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Home My WebLink About0021 BETH LANE - Health 21 BETH LANE,HYANNIS A= 272 176 v in I� COMMONWEALTH OF MASSACHUSETTSE ��O EXECUTIVE OFFICE OF ENVIRONMENTAL Ak �� 3 DEPARTMENT OF ENVIRONMENTAL P ECTION � : TOWN OF BARNSTABLE ONE WINTER STREET..BOSTON, MA 02108 617-292-55 Os HEALTH DEPT. V WILLIAM F.WELD TRUDY COaE Governor Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner PART A CERTIFICATION, -21. Beth Ln, H Property Address: yi3.riniS Address of Owner: Cindy Chicoine Date of Inspection: /? - 9 .,. (If different) - Name of Inspector: Wm E.Robinson Sr I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: WM E Robinson Septic Serve -P Mailing Address: PO Box 1089 , Ccnt-Prvi l 1 p MA 02632 Telephone Numbers 5 0 8 7 7 5_8 7 7 b CERTIFICATION STATEMENT E 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 Conditionally Passes F _ Needs Further Evaluation By the Local Approving Authority . Fails Inspector'sSignature: Date: Al�Q— The System Inspector shall,submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the'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: r AI, SYSTEM PASSES: I have 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 no t evaluated are indicated below.COMMENTS: B] 5 STEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. A Indica 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, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is 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 04/25/97) - Page 1 of 10 DEP on the World Wide Web: http:/twww.magnet.state.ma.usldep C.1 Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ., PART A I CERTIFICATION (continued) Property Addreis: 21 Beth Ln, Hyannis Owner: C h iC O ine Date of Inspection: Ib— —� B) STEM 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). Describe observations: broken pipe(s) are replaced obstruction is removed 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] FURTH EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: onditions 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) YSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER HICH 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) SYS EM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENV RONMENT: _ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS 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. Method used to determine distance (approximation not valid). 3) OT ER (revised 04/25/97) Page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address- 21 Beth Ln, Hyannis Owner: C h i c o ine , Date of Inspection: /G D] SYSTEM FAILS: You ust indicate easier "Yes" or "No" as to each of the following: 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. Yes No Backup of sewage into 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 SAS or cesspool: 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 112 day flow. s _ Required pumping more than 4rtimes 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'cesspo6l 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 YSTEM FAILS: You must ndicate either "Yes" or"No" as.to each of.the following: T e following criteria apply to large systems in addition to the criteria above: T e system serves a facility with a design flow of•10,000 gpd or greater (Large System) and the system is a significant threat to blic health and safety and the environment because one or more of the following conditions exist: Yes N 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 own or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program k requiremen of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. I (revised 04/25/97) Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 21 Beth Ln, Hyannis Owner: C h is o ine Date of Inspection: 16 d_9 j Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes i No _ Pumping information was provided by the owner, occupant, or Board of Health. ✓ _ None 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. ✓ _ As built plans have been obtained and examined. Note if they are not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up. _ The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. All system components, excluding the Soil Absorption System, have been located on the site. _ 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. The size and location of the Soil Absorption System on the site has been determined based on: The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. _ Existing information. Ex. Plan at B.O.H. � Determined in the field (if an of the failure criteria related to Part C is at issue, approximation of distance is_ Y unacceptable) [15.302(3)(b)] J (revived 04/2S/97) Page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION t Property Address: 21 Beth Ln, Hyannis Owner: ChiCOine " Date of Inspection: FLOW CONDITIONS RESIDENTIAL Design flow:-yZO g..p.d./bedroom for S.A.S. Number of bedrooms: Number of current residents: Garbage grinder (yes or no):_a 1`800CU ft per qtr (average) Laundry connected to system (yes or no):,Y1y Seasonal use (yes or no): 4-1 .o Water meter readings, if available (last two (2) year usage (gpd): 8/7/96 749 z �x� Sump Pump (yes or no):- ,L 8/1.0/98 889 Last date of occupancy:/b G--5'"F- COM RCIAUINDUSTRIAL: Type of tablishment: Design flo :.gallons/day Grease trap present: (yes or no)_ ; Industrial aste Holding Tank present: (yes or no)_ Non-sanita waste discharged to the Title 5 system: (yes or no)_ Water met r reading s, ifavailable: Last date of occupancy: OTHER: Describe) Last date of occupancy GENERAL INF ORMATION , PUMPING RECORDS and source of information. . . � f L System pumped as part of inspection: (yes or no)�.p,. If yes, volume pumped: gallons Reason for pumping: TYPE OF STEM 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) I/A Technology etc. Copy of up to date contract? Gather APPROXIMATE AGE of all components, date installed (if known) and source of information: ZI/G�`ZLC/ As Sewage odors detected when arriving at the site: (yes or no)�ti0 (revised 04/25/97) Page 5 of 10 SUBSURFACE SEWAGE 'DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 21 Beth Ln, Hyannis Owner: C h i C 0111 Date of Inspection: /G—G-a! BUILDING SEWER: (Locate on site plan) Depth below grade: Material of construction: _cast iron _40 PVC_other (explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK:_ (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How dimensions were determined: Comments: n outlet tees or baffles depth of liquid level in relation to outlet invert (recommendation for pumping, condition •f inlet and •u e p � , structural integrity, evidence of leakage, etc.) GREASE TRAP: (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (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.) (revised 04/25/97) Page 6 of 10 SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 21 Beth Ln, Hyannis Owner: C h is o ine Date of Inspection: /U TIGHT- R HOLDING TANK: (Tank must be'pumped priorto,or at time, of inspection) (locate o site plan) Depth be ow grade: Material f construction: _concrete _metal._Fiberglass _Polyethylene _other(explain) Dimensio s: . Capacity: gallons Design f w: gallons/day Alarm I vel: Alarm in working order_Yes; No Date previous pumping: Comm ts: (conditi n of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: V " (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box;etc.) PUM CHAMBER:. (locate n site plan) Pumps i working order: (Yes or No) Alarms in working order (Yes"or No) Comment (note con ition of pump chamber, condition of pumps and appurtenances, etc.) (revised 04/25/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 21 Beth Ln, Hyannis Owner: Chicoine Date of Inspection: /o`C—5� b 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, number: leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: -2 C G Pr f leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) '� L IYzctiA.c� I�197 �61J �'! 