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Home My WebLink About0311 COMPASS CIRCLE - Health Eoirnpass Circle P, 10 433 i 0 YOU WISH TO OPEN A BUSINESS? a For Your Information: Business certificates(cost$30.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L.-it does'not give you permission to operate.) Business Certificates are available at the Town Clerk's Office, 1' FL., 367 Main Street, Hyannis, MA_02601 (Town Hall) i .. - DATE: 1016106' Fill in please: ' APPLICANT'S YOUR NAME: /L'® Z» Die, : o JZA 0 � } � BUSINESS YO ME ADDR S GO/`l'P C/Z TELEPHONE # Hom Telephone Number 7 NAME OF NEW BUSINESS / D` ,AJ W 0 TYPE OF BUSINESS IS THIS A HOME OCCUPATI.ON7 . YES NO °L , Have you been given approval f o the build* division? YE NA ` � a N� :MAP PARCEL NUMBER a s ADDRESS OF BUSINESS— When ��J GZ / D 3�' o �_ When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of tfae Town ofn Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (co`" r of Yar&ou Rd. & Main Street),to make sure you have the appropriate permits and licenses required to legally operate your business in tm- town.=r- 1. BUILDING COMMISSIONER'S OFFICE rn This individual has bee formed y permit requirements that pertain to this type of business. °O Authorized Signature** FOLLOW HOME t OCCUPATION RULBS COMMENTS: Z g !G N S U i�E S 2. BOARD OF HEALTH This individual has bee forrve .of th ermit requirements that pertain to this type of business. -Z A horized Signature; COMMENTS: �Tz2te 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature.* COMMENTS: Date: O TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAME OF BUSINESS: / ,�j I � /off� ' BUSINESS LOCATION: 311 C04 �\ 5 CIZ INVENTORY MAILING ADDRESS: ZMA 9_121'-)"JI HA W601 TOTAL AMOUNT: TELEPHONE NUMBER: - 6 00 0 7 CONTACT PERSON: EMERGENCY CONTACT TELEPHONE NUMBER: MSDS ON SITE? TYPE OF BUSINESS: INFORMATIO /RECOMMENDATIONS: Fire District: Av-e Q�h Waste Transportation: Last shipment of hazardous.waste: Name of Hauler: Destination: Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous materials use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed/Maximum Observed/Maximum Antifreeze (for gasoline or coolant systems) _ Misc. Corrosive NEW USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road Salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides NEW USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel, Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil NEW USED Misc. petroleum products: grease, Photochemicals (Developer) lubricants, gear oil NEW USED Degreasers for engines and metal Printing ink Degreasers for driveways & garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Misc. Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt & roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (inc. carbon tetrachloride) NEW USED Any other products with "poison" labels Paint &varnish removers, deglossers (including chloroform, formaldehyde, Misc. Flammables hydrochloric acid, other acids) Floor &furniture strippers Other products not listed which you feel Metal polishes may be toxic or hazardous (please list): Laundry soil & stain removers (including bleach) c Spot removers & cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS COMMONWEALTH OF MASSACHUSETTS Z Z. . EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS . DEPARTMENT OF ENVIRONMENTAL PROTECTION RECENED. 1AP DARCEL NOV 0 4 2004WT . TOWN OF BARNSTABLE TITLE 5 HEALTH DEPT. OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Prop"Address-. 311 Compass Circle. Hyannis Owner's Name: Dorothy Beauvais Owner's Address: Date of Inspection:_fV-- �— L Name of Inspector:(please print) W i 11 i am E_ .Robinson Sr. Company Name: William E. Robinson Septic Service Mailing Address: P 0 Box 1089 Centerville, MA Telephone Number: t5081 775-8776 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 Sec bn 15.340 of Title 5(310 CIYIR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: /0z 'L d� Date:Jl�✓G-�3 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Heatthvr DEP)within 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 DEP.The original should be seat to the system owner and copies:sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the 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 6/192000 page 1 Page 2 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 311 Compass i rrl P Hyannis Owner. Date of Inspections s Inspection ummary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Sy em Passes: 1 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. Syste Conditionally Passes: One r more system components as described in the"Conditional Pass"section need to be replaced or repaired.Th system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. The septic is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,ekhibits_ ubstantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existing tank is rep aced with a complying septic tank as approved by the Board of Health. •A metal septic will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the is less than 20 years old is available. ND explain: Observation f sewage backup or break out or high static water level in the distribution box due to-broken or obstructed pipe(s)or ue to a broken,settled or uneven distribution box.System will pass inspection if(with approval of Board of ealth): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system quired pumping more than 4 tunes a year due.to broken or obstnxted pipe(s).The system will pass inspection if( ith approval of the Board of Health): broken pipe(s)are replaced obswctkm is tn=vod ND explain: Page 3 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:_ 311 Compass Circle Hyannis Owner: Dorothy Beauvais Date of Inspection: C.