HomeMy WebLinkAbout0089 WAGON LANE - Health 89 WagCp Lane
Hyannis
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L COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
s
TITLE 5 r
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: O I waag 1�_n.
_ YV1C1�, RECEIVEp
Owner's Name: -5 ,
Owner's Address. 'S Is
® 3 3 DEC 0 4 2001
Date of Inspection: 101 10Lg1 101 p0 HEOF 13 DESrABIE
Name of Inspector: (please print) i°V►��C�►� �dUl��, �1 PT.
Company Name: '
Mailing Address: 5�
iMc..
Telephone Number: 5 '3
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 the inspection..The inspection was performed based on my
training and 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:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: IA Sz=L12 ,-Date:
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.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority.
Notes and Comments
****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 14
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OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: g
Owner: -
Date of In ection: i a O k
Inspection Summary: Check A,B,C,D or E/ALWAYS complete
A. System Passes:
I have not found any information which indicates that any of the failure criteria described in 310 C MR
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
B. Sy tem Conditionally Passes:
On or more system components as described in the"Conditional Pass"section need to be aced or
repaired.The stem,upon completion of the replacement or repair,as approved by the Boar Health,will pass.
Answer yes,no or no determined(Y,N,ND)in the for the following stat ents.If"not determined"please
explain.
The septic tank is me and over 20 years old*or the se ' tank(whether metal or not)is structurally
unsound,exhibits substantial in Itration or exfiltration or failure is imminent. System will pass inspection if the
existing tank is replaced with a co lying septic tank roved by the Board of Health.
*A metal septic tank will pass inspec 'on if it is stru lly sound,-not h aking and if a Certificate of Compliance
indicating that the tank is less than 20 y old i vailable.
ND explain:
Observation of sewage bac p or break aa>E�or thigh static wader level in the distriln iion box due to broken or
obstructed pipe(s)or due to a br en,settled or une distribution box.System will pass inspection if(with
approval of Board of Health):
broken pipe(sJ are re��ad
obstruction is removed
distribuliaa btm m heeled nplaced
n
ND explain:
The sy em required pumping more than 4 times a year due to broke obstructed pipe(s).The system will
pass inspect' n if(with approval of the Board of Health):
broken-pipe(s)are replaced
obstruction is removed
ND explain:
2
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Page 3 of 11
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
n ' r CERTIFICATION(continued)
Property Address: �� W
Owner:
Date of Ins ection:
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in ordert6 determine if the system
is failing rotect public health, safety or the environment.
1. System 1 pass unless Board of Health determines in accordance with"310 CMR 15.303(1)(b)that the
system is no unctioning in a manner which will protect public health,safety and the environment:
Cesspool or p 'vy is within 50 feet of a surface water
Cesspool or pri .is within 50 feet of a bordering vegetate Zetland or a salt marsh
2. System will fail unless the Board of Health(an Public Water Supplier,if any)determines that the
system is functioning in a manner that pro cts t e public health,safety and environment:
_ The system has a septic tank and soil so tion system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a sure wat supply.
The system has a septic tank ano AS and the SA is within a Zone 1 of a public water supply.
The system has a septic and SAS and the SAS is 'thin 50 feet of a private water supply well.
The system has a septic and SAS and the SAS is less th 100 feet but 50 feet or more front a
private water supply well". Method used to determine distance
"This system passes if a well water analysis,performed at a DEP certi ed laboratory, for coliform
bacteria and volatile o anic compounds indicates that the well is free from llution from that facility and
the presence of amm nia nitrogen and nitrate nitrogen is equal to or less than m,provided that no other
failure criteria are ggered.A copy of the analysis must be attached to this form.
3. Other:
3
Page 4 of I I
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OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION.(cantinued)
Property Address: 0
Owner:
Date of I nsped lion: '� Q
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
ckup of sewage into facility or system component due to overload d or clogged SAS or cesspool
Di harge or ponding of effluent to the surface of the ground or su ace waters due to an overloaded or
clog ed SAS or cesspool
Static 'quid level in the distribution box above outlet invert d to an overloaded or clogged SAS or
cesspoo
Liquid dgirl
in cesspool is less than 6"below invert or avai ble volume is less than'h day flow
Requireing more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of timesp
Any poof th SAS,cesspool or privy is below hi ground water elevation.
