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HomeMy WebLinkAbout0028 CHERRY STREET - Health T 29 Cherry Sttect- - Sewer Acct#4502 Hyannis}4WI-I A = 309 '1-124=• Z 1 F6 ' COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION a Q TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM'FORM PAST A CERTIFICATION Property Address: 28 Cherry Street [RE:CEIVE® Hyannis, MA 12003 Owner's Name:_F_.1 i zafjeth R1 ac-1chii n—rollado 2Owner's Address• F BARNSTABLE Date oClnspection: ALTH DEPT. Name of Inspector:(please print) Wi 1 1 i am F. Robi nson Sr. ��QQ CompanyNamc: William E. Robinson Septic Service MAP Mailing-Address: P O Box 1 089 PARCEL , �� Centerville. MA Telephone Number: f 5081 775-8776 LOT 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 the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to SSection.15.340 of Title 5(310 CMR 15.000). The system: `I Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: y Date: c---0O The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or bas 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 DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the appro.ving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under tite conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of.use. Title 5 Inspection Form 6/15/2000 page 1 ' ` f a e2ofll P g •� OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASpN FORM.; S SUBSURFACE SEWAGE DISPOSALART ASYSTEM INSPECTI CERTIFICATION (continued) Property Address: 28 Cherry Street ^nni s M� Owner. hurn—Collado Date of Inspection: ^ Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Sy tem Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. ystem Conditionally Passes: T One or more system components as described in the"Conditional Pass"section need to be replaced or repaire .The system,upon completion of the replacement or repair.as approved by the Board of Health,will pass. Answer es,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. e septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial inf Itration or exfiltration or tank failure is imminent.System will pass inspection if the existing is replaced with a complying septic tank as approved by the Board of Health. •A me septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicati g that the tank is less than 20 years old is available. ND expla' Ob rvation of sewage backup or break out or high static water level in the distribution box due to-broken or obstructed 'pc(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with approval of oard of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The s stem required pumping more than 4 times a year due to broken or obsuwcd pipe(s).The system will pass inspecti n if(with approval of the Board of Health): broken pipes)are replaced obstruction is Ii DWA ND explain: L Page 3 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS , . SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM -.:PART A _ CERTIFICATION(continued) Property Address: 28 Cherry Street Hyannis, NA Owner: al Re rn—Collado Date of Inspection: —6 C. Further Evaluation is Required by the Board of Health Conditions exist which require further evaluation by the Board of Health in order to determine if the system" is fa ling to protect public health,safety or the environment 1. System will pass unless Board of Health determines in-accordance with'310.CMR 15.303(lj(b).that the system is not functioning,in a manner which will protect public health,safety and.the environment: Cesspool or privy is within 50 feet of a surface water -- .Cesspool or privy is within 50.feet'of a bordering vegetated`wetland or a salt marsh. 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines.Ihat the • systems.functioning in a manner that protects the public health,safety and environment: _ The system has a.septic tank and soil absorption system(SAS)and the.SAS is within 100 feet of a surface water supply or tributary to a surface water supply: J`fhe system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is 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 froul a pr ate water supply well'•.Method used to determine distance *This system passes if the well water analysis,performed at DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and. e 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. 3. Other: 3 Page 4 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS = , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ..PART A,, CERTIFICATION(continued) PropertyAddress: 28 Cherry Street Hyannis, MA Owner. Elizabeth Blackb ,__ern=Collado Date of Inspection: —)9—0 D. System Failure Criteria applicable to all systems:. ; Yo o must indicate`yes'•or"no"to each of the following for all inspections: Yes N _ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _ the surface of the ground or surface waters due to an overloaded Discharge or ponding of effluent to 'or. clogged SAS or cesspool _ Static liquid level in the distribution box above outlet invert due to an overloaded orclogged SAS or cesspool _ _ Liquid depth in cesspool is less than 6"below available volu invert..or me is less than'h day flow . Required pumping more than 4 times in the last year NOT due to clogged or obstructed p►pe(s).Number