HomeMy WebLinkAbout0047 CASTLEWOOD CIRCLE - Health 47 :Ca tfewoodlci 16
Hyannis P
A _ 273 057
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No. d-V lJ ? ' a t Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
Zipplication for aiopogaf 6p5tem Con5trUCtion Permit
Application for a Permit to Construct( ) Repair q) Upgrade( ) Abandon( ) ❑Complete System Individual Components
Location Address or Lot No. 1^I 7 Cis Fie' C i(C I e Owner's Name,Address,an Tel.No.
Assessor's Map/Parcel �73 OS 7 ��,�i f � (( ( I ��J C
Installer's Name,Address,and Tel.No. Designer's Name,Addres and Tel.No.
Type of Building: �, C G+-
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder ( )
Other Type of,Building 419)S -e No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) Q�Lr IC!,, L t;V•p' fr,-A �C)L).S to +0
C.•/%D(�) -A-C nl`C -�tC7 U(-Ci t\n s (Ar
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 ea_lth.
Signed Date 2) `(77
Application Approved by &Vj Date z - 07
Application Disapproved by: Date
for the following reasons
Permit No. 2—o o? —u r� Date Issued
No. �0 (� 7 �G6 / • Fee: IUU —
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
application for ai.5PO4a[.6V5tem (Con5trUction 3permit 1
Application for a Permit to Construct( ) . Repair q) Upgrade( ) Abandon( ) .❑Complete System Individual Components
Location Address or Lot No. 4� �GS F I C 1fC e Owner's Name,Address,and.Tel.No.
Assessor's Map/P4cel `a7°3 (� -7
Installer's Name,.Address,and Tel.No. Designer's Name,Address and Tel.No. _
Type of Building: N CV, - "
Dwelling No.of Bedrooms 3 ` Lot Size. sq.ft. Garbage Grinder ( )
Other Type of Building 4o,)S, vO No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision.Date . <
Title
Size of Septic Tank Type of S.A.S.
. j
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) Q -D�e� L t N P f{�x�\ �C x�.5 +r)
_tCl P,3 . CS C) 4 C,./JV -`t U r
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 o1Health.
Signed Date 3 43,07
Application Approved by �W �, Date - D 7. 1
Application Disapproved by: Date r
for the following reasons
Permit No. ''-O o-.7 -U Date Issued 07
�
THE COMMONWEALTH OF MASSACHUSETTS° �`�I BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
f THIS IS TO CERTIFY,that.the On-site Sewage Disposal System Constructed ( ) Repaired.(�� ) Upgraded ( )
Abandoned( . )by _N�
at 9 1 Cc.S,,\IQ Weep ep C� r has been constructed in accordance J
with the provisions of Title 5 and the for Disposal System.Construction Permit No. ,04 -7 U(f-j dated /
Installer -Do o c G S A \. (n )ti1 Designer
#bedrooms Ill �.�" Approved design flow gpd
The issuance of this permit shall not be construed asla guarantee that the system will:fun on as,designed!-`
Date ✓ ./ Inspector.
---------------------------------------------- -
No. On 2 - 0?3 Fee �UG -
.,TH-E.COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS
xi5po5al *pgteM Congtruction 3permit
Permission is hereby granted to Construct ( _\\ ) Repair (� ) Upgrade ( ) Abandon ( )
System located at y 7
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty
to comply with Title 3 and the following local provisions or special conditions.
Provided: Construction must be completed within three years of the.date of tlits permit.
r by-'
Date �/ �� Approved //�
/ V
z S "j
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL M.g
DEPARTMENT OF ENVIRONMENTAL PROECTIO ION8Ak��S ABLE
i
2C05 MAR 31 PM 12: 01
j DIVISION
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT'S
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: C�fTle wood..
41
Owner's Name: e ,� �-o�,,,�
Owner's Address: O .p
Date o ehn�s 3 r9--- --
f Inspection: Od 0o
— y_ o.�
Name of Inspector easeprint)z 7,
Company Name:
Mailing Address: O J p V
Telephone Number.
