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HomeMy WebLinkAbout0229 COMPASS CIRCLE - Health 229 COMPASS CIRCLE, HYANNIS A=310.427 D TOWN OF, — STABLE LOCATION y ®m/✓1455 SEWAGE # 9 �t A VILLAGE N�l AW�t ASSESSOR'S MAP & LOT ® ` INSTALLER'S NAME&PHONE NO.1JM Pz 1?, r3 Shia iL -7'2S--X'7?& SEPTIC TANK CAPACITY i 00� LEACHING FACILITY: (.type) I Y-\M►SC-1-s (size) f-i q�4 NO. OF BEDROOMS m� BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the. Maximum Adjusted Groundwater Table to the 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 i �� �� c � -� .. �� m � -cs � � �. r. 4�S! q'!�r , w s®� _ �� e - ._ - y ,� - • No. Fee 5 0 • 0 0 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: s / PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASVACHUSETTSYe c/ Z[ppYication for Migpogal 6pgtem Congtruction Permit Application for a Permit to Construct( x)Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No?2 9 Compass Circle Owner's Name,Address and Tel.No. Hyannis MA . �'' Joseph Maruca Assessor'sMap/Parcel / {1�y 420 South St Hyannis MA 02 601 Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No. W E Robinson Septic Service P O Box 1089, Centerville MA 0263 Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder J10) 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 T e a r_h i n g c o n s i s t i ng of a D-Box and three stnneparked maximizars —` 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 Env' onmental C e and not to place the system in operation until a Certifi- cate of Compliance has been issu d by th' th. Signed Date Application Approved by Date Application Disapproved for the following reasons Permit No d Date Issued "� TOWN OF BARNSTABLE LOCATION C'2c �' SEWAGE # 9,F=S Fy VILLAGE N N i S ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. L SEPTIC TANK CAPACITY I OVG LEACHING FACILITY: (type) - �i 1�1FaX�Nu�jC i� _ (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the 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 © - --- I y5' No. I 42 IF .. Fee 50.00 computer: COMMONWEALTH OF MASSACHUSETTS Entered in comp Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MAS ACHUSETTS applit'atton for Mi_qpo!6a1 6potem Conotrurtion Permit Application for a Permit to Con truct( X)Repair Upgrade Abandon El Complete System El Individual Components Location Address or Lot No 2 9 Compass Circle Owner's Name,Address and Tel.No. Assessor's Map/Parcel Hyannis MA Joseph Maruca 2/0 -,V .Z ? 4//4420 South St, Hyannis MA 02601 Installer's Name,Address,and Tel.No. 775-8776 Designer's Name,Address and Tel.No. W E Robinson Septic service P 0 Box 1089.,,- Centerville MA 0263� Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder(no) 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 Neaching consisting of a D-Box and three stonepackAd maximizers Ael Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenanc'e i of thdafore described on-site sewage disposal system in accordance with the provisions of Title,53 of the EE�nvnnn�iental C d I .4e and not to place the system in operation until a Certifi- cate of Compliance has been i7ssu d by th L� Palth. ,7—�r' vo� Signed- -,e-,,ol . — Date Application Approved by Date Ov Application Disapproved for the following reasons Permit No. Date Issued ;9 THE COMMONWEALTH OF MASSACHUSETTS Maruca BARNSTABLE, MASSACHUSETTS l Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed Repaired xxo Upgraded Abandoned( )by at 229 Compass Cir, Hyannis -has been constructed in accordance .41 n 7- 9 with the provisions of Title 5 and thef Di al System Construction Permit No. dated gy,Di _, Installer W E Robiri,-4on—_.qPnf0' Rgm,_,A,i -Designer 7 - . 7'The issuance of this rrrui�/W�111'n1z:!1>t-'be�cons �e&ras"guarantee that the syst '11 functioWis dsigned. Y' e a e wi Date 17 IF Inspector ---------- ---------------------------- No. 9 4?'- Fee $50.00 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Maruca Miopagat *pqtem Con5truction Permit Permission is hereby granted to Construct )Repair( X)Upgrade Abandon System located at 229 Compass Circle Hyannis lastaller W E -Robinson Septic Spryjcp 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: Construction must be completed within three years of the date of this 11q,0nit. Date: -Cl— Approved by 9 -, R NOTICE: This Form Is-To-Be Used-For the Repair-Of Failed- septic-systems-Only: CEWTIFICATtON-O -SKETC-J-NNaAPPLIC-AT10N--V0R,.A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT ENGINKERED PEANS)._ J 1, W-illiam-F:-maims ,Sr.-" - ,-hereby-s ify- hat-the-applicationfor-disposal forks construction permit signed by me dated �� �' , concerning the property located at 229 compass�ixcle�-H s, --meets-all-of the following criteria: J * There..are.na_wetlands_#ithin.100-feetof the proposed.leaching.facility. i * There are no private wells within 150 feet of the proposed septic system. * There-is.naincrease_in.flow-andlor-change-in.use_proposed. i * There are no variances requested or needed. * Ifthe-proposedleachingfaci14wilLbe_located with"ti0-feet_o£any._wedands,_the-buttom-of-the . proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table_elevation. Please complete the following: A).Top-of-Grnund Elevation-(according.to the Engineering Division.