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HomeMy WebLinkAbout0028 BLUEBERRY HILL ROAD - Health 28 Blueberry Hill Road A=249-066 Hyannis 1 0 III a 116 It TOWN OF BARrINSTABLE �7 LOCATION,, 61 oclU gay H 1 LL R/ SEWAGE# 0 VILLAGE �/-t ��,f' tASSESSOR'S MAP&LOT C7 J� Z y 6 INSTALLER'S NAME&PHONE NO. V7�� G; ;�`'� SEPTIC TANK CAPACITY LEACHING FACILITY.(type) ' �� ` g.i � �I'� (size) S ( x t Pl NO.OF BEDROOMS 1%l3 n 74 BUILDER OR OWNER,`f PERMIT DATE: ;/ COMPLIANCE DATE: 5-I Q 1 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 lea hin ity) — Feet Furnished by W � a � M �'- g g el A No. d'�/ l �Q Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 21ppliLation for Misposal *pstpm Construrtiun Permit Application for a Permit to Construct( ) Repair( 4pgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.498 /�1��?i y A>* � Owner's Name,Address,and Tel.No/v;� r8 ��o✓ Assessor's Map/Parcel Installer's Name,Address,and Tel.No./91/.��a�<� Designer's Name,Address,and Tel.No.S®a'— Type of Building: Dwelling No.of Bedrooms 3 Lot Size IF d'®p sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 33619 gpd Design flow provided 3��.' T gpd Plan Date Y���� Number of sheets i2 Revision Date Title �oPmsro� ✓ass 2 Syl��r� !,®i�aor�t�> ��/r�s� Size of Septic Tank /1.f'pe::> / Type of S.A.S. Z— ,n©e7 4vl Description of Soil Nature of Repairs or Alterations(Answer when applicable) /S oa g:Q/ 74&rle _3 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 Certificate of Compliance has been issued by this Board of Health. Signed Date Application Approved by Date < Application Disapproved by Date for the following reasons Permit No. Date Issued No. _0 t f�� ' ®' Fee �/ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION TOWN OF BARNSTABLE, MASSACHUSETTS Yes 21pplitation,tot aVsposal *pBtem (Construction Permit Application for a Permit to Construct( ) Repair(�f/1tipgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.28 /,0/s�ei4!0r y f�i - Owner's Name,Address,and Tel.No.-if�,gr i e 1rA"0W X y/6 S ,2,0-7 r d%0V_r psi%/S moo/ Assessor's Map/Parcel 2 66" Installer's Name,Address,and Tel.No./ v/ -rai�ii' Designer's Name,Address,and Tel.No.S�� y77-S'T/3 3SD ✓t4�`* S7 F�9.g�rr, 'n�' w6rGr .v, � ��•yout� sob—Tlr-.?A�r /� .��.sf- C'/'ossfi���o� v�sro� Type of Building: Dwelling No.of Bedrooms Lot Size ,70 6'OD sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(miriatequired) gpd Design flow provided gpd Plan Date 6&1/z��6 Number of sheets :�2 Revision Date t,r TitleJrr^Yi? fytM liro� Size of Septic Tank %,Zpe2 Type of S.A.S. > Description of Soili t Nature of Repairs orAlteratiotis(Answer when applicable) s'�or�. 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 Certificate of Compliance has been issued by this Board of Health. Signed Datea- Application Approved by e-� Date Application Disapproved by Date , for the following reasons rr Permit No. �r}� � ) Date Issued '�. s"' —1 fo --------------------------------------------------------------------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(� Upgraded( ) Abandoned( )by -_ at ?has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No M 6 dated 3_ Installer '_Z4_-I� �- � Designer #:bedrooms Approved design flaw 3 3 o gpd ,The issuance of this p rmit hall not be construed as a guarantee that the system will�n �ti� as deli d. Date I Inspector ` n O R,( IIt - -------------------------------------------------------------------------------------------------------------------- No.2 y f 6 57-:� Fee ( �V THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal *pstem CoustrUction permit Permission is hereby granted to Construct( ) Repair(A-< Upgrade( ) Abandon( ) System located at �� ���,� �l Z, and as described in the above Application for Disposal System Construction Permit. The applicant recognized 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 Approved by Town of Barnstable r°�yo Regulatory Services a�Rrtsras Richard V. Scal.i,Interim.Director * � ' MASS. Public Health Division a63q. ♦0 039.