CERTMCATION STATEMENT
I certify that I have personally inspected the sewage disposal
below is true,accurate and complete as of the time of the' system at this address and that the information reported
training and experience in the proper function and mspection The inspection was performed based on my
aPProved system inspector pursuant to Sectio 5.340 of Title 5 310 CMR 15.00nance of on site sewage ��systems.I am a DEp
/� � � system:
/Passes
Conditionally Passes
Needs Further Evaluatio by the Local
I
• Approving Authority
Inspector's Signature:
Date: --p
The system inspector shall su?,cony,f this —�
DEP)within 30 days of completingthis inspection report to the Approving Authority(Board of Health or
ei�0r 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 a
DEP•The original should be sent to the system owner and copies sent to the buyer,eaPPOPate applicable,and the approvingonal Office of the
g
Notes and Comments
Ze-%rjnP80F=0n`
edescribes conditions at the time of in does not address how the system will perform ion n the future under under1the ame or tions of use atth
conditions of use.
_ 1
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY A
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORIEN7'S
" FORM
PART A
CERTIFICATION(continued)
r Property Address:
Owner.
i Date of Inspection:
Inspection Summary: Check
A�B,C,D or E/ALWAYS complete all of Section D
A. Systempasses:
I have not found any information which indicates that 15.303 or in 310 CMR 15.304 exist °f the failure terra described in 310 CMR
Airy failure criteria not evaluated are indicated below.
Comments:
B• System Conditionally Passes:
Z"e or more system components as
repaired The system,upon completion of the scribed in the. Conditional Pass"section need to be replaced or
replacement or repair;as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,NNND)in the for the following statements If"not of determined ply
The septic tank is metal and over 20 years old-or the se c
unsound,exhibits substantial infiltration or exfiltration or tank failure is (whether metal or not)is .
existing tank is ileplaced"MithiY. .._.:. ..... .. ...
*A metal septic tank will a complying septic tank as approved by the Board of Health em will Pass inspection if the
Pass inspection if it is structurAlly sound,not leakin
g that the tank is less than 20 years old is available. g and if a Certificate of Compliance
ND explain:
Observation of sewage backup
obstructed pipe(s)or due to a bro or break out or high static water level in the distribution box due to broken or
' or
or uneven distribution box System will
approval of Board of Health): pass inspection if(with
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed
pass inspection if(with approval of the Board of Health): pipe(s). The system will
broken Pipe(s)are replaced
obstruction is removed
ND explain:
° Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY A SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM
' ORM
PART A
CERTIFICATION(continued)
Pro3 / _ /
Perty Address: �S7' wood Cr ✓+
Owner: / �,,� a.n✓Js tOa-b o�
r Date of Ins u pection: 3 4_o—
C. Further Evaluation is Required by the Board of Health:
!Conditions exist which require further evaluation
is failing to protect public health,safety or the environmem.the Board of Health in order to.determine if the system
1. System will pass unless Board of Health determines in
system is not functioning in a manner which will accordance with 310 CMR 15.303(i)(b)that the
Protect public health,safety and the environment:
— Cesspool or privy is within 50 feet of a surface water
_..Cesspool or pu ivy is.within 50 feet of a bordering vegetated g fated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
The
surface water
hass a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
supply or tributary to a surface water supply.
-- The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
SUPPI
_. .._ The system has a se" 'c tank .
Im and SAS and the SAS is Y.
within 50 feet of a private water supply well.
