HomeMy WebLinkAbout0209 GREENWOOD AVENUE - Health 20.9 Greenwood Avenue
Hyannis P
A = 288 105
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No. I ✓ � Fee �23
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
Rpplitation for Misposal 6pstrm Construction 3permit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon(A ❑Complete System ❑Individual Components
Location Address or Lot No. ;tog Ge)EWLt)cac)D AOV Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel NYaQjol S 3�WSu�aAc.,4
r VWj G'T O
Installer's Name,Address,and Tel.No. j®$—%1-1 .$g17 Designer's Name,Address,and Tel.No.
CA0P6W11DC rclJC 'Q(SCS u,C. J
"— C1ltc— 5 MA.5i4p l
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(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
Nature of Repairs or Alterations(Answer when applicable)
At34-1yDau &YjsTc?jG 3ewrtC_ s ytr�
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 Boatdd of He ' II
Si e" n Date Ci-- 19-;LON
Application Approved by All, Date
Application Disapproved by Date
for the following reasons
Permit No. Date Issued — (���d 1 Y
No. 6� J y� Fee S
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
es
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
ftplitation for Disposal bpstem Construction permit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon 0a ❑Complete System ❑Individual Components
Location Address or Lot No.aQ9 GeZW W(k)A AO:� Owner's Name,Address,and Tel.No.
6tiUJAPb t ter wt l36.W �40c_feb
Assessor's Map/Parcel ag d SV D
Installer's Name,Address,and Tel.No. tj oa Designer's Name,Address,and Tel.No.
CA06W DE Ec�JTGZPaISLS LA-C
e� s SN N l Ar
Type of Building: c
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
_. 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
1
Nature of Repairs or Alterations(Answer when applicable)
ABA-0 )1J E&) ToJG c5CQTtG
3` 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 Bo d of He
+� Si • e Date Gq— 19-- DL 4
Application Approved by Date / `/ 0(y
(�'.
Application Disapproved by Date
for the following reasons
Permit No. �� 1 " 39
t Date Issued
- - - - - - - - - - -------------•------- ----------------------
THE COMMONWEALTH OF MASSACHUSETTS °1
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO^^CgqERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( )
y Abandoned( )by O_ pew t DC ro7wg is t-Lc.
at a09 C—'GE>jg)&-p-b AQG O,lAOM& has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. U(y-3Y3 dated
installer e_AK )1,DE 6aJ K 1SE5 L1.L Designer U 1A r
1
#bedrooms Approved design flow >� h gpd
o
The issuance of this.perm' shall the onst ed as a guarantee that the system willrfunct1 de i ed.
�f
Date . Inspector
- V tD<--
No. t Fee
i THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION BARNSTABLE,MASSACHUSETTS
Misposaf 6pstem (Construction 3permit
Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon(X)
System located at (x' IQ6�Alwnaz) AVE HYAUA) 15
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.
i
i
Provided:Cons t uctio must be completed within three years of the date of this permi.
Date / Approved by 4 °i�/•
AsBuilt Page 1 of 1
---- TOWN OF B STABLE
LOCATION �eC'/nli SEWAGE#
VILLAGE ASSESSOR'S MAP&LOTa-L t0S
INSTALLER'S NAME&PHONE 0.
SEPTIC TANK CAPACITY
LEACHING FACILrrY:(type) (size)
NO.OF BEDROOMS
BUILDER OR OWNER y
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 tlands exist
within 300 feet of leaching facility) Feet
Furnished by
irs
e cIL
x At-cP
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http://issgl2/intranet/propdata/prebuilt.aspx?mappar=288105&seq=1 9/19/2014
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Town of Barnstable Barnstable
.� Regulatory Services Department M�ftwlcaC'j
IARNSTABM I '
- 9� KASS,
-��' - - - 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 -0400
March 28, 2013
EDWARD & KIMBERLY HOWARD
36 SURREY LN IMPORTANT NOTICE
AVON, CT 06001 Map & Parcel: 288- 105
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 209 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 OARD OF HEALTH
Thomas A. McKean,R.S., C.H.O.
Agent of the Board of Health
Cc: Barbara Childs,WPC/Roger Parsons, Town Engineering, DPW
Enc.
QASEWER connect\Letters Stewart Creek Sewer Connects\MAILING LetA Sewer 2Pgs Merged 3-28-13 Yr2015.doc
1�
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 ygur 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:
http://www.town.barnstable.nia.us/cdbg (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.barnstable.ma.us/PublieWoi-ksTecIi/sewerinstallers. 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 Connects\MAILING LetA Sewer 2Pgs Merged 3-28-13 Yr2015.doc
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- - f.�14 to t<•,
n
COMMONWEALTH OF MASSACHUSETTS s
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS ;2
DEPARTMENT OF ENVIRONMENTAL TROTECTION ,
e� t
A
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR yOLUNTARY ASSESSMENTS
j SUBSURFACE SEWAGE DISPOSAL!SYSTEM FORM , f
k PART A fr
;.
