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HomeMy WebLinkAbout0115 ENTERPRISE ROAD - Health ViNTERPRISE ROAD, HYANNIS A=94 054 a J 4' k r { No. 7 d Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Zippfication for Mi5po.5ar *pgtem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ❑Complete System El Individual Components Locations Address or LotNo. Owne,''ss-+Name,Address and Tel.No. Assessor's 1Napl ar�el 9 -os`1 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. GUx (,-0 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) 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 Nature of Repairs or Alterations(Answer when applicable) 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 by this oard o ealth. _ Signed / Date /,t,) •S `�� Application Approved by DateL,/�f Application Disapproved for the fo owing reasons Permit No. 7 ` Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded( ) Abandoned( )by at has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. -dated Installer Designer The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date Inspector �j t � - • .. . .j.. ';4Y3..4• , 4`�(rP.:.. :"t...wnw, ,.-..sT^-s..i:. ..r'r ......i, •s/•'y.r •.M• Y -•j' "'y`�-ti No. e4e ' THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: IYes PUBLIC}HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Zipphration for Mi-4pozar *p!tem �Com6truction ernttt Application for a Permit to Construct Repair Upgrade( 1)Abandon ❑Complete System ❑Individual Components PP ( ) P ( ) Pg � ( ) P Y � P Location Address or Lot No. n / Owner s Name,Address and Tel.No. - Assessor's/ az7O�nn Installer's Name,Address,and Te1rNo. - Designer's Name,Address and Tel.No. Type of Building:' Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. ylan Date Number of sheets Revision Date ti Title Size of Septic Tank Type of S.A.S. Description of Soil + Nature of Repairs or Alterations(Answer when applicable) Date last inspected: y 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 issu d by thisofoard o ealth. _ Signed (' Date Application Approved by Date IX — — Application Disapproved for the fo owing reasons Permit No. C7 X " '7 7 `/ Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed/ )Repaired ( )Upgraded( ) Abandoned( )by at has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer Designer The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date Inspector --------------------- ----------_------ No. Fee THE COMMONWEALTOF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS 0iopogal �teMi C ttgtr c ivr�_. ermit Permission is hereby granted to Construct( )Repair( )Upgrade( ) bandon( ) System located at 4"t 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 permit. Date: / T�r�/ Approved by ,� TOWN.OF BARNSTABU B _ DING PERMIT APPLICATION Map. Parcel .IS' Permit# Health Division Date Issued Conservation Division Fee Tax Collector S2�'TgC ��S Treasure �� WITH Tfi 5 ENVIRONMENTAL CCLEa AMD Planning Dept. TOWN REGULAT;; ; Date Definitive Plan Approved by Planning Board Historic-OKH Preservation/Hyannis Project Street Address `t CT)tn/ L— f Village Owner Address Telephone Permit Request 6f:� i I n JL Square feet: 1 st floor:existing proposed 2nd floor: existing proposed Total new Estimated Project Cost Zoning District Flood Plain Groundwater Overlay Construction Type Lot Size Grandfathered: ❑Yes ❑No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House: ❑Yes ❑No On Old King's Highway: ❑Yes ❑No Basement Type: ❑Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: existing new Half:existing new Number of Bedrooms: existing new Total Room Count(not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑Gas ❑Oil ❑ Electric ❑Other Central Air: ❑Yes ❑No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑No Detached garage:❑existing ❑new size Pool:❑existing ❑new size Barn:❑existing ❑new size Attached garage:❑existing ❑new size Shed:❑existing ❑new size Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ 1 Commercial ❑Yes ❑No If yes,site plan review# N rr Proposed Use _. Commonwealth of Massachusetts Executive Office of Environmental Affairs Dept. of Environmental Protection One winter Street,Boston,Ma. 02108 Jolm Grad D.E.P. Title V Septic Inspector P.O. Box 2119 Teaticket, MA 02536 WILLIAM F.WELD (508)564-6813 Governor ARGEO PAUL CELLUCCI Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Mn,PaCN Pa(,.cosy L. I ) Property Address: 114 Enterprise Rd.Hyannis Address of Owner: Date of Inspection: 8115198 (If different) Name of Inspector: John Graci Dave McCarthy;135 Hollidge Hill Lane Marstons Mills Ma.02648 1 am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000) Company Name,Address and Telephone Number: 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: x Passes This Inspection Is based on criteria dented In Title V Conditional) Pa es code 310CMR16.303.Myftndings are of how the system Is performing atthe time of the Inspection.My inspection does — Needs Fur er valuation By the Local Approving Authority eeptlepeyNatem warranty d any oil or s components useful Itre ofths Fails Inspector's Signature: Date: sn6198 The System Inspector shall su mit a copy of this inspection report to the Approving Authoritywithin thitty(30) ,a days of comp) ing is inspections. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector,and the stem own r s. II submit the report to the appropriate regional office of the Department of Environmental Protection. f , The original should be sent to the system owner and copies sent to the buyer,if applicable and the;approving aE� r® 11r AUG 1 1998 INSPECTION SUMMARY: � TOINNDFSARNSTA9LE ` HEAITHDEPT. Check A, B, C,or D: � A] SYSTEM PASSES: �• � x I have not found any information which indicates that the system violates any of the failure criteria defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B] SYSTEM CONDITIONALLY PASSES: _One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes inspection. 