�A Thomas McKean, Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer& Designer Certification Form Date: S 19 l 6 Sewage Permit# 2 212 —/ Assessor's Map\Parcel 2 49"(e(. Designer: e_i�o�:ti,ea�;.r,� t�+v^4+s 1 n Installer: Cg p-e CP A Ser v,t es Address: t Z i,o, CcZ s z\l� I�'� Address: -Lsd Maj n St- MA MA OZG73 On S1 cc Seey2s was issued a pernvt to install a (date) (installer) septic system at_ 2-9 ute- a 1 1 l a n1 s based on a design drawn by address,) fe w-C m e CeN t—e.t- f 6 dated Ll Z`1( t 6 (designer) I certify that the septic system referenced above was installed substantially according to the design.. which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Strip out (if require was inspected and the soils fP were found satisfactory. -5ec��� Q,, er- 1;. ,�,cJJ aMd Ca v►hgc.+eca I certify that the septic system referenced above was installed with major changes (i.e. greater than 1 U' lateral relocation of the SAS or any vertical ,relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. Strip out (if required)was inspected and the soils were found satisfactory. 1 certify that the system referenced above was constructed in co liance with the terms of the J\A approval.Letters.(if applicable) C' PETER T. 0'" (Installer's Signature) CDME CML No. 35109 P\ ja& A AfrSj4t1F� ``�' (Designer's Signature) (Affix DeS4 Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC.HEALTH DIVISION. THANK YOU. QASeptickDesigner Certification Form Rev 8-14-13.doe i N LOCUS ® Route 28 a f Hp\Rd m B\uebell � w ou = m o U � So`rh M% Street SCHOOL N 70'18'30" E oB.oS 81.00, 100.29 x LOCUS MAP SHED SHED /S:D NOT TO SCALE % 0 99——EXISTING CONTOUR Q� x 100.98 EXISTING SPOT GRADE NI EXISTING WATER SERVICE I G EXISTING GAS SERVICE H.W.—OVERHEAD WIRES I TEST PIT + 0 I 99.56 BENCHMARK LEGEND 99'3 X 0 LOT B 0 20,600 ±SF 99,43 PARCEL ID: 249-�066 I EXISTING CESSPOOLS q) PUMP, FILL WITH SAND o, AND ABANDON li/ v + HOLLY O 25'---1 Z o `O : � n99, TP-2 R S.A.S....•:-a� N � 0 o TPo1 N O N 7 PROPOSED N , 99.87 �+° O / O o SEPTIC TANK �950' " h=- 36' - . BE/VCHMARK 0 EXIST. CLEANOUT COR./BULKHEAD / , ./� - _ �� -0 �c 100,36 x 100,37 EL.=104.77 / 0 Ci 101.16 2 o DECK � x 101.00 / BM / 101.43 02.4 / x shr. / 10.0;65 / GARAGE 100,2� EXISTING / + 0 101.63 HOU$E�#28� / x T.O.F.=102.46t PORCH 101.55 .10 / 101.35 101.72 a x 0 101,58 101.08 / 100.79 / x 100.48 p / CB GRAVEL LAMP CB 100.65 PARKING 125.00' J6 101,23 N 70'18'30" E UP 100.03 100.13 edge of pavement 100.28 100.43 100.58 BLUEBERRY HILL ROAD of 44Ss9CyG PETER T. PROPOSED SEPTIC SYSTEM UPGRADE PLAN M cvLEE 28 BLUEBERRY HILL ROAD, HYANNIS, MA No. 35109 Prepared for: Cape Cod Septic Services, 350 Main St, W. Yarmouth, MA 02673 �� OWNER OF RECORD 'f'pr G/S1ER Engineering by: SCALE DRAWN JOB. NO. NATALIE RYAN SPECIAL NEEDS TRUST Engineering Works, Inc. 1"=20' P.T.M. 141-16 416 SAMPSONS MILLS ROAD 12 West Crossfield Road, Forestdole, MA 02644 DATE CHECKED SHEET NO. COTUIT, MA 02635 rz" J (508) 477-5313 4/29/16 P.T.M. 1 Of 2 NOTE: TO PREVENT BREAKOUT, THE PROPOSED FINISH GRADE SHALL NOT BE < EL:97.0 FOR A DISTANCE OF 15' AROUND THE K PERIMETER OF THE S.A.S. SEPTIC TAN INSTALL RISERS & COVERS OVER INLET AND PROPOSED D-BOX PROPOSED S.A.S. OUTLET SET TO 6" OF FINISH GRADE. INSTALL WATERTIGHT RISER & PROVIDE ONE ACCESS MANHOLE TO WITHIN 3" T.O.F.=102.46t COVER SET TO 6" OF GRADE OF FINISH GRADE FOR INSPECTION PURPOSES F.G. EL.=101.0E F.G. EL.=100.0t F.G. EL.=100.3t � F.G. EL.