1��l�rB� ItJV. 'I pp� I oao ►UV.4 5 DIST- s W. i+W. f Box 1¢-G SePnc lOOp `� •� t ToatK L%Ar-N z. zn r PIT f . �.•r. W i rcl '. 1. 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