Any porof cess ool or privy is within 100 feet of surface water supply or tributary to a surface
water s .
Any porf a cesspo 1 or privy is within a Zone of a public well.
Any porof a cesspool r privy is within 50 fe of a private water supply well.
Any porf a cesspool o rivy is less than 1 feet but greater than 50 feet from a private water
supply ith no acceptabl water quality alysis. [This system passes if the well water analysis,
perfort a DEP certified boratory, r coliform bacteria and volatile organic compounds
'indicatt the well is free fro pollut'on from that facility and the presence of ammonia
nitroged nitrate nitrogen is eq 1 t or less than 5 ppm,provided that no other fadur+e eriieria
are triggered.A copy of the analysis us(be attached to this form.[
(Yes/No)The system fails. I have dete ed t one or more of the above failure criteria exist as
described in 310 CMR 15.303,ther fore the s tern fails. The system owner should contact the Board of
Health to determine what will be cessary to c ect the failure.
E. Large Systems:
To be considered a large system the sy tern must serve a facility 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 larg systems.uadditiam o]hearrtaiaabova
yes no
the system is within 0 feet of a surface drinking water supply
_ the system is wit in 200 feet of a tributary.to a surface drinking water supply
the system is cated in a nitrogen sensitive area(#terim Wellhead Protection Area IWPA)or a mapped
Zone II of a blic water supply well
If you have answere "yes"to any question in Section E the system is considered a significant threat, r answered
"yes"in Section D above the large system has failed.The owner or operator of any large system consi red a
significant threat'under Section E or failed under Section D shall upgrade the system in accordance with 10 CMR
15.304.The system owner should contact the appropriate regional office of the Department.
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Page 5 of 1 l
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OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 89 %v
Owner
Date of Inspection:
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
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?
_ -Z Have large volumes of water been introduced to the system recently or as part of this inspection?
_ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
4z _ Was the facility or dwelling inspected for signs of sewage back up?
Jz Was the site inspected for signs of break out?
AZ_ 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 baffles or 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)]
5
Page 6 of 11
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OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: n
Owner: - Da
Date of Insp ction: ) ej
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual)..3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bednK ms): 3 3�
Number of current residents: 9-
Does residence have a garbage grinder(yes or
Is laundry on a separate sewage system(yes o no:__ [if yes separate inspection required]
Laundry system inspected(yes or no):—
Seasonal use: (yes o no \r
Water meter readings, if available(last 2 years usage(gpd)): (V A
Sump pump(yes or V'_
Last date of occupancy:
COMM C
L/INDUSTRIAL
Type of establis t:
Design flow(based on CMR 15.203): eDd
Basis of design flow(seats/pe /sgft,etc.):
Grease trap present(yes or no):—
Industrial waste holding tank present(yes or n
Non-sanitary waste discharged to the Title 5 system y 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 inspection(yes or >o .
If yes,volume pumped: gallons--How was.quantity pumped determined?
Reason for pumping:
TYKE 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 thecunent operation and maintenance contract(to be
obtained from system owner)
_Tight tank _Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed if known)and jour e of information: ,
tQ tn'Q' •rw`v 14 g
Were sewage odors detected when arriving at the site(yes o no _
6
Page 7 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
r SYSTEM INFORMATION(continued)
Property Address: t/V
Owner:
Date of Ins ection: M a1�0 t
BUILDING SEWER(locate on site plan) _
Depth below grade:
Materials of construction:_cast 40 PV other(explain):
Distance from private water supply well o �me:
Comments(on condition of jo' nting,evidence oo age,etc.):
SEPTIC TANK:_(locate on site plan)
N
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: 1000 qo�Q
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle: 's
Scum thickness:_Q e' „
Distance from top of scum to top of outlet tee or baffle: „
Distance from bottom of scum to.bott?m of outlet tee or baffle: 1
How were dimensions determined: s�nspe, t I ,
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
GREASE TRAP:_(locate on site plan)
Depth below grade:_
Material of construction: concrete_ fiberglass__polye ne_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or b e:
Distance from bottom of scum to bottom of et tee or baffle:
Date of last pumping:
Comments(on pumping recomme tions, inlet and outlet tee or baffle condition,strut tegrity,liquid levels
as related to outlet invert,evi ce of leakage,etc.):
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner:
Da
te of Ins ction• jok
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete etal fiberglass_pol �ylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working or (yes or no):
Date of last pumping:
Comments(condition of alarm an oat switches,etc.):
DISTRIBUTION BOX:_JZ(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
leaks a into or out of box,etc.
