HomeMy WebLinkAbout0176 GREENWOOD AVENUE - Health 176 GREENWOOD AVENUE, HYANNIS
A=
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Y
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
6
01ppliLotlon for MispoBAY 6pstem Cori etlon Permit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon(X ❑Complete System ❑Individual Components
Location Address or Lot No. (r7 A V G Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel a g g ( HYA W is 6�t Roe
Installer's Name,Address,and Tel.No.Avg r2g,-17 Designer's Name,Address,and Tel.No.
CAPGvlD& &jo-r&2PA�5,63 ",_ O/A
153 5
Type of Building:
Dwelling No.of Bedrooms N4 Lot Size t' sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided ON/4- gpd
Plan Date Number of sheets ' Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
A ml,jo aN ew,,ntya Ssync-
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health
Si d Date
Application Approved by Date
Application Disapproved by/ Date
for the following reasons
1
Permit No. /'�/y — ! Date Issued
No. (�" I � I �� r _ VW1. Fee J
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes
PUBLIC HEALTH DIVISION ,TOWN OF BARNSTABLE, MASSACHUSETTS
0[pprication:for bisposal 6pstim Construction 3oefmit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon(X ❑Complete System ❑Individual Components
Location Address or Lot No. (r( wo?- ,q LIG Owner's Name,Address,and Tel.No.
HYoA-kw1S C(.tZA136� 34t'u-ri
Assessor's Map/Parcel g g ( pejC r5
Installer's Name,Address,and Tel.No.sV$.c�`17 ,g$-17 Designer's Name,Address,and Tel.No. s;
a�ro�v��� p2ts� c.c.c �J/A
h
Type of Building:
Dwelling No.of Bedrooms AM Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
'/Other Fixtures
A `� P
Design Flow(min.required) �} gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil a
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 Certificate of
Compliance has been issued by this Board of Health. 4
t Si d Date 'a�a ��0(�(
Application Approved by Date S'/a 7- �o!y
t Application Disapproved b Date
for the following reasons
Permit No.?��G/ — �/�Gl 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(X)by d- 4P6-Q)IDl` C-?V 113- M UeZS: �L
at L%,GjQ6MhX20a AtJ6 H y`q iUW 5 has been constructed in accordance k
with the provisions of Title 5 and the for Disposal System Construction Permit No.2A)/L-1 dated J k-7,e'ZO 14
Installer 0) 4j5g5 4-L<r Designer �J1A
#bedrooms Approved design-flow / / gpd
The issuance of this permit shall�� of be construed as a guarantee that the system will`f/unc�to�nas,de/siygne�d`,,
Date
C ,1 rl' V Inspector T`�'.tl �'s1 J fl / -- s � f I 'l J 1 Ut� N
_____-�_______________.______________________._.__ ___- ____.__.__,_ _____._____._.____.- _ -.
No. - ., I Fee cvd
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Zisposal 6peitem Construction permit
Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon(
System located at (r��Q—�� lWo:)0ti D
and as described in the above Application for Disposal System Construction Permit. The applicant recognized 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 11�177,J n M Approved by
J
I
- Barnstable
�� � Town of Barnstable
Regulatory Services Department AFftedeaM
■A8N8TABM I
, `039.
. Public Health Division
200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Thomas F.Geiler,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL#7012-1010-0000-2848 -0363
March 28, 2013
ELIZABETH BARRETT
PO BOX 715 IMPORTANT NOTICE
HYANNIS PORT, MA 02647 Map & Parcel: 288- 149
The Department of Public Works informed us that public sewer lines are now
available in your neighborhood. According to our records, your property has a septic
system. This letter directs you to connect your dwelling, at 176 Greenwood Ave,
Hyannis, MA, to public sewer on or before 3/30/2015.
The old septic system must be either removed or filled in due to future safety
concerns. This may be done by the same contractor who connects you to the sewer.
Septic Abandonment Permits ($ 25) are issued at the Public Health Division, 200 Main
Street, Hyannis.
Failure to comply with this Board of Health Order may result in a complaint
against you, in a court of law.
For additional information pertaining to the sewer connection, please see the
reverse side of this page.
PER ORDER OF THE B ARD OF HEALTH
omas A. McKean, R.S., C.H.O.
Agent of the Board of Health
Cc: Barbara Childs,WPC/Roger Parsons, Town Engineering, DPW
Enc.