CERTIFICATION`�
ao5fief �} fi
Property Address: 209 GREENWOOD AVE HYANNIS,MA 02601 `` RECEIVED ;
Owner's Name: MR GULLIVER
Owner's Address: PO BOX 152 HYANNISPORT,MA 02647
FEB 132002 *
Date of,Inspection:2/1/02
TOWN OF BAR
NSTABLE
' HEALTH DEPT. ";' l« �•
Name of Inspector: (please print) t;. • JOHN GRACI
Company Name: SEPTIC INSPECTIONS
Mailing Address: PA.BOX2119 TEATICKET,MA"0253612
Telephone Number: 508-564-6813 FAX 508-564-7270
' CERTIFICATION STATEMENT
4
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below s�
true,accurate and complete as of the time,of the inspection.The inspection was performed based on my training and �
u4 h
experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system
inspector pursuant to Section 15.340 of Title 5(310 CMR 15 000) .The system: Y '
X Passes
_ Conditionally Pas es
_ Needs Furthe aluation by the Local App%ving Authority rty
Fails `
x,
�'l irk • •. p f"� Az
Inspector's Signature: }.
z Date: 2/1/02 a � ;
The system inspector shall submit copy of this inspection report to the Approving Authority(Board of Health or DEP)w thutr F ,
y 30 days of completing this inspect' n.If the system is a shared system ot�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-bets '
3 :
sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. c 40PP
a
Notes and Comments f `. t
SYSTEM PASSES TITLE V INSPECTION:RECOMMEND PUMPING NO
SYSTEM THEN EVERY TWO YEARS TO - '£� '
nM }
PROLONG THE SYSTEM'S USEFUL LIFE.
' • i4Z ' i
****This report only describes conditions at the time of inspection And.under the conditions of use At that thne.TNU
ow the system will perform in the future under the same or different conditions of use
inspection does not address h i'
xr2 �l
� .
Tiflr C Incnr�finn Pnrm (,il5rnnn'" I
Page 2 of 11 r '
OFFICIAL INSPECTION FORM—NOT FORkVOLUNTARY ASSESSMENTS '
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART, at.
CERTIFICATION(continued)
Property Address: 209 GREENWOOD AVE HYANNIS,MA 02601
Owner: MR GULLIVER �.
Date of Inspection: 2/1/02
k A B C D or E/ALWAYS complete all of Section D
Inspection Summary: Chec . ,,. .
A. System Passes: u .
X I have not found any informatiorrwhich 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`" i
Comments:
SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING NOW AND THEN EVERY TWO YEARSk
TO PROLONG THE SYSTEM'S USEFUL LIFE.
'j B. System Conditionally Passes:
f _ One or more system components as described in the"Conditional Passe'-section need to be replaced or repaired.The system;' '
upon completion of the replacement or repair,,as.approved by the Board of Health,will pass.
Answer yes no or not determined( -in the for the follo wing statements. If"not determined"please explain
, Y,N,ND)
l 4 J
n/a The septic tank is metal and over 20 years'old*..or the septic tank(whether metal or not)is structurally unsound,exhibits tT Y
jsubstantial infiltration or exfiltration or tank failure is imminent System will pass inspection if the existing tank is replaced, a� �
with a complying septic tank as approved by the•Board of Health tAs
*A metal septic tank will pass inspection if it is structurally sound,not`le#eking and if a Certificate of Compliance indicating
that the tank is less than 20 years old is available. _
:i ND explain: n/a. '
} i 5z ��E
n/a Observation of sewage backupor break'out or high static.water level m the distribution box due to broken or obstructed i k'
o
pipe(s)or due to a broken,settled or uneven'distribution box. System will'pass-inspection if(with approval of Board of '�k T
111 Health):
zs.,
�F 3� ;
_ broken.pipe(s).are replaced
_ obstruction is removed
distribution`box is leveled or replaced i
ND explain: n/a :' {
n/a The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass
inspection if(with approval of the Board of Health):
i .
,
, va
_broken pipe(s):are replaced 7 }
_obstruction is removed a
t
r
ND explain: n/a44
it t ; f �3§1•+x., t _ Sty M �_._
l
' fi�C C1h�
Pa e 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR?VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM;INSPECTION FORM tY
PART A � ,.
CERTIFICATION(continued) 4
Property Address: 209 GREENWOOD AVE HYANNIS;MA 02601� r
Owner:R MR GULLIVER
Date of Inspection: 2/1/02 ti f z
F.N`�H m t-:�".,C�rah a.. k
C: Further Evaluation is Required by the Board of Health:
_ Conditions exist which require further evaluation.by the Board of Health m order to determine if the system is failing toy
. t
protect public health,safety or the environment.