of times pumped _ Any portion of the,SAS,cesspool or privy is below high ground water elevation. _ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. y portion of a cesspool or privy is within a Zone 1 of a public well. _ y:portion of a cesspool or privy is within 50:feet of a private water supply well. y portion of a cesspool or privy is less than 100 feet,but greater than 50 feet from a private wMel 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,tree 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 forma es/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E? arge Systems: To be onsidered a large system the system must serve,a facility with a design flow of 107000 gpd to 15,000 gpd. You mu t indicate either"yes"or"no"to each of the following: (The foil wing criteria apply to large systems in addition to the criteria above) yes no _ the system is within 400 feet of a surface drinking water supply th system is within 200 feet of a tributary to a surface drinking water supply the ystem is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zon 11 of a public water supply well If you have answered"yes"to any question in Section E the system is consi.dered a significant threat,or answered "yes"in Sectio t D above the large system has failed.The owner or operator of any large system considered a significant thr eat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 4 I 1 r Page 5 of I 1 ' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM " PART B CHECKLIST Property Address: 28 Cherry Street Hyannis, MA Owner: Elizabeth Blackburn—Collado Date of Inspection: Check if the following have been done.You must indicate'ryes"or"no"as to each of the following: Yes N Pumping information was provided by the owner,occupant,or.Board of Health; — V Were any of the system components pumped out in the previous two weeks? Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of this inspection? J — Were as built plans of the system obtained and examined?(If they were not available note as,N/A) . — Was the facility or dwelling inspected for signs of sewage back up? t/ Was`the s g site inspected for signs of break out? — — P — Were all system components,excluding the SAS;located on site? Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? _ '✓ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems.?_ The size and location of the Soil Absorption System(SAS)on the site has been determined based on:. Ye no . ✓✓—/— Existing information.For example,a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation.of distance is unacceptable)[310 CMR 15.302(3)(b)] 5 t - V Page 6 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY:ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C., SYSTEM INFORMATION Property Address: 28 Cherry Street Hyannis, MA Owner: Elizabeth Blackburn-Collado Date of Inspection: FLOW CONDITIONS RESIDENTIAL. ... Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):3 G fl Number of current residents: 7__— Does residence have a garbage grinder(yes or no):_z�,q Is laundry on a separate sewage system(yes or no):IL [if yes separate inspection required) Laundry system inspected(yes or no): Seasonal use:(yes or no):�/U Water meter readings,if available(last 2 years usage(gpd)):' Q ��` tti^ ugh 2-2"0 0 3 = 105, 00091 Sump pump(yes or no): v Last date of occupancy: U COMMERC L/INDUSTRIAL Type of establi ent: Design now(b ed on 310 CMR 15.203): gpd Basis of design ow(seats/persons/sgft,etc.): Grease trap pre nt(yes or no): Industrial wast holding tank present(yes or no):_ Non-sanitary w ste discharged to the Title 5 system(yes or no)*:— - Water meter r dings,if available: Last date of o cupancy/user OTHER(de tribe): GENERAL INFORMATION Pumping Records Source of information: Cb 07 l Was system pumped as part of the inspection(yes or no): R.,U If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: TYP OF SYSTEM 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) _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(Xknown)and source of information: ���ti `ram-Gz- �,%�- S�✓/L �9 ..Were sewage odors detected when arriving at the site(yes or no):.A-d 6 Page 7 of 11 OFFICIAL INSPECTION FORM-NOT-FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM:INSPECTION FORM -` PART C SYSTEM INFORMATION(continued) Property Address: 28 Cherry Street Hyannis, MA Owner: Elizabeth Blac burn—Collado Date or Inspection: "Z U BUILDIN SEWER(locate on site plan) Depth belo grade Materials o construction: cast iron _40 PVC_other(explain): Distance fr in private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:_(locate on site plan) Depth below grade; � Material of construction: j✓concrete—metal_fiberglass—polyethylene othe Im r(ex a' p ) If tank is metal list age:_ Is age confirmed-by a Certificate of Compliance(yes or no):_,(attach a copy of certificate) Dimensions: a' a U Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: L Scum thickness: 'LI 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 were dimensions determined: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outl t invert,evidence of.leakage.etc.): -� A ld �, IEGREAS P:—(locate on site plan) Depth below grade:— Material of construction:—concrete—metal—fiberglass_polyethylene_other " (explain): Dimensions: Scum thickn ss: Distance fro top of scum to top of outlet tee or baffle: Distance from ottom of scum to bottom of outlet tee or baffle: Date of last p ping: Comments(on umping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to tlet invert,evidence of leakage,etc.): 7 Page 8 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM' PART C SYSTEM-INFORMATION(continued). property Address: 28 Cherry Street Hyannis, MA Owner*. Elizabeth Blackburn-Collado Date of Inspection: TIGHT or HO DING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below gra e: g _�. Y Y Material of cons ction: concrete. metal fiberglass of eth lene other(explain): Dimensions: Capacity: allons Design Flow: allons/day Alarm present( es or no): Alarm level: Alarm in working order(yes or no): Date of last pu ping: Comments(c dition of alarm and float switches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 0 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.): l� PUMP CHA BER: (locate on site plan) Pumps in wor ing order(yes or no): Alarms in wor"ing order(yes or no): Comments(n to condition o!pump chamber,condition of pumps and appurtenances,etc.): 8 r Page 9 of I 1 OFFICIAL INSPECTION.FORM-NOT.FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: - 28 Cherry. Street Hyannis, MA Owner:Elizabeth Blackburn—Collado Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): tzoocate on site plan,ezcavation'not required) If SAS not located explain why: TYP leaching pits,number: leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system .Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): , CESS OOLS: (cesspool must ( p m s be pumped as part of mspection)(locate on site plan) Numbe and configuration: Depth— op of liquid to inlet invert: Depth of olids layer: Depth of um layer: Dimension of cesspool: Materials o construction: Indication o groundwater inflow(yes or no): Comments( ote condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): i PRIVY: (locate on site plan) Materials of c nstruction: Dimensions: Depth of soli s: Comments( ote condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of►l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM . PART C SYSTEM INFORMATION(continued) ]Property Address?8 Cherry street Owner: Hyannis. MA F.1 i �ahE,th R1 ackburn—Collado Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. g dd �D �p 1� i 10 Page I 1 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 28 Cherry Street Hyannis, MA - Owner: Elizabeth Blackburn—Collado Date of Inspection: &— lG 0 3 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to groundwater feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: -: You must descr i hpw you established the hi h ground water elevation: v e y 11 P Li1 s� TOWN OF BARNSTABLE SEWAGE # - 3c?3 VILLAGE , ASSESSOR'S MAP & INSTALLER'S NAME & PHONE NO. p //dSo.4/- J-/X fyl � SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (siie�)'X 15 V L' 3UULmu NO. OF BEDROOMS PRIVATE WELL OR.-PU4I aT ER� BUILDER OR O WNER DATE PERMIT ISSUED: `J� DATE COMPLIANCE ISSUED VARIANCE GRANTED: Yes No �� e 2 sysnJ ' s e a - 1 O f •� C 40. 00 No. � .. � '`" r Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01pplication for Mi!gpO.5aY *pgtpm Com9truction 3permit Application is hereby made for a Permit to Construct( )or Repair(x )an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. 28 Cherry St Elizabeth Blackburn Hyannis Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. W.E. Robinson Septic Sery P.O. Box 1089 Type of Building: Dwelling No.of Bedrooms 3 Garbage Grinder(n9 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 Description of Soil sand Nature of Repairs or Alterations(Answer when applicable) install a 1 500 a l septic tank d—box & c onnect to existing 1 �" `%4 Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued b this Boardof altp. r % Signed y Date Application Approved by Application Disapproved for the Vollowing reasons Permit No. G ��'� Date Issued _�,.,. " Aid .s�t- .r..-•TF�^.�'-.v, ...r..J `..�-Y��" 'S - a 7'' . ..�a."-es.r1`...+"!.%� �. x-+,5y1'�''"! .M'•''�`;'.`.+..-•.i\. +r-.v-r r�j.-•'..j,�.��°''"` � T k S�' ram,•,,..,,r -r `' kt, `.y Qf e� ID 'Llciw+�� Q / ` f I >t' i,�WYWIIr.+�" . i No. $7V . � ��'// Vf x K Fee 9 0.0 0 e - . .THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-TOWN OF BARNSTABLE., MASSACHUSETTS r ` , i fication for Migpoaf *pgtem Construct,on Vermit # Application is hereby made for a Permit to Construct( )or Repair(X )an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. - a'. 