QASEWER connectEetters Stewart Creek Sewer Connects\MAUNG LetA Sewer 2Pgs Merged 3-28-13 Yr2015.doc
Y
Public Health Division March 28, 2013
ADDITIONAL INFORMATION AND REMINDERS FROM OTHER DIVISIONS:
SAVINGS AVAILABLE/GRINDER PUMP:
A reminder to those of you who need a grinder pump for your connection:
Department of Public Works (DPW) sent you a letter in December 2012 stating the town,
for a limited time of two years, only from the receipt of the DPW letter, would provide
you with the pump at no charge. (This can save you thousands of dollars.) Please note:
You must pay the installation cost through your own contractor. Please make your
contractor aware of this, if interested. Also be aware: this is a shorter deadline than
the Public Health Division's deadline on the reverse side of this page.
SAVINGS AVAILABLE/PERMIT FEE:
The Town offers a waiver of the residential sewer connection fee of $420.00 for those
properties that connect within two years of the receipt of the DPW December 2012 letter.
LOANS:
For loan(s) available, please see the enclosed brochure, or see the town website:
littp://www.town.bai-nstable.ma.Lis/cdb,L� (under the "CDBG Programs", see "Sewer
Connection Loan Program). For loan specific questions, you may contact Kathleen
Girouard, Growth Management, at 508-862-4702.
CONTRACTORS:
Information on Licensed Sewer Installers is available on our web site at
www.town.bai-nstable.ma.us/Publ]cWoi-ksTecli/sewerinstallei-s. Contractors, approved to
perform sewer connection work in the Town of Barnstable must obtain and file a Sewer
Connection Permit with DPW-Water Pollution Control Division, 617 Bearse's Way,
Hyannis—contractors, please call Dave Anderson at (508) 790-6244.
FOR ANY QUESTIONS /ASSISTANCE:
Len Gobeil at the Town Manager's Office is available to provide you with direction you
may need in reference to the Stewart Creek Sewer Connections. You may contact him at
508-862-4701.
QASEWER connect\Letters Stewart Creek Sewer ConnectAMAILING LetA Sewer 2Pgs Merged 3-28-13 W2015.doc
41
f o,9 !OG
Commonwealth.of Massachusetts
Executive Office of Environmental Affairs�� ll E.P Title V Septic Inspector
Department of �4 . =
� ''' S� ,,,P.O Box 2119
Env��onmental Protect*
.,,.---''T�aticket, MA 02536'
t,NUllam F.wad (508)•564-6813
Trudy t,oxe
t3eeretery, FA
Llavtd B.Struh•
Contmteewna
SUBSURFACE SEWAGE DISPOSAL SYSTEM`INSPECTION FORM
PART A
CERTIFICAT
ll Ave.., alo �b,(
Property Address: ('1�p C7r(t'C(�uJO4o Address of Owner:
Date of Inspection: 4 it�'q(o (If different)
Name of Inspector: r
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 to the proper function and
maintenance of on-site siwwaage disposal systems. The system: ""
Conditionally Passes
Needs Fun r.Evaluation By the local Approving Authority
Fails
Inspector's Signature: Date:
qb F
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 flo„• of'10,000 gpd.or greater, the in and the system o�+ner shall submit
the report to the appropriate regional office of the Department of Environmental Protection
The original should be sent to ine system owner and copies sentto tier buser, if applicaUe and the.appro.ir,g au.hority. .
INSPECTION SUMMARY:
Chec. A, B, C, or D
Aj SYSTEM PASSES:` .
have not found any information which indicates that the system violates any of the fatlure_cr'itena as defined.in 310 CMR..15.303.'
Any failure criteria not evaluated are indicated below.
Bi 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, 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. .
trevised 6/15/9k► 1
One Wit •r Strom • 02108 • FAX(617)t1W1049 • TNephone(617)M-M00
0 Printed on Recycbd Paper
SUBSURFACE SEWAGE'DISPOSAL,SYSTEM INSPECTION..FORM
4 PART A,
CERTIFICATION (continued)
Property Address: �i f
Owner:
Date of Inspection:
r
BJ SYSTEM CONDITIONALLY PASSES(continued) `
_ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipets) or due to a broken, settled or uneven distribugon box The system will pass inspection if(with approval of the, .
Board of Health):
broken pipe(s)are replaced'.
obstruction.is removed t
distribution box is levelled or replaced �.r
G )
_ The system required pumping more than four times a year due to broken or obstructed pipets){ 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 systemis 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:. , -
s
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 JHAT PROTECT THE PUBLIC HEALTH,AND SAFETY AND THE
. ,,
ENVIRONMENT:
{
I he wstem nd� a seoni. tdnh anu ui; db>urption sysitni and is 1hiilLri iu0 feet to a 5u1pce "atc'r a
surface water supply.