1. .System will pass unless Board of Health determines in accordance;with 310 CMR 15.303(1)(b)that the system
! not functioning in a manner which,will protect public health;safety'and the environment:
r .
_ 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 ;fK
wt
r ,
2. System will fail unless the:Board of Health(and,Pubhc 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 r}r
_ and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS
{1
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. {,
1
_ The system has a septic tank and SAS,and the SAS is less than 100 feet but 50 feet or more from a private water ; �*A
supply well**.Method used to determine distance n/a
} o- al '"k
**This system passes if the well water'analysis,performed at a1DEP certified laboratory,for coliform bacteria andi �
volatile organic compou indicates that the well is free from pollution o that facility and the presence of ammonia-
ids k
nitrogen and nitrate nitrogen is equal to or less than_5 ppm,provided`thaYno other failure criteria are triggered A copy, t
}�R
of the analysis must be attached to this form. y
} a
,I
3. .Other:
i. 3 } 4r, •E ry .q ..
n/8
<�r r%nF� r
•'
J a k
;
7;
t Y.*k
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Page 4 of 11
ar
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OFFICIAL INSPECTION'FORM=NOT FORVOLUNTARY ASSESSMENTS S
SUBSURFACE SEWAGE`;DISPOSAL SYSTEMINSPECTION FORM �
PART AA. y'
CERTIFICATION,(continued)
Property Address: 209 GREENWOOD AVE HYANNIS,MA 02601"3
Owner: MR GULLIVER
Date of Inspection: 2/1/02 4 '
• r Nei r k�r_��� r
D. System Failure Criteria applicable to all systems: '`; ,
You must indicate"yes"or"no"to each of the following for all mspectionsw; _`
Yes No
- X Backup of sewage into facility or system component due to odverloaded,or clogged SAS or cesspool .. �
X Discharge or ondin of effluentYto the surface of the ground or�surface waters due to an overloaded or clogged
- g P g 4
SAS or cesspool '° r
X Static liquid level in the distribution box above outlet invert due to-an overloaded or clogged SAS or cesspool
X Liquid depth in cesspool is less than 6"below invert or available volume is less than''/Z day flow
X Required pumping more than 4 N
times in the last year OT du e�to clogged or obstructed pipe(s).Number of times � `� p
Y `fit wf -
pumped nLa.
I` _ X Any portion of the SAS cesspool or privy is below high ground water elevation.
_ X Any portion of cesspool or privy•is within 100 feet of a surface�watensupply or tributary to a surface water supply
j - X Any portion of a cesspool or privy is within a Zone 1 xof a public;wel1. k
_ X Any portion of a cesspool or privy is within 50 feet of a private water.supply well.
_ t greaterjthan 50 feet from a private water supply well wh
X Any portion of a cesspool or privy is less than 100 feet bu
no acceptable water quality.analysis. [This system passes if tthe well water analysis,performed at a DE
7 '
' certified laboratory,for coliformrbacteria and volatile organic,compounds indicates that the well is freed ,
j from pollution from that facility and the presence of aritmonta`,nitrogen and nitrate nitrogen is equal to ors
less than 5 ppm,provided that no other failure criteria F,are triggered.A copy of the analysis must be $
attached to this form.] 'f
(Yes/No)The system fails.I have determined that one or more�of the above failure criteria exist as described mx3105---�,r
CMR 15,303,therefore the system faik The system owner should contact the Board of Health to determine what will be `
necessary to correct the failure.
nv.} Ana
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. M$ -
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria-above):.�
yes no %W }�
X the system is within 400 feet of a surface drinking water supply 24
X the•system is within 200 feet of a tributary to a surface drinking water supply , r
X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Y
Zone 1I of a public water supplywell
+ S
If you have answered"yes"to any question in Section E the"{system is considered a significant threat,or answered xr� {
��
es"in Section D above the largo sykem ha®failed,The owner or operator�of any_large system considered a significant thr h
under.Section E or failed under.Section D shallrupgrade the system in,accordance with 310 CMR 1�.3�4.The system ownef .
should contact the appropriate regional'office}of the,Department F
lei t
,,a , .t Q . +..•,:.E;r.,;fin,,. ,�}•�.'.+
r
Page 5 of 11 i
ix
OFFICIAL INSPECTION FORM-NOT FORlYtQLUNTARY ASSESSMENTS
` k
SUBSURFACE SEWAGE DISPOSAL SYSTEM:INSPECTION FORM
� � a
PART B ,
CHECKLISTt4
Property Address: 209 GREENWOOD AVE HYANNIS,MA 02601
Owner:.MR GULLIVER � �
Date of Inspection: 2/1/02
Check if the following have been done.You must indicate"yes"or"no'.°as to each of the following:
Yes No
X _ Pumping information was provided by the owner,occupant,o�Board of Health
X Were any of the system components pumped out in the previous two weeks
X Has the system received normal flows in the previous two week,period? ,
X Have large volumes of water been introduced to the system recently or as part of this inspection?
