HomeMy WebLinkAbout0105 HAMDEN CIRCLE - Health 105 Hamden Circle, Hyanuis
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9,, RTOLOTTI CONSTRUCTION,INC.
765 WAS BY ROAD,MARSTONS.MILLS,MA 02648; 't
-9399. 508-428-8926 FAX: 508-428-9399
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR4 ' ° y
PART A
CERTIFICATION
Property Address: 06- #all �e� Li& '
Date of Inspection: // Inspecto 's Name: '
Owner's Name and Address:
CERTIFICATION STATEMENT:
I certify that I have personally inspected the sewage disposal system at this address and that the informa-
tion reported below is true,accurate and complete as of the time of inspection. The inspection was per-
formed based on my training and experience in the proper function and maintenance of on-site sewage
disposal/systems. The System:
►/ Passes
Conditionally Passes
Needs Further Eva tion By e L al,Aproving Authority
Fails
Inspector's Signature: Date: /�9 a
The System Inspector shall submit.a copy of this inspection report to the Approving authority within thir-
ty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional
office of the Department of Environmental Protection. The original should be sent to the system owner
and copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
A)SYSTEM PASSES:
t/ I have not found any information which indicates that the system violates any of the failure
criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated aie indicated
below.
B)SYSTEM CONDITIONALLY PASSES;
One or more system components need to be replaced or repaired. The system,upon comple-
tion of the replacement or repair, passes inspection.
Indicate yes,nor,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 sep-
tic tank is replaced with a conforming septic tank as approved by The Board of Health.
Sewage backkup or breakout or high static water level observed in the distribution box is due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. The
system will pass inspection if(with approval of The Board of Health):
- 1 -
SUBSURFACE SEWAGE-DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued){
��`»,,, ,• Broken pipe(s)replaced w
Obstruction is removed
Distribution Box is levelled or replaced
The System required pumping more than four times a year due to broken or obstructed pipe(s).
The system will pass inspection if(with approval of The Board of Health):
Broken pipe(s)are replaced
Obstruction is removed
C)FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
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 SAFE
TY 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 SYST
EM.IS FUNCTION-
ING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has aseptic tank and soil absorption system and is within 100 Feet to a surface
water supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and.is with 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 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 and volatile organic compounds indicates that the well is free from pollution from
the facility-and-the presence of ammonia..nitrogen and nitrate nitrogen is equal to or less
than 5 ppm.
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 into facility or system component due to an overloaded or clogged SAS
or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an
overloaded oc.clogged SAS or cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clog-
ged'SAS'orcesspool'4 ,• x
Liquid depth iri cesspool is less than 6"below invert'or available volume is less than 1/2
day flow.
Required pumping more'than 4 times in the last year NOT due to clogged or obstructed
pipe(s). Number of times pumped
-2-
a .
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater
elevation.
Any portion of a cesspool or privy is within 100 Feet of a surface water supply or tributary to .
a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 Feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 Feet but greater than 50 Feet from a private
water supply well with no acceptable water quality analysis. If the well has been analyzed
to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic
compounds,ammonia nitrogen and nitrate nitrogen.
E)LARGE SYSTEM FAILS:
The following criteria apply to a large system in addition to the criteria above:
The design flow of a 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 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.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Check if the following have been done:
y Pumping information was requested of the owner,occupant, and Board of Health.
None of the system components have been pumped for atleast two weeks and the system has
been receiving normal flow rates during that period. Large volumes of water have not been
introduced into the system recently or as part of this inspection.
✓As-built plans.have been obtained and examined. Note if they are not available with N/A.
The facility or dwelling was inspected for signs of sewage back-up.
✓The system does not receive non-sanitary or industrial waste flow.
_ The site was inspected for signs of breakout.
V All system components,excluding the Soil Absorption System, have been located on site.
The septic tank manholes were uncovered,opened,and the interior of the septic tank was in-
spected for condition of baffles or tees, material of.construction,dimensions,depth of liquid,
depth of sludge,depth of scum.
l/fhe size and location 0 f he Soi
lAbsorption
System
monthesi
te has bee
nde
termined based on
existing information or approximated by non-intrusive methods.