28 Cherry St Elizabeth Blackburn 'i Hyannis Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. W.E. Robinson Septic Sery k P.O. BOX 1089 t Type of Building: Dwelling No.of Bedrooms 3 Garbage Grinder(nq ` Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures f Design Flow gallons per day. Calculated daily flow gallons. u Plan Date Number of sheet Revision Date - �. Title � d ' Description of Soil sand Nature of RepairsorAlterations(Answer when applicable) install a 1 ,500 al se tic tank f d-box & c onnect to existing 1.e - Ja A; W j i Date last inspected: f -\-- Agreement: i The undersigned_agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system s in accordance with,the provisions of,Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued'b this Bo d of alth Signed _ V Date _ /— A plication Approved by ( - 1 Application Disapproved for the Vollowing reasons 1 Permit No. �Gj`�� " a Date Issued _ ---- —�—--i� __ ---- THE COMMONWEALTH OF MASSACHUSETTS £ j sPUBLIC"HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS (Certiftcate of Compliance ; THIS IS TO CERTIFY,that the On-site Sewag a Disposal System installed( )or repaired/replaced(X )on y by W.E. Robinson Septic Sery far Elizabeth Blackburn as zo erry St Hyannis has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 7/ dated -7 Use of this system is conditioned on compliance with the provisions setjogh below: No. l - a 3 Fee 4 0.0 0 Blackburn THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS ligogal *pmem Con,5tructton Vermtt Septic ServRobinson W.E. Se Permission is hereby granted to p to construct'(X )repair( )an On-site Sewage System located at 28 Cherry St Hyannis 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. All construction must be completed within two years of the date below. Date: 7—If— 112 Approved by � r.. .14 CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS) 4 t ✓ " , hereby certify that the application for disposal works construction permit signed by me dated �"�` , concerning the property located at G c S meets all of the CY following criteria: • There are no wetlands within 300 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system • The observed groundwater table is 14 feet or greater below the bottom of the leaching facility • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. SIGNED : 1 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]. •1 t �y 4 I � \I ._ ,�'�� —� s �, ^�� � /nr/( / � Y' TOWN OF BARNSTABLE L.0CATION 32K C i ��(_ S ` SEWAGE # ""�1 _ VILLAGE (- `/ 4wc4:i ASSESSOR'S MAP & LOT _ INSTALLER'S NAME & PHONE NO. i4-40 f_ L_A 0,j fs, <� SEPTIC TANK CAPACITY_ d,-,e ,SVr�� LEACHING FACILITY:(type) i�(��e Gt "s' Piq— (size) w� NO. OF BEDROOMS PRIVATE WELL ORjqBLIC WATER_ BUILDER OR OWNE vLl DATE PERMIT ISSUED: DATE COLIPLIANCE ISSUED_ VARIANCE GRANTED: Yes No_� c --� . 2 --� ��, Q.3 l6' _ '� x o � ,� � �- � a, n /� V � ` 1� 'CGa V +i � , v. t a �-p Fmc THE COMMONWEALTH-OF MASSACHUSETTS BOARD OF. HEALTH Appliration for Disposal Works Tonstrnrtion fermi# Application is hereby made for a Permit to Construct ( ) or Repair ( 't�i Individual Sewage Disposal System at: ..... .Location--Address .... ................... ... or Lot-No....• -•------•-- ............. ......'�� ....C34. s� ... .�mow--------------------- ---------•-----......=5�-!�^... -------------------_-_-_------____-_----------_-_- Owner a ........... p Address � aw.. . ----------- --------------------- : ........ ................................... .... Installer Address ' Type of Building Size Lot...........................Sq. feet ,., Dwelling—No. of Bedrooms.......... ..............................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of ersons____________________________ Showers a YP g ---------------------------- P ( ) — Cafeteria ( ) Otherfixtures --------------- ----------------------------------------------------------------•-•-----------------=--------------•-------............•-••---....... W Design Flow......... _....................gallons per person per day. Total daily flow.......__��__-___�_a_-.P..................gallons. OG Septic Tank ' Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ Disposal Trench—No_ ____________________ Width.................... Total Length________:..___.... Total leaching area....................sq. ft. 3 Seepage Pit No.___._.1------_..... Diameter.....L_D._...... Depth below inlet.....(0-......._. Total leaching area..................sq. ft. Z Other Distribution box (, ) Dosing tank ( ) aPercolation Test Results Performed.by.......................................................................... Date........................................ Test Pit,No. 1................minutes per inch Depth of Test Pit............._....... Depth to ground water......................... G4 Test Pit No. 2......:.........minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 ---------------------------------------------------- --------------------------------------------------•--...-----....-•------------------•- ----••-- 0 Description of Soil...............................................................................-.......................................................................................... V ------------------- _-_-___- - - �1 ...----•--................................................._...----------...__.._..-------•----••---••-•••---------------••----...--------•••-•---•-------•------...._.__...__-._.._..__.... x -- U Nature of Repairs or Alterations—Answer when applicable.__.__A4-10-9...___Q-.N ...... ............ rs .t ._._css_jpc .�- --- --=.....------------------------------------------------------------------------------------------ Agreement The undersigned agrees to install the ,aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITi LE 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 bo of health. Signed.. � j �i-----------•- ---•----- ' Date Application Approved By.................... - --+�.,. .................... '- "-�'6- Date Application Disapproved for the following reasons:.......................