X Were as built plans of the system obtained and examined?(If they were not available note as N/A)
X _ Was the facility or dwelling inspected for signs of sewage back up?
X _ Was the site inspected for signs of break out? s a Ater
X _ Were all system components,excluding the SAS,located on,site? F i
X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the fi +
1 baffles or tees,material of construction,dimensions,depth`of liquid,depth of sludge and depth of scum?
! • f A .
j X _ 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
f the Soil Absorption System(SAS)on the;site has been determined based on: R'
Yes no
X Existing information.For example,a plan at the Board of Health
X _ Determined in the field(if any of the failure criteria related to�Part C is at issue approximation of distance is
O( )]3 b ' . .,.
unacceptable)[310 CMR 15.3 02
5 `
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR�IVOLUNTARY ASSESSMENTS
-0aa : „
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM w
PART C k
SYSTEM INFORMATION d
Property Address: 209 GREENWOOD AVE HYANNIS,MA 02601 ,;` a €
Owner: MR GULLIVER c
Date of Inspection: 2/1/02 f r r
FLOW.CONDITIONS '£x
RESIDENTIAL `
• ���, `fie `_
Number of bedrooms(design):3 Number of bedrooms(actual) 3 at,; p ` ,<`
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):330 4" M. ,�Y<
Number of current residents: 2
Does residence have a garbage grinder(yes or no): NO
Is laundry on a separate sewage system(yes or no NO [if yes separatef utspection required]
Laundry system inspected(yes or no) NO
Seasonal use: (yes or no):NO fi
Water meter readings,if available(last 2 years usage(gpd)): n/a
Sump Pump(yes or no): NO „ t
C
Last date of occupancy: n/a P
COMMERCIALANDUSTRIAL 4 �'
Type of establishment: n/a
Design flow(based on 310 CMR 15.203):,n/agpd '7
Basis of design flow(seats/persons/sgft,etc.): n/aWT
Grease trap present(yes or no):NO F ,
i -
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: n/a ,
{ Last date of occupancy/use: n/a
OTHER(describe): n/a �
.GENERAL INFORMATION
Pumping Records
Source of information: n/a �' y w
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: n/agallons--How was quantity pumped determined?n/a fi• . .
1 3a
Reason for pumping: n/a
TYPE OF SYSTEM
X Septic tank,distribution box,soil absorption system
Single cesspool
r t
J y _s �•i :.
_Overflow cesspool
_Privy
_Shared system(yes or no)(if yes,attach.previous inspection records,:ff any)., }
_Innovative/Alternative technology.Attach a'copy of the current operation and maintenance contract(to be obtained from
system owner) It
'
_Tight tank Attach a copy of the DEP approval k '
,i Other(describe): n/a
Approximate age of all components,date installed(if known)and source of information:
k °
' 1973
917 {
Were sewage odors detected when arriving at the site(yes or no) NO;#
<�
.,7
Page 7 of 11 `.
�•
ORVOLUNTARY ASSESSMENTS k ��
OFFICIAL INSPECTION FORM—NOT F ,
SUBSURFACE SEWAGE DISPOSAL SYSTEM:INSPECTION FORM sx
PART C'
SYSTEM INFORMATION(continued)
Property Address: 209 GREENWOOD AVE HYANNIS,MA 0260V'�
Owner: MR GULLIVER
Date of Inspection: 2/1/02
BUILDING SEWER(locate on site plan) �
j Depth below grade: 18"
Materials of construction:_cast iron _40 PVC!Xother(explain):ORANGEBURG �, t� Ze
Distance from private water supply well or suction line: n/a
Comments(on condition of joints,venting,evidence of leakage,etc.):
TOWN WATER `$ ,
s z
SEPTIC TANK: X(locate on site plan) #
Depth below grade: 12" i
Material of construction:Xconcrete metal fiberglass_polyethylene other(explain)n/a A ;
If tank is metal list age: n/a Is age confirmed by a Certificate of Compliancea(yes or no): NO(attach a copy of certificate) .`x �;
Dimensions: 6' X 6' BLOCK CESSPOOL" ;}
Sludge depth:3"
Distance from top of sludge to bottom of outlet tee or baffle:31" �{
Scum thickness: I" R
Distance from top of scum to top of outlet tee or baffle: 12" �'
Distance from bottom of scum to bottom of outlet tee or baffle: I I" 4
How were dimensions determined: MEASURED #
Comments(on pumping recommendations, inlet'and outlet tee or baffle condition,structural integrity, liquid levels as rela t ed�W { r
1 �, r ,,
to outlet invert,evidence of leakage,etc.). .