-3-
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
continued
CHECKLIST(continued)
V The facility owner(and occupants, if different from owner)were provided with information on
the maintenance of Subsurface Disposal System
proper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
FLOW CONDITIONS
RESIDENTLAI: 3
Design Flow:aao gallons Number of Bedrooms: Number of Current Residents:
GarbageGrinder:� Laundry Connected To System: Seasonal Use: A)d
_
Water Meter Readings, if l ailable:
Last Date,of Occupancy: /&A h
A)d
./I
COMMERCLAiND 1ST iAL.
Type of Establishment: ,
Design Flow: gallons/day-,Grease Trap.Present: (yes or no)
Industrial Waste Holding Tank Present:
Non-Sanitary Waste Discharged To The Title V System:
Water Meter Readings,If Available: Last Date of Occupancy:
OTHER: Describe)
Last Date of Occupancy:
GENERAL INFORMATION
l
PUMPIN.G.RE.CORDS and source of informalLton; . �9y
System Pumped as part of inspection: N O If yes,volume pumped: gallons
Reason for pumping:
TYP"F SYSTEM:
V Septic Tank/Distribution Box/Soil Absorption System
Single Cesspool
Overflow Cesspool
Privy
Shared System(If yes,attach previous inspection records, if any)
Other(explain):
TE AGE of all com nents date installed(if known)and source of_information: .:
ASe
PRO ge odois defe to when'arriving at the site '` )
_ -4-
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
GENERAL INFORMATION (continued)
SEPTIC TANK:
Depth below grade.-JC2_„L Material of Construction: &--c*oncrete metal FRP_Other
(explain)
Dimisions:,R 5'Yb' X51 Sludge Depth: Scum Thickness:
Distance from top of sludge to bottom of outlet tee or baffle: 3 3-
Distance from bottom of scum to bottom of outlet tee or baffle: .3
Comments: (recommendation for pumping,condition of inlet and outlet tees or Wes,depth of liquid
level in rel tip onto ou et invert,structural integrity,evide ce of leakage,etc.) , GL. /I.YX� u
t✓C // ,
UA
GREASE T :—A1CL
Depth Below Grade: Material of Construction:_concrete_metal_FRP_Other
(explain)
Dimensions: Scum Thickness:
Distance from top of scum to top of outlet tee or baffle:
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.)
TIGHT OR HOLDING TANK:
—LZ
Depth Below Grade: Material of Construction:_concrete_metal_FRP_Other(explain)
Dimensions: Capacity: gallons Design Flow: gallons/day
Alarm Level:
Comments: (condition of inlet.tee,condition ofa.larnn and float switches,etc.)
DISTRIBUTION BOX:
Depth of liquid level above outlet invert:1�t ULi�/Y
Comments: (note if lovel and distribution i:.equa ,evidence of solids carryover,evi ence of leakage into
or out of box etc.) - �yv cJ9
PUMP CHAMBER:
Pump is in working order:
Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) -
-5-
' SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
SOIL ABSORPTION SYSTEM(SAS): ✓
may be approximated b non-intrusive
excavation not required,but. pp Y
(Locate on site plan, �possible;exca q Y.
methods) If not determined to be present,explain:
Type:
Leaching alleries nu tuber:
Leaching pits, number. Leaching chambers, number: Leac g g ,
Leaching trenches,number, length:
Leaching fields,number,dimensions:
Overflow cesspool, number:
Co nts: (note condition of soil,signs.of h aulic ailure lev 1 of pondin condition of ve a tion,
1
etc: '
CESSP0 OLS:Number and configuration: Depth-top of.liquid to inlet invert.
Dimensions of Cesspool:
Depth of solids layer: Depth of scum layer: (�
Materials of construction: Indication of groundwater:
Inflow(cesspool must be pumped as part of inspection)
Comments: (note condition of soilk, signs of hydraulic failure, level of ponding,condition of vegetation,
etc.)
PRIVY:_/_0CJ
Materials of construction: Dimensions:
Depth of Solids:
Comments: (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,
etc.)
-6-
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include ties to atleast two permanent references, landmarks or benchinarks.
Locate all wells within 100 Feet.
� .120 � 3
3
DEPTH TO GROUNDWATER: ,
Depth to groundwater:- Z/' Feet
Method of Determination or APpro imation: X��1Qj (
317 ifs
No.....74.w�S4 .3
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliration for Uhipoii al Workii Tnnitrnrtiun Vanfit
Application is hereby made for a Permit to Construct ( ) or Repair ((%1-4 an Individual Sewage Disposal
System at:
t� Location-Address or Lot No.