+........................................................................................ _ ........................................................................•--..._.....----•-----------...----------------..._._....--•--••-----•-•--.._..---------••-•--•--••---•••••----•-•------..._..._ Date PermitNo........ ----.........--------- Issued--------------- ----------•---•--------•-------------- Date �R.t�'�""7A.'�,..�—....r.eJ,:.`•,..���µ�.�..�.��.... r`I""�... .�.r.-a....,. .�...:.r•. .i�.:... .s..,.Svc-^�r.;'4c.,��:� t`�...,,•.:$�1. - ..s. �., .-.. ..r' .. � ..r•t-..,�. f y 4 c No.....E5------Li 3y C.J t✓ ,. b c� Fzz........ ...G THE COMMONWEALTH OF MASSACHUSETTS BOARD; OF HEALTH �b V.J.VI✓.......OF......�. !'� AV ' iration for Disposal Works Tonstrartion "trutit Application is hereby made for a Permit to Construct ( ) or Repair ( C)-a r` Individual Sewage Disposal System at: NST ............. ....................... ....................................................... Location-Address ----or.. Lot No. ko ...- Owner a G W • ► w --- v A:ddress `--r� � � ......:............... . ...._� .�-•......S- •9.........-_................ -------------------�...u- - -- ---••-----------------______-__-------•---•----_- M Installer Address Q7i Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms.........��.._____.---- .....Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers a YP g -------------•-------------- P (. ) — Cafeteria ( ) QOther fixtures ------------------------------•-----•..........---••-..•-••--•.._..--•••---•••••-•---•-----•-••••••••••-•--•-----•--...._.....-••••---........._--_... Design Flow: _..:."�Z .....................gallons per person per day. Total daily flow.......�-�Z�__....•.................gallons. Septic Tank—Liquid capacity,,..........gallons Length................ Width................ Diameter---------------- Depth................ Disposal Trench—No..................... Width...... Total Length.................... Total leaching area.........::_........sq. ft. Seepage Pit No,...'__.I__.__-____-- Diameter....t..l).__..... Depth below inlet.....f�-............. 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........................ L� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a •-------------------------------------...-•----------------------------••------------------------------------------.........•......-...... ••--•-------------- 0 Description of Soil......................................................................................................................................................................... W U Nature of Repairs or Alterations—Answer when applicable......4.10 D.._...�.1�: .......6 (5-........;�y.! .T................. -------------------------------------•-......... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITL is 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. --.. - ............ ........& .. ......................... ' Date APplica.tion Approved BY _ �' 1 ------------- -------- - £-�` . ." M. . V... `f ., —.:'```-` " _ `Date Application'Disapproved for the following reasons:.............................................................................................................. ....---••-•---------••-----------------------------------•---------------...-------------...-•------------••-••-•-•-•--•--•-•-•----------------...-•••••-•••---•------...-----••••••-••--•-•---••_•---- Hate Permit No....---- ----------. - __..__ ........................................................_.._._.....----------- Issued_•---- Date — -- ---------- ------ ---------- ---' THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ....47 w!A✓ ................. Tertif irate of Touts Hatta THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired Gi/� �- 14r.✓✓)....6:CJ'�_,:� �. . ................ --_-_----------•----•-----___.___----.......:.._._....... -bY-••----••....................v ..._ Install at_...--•--•-•-••-•`�....3-------�....�• -��!-----------°`.-- _ . !��,>ru------------------------------------•.........--••---------- --- ---- . has been installed in accordance with the provisions of TITIZ 5 of The State Sanitary Code as described in the application for,Disposal Works�Construction Permit No.........Sa..... ...... dated................................................ + THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE........................... .......��..: ............................ Inspector_.....-----........)----i ..;:....---------------•----...----••-----...........-- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............ 0F. J � .0..................... No.--R&:..� z/ .. ^ "I,.. FEE............ ..... Disposal Vorkp-,&notrurtion rerutit Permission is herebyranted........ ....... ......: �- l g .............. - , .- to Construct ( ) or Repair ( t-)-a.Iu Individual Sewage Disposal System at No.----••• ••. �1. Street as shown on the application for Disposal Works Construction Permit No________________ Dated`...._....._...._._.......__._....._._.... Board of Health DATE............... ---- 1 ...................................