' CESSPOOL AND ALL COMPONENTS.ARE STRUCTURALLViSOUND;AND FUNCTIONING PROPERLY T sad F
RECOMMEND PUMPING NOW AND THEN EVERY•TWO YEARS T,O-PROLONG THE SYSTEM'S USEFUL i-�
LIFE. ° ' ' �•' g�}` `
''_
GREASE TRAP:—(locate on site plan) _
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene'_other(explain): n/a �
Dimensions: n/a
s, �
Scum thickness: n/a " F
Distance from to of scum to top of outlet tee or baffle: n/a '
p
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
j: Date of last pumping: n/a `4 ,�
m F,
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related
to outlet invert,evidence of leakage,
b I
.� _' '5 � j j �i t`5 fit,� •i �.
F g
Page 8 of 11
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i1-5a
OFFICIAL INSPECTION FORM—NOT FOXVOLUNTARY ASSESSMENTS
SU
BSURFACE SEWAGE DISPOSAL SYSTEM�INSPECTION FORM
PART C
SYSTEM INFORMATION(continued) y I
Property Address: 209 GREENWOOD AVE HYANNIS,MA 02601
Owner: MR GULLIVER
Date of Inspection: 2/1/02 .
TIGHT or HOLDING TANK: (tank must be pumped at'time of mspection)(locate on site plan) ,
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene other(explain): n/a
Dimensions: n/a f3 „
;, .. ' r1
Capacity: n/a gallons
Design Flow: n/a gallons/day s x
r,11k
Alarm present(yes or no): N/A '`� '
Alarm level:N/A Alarm in working-order(yes or no):NO s,L �'
,E'- 'asikY r
Date of last pumping: n/a
Comments(condition of alarm and float.switches,etc.):
n/a
sent must be o ened (locate on site plan) _M
DISTRIBUTION BOX:_(if pre ;. _ \ p ) _
Depth of liquid level above outlet invert:.n/ai�61
Comments(note if box is level and distribution to outlets equal,,any evidence of solids carryover,any evidence of leakage into ,w, "
or out of box,etc.):
n/a v .
PUMP CHAMBER:_(locate on site plan) *'Pumps in working order(yes or no): NO !
Alarms in working order(yes or no):NO
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
f
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Page 9 of 11 ;
y
t
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS ,
SUBSURFACE SEWAGE'DISPOSAL SYSTEM INSPECTION FORM r
st
PART C " .i �k
SYSTEM INFORMATION(continued) „i �
Property Address: 209 GREENWOOD AVE HYANNIS,MA 0260I ��
Owner: MR GULLIVER
j Date of Inspection: 2/1/02
41,
1 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) ,
}
i If SAS not located explain why:
t QJ
Type
i' 000 GAL 6'X 6' leaching pits, number: ''` t
n/a leaching chambers, number n/a , L��;• "
n/a leaching galleries, number J nla
j leaching trenches, number, length: nla
n/a
leaching fields, number <<; n/a
num
i n/a overflow cesspool;> ber y, " ; nla rn v
1 innovative/alternative system a
n/a t a,
Type/name of technology4vX n/a
,,rl
1 .,. ✓ ACC.�" d � } �
Comments(note condition of soil;:signs of.hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.)
` PIT IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY:PIT NEVER HAS NEVER BEEN MORE . , �r
THAN:HALF FULL AND WAS EMPTY AT TIME OF INSPECTIONBOTTOM IS AT 9'.
w
44
CESSPOOLS: (cesspool must be pumped as part of inspection)(locateon site plan)
Number.and configuration: n/a
Depth,-top of liquid to inlet invert: n/a
Depth of solids layer: n/a
Depth of scum layer: n/a
Dimensions of cesspool: n/a
Materials of construction: n/a fi 3 M
Indication of groundwater inflow(yes or no): NO
Comments(note condition of soil,signs of hydraulic failure,level of pondmg,condition of vegetation,etc.):
n/a
<t "I 4411
d
PRIVY: (locate on site plan) W'jZz
Z
Materials of construction: n/a
Dimensions: n/a ,
S
Depth'of solids: n/a
Comments(note condition of soil,signs of hydraulic failure,level of ponding,'condition of vegetation,etc.):
I n/a rC x
M
Page 10 of I I
OFFICIAL INSPECTION FORM—NOT FOR"VOLUNTARY ASSESSMENTS
E DISPOSAL SYSTEM.INSPECTION FORMkfY g tt.