—" The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from
private water supply well**.Method used to determine distance a
This system passes if the well water analysis,performed at a DEP certified Tabora
bacteria and volatile organic compounds or coliform
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
failure criteria are triggeredm Provided that no other
or
3. Other:
Page 4of11
I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM
I
PART A
CERTIFICATION(continued)
s
Property Address:
Owner: t—
Date of Inspection:
D. System Failure Criteria applicable to all systems:
You must indicate`yes"or`no"to each of the following for all inspections:
Yes No
= p of sewage to facility or system component due to overloaded or clogged SAS or 1
��o ponduig of effluent to the surface of the ground or surface waters due to an overloaded or
ogged SAS or cesspool
v Static liquid level in the distribution box above outlet urvert due to
spool an overloaded or clogged SAS or
d depth m cesspool is less than 6"bel,Uqmow invert or available volume is less than%day flow
pumping more than 4 times in es pumped the last year NOT due to clogged or obstructed pipe(s).Number
tim
portion of the SAS,cesspool or privy is below hi
— portion of cesspool or privy is within 100 feet of ah ground water elevation
ter yummy' . surface water supply or tributary to a surface
Portion of a cesspool or privy is within a Zone 1 of a public well.
3'portion of a cesspool or privy is within 50 feet of a
!/ Any
Portion of a �,• Private water supply well.
cesspool or is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
Performed at a DEP certified laboratory,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,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
" (Yes/No)The system fa, iIs I have determined that one or more of the above
described in 310 CMR 15.303,therefore the stem failure criteria exist as
system owner should contact the Board of
Health to determine what will be neces
sary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15 000
gpd.
You must indicate either`yes"or"rid'to each of the following:
('The following criteria apply to large systems in addition to the criteria above)
yes no
system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface ddnlang water supply
— — the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—TWPA)or a mapped
II of a public water supply well
If you have ered"yes"to any question in Section E the system is considered a significant"Yes"in Section D above the large system has failed The owner or operator of airy lare system considered a
significant threat under Section E or fair undet.Scetion-D shall upgrade the stem�15.304.The system owner should contact the a �' rdance..with 31Q.CMR
appropriate regional office of the Department.
Page 5 of 11
OFFICIAL,INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART B
CHECKIAST
i Property Address• �r'77",,d c „
t
Owner: /�v N r C7a 6 0/
Date of Inspection:
Check if the 110110wing have been done.You must indicate es"or"no"as to each of the followin
Yes
Pumping information was provided by the owner,occupant,or�d Health
-- _" Were any of the system components out Piped in the previous two weeks
_v �s the system received normal flows in the previous two week
period
zllHave large volumes of water been u*oduc-ed to the system recently or as of
1� this inspection
Were as built plans of the system.obtained and examined?(If they were not available note.as RT/A
Was the )facility or dwelling mspected for signs of sewage back up
— — Was the site inspected for signs of break out .
—/ Were all system components,excluding the SAS,located on site
v Were the septic tank manholes uncov
of the bales or tees,material of �oPC114-and the interior of.the tank'
coast ruction,dimensions, _. for the condition _.
- ors;c�pth of liquid,depth of sludge and depth of scam
.Was the facility owner(and occupants if different from maintenance of subsurface.sewage .-s ms. °wner)p ovided with information on the proper
The size and location of the Soil Absorption System(SAS)on the site
has
been determined Yes nq �— based on:
e xisting informatiion.For example,a plan at the Board ofHeal
is Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
Part-
unacceptable) CAR 15.302(3)(b)j
i
i
Page 6 of i l
OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE,SEWAGE DISPOSAL SYSTEM INSPECTION'FORM
PART C
SYSTEM INFORMATION .
Property Address: Cad►S 7�e Al-W c/ r-
Owner. C/o
Date of Inspection: - - 0 S
BESIDENTiAi, :FLOW.CONPrl1ONS
Number of-bedrooms(design): Numberr of bedrooms.(actoai): 3
DESIGN flow based on:3 10,CMR-15.203(for.example: 110 gpd.x#of bedrooms): 3Jo
Number of-current residents: 0
Does residence have a garbage gender(yes or no):
Is laundry on a separate sewage system(yes or no):AID [if yes separate inspection required]
Laundry system inspected(yeas or no):iV 0
Seasonal use:(yes or no):/fie
Water meter cgs,if available(last 2 years usage(gpd)):
Sump pump(yes or no): 100
Last date of occupancy:
COMMERCIAL/IlqDUSTRL4L
Type of establishment:
Design flow(based on 310 CMR 15.203): per.