....................L»..........A ...................................... .................................................................................................
Owne Address
Installer Address
d Type of Building Size Lot............................Sq. feet
aU Dwelling No. of Bedrooms........................ .....Ex Expansion Attic
g— --------------- p ( ) Garbage Grinder ( )
a Other—Type of Building ............................ No. of persons.....................------. Showers ( ) — Cafeteria ( )
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........................................
W
Test Pit No. 1................minutes per inch Depth of Test Pit.---------_----.-- Depth to ground water..--....................
G4 Test Pit No. 2....:...........minutes per inch Depth of Test Pit..........----...... Depth to ground water..............--........
9 ------------------------------------------••--•--••-----••-••--------- --•--•••----------------------......------._.........-•---------------......._.....•.
O Description of Soil - SV ................. '�'`�✓ ram ' '
U ------•-•-•--•••---------------••••--------••-•-------•----••----------------••••---......•--------•--•---•-•--•--•-------...--•------•---•......
W
x ---•-------------•--•-----------------
U Nature of Repairs or Alterations—Answer when applicable.- . L` c�SPaOL >
--------------------------- •- .............................
.� iL-------l�QO - �. C�� $ � . .................t �.f cam`
S 7 0
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental 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.
Signed.... �. —----------_---------- ......A5�� � .k---
Dace
Application Approved By ..................------
-Dace
v u 2y`
.. ............................................................... ....1.,/�. . F
Application Disapproved for the following reasons- ------ ---- ------ ----- ----- -------------- -- ---- --- --- ------------ -------- -----------------------
--------------------------------------- -------------..............................................................-- ------------ ---------------- - ------------------ - ----------------- ----------------------.................
are
PermitNo. --..... .- 7- ---------_--------------- Issued .........................................................D-----------
Dace
.. 317
No....�C...........L y Fim ......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Applirttftnn for Dhiposal Works Tonstrnr#inn rrrnti#
Application is hereby made for a Permit to Construct ( ) or Repair ((k-4 an Individual Sewage Disposal
System at:
........ 1 ..._..... � ? C c... t .................`... .........../:..y ..nN/ 5.. -Lot.N--
...........................................
Location-Address or o
. ................C............. ...................................... ••__________________________________•.••_• .....-•----•........------.........-•••••••...........
Owner, Address
a ........ .......... � .�-•--...n � .,......r.ca....... ! .... -18.).......KossK.............---••-••--•--•--•-•........................
Installer Address
Type of Building Size Lot............................Sq. feet
V Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
'4 Other—T e of Building No. of persons............................ Showers — Cafeteria
Otherfixtures ---------------------------------------------------------------------------------------
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 ( )
1.4 Percolation Test Results Performed by.......................................................................... Date....
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
fsl Test Pit No. 2................minutes per inch Depth of.Test Pit..._................ Depth to ground water........................
P ----------------- ---------------•-----•-•----•......------...........---•--...........--.....--•........................................
--------
O Description of Soil......0-2..•--....S.�.�-....................•------ ...... �L� S�
W ...... ... ................�.. ... �tw ----------
U -•------------------------------•--••-••••----------•----------•----------..........------•--••-------........•-•---------............._•.;---.........-•-------p-------•------------.-...---...--------
W
UNature of Repairs or Alterations—Answer when applicable._.9�?)� ........ _______n �___________________________
......... �-------------- ------•-- ------ ...........................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliaan--c-ee has been issued by the board of health.
Signed .............`......>. -----...\...:...,...................... ------.V.4
Dare
Application Approved By ------------------------v
Date
Application Disapproved for the following reasons: .......................................................................................................................................
-------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------
/' Date
PermitNo. .. ........................ Issued --------------............-----------------...--------------------- .
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
(IT r#tfira e of (11oncpltttne
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (�)
by.......... ���.c ��` ........:. ......�T_Vjc..
Installer
_
at �. .........�.s ....................................................' 4 4.aa. --........--------......------------....................------..................
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. __?Z----6-7..t-1.............. dated ................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.. .............. o c�.. ..y.'.%. ..------------------.................. Inspector ------ ---------...................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
No....�. �.:............�� FEE.... ..........