SUBSURFACE SEWAGE
PART C
SYSTEM INFORMATION(continued) /
{
Property Address: 209 GREENWOOD AVE HYANNIS,MA 02601. Z
Owner: MR GULLIVER �
Date of Inspection: 2/1/02 r
SKETCH OF SEWAGE DISPOSAL SYSTEM uua�
Provide a sketch of the sewage disposal system including ties to at leastitwo Permanent reference landmarks or benchmarks t{?
rv:
i y J
Locate all wells within 100 feet. Locate where public water supply enters the building.
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Page 11 of 11
' SSESSMENTSxa
VOLUNTA10.
" NOT FOR' t, x FORM
OFFICIAL INSPECTION FORM—
S
ACE SEWAGE DISPOSAL SYSTEM INSPEC'1 }
SUBSURF PART C ��
ATION.(continued)
SYSTEM INFORM
MA 02601�F
t1Fr
Property Address: 209 GREENWOOD AVE HYANNI ,
R GULLI
owner-. M
Date of Inspection: 2/1/02
a
� SITE EXAM
Slope
Jh 4 Li
_Surface water
_Check cellar '"
Shallow wells
round water 12 feet
? Estimated depth to g
round water elevation:
all methods used to determine the high g
Please indicate(check) design plan reviewed:nla
' plans on record-if checked,date of desi p
' NO Obtained from system design p +
site(abutting property/observation hole within 150`feet of SAS)
YES observedlain:n/a
NO Checked with local Board of Health-exp attach documentatton) : +
i Checked with local excavators,installers-( f
I NO
NO Accessed USGS database-explain:;n/a
round water elevation:
You established the high g ,
You must describe how Yr
INED BY HAND AUGER 1{2 FT.NO WATER ENCOUNT,ERE
DETERM °�
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i
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SAS
1 a
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Z�)c E
Commonwealth of Massachusetts
ExecutNe Office of ErMonn-antai Affairs John Grad
D.E.P. Title V Septic InLspector
Department of P.O. Box 2119
Environmental Protection Te 508)t, -6113
(sox� s6�i-cx536
l3
A 8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION RfCc r0
Property Address: 209 Greenwood Av. Hyannis Port Address of Owner: °n MAY 2 19
Date of Inspection:5116197 (If different) row/V 9T
Name of Inspector John Graci Etta Dickinson:86 N.Main St N.Graflon .04 36 HIC H�NSr� f
Company Name,Address and Telephone Number:
� z �
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 defined in Title V
_ Cond#mita
sses code 310 CMR 15.303.My findings are of how the system Is
Needvaluation B the Local Approving Authority performing at the time of the Inspection.My Inspection does
Y PP 9 tY not Imply any warranty or quarantee of the longevity of the
Fails septic system and any of its components.useful life.
Inspector's Signature: Date: 5119197
The System Inspector shall sy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspections. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit
the report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
Check A, B.C,or D:
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.
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, cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is
I imminent.The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved
II by the Board of Health.
(revised 11115195)
One Winter Street a Boston,Massachusetts 02108 a FAX(617)556-1049 a Telephone(617)292-5500
1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 209 Greenwood Av.Hyannis Port
Owner: Etta Dickinson:96 N.Main St.N.Grafton Ma.61536
Date of Inspection:5116197
— Sewage backup or breakout or high static water level observed in the distribution box is due to a broken,
settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health):
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 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 system 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 volatile organic compounds indicates that the well is
free from pollution for that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm.
3) OTHER
D) SYSTEM FAILS:
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.
— , 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. j
SAS is in hydraulic failure.
(revised 11115195)
2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 209 Greenwood Av.Hyannis Port
Owner: Etta Dickinson:86 N.Main SL N.Grafton Ma.01536
Date of Inspection:5116197
D)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 1/2 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:
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:
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone II of a
public water supply well)
The 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 11115195)
3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECLIST
Property Address: 209 Greenwood Av.Hyannis Port
Owner: Etta Dickinson:86 N.Main St.N.Grafton Ma.01536
Date of Inspection:5116/97
Check if the following have been done:
X 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.
NaAs 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 existing information or
approximated by non-intrusive methods.
x The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 11115195)
4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 209 Greenwood Av.Hyannis Port
Owner: Etta Dickinson:86 N.Main St N.Grafton Ma.01536
Date of Inspection:5110/97
RESIDENTIAL: FLOW CONDITIONS
Design flow: 0 gallons
Number of bedrooms: 3
Number of current residents: 0
Garbage grinder(yes or no): No
Laundry connected to system(yes or no): Yes
Seasonal use(yes or no): No
Water meter readings,if available: nla
Last date of occupancy: one earago
COMMERCIAL/INDUSTRIAL:
Type of establishment: n/a
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: n/a
Last date of occupancy: Na
OTHER:(Describe) n/a
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System has not been pumped in the[last two years.