The s�sien- hay a septic tank and soil absorption system and is within a Zone I of a public water supply well
The system has a septic tank,and soil absorption system and is within 50 feet of a private water supply well.
The s�-stem has a septic tank and soil absorption system and 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
DI SYSTEM FAILS: d.
! I
I have determined that the system violates one of more of the following failure criteria as defined in°310 CMR 15.303-The basis
for this determination is identthed belgw.}The Bgard of.Health should be contacted to determine what be necessary to correct
the failure:
erloaded or dogged SAS or cesspool.
Backup of sewage into facility or ystem Component due 4o an ov
gischarge.or potndirtg,of effluent to the surface of the grottrRd or surface waters due to an overloxled or dogged SAS or
cesspool.X,
r .
(revised 6/15/95) ,
1
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a
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner.
Date.of Inspection;
DI SYSTEM FAILS(continued):
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 1/1 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.j•
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.
El LARGE SYSTEM FAILS: i.
The following criteria apply to large systems in addition to the criteria.above:
The design flow of system is 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:
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 8/15/95) 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART 6
CHECKLIST
Property Address: `�� �CE�1vJ wA P A_
Owner. Ll CA,Date of Inctron.LA
Check if the following have been done:
_L,permping information was requested of the owner, occupant, and Board of Health.
1-<one of the s components have been pumped for at least two weeks and the system has been receiving normal (low rates
system
during that period. large volumes of water have not been introduced into the system recently or as part of this inspection.
_c.Acsbuilt plans have been obtained and examined. Note if they are not available with N/A.
L-TMe facility or dwelling was inspected for signs of sewage back-up.
� e system.does not receive non-sanitary or industrial waste flow
L^f<site was inspected for signs of breakout.
H system components, excluding the Soil Absorption System, have been located on,the site
_131;re 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;
`-7he size and location of the Soil Absorption System on the site has been determined based on.existing information or
approximated by non-intrusive methods"
i:?nr nrr,.,rantc, if diffarCnt imm ownp!l were provided with information on.the proper maintenance of Sub-
Surface Disposal System-
4
(revised 8/15/95)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: �1� (CPinI.JO .�"�ll� f«hw..
Owner. �
Date of InspecfiAn u
FLOW CONDITIONS
RESIDENTIAL:
Design flow: eal ons
Number of bedrooms:
Number of current residents:, rt
M,•k�
Garbage grinder (yes or no):-uP
Laundry connected to system (yes or no):_4_lcs, ,
Seasonal use (yes or no): CV-�, -
Water meter readings, if available:
Last date of occupancy:
COMMERCIAUINDUSTRIAL M(--N .
Type of establishment:
Design:flow: aallons/day
Grease trap present: (yes or no)_
tndustrial Waste Holding Tank present: (yes or no,)—
Non-sanitary waste discharged to the Title 5 system: (yes or no)_, m. ' .. . .' .,, ,...... :.... ..� ,;;.T,.
Water meter readings, if available.
Last date of occupancy: '
OTHER: (Describe)
Last date of occupancy: a ,
GENERAL INFORMATION" ~ »
PUMPING REC RDS nd source of inform tion: £'
S stem pumped as part of ins iorr. (yes or no)
If yes,volume p,�mned gallons ,
Y
Reason.for pumping: >j1
TYPE OF SYSTEM .. . . .�. _:h�... .
Septic tank/distribution box/soil absorption system,
✓Single cesspool—Le .
Overflow cesspool--�--• :
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if.any)
Other(explain)
APPROXIMATE AGE of I co onents, d`at�e,install (iceknown) and source of mformahon. ` 04
Sewage odors detected when arriving at the..site: (yes or no)Ct -
- r :
P .
(revised
SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION .FORM'
PART C
SYSTEM-INFORMATIQN.(continued)
Address:.T�lo tS`�l C�;{�w000 rv�.Property
Owner:
Date of Ins ions:L WO
, s
SEPTIC TANK:V\1?S.
(locate on site plan)
Depth below grade:_._ f .
Material of construction: _ ncrete :metal _•,FRP other(explain)
co
Dimensions:
Sludge depth:
..
Distance from top of sludge to,bottom,of outlet tee or baffle:,.,,_
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:
Comments:
ndition of inlet and outlet tees or baffles;depth_of liquid level in relation to outlet invert,structwtal
(recommendation for pumping, co
integrity, evidence of leakage, etc.)
GREASE TRAP:,zx�
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal lFRR other(explatn).