Basis of design flow(seats/persons/sgketc.):
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 occupancyhw:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: —9 G,PG0 4's o
Was system pumped as part of the inspection(yes or no):
If yes,volume pumped:_gallons—How was quantity pumped determined?
Reason for pumping:
TYP SYSTEM
—Septic tank,distnbution box,soil absorption system
_Single cesspool
Overflow cesspool
—ivy
_Shared system(yes or no)(if yes,attach previous inspection records,if any)
_Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
—Tight tank _Attach a copy of the DEP approval
—Other(describe):
Approximate age of all components,date installed(if known)and source of information: _
of L,- ✓i ,!.1 ti/
Were sewage odors detected when arriving at the site(yes or no)./6
f
Page 7 of 11
OFFICIAL INSPECTION FORM-:NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWiAGE.DISPOSAL SYSTEM INSPECTION FORM
PART:C
�,(. SYSTEM INFORMATION(contimwM
Property Address: / / 64 r Ale ,/ 6 ,
�.Owner: ah„/1 /IlA oabo/
C/�oae/�—'
Date of Tnspectioe•
BUILDING SEWER(locate on site plan)
Depth below grade;
Materials of constmction: iron _40.PVC_other
Distance from private water ( )� supply welt ar suction kae:
Comments(on condition of joints;ventinevidence of leakage,etc.):
SEPTIC TANK:—(ate.on site plan)
Depth below grade:
Material of construction:=i nCo z _mom_ g�--polyethylene
_other(expia
If etal list age:
certificate) — _Is age c�nfirnned by a.Certificate of
Compliance'(yes or no):_(attach a copy of -
Dimendow X
Slud deptik ,
D"'mm.fim:fop of-Amige to bottom of outlet twor baffie:
Scum thickness:. p
Distance from top of scum.to top of outlet tee or baffle:
Distance from bottom of scum:to botto of outlet tee o baffle:
How were dimensions:determined o(e /5Ca
ICR
Comments(on pumping recommendations,inlet and o tee or,baffle condition, structural as belated to outlet invert,evidence of leakage)•.etcirate)): gItity;'liquid levels
T''`l f 7e—lp-17�
cRs /
Z—eG
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(on pumping recommendations,inlet and outlet.tee or baffle condition,
as related to outlet invert,evidence of leakage;etc.): uraldutegrity,liquid levels
a Page 8 of 11
{
4
OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART.C
SYSTEM/INFORMATION(continued)
Property Address:, I CPLik-ood Cie
Owner.
Date of Inspection: zr_o
TIGHT or HOLDING TANIK;��tank must be pumped at time of inspection)(loc ate on site plan)
Depth below grate:
Material of construction: concrete metal
fiberglass_polyethylene other(explain):
Dimensions:
Capacity: �Ilons
Design Flow: gaUons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
.Date of last pumping
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX:�if present,must be opened)(locate on site plan)
Depth of liquid level above outlet invert;
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
PUMP CHAMBER.&locate on site plan)
Pumps in working older(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
_ i
• Page 9 of l l
OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE-DISPOSAL.SYSTEM.INSPECTTON.FORM.
SYSTEM EVFORA4ATION(
Property Addn.= s/7"/e cv 0 0 C CI r
Owner.
c9�6O/
Date of Inspec&a.- o S
SOIL ABSORPTION 5Y5T M(SAS): . (Inca oa site Plan;esca�ation apt.
If SAS not located why!
Type
:lung
-leaching ChRMOM munber: / S�Q
leaching galleries,nunberleaChilig
,111IMber,.length:
leaching fields,munber,dimensions
overflow cesspool,number.
inno�ldaftanzative system .TypeJffime.of technology:
Comments(me condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.): i/O Q/ 1 / / O/6d7�i/1 I n �CJJ �IT L, .f7ri/rf 4 7 O �/
CESSPWI&;/ (cesspool a9 be moped as part of in on)(ioca to on site plan)
Number and.
co$figmrabtoa. ..