Disposal Works Tnntrndinn. rrntit
Permission is hereby granted...... .......``L''JS`.............................................................................................
to Construct ( ) or Repair ((C) an Individual Sewage Disposal System
atNo.......1.6 ........... . ............1 --------------•---•----------
Street ���
as shown on the application for Disposal Works Construction Permit No.......:::.......... Dated..........................................
__A ..................................................
Board of Health
DATE...................
r
FORM 36508 HOBBS 6 WARREN,INC..PUBLISHERS
TOWN F BARN -ABLE �
LOB=,kTION il- N Of iL- SEWAGE #
VILLAGE 4 NA ASSESSOR'S MAP & LOT
,j INSTALLER'S NAME & PHONE NO. H�t�L 5 CC
SEPTIC TANK CAPACITY 2) 87n
LEACHING FACILITY:(type) ize) ,acr6
NO. OF BEDROOMS PRIVATE WE R.PUBLIC WATER
r
BUILDER
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED: \�' 2-:1 I
VARIANCE GRANTED: Yes No
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TOWN F BARNSTABLE
LOC: f'ION/(�Say4laz �CY/1� /.k. b SEWAGE #
VILL.43E_ a/2/ ASSESSOR' MAP & LOT 177
V SPEc3 et NAME&PHONE NO.
SEPTIC TANK CAPACITY D c
LEACHING FACILITY: (type) (size)�d�U NO.OF BEDROOMS 0
BUILDER OWNER
PERMTTDATE: COMPLIANCE DATE:
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 wetlands exist
within 300 feet of leaching facility) J Feet
Furnished by
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C.�
CA1
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�3� W
C13 _
L0CAT ON SEWAGE PERMIT NO.
e
VILLAGE aW,3�7
INSTA LLER'S NAME & ADDRESS
BUILDER OR OWNER
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED
3 ,
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No..__.. .. Fl�s....ls ........
..........�-• .
w` ¢• THE COMMON, !EALTH OF MASSACHUSETTS
BOARD OF HEALTH
r2KWA1.....OF................ A4eWf7. XA! ....................
' Appliratiun -fur Ropofial Works Tonotrurtiun Vaniit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: --•------ �!
........---•---------------------L •+ !
//�� .-Location-Address ��'a T e ��� or Lot No.IC7 ,•./ '�
------------
Owner .T��..1/��-•--•f1'iK.4*.l ------•-------------------- s._. L± ----------------•----.._.
Owner j7 - Address
a -------------•---•-- • - ---------- ._ v 1z14 lit./�-C.. ....------------------------.
Installer Address
UType of Building Size Lot-------/Zh7= Sq. feet
Dwelling—No. of Bedrooms------------- -................._._.._.Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ---------------------------- No. of persons..........._---------------- Showers ( ) — Cafeteria ( )
P-4 Other fixtures ------------------------------
W Design Flow-------------------------*• ........gallons per person per day. Total daily flow-------------:Z2,4-----------.....gallons.
WSeptic Tank—Liquid capacity-/6Mgalions Length--_ -- Width__4 .P. Diameter................ Depth.._---_-.-..--
x Disposal Trench—No. .................... Width.................... Total Length-------_............ Total leaching area....................sq. ft.
Seepage Pit No------------/..... Diameter........ Depth below inlet----e'�' _... Total leaching area--- .�_.S__---sq. ft.
Z Other Distribution box (1,4,' 1 Dosing tank ( )
'-' Percolation Test Results Performed by--------- ...... -____------
,a Test Pit No. 1--,." .?--minutes per inch Depth of 'Pest Pit._.c 7�!44.w Depth to ground water..-...-
(4 Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground water-_.-.--_-_---.__.--_
-------------------------------------------------------------------------------------------------------------------------------------------- ................
O Description of Soil-------�--- ---- icor,---- �Y eIO✓ls �------0'�'1��----------------------------------------------------------
W
......................... - _--------/=-....
UNature of Repairs or Alterations—Answer when applicable..--------------------------------------------------------------------......I-------------------
---------------------------------------------------------------------------------------------------------- ---------------------------------------------- --------------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance.with
the provisions of Article \I of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has beenFssued by the board f h'ealth.
Sied.-• . .-• ....... ....... �% `-•• -
A lication Approved B l Date
PP PP Y /` = GL!LL..- {1 '1 -77
Date
Application Disapproved for the following reasons-------------`...-----------------------------------------------------------------------••--Da.t.e-----------•--
-------------------------------------•--..............-----------------------------------•--------------------•---•--•••---•------------------•----------------•--------••--------------•---------------
y ate
PermitNo.........................................----•--........ Issued--- .... ----------- -----`-----•----- --------•--•
Date
No. ..