7�—�I. �l of At" l l `� /•t�., �� CESSP OLS: _ (locate site plan) Number a d configuration: Depth-top f liquid to inlet invert: Depth of so ids layer: Depth of scu layer: Dimensions f cesspool: Materials of nstruction: Indication of roundwater: infl w (cesspool must be pumped as part of inspection) Comments: (note condition if soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY:_ (locate on site plan) Materials of constru ion: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 04/25/97) Page 8 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 21 Beth Ln, Hyannis Property Address:Owner. C h 1C O lri2 Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) �� 1l i3 a G l� 17 3 (revised 04/25/97) Page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 21 Beth Ln, Hyannis Owner: C h iC O ine Date of Inspection: 16-4 Depth to Groundwater� Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation. Must be completed) (revised 04/25/97) Page 10 of 10 TOWN OF BARNSTABLE LOf ATION I �-' L> SEWAGE # VILLAGE ASSESSOR'S MAP & LOT 2.7 INSTALLER'S NAME&PHONE NO. ra A,9 a,-- 7 7 4 SEPTIC TANK CAPACITY � LEACHR�Irj FACILITY: (type) (6 k t1 '� J(size) J 6 " NO.OF BEDROOMS 3 BUILDER OR OWNER 0 Ali e ® i e-1 PERMITDATE: /L/'�� rI COMPLIANCE DATE: ��"!�1 Ol7 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 ti _ v f �' - 0 k �"_ � k 1 `` � � � _ �'t' ! � � -cy t '9'' . °° n c � � � � � � � 4 � tt � - I', i � J No. F ` Fee$5 0 . 0 0 THE COMM WE TH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - O N OF BARNSTABLE., MASSACHUSETTS ZippYicatiou for Digpo r *paem Cott.5truction i3ermit Application for a Permit to Construct( )Repair(x)Upgrade( )Abandon( ) El Complete System O Individual Components Location Address or Lot No. 21 Beth Lane Owner's Name,Address and Tel.No. Cindy Ch i c o i n e Assessor'sMap/Parcel Hyannis, MA 21 Beth Lane, Hyannis, MA 02601 � Z 1�< 771 —7241 Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No. Wm E Robinson Sr Septic Service PO Box 1089, Centerville, MA 02632 Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ng 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 sand Nature of Repairs or Alterations(Answer when applicable) Title 5 Leaching trench 4 ' x 2 ' x 60" and new D—Box. 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 issugd by this ar f Health. Signed ,� � Date `" V Application Approved by Date r' _ Application Disapproved for the following reasons Permit No. - Date Issued r" ,� No. z � Fee$50,00 THE COMM WE /TIH OF MASSACHUSETTS Entered in computer:. Yes PUBLIC HEALTH DIVISION - O N OF BARNSTABLE, MASSACHUSETTS fs Application for Migpo Y 6potem Construction Permit _ Application for a Permit to Construct( )Repair(x)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 21 Beth Lane Owner's Name,Address and.Tel.No. Cindy "co ne Hyannis, MA 21 Beth Lane, Hyannis, MA 02601 Assessor's Map/Parcel 7 7 7 71 —7 2 41 Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No. Wm E Robinson Sr Septic Service PO Box 1089, Centerville, MA 02632 Type of Building: Dwelling No.of,Bedrooms,, 3 Lot Size sq.ft. Garbage Grinder( n� Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures 1 I 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 sand " Nature of Repairs or Alterations(Answer when applicable) Title 5 Leaching trench 4 ' x 2 x6 0'° and new D�Box. 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 issu d by th' ar of Health. Signed Date F`/ V 9 J Application Approved by Date Application Disapproved for the following reasons Permit No. " Date Issued ——————— —--=----- ————— _ t 'THE COMMONWEALTH OFf MASSACHUSETTS r Chicotrle BARNSTABLE, MASSACHUSETTS .tr , Certificate of Compliance , THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed} Repaired(xX Upgraded g P Y ( ) P ( )UPg ( ) Abandoned( )by at 21 Beth Lane, Hyannis has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No 7- '� dated iff Installer Wm E Robinson Septic Sry Designer The issuance of this permit shallGnot b cgnlstrued as a guarantee that the system w nction as designed. Date 1 J Inspector `s i No. Fee THE'COMMONWEALTH OF MASSACHUSETTS i PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Chicoine ligpogal *pztem Construction Permit Permission is hereby granted to Construct( )Repair(xx)Upgrade( )Abandon( ) System located at 21 Beth Lane Hyannis, MA Installer Wm E Robinson Sr Septic Service 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:Constructio. mm�u/s't be competed within three years of the date o�f.