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HomeMy WebLinkAbout0115 OAKVIEW TERRACE - Health 115 Oak- View. Terrace 268-298 %fay 5-9 Hyannis w i COMMONWEALTH OF MASSACHUSETT S EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS m a DEPARTMENT OF ENVIRONMENTAL PROTECTION /Yl a 9P z S�? TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: �S DCi�/�,e h/ T"�✓ram�� hH a6o� J�j Owner's Name: y e� �H , Owner's Address: / .S A eW ee -a e e-- a ✓/ S oZGO� Date of Inspection: �. a6 /O' Name of Inspector: (please print) �' "�G'rh� /-o% Company Name: it/ i Q— t_,_ Mailing Address: 0 6ax /.I. ill Ea a 6�01 E s Telephone Number — k ; c� a CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information" eported- below is true,accurate and complete as of the time of the inspection.The inspection was performe based on my rn training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to S 1 15.340 of Title 5(310 CMR 15.060). The system: �� passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails --- Inspector's Signature:- �'" _ .. • - Bate: ��a6. Off- _. -- -- ---- i The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.Theloriginal should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments- T a"4,- ri-eee✓f ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: /1, %e✓-a C—e-, 0/ Owner: Z &Ne Date of Inspection: S 0 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Syste ses: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System-Conditionally Passes: /1/ One or mores stem com ponents mponents as described in the"Conditional Pass"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(Y,N,ND)in-the for the following statements.If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound, exhibits substantial.infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in.the di_stribution.box due-to broken or obstructed pipe(s)or due to a_broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain- 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):' broken pipe(s)are replaced obstruction is removed ND explain: T do c incnanr;nn r ,.,.,sir ci�nnn 2 Page 3 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: l�J ©G wic W %el,-c ee ffo,rin/ ' , Owner: a'j e o'— r / Od Gol Date of Inspection: 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 public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 C1bIR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 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 supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria-and-volatile or ganic-compounds indicates that the welris free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. .3. Other: ` Trio c r.,�.o .c „ �,..,, 4i1cnnnn 3 ' Page 4 of 11 i OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) . Property Address: //S Of 4-0er,, TPr,GC-c_ Owner: Z-A - — Date of Inspection: a G 6 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No � �B ckup of sewage into facility or system component due to overloaded or clogged SAS,or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or gged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or ° spool "�Lam• luid depth in cesspool is less than 6"below invert or available volume is less than%z day flow ✓Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number ,,,of times pumped _ Any portion of the SAS,cesspool or privy is below high ground.water elevation. _✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface `wyater supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. ✓Qny portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (Yes/No) The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: ---- To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. 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 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 one II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes"in Section D above the largesystem has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: �G�✓v/-Ek/ le ' C-e_ Owner: z,o►H �viv�r 0,46 0/ Date of Inspection: C 0 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes N ; Pumping information was provided by the owner,occupant,or Board of Health C/Were any of the system components pumped out in the previous two weeks ? Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of this inspection 9 ./ Were as built plans of the,system obtained and examined?(If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up?; Was the site inspected for signs of break out? Were all system components,excluding the SAS,located on site? ✓— Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition. of the bafflesor tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? _ The size and-location.of-the Soil.Absorption System(SAS)-on.the-site has-been determined..based on: Yes no Existing information.For example,a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property address: J ©a�✓vi�t,/ 7'e✓zac �,GtNr�rs � � ©oZG•©/ Owner• 'La ktt Date of Inspection: 02 FL W CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): �3 O Number of current residents: O Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no):AV [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use: (yes or no): Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no): Last date of occupancy: COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the ins ection(yes or no): O If yes, volume pumped: gallons--How was quantity pumped determined? Reason for pu ing: TYP OF SYSTEM _Septic tank, distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) . Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval Other(describe): I Approximate age of all components,date installed(if known)and source f information: Were sewage odors detected when arriving at the site(yes or no): d Title G fncnnrtinn Anrm (./15/7(1M 6 Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: /S ���✓(/I�.G✓ . ✓iGC� nrt 1 '-�/ ©ox-co/ Owner: v.{_ Date of Inspection: BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction:_cast iron _4 0 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:_(`� locate l on site plan) Depth below grade: Material of construction:_concrete_metal_fiberglass__polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate)- Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: a Scum thickness: q Distance from top of scum to top of outlet tee or baffle: �f Distance from bottom of scum to bottoms 9f outlet tee o baffle: 6 �i How were dimensions determined: /"o/ems Jeri/ce-- Comments(on pumping recommendations,inlet and outl6f tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of letk�e, tc.): ,n /�ecov�ir7oa de ah ci o,o N ro 1-7 Q� _ GRE-ASE TRAP:k—/(,-Ocate on site plan)_.- Depth below grade:— Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: 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: Date of last-pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet.invert, evidence of leakage,etc.): T;*ia : Ir cr a *inn Gnrm sir ti�nnn 7. Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C /^ SYSTEM.INFORMATION(continued) Property Address: //J ©a4,11/Pk/ /-'i//Gce-- r Owner• L a Date of Inspection: o2G p TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): i Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage 'into out f box, t(: ): �o� �e PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms-in working order(yes or no): Continents(note condition of pump chamber,condition of piiinps and appurtenances,etc.): 411 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C r SYSTEM INFORMATION(continued) Property Address: h Owner: C71- Date of Inspection: 6 �� SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type �1-e leaching pits,number: , leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number, dimensions: overflow cesspool, number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc. : i i /S✓�J o , 7L G i t4✓,C. CESSPOOLS: /!/ (cesspool must be pumped as part of inspection)(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 groundwater inflow(yes or no):- Comments(note condition of-soil, signs of hydraulic failure,Ievel of ponding,condition of-vegetation,-etc:J - PRIVY: f/ (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.): Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: // tiaHhrr . /j�i4 Od6D� Owner: �-- 4- nPj Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet. Locate where public water supply enters the building. ��cl✓ 0 _d y 3 ' -- �� C; 03 T;*io : r o f;nn Fnrm �i :i�nnn 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Q 7�dIc, c e— �vt✓! Owner: A K< Date of Inspection: 016 O -10 SITE EXAM Slope Surface water Check cellar to Shallow wells Estimated depth to groundwater a/'&?feet Please indicate(check)all methods used to determine the high ground water elevation: IQ Obtained from system design plans on record-If checked,date of design plan reviewed: Oed site(abutting property/observation hole within 150 feet of SAS) ----Checked with local Board of Health-explain: . i//� Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you e tablished the high ground wate elevation: wv G� W f C a 1. . e / 6-elo c,, 0 07- +cle_ 6) O © o �i I 11 C'4,61/ — ai, � 7 1 I t � t I 7 y } I ` I. � I I I � � I ij t• I I i\ � � � tl I N 0 I 1/{/ IN TIC 1 qJ �. --tom-+— ---- _�- � •m ALli P i z r ➢ .� K13`f i>>z-nw>J/��vrt,�vlAvrz.F.�N I;.AT1:>= li5 vAi<✓�=us r�z, IT�aJv�vi� f j I N 7Q ka.CPNlrA _I ._N AT1@aJ '3dL ' z 2,Xt1(?T .UD Dlnnl:Coi.iL QrGQ� '-::�g�;nE_an-4 antra 4RaD6 .P .'' �-R•cz�/ r2/F�✓��_�i?I� MAy2E F�.l �re`i_.;.. !1.5..._d_/?K��Sw.'t=�.,li-ynntxtj5 t'/02k4--3D iZ Y a, 4 . -ENT* E tXc Fief ,,, 2 I NrnvDsew+ap �� n1cFP2n; _:: w 1 ......... ye-Breve__ � YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates (cost$30.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME.in town(which you must do by M-G.L.=it does not give you permission to operate.) Business Certificates are available at the Town Clerk's Office, 1 FL., 367 Main Street, Hyannis, MA 02601 (Town Hall) -DATE: IZI 1 - 0700 Fill in please: '>r i APPLICANT'S YOUR NAME/S: U �A 5 i-�kN GEC C -J `' ?tvZ�, o r s BUSINESS YOUR HOME ADD��E/SdS: t ICE OA-K Ui�U� ^ ia✓ (5 U) 300 1 ''f/I- ,N TELEPHONE # Home Telephone Number �4 NAME OF CORPORATION: NAME OF NEW BUSINESS 7ESSA TYPE OF BUSINESS C '06,1�'�e r 7A17SC IS THIS A HOME OCCUPATION? YES NO ADDRESS OF BUSINESS l!T 0At<V,'Ew +GXX4 Cc' Py4e�-J --0,2601 MAP/PARCEL°NUMBER ��g � (Assessing) When starting a new business there are several things you must do in order to tie in compliance with the rules and regulations of the Town of Barnstable. This form is intended.to assist you in obtaining the information you may need. You MUST GO TO 200 Main St - (corner of Yarmouth Rd: &Main^Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1: BUILDING COMMISSIONER'S OFFICE This individual has been informed of any permit requirements that pertain to this type of business. Authorized Signature* COMMENTS: 2. BOARD OF HEALTH This individual ha be rmed ofT!