-G.I.S..map)-.. B)Observed Groundwater Table Evaluation(according to Health Division well map) SIGNED:-- ` DATE:.f^ ` LICENSE-A-SEPTIC S.S-TEN1 INST-ALLF-R1,N., -RE-T©W-14-OF-BARNSTABLE NUAMER, 20-1998 (Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, thisplan-shouldbe-submina --- Cyr a - -_ �� _ � � 1 L.1 �• V� ~ t�U COMMONWEALTH OF MASSACHUSETTS ' EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS 01 s DEPARTMENT OF ENVIRONMENTAL PROTECTION ® r ONE WINTER STREET. BOSTON. MA 02108 617-292- 500 1998 r a Olt .� ' �o� W ILLIAM F.WELD UDY CORE Governor ► Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner PART A CERTIFICATION 229 Compass Circle Joseph Maruca/Admin. Property Address: Hyannis, MA Address of Owner: 420 South Street Date of Inspection: 9—9 9 8 (if different) Hyannis MA 02601 Name of Inspector: Wm E Robinson Sr 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). Company Name: Wm E Robinson Septic Servic Mailing Address: PO BOX 1 089, C _nt.[Prvi 1 1 e, MA 02632 Telephone Numbery 508 ` 775_R776 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes _ Conditionally Passes Needs Further Evaluation the Local Approving Authority _ Fails Inspector's Signature: / Date: 9 t, 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: AJ 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 not evaluated are indicated below. COMMENTS: Bl SYSTEM 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. Indicate yes,no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined",explain why not: The septic tank is metal, 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.us/dep j Printed on Recycied Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM r� PART A CERTIFICATION (continued) Property Address: 229 Compass Cir, Hyannis '"Owner: Maraca ate of Inspection'9" 9—9 8 BJ,SYSTEM CONDITIONALLY PASSES (continued) ,)> {' +� tSewage 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) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: C ditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the blic health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) S STEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT T E SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE E VIRONMENT: 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: 229 Compass Circle, Hyannis Owner: Maruca Date of Inspection: 9—9—9 8 D] SYSTEM FAILS: You must indicate ei;!er "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 o 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 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE S STEM FAILS: You must in icate either "Yes" or "No" as to each of the following: Th 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 ublic health and safety and the environment because one or more of the following conditions exist: Yes o 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 ow er or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirem nts of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04/25/97) Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 229 Compass Cirr, Hyannis Owner: Maruca Date of Inspection: 9—9—9 8 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No / Pumping information was provided by the owner, occupant, or Board of Health. v _ 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. v _ 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 any of the failure criteria related.to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)) J1 (revised 04/25/97) page 4 of 20 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 229 Compass Cir, Hyannis Owner: Maruca Date of Inspection: 9—9—9 8 FLOW-CONDITIONS RESIDENTIAL: Design flow: L .p.d./bedroom for S.A.S. Number of bedrooms:_ Number of current residents: (�1' Garbage grinder (yes or no):�L0 Laundry connected to system (yes or no):I&�75 Seasonal use (yes or no): %o Water meter readings, if available (last two (2) year usage (gpd): 6/9 6 — 6/9 7 — 9200 cu f t ( 69, 000g) Sump Pump (yes or no):A�.� 6/9 7 _ 6/9 8 — 6100 cu f t ( 45, 750g) Last date of occupancy: C MERCIAUINDUSTRIAL• Type of establishment: Des ig flow: gallons/day Grease trap present: (yes or no)_ Ind ustri I Waste Holding Tank present: (yes or no)_ Non-sa nary waste discharged to the Title 5 system: (yes or no)_ Water eter readings; if available: Last d to of occupancy: OTHE : (Describe) Last d of occupancy: GENERAL INFORMATION PUMPING RECOltR✓DS end source of information: r A System pumped as part of inspection: (yes or no)"e' If yes, volume pumped: a-e o gallons Reason for pumping: WA)"O TYPE 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) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage.odors detected when arriving at the site: (yes or no) lb (� . t - (revised 