Depth-top of liquid-winlet invert:
Depth of sdxls layw_
Depth of scam lapw.
Dimensians cf cesspool:
Materials of coion:
Indication of gfenmdwater inflow(yes or.nor.
Commends(u0te4wdit=of soil,signs of hydraulic fture;level of ponding,condiion of vegetation,etc.)
PRIVY:&{locate on site#W)
Materials of.conon
Dimcn6ons;
Depth of soh&
Comments(notecondition ofmil,2gns.Of hydrAWW failure,level.of.ponding,condition ofvegetatwn� etc.):
I
j• Page 10 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION( }
Property Address: ! �2Gvpp� C
Owner. Glove/ ,
Date of Inspection:
SKETCH.OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference.landmarls.or
benchmarks.Locate all wells within 100 feet Locate where public water supply enters the buildiag
filve-
10
``:
xa- dy'
< .3
d3- 3a
Page l l of I1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner_ C ' awe 6 .v /
Date of Inspection: — _ 0 4-
SITE EXAM .
Slope
Surface water
Check cellar
Shallow wells 3a1
(0— �f
Estimated.depth to ground water-2 4 feet. 3
Please indicate(check)all methods used to determine the highground water.elevation:
ObUined
from system design.plans on record-If checked;date of desigit plan reviewed
site(ahluing pmPertY/observation hole within 150 feet of SAS)
Checked with local.Board of Health-explain: ✓Lj G��
Checked with local excavators,installers-(attach�cumetion)
Accessed USGS database-explain:
You must describe hovy you established the high ground,water elevation: ^7
Gr0 NG► (VG. r 7 G R4
1 B O c0
c9 0�A t ,
0009 t .
r�ftot-,
17
. J
G- w 3
\\L O CATION *7 SEWAGE PERMIT NO.
� �Sll•� �y v s� C(i' ' ,,�.
VILLAGE f�
INSTA LLER'S NAME i ADDRESS
8 U I L D E R OR OWNER
DATE PERMIT ISSUED .17- �S-
DATE COMPLIANCE ISSUED S
. /
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�No. _ Fps
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
'Z-'` /
Appliratinn for 11ispas al Works C omarnrtiun rrranit
Application is hereby made for a Permit to Construct ( ) or Repair (!/f an Individual Sewage Disposal
System at: '
5.7... .f_!.'..1 k/odot' circ 0
.................---------... ................... .-•---•--•----------•---.......------.........................
Q Locat)�'o�p•Actress // o Lot Into.
_. � .�. l7�......r.D. ell................. cl.!,Rl,o.
�•� .........
Owner ddri t.- ..__
� .............
Installer Address
Type of Building' Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms........'.'�.3.............................. Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
a' Other fixtures ................................. .
d .........•--•.........
W Design Flow.........�................................. per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid-capacity............gallons , Length................ Width................ Diameter................ Depth...i..._...__..
x Disposal Trench—No..................... Width.................... Total Length.................... Total.leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by........................................................................... Date........................................
Test Pit No'"1----------------minutes per inch Depth of Test Pit.................... Depth to ground water........................
(T, Test Pit No. 2................minutes per inch-depth of Test Pit.................... Depth to ground water........................
:5'r.+.�? .7..,..-O`-e O Description of Soil................. ...
....-•--------------•---•-•--•-----------•--------------••---------....
U ----------------
-------•----•--------
_.. ---•-••------•----.
W 4
U Nature of Repairs or Alterations—Ar when applicable______.,!�tS.4_......_.._!?v t _ ��` ..... ............
•------- ��--. ..`��-`---- --"----`•�--------------•-•-•------------------------ -
Agreement:
The undersigned agrees to install the a or-edescribed Individual Sewage Disposal System in accordance with
the provisions of TIIa' 5,of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee • sued y the board of health.
w
ed
...••----•-Application Approved B .... ..._/AV. ... ate
q
Date
Application Disapproved for the following reasons:------•-------••-------•---••---•--•-------------------•----------...-----------•----------------............_..