�k' e it. Date: Approve4y NOTICE: This Form is to be used for the Repair of Failed Septic Systems Only CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WOHKS CONSTItUCTION I'EItM1' t V1'I'II0UI' DESIGNED PLANS) Hereby certify that the application for disposal works construction permit signed by me dated �L�`� `� , concerning the p p Y ro ert located at / '" c meets all of the following criteria: re are no wetlands within 300 feet of the proposed septic system crc are no private wells within 150 feet of the proposed septic system 0ie observed groundwater table is 14 feet or greater below the bottom of the leaching facility .- ere is no increase in flow and/or change In use proposed • 4h re are no variances requested or needed. SIGNED: y I 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]. �i �� , �. G) �--- 'Q. �� f �' p TOWN OF BARNSTABLE SEWAGE# LOCATION l �• ASSESSOR'S MAP & LOT VILliAGE INSTALLER'S NAME&PHONE NO. 7� 7 SEPTIC-TANK CAPACITY d` LEACHIN G FACILITY is { �� 4 �, (size) NO:.OF BEDROOMS BUILDEROR OWNER PERIvitTDATE: Z��'� 7 COMPLIANCE DATE: SC'-lei Separation Distance Between the: Feet Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Private Water Supply Well and Leaching Facility (If any wells exist Feet on:'ite'or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facility) Furnished by r i 3 LOCATION SEWAGE PERMIT NO. VILLAGE ]/� �`�orAlkyiS l "/Y4sS_ INSTALLER'S, NAME i ADDRESS JOH.N A. AALTO BACKHOE SERVICE a150 Walnut Street West,Barnstable. Mass. 0 66R 0 U I Ltd E R OR OWNER I-ul"o 11 DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED _l.�"�� i i i /eve (? No..........''D,.---- - � FIZIE............................. THE COMMONWEALTH OF MASSACHUSETTS BOAR® O HEALTH ------------ -----.................OF............ L....-------........................................ Xppliration for Bhopoal Works Tuntrurtion Vautit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: • � . -k � �. - g....00 • .... --- •• ,f . Locatwn•A ess Lot No. .-- = .:. . ---•--•-•-------- ---� ��....--•-� '------•..... f........--••-- O�ner Address aE �� .............. •------..--..-•-----•----•-••-•----^.._.--••----•--••-- � Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms..... ..................................Expansion Attic ( ) Garbage Grinder ( ) Other Type of Building .............................No. of persons............................ Showers ( ) — Cafeteria ( ) a 'Other fixtures .................................... W Design Flow.................... .............gallons per person per day. Total daily flow.................�.3_ ...........gallons. W Septic Tank—Liquid capacity-.�®uQgallons Length. 1........ Width-----�-r.. Diameter---------------- Depth.....YL_.. tal x Disposal Pit Nol..-.�o•-••••-•-•Diameter idth-®�;�.�--De Tobelownnlet.._..�•'.-_ Total allleacchin area area._ �.ssq. ft. I� --- o P ®�M1 �� g q Z Other Distribution box (�— Dosin tank ( ) aPercolation Test Results Performed by. . '�. `�5.-----•-......•-•------••-----... Test Pit No. 1_.__: ,2-minutes per inch Depth of Test Pit---12__.......... Depth to ground water...... Test Pit No. 2........<i.....minutes per inch Depth of Test Pit------e(.......... Depth to ground water........i_r............. `` ---•--•-•-••-------------------....... O Description of Soil '� �� 1 t�.9�_`�_`..............•------�` ..._-.. e.� . x ----••-•••------------••--------------•--------••-••------------•----•---.--------•-•----•--•---•••---••------......--------------•-••-•---•-••--•••----•-•-•---•-•-------------•----------•----•...... 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 iITI 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b sued4blyh of heal h.ned.. ¢ - Date Application Approved By....-- e�N-�.�7�-••----••-•-•---- 1�� 7,�1�... Date Application Disapproved for the following reasons:--•-•-•••••-----•-••-•-•----•---•••••-•-••----•--------------•--••--------------•------......_._........._--••-- ........................................--•---•.....--..._.......---•....