PUMP CHAMBER: (locate on site plan
Pumps in working order(yes or no):
Alarms in working order'(yes or no):
Comments(note condition of c amber,condition ofpumps and s,etc.):
8
Page 9 of I I
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OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: q9 w
Owner:
I
Date of In ection: ibl2ff8k
SOIL ABSORPTION SYSTEM(SAS): V (locate on site plan,excavation not required)
If SAS not located explain why:
Type
Ei leaching pits,number: of
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.): �t '�
Oa
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site pl
Number and configuration: ti
Depth—top of liqui - -
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 h auli ilure,level of ponding,condition of vegetation,etc.):
PRIVY: (loXieMaterials of cons
Dimensions:
Depth of so ' s:
Co mme ?(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegeta ' n,etc.):
9
Page 10 of 11 .
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OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: Q
Owner:
Date of In �ection: -1 Q
i
1
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.
A-1
V'
1
1C)
10
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y Page 1 1 of 1 1
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: <29 WQ
ON on Ad&
Owner:
r .
Date of In ection: IbIa O S
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
i-1--
Estimated depth to ground water 13 feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS
Checked with local Board of Health-explain: .Cp.¢•c z .19A2AE, �', C�tntiG�.c.�. 'YV� _as
Checked with local excavators, installers-(attach documentation) r �� 1p19`�1
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
11
TOWN OF BARNSTABLE
L')CA-1ION ZI G. rmgNq.1 I m-& SEWAGE # IU�
VILLAGE *r1mr-4(5 ASSESSOR'S MAP & LOTS d`', 9,b'
INSTALLER'S NAME&PHONE NO. LJr �f of ;PDXQ J <�tC "175m R 1 "7
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) . (size) j
NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: a COMPLIANCE DATE: 3 lwk
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) Feet
Furnished by
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P; AKESSORSAWNa
No. 21
PARCELNk__4z 1 � e 40 . 00
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
Application for Mtgpool *r5tem Construction permit
Application is hereby made for a Permit to Construct( )or Repair(x )an On-site Sewage Disposal System at:
Location Address or Lot No. Owner's Name,Address and Tel.No.
89 Wagon Ln Bill Nadone
Hyannis MA 771 -6949
Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No.
W.E. Robinson Septic Sery
P.O. Box 1089
Type of Building:
Dwelling No. of Bedrooms 3 Garbage Grinder(n9
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Description of Soil gravel
Nature of Repairs or Alterations(Answer when applicable) additional precast stonepacked
leachpit according to engineer plans ' a-4A"d
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 Environ ental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this Board e th.
Signed �� C Date
Application Approved by
Application Disapproved for the following reasons 44
Permit No. �� ��� Date Issued �' �
b {� """s;e:`.. V e.:rt r+.��:w•�t` iiw+^w.w,:ir'a..�rv�.:t: E ,�� _ �;,;d w�/r/'`) ,.s ,. s-.•`�S Y �±;4 — � ,�..�.:-
No.
THE COMMONWEALTH OF MASSACHUSETTS
r
PUBLIC HEALTH'bIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS-
01ppYication for �Dtgogaf *pgtem Congtruction Permit
Application is hereby made for a Permit to Construct( )or Repair(X )an On-site Sewage Disposal System at:
Location Address or Lot No. Owner's Name,Address and Tel.No.
89 Wagon Ln Bill NaMone
Hyannis MA", ,771 -6949
m
Installer's Name,Address,and Tel.No. 7 7 5^�8 7 7 6 Designer's Name,Address and Tel.No. f%J
W.E. Robinson Septic Sery
P.O. BOX '1089 ;
Type of Building:
Dwelling No.of Bedrooms 3 Garbage Grinder(n9
` Other Type of Building ' - No. of Persons Showers( ) Cafeteria( )
Other Fixtures {:
Design Flow x t gallons per day. Calculated daily flow gallons.