............................•• ----••-••••--••-:Lz---•--•---•----- . . . ........
Date
Permit No.............qqfJ 5_-41A:-•-•-•-•----•---- Issued.................... . �S
ate .
------------
Fic
THE COMMONWEALTH OF MASSACHUSETTSi-
BOARD OF HEALTH
...........OF......`,�4.A.102.,� ..�r`--IQ.....................................
Appliratiun for Disposal Works Tonstrudion Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair (vj an Individual Sewage.Disposal
System at:
................. • L ................ ....•--..... ..-•----•----•--..........--.............
.. .....
/��e Location-Address / or Lot No. L,( /
���C L,l ..��!J. .t S!�dQ .ttt.G.�a. ,l-'�Y�s.!2
Owner / C Address�
a ........................ �Gf�'ai r+--•-•----------.-.--.---.-- ...��Q.��ls_lt2trJ.�_..,,J�..../!lrl,..�i..�..flK/.J/...............
Instal el r Address
UType of Building Size Lot............................Sq. feet
�. Dwelling—No. of Bedrooms......_3...............................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
dOther fixtures .............................................................------...........--•-•----...------------------------------------.......-••-............
WDesign 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-------------------_ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by......................................................................... Date........................................
Test Pit No. 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........................
M ••... •••--....•••••-•......•-••••••••••••-•••-•••--••...--••••••••••••••-•-•--••••••-•-••-........•-•......-•-._...•••---•••-•-•-••••••...-•................
xDescription of Soil----------------5.�h� e ------------.........----------------------------------------------------------------------------...------------.
U •••••••••••••-•••••-•-••-•-•••-••--•••---•...._......•-••--......-••-•-•••--•.........•••••-••••••••.....•••-•••••-•-•-••-•-•-••--•••••••••-•-••••-•--••-•••••-•--•-••••-••......--•••-......-•--••----
W
x ••--••---------------• •---------•-------------------------...----------------------•------------------------------------------/•---------------......................................................
U Nature of Repairs or Alterations—Answer when applicable._____yc�tfl.f_._�_ult..7r�Q............. dP......._._._.
Tom .
----------•- •.e ��7,. 3 �`-
----------------
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 bee *ssued by the board of health..
ned ... N4------------------ ---
Application Approved B l / Date
PP PP y......•••_ Y �......�1^:..r'•-_------------ --- ............{-- L
Dat
Application Disapproved for the following reasons:..............................................................................................................
............................................•----------------.....---------------•-------....------.......-----------•--•---......---------------...-----------------------------------------------...•--
Date
PermitNo.......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
rc�..............OF...........
Qrh.J�- ...........................................
Trrfif iratr of ToutpliFanrr
THIS IS TO CERTIFY, That the IInndiviiddual Sewage Disposal System constructed ( ) or Repaired )
by------------------------------------------------9Q�ea.----• ----------------------•-•----.....-----------•-----......------------......................-------•---•...
• r•
at. Installer
a
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No... .:_.. .a. .......... dated.L _z_ f, ....................
THE ISSUANCE O THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A G ARANTEE THAT THE
SYSTEM WILL FUNC ON S ISFACTORY.
DATE........................1 . ------------------------ Inspector........
....... ...... ..6x4a.1o.
1 ,
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
L ��/p. en.............OF....-.- q/� 2.1.L.!►. ...• .......................................
FEE. ....... ----
DiopooFal Works 0ono#knrfwi'tt rranit
Permission is hereby granted................... o k....... .---------------------------------......----......••••......................_.
to Construct ( ) or;Repair ( ) an Individual Sewage Dis osal System
at No. 7
Street
as shown on the application for Disposal Works Construction ermit ::_ l.k__.. Dated_. ----------------
__ _..{s .
A—Z
C .
..................... Board of Health
FORM 1255 A. M. SULKIN, INC., BOSTON