04/25/97) Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 229 Compass Cir, Hyannis Owner: Maruca Date of Inspection: 9—9—9 8 BUI T ING SEWER: (Local on site plan) Depth low grade: Material f construction: _cast iron _40 PVC_'other (explain) , Distanc from private water supply well or suction line Diame r Comme ts: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK:_ (locate on site plan) Depth below grader S6 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: lL Sludge depth: C�' J Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: 0 Distance from top of scum to top of outlet tee or baffle:_ Distance from bottom of scum to bottom 91 outlet tee or baffle: �1 How dimensions were determined: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level n relation to outlet invert, structural integrity, evidence of leakage, etc.) 00 � o/ l� I �14'A ^� i >7 K 10 ab t AS rV GREA E TRAP: (locate on site plan) Depth low grade: Materi I of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain) Dime sions: Scu thickness: Dist nce from top of scum to top of outlet tee or baffle: Dis nce from bottom of scum to bottom of outlet tee or baffle: Da of last pumping: Com ents: (reco mendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural inte ity, evidence of leakage, etc.) (revised 04/25/97) Page 6 of 10 V t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) -Property Address: 229 Compass Circle, Hyannis Owner: Maruca Date of Inspection: 9—9—9 8 T HT OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection) (lo to on site plan) Depth low grade: Materia of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain) Dimensi ns: Capaci gallons Design low: gallons/day Alarm I vel: Alarm in working order_Yes; _ No Date of revious pumping: Comme ts: (conditi 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 eqqual, evidence of solids carryover, evidence of leakage into or out of box, etc.) PU CHAMBER:_ (loca a on site plan) Pu s in working order: (Yes or No) Al ms in working order (Yes or No) C ments (not condition 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: 229 Compass Circle, Hyannis Owner: Maruca Date of Inspection: 9—9—9 8 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: leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of pgndin , condition of vegetation, etc.) CESSPOOLS: _ l_d i I(locate on site plan) >, Number and configuration: v Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Co ents: (not condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PR _ (Io to on site plan) Mat vials of construction: Dimensions: Dep of solids: Com ents: (not condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (zevieed 04/25/97) Page 8 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 229 Compass Circle, Hyannis Owner: Maruca Date of Inspection: 9—9—9 8 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) Y �- V � r (revised 04/25/97) Page of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 229 Compass Circle, Hyannis Owner:.;Z MaruCa Date of Inspection: 9—9—9 8 x. Depth to Groundwater L Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record tAbservation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps 9 Check pumping records Check local excavators, installers Use USGS Data Describe gu�,p wn wordshow y¢u established the High Groundwater Elevation. (Must be completed) .(revived 04/25/97) Page 10 of 10 1 LO-C ' T 0 SEWAGE P M NO. z �MAV A 64-67 VI L'AG E INSTA LLE S NAME & ADDRES BUILDER OR WNER DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED s c If r f1 E G N .. .. .. .... THE COMMONWEALTH OF MASSACHUSETTS BOA FAD I-1 EATH - - ..................O F........... ......................................... , ppliration for DWposFal Works Tonstrurtinn Prrmit Application is hereby made for a Permit to Construct �or Repair ( ) an Individual Sewage Disposal System at.2'z�...X. ............. -•••-••-•---------••---•-••...............• ••••••••...............•................. Locati dd s or t No. .............................. �..^ / ��j ................... ..•................ ner Address a .tea..... .._. ................................... Installer Address Uype of Building Size Lot....�Q_.,r_FF..Sq. feet Dwelling—No. of Bedrooms...._._ -__--_-Expansion ttic ( ) Garbage Grinder ( ) P4 Other—Type of Building .�jY -.a..-.-.---_--_ No. of persons........ .................. Showers (� — Cafeteria ( ) Ga Other_fixtures --•---------------------------•--- w Design Flow........�...�...........................gallons per person per day. Total daily flow.__...._...330. .__...._............gallons. WSeptic Tank—Liquid capacity..A q!Vgallons Length....... .____ Width.....?........ Diameter................ Depth................ x Disposal Trench—No.------z............. AAidth.................... Total Length.................... Total leaching area....4/d-7.....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...... ,,KA,!r ......... Date....�GU-..� .,p .. aTest Pit No. 1................