4fCo3� -� w '. ,r. THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEALTH
tt w ,,:.... Y��✓. 4tr,4`_......OF...............t!° *�+r� ':r !,aA' �' �IG ........................
���• `;�•�s��irtt#�nt� -fax �i,��u�tt1 �ark� Cnutt��rtirtiutt �rrtlitt
Application is hereby made for a Permit to Construct. ( ) or Repair ( } an Individual Sewage Disposal
System at
Location Address or Lot No.
.�- empire 3 z �,•. 'S ,��
fy" ___.. l _______________________ !=�: .................................._..._ r a, 1` {e' 1't•�4'•. ----_ -- Aw t� s�lr9C�3YP'r/ - yp' _
Owner + Address
--------------•---•• �` -- ------ a'---- * -------•---------------: ..-----•._- --------------..............
Installer zAddress
UType of Building Size Lot.......10,=-—_Sq. feet
Dwelling—No. of Bedrooms__-_ ____Expansion Attic ( ) Garbage Grinder ( )
aq Other—Type of..Building ___________________________ No. of .persons.--------------------------- Showers ( .') Cafeteria ( )
0.1 Other fixtures ----- ------------------------ --- - -- - --
w Design Flow------------------------- '� __:___-.gallons per person per day. Total daily flow------------a..2 ................gallons.
WSeptic Tank—Liquid capacitvt✓4M. .gallons Length--do_d--- Width -4'"0- Diameter----------------- Depth----------------
Disposal Trench—No Width.________`_-____. Total Length Total leaching area___:................sq. ft.
Seepage Pit No............ Diameter Depth below inlet_...? __ _____ Total leaching area.__" _:�sq. it.
z Other Distribution box (ire^)'' Dosing tank ( )
Percolation Test Results Performed.by.-____, efe¢ ,�1 '._ AW4r ._ "`Date____te a-+✓`�
Test Pit No 1*40::.�-,.,..__minutes per inch Depth of Test Pit_.. '? •__, Depth to ground water, __•
(s, Test Pit No. 2_ ............minutes per inch Depth of Test Pit____________________ Depth to ground. water------------------------
--------------- ----------------••-----••-•-•--•------••-- ..........................................•-.......................................................
Descrpton o oI fir , � - �- e ------------------------------ ---- ----- -
. ---•--- -•••--- •--•-------------------------------------- ------- --
,
w
VNature.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 Article XI of the State Sanitary Code The undersigned further agrees not to placee-the system in
operation until a Certificate of Compliance has beenissued by the board of health ' .
Sl eCl :-... - y° Ls v ' Dat
Application Approved By-=----- * ::............ .../� ......'
Date
Application Disapproved for the following reasons: -----•---=---•----------------•---------------_____:••-- .....................................................
-----------------------------------------------------------------------------------------------------
Date
PermitNo..................................................... Issued...................... .................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD Of HEALTH
I ..............................:..:..OF... .: C'/ ..........,.......................................
Trrttfirtttr of (611mphaurr
THIS I- TO CERTIFY That, the Indivi ewa e Disposal System constructed (I-0100,or RepairedZZ
( )
. �by = -=-.-- - ..............-- ------------------------------ -------------------------------
Inst er
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has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No----- _ _------------------- dated...... 9 7.............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTAUED AS A GUARANTEE'.'THAT THE
SYSTEM WIL F NCTI N SATISFACTORY. �-
DATE---------------•--l- --------- ................... Inspector-------------------------------------------------------------------------------•-
r;
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
` ....................................... ..OF...." "r .t " •,
No.•------ ----••••--•• FEE.--- ...
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Permission is hereby granted.• -R- `_- - ` -_ � Jj ----. ' •4 `
to Construct ( ) or Repair ( , ) an Individual Sewage Disposal System
atNo.- - 1 Al• tr f _T_ !.. �( .../ t '41-------------------------------------------------------------------------------
at
as shown on the application for Disposal Works Construction P. it Dated.__./0-7fY '�7____.___.__ ;
--- --
y � Board of He
DATE - 7-- --ZPw-------••-------•-----•-•••---=---._.
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS .
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