•--•----------•--------•----------------------•-••------•-•------•------------------•----•.._...•----------•-•----............ -•_-•-•-Date. PermitNo......................................................... Issued-- I- - 3...�. . ....� Q Date - . J No........ ....... ...Z......................... THE COMMONWEALTH OF MASSACHUSETTS -0 BOARD, HEALTH .............. ........... ........OF...........xp�-�- ....................................................... Works Tonotrurtion Frrutit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: .Bye... Location-A ressLot N.. ✓ 5 ..........A4 ... ....:3.................. .......... ............................ ... ................ 0 ,ne.r Address w ,V Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms....._:...................................Expansion Attic Garbage Grinder ( ) P4 Other—Type of Buildinhjo g ............................ of persons........................... Showers Cafeteria ( ) P"4 Other fixtures ------------------------------- ..................................................................................................................... C11 .7Z Design Flow................ ,S_ ...5.........................gallons per person per day. Total daily flow................. ............gallons. Liquid capacity../P'q.(�gallons ....... Y.! Diameter________________ Depth.... 04 Septic Tank Length-2q... Width....' .- Disposal Trench—No_.................... ..s Width. ........... Total Length.__..____.__..._... Total leaching area.__........ q. f t. . .Seepage Pit No........ ........... Diameter,.... Depth below inlet I leaching area..: ..`.. .....sq. ft. I Z Other Distribution box Dosing tank �.., "' -.- -. ........ .. Date-57-9,,— _Percolation Test Results Performed by... ..... ...... �f ............ ............ . 7 �' Test Pit No. I-----4.1?Z�_minutes per inch Depth of Test Pit---LL........... Depth to ground water.... Test Pit No. 2....... .....minutes per inch Depth of Test Pit................_.. Depth to ground water........t..K........... ----------- y,-S....................... ..... 0 D .escription of Soil................................................................................7.................... U ......................................................................................................................................................................................................... W - ........................................................................................................................................................................................................ �4 UNature of Repairs.or Altee'4 rions—Answer when applicable.............................. ............. ................................................... ................................................................................................................. ..................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees,not to place the system in operation until a Certificate...of Compliance has been issued by the board of health. ned ---------------- ---------------------- ------------- Application Approved By___ len4.elA.4. ..... ........................................ ... ............................... . ....................... Date Application Disapproved for the following reasons:................................................................................................................ ......................................................................................................................................................................................................... .—Date Permit No_, ................................................... Issued_..4/:::./ ........................... Date THE-';COMMONWEALTH OF MASSACHUSETTS BOARD OFYEALTH . ........ .............. ......... ......... OF........... ............. ....... T S S TO T That the Individual Sewage Disposal System constructed or Repaired by .. 11 ............... ............. . Installer .. 