=100.0t MAINTAIN 2% GRADE (MIN.) OVER S.A.S. L = 10' L = 4, L = 13' S=1% (MIN.) p L= MIN. 4"SCH40 PVC _ , 4"SCH40(PVC ) ®"SCH 0(PVC) 6" Lil 70"I 6 ®Baaa®B 14" as®a9Ba 48" UQUID Baaaa66 LEVEL AD 4 4.8' 4' INV.=98.97 PROPOSED INV.=98.80 INV.=99.50 D-BOX EFFECTIVE WIDTH = 12.8' INV.=99.25 INV.=96.50 PROPOSED SEPTIC TANK 2-500 GALLON LEACHING CHAMBERS SURROUNDED WITH STONE AS SHOWN CONNECT TO EXISTING SEWER PIPE H-10 RATED AT CLEANOUT, INV.=99.70t verif TOP CONC. ELEV.=97.8t Al NOTES: BREAKOUT ELEV.=97.0 eGE 1) CONTRACTOR SHALL VERIFY ALL EXISTING PIPES & INV. ELEV.=96.50 aaaaa seINVERTS EXITING HOUSE, PRIOR TO INSTALLATION. BOTTOM ELEV.=94.50 2) SEPTIC TANK & D-BOX SHALL BE SET LEVEL AND 4' 2 x 8.5'=17.0' 4' TRUE TO GRADE ON A MECHANICALLY COMPACTED 4' OF NATURALLY OCCURRING EFFECTIVE LENGTH = 25.0' SIX INCH CRUSHED STONE BASE, AS SPECIFIED PERVIOUS MATERIAL IN 310 CMR 15.221(2). 4' MIN. SEPARATION TO G.W. LEACHING SYSTEM SECTION 3) INSTALL INLET & OUTLET TEES AS REQUIRED. BOTTOM OF TP, EL.=88.5 - 4) GAS BAFFLE TO BE INSTALLED ON OUTLET TEE 3/4" TO 1-1/2" DOUBLE AS MANUFACTURED BY TUF-TITE, ZABEL OR EQUAL. WASHED STONE SEPTIC SYSTEM PROFILE 3" LAYER OF 1 DOUBLE WASHEDHED STT ONEE N.T.S. (OR APPROVED FILTER FABRIC) SOIL LOG GENERAL NOTES: DATE: APRIL 26, 2016 (REF#15,025) 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL SOIL EVALUATOR: PETER McENTEE PE(SE#1542) BOARD OF HEALTH AND THE DESIGN ENGINEER. WITNESS: DAVID STANTON R.S. HEALTH AGENT 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS ELEV. TP-1 DEPTH ELEV. TP-2 DEPTH OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE LOCAL RULES AND REGULATIONS. 99.5 A 0" 99.5 A 0" 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR SANDY LOAM SANDY LOAM 10YR 4/2 10YR 4/2 TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE 98.8 g" 99.0 6 - DESIGN._ENGINEER.:. 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING SANDY LOAM SANDY LOAM 10YR 5/8 10YR 5/8 FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN 96.7 34" 96.5 36" ENGINEER BEFORE CONSTRUCTION CONTINUES. C1 C1 5. ALL ELEVATIONS BASED ON AN ASSUMED DATUM. PERC LOAMY SAND LOAMY SAND 38'/56" 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF 10YR 5/3 10YR 5/3 THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF 93 0 C2 78" 93 0 C2 78" HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. 8. THERE ARE NO WELLS WITHIN 150' OF THE PROPOSED S.A.S. MED. SAND MED. SAND 9. ALL AREAS CLEARED FOR CONSTRUCTION SHALL BE RESTORED AS 2.5Y 6/6 2.5Y 6/6 AGREED UPON BY OWNER AND CONTRACTOR OR AS OTHERWISE DIRECTED BY THE APPROVING AUTHORITIES. 88.5 132" 88.5 132" 10. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY PERC RATE <2 MIN/IN. "C" HORIZON THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING NO GROUNDWATER ENCOUNTERED CONSTRUCTION. 11. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS IN THE AREA BENEATH AND FOR 5' ON ALL SIDES OF THE S.A.S. AND REPLACE WITH CLEAN SAND AS SPECIFIED IN 310 CMR 255(3). 12. AREAS REQUIRING STRIPOUT OF UNSUITABLE MATERIALS SHALL BE GARAGE HOUSE(1128) INSPECTED BY DESIGN ENGINEER PRIOR TO BACKFILL BACK 13. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY AND shr. NOT CONSIDERED TO BE A PROPERTY LINE SURVEY. 14. THE ENGINEER IS NOT RESPONSIBLE FOR ANY UNDOCUMENTED SEPTIC SYSTEM COMPONENTS NOT SHOWN ON THE PLAN DECK DESIGN CRITERIA NUMBER OF BEDROOMS: 3 BEDROOMS SOIL TEXTURAL CLASS: CLASS I (LOADING RATE=0.74 GPD/SF) --- DESIGN PERCOLATION RATE: <2 MIN/IN N DAILY FLOW: 330 GPD O ' /PROP. S.A.S. DESIGN FLOW: 330 GPD GARBAGE GRINDER: NO-not allowed with design -25'-'� LEACHING AREA REQUIRED: (330 GPD) = 445.9 SF SEPTIC LAYOUT .74 GPD/SF PROPOSED SEPTIC TANK: 1500 GALLON CAPACITY PROPOSED D-BOX: 1 INLET, 3 OUTLET (MINIMUM), H-20 RATED PROPOSED SEPTIC SYSTEM UPGRADE PLAN USE 2-500 GALLON LEACHING CHAMBERS IN SERIES 28 BLUEBERRY HILL ROAD, HYANNIS, MA SURROUNDED BY DOUBLE WASHED STONE ON ALL SIDES SIDEWALL AREA: 2(12.8' + 25.0') X 2 = 151.2 S.F. Prepared for: Cape Cod Septic Services, 350 Main St, W. Yarmouth, MA 02673 BOTTOM AREA: 12.8' x 25.0' = 320.0 S.F. Engineering by: SCALE DRAWN JOB. NO. Engineering Works, Inc. N.T.S. P.T.M. 141-16 TOTAL AREA:.............................................................. 