�rrmE�i a ements that pertain.to this type of business. MUST COMPLYWITHALL Authorized Soature HAZARDOUS MATE IALS REGULATIONS ** COMMENTS: 3. CONSUMER AFFAIRS [ CENS G AUTHORITY) This individual has n in m d f the licensing requirements that pertain to this type of.business. Authorized Signature* COMMENTS: Date:/2- 11�j i p�' TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAME OF BUSINESS: 16 SSA BUSINESS LOCATION: i i r 0,gk'viG-0 INVENTORY MAILING ADDRESS: L� TOTAL AMOUNT: TELEPHONE NUMBER: CONTACT PERSON: d-v CAS EMERGENCY CONTACT TELEPHONE NUMBER: ��� �13�-��I�O IS(D� �3�0-}0 MSDS ON SITE? TYPE OF BUSINESS: � PE"tk re g,vdSE INFORMATION/RECOMMENDATIONS: Fire District: Waste Transportation: Last shipment of hazardous.waste: Name of Hauler: Destination: Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous materials use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed/Maximum Observed/Maximum r� Antifreeze (for gasoline or coolant systems) Misc. Corrosive NEW USED Cesspool cleaners Automatic transmission fluid Disinfectants -� Engine and radiator flushes Road Salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants 3 Motor Oils Pesticides NEW USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel, Aviation gas Photochemicals (Fixers) 5 Diesel Fuel, kerosene, #2 heating oil NEW USED Misc. petroleum products: grease, Photochemicals (Developer) lubricants, gear oil NEW USED Degreasers for engines and metal Printing ink Degreasers for driveways &garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Misc. Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt & roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (inc. carbon tetrachloride) NEW USED Any other products with "poison" labels Paint &varnish removers, deglossers (including chloroform, formaldehyde, Misc. Flammables hydrochloric acid, other acids) Floor&furniture strippers Other products not listed which you feel Metal polishes may be toxic or hazardous (please list): Laundry soil & stain removers (including bleach ) Spot removers &cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS 6-5--- 7 7 s- N L O CATION SSA.,AW__Ay„G E PERMIT NO. VILLAGE INSTALL ,R'S N,A14E A ADDRESS Ll B U I L D E R OR OWNER , rn — DATE PERMIT ISSUED <O �s DATE COMPLIANCE ISSUED i i � . Q� b'a s rr � dr ,..: e3'� t�� r ao� � \\ a� \ � �_�� �� � ,�. T� , i �. No.BJr. ...2gn Fss.. n ..... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ..........I.®cvO.................OF.......... G�.�. .................. Applira#iott for Dispog al Works Tomi#rurtinxt ramit Application is hereby made for a Permit to Construct (k) or Repair ( ) an Individual Sewage Disposal System at: \ ................_......0A.KYLEW.......1-�7?:!ef� ---•--........... .......................L ....... .......... Locat' n,Address ( or Lot No. P ..._.__ - 1...W.J l..0.sSh----------- ---. ..:�.�._..�.���---•�i.e��- k?.�...................._----- Owner �j'� Addr T . .....& 9-3_4zma�... Installer Address UType of Building Size Lot_._�0t_ 1 __----Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) - Garbage Grinder ( ) aOther—Type of Building ........................... No. of persons............................ Showers ( ) — Cafeteria ( ) 0.' Other fixtures -------------------------------- . d --------------••--------- W Design Flow.._.._..............gallons per person per day. Total daily flow........... .....�.3!........gaal�ops. WSeptic Tank—Liquid capacity./COP.gallons Length..... Width...... ...... Diameter________________ Depth....._ ........ x Disposal Trench—No..................... Width...................... Total Length............j....... Total leaching area................ _.sq. ft. Seepage Pit No._..._._1.-__ ,_-- Diameter-__tP......_..... Depth below inlet....... ........_. Total leaching area.S11 sE}.-tt�•P Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by________________w_ ._._W4c:_�.JIQC........... Date....... .......... Test Pit No. 1..:4Z-....minutes per inch Depth of Test Pit___-_-TT.... Depth to ground water____. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water......................... O Description of Soil........................ --..... ....... ............................ x -------------•-------------------•--.-----------•-•- - - - - - ------- ------------------- ---------- ---.---- - - --!-------------- -•---.---------•------.----------•----------- U W ----------------------------------------------•---•-•--------------------------.._..----------------------------------------....---------------------------•------------------•----------------•---•--- 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 TITLL 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a C tificate of Compliance has bun issued by thA board of health. PPlication Approved `By e ------------------ ---------------- ----- -- - ----•- ------ vt�g - -- -..