- Further Evaluation is Required by the Board of Health: t _ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is fail g to protect public health,safety or the environment. 1. stem will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the s stem 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. SysteT 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 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. — Th system has a septic.tank and SAS and the SAS is within a Zone 1 of a public water supply. — Th system has a septic tank and SAS and the SAS is within 50 feet of a private water supply,well. Thesystem has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more front a private ater supply well•• Method used to determine distance "This stem passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria d volatile organic compounds indicates that the well is free from pollution from that facility and the prese cc of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure c teria are triggered.A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 311 Compa Circle -le Hyannis Owner: Dorothy Be uv i Date of Inspection: — D. System Failure Criteria applicable to all systems: You ust indicate')+es"or"no"to each of the following for all inspections: Yes o Backup of sewage into facility or system component due to 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%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 SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within I00.feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or.privy is within a Zone 1 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.(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 or 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 (Yes/No)The system fails.1 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 Large Systems: T be considered a large system the system must serve a facility with a design now of 10,000 gpd to 15,000 g d. Y u must indicate either"yes"or"no"to each of the following: ( to following criteria apply to large systems in addition to the criteria above) y no _ 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 We Protection Area—IWPA)or a mapped Zone II of a public water supply.well I you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of arty large system considered a s ignificant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 0 The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 1 I OFFICIAL INSPECTION FORM-NOT FOR YOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 311 .Compass Circle Hyannis Owner: Dorothy Beauvais Date of Inspection: U Cr Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No/ 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? 1/ 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?. 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 site inspected for signs of break out? Were all system components,excluding(he SAS,located on site? 4,1 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? _ _v 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:, Yes 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 Cis at issue approximation of distance is unacceptable)[310 CMR 15302(3)(b)) i 5 Page 6 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 311 Compass Circle Hyannis Owner: Dorothy Beauvais Date of Inspection: /0—G —O y/ FLOW CONDITIONS RESIDENTIAI. Number of bedrooms(design):. Number of bedrooms(actual): _l DESIGN flow based on 310 CMR 11.203(for example: 110 gpd x t/of bedrooms): . 66 Number of current residents: Does residence have a garbage der(yes or no):_e!�- d Is laundry on a separate sewage system(yes or no): C[if yes separate inspection required] Laundry system inspected(yes or no):*-d Seasonal use:(yes or no): .Va 3 Water meter readings,if available(last 2 years usage(gpd)): 2003 — 750 gal Sump pump(yes or no):ti� — gal Last date of occupancy: COMMERCIA NDUSTRIAL Type of establis lent: Design flow(b ed on 310 CMR 15.203): gpd Basis of desio now(seats/persons/sgft,etc.): Grease trap esent(yes or no):_ Industrial w ste holding tank present(yes or no):_ Non-sani waste discharged to the Title 5 system(yes or no):_ Water met r readings,if available: Last date f occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no): If yes,volume pumped: gallons-=0ow was quantity pumped determined? Reason for pumping: &10��i TylpF OF SYSTEM eptic 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/Altemative 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: Were sewage odors detected when arriving at the site(yes or no):zu 6 ]'age 7 of OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 311 Compass Circle Hyannis Owner:Dorothy Beauvais Dale of inspection: 'dr BUILDILnstruction: locate on site plan) Depth b Materialn:_cast iron _40 PVC_other(explain): Distanceater supply well orsuction line: Commen of•outts,venting,evidence of leakage, J g, ak c etc.): ) SEPTIC TANK: /(1ocate on site plan) Depth below grade: e a Material of construction: on _metal_fiberglass_polyethylene _other(explain) If tank is metal list age:_ Is age confirmed-by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions:-- ,a. [� k � Sludge depth:_ O —1 � Distance Gom top of sludge to bottom of outlet ice or baflle4, , 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: L How were dimensions determined: d �� e 1✓ rS Comments(on pumping recommendations,inlet and outlet tee or baffle conditicn,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): r �- l� GREASE TRAP:_floc *`on site plan) Depth below grade:_ Material of construction: concrete._metal fiberglass_polyethylene—other (explain): — Dimensions: Scum thickness: Distance from top ors um to top of outlet tee or baffle: Distance from bottom mpin pum f scum to bottom.of outlet tee or baffle: Date of last pug Comments(on ng recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet' vert,evidence of leakage,etc.): 7 Page 8 of 11 7 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 311 .Compass Circle Hyannis Owner: Dorothy Beauvais Date of Inspection: dh_G TIGHT or HOLDING T K: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction- concrete mewl fiberglass_polyethylene other(explain): Dimensions: Capacity: itallons Design Flow: gallons/day Alarm present(yes r no): Alarm level: Alarm in working order(yes or no): Date of last pum tng: Comments(con ition 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.): G� PUMP CHAMBER: (lo to on site plan) Pumps in working order(y or no): Alarms in%working order cs or no): Comments(note conditi n of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 311 Compass Circle Hyannis Owner: Dorothy Beauvais Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): V(locate on site plan,ezcavation'not required) If SAS not located explain why: Type 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.): 76 n :r CESSPOOLS: (cesspool mu be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet in ert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater nflow.(yes or no): Comments(note conditio of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (loca on site plan) Materials of cons ction: Dimensions: Depth of solids: Comments(note ondition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 311 Compass Circle Hyannis Owner: Dorothy Beauvais Date of Inspection:/U— —6� 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� 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 311 Compass Circle Hyannis Owner.Dorothy Beauvais Date:of Inspection: / —e,-A q SITE EXAM Slope Surface water Check cellar. Shallow wells Estimated depth to ground water 1LS 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 propertylobservation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) t�ccessed USGS database-explain: You must describe how you established the high ground water elevation: 11 f SEWAGE PER N Lo T C G �� V LLA E NAME D ADDS INST A, LLER' ar BUILDER OR 0 . NE.0 DATE P.:EI(MIT ISSUED C ® MPLIANCE ISSUED i'� _ %, k�•— '7� DAT E ' .A9 Qo Cal a �I 4 NO..: .r..'�... _....... ..._ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Q. .................OF..... AVp ira#inn for DhipogFal Works Toustrnr#inn ramit Application is hereby made for a Permit to Construct (111�_or Repair ( ) an Individual Sewage Disposal System at: �1css -3� Locaf eLr ��j a ` - _............ /.( _.. ... � Ower i- Addrtess .... . . / .......................... ............ ---___-_________ -------------•--.......------------ ..._ ................... ..... Installer I Address Q Type of Building Size Lot......Z 491CL_Sq. feet a Dwelling—No. of Bedrooms.__ __._ Expansion Attic ( ) Garbage Grinder ( ) ----------- aOther—Type.of Building <___ No. of persons...... ................. Showers ( ) — Ca pia ( ) QOther fixtures -------------------------------•--••-----------.._..--.-----------•-------------------------------._...------------------•-•------.._..--`: W Design Flow....... .........................gallons per person per day. Total daily flow............. �_�_n....................gallons. W Septic Tank—Liquid capacitylApdgallons Length_ ______X_ Width________________ Diameter__-________.____ Depth___._____._.__-- x Disposal Trench—No_.................... Width.................... Total Length.................... Total leaching area_.-,.-? /=__.._._.sq. ft. Seepage Pit No......10.1(_97_ Diameter.......d.......... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box (} ) Dosing tank '-' Percolation Test Results Performed by.., �'T14 __ !;w �J _________________ Date___.��'�? / _/, , Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water_..40C'.^'......... 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Chi ...............------------•---••---•-•. . _ ._.._._.. �........... _ Description of Soil._ @ � <=z'J� `�� P `� .,... ...�-- -•x................ ... U ••-•--•----------------- ---•------•---------•--- ------------------------- •------------------------------------------ ------------ ... ---------- •--•••---------W UNature of Repairs or Alterations—Answer when applicable_______________________________________________________________________________________________ ._...----•--.......--•-••-•----------•---••-----•••----------•--•-----•----•-•••••••••-•-----------•.................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITIE 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. Signe -• •-- -•••_._.......e�.�� .. -Application ---�-•------ A A PProved B _______ Y --'--��•-------•••••----.......•••------------------•----•----........._..•-•--- -•• �- G.--- Date Application Disapproved for the following reasons:-------•-----------••.............•--------------------•--•---•-------------•--------------••---•-._....._••--•- . .......•••--•••----•-.._..---•--------•---•-•-----•-••-•-•---•---•--•••-•--------••-•---.._..•--•---....... ,,� t . ----------•--- Date ��.�_ j; Permit No... �...........-•------•-•--•----•--•-... Issued.. ••-==•=-••-••-•--:.......................••- Date a No.... ....... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .................OF..... / �.r. F, Allp iration for Disposal Works Tonstrnrtion Vrrmit Application is hereby made for a Permit to Construct (sue) or Repair ( ) an Individual Sewage Disposal System at ... - -- -- Location-Address /C r Lot o. --...... t 1 Ow er Address _ _�____-___ �_ f A/7.1L .......................... ..............................^_._............................/ ................ .......................... Installer Address d� Type of Building Size Lot.......✓�''f.r� ..Sq. feet a, Dwelling—No. of Bedrooms.... ...... ........... . .....Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building, ..... _. No. of persons......6................. Showers ( ) — Cafeteria ( ) d Other fixtures -----------•---------------------------•-------------......•--------------....---------------••"......--'-'-.. _, -, W Design Flow........ ............................gallons per person per day. Total daily flow............t '.==. ..................gallons. WSeptic Tank—Liquid capacity.lC?t' gallons Length._`_..... . Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Width................ Total leaching area..-Fe'./........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. I................minutes per inch Depth of Test Pit.................... Depth to ground water..t° .`` .. (z, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ---•------------••----•-----••-•--......... -----...... .---.•-- --... . O Description of Soil--- o _.• r,.......� �.... f" j�, U --•----'--•----'------•----'•-'-------•---•--•---'--•----------•-----•-•..................•-••-----.._...-'-•-'--------••--•----'-'-'••......-_.. W x -------------------------- ----------------•-------'---•-••---••••-•-'-------------•'•'-"----•----•--•••--'•---------------•-'------------------••-•-'----•••••--.._.................-•-.............. 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 TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been is lied by the board of health. _ P Signed-., .............--...... .......................... ........ Date Application Approved B _f ........................................0 ' PP PP Y Date Application Disapproved for the following reasons----------------•----------------•----------'-'--------------'---•--------------•-••'-'---'--'•'-••-'-'-"......• -•'----'--------------------•----•--•'---•--------••-•------•--------------------•----"•-----•-'•"_---•.._.....'--'--'-"'-•-'-'-----'---•'-'--:..-•--"--"--'-----------•••'-----•'-••'•----••-•-•••- Date Permit No.........................................................'�� Issued j" ~_T r7_.r.. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH w FF up rrtifiratr of Tom-plionrr THI IS TO 'CERTIFY, Th, the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by --....-•-- '•'-••....----•'--'--------------------•---•••-....---.......---•""---..._................--'-......--••-.....-'-•--_.._. Inst 1 �c •.• -•----"'----------'...................'-•-•---------....----'------- has been installed in accord nce with the provisions of TZT LE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.......S7......................... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.................................................................................... ° THE COMMONWEALTH OF MASSACHUSETTS A. BOARD OF'=.;':HEALTH -! No......................... FEE.----...`-..... ....... Disposa or�Zt on tr ion permit I , Permission is hereby granted .. '`' -----••.............................•....... to Construct � or Repair ( ) -n Individual Sewage Disposal System atNo...... `------`=--- .( ...............------------....-----.....----'-••----.•....----------•-••---•"----...•---- Street as shown on the application for Disposal Works Construction Permit No..__.z.rJ......... Dated......... `. :.. ........ .............................."---•'---.....'---------....---...........---....'-'---..........__..._.» Board of Health DATE............................................................................ , FORM 1255 HOBBS & WARREN, INC., PUBLISHERS Lob r_b 5.r' ...� _'n. • i , _ • ""Sad kk."" •J,. ' .z - • A 1' Y T a. 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