Dimensions:
Scum tnic{.ne». + _
Distance from top of scum to top of outlet tee or baffle: ,..
` ttn^' ^tcri�m in bottom
fljctanro from ho of outlet tee or bahle:.__,, ••
condition ot,tnlet and outlet tees or baffles, depth of liqu
id uid level in relation to outlet invert, structural
rpumping, .
(recommendation for
integrity, evidence of leakage, etc.)
6
(revised 8/15/95) :
r
SUBSURFACE.SEWAGE`DISPOSAL'SYSTEM INSPECTION FORM
PART C
\ SYSTEM.INFORMATION,(continued);
Property A d ess:
Owner:
t
Date of In pection: y L `4
TIGHT OR HOLDING TANK:D\A
(locate on site plan) .ry
Depth below grader
Material of construction: __concrete metal �FRP other(explain) "
Dimensions:
Capacity: eallons
Design flow: eallons/day
Alarm level:
t
Comments:
(condition of inlet tee,°condition of alarm and',float switches, etc)
DISTRIBUTION BOX a-
(locate on site.plan)
Depth of liquid level above outlet invert: N
Comments:
(note if levei and distributPur, i>eyudi, e,IdeilcC of Wid., ca:rtc,rr, e%idence of leakage into or out of box,.e!c.)
PUMP CHAMBER:n1C'r
1 (locate on site plan)
,a
Pumps in working order:(yes or no)
Comments:
(note condition of pump chamber,condition of pumps and appurtenances, etc.) .. ...._ .. .. .. _ '
(revised 8/25/95)
SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM;,
PART C
SYSTEM INFORMATION (continued)
Property Addr s:.�o
Owner: ell. t r
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS):
i!:_�.
(locate on site plan, if possible, excavation not required, but may be approximated by non intrusive methods).,,'
If not determined to be present, explain:
,r
k.
Type:
leaching pits, numb :_jy
leaching chambers, number. i-
leaching galleries, number. a,
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number: -::)X
Comm : (note condition of soil, si ns of h draulic failure, level of ponding,'condition of wegetation,etc.) US,
CESSPOOLS _
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of ground,.atc-._"rA-A2.,
inflow (cesspool-must be-pumped as part.of inspection)
C : (note condition pf soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc,)
>s.
i
PRIVY:
(locate on site plan)
Materials of construction: l�urtensjQnS; ..
Depth of solids:
Comments: (note condition of soil, signs of hydraulic.failure, level.of ponding, condition of yegg4 on,vtc)
(revised 8/15/95)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
\ SYSTEM INFORMATION (continued)
Property Ad ress � �o, �t e1V bQ O (.�,�
Owner: Q��
Date of.Inspection: LA k&G
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at.least two permanent references landmarks or benchmarks
locate all wells within 100`
el
DEPTH TO GROUNDWATER
Depth to groundwater:_, feet
method of determination or approximation: �S�S `(\C�otUSS(��-1
9
(revised 8/15/95)
TOWN OF BARNSTABLE
` LOCATION 1 7C 6o---elk) 6oaoD 4ve- SEWAGE
VILLAGE , O Z ASSESSOR'S MAP & LOT a: �' 17L
INSTALLERS NAME & PHONE N�Qc��� "0
SEPTIC TANK CAPACITY
LEACHING FACILITYAtypeY-P_4� (size)
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNERi � �/V
DATE PERMIT ISSUED:
DATE .COMPLIANCE ISSUED: '
VARIANCE GRANTED: Yes No
� �
� �, � ;�,
� � ��
� o, o
� � � ,
No qg�
THE
BO�eRDAOF FHE LTHSA S
, � ...a . .
l�
Appliratiun for llhipouttl Works Tonutrurtiun Frrutit
Application is hereby made for a Permit to Construct ( ) or Repair (1,�an Individual Sewage Disposal
System,at
J....t......... ...-••...............................•------ ---- =--........--:............_..........__-
a ion•�ddress or Lot No,
.. .. . ....................................
1'� 1N...N...�s... �' =%..... .............-...._....---
Owner �( Address
Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms:._ ________________________________Expansion Attic _( ) Garbage Grinder ( )
Other—Type of Building ..........._ No. of persons............................ Showers —
Pa YP g .............•-- P ( ) Cafeteria ( )
Other fixtu
- .... ..........---.----------------•--------------.----..----••---.... ----------
-------------......-------
W Design Flow....:3.7.............................gallons per person per day. Total daily flow............................................
WSeptic Tank—Liquid capacity...'-........gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area.............._ .sq. ft.