--•--- Date Application Disapproved for the following reasons:................................................................................................................ -----------------------------•-------...-•--•------.......---------------------------------•--......--•-----•-•---•--•-•---------•--------•--------------......-------------------••-------•------_...•. Date ✓`i Permit No.--------•---•............ •-- .............................. .....•---------•--•------------ Issued.-----------._....- . Date �t No��. Fx$..— ......... THE COMMONWEALTH OF MASSACHUSETTS BOAR® ' HEALTH Ap lir. ation for Disposal Works Tonstrnrtion runtit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: 3 o a. a f✓ / ocatio - ess� or Lot No. 1.�� " l lr._._...C.IS. :.f11.Ci :�.C�. ....... �:._... ::. er .��y�t'N....` ��„Ad gss �y � Installer Address Type of Building Size Lot.l��._S-�_et._.Sq. feet p., Other—Type of Building ............................ No. of Expansion Attic ( ) Garbage Grinder ( )Dwelling—No. of Bedrooms___......3.._....._.. persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures -------------------------------- - W Design Flow...............&S.....................gallons per person per day. Total daily flow.........33.0......................gallons. WSeptic Tank-Liquid capacitylClllD__ga]lons Length........ ...... Width... Diameter................ Depth....___.._...__. x Disposal Trench—No. ............:....... Width__---f.............. Total Length__....._).._.._.... Total leaching area.64. r_�___sq.(W9 Seepage Pit No---------I.......... Diameter-----1f _-_-..... Depth below inlet...6.............. Total leaching area..................sq. ft. Z Other Distribution box ( Dosing tank Percolation Test Results Performed by_..._..___L ..... [ !t Date.... .......... ,aa Test Pit No. 1_C.?.......minutes per inch Depth of Test Pit--- q....... Depth to ground water_J_Vr!/V... ....... 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ----------------------------------------------------------------------------------------------- __.. _ - ------------------------------------------------------- DDescription of Soil............................................ c..,-----------------------------------••-----------------------••------------------------------ x U ---•-----------------•---------•---------••-••-•._...----.....---•----------•--------•--......•-------.....--------------------------••--•----•-•--•................................................... W e •--------------------------•--•--•--------•.------------•------------------•-_.....---------••--•--------•-----------------------------•-.•--•----------------•----------•--•------•---•--------..•---- U Nature of Repairs or Alterations—Answer when applicable............................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitar Code—The rsigned further agrees not to place the system in o atio until a ificate of Compliance has ee issued by he bo r f h GG/ " �� Datd Application Approved By. .. -----------------• ------------------------------------ ------ ---- . Date Application Disapproved for the following reasons-------------------------------••-----••-•-------•-----•-----------------------------------•--------------...•••. ---------------------------------••-•---.....--•....-----------•-•-•-••---•---•--•...........--------•-•---------------------•----•--•--------•-...---------•-•----•---•-------------•------------....-- Date PermitNo......................................................... Issued-....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS :..'. BOARD OF HEALTH ..........................................OF..................................................................................... Trrtifiratr of Tantpliaurr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repai ( ) C -� Installer at,...............4,P1--------•---9•----- ............ ......... ........... has been installed in accordance witli the provisions of TITLE t —of The.State Sanitary Code� as described in the application for Disposal Works Construction Permit No.__.._.g.............................. dated---.__ :P.f_/Q/iQ.Q_S................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL U T,!ON SATISFACTORY. DATE............ ........... --•----------• ------- Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS .BOARD '� HEALTH ...........................................OF.................................. , No......................... FEE.- ............ - n nrtUan r it Permission is hereby gran e '-------------------=- ------------- ------ --•-- --- 1: .................................................. to Con* ( ).o�R� it ( ) an Individual Sewage- Disposkal System C.>�� 11 c�*.� Teri. C-c? -} �u,c�-�Mo at No.. ................................... •--- �----• ------------ -------•-•---------------------•--•-----------------------------•--•....... " Street as shown on the application for Disposal Works Construction Permit Now _r'... Dated.._._ �1.v9_ .......... Ig l 1 Board of Health ho V DATE--------------- ' ------••_..... •" FORM 1255 H e BBS & WARREN. INC.PUBLISHERS ' 42 /,73 lcJ�S/�E�7a -- - --- - - - — 36 36 34 - 4' - 3a ---- — - _ — — ---- — — — — /U O TE ExTE-,vD /9:4 J_ A F' 4_IC/9 A3 E ,. ------ e Xfs-f-fn9 gt-our nl pr-oclit? H0�2fZ. 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