System pumped as part of inspection:(yes or no)No
If yes,volume pumped:0 gallons
Reason for pumping: n/a
TYPE OF SYSTEM
Septic tank/distribution box/soil absorptions system
X Single cesspool
X Overflow cesspool
Privy
Shared system(yes or no) ( if yes, attach previous inspection records,if any)
Other(explain)
APPROXIMATE AGE of all components,date installed(if known)and source information:
1960
Sewage odors detected when arriving at the site: (yes or no) No
(revised 11115195)
• 1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 209 Greenwood AV.Hyannis Port
Owner: Etta Dickinson:86 N.Main St N.Grafton Ma.01536
Date of Inspection:5116/97
SEPTIC TANK:_
(locate on site plan)
Depth below grade: n1a
Material of construction:X concreate_metal_FRP_other(explain)
Dimensions: n/a
Sludge depth:n1a
Distance from top of sludge to bottom of outlet tee or baffle: n1a
Scum thickness:n1a
Distance from top of scum to top of outlet tee or baffle:n1a
Distance form bottom of scum to bottom of outlet tee or baffle: nla
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.)
n1a
GREASE TRAP:
(locate on site plan)
Depth below grade: n1a
Material of construction: _concrete_metal_FRP_other(explain)
Dimensions: n1a
Scum thickness:n1a
Distance from top of scum to top of outlet tee or baffle:n1a
Distance from bottom of scum to bottom of outlet tee or baffle: nla
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.)
nla
(revised 11115195)
6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 209 Greenwood Av.Hyannis Port
Owner: Etta Dickinson:96 N.Main St.N.Grafton Ma.01536
Date of Inspection:5116197
TIGHT OR HOLDING TANK:
(locate on site plan)
Depth below grade: n1a
Material of construction:_concrete_,metal_FRP_other(explain)
Dimensions: n1a
Capacity: n1a gallons
Design flow: n1a gallons/day
Alarm level: n1a
Comments:
(condition of inlet tee,condition of alarm and float switches, etc.)
n1a
DI
STRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert: wa
Comments:
(note if level and distribution is equal,evidence of solids carryover, evidence of leakage into or out of box etc.)
n1a
PUMP CHAMBER:
(locate on site plan)
Pumps in working order.(yes or no)
Comments:
(note condition of pump chamber,condition of pumps and appurtenances, etc.)
n1a
(revised 11,15195),
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 209 Greenwood Av.Hyannis Port
Owner: Etta Dickinson:86 N.Main St N.Grafton Ma.01536
Date of Inspection:5116/97
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:
Na
Type:
leaching pits,number: 1,000 gallon leach pit
leaching chambers,number:n1a
leaching galleries,number: n1a
leaching trenches,number,length: n1a
leaching fields,number,dimensions:n1a
overflow cesspool,number:n1a
Comments:(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
The overflow was empty at the time of the Inspection it is structurally sound
CESSPOOLS:X
(locate on site plan)
Number and configuration: one
Depth-top of liquid to inlet invert: empty
Depth of solids layer: nla
Depth of scum layer: n1a
Dimensions of cesspool: 6'x6'
Materials of construction: block
Indication of groundwater: none
Nd inflow(cesspool must be pumped as part of inspection)
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 year for maintenance
PRIVY:_
(locate on site plan)
Materials of construction: n1a Dimensions: n1a
Depth of solids: n►a
Comments:(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.)
Na
i
(revised 11115195)'
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 209 Greenwood Av.Hyannis Port
Owner: Etta Dickinson:86 N.Main St.N.Grafton Ma.01536
Date of Inspection:5116107
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
H
OA
O� AA18
�A 36
g� a�
DEPTH TO GROUNDWATER
Depth to groundwater: 12 feet
method of determination or approximation:
USGS Maps and Charts
(revised 11115195)
9
TOWN
IIO,,F��B STABLE
L&-A'7ION ®� e lNw SEWAGE #
VE LAGE ASSESSOR'S MAP & LOT WS
INSTALLER'S NAME &PHONE O.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
r
NO.OF BEDROOMS ���Gh1
BUILDER OR OWNER
PERMIT DATE: -COMPLIANCE DATE:
r
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' tlands exist
within 300 feet of leaching facility) + Q Feet
Furnished by
ra
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LOiOAA T//10N /y )y �E W PERMIT NO._
CT V ':s �� Ii✓U Q N 9/'p �t7
VILLAGE
N S T A L L E R'S NAME & A D D R E S S J. CRAIG 'ME®EIR®S
`racking & Bulldo in
142 Corporation Street
u
- OWNER
DATE PERMIT ISSUED
OAT E COMPLIANCE - ISSUED
N AA
0
O0
J
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1
No.._&? ��_ r E4... ...............
THE COMMONWEALTH OF MASSACHUSETTS
BOAR F HEALTH
®.................0F...................... .'... .