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........................ 9 O Description of Soil...... L ........................................................... x �., w U Nature 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 TIT LE. 5 of the State Sanitary Code— The undersigned further agrees not to place the system i operation until a Certificate of Compliance has been i ed by�board h. - .i ned . .. to Application Approved By....` ........ --• ....... ...... ---------------•------- ...1 '� -7 ...... Date Application Disapproved for the following reasons:--•--------••-----•-------------------------------•--------------•••••--•-•-------•-....._......--•--...._..._.. --------------•-•-............----............_.....--------.....-•------------------•--•----------------._....._..-•.-------•-••------------------ r Date Permit No......................................................... Issued---•--•-- Date No..-•••-. ...��.s..... ............... THE COMMONWEALTH OF MASSACHUSETTS �� --- BOARD OF H�jEA�_,TH / v�✓....................... OF. .ik. , ....................................... �.. Appliration for Disposal Works (9vnstrurtinn rrrmit Application is hereby made for a Permit to Construct (/'� or Repair ( ) an Individual Sewage Disposal Systemt .. ..4 . --•---- f_.r- •------- ----• ---- ....................... ..... Location'--'Aildr ss or LA No. �j •-s:rC .. .-�... ..r,�............................... .....V:t..... tv1410 � ................................................. O her Address Installer Address Type of Building Size Lot......A�.:.rs k6)Sq. feet Dwelling—No. of Bedrooms..._._�.:................................Expansion ttic ( ) Garbage Grinder ( ) Other—Type e of Buildin s ..... No. of persons.........2................ Showers ( � — Cafeteria ( ) Gi g QI Other fixtures -------------------------------- .... W Design Flow_._....__ %..........................gallons per person per day. Total daily flow............�....�..._..........•....gallons. WSeptic Tank—Liquid*capacity....t?Q�gallons Length................ Width..... ........ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length._............_..... Total leaching area....4 72....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....... r :- Z46_............. =` !!?:-............ Date...../-/0. Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water.....v Oil Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 9 / • ----------------------------------- y.----- ............------......-•-•---•----...-.---..---..--•------•--•---••-•---•--•--•---.......----••... Descriptionof Soil a..............%?.....:......._ ..... ... ; ---� ------.........-----------------•-------•----....--------------•-- W U Nature 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 TITS.:; p 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been isAied by the board of health. / f� r Daie Application Approved By---- .....:: .. ...... . .. �- ------------------- Date e Application Disapproved for the following reasons: .......................................... ..............................................._..............................................................................._........................................................................ Date 0 PermitNo......................................................... Issued.............................. Date ... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF... f9rrtifirate of ToutpliFaatrr THIS IS TO GER. TIFY,1That�t a Individual Sewage Disposal System constructed ( r)� Repaired by......�. =.._.. :1.e!� ••--•:-•-••........•--••- ..-•----•-•••--------•-•--•-•-••-•••-•-•-•--•--•..................................••••......---•••......-•-- /E, IInst er v has been installed in accordance 451 the provisions of T 1 ''' r of The State Sanitary Code as described in the application for Disposal Works Constr'uetlon Permit No.- r-.--. .------_----_- dated....��."_���.".��._�__._..__.._. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.........................•--•---------------•--..........•••-•-._..._.....-•---• Ins pector-•-•----.....-----------------------.......... THE COMMONWEALTH OF MASSACHUSETTS BOARD 0' F 0,.ALT No........... ........... FEE - .......... . Disposal,Vor zT ton/ #r%ion rrmii YgPermission is hereb ranted--. ` ... ..,...... to Constr cat' ( or R-pair ( ) an Indivi.dual Swage Disposal System at No.. U7`. '----f •-•/A-n�, �_. (<�i _.._. .- .....�.......... •---• ----------------------- --------•-•----•--------------•-----.------ Street as shown on the application for Disposal Works Construction BeIVEt ....k..... . ....... Dated.... . 1 ' .......... ...._.. . ................................... DATE..... 2..` ��---------------------------------------- rBoard of Healt FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS f` i t r s if } �,FdGCII/a,^S XO �FiN+S H Cr'QA D�`-•g.�o i•- �1 N 4SF1 G1PJ4 vE F►tinrM G�t,4 Z�G" _ _ _. 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