'e at......... . .. . . ... . . . - ---- ------------------------------------------------------- .... (I eas des trib d * tl the provisions of T- -- --------A T� has been instilled in accordancewith 19 SanitaryC d 1 e in the ,� he State application,for Disposal Works Construction it o---- --------------------------------- dated_ /7.4t... ..................... Perm N THE I.SSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM-.WILL FUNCTION SATISFACTORY. Inspector..DATE..----- ........................................... W-4.1w--------------------- 7� THE COMMONWEALTH OF MASSACHUSETTS BOARD j9F HEALTH ...... ...OF....... ....................................... ........... N .......... FEE........................ din I--7 or Permission ij�s�hareby granted ... ..................................................... to Con r R;eVr n,1iWfVlduaf' age Disposal System at No.P &V.V ..... ----- A ----------- ................ ..................... Street ;7 as shown on the application for Disposal`Works Construction Tortffit No.,41. Dated...h7jO�!.4�.. . ............ ............................ 7.... oarl4o DATE............... ............................7........................ Y FORM 1255 HOBBS & WARREN. 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I . .1 11 I I I . , , f�ml ,-1 . - LEACHING PIT . NOTES: ' I � - � , I , I ' LUENT 3ZO' - GALS. . I � � - 11 .0 I 0. 1, . I I . I . � I . I I . � �, - I I � - . I � I 0 ... r I I I I � . I 1 I I I I �, ;� I � I � � . �� I I I -i , , "I , .. I .� I 11 I : I . e� - . D � I I t I U I I I .. I I I ,� I I I I I I 1 I I - �: 'ESLT, .'.TOTAL � AILY EFF 1; I I I I I I � - , I, I . I . . I , I i I I I I . I , .. � I 11 -, I � '' T: ". ' � . 1, - . � ,:'� �, , . ' .� I I II � . I I I 11 I . I � I . I . ' � r, .1 � - -�t - i , .1 11 I I I I ' 'I �l I � I I - I I .. I . I I � . I .1 I . I� I 11 , , _. 1, ,I" , , I I I � I � I � I 11 I I I I I � I I - - � � � I � , I I �I I � I � , I I I I 1 . - . 0 1 1 1 . I -, '. �_' . ��,I I .',- CONC. TO BE 4000 P.S.1 a . 28 DAYS . - I . �, �,�, lir,-� ,S E PTI 0� TAN K I 000 GAL. , . I I i " I � ''I 11 I I I I - 0, � �- ,� I : I .11 0 1 ,. � I I I I - 1. � . �I�_,,' . , �L, ' I I ., ll.,� . . I �. �� ,,, " . I I . I - - "I I ' ' " -, I � ,. I$ ' I . 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I -1 I I I I I .1 11 1� I I I I I � 11 �. - I I - - . � 11 I � 11 I 1 . � ,, .,� .,� I I I- -� . " , I ,� -NOTES � I . � . �. I i I � I e � � I � . I I I 1. I 1, �� '4 � f �, I ` I - . % � I - - 4 � " ,,GENERAL , I I :t,,,z �11 00 I I � I I 1 4', 1 � r 11 I ,, �, �I ., , , I I � I. I I � 14 - ,,,, , - - I ". I 1 .11 - �l , D I - - � '-, , I . - � I I I - � �I 1. I . I .I,. - , , I . i � . I I- I * . ,�, :, �: , , I I I I � I 11 . . i , Rsl�', 1� � , . , , � � I I . � �� _10, � , , - _z -� ,GREATER DEPTH REQUIREMENTS I I . - �� I I � , - �l ,� 0 C L'aj,zl<'_4.;t,._l FLY N N"_ auIL . � ,. " " ,, " : � I . � 11 . , ,. .1 I , . . , _ �11 ' ' i I . I I I I � I � � .1 � , , 11, o � . �, ' I v - - , , -1 i , , 1, I I � I , I 1, ll� I � I �l I _ I 11 I 11 � � . ALL SYSTEM COMPONENTS SHALL BE INSTALLED IN : 11 i� I I , � - 11 .: , I . 11 I . I � � . I , , . , r �' 11 . I 11 I I I I - : .1 ,! I . I . . .1� I I I -, � L � . I � .". I �' I I I I I I - � _ I I I � � I I I . . 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I - I- I . . � .: I L I � � -1 t � I I 11 .1 , :, �N _� � ,� �� 1. - I R QUIREb,T0 REMOVE ALL LOAM AND CLAY CONTAINING :� � J ' I I I I � I 11. � " I I 11 I I I ., t . . 11 . � I I I I � I � '. � I I I 1, " 1, ll)i, . � I I � . I . I I . I I I I � I I � 1. � � I I . I I I , � - � I I I I . I ._� - ,01 -.'-" ,� "I � 2. 'ANY CHANGETO, THISt-PL`AN,-MUST BE ,APPR D. BY',THE , ,, . I I I � 11 � I 1. , , - � I . I I I , - � 11 I .1. A " ' 1.1. I . . . � I I I I I I ,. I �� I � .� . I I -11 I . I . � _ I 1, I- - .- , , ' . . �� ?, I . i I I I� . � - I ��, 11 �. r ,� - I I I I I I I _, I� ". ll� I � TERIAL BENEATH PIT. REPLACE EXCAVATED MATERIAL ,,, 'r'' 1: -'BD: 6F-,t EALTH ''AND CHARLIES D."$P,OHR .r - - I , I . I I . , , I , , 11 , � I � I I � I , " � , ""_I I -, � I I 1- ,�. , � I � � 1 : I I �k r ,: ,2: , I I . : , -,_ _-�'�, , " � I I I � I I I I I � I . I I : , I ,. 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