Applirta#ilan for Mgpviial Workg Tnntrurtion ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
syst t: ...........
. .......... ....
..
L�-Address or Lot No.
....
Y... ............................................. ••............. .... -•---.................---..--....
a Owner" r
._ -------- --------•----....-•---•--....-----................................. . ................ -- .....e..............:--•- •- - .L:.:...........
Installer Address
ype of Bui in Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms.....-3...............................Expansion Attic ( ) Garbage Grinder ( )
'4 Other—Type e of Building .... No. of persons............................ Showers
C4 YP g ------------------------ P ( ) — Cafeteria ( )
Q' Other fixtures -----•......-••-••......--•-••-- .
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
W Septic 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-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-------.................
•--•----•---------------------------------------••---------•---••---.......-•---------...._......------•.....--•----------•-----•......---------...---....--
ODescription of Soil------------- --•-- ------------.. ------•------.......-•-----------------•-------••--•••••--•----•-••-••---------•----•----•--••-•-----•------•--------------•-.
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 TL I.l:;a. 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has ben iss d by the board of health.
g �a .---•--••--•---•-•- �.-� (�
Si ne --•-
3te
Application Approved By....... � =........ .. . ................
Date
Application Disapproved for the following reasons---------------------------------------------------------------•------------------•---•••---•---------•---------
-----•---------------•---•-------..._.._...--•---••--•-------......-•----•-------•---....._..-------........-------------------•-----•--•---•--------•----------------•----•-•--••---Date•-•-----------
PermitNo......................................................... Issued.......................................................
Date
No....t '.. 3 9 FM:s'y....................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD ' OF HEALTH
�....=�`''... OF....................:..`
Appliration for Biipoaal Works Tonitrnrtion ami#
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
syst.....................
........................................ ..................1Z;1...................
Loca ..................
tes i�Address or Lot.......No.
. ... ---•--------•-• -•-•-----_---•----. _.._.._----- -•-----•--•----- ------• ................
r-:— P s "�`•"' caner " �jr'4v ✓ i sG L/t
' ----------------- _._........._----------•---•=•••---• - - -_....< �......_.._.. :.......-•-
r Installer Address
Ue of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms.........._.................................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons____________________________ Showers — Cafeteria
GI 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 ( )
F-I Percolation Test Results Performed bY---•-•••-•••---•------•---•-•______-_...
_............................=..... Date........................................
aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water.........._.............
4, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
04 •---•-•-•••---••-------•-•••--•.............••••...._.__......_.._..----•-------•---........-----......•-••---•-'.._.........------------.........-----__---
O Description of Soil.........
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U Nature of Repairs or Alterations—Answer when applicable................................................................................................
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Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of ILT1,; 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b en iss end by the board of health.
Swig-ned.............. r �_---•---'--..........---•--- ...--•----- fir "`.?..--
Application Approved By--•-•-•--r. -� t_ _... ..�% �'1d/.�
Date
Application Disapproved for the following reasons----------------•----------------------------- ............................................................
' •-------------------•---•------•------•--------••----•--•----•------•-----....._......_..--•---------•---'-------•-------•---•---------•---•---•---•---•-----------•--•------•----...Date ----•---•---
PermitNo......................................................... Issued.......................................................
Date
t}, THE COMMONWEALTH OF MASSACHUSETTS
�f = BOARD OF HEALTH
f..... '` �� ..................OF. -
%Trr#ifiratr of Tomplianrr
THIS IS-50 CERTIFY, That
� *ee Indivi ual Sewage Disposal,-System.canst. ted��) o Repaired .(�',)
A ✓yp"�"'W.4'w'M
{
�' Installer
at. `� ..__...... 61
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has been installed in accordance with the provisions of TITL:: 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No------- ____________ dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NFACHUSETTS
AS A GUARANTEE THAT THE
SYSTEM WIrLL_ .gTIQN SATISFACT R .
DATE.......`:....... 1."'.at�_.Y... In ----------•------.._.._._........_......_.........-•---•..
J
THE COMMONWEALTH O
BQARD�,.PEALTH
y ........OF......... :_...._ .:' `.'.a.•-•......................_......._.........
No.....��'.....":2 of FEE.......................
121
Permission is herebyranted. _._.` --•-••--•• ---.. ......... '
g j
to Consttuc-• .t- ) or Repair )-aa Indiyidtfalke age Disposal Sy '
�q �
at No.....J .:dt'-<I!dC-- 1 sL.- I `�=514 ✓�i:r-� °_. •`�} -... -►-��t ?' �tY. !
Street
as shown on the application for Disposal Works Construction Permit No..................... DAted..........................................
.........................................
��� Board of Health
DATE........•-- -------•-1-� •-•••----------••-------•--------------
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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