471.2 S.F. 12 West Crossfield Road, Forestdale, MA 02644 DATE CHECKED SHEET NO. DESIGN FLOW PROVIDED: 0.74 GPD/SF(471.2 SF) = 348.7 GPD (508) 477-5313 4/29/16 P.T.M. 2 Of 2 Town of Barnstable P# A Department of Regulatory Services t Public Health Division Da �'te i 1 Hy�A 1659. �4� 200 Main Street, annis MA 02601 Ul Date Scheduled b Time I I AIA Fee Pd.� 0 d -t-ry Soil Suitability'Assessment for Sew ge isposal Performed By: �i�� C�n�-¢� Ste—f�y'tr Witnessed By: V, LOCATION &GENERAL INFORMATION Location Address._� Owner's Name �Z y�h �.e C LC Ark'I Address g-iS Sgvh�SQri S M`)) 12�. ^ � .� MA 0 2�3S— Assessor's Map/Parcel: Z4-0� — Q fE, Engineer's Name NEW CONSTR U CTION REPAIR k Telephone# S'Q? —73 7— 1--7 Land Use l�s`Ch `d '\ Slopes(TO) �'"-�Z.. Surface Stones Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well :� ft Drainage Way ft Property Line `d t('-" ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) n II l . .- SV=Zjud�ITs iZ�d� Parent material(geologic) �(aecG� 4 y}"`�21 Depth to Bedrock rJ Depth to Groundwater. Standing Water in Hole: Cic Weeping from Pit Pace c Estimated Seasonal High Groundwater 2 DETERMINATION FOR SEASONAL HIGH'WATER TABLE Method Used: Depth Observed standing in obs.hole: in. Depth to soil mottles: in. Depth to weeping from side of obs.hole: ____ in, Groundwater Adjustment fr• Index Well# Reading Date: Index Well level— Aej.faetor Adj.Groundwnter Level w — — PERCOLATION TEST Date Time Observation Fe— Hole# 2 `fiche at 9" Depth of Perc �y� Time at 6" Start Pre-soak Time @ `�t ! _ Time(9"-6") End Pre-soak L Z Rate Min./Inch. Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the. Barnstable Conservation Division at least one (1) week prior to beginning. Lr Q:ISEPT[CIPERCFORM.DOC DEEP.OBSERVATION HOLE LOG Hole# r Depth from Soil Horizon Soil Texture Sail Color Soil Other Surface(in,) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. Consistency,% ray 1 �aY�2Hlz A 3 l- 3�k-78 C1 ta a--573 to CL DEEP OBSERVATION HOLE LOG Role# z Depth from Soil Horizon Sail Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stcnes,Boulders. OVLAL onsi en ravel 6.- 3 4; s L to y A-s« --)k Ct L Sq11-.I bQ Y 25/-3 21'-13z- C L- rA. S-kv, 2-,ST y DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Sail Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency. Gravel)- DEEP OBSERVATION HOLE LOG. Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. + r Flood Insurance Rate Man: Above 500 year flood boundary No_ Yes Within 500 year boundary t o Yes Within 100 year flood boundary No! Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? �S If not,what is the depth of naturally occurring pervious material? Certification I certify that on iJ I (date) I have.passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with . the required t ing,expertise and experience described in 310 CMR 15.017. • Signature . Date--"T-6 Q:\S.8PnC%P9RCFORM.DOC TOWN OF BARNSTABLE LOCATION_a_ $ Z l. xY I-> ;r,r�� 1 I SEWAGE # VILLAGE ��.�5 ASSESSOR'S MAP & LOT �� INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) Y '6 (size) NO. OF BEDROOMS '_PRIVATE WELL �Ll �AT BUILDER OR OWNER , DATE PERMIT ISSUED: DATE .COMPLIANCE ISSUED: �2 VARIANCE GRANTED: Yes No �( tj L _� --- -� i - _-' _l- JJam�;,�, / / ����� a /K a. `11 /d 2�r/' ���► � `` � � (�'U` 1i�l1� p rD- 14 q No... _..