`r Plan Date t Numberof sheets Revision Date
R Title '^•
Description of Soil gravel
Nature of Re airs or Alterations(Answer when applicable) additional precast stonepacked
leachpi�t. according to engineer plans 0,4,4
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and mattenance of the afore described on-site sewage disposal system
.in accordance with the provisions of Title 5 of th�Environentaj,,Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued b this Boaz
Signed t Date
Application Approved b-, _
~ /k Application Disapproved for the following reasons
Permit No. Date Issued �'" ��' /•"° �
t
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
�d
i
Certificate of (Compliance
THIS IS TO CERTIFY that the On-site Sew a Disposal System installed( r at ed/re laced( X)on
b W.E. )tobinson Septic Servigg. i� �ivaaone
as 89 Wagon Lane Hyannis " has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. _/O dated '^" %�— A' '
Use of this system is conditioned on compliance with the provisions set forth
nZ
Fee 40.00
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Xi!9pogal'*pq;tem (Construction Permit
Permission is hereby granted to W.E. Robinson Septic Sery
to construct( )repair( X)an On-site Sewage System located at 89 Wagon Lane Hyannis
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
All construction must be completed within two years of the date,*low.
Date: '" !� Approved b �� `:
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d�STR.uMC=l. -r Su2ve 1 HIE ni=FSE'T� slaaV�
Nor 1APPLICPt
L'0 C T ION SEWAGE . PERMIT . NO
VILLAGE
I`
INSTALLER'S NAME. ADDRESS
0 UILDE R . OR OWNER
GATE PERMIT ISSUED
DAT E C 0 M P L I A N C E ISSUES
0
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Fizz.
THE COMMONWEALTH OF MASSACHUSETTS UI
BOARD OF HEALTH
..........ro-1-4-4.,_...--....OF. i ...... ........................
Appliration for Uhipoiial Vorkg Tomtrurtion Fautit
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at:
iz........... ....... ...
----- ------- . .. .... . .......—.1. ...................
�Xri-A d&s or Lot
.. .......... L1<11
----- .............I....... ........ .........
Own
...........
T� .............................. ... .. .................... 6.e j,'
....... .............. ............ in Address
�6,
of Building g Size Lot.. ..................Sq. feet
U oms........3Garbage Grinder
Dwelling—No. of Bedro ........:...........................Expansion Attic
Other—Type of Building ............................ No. of persons............................ Showers Cafeteria
04 Other fixtures ...................................................................................................................................................
Design Flow........ 0.........................gallons per person ay. Total daily flow......3,�?.a........................gallons.
1:4 Septic Tank—Liquid capacity-)t..OV..gallons Length....)._...... Width......5....... Diameter_-------------- Depth,--- . .....
Disposal Trench—No. .................... Width.................... Total Length....._.. ._._.... Total leaching area....................sq. ft.
Seepage Pit No._/./._d7V.. Diameter....._? --- Depth below inlet...... .... Total leaching area..a_4?!;;Lq. ft.
Z Other Distribution box Dosing tank
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I J=I-:_._.minutes per inch Depth of Test Pit.....Lz:!...... Depth to ground water-----Md.
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.............._.....___.
.........................................
......... ................................ ..
0 Ppscription of Soil-------- . --:5
....... ..... A—I -----------
.p ... ....... ........................................................................I.......................
U .....................
..........................................................................................................................................................................................
--------------
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 IL LE, 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of, Compliance�hhbeen issued by the board of health.
5,g gned......... ........... .. ....... ..........
Application Approved By...... ...... .......i.n......................................................................... ......... Date
-e .............
or? ................
e follow g r
Application Disapprove r following reasons:......................................................-------------- ..................
.........................................................................................................................................................................................................
Date
PermitNo......................................................... Issued-----.....------------------..._......---....__._..----
Date
................ FIMB..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOA RP,QF HEALTH
........... ........0 F......... ......................
Appliration for Uhipaiial Works Toustrudion "amit
V
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at:
7 �f------- . ....... . ....... .................
...... X .................
................. ... ...........................
------—---------*"nw-Add or t
.. .......