3 Seepage Pit No..................... DiameterC :4' Depth below inlet...•........... Total leaching areaA.6.�...r ...sq. ft.
Z Other Distribution box ( ) Dosing tank ( , )
aPercolation 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........................
x ------------------------------------.....•••---------------------------.-------.-..--------.•-•••.----------------------------------------•--..........--••-
0 Description of Soil.........-.............................................................................-------•-------;--.............--.....---•••--•-••-•--••---...........--------
DC
U ---------------------------------...................................................................................................
W ..................................-....................---.................................................... .........
x UNature of Repairs or Alterations-Answer when applicable ............!
..................••---
- _--
.. ..............•---------•-•---------•._....----•- -----.......-----..-.-•••-•....... t..... ...
Agreement
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance wit_ ',
the provisions of iITI.I 5 of the State Sanitary Code The undersigned further agrees not to place the system'in
operation until a Certificate of Compliance has been issuedeby he b oasd of health. p-
Date
ApplicationApproved By...........-••-•-••--h'•..... ............................................................
Date
Application Disapproved for the following reasons:...............i.............................................................................................
--•••----•-•••-••----......-•-•--•--•..........................................•--•-•-=--•-•--------••......................-------------•-------••---•--•--..............----------.................._
<:;;—:Permit No............................... ....._- Issued............................................D�-.....
Date
No �
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF..5N.
Applutttion for Diupuuttl Marks Tonutrixr#ion Fermi#
Application is hereby made for a Permit to Construct ( ) or Repair (t,,�an Individual Sewage Disposal
System at:
Location•Address or Lot No.
-/C.�',:.A...�.......---•--•--.._.. ...-1�/�LN/Nl�)s...�x:,�=-�...........................
• �'.' _:...C l u Y J Owner..... ................................. ....C � N' /C,I Address ..M.„.NM.....
W r
Installer Address
Type of Building Size Lot............................Sq. feet
►.� Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
` Other—T e of Building No. of persons............................ Showers — Cafeteria
04 Other fixtur
WW Design Flow.... 3..7.............................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.
3 Seepage Pit No-----_------------- Diameter64_--- Depth below inlet............... Total leaching area__-..,.A.2.sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation 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....................................................................•--•---•----......-•----••---------•-----•---..._....--------•---......••--..._••-•••---•--•-••_....
Z .................................................................................................. ................................- ;---•- .....----- •--•-••••-•-•-••--•-•--•_..
U Nature of Repairs or Alterations—Answer when applicable_.__ X_ �= Co/p . ...............................
................................................................................••••••-....... '....--fir_e....------------...-----...._................•-••-•--•-...._.._.....••--
Agreement
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System.in accordance with
the provisions of TIT-TS5 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. r
Signed.......•Ti✓--- ...--•=-•--------------------------•---••-•- ......................... _.
Application Approved B = 7 - ' !=-------------•-•-•----•----------•---•PP PP By....... --�� -
Date
Application Disapproved for the following reasons:..............._.........................................................................................._--
..•--•--•-••-•....._...--•••••••-•-•-...••--•-••••--•••••--..._...-••......_..---•-••-•---.......--•-•--••-----•••-._.....---••-...--•-•----=•-....-•-•--••------•---•••--•-•--•-•••-.....-••-•--••-•--
Date
PermitNo.......................,._._._�.._..._...__......... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS \ '11
BOARD OF HEALTH
CIrr#ifuttte of faomplittnrr
THIS IS TO CERTIFY That the Individual Sewage Disposal System constructed ( ) or Repaired (�
by.......................
......... '••.r�. C••-•-- .---------•-•--•---------------- -----.......------------ ......---------..... .........._-------•-
Installer
...
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..._� '7-- 4( dated...... ._ ._.�'t i. �__ `-7...........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THATJHE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE ... -- :................... --•••••• Inspector................. - ... -------.. ........:.........._........... .........._
_- --__- -----------�------------------ �- s---- -------- --------1------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
of 1 .Oa'lUs!e-_-•.................................. p _
�iu�o�tt1� orku �on��r�tr#ion �rrmtt
Permission is hereby granted........ •.��C/ -•-•-----•--------------------•----.......----•---
to Construct ( ) or Repair (1i)an Individual Sewage Disposal System ,.�v
at No.:�-T�l 1,_/P,F'P n/Gt)Gt/� /yc��2----- ------.. "U 0 f ....--- --
..........
Street
as shown on the application for Disposal Works Construction Permit No. R03 D�at d"•!. _`' 7
t,� -.------
Board of Health
DATE...............V.-...=•o•f••- ..........................