- --- ...... Fins_ THE COMMONWEALTH OF MASSACHUSETTS ,BOARD OF HEALTH avw...........0F.-.->>J ..✓..k``�Rc. �—............ ..... Appliratinn for, Binonsal Marks Tonstrurtinn 11truti# Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ................___. .... �a a:e v ...... = ------------------------1-4 yek-Y VQ�............................................ p Location-Address or Lot No. ................. ar_.......... C.,.w.r---------------.......-----------------.... ................ ............................................................ Ow per �.� - - -..�.1�� :...yes................. 3 ..' _..,~.......................................................................... p� Address Installer UType of Building Size Lot............................Sq. feet ►-� Dwelling—No. of Bedrooms.........3.............................Expansion Attic ( ) Garbage Grinder ( ) aa Other—T e of Buildin yp g ---------------------------- No. of persons..-.---•-.-•---------....... Showers ( ) — Cafeteria d Other fixtures W Design Flow_____________________ _____________________gallons per person per day. Total daily flow..__...___ . .---_._._--•---gallons. WSeptic Tank—Liquid capacity............gallons' Length-•----_____ - Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.......I............. Diameter.....1-a........ Depth below inlet .... ...___... Total leaching area.....:............sq. ft.' Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed.bY..:_...... ........................................................ Date........................................ Test .Pit No. 1.......I..........minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2........:.......minutes per inch Depth of Test Pit.................... Depth to ground water........................ ---------•------------------------------------------ ----...------•--•----•--......•-•---------•-----------.......... O Description of Soil•::..................................... ...... ......... ••-•...-... ........ -•.•••. x 1 V ••-••---•------•-••••-•-••-•------------------ ------- •••---••-•--=;-••••-----•-•-••-•-•••••.......-----....---•-----•-- U Nature of Repairs or Alterations—Answer when applicable._-___-•-�' j.......__.__y .._ ...(ti_ ..r....._____: ............. l r1-`n"- ------ .......... ........ per'.5---------------->-•----•------------•----•-------•---•-•--...-- Agreement: `..! The'undersigned agrees to install the aforedescribed•,g:.Individual Sewage Disposal System in accordance with the provisions of LITii, 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b b the bo of h�th,igned. •- � 1 - - ...----••• } Dat APPlicatiori Approved BY -------•------- Date Application Disapproved for the following reasons:--------------------------------•---•-------------------.....----------...-------•--•----•••......---------.--- ------------------------------------------------------------------------------:.................----................----•-------------•-------------------- •-••••-•-•••......---•...........•.... Date PermitNo..... ........ ------------- ------- Issued......................................................-- Date FEs............._. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........... .............................. Appliration for Bi-oposal Works Tanstrnrtion Prrmit �., Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: �f j} . ..................... Location-Address � � or Lob No. -----•-•---•---• ------- ................................... ... ................... .............................................. K--^� Owner Address ..................t.�.. ,a -•------•-•--•-•-----•••. `'' v 7 t a...................-..._._....._... ...__......._..........._......-..---..._...a__••_____._................._..... Installer Address Type of Building Size Lot......................... U . ..Sq. feet Dwelling—No. of Bedrooms........- ---•.._-----_::--------------Expansion Attic ( ) Garbage Grinder ( ) p, Other—Type of Building ............................ No. of persons._......____....__......_._. Showers ( ) — Cafeteria ( ) dOther fixtures .•...........--•------- {••• •-------••--•--•-- -----•... --••-----•------•............... W Design Flow.................: ...................gallons per person per day. Total daily flow......_.... . '_..............gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ xDisposal Trench—No..................... Width.._.___._.__...__.__ Total Length........:.._........ Total leaching area....................sq. ft.. Seepage Pit No.......I............. Diameter.....1.2Ll ..... Depth below inlet- ...... '....... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed bY...................... .:. ------------------- --•-•--•---•--•:P ground ----_. Date......................•................. Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to water....................... G4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Descriptionof Soil ................................•.........................................................................................................0......._.......... W - x ---•--•-•--•......•-----...--••--......•--•-------•-•-•----•-----•.,•--- ....--••-•-----•••-----•-•...............•---------•--------••----••--•---•-•---=--•-----------. ------------ U Nature of Repairs or Alterations—Answer when applicable.-.--___-/9-Y���........... � .._��' ......... c... ..:............: S . •�U .......me,a......... J_ 7 /mac �"`-r-c-K' cc,L- ....................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of,iITld 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. : z Date Application Approved By..............ma-......... f �^ Date Application Disapproved for the following reasons:.........-.........................................................................................•--......-•-•- .................. ......................................................-=.................----...-.................................................---------------------• ...................... Date Permit No. ._..... Issued....•.........................•-•------................ Date THE COMMONWEALTH OF MASSACHUSETTS BOA�R`D} OF HEALTH Tnrtifiratr of Tomplittnrr THIS IS T.O CER:TI.FY, That the Individual Sewage Disposal System constructed ( ) or Repaired (e )4 r by '-----.._.::. C.i Z ......--•-•---••.•--• --•--......-•.............•----••...------------••--••-•-•--••-•--._._..........-•......._.... —y Installer � l - -i at................................ ,. has been installed in accordance with the provisions of TI=" r j of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.. ��..... . .. .......... dated ...-. -.t'. `::.� _�.. ........ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FU7��RY. DATE .--...--_•--• Inspector.......... .............................................................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No!b................... FEE.......�r.___o...... 11isposal Works�Tonatrurtion hermit Permission is hereby granted.......... ..............: _-_ - . ••--•••-•----•••••----•---•-------------------•----------------.----•-•.---- .... to Construct ( ) or Repair Individual Sewage Disposal 'System at No. r- - - -- ..• - S�qm.i� et '- L �? -A,as shown on the application for Disposal ��'orla Construction P No.���•___.� 3�Dzted_. --_.- .......� e� Buard of Lfeallh DATE.......------ ................-----.......................