... ........ ......... ............
-- - ------ ---------- .......... -.01............................... .....................................
r .....................
Own .5;
..................... . ...........
------------------------------
Inst 410 Address
of Building Size Lot..... i....... ......Sq. feet
U
..Dwelling—No. of Bedrooms....... ....3.....1
..........................Expansion Attic Garbage Grinder
44 Other—Type of Building ............................ No. of persons............................ Showers Cafeteria
04 Other fixtures .... I .-
----------
Design Flow........ .......................__gallons per person jierday. Total d ...................*---------allons.
w------- ......_..................gallons.
Liquid capacity.ji..d.k.gallons Length_._.__'`........
9 Septic Tank Wi�th....n Diameter------------ ... Depth.. �'---__-
x Disposal Trench—/No. .............. Width.... _............. Total Length-----4. ._/1--- Total leaching area____..........___sq. ft.
Seepage Pit No......I.-M_ _,_ Diameter......'........_ Depth below inlet...... ........ Total leaching area..2 :o......sq. f t.
Z Other Distribution box Dosing tank ( )
Percolation Test Results Performed by.................................. Date_..........................*-------- 7....................
Test Pit No. ...minutes per inch Depth of Test Pit...... ...... Depth to ground water......
44 Test Pit No. 2................minutes per inch Depth of Test Pit.._...........___... Depth to ground water.........................
9 ............j�---- ..... C. . .....
---4----------------------0..................
0 D�pscriation of Soil...... .............6nm
Z: .. .....i ............ ---------- .......... ........................... ........
::Y�V* so
U .............. . ....... .t.....................................:1 ................114.......!........................................................................................
.......................................................................... .............................................................................................................................
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 Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance haAeen issA ed by the board.of hedlth.,
ned.. _�--n-....a----.M........74.f.-.-.-V V....
5 i5 ----
Application --
ApprovedBy..... ..... .................................................................................
Application Disapproved r t following., sons:................. ......................................................................................
.................................................................................................................. ..........................................................................
Date
PermitNo......................................................... Issued..... ...............................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH '
' ......................................._OF...................................................... e. .......................
0ardifiratr of Tumptiatta
T11- 0 TIFY, That the Individual Sewa Disposal System constructed,( or Repaired
by.. 0... ........ ................ ............pw�o..................................................................................................
taller
rs
at. ... . ............ ..... .......1141 ................................. --------------------- ---------*-------------------
has been installedin accordance with thee, v* ions of 'LITZZ, he State...S......anitary 'rued in the
application for Disposal Works Consm"U" on Permit No._rl....'Vir.............. dated --------..................................
..........
THE ISSUA CE F THIS TIFICATE SHALL NOT BE CONSTRUED A GUARANTEE THAT THE
visl
_It�l th
e
er
0 P in
Tj FICATE CONSTRUE®
SYSTEM WIL7F� ION SATISFACTORY.
DATE... ....................................................
.... inspector........ .... ...................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOAR'[ —0'R HEALTH
. ........ .............OF...... .........
No....K................. FEE..-_....................
Disposal k T io Jon r.mit
Permission is>h e'by qe py grar .. . . .... . ........ .................................................................
to Construct or Re an I ivid al era >S Syst
atNo.-------- .............. ............/. .......... ......... ......................................................�:�
7.............. 07 Street
as shown on the p I c/tion r Disposal Works n ruction Permit Dated..........................................
........ ..... .. ......... ............................................................. .
Board of Health
DATE........ .... .... ......................................................
FORM 125 HOBBS & WARREN, INC.. PUBLISHERS N"
eir:Osz0OM �\ ►I
���� GLG- FAM►L.� _ �
wo q,,tzBAGE 6wtir->E2
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SEPT►G TA►vK = 330x15o'/• = �9%G.P �
U51< 100o
c»5Po5AL PIT V5E 1000 GAL-.
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PE2COLATIoN RAYE I'�iN 2MIN OP-LE55
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BAXTER
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P L.A r,.I R E F E IZE N GE
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LOG�T WIT ItJ NE 000 P L N I
DATE BAXTG vn a w`(6 I N C.
R.E6 I ST r-- 2EfU't-AN D 5 u IZV i'c�(oeS
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