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 exhlbatiun, of lank 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 04r1757) One Winter Street • Boston,Massachusetts 02108 . FAX(617)556-1049 • Telephone(617)292-5500 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 114 Enterprise Rd.Hyannis Owner: Dave McCarthy;135 Hollidge Hill Lane Marstons Mills Ma.02648 Date of Inspection:9115198 _ Sewacte backur)or.breakout or hiQh.static water level observed.in.the distribution box is due to a broken. or obstructed pipe(s)or due to 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 leveled 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: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public 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) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface of water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply well. The system has a septic tank and soil absorption system and 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 presense of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid) 3)Other D] SYSTEM FAILS: You must Indicate either"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 No Backup of sewage in 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 cesspool. SAS is in hydraulic failure. (revised 04127)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Enterprise 114 Property Address. Rd.Hyannis Owner: Dave McCarthy;195 Hollidge Hill Lane Marstons Mills Ma.02648 Date of Inspection:W15199 D]SYSTEM FAILS(continued) Yes No 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 112 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Numbers 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 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. 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 SYSTEM FAILS: You must indicate either"Yes"or"No"as to each of the following: The following criteria apply to large systems in addition to the criteria: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes 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 Wellhead Protection Area(IWPA)or a mapped Zone 11 of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 041271971 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: 114 Enterprise Rd.Hyannis P Y rP Owner: Dave McCarthy;135 Hollidge Hill Lane Marstons Mills Ma.02648 Date of Inspection:8115199 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: _c_ — Pumping information was requested of the owner, occupant,and Board of Health. x None of the system components have been pumped for at least two weeks and the 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. _x As built plans have been obtained and examined. Note if they are not available with N/A. x — The facility or dwelling was inspected for signs of sewage back-up. x — The system does not receive non-sanitary or industrial waste flow. -x_ — The site was inspected for signs of breakout. x All system components, excluding the Soil Absorption System, have been located on the site. x 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. x 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 Systens. x Existing information. Ex. Plan at B.O.H. x Determined in the field(if any failure criteria related to Part C is at issue, approximation of distance is unacceptable)[15.302(3)(b)] (revlsed 04127)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 114 Enterprise Rd.Hyannis Owner: Dave McCarthy;135 Hollidge Hill Lane Marstons Mills Ma.02048 Date of Inspection:9115198 FLOW CONDITIONS RESIDENTIAL: Design flow: 0 9•P•d./bedroom for S.A.S. Number of bedrooms: 0 Number of current residents: 0 Garbage grinder(yes or no): No Laundry connected to system(yes or no): No Seasonal use(yes or no): No Water meter readings,if available:(last two(2)year usage(gpd): rda Sump Pump(yes or no): No Last date of occupancy: n1a COMMERCIAL/INDUSTRIAL: Type of establishment: Commercial Buildings e000 square feet Design flow:0 gallons/day Grease trap present: (yes or no) No Industrial Waste Holding Tank present:(yes or no) No Non-sanitary waste discharged to the Title 5 system:(yes or no) No Water meter readings, if available: nra Last date of occupancy: nra OTHER:(Describe) rda Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: rda System pumped as part of inspection: (yes or no)No If yes,volume pumped:0 gallons Reason for pumping: rda TYPE OF SYSTEM x Septic tank/distribution box/soil absorptions 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 Information: 2026 years Sewage odors detected when arriving at the site:(yes or no) No (revised 04127)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 114 Enterprise Rd.Hyannis Owner: Dave McCarthy;135 Hollidge Hill Lane Marstons Mills Ma.02048 Date of Inspection:9115198 SEPTIC TANK: x (locate on site plan) Depth below grade: level Material of construction:x concreate metal FRP Polyethylene—other(explain) If tank is metal, list age pia_. Is age confirmed by Certificate of Compliance No (Yes/No) Dimensions: Le'6^h5-7"w4'10" Sludge depth:10" Distance from top of sludge to bottom of outlet tee or baffle: 24" Scum thickness:" Distance from top of scum to top of outlet tee or baffle:4" Distance form bottom of scum to bottom of outlet tee or baffle:e" How dimensions were determined: Measured Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage, etc.) Septic tank and all components are structurally sound and functioning property.Recommend pumping now and then maintained two years. GREASE TRAP: (locate on site plan) Depth below grade: rda Material of construction: _concrete_metal_FRP_Polyethylene_other(explain} Dimensions: rda Scum thickness:nfa Distance from top of scum to top of outlet tee or baffle:rda Distance from bottom of scum to bottom of outlet tee or baffle: rda Date of last pumping;,t— Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage, etc.) n!a i BUILDING SEWER: (Locate on site plan) Depth below grade: 5-- Material of construction:_cast iron_40 PVC_other(explain) Distance from private water supply well or suction line?o— Diameter. nla Comments:(conditions of joints, venting,evidence of leakage, etc.) (revised 04117)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 114 Enterprise Rd.Hyannis Owner: Dave McCarthy;135 Hollidge Hill Lane Marstons Mills Ma.02648 Date of Inspection:8115198 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: rda Material of construction:_concrete_metal_FRP_Polyethylene—other(explain) Dimensions: nra Capacity: nla gallons Design flow: rda gallons/day Alarm level:_nia Alarm in working order?_Yes_No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches,etc.) rda DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: n1a Comments: (note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box etc.) Na PUMP CHAMBER: (locate on site plan) Pumps in working order:(yes or no)ILo Alarms in working order(yes or no)_v,,. Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) rda (revised 0427197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C M INFORMATION continued SYSTEM (continued) Property Address: 114 Enterprise Rd.Hyannis Owner: Dave McCarthy;135 Hollidge Hill Lane Marstons Mills Ma 02648 Date of Inspection:8t15f98 SOIL ABSORPTION SYSTEM(SAS):x (locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: roa Type: leaching pits.number: 2.1000 gallon leach pits connected to Septic tank leaching chambers, number:nla leaching galleries, number: nla leaching trenches, number,length: nla leaching fields, number, dimensions:nla overflow cesspool, number:6'x5'block connected to main cesspool Alternate system: nra Name of Technology._Wa Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) The leach pits and cesspool are all empty.The pits have not had more then 1.5'In them,the overflow cesspool shows signs or being full. CESSPOOLS:x (locate on site plan) Number and configuration: one Depth-top of liquid to inlet invert: empty Depth of solids layer: nia Depth of scum layer: nla Dimensions of cesspool: 5'x6' Materials of construction: block Indication of groundwater: nla inflow(cesspool must be pumped as part of inspection) rda Comments: (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.) Main cesspool and all components are structurally sound,recommend pumping system every one year. PRIVY:_ (locate on site plan) Materials of construction: rUa Dimensions: Na. Depth of solids: nla Comments: (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.) We (revised 04127)97) • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 114 Enterprise Rd.Hyannis Dave McCarthy;135 Hollidge Hill Lane Marstons Mills Ma.02848 8J15198 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) I co C7V M (rwloado4f ST) Pay ! o! 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 114 Enterprise Rd.Hyannis Dave McCarthy;135 Hollidge Hill Lane Marstons Mills Ma.02648 8115198 Depth of groundwater 12 Please indicate all the methods used to determine High Groundwater Elevation: Obtained from design plans on record. Observation of Site(Abutting property,observation hole, basement sump etc.) Determine it from local conditions Check with local Board of Health Check FEMA Maps Check pumping records Check local excavators, installers x Use USGS Data Describe in your own words how you established the High Groundwater Elevation.(MUST be completed) USGS Maps and Charts (revisedo47/197) sage 10 of 10 TOWN OF BARNSTABLE IQCATION ��J � it—�� SEWAGE # VILLAGE ASSESSOR'S MAP & LOT — oS5 � � L SEPTIC TANK CAPACITY LEACHING FACILITY: (type) i ) NO. OF BEDROOMS B-Hffl:HEit-EftOWNER 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 TOWN OF B STABLE LOCA';`" a L SEWAGE # '1ILLAGE IBIS ASSESSOR'S MAP&LO INSTA',LER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 1 o LEACHING FACILITY: (type) 4 n--�*—(�ta sa- fly (size) NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: COMPLIANCE Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet' Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility!(If any wet ds exist within 300 feet of leaching facility) Feet Furnished by J _ 1 n �, �, o .� , . LOCATION SETA E PERMIT NO. ILLAG INSTA LLER'S NAME i ADDRESS .4c amfz BUILDER OR OWNER , � v C o0 s use( y-fs DATE PERMIT ISSUED DATE COMPLIANCE ISSUED /,0 4 JL j . VD a .� FEB......j...�......... THE. COMMONWEALTH OF MASSACHUSETTS ' BOAR® OF HEALTH ..........................."...............O F................... Appliration for Uhipos al Worko Tonstrnrthin Vamit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: 1v n. AIL/s� a� ..... �� .:. ..._ - --.............................................. .......••---•--•-•-••-•--......--•-----•---. ............................ --.. .. ---------•-------- Location-Address or Lot No. ..V-----..L.: 4�.L ...... IL '--? ............... Owner Address _........c.czs�.�,.5 .......................................... ..........----•-...1'� A_ 1.�.15� °b.1 5. .......................... Installer Adflress Type of Building Size Lot.., _Q G.......Sq. feet U Dwelling—No. of Bedrooms.........................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building a No. of persons............................ Showers — Cafeteria Pa Other fixtures :----------_----------- ------ . W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width....;................ Diameter---------------- Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet................................ Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) �-' Percolation Test Results Performed by.......................................................................... Date........................................ aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a 0 Description of Soil---------------•------••----------------.....................----•-•--------------------------------------------------------------------------•••••.....-----------•.... U -•-.....••••--•--•••------•••--••-•--•-------•--•---------•---....-•--•-••----•----••----......•-••-••--•-•--------•---------------------••-•---••-•---••--•-----••••-•----•----••-•-•-•------••-------- W UNature of Repairs or Alterations—Answer when applicable_:!�.-?04®_.. ._........? .... .............................................................. !�" ..........=.......................................................................-..................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITH:*• 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance h issued 1 y the boar of healt Jam.... ., J Date Application Approved By....------•- - ---•Z--------------------------•--- ......�11.........P:"_f ..... -----------------------------------------------•................-•Date----•-------•. Application Disapproved for the following reasons__________________________ Al ..............•-----........-----•----------------------......------------------------•-•---------------.-----•----••-----••--•-•---------------------•--••••••---•-•-••----•••-----•---•••------.....•. Date PermitNo----------------------------.......................................................... Issued....................................................... Date =� No. ....fi;g4 ... `r 1' Fss......`3.....'-'°' ...... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ' ........................._.................OF.........................------...........-- ........ ApplirFation for Mqpaaal Works Tonstrurtion ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at ............. ...s // -.... ------------------------------------------ Location-Address or Lot No. 4 c2 _tla.......L"IC.91 LMt--..... ? u:S •r........... .................... ....Lam................. \� Owner Address Installer AZess Type of Building Size Lot..Ay.OAG.......Sq. feet a, Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) �--4 Other—Type of Building ... No. of persons............................ Showers — Cafeteria a, Other fixtures ------------------------•------•-- W Design Flow•.•.........................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid'capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No---_------_------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water......................... Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a .............................................................................................................................................................. 0 Description of Soil..............................------------------------------------------------•---------------------------------•-•-------•--------------••-•--•---------------- ----------------------------------------------------------x W ----••......----•• --•--••-•-------•------------•-• -••--••--•-----•-•......•-••-•-••••---•........................................................... .................................... UNature of Repairs or Alterations Answer when applicable .xO04 4 ....�....lD�?... T Agreement: The undersigned agrees to install the aforedescribed Individual.:Sewage Disposal System in accordance with the provisions of TIT1:;=. 5 of the State Sanitary Code— The undersigned,,#urther agrees not to place the system in operation until a Certificate of Compliance h . issued by the boar of healt ------------- ...................._.... Application Approved By............. ......'_lV..s-^��r ..--- �_L at Date Application Disapproved for the following reasons:-•-----------------------•----------•------------------•---------------------------------------•-------•••--•. -•••••----••----•-•-•-•-.....•••-•----------•--•--•-------•------•------•••-----•.........-••-••----•••--...............•••--•---•......---------•••----- ••----•---•--•--•--•------. ••----•••..----- Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........... .. 7`' `. ..OF..... ......................................... Tntifiratr of Toutplianrr THIS IS TO CERTIFY That the Individual Sewage Disposal System constructed ( ) or Repaired ( ` by---------------- r_• ........` .......................-------------------••--------...------•----------------------•------...............-•--•----•-----•--------. L Instill has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No---ts�_�..':_->.�e�. •------- - • dated------------------------------------•---.._..__. THE ISSUA E F THIS CERTIFICATE SHALL NOT BE CO S Rll AS A ARANTEE THAT THE SYSTEI�+IIrWIL U TION SATISFACTORY. DATE__l_©.... ..... .:................ Inspecto . ... --------•-•--• ------••-••--•......................_............- THE COMMONWEALT SSACHUSETTS BOARD HEALTIt No c 1 . 1.... r...................OF....... ...... .... �,r ..__. FEE ......... .......... Mapilli a1 nr Tnntrnrtinn Permit Permission is hereby granted .. ...�..�._ to Construct ( ) or Repair an Individual Sewage Disposal System om ...........................................................No............. . ...---- ---------- Street as shown on the application for Disposal Works Construction Permit No --- _ Dated.